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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6700
} | Medical Text: Admission Date: [**2160-1-6**] Discharge Date: [**2160-1-17**]
Date of Birth: [**2107-7-20**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Mercaptopurine
Analogues (Thiopurines)
Attending:[**First Name3 (LF) 5378**]
Chief Complaint:
Baclofen Overdose.
Major Surgical or Invasive Procedure:
1. Nasogastric tube
2. PICC line
History of Present Illness:
This is a 52 year-old female who is a pathologist at [**Hospital1 2025**] with a
history of worsening MS [**First Name (Titles) **] [**Last Name (Titles) **] who presents to the ED
with Baclofen overdose. The history was obtained from the
patient's husband. The patient has relapsing progressive
multiple sclerosis that has been worsening over the last two
years and has been wheelchair bound. The husband states that she
has had [**Last Name (Titles) **] for years, but seemed more depressed over the
last week. He could not identify a particular trigger, but
thought that the holidays had made things worse. The patient was
at home alone when the husband got a call from his wife who was
tearful and said she had taken "20 tabs" of baclofen, but the
husband thought she had taken more. Per ED they had estimated
~80-170 pills equaling 3400mg) He called EMS and on arrival they
cound her "sleepy" and tachycardic to the 120-140's.
.
In the ED she was 97.6 98 158/78 14 100% RA. She became more
somnolent then unresponsive and was intubated for airway
protection. She was started on a propofol gtt in the ED. Initial
vent settings were Tv: 500, PEEP: 5, RR: 12 and FiO2: 50%. CXR
showed right main-stem intubation and tube was withdrawn 3 cm.
Her ABG was 7.32/45/132/24. She was given 25g of charcoal. Her
labs were significant for a tox screen positive for opiates and
amphetamines. She had a mildly positve UA and was give cipro.
She was seen by Tox in the ED who recommended supportive care,
tachyarrhythmias per ACLS and bradydysrhythmias with atropine.
.
On arrive to the ICU the patient was intubated and sedated.
.
ROS: unable to obtain
Past Medical History:
Relapsing progressive multiple sclerosis
[**Last Name (Titles) **]
Sleep apnea - mixed picture: CPAP dependent
Sarcoidosis (in lung, diagnosed when moved to US for residency)
Social History:
She was practicing at [**Hospital1 2025**] as a liver pathologist until 5 months
ago. Husband is a pulmonologist. She was born in [**Country 18084**],
brought up in [**Country 4754**].
Family History:
Her brother has MS, but currently less severe.
Physical Exam:
On Admission:
GEN: intubated and sedated
HEENT: pupils reactive to light, sclera anicteric, no epistaxis
or rhinorrhea, MMM, OG in place
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB anteriorly, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses/ supra-pubic catheter
EXT: No C/C/E, no palpable cords
NEURO: CN II ?????? XII grossly intact. grimace to pain. Patellar DTR
+1. Plantar reflex downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
At discharge:
General: awake, alert, and oriented
Neuro exam: She has normal pupillary reactions and EOMs. No
dysarthria. Strength in UEs reveals right>left and
distal>proximal weakness mostly in an UMN pattern although right
biceps also are quite weak. FEs are particularly weak at 2-3/5,
and FFs slightly weak (5-/5). Elsewhere mostly [**4-8**]. Tone
relatively normal in UEs but prominent spasticity bilaterally in
LEs with only trace IP movement, [**4-8**] quads, 2-3/5 foot DFs. Toes
easily upgoing.
Pertinent Results:
Labs on admission:
[**2160-1-6**] 05:08PM WBC-9.8# RBC-4.77 HGB-13.5 HCT-41.1 MCV-86
MCH-28.4 MCHC-32.9 RDW-13.9
[**2160-1-6**] 05:08PM PLT COUNT-394
[**2160-1-6**] 05:08PM NEUTS-84.4* LYMPHS-8.9* MONOS-4.1 EOS-0.9
BASOS-1.8
[**2160-1-6**] 01:37PM GLUCOSE-140* UREA N-12 CREAT-0.4 SODIUM-135
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
[**2160-1-6**] 01:37PM PT-11.9 PTT-23.0 INR(PT)-1.0
[**2160-1-6**] 01:37PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2160-1-6**] 01:43PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-POS mthdone-NEG
[**2160-1-6**] 01:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2160-1-6**] 01:43PM URINE BLOOD-MOD NITRITE-POS PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2160-1-6**] 01:43PM URINE RBC-[**3-8**]* WBC-[**6-13**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2160-1-6**] 01:43PM URINE CA OXAL-RARE
[**2160-1-6**] 09:36PM TYPE-ART RATES-14/ TIDAL VOL-500 O2-50
PO2-31* PCO2-42 PH-7.39 TOTAL CO2-26 BASE XS--1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2160-1-6**] 03:35PM TYPE-ART PO2-132* PCO2-45 PH-7.32* TOTAL
CO2-24 BASE XS--3
.
Micro:
[**2160-1-8**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B: negative
[**2160-1-8**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE: no
growth
[**2160-1-8**] URINE Legionella Urinary Antigen: negative
[**2160-1-7**] BLOOD CULTURE Blood Culture: pending
[**2160-1-6**] MRSA SCREEN MRSA SCREEN-negative
[**2160-1-6**] BLOOD CULTURE Blood Culture: pending
[**2160-1-6**] URINE CULTURE: pansensitive ESCHERICHIA COLI
.
Imaging:
[**2160-1-11**] CXR: OGT in stomach. RUE PICC stable. Lungs remain clear
without effusion or pneumothorax.
[**2160-1-8**] EEG: IMPRESSION: This tracing gives evidence for a severe
diffuse
encephalopathy with periods of runs of what looks like
relatively
sustained epileptiform activity over both central regions and
also
occasional multifocal independent interictal epileptiform spike
wave
discharges seen on the spike detection algorithm only. It is
also noted
that the frequency of the sustained epileptiform activity seemed
to
decrease during the course of the study.
[**2160-1-7**] CXR: The ET tube tip continues to be relatively low, 2 cm
above the carina. There is progression of the left lower lobe
opacities, still most likely represent atelectasis, but should
be further followed to exclude the possibility of developing
infection. Otherwise, no significant change has been
demonstrated.
[**2160-1-6**] CXR: The patient is intubated with the tip of the ET tube
in the
proximal aspect of the right main stem bronchus. If the tube is
withdrawn
approximately 3 cm, it would be appropriately positioned. There
is left
retrocardiac atelectasis. No pneumothorax or pleural effusion is
present.
There is an OG tube within the stomach. Cardiomediastinal
silhouette and hilar contours are normal. IMPRESSION: Right
mainstem bronchial intubation. Mild retrocardiac atelectasis.
Brief Hospital Course:
52 year-old female pathologist with history of worsening MS [**First Name (Titles) **] [**Last Name (Titles) 34499**] admitted with Baclofen overdose. Hospital course
complicated by seizures and delirium.
.
#Baclofen overdose: Husband reports that she took 70 Baclofen
pills. Tox screen was negative for coexisting substances. She
was intubated for airway protection given sedation in the ED.
She was seen by toxicology in the ED who recommended supportive
care. On the first hospital day, she had brady and
tachyarrhythmias. In addition, she had two seizures that day-
the first of which was self limited and the second which did not
respond to IV Ativan. She was started on a midazolam drip for
seizure prevention. She was subsequently loaded with Dilantin
and then midazolam was weaned once Dilantin was therapeutic.
She was also hooked up to cEEG. The seizures were beleived to be
due to Baclofen withdrawal. Her Baclofen was restarted at half
dose 36 hours after intoxication taking the half life of
Baclofen into consideration. It was subsequently increased to
home dose. Her EEG improved after she was restarted on her home
dose of Baclofen. Her Dilantin was then stopped as she does not
have an underlying seizure disorder but rather had seizures as
she was withdrawing from thr Baclofen.
.
#Respiratory Distress: She was intubated for airway protection
in the setting of sedating overdose with Baclofen. Initial CXR
showed right main stem intubation with subsequent LLL
atelectasis. The ETT was pulled back and confirmed with CXR.
On the third day of hospitalization ([**1-8**]), she had a new
leukocytosis, a fever to 100.7, and thick secretions with some
concern for a RLL infiltrate. Vancomycin and Cefepime were
started for HCAP treatment for a planned 8 day course. A PICC
line was placed for these antibiotics. She was extubated without
issue after 5 days of invasive ventilation. After transfer to
the Neurology service from the ICU, she had no evidence of any
infection and her CXR was clear, so it was decided that her
antibiotics would be stopped (on [**1-13**]). During her stay on the
floor, she has had no respiratory issues.
.
#Psych: Given her impulsive suicide attempt, she was followed by
the psych department while she was an inpatient. They determined
that discharge to [**Hospital1 **] reheab, where she would be followed
by the psych department there, would be a safe discharge for
her. Her Effexor ER was initially held, but was subsequently
restaretd at a dose of 37.5 mg as per psych. Can Consider adding
Adderall when at rehab as per psych.
.
#UTI: She had a mildly positive urinalysis and a urine culture
revealing pansensitive E.coli. She was initially treated with
ciprofloxacin on [**1-7**]. However, this was discontinued once
Vancomycin/Cefepime was started on [**1-8**].
.
#MS: She has secondary progressive MS. [**Name13 (STitle) **] her outpatient
psychiatrist and neurologist, venlafaxine and mycophenalate were
held during her acute illness. Mycophenalate was restarted on
[**1-12**]. Venlafaxine was also subsequently restarted at a dose of
37.5 mg daily as per psych.
.
#FEN: She was fed with TPN during her intubation. She failed
speech and swallow on the day of extubation. A nasogastric tube
was placed for both tube feeds and medication administration. A
repeat speech and swallow evaluation showed that she had no
difficulty with swallowing and she was started on a regular
diet.
Medications on Admission:
Tylenol #3 2 tabs [**Hospital1 **]:prn
Adderall 10mg [**Hospital1 **]
Baclofen 20mg QID
Cellcept 1000mg [**Hospital1 **]
Pramipexole 0.125mg 1-2 tabs prn
Vesicare 10mg daily:prn
venlafaxine 150mg SR daily
Bisacodyl 10mg recally twice a week
vitamin d3 1000U daily
cyanocobalamin 1000mcg sl daily
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. pramipexole 0.125 mg Tablet Sig: 1-2 Tablets PO daily prn.
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
5. baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
6. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
8. venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for hold for loose stool.
10. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
q6h prn as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Baclofen Overdose
Secondary Progressive MS
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 to the hospital with a Baclofen overdose,
which you say was an impulsive and not a planned act. Upon
arrival to the [**Hospital1 18**] ED, you were intubated for airway
protection. You were seen by toxicology, who reccommended
supportive care. During your first day in the hospital, you had
2 seizures for which you were started on Dilantin and placed on
cEEG. The seizures and the subsequent delusions you experienced
were likely due to withdrawal from Baclofen. You have since been
restarted on your home dose Baclofen. The Dilantin has also been
stopped as you do not have an underlying seizure disorder. After
you were extubated, you were transferred to the Neurology
service. While on the neurology service, you passed a speech and
swallow eval and was started on a regular diet. You were also
seen by PT, who reccomended that you would benefit from rehab
given that you were bedbound for 1 week. You were seen by
psychiatry, who restarted you on your home Effexor and also
helped formualte the plan for a safe discharge to [**Hospital1 **], where you will be followed by the psychiatry service
there. With regards to your MS, you were continued on your home
dose of Cellcept.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1045**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2160-1-22**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Phone:[**Telephone/Fax (1) 6856**]
Date/Time:[**2160-1-22**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2160-1-29**] 1:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]
Completed by:[**2160-1-17**]
ICD9 Codes: 486, 5990, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6701
} | Medical Text: Admission Date: [**2194-9-24**] Discharge Date: [**2194-9-24**]
Date of Birth: [**2143-1-30**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Darvon / Gabapentin / Mucinex / Robitussin /
Lyrica / Lipitor / Oxycontin / Codeine
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Colonic ischemia
Major Surgical or Invasive Procedure:
Exploratory laparotomy [**2194-9-24**]
History of Present Illness:
51F s/p CRT on [**2194-6-5**] with h/o persistent abdominal pain and
associated nausea, diarrhea and ongoing c.diff w/ multiple
recent admissions now presented to [**Hospital3 417**] Hospital from
[**Hospital **] Rehab late evening [**2194-9-23**] w/ acute abdominal pain and
h/o recent coffee-ground emesis w/ leukocytosis peak at 25.2 w/
60% bands and lactate of 13.7 initially and then 9.3, also
hypotensive on high-dose levophed on transfer to [**Hospital1 18**]. CT
abd/pelv reviewed here demonstrated colonic distension/dilation
w/ pneumatosis. Pt arrived intubated and sedated w/ abd TTP,
still requiring vasopressor support. She was taken to OR
emergently for ex-lap and possible total abdominal colectomy.
Past Medical History:
PMH: ESRD d/t chronic glomerulonephritis now s/p cadaveric renal
transplant [**2194-6-5**], hypercholesterolemia, HTN, GERD, restless leg
syndrome, persistent C. diff infection
PSH: failed living related kidney transplant [**2187-1-30**], cadaveric
renal transplant [**2194-6-5**], RUE AV fistula with multiple revisions
for aneurysm s/p removal and wound revision, PD catheter
placement
Social History:
Lived at home with husband and children prior to recent surgery
and has been in/out of rehab since.
Has smoked [**12-7**] PPD for the last 30 years but despite plans to
quit after her transplant she has not.
Denies past or current alcohol or illicit/recreational drug use.
Family History:
Mother had DM Type 2
Brother had brain aneurysm
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Levoph 0.25, Fent 200, Versed 4
O: T: 100.1 HR: 119 BP: 103/49 RR: 33 O2Sats: 100%
CMV 100%/450x18/5
Gen: Intubated, sedated.
Neck: Supple.
Lungs: coarse bilaterally.
Cardiac: RRR.
Abd: no BS, mildly firm, +diffuse TTP, mild distension.
Extrem: no edema.
Pertinent Results:
[**2194-9-24**] 12:47PM BLOOD WBC-5.4# RBC-3.00* Hgb-9.7* Hct-29.0*
MCV-97 MCH-32.4* MCHC-33.6 RDW-21.3* Plt Ct-179
[**2194-9-24**] 12:47PM BLOOD PT-19.7* PTT-37.0* INR(PT)-1.8*
[**2194-9-24**] 12:47PM BLOOD Fibrino-415*
[**2194-9-24**] 12:47PM BLOOD Glucose-69* UreaN-44* Creat-1.5* Na-138
K-3.3 Cl-104 HCO3-17* AnGap-20
[**2194-9-24**] 01:48PM BLOOD Glucose-70 Lactate-5.0* Na-138 K-3.3*
Cl-110
[**2194-9-24**] 01:13PM BLOOD Lactate-5.3*
[**2194-9-24**] 12:47PM BLOOD ALT-43* AST-133* LD(LDH)-471*
AlkPhos-120* TotBili-0.9
[**2194-9-24**] 12:47PM BLOOD Albumin-2.5* Calcium-7.8* Phos-6.2*#
Mg-2.5
[**2194-9-24**] 01:48PM BLOOD Type-ART pO2-283* pCO2-35 pH-7.29*
calTCO2-18* Base XS--8 Intubat-INTUBATED Vent-CONTROLLED
CT abd/pel (OSH, no official report - reviewed here w/ Dr.
[**Last Name (STitle) **] - demonstrated diffusely distended colon w/ bowel wall
thickening and ?pneumatosis but no obvious free fluid/air
Brief Hospital Course:
Patient arrived in SICU on cardiopulmonary support (levophed,
vent, sedated). Outside chart reviewed including CT abd/pel w/
Dr. [**Last Name (STitle) **]. Patient w/ clinical and radiographic signs of
colonic ischemia. Decision was made to take patient emergently
to OR for exploratory laparotomy w/ likely total abdominal
colectomy. [**Name (NI) 1094**] mother [**First Name8 (NamePattern2) **] [**Name (NI) 2716**]) who is one of her
healthcare proxies (husband is primary but has hearing disorder)
was contact[**Name (NI) **] via cell phone for operative consent which was
obtained. Intraoperative findings were consistent with
pan-necrosis of small and large bowel - a non-survivable injury
and thus, patient's abdomen was closed and she was returned to
the SICU where after discussions w/ the family and surgical
staff, she was made CMO. She was removed from all medications
except morphine for comfort. She eventually expired at 10:28pm.
Her case was declined by the medical examiner but the family
requested and consented for an autopsy.
Medications on Admission:
fentanyl patch 25mcg per hour, D5NS w/ bicarb, sterile water
250cc PO q6h, vancomycin 250mg PO q6hr, flagyl 500mg IV q6h,
Jevity 1.5 cal TF, zofran PRN, tramadol 50mg q6h prn,
ergocalciferol 50,000units PO weekly, methylphenidate 5mg PO
BID, azathioprine 50mg PO daily, valcyte 450mg daily, protonix
40mg daily, citalopram 10mg daily, dapsone 100mg daily,
levothyroxine 50mcg dialy, metoclopramide 10mg before meals and
bedtime, tacrolimus 2mg q12h, clonazepam 0.5mg nightly,
mirtazapine 15mg daily, acetaminophen 650mg q6h prn, albuterol
sulfate 2 puffs INH q4h prn, simethicone 80mg q8h prn,
ipratropium 2 puffs INH q6h prn
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Pan-necrosis of small and large bowel
ESRD d/t chronic glomerulonephritis s/p cadaveric renal
transplant [**2194-6-5**]
hypercholesterolemia
HTN
GERD
restless leg syndrome
persistent C. diff infection
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6702
} | Medical Text: Admission Date: [**2163-4-8**] Discharge Date: [**2163-5-6**]
Date of Birth: [**2087-12-30**] Sex: M
Service: CCU
CHIEF COMPLAINT: Dyspnea.
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
male with a history of coronary artery disease, status post
multiple myocardial infarctions in the past, status post
right nephroureterectomy on [**2163-3-7**] for a transitional
cell carcinoma, who presented on the day of admission to
[**Hospital3 **] with worsening lower extremity edema and
exertional dyspnea since discharge.
The patient awoke on the morning of admission with acute
dyspnea and presented to [**Hospital3 **] where his
electrocardiogram revealed new lateral ST depressions of 2 mm
in V5 through V6 which was initially read as left ventricular
hypertrophy with strain, and he had an initial creatine
kinase of 40 with a negative troponin, but an oxygen
saturation of 85% on room air. The patient was given
Lasix 120 mg intravenously, nitroglycerin, morphine sulfate,
given 100% nonrebreather, and his oxygen saturation improved
to 100%. He was diuresed and sent to the [**Hospital1 346**].
On review of the patient's history, he admits to having
frequent bologna sandwiches and can soups and was unaware of
their sodium content.
At [**Hospital1 69**], the patient had a
blood pressure of 130/54, pulse of 72, respiratory rate
of 26, and an oxygen saturation of 100% on 50% Venturi mask
with electrocardiograms that revealed 1-mm ST depressions in
V5 through V6.
The patient was admitted to the C-MED Service, and several
hours later suffered acute worsening dyspnea with 5/10 chest
pain, and diaphoresis, and an electrocardiogram that showed
ST depressions in II and F as well as V4 through V5, with a
rate of 120, and a blood pressure of 150/90. The patient was
given intravenous nitroglycerin, morphine, Lasix, and
heparin.
He was taken to the catheterization laboratory where he had a
pulmonary artery pressure of 62/30 and wedge of 35. He was
found to have a left main coronary artery with a 40% distal
lesion, left anterior descending artery with a 50% proximal
lesion, left circumflex with a 50% middle lesion, second
obtuse marginal and third obtuse marginal were totally
occluded, right coronary artery with a 70% proximal lesion.
An echocardiogram revealed global hypokinesis, left
ventricular ejection fraction of 20%, and mild-to-moderate
mitral regurgitation.
The patient was transferred to the Coronary Care Unit for
observation, diuresis, and afterload reduction in the setting
of 3-vessel disease and left ventricular dysfunction.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post myocardial
infarction in [**2149**], as well as a non-Q-wave myocardial
infarction in [**2159**].
2. First-degree anterior vesicular block.
3. Congestive heart failure with an ejection fraction that
was markedly depressed by not quantified on a recent outside
hospital echocardiogram.
4. History of prostate cancer.
5. History of colon cancer, status post right
hemicolectomy.
6. Type 2 diabetes mellitus.
7. Chronic obstructive pulmonary disease without a history
of intubation or hospitalizations.
8. Hypertension.
9. Peripheral vascular disease, status post left
femoral-popliteal in [**2155**] with known carotid artery disease
with a right internal carotid artery of 80%.
10. Transitional cell bladder cancer, status post right
nephroureterectomy on [**2163-3-7**].
11. Postoperative confusion.
12. Chronic renal insufficiency (with a bowel sounds
creatinine of 2 to 2.5).
13. Anemia of chronic disease.
ALLERGIES: IODINE which causes anaphylaxis.
MEDICATIONS ON ADMISSION: Lopressor 50 mg p.o. b.i.d., NPH
15 units subcutaneous q.12h., clonidine 0.15 mg p.o. q.o.d.
alternating with 0.3 mg p.o. q.o.d., allopurinol 100 mg p.o.
q.d., Lipitor 20 mg p.o. q.d., enteric-coated aspirin 325 mg
p.o. q.d., Lasix 120 mg p.o. q.d., multivitamin,
trazodone 25 mg p.o. q.d., Protonix 40 mg p.o. q.d.
SOCIAL HISTORY: The patient has a 100-pack-year smoking
history. He quit smoking 14 years ago. The patient is
married. His wife is his primary caretaker. His health care
proxy is his daughter, [**Name (NI) 1494**]. [**Name2 (NI) **] has four daughters and
one son.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's
temperature was 97.4, pulse of 94, blood pressure of 140/69,
respiratory rate of 21, 100% on 100% nonrebreather. On
general examination, the patient was a pleasant elderly man
in mild respiratory distress. Head, eyes, ears, nose, and
throat examination revealed pupils were equally round and
reactive to light and an oropharynx was that clear and moist.
Neck examination revealed elevated jugular venous pressure to
10 cm of water. Chest examination revealed crackles up to
one-third of the lung fields bilaterally. The patient had
fair movement. Cardiovascular examination revealed distant
heart sounds, a regular rate and rhythm. No third heart
sound or fourth heart sound appreciated, and a soft 3/6
systolic blowing murmur heard at the left lower sternal
border radiating to the apex. Abdominal examination revealed
no hepatosplenomegaly, normal bowel sounds, with a nontender
and nondistended abdomen. Extremity examination revealed 2+
edema.
PERTINENT LABORATORY DATA ON PRESENTATION: The patient had a
white blood cell count of 10.5, hematocrit of 25.3, platelets
of 195. The patient's creatinine was 2.5. The patient's
creatine kinase was 39 with a troponin of 0.6.
RADIOLOGY/IMAGING: An echocardiogram status post
catheterization revealed the patient had an ejection fraction
of 15% to 20%, severe global left ventricular hypokinesis,
and a normal right ventricle. There was 2+ mitral
regurgitation.
HOSPITAL COURSE: The patient is a 75-year-old male with a
history of diabetes, coronary artery disease, congestive
heart failure, and chronic renal insufficiency who presented
with a congestive heart failure exacerbation.
1. CARDIOVASCULAR: From a coronary artery disease
standpoint, the patient had 3-vessel disease with 40% left
main lesion, 50% left anterior descending artery lesion, a
40% first diagonal lesion, a circumflex lesion with a 60% to
70% midvessel stenosis, a 70% proximal right coronary artery
lesion, and a totally occluded first obtuse marginal. No
intervention was performed on the patient's first
catheterization.
Within 48 hours of the patient being in the Coronary Care
Unit, the patient developed an episode of bradycardia,
hypotension, and hypoxic arrest requiring intubation and the
use of pressors. In this setting, the question arose of
possible ischemic mitral regurgitation in addition to viable
myocardial compromise by rate-related ischemia.
The patient was taken to cardiac catheterization four days
later, at which point he received stents to his right
coronary artery and first obtuse marginal. He was maintained
on aspirin and Plavix.
From a myocardium standpoint, the patient had a right heart
catheterization on presentation which showed elevated
left-sided filling pressures with a mean pulmonary capillary
wedge pressure of 37 mmHg. The patient initially required
Levophed and dopamine which was able to be weaned off within
the first 24 hours after intubation. The patient was then
started on afterload reduction with hydralazine and then
nitrates.
From a rhythm standpoint, the patient presented in normal
sinus rhythm but then developed intermittent Wenckebach until
nine days into the admission when the patient developed
atrial flutter without rapid ventricular response. The
patient was anticoagulated and chemically cardioverted with
ibutilide.
The patient was eventually stabilized on a heart failure
regimen that included hydralazine and Isordil.
2. PULMONARY: From a pulmonary standpoint, the patient was
initially intubated for hypoxic respiratory failure secondary
to flash pulmonary edema in the setting of known poor
systolic function. The patient also had renal insufficiency
in the setting of recent right nephroureterectomy. The
patient was intubated for progressive hypoxia. He was
started on continuous venovenous hemofiltration, and then the
patient's clinical status improved. He was extubated two
days later.
Twenty four hours later, the patient became progressively
lethargic, developing ventilatory failure as well as
hypoxemia, and the patient was once again reintubated. The
patient was able to be extubated within approximately three
days of intubation. The patient was once again extubated,
and within 48 hours was reintubated for hypoxic respiratory
failure.
At that point, Pulmonary was consulted and felt that the
patient's multiple reintubations had to do with poor cardiac
status limiting increase cardiac output and stress response
to mild episodes of respiratory compromise including mucous
plugging and aspiration.
Multiple meetings were held with the family regarding goals
of care, and at all times they wished to pursue reintubation
and resuscitation with the exception if the patient were to
require long-term ventilatory care. They were amenable to
tracheostomy and percutaneous endoscopic gastrostomy tube
placement if needed. The patient was successfully extubated
and did well status post third extubation.
3. INFECTIOUS DISEASE: The patient had presented with a
low-grade temperature and possible right lower lobe
infiltrate. He was empirically started on Levaquin and
Flagyl. Subsequent cultures grew only pan-sensitive
enterococcus in his urine. The patient completed a 10-day
course of levofloxacin and ampicillin for a urinary tract
infection.
When the patient experienced his decompensation status post
initial extubation, he was started on vancomycin and
ceftazidime for a possible line-related sepsis and
ventilatory-associated pneumonia. This was continued for
approximately seven days. After the patient's second
extubation, he was found to have progression of a right lower
lobe consolidation and was restarted on ceftazidime,
vancomycin, and ciprofloxacin. This was to cover
ventilatory-related pneumonia.
The patient had a right femoral internal jugular tip which
had grown out methicillin-resistant Staphylococcus
epidermitis for which he received a single dose of
gentamicin. The patient was continued on coverage for
ventilatory-associated pneumonia for 10 days; after which his
antibiotics were discontinued. He had a normal white blood
cell count at that time and was afebrile.
4. RENAL: The patient developed progressive oliguria in the
setting of known chronic renal insufficiency within the first
48 hours of presentation. His acute renal failure was felt
to be secondary to acute tubular necrosis from hypotension.
The patient subsequently underwent two cardiac
catheterizations which also were felt to have contributed to
dye-associated nephropathy. The patient was initially
started on continuous venovenous hemofiltration with
excellent results and excellent control of his volume status.
The patient was then started on hemodialysis.
Over the course of the admission, the patient did not have
significant improvement in urinary output averaging about
600 cc per day. Although possible renal recovery was not
excluded, it appeared to the Renal Service that the patient
would remain on prolonged hemodialysis. The patient had a
Perm-A-Cath placed for durable hemodialysis access.
5. HEMATOLOGY: The patient presented with a low hematocrit
which was initially thought secondary to chronic anemia. The
patient had been anticoagulated for several of his
catheterizations and after stent placement. He exhibited
significant bleeding around lines and had multiple clot
suctions in his endotracheal tube. Anticoagulants were held.
The patient was evaluated for DIC, which laboratories were
found to be normal. His hematocrit eventually stabilized.
He was transfused with blood products to maintain a
hematocrit of greater than 30.
6. GASTROINTESTINAL: The patient presented with borderline
nutritional compromise. He was provided tube feeds through
nasogastric tube. When the patient was extubated, he was
evaluated for his swallowing and was found to aspirate
significantly at the bedside. The patient was re-evaluated
after his third extubation with video swallowing and was also
found to have marked aspiration. After discussion with the
family, a PEG-J placement was elected. The patient underwent
this procedure without difficulty. He will receive tube
feeds until it is felt that his swallowing capacity may be
re-evaluated.
7. EAR/NOSE/THROAT: The patient complained of difficulty
hearing after his second extubation. This was thought to be
possibly secondary to drug effect; although the only ototoxin
he received was gentamicin, and he had only received one dose
of this. The patient had marked cerumen impaction on
examination, and upon removal of the cerumen the patient's
hearing improved slightly. After the patient's third
extubation it appeared that his hearing had improved. He
will likely need formal audiologic testing and possible
hearing aide.
8. PSYCHOSOCIAL: The patient remained full code throughout
the admission. Multiple discussions were held with the
daughters and with the patient. He felt strongly that his
daughters should make the decision for him regarding his
health care. His daughters felt that he would want
aggressive respiratory and ventilatory efforts as long as he
was not to remain on machines indefinitely.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE FOLLOWUP: The patient was discharged with followup
with primary care physician's (Dr. [**First Name8 (NamePattern2) 12041**] [**Last Name (NamePattern1) 5361**]) office
within one week of discharge.
DISCHARGE STATUS: The patient was to be discharged to acute
rehabilitation for ongoing conditioning and management of
pulmonary hygiene.
NOTE: The remainder of this dictation will be dictated as an
Addendum as the patient approaches discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2163-5-5**] 14:27
T: [**2163-5-5**] 15:12
JOB#: [**Job Number 22146**]
ICD9 Codes: 4280, 4240, 486, 5990, 5845, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6703
} | Medical Text: Admission Date: [**2138-9-29**] Discharge Date: [**2138-10-4**]
Date of Birth: [**2138-9-29**] Sex: M
Service: NB
[**Known lastname **] [**Known lastname 61773**] [**Known lastname 60891**] was born at 36-4/7 weeks gestation
by spontaneous vaginal delivery after induction for pregnancy
induced hypertension. This mother is a 36-year-old gravida 2,
para 1, now 2 woman. Her prenatal screens are blood type O+,
antibody negative, rubella immune, RPR nonreactive, hepatitis
surface antigen negative and Group B strep unknown. Rupture
of membranes occurred six hours prior to delivery. The mother
did receive intrapartum antibiotics for GBS prophylaxis. The
infant emerged with decreased respiratory effort requiring
bag and mask ventilation, his Apgar's were 6 at one minute
and 8 at five minutes. Of note is that the infant also had a
true knot in his umbilical cord. The birth weight was 3395
grams, the birth length 19-1/2 cm. And the head circumference
was 34.5 cm.
PHYSICAL EXAMINATION: On admission revealed a full term non-
dysmorphic infant anterior fontanel open and flat, bruised
faced due to rapid second phase of labor. Positive bilateral
red reflex, intact palate, mild subcostal retractions,
positive grunting, breath sounds were equal. Heart was
regular rate and rhythm. No murmur. Abdomen soft, nontender,
nondistended. Extremities well perfused, stable hips, spine
intact, bilateral descended testes and age appropriate tone
and reflexes.
NICU COURSE BY SYSTEMS: He continued to have respiratory
distress after admission to the NICU requiring nasopharyngeal
continuous positive airway pressure. He weaned from that to
nasal cannula oxygen on day of life #2 and then to room air
also later on day of life #2 where he has remained. He
continues to breath comfortably. Lung sounds are clear and
equal. He has had no apnea or bradycardia.
Cardiovascular status: He has remained normotensive
throughout his NICU stay. His heart has regular rate and
rhythm and no murmur.
Fluid, electrolyte and nutrition status: At the time of
discharge his weight is 3,175 grams. Enteral feeds were begun
on day of life #2 and advanced without difficulty to full
volume feeding by day of life #4. At the time of discharge he
is breast feeding or taking 20 calorie per ounce formula on
an ad lib schedule. He has remained U-glycemic throughout his
NICU stay.
Gastrointestinal status: He was treated with phototherapy
from day of life 3 until day of life 4. His peak bilirubin on
day of life 3 was total 15.5, direct 0.4. A rebound Bili is
pending.
Hematology: The infant has never received any blood product
transfusions during his NICU stay. His hematocrit at the time
of admission was 50.3. The infant is blood type O+, direct
Coombs' negative.
Infectious Disease: Ampicillin and gentamicin was started at
the time of admission for sepsis risk factors. The
antibiotics were discontinued after 48 hours and the blood
cultures were negative and the infant was clinically well.
Sensory
Audiology: Hearing screening was performed with automated
auditory brain stem responses and the infant passed in both
ears.
Psychosocial: The parents have been very involved in the
infants care throughout his NICU stay.
Genitourinary: A circumcision is planned prior to discharge.
The infant is discharged in good condition.
He is discharged home with his parents.
His primary pediatric care provider will be Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7363**] of
[**Location (un) 1439**], MA.
RECOMMENDATIONS AFTER DISCHARGE: Feeding: Formula, breast
feeding with appropriate support as needed.
The infant is discharged on no medications.
A State newborn screen was sent on [**2138-10-2**].
The infant has not yet received his first hepatitis B
vaccine.
Recommended immunizations:
1. Synagis RSV prophylaxis to be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following
three criteria: Born at less then 32 weeks. Born between
32 and 35 weeks with two of the following: Day care
during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings or 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 and for the first 24 months of the childs
life immunization against influenza is recommended for
household contacts and out of home caregivers.
FOLLOW UP: Includes follow-up with his primary pediatric
care provider and lactation support as needed.
DISCHARGE DIAGNOSIS:
1. Prematurity at 36-4/7 weeks.
2. Status post transitional respiratory distress.
3. Sepsis ruled out.
4. Status post hyperbilirubinemia of prematurity.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 56577**]
MEDQUIST36
D: [**2138-10-4**] 06:26:40
T: [**2138-10-4**] 08:31:29
Job#: [**Job Number 62998**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6704
} | Medical Text: Admission Date: [**2105-10-15**] Discharge Date: [**2105-10-26**]
Date of Birth: [**2021-10-31**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p MVA
Major Surgical or Invasive Procedure:
[**2105-10-16**] Thoracic epidural placement for pain control
[**2105-10-20**] Placement of PICC line
History of Present Illness:
This is an 84-year-old female involved in a collision. She was
the restrained driver involved in an accident. Extensive damage
to the car including bending of the steering wheel. The patient
was complaining of pain in her chest as well as in her right
lower extremity. Hit her head on steering wheel. Patient does
recall loss of consciousness. In the ED, CT pan-scan was
performed, showing injuries as below. A pigtail catheter was
placed for the left pneumothrorax.
Past Medical History:
PMH: A-fib, renal artery stenosis, s/p L renal a stent placement
[**2097**], HTN, dyslipidemia, COPD (per [**2097**] d/c summary, pt denies),
bowel obstructions s/p ex-lap (details unclear) c/b mesh
infections, frequent falls.
PSH: AAA repair and ABI [**2093**], b/l TKA, L3/L4 laminectomy, remote
appendectomy, remote ovarian cystectomy, R THR [**2101**], mult bowel
obstructions s/p ex-lap (details unclear) c/b mesh infections
Social History:
denies ETOH, denies tobacco
Family History:
Non-contributory
Physical Exam:
HR: 90 BP: 150/100 Resp: 20 O(2)Sat: 100% on 2 L Normal
Constitutional: General appearance: The patient arrives
boarded and collared and is in no acute distress. The GCS is
15.
Head: The scalp is nontender and shows a laceration at the
left forehead near the hairline.
HEENT: The extraocular muscles are intact and the pupils
both constrict to light, [**2-11**]. The midface is stable.
Neck: There is no C-spine tenderness or step off.
Upper extremities: The upper extremities a extensive
abrasion over the left arm near the elbow.
Thorax: The chest wall is tender on the left side.
Lungs: The lungs are clear and symmetrical.
Heart: The heart sounds are crisp.
Abdomen: soft, scaphoid, and mildly tender in the right
abdomen.
Spine: There is no thoracic or lumbar spine tenderness.
Hips and pelvis: The pelvis is stable and the hips are
nontender.
Lower extremities: no long bone signs; there is a large deep
12 cm laceration of the left leg below the knee.
Neurovascular function distally is normal. There is an
abrasion on the right knee.
She has dopplerable pulses in both legs.
Neurological: The patient moves all 4 extremities equally.
Pertinent Results:
[**2105-10-15**] CT CHEST W/CONTRAST:
1. Displaced fractures of the left anterolateral 3rd through 6th
ribs with
small left pneumothorax.
2. Nondisplaced sternal fracture without significant hematoma or
vascular
injury.
3. Trace left-sided pleural effusion measuring simple fluid
density.
4. Significant subcutaneous emphysema over the left anterior
chest wall.
[**2105-10-15**] CT C-SPINE W/O CONTRAST:
Possible nondisplaced fracture of the left transverse process of
T1. No other fractures identified. Mild anterolisthesis of C6 on
C7, age
indeterminate, may be due to degenerative change.
[**2105-10-16**] ANKLE (AP, MORTISE & LAT) BILAT PORT:
Right distal fibular fracture.
[**2105-10-16**] Echo:
The left atrium is moderately dilated. The right atrium is
moderately dilated. 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 mildly thickened (?#). There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild mitral regurgitation. Moderate pulmonary
hypertension.
[**2105-10-15**] 04:10PM WBC-14.9* RBC-4.10* HGB-12.8 HCT-38.6 MCV-94
MCH-31.1 MCHC-33.1 RDW-14.1
[**2105-10-15**] 04:10PM PT-12.8 PTT-27.5 INR(PT)-1.1
[**2105-10-15**] 04:10PM PLT COUNT-432
[**2105-10-15**] 04:10PM FIBRINOGE-347
[**2105-10-15**] 04:10PM LIPASE-21
[**2105-10-15**] 04:10PM UREA N-26* CREAT-1.5*
[**2105-10-15**] 04:20PM LACTATE-1.5
[**2105-10-15**] 04:20PM PO2-44* PCO2-54* PH-7.37 TOTAL CO2-32* BASE
XS-3 COMMENTS-GREEN
Brief Hospital Course:
Ms. [**Known lastname 32734**] was admitted on [**2105-10-15**] under the acute care
surgery service to the trauma ICU for further evaluation and
management of her injuries. She remained hemodynamically stable
on [**2105-10-18**] and was transferred to the surgical floor.
She had a significant forehead laceration was sutured on
admission. Sutures were removed prior to discharge and site
remained clean and dry at the time of discharge.
Neuro: A thoracic epidural was placed on [**2105-10-16**] for pain
management given her rib fractures, which was removed on
[**2105-10-19**]. She was transitioned from IV to PO analgesics. By the
day of discharge on [**2105-10-26**], her pain was well-controlled with
scheduled tylenol and prn tramadol and low dose oxycodone. On
[**2105-10-21**], Ms. [**Known lastname 32734**] was triggered for a transient episode of
altered mental status. Urine cultures were sent which were
negative. A chest xray was obtained which stable showed
bibasilar atelectasis and no evidence of infiltrate. She
remained hemodynamically stable during this episode, which
resolved quickly without intervention. She remained alert and
oriented at her baseline mental status upon discharge.
Cardiac: Her vital signs were monitored routinely throughout her
hospitalization. On arrival to the ED, her ECG showed rapid
atrial fibrillation with RVR (history of known atrial
fibrillation). She was rate controlled initially with IV beta
blockers in the ICU, and was then transitioned to her home
cardiac medications. She remained in atrial fibrillation at her
baseline throughout her floor course, with adequate rate control
in the 60s and 70s. A bedside echo was performed to evaluate her
cardiac function on [**2105-10-16**] (see pertinent results section). On
[**10-24**], she became slighly hypotensive down to a systolic BP of
80 with diuresis. On [**10-25**] albumin was given and her systolic BP
remained > 100 thereafter.
Pulm: A pigtail CT was placed on admission given her left sided
pneumothorax. It was removed on [**10-18**], with the post-pull chest
xray showing no evidence of pneumothorax. Subsequent chest xrays
showed bibasilar pleural effesions, and aggressive pulmonary
toileting and incentive spirometry were encouraged. A chest xray
on [**10-25**] revealed mild pulmonary edema, and gentle diuresis was
continued with lasix. She was also started on nebulizers as
needed. Her O2 therapy was weaned and her O2 sats remained in
the high 90's on 3L of NC at the time of discharge.
GI: On admission she was kept NPO and given IV fluids for
hydration. On [**10-16**] she was placed on a regular diet. On [**10-18**],
she began to develop nausea. She continued to have intermittent
episodes of nausea/vomiting, and a KUB on [**10-19**] showed evidence
of an ileus. She was given a 1X dose of methylnaltrexone as well
as a dulcolax suppository, and she subsequently had multiple
bowel movements. She subsequently had multiple episodes of
diarrhea, and stool samples were sent for c. diff and she was
empirically started on oral flagyl. She continued to be
intermittently nauseated and a repeat KUB was obtained on [**10-23**]
which showed continued evidence of an ileus with dilation of the
stomach, small, and large bowel. On [**10-25**] she was c. diff
negative x's 3 samples and flagyl was discontinued. On [**10-26**],
she denied any further nausea and vomiting, and was tolerating a
regular diet with no abdominal pain.
GU: U/A on admission was suspicious for a UTI and she was placed
on a 3 day course of oral ciprofloxacin. A repeat U/A [**10-18**] was
normal. A foley catheter was placed for urine output monitoring
on admission. It was removed on [**10-17**], however, she had an
episode of urinary incontinence and retention on [**10-18**] and the
catheter was replaced. Her I&O's were closely followed
throughout her admission. Her baseline Creatinine was 1.5, which
peaked at 1.9 and began to return to normal at 1.6 on
[**2105-10-24**]. Her urine output remained borderline at 20-25
mL/hour, with the return toward baseline kidney function and
adequate PO intake of fluids. She was discharged to rehab on
[**10-16**] with the foley in place for continued urine output
monitoring.
Heme/ID: Her electrolyes were routinely monitored and repleted
as needed. Continued hypocalcemia and hypophosphatemia were
noted at the time of discharge and she was discharged on 3 days
of neutra-phos as well as calcium supplements. Her initially
leukocytosis of 14.9 resolved quickly, and her WBC count
remained within normal limits throughout the remainder of her
hospitalization. Antibiotic courses were notable for cipro and
flagyl as discussed above. Her hgb and hct were routinely
checked and remained stable.
Musk: Orthopedics was consulted for her right distal fibula
fracture. The injury was determined to be nonoperable and she
remained weightbearing as tolerated in an aircast boot on her
RLE. Physical therapy was consulted to evaluated her mobility, a
discharge to an extended care facility when medically stable was
recommended. The patient was encouraged to mobilize out of bed
as tolerated. Follow up was scheduled in the orthopedic clinic
after discharge.
Prophyl: She was started SC heparin for DVT prophylaxis after
removal of the thoracic epidural. Her home dose of protonix was
continued during her hospitalization.
On [**2105-10-26**], Ms. [**Known lastname 32734**] remained afebrile and hemodynamically
stable. She expressed adequate pain control and was tolerating a
regular diet. She was discharged to rehab with plan for coninued
physical therapy, cardiopulmonary assessment, urine output
monitoring, and pain management. Follow up was scheduled with
orthopedics as well as the acute care service.
Medications on Admission:
advair diskus 250-50mcg'',
amytriptyline 25'HS,
amlodipine 5',
cardizem cd 180'
furosemide 60'
labetolol 300'HS
procrit solution [**Numeric Identifier 961**] unit/ml, 1ml subq/week
pantoprozole 40'
simvastatin 80'
Spiriva'
terazosin 5'
vesicare 10'
ezetimibe 10'
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
5. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. labetalol 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. terazosin 5 mg Capsule Sig: One (1) Capsule PO Q 24H (Every
24 Hours).
12. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO Q 24H (Every 24 Hours).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
16. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
17. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
18. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
19. ipratropium bromide 0.02 % Solution Sig: One (1) nib
Inhalation Q6H (every 6 hours) as needed for wheezing.
20. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
21. potassium & sodium phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for
2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
left [**2-15**] rib fractures, right [**3-18**] rib fractures, sternal
fracture, right distal fibular fracture, multiple lacerations,
and a left pnuemothorax
Secondary:
renal artery stenosis
Hypertension
dyslipidemia
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Needs assistance to transfer
Discharge Instructions:
You were admitted to the hospital after you were in a motor
vehicle accident. You sustained left [**2-15**] rib fractures, right
[**3-18**] rib fractures, sternal fracture, right distal fibular
fracture, multiple lacerations, and a collapse in your left
lung. The orthopedic service saw you for your fibula fracture
and recommended the aircast with weight bearing as tolerated
until you follow up with them in clinic in 2 weeks. The acute
pain service also was consulted to make sure you had adeuquate
pain control and placed an epidural. You were then transitioned
to pain medication by mouth after the epidural was removed. You
were requiring some oxygen to maintain appropriate oxygen
saturation levels. This was thought to be due to your rib
fractures and some extra fluid that we gave you diuretics for.
You were initially placed in the ICU for your rib fractures and
were brought to a regular hospital floor 3 days later. At the
time of discharge you had your forehead sutures removed, you
were having bowel movements, and your pain was well controlled.
Please follow up with the providers listed below.
General Instructions for Rib fractures:
You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain.
You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
[**Name10 (NameIs) **] is a complication of rib fractures.?????? In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake.?????? This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.??????
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.??????
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.??????
Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.??????Do not drive a vehicle or drink
alcohol while taking narcotics.
Do NOT smoke
Return to the Emergency Room right away for any acute shortness
of breath, increased pain or crackling sensation around your
ribs (crepitus).
You may bear weight as tolerated on your right leg while wearing
the air cast boot we have given you.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2105-11-10**] at 10:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2105-11-10**] at 10:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2105-11-12**] at 2:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Notes: You will need a chest x-ray prior to this appointment.
Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) 3202**] Radiology 30 minutes prior to your appointment.
Completed by:[**2105-10-26**]
ICD9 Codes: 5119, 4168, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6705
} | Medical Text: Admission Date: [**2190-4-5**] Discharge Date: [**2190-4-17**]
Date of Birth: [**2156-11-23**] Sex: M
Service: MEDICINE
Allergies:
morphine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Infected ICD lead
Major Surgical or Invasive Procedure:
ICD removal and reimplantation
History of Present Illness:
This is a 33 yo male with PMHx of congenital heart defect s/p
ASD repair [**2159**], s/p MV repair [**2174**] and then mechanical MVR
(model number #[**2184-1-18**]),
complicated by complete heart block s/p pacemaker, developed
pacemaker-induced cardiomyopathy, upgraded to biventricular ICD
upgraded in [**2188**], who presents with an infected, eroded, exposed
lead to OSH this AM.
.
He initially noted a small pustule around the [**Year (4 digits) **] pocket 2
weeks ago. At that time, he had no fevers, chills, and denied
pain or drainage from the site. He visited his outpatient
cardiologist, Dr. [**First Name (STitle) **], 3 days prior to admission, and was
started on Keflex. He presented to OSH ED today after he noticed
that exposed leads after the pustule spontaneously drained. He
denied any recent fever (highest temp 99F on Friday), chills,
sweats, or pain or redness at site. Further denies trauma in the
area.
.
He was noted to be afebrile, HR 75 (paced), BP 129/81, satting
99% on RA. Prior to transfer, the patient was started on 1.25mg
vancomycin q12 and Ancef 1g q8. INR at the OSH was noted to be
3.0, with goal INR 2.5 to 3.5. Labs showed glucose of 136, BUN
of 13, creatinine of 0.69, sodium 139, potassium of 3.9,
chloride of 106, bicarb of 26, WBC of 10.4, hemoglobin of 14.3,
hematocrit of 41.5, platelets of 299,000. CXR showed no
subcutaneous air and pacerleads looked intact. He was
transferred to [**Hospital1 18**] on the same day for hardware removal and
reimplantation.
.
On arrival to the floor, patient was afebrile and comfortable,
VS were 98.2, 117/80, 86, 18, 100% RA. He denies chest pain and
shortness of breath.
.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia,
(-)Hypertension
2. CARDIAC HISTORY:
*Premium ASD repair [**2159**]
*MV repair [**2174**]
*H/o Afib
*MVR and Maze in [**1-/2184**] c/b CHB s/p PPM with pacemaker induced
CM s/p *BiV ICD upgrade (EP-Hx: [**2184-2-18**] PPM placement for CHB
post MVR; [**2184-10-29**] Upgrade to BiV ICD afer noted to have CM (EF
45--->17%); [**2188-4-8**], Generator change, RV PPM and Fidelis Lead
extraction)complicated by a hematoma
.
3. OTHER PAST MEDICAL HISTORY:
None
Social History:
Lives with parents. Works at Shaws. Independent of ADLs.
Family History:
Two sisters, both in good health. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory
Physical Exam:
VS- 98.3 101/66 83 20 93%
General- Well appearing, NAD.
Cardio- RRR, nl s1s2, +2/6 systolic murmur
Chest - Surgical dressings CDI, left arm in sling
Resp- CTAB anteriorly, no w/ra/rh, respirations unlabored.
Abd- S/NT/ND, NABS
Ext- No cce, DP 2+ b/l.
Pertinent Results:
[**2190-4-5**] 08:30PM WBC-9.9 RBC-4.90 HGB-14.8 HCT-43.8 MCV-90
MCH-30.2 MCHC-33.8 RDW-13.3
[**2190-4-5**] 08:30PM GLUCOSE-124* UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-30 ANION GAP-10
[**2190-4-5**] 08:30PM CALCIUM-9.9 PHOSPHATE-3.4 MAGNESIUM-2.2
Chem
Admission: [**2190-4-5**] 08:30PM BLOOD Glucose-124* UreaN-11
Creat-0.8 Na-139 K-3.7 Cl-103 HCO3-30 AnGap-10 Calcium-9.9
Phos-3.4 Mg-2.2
.
Coag
[**2190-4-5**] 08:30PM BLOOD PT-22.1* INR(PT)-2.1*
[**2190-4-6**] 07:20AM BLOOD PT-18.2* INR(PT)-1.7*
[**2190-4-7**] 06:45AM BLOOD PT-14.1* PTT-150* INR(PT)-1.3*
.
LFTs:
[**2190-4-6**] 07:20AM BLOOD ALT-36 AST-39 AlkPhos-61 TotBili-0.5
.
Vanc:
[**2190-4-5**] 08:30PM BLOOD [**2190-4-5**] 08:30PM BLOOD Vanco-8.9*
[**2190-4-6**] 05:20PM BLOOD Vanco-5.9*
.
Digoxin
[**2190-4-6**] 07:20AM BLOOD Digoxin-0.6*
.
.
Imaging:
CXR ([**2190-4-5**])
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The lung volumes are normal. Moderate cardiomegaly,
status post
valvular replacement. Pacemaker in situ. No acute changes,
notably no
pulmonary edema, no pneumonia. No pleural effusions. The study
and the report were reviewed by the staff radiologist.
.
TTE ([**2190-4-6**]):
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is an inferobasal left ventricular aneurysm.
Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %) secondary to inferior and posterior
akinesis. The basal inferior and posterior walls are aneurysmal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. A bileaflet mitral valve prosthesis is present.
At least moderate [2+] tricuspid regurgitation is seen. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion. No
valvular or wire-associated vegetation seen.
.
TEE ([**2190-4-8**]):
No mass/thrombus is seen in the left atrium or left atrial
appendage. No mass or thrombus is seen in the right atrium or
right atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is moderate regional
left ventricular systolic dysfunction with akinesis of the mid
anteroseptal wall. There is moderate global left ventricular
hypokinesis (LVEF = 30-35 %).
Right ventricular cavity size is normal with mild global free
wall hypokinesis. There are three aortic valve leaflets. There
is no aortic valve stenosis. Trace aortic regurgitation is seen.
A mechanical mitral valve prosthesis is present. The motion of
the mitral valve prosthetic leaflets appears normal.
Characteristic washing jets are seen. A mild paravalvular mitral
prosthesis leak is probably present.
Moderate to severe [3+] tricuspid regurgitation is seen. The
tricuspid regurgitation jet is eccentric and may be
underestimated. No masses or vegetations are seen on the
tricuspid valve. No masses or vegetations are seen on the
ICD/pacemaker leads in the right atrium and right ventricle.
There is no pericardial effusion.
.
[**2190-4-16**] CXR
Right ICD leads terminate in the right atrium and ventricle.
Again
seen is a tubular structure overlying the left hemithorax that
is presumably external to the patient. Median sternotomy wires,
and surgical clips are noted. The lungs are clear. There is mild
cardiomegaly.
Brief Hospital Course:
Patient is a 33yo M w/ PMHx of congenital heart defect, s/p ASD
repair at age 2, MVR, pacemaker induced cariomyopathy, s/p ICD
placement who presents with an infected, eroded, exposed [**Month/Day/Year **]
lead, s/p hardware removal and reimplantation.
.
ACTIVE PROBLEMS:
# [**Name2 (NI) 19721**] lead infection: Upon presentation, the patient was
afebrile with [**Name2 (NI) **] leads exposed in the left upper aspected of
the chest with no surrounding erythema, palpable fluctuance, or
purulence. The patient was started on IV cefepime and vancomycin
under the guidance of infectious disease consult service. Blood
cultures were drawn daily while the infected [**Name2 (NI) **] and generator
were in place. TTE did not show evidence of valvular vegetations
given the concern of wire-associated endocarditis. The patient
was taken to the operating room [**2190-4-7**] for [**Year (4 digits) **] lead
and generator extraction. Blood cultures remained negative.
Cultures of the pocket grew PROPIONIBACTERIUM ACNES. His [**Year (4 digits) **]
pocket was closed by plastic surgery on [**2190-4-13**] without
complication. He then underwent a pacemaker replacement on his
right anterior chest on [**2190-4-14**] with removal of the temporary
pacing device. He is to continue antibiotic thearpy for 10 days
following his new pacemaker placement, with linezolid and
moxifloxacin.
.
# [**Date Range 19721**]-induced cardiomyopathy: ICD exchanged in [**2188**]. Patient
with an EF of 35%. Followed by an outpatient cardiologist. His
outpatient medications of lisinopril, metoprolol, and digoxin
were initially held due to concern of hypotension. They were
restarted at lower doses, including lisinopril 5mg daily and
metoprolol tartrate 12.5mg [**Hospital1 **]. The patient's digoxin level was
therapeutic when checked during admission.
.
# Status post mechanical MVR: Model number #[**Serial Number **]. Patient's
goal INR 2.5-3.5. The patient was stopped on coumadin in the
setting of intiating antibiotics (anticipate elevated INR) and
started on a heparin drip. Coagulation studies were followed
through the admission, and the heparin drip was adjusted
accordingly. His INR was 2.2 on day of discharge and heparin was
stopped. He was discharged on 7.5mg warfarin daily.
.
TRANSITIONAL ISSUES
- He needs close monitoring of INR due to antibiotic use. He
will have his INR checked at Dr.[**Name (NI) 220**] office on Monday.
- He should followup with device clinic this week for
interrogation and to have stitches removed.
Medications on Admission:
Coumadin 5-7.5mg qday (INR goal 2.5-3.5)
Lisinopril 10mg [**Hospital1 **]
Digoxin 250mcg [**Hospital1 **]
Metoprolol succinate 100mg [**Hospital1 **]
No longer takes ASA
Discharge Medications:
1. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
2. digoxin 250 mcg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
5. metoprolol succinate 25 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. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. [**Hospital1 19721**]-pocket infection
2. s/p ASD repair
3. s/p MVR
4. [**Hospital1 19721**] induced cardiomyopathy
5. sCHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1968**],
It was a pleasure to care for you at [**Doctor First Name **]-[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. You
were transferred to us for a [**Last Name (NamePattern1) **]-pocket infection. You were
treated with antibiotics. You device was replaced. You will be
on the antibiotics for 10 days after implantation.
Please note these medication changes to your medication:
Linezolid 600mg twice daily for 8 more days for infection
Moxifloxicin 400mg daily for 8 more days for infection
Reduce lisinopril to 5mg daily (this can be further discussed
with Dr. [**First Name (STitle) **]
Reduce metoprolol succinate to 25mg daily (this can be further
discussed with Dr. [**First Name (STitle) **]
Followup Instructions:
Name: DREW,[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Location: [**State **]CARDIOLOGY CENTER
Address: [**Location (un) **], [**Apartment Address(1) 77647**], [**Hospital1 **],[**Numeric Identifier 91109**]
Phone: [**0-0-**]
Appointment: Thursday [**2190-4-22**] 10:20am
Department: CARDIAC SERVICES
Please call to make an appointment on Thursday or Friday.
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
Name: NP [**Location (un) 3230**] [**Location (un) 110215**]
Address: 450 VETERANS [**Hospital1 **] PKWY [**Apartment Address(1) **], EAST [**Hospital1 **],[**Numeric Identifier 110216**]
Phone: [**Telephone/Fax (1) 110217**]
Appointment: Friday [**2190-4-23**] 1:00pm
Department: INFECTIOUS DISEASE
When: FRIDAY [**2190-4-30**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SPINE CENTER
When: FRIDAY [**2190-4-30**] at 2:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 39347**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4254, 4271, 4589, 2851, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6706
} | Medical Text: Admission Date: [**2173-4-14**] Discharge Date: [**2173-4-18**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 30062**]
Chief Complaint:
Hypoxia & GI bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 y/o M with PMHx of Dementia, CAD s/p PCI, COPD and recent
ARDS s/p appendectomy who was at [**Hospital **] rehab prior to recent
admission for GI bleed. Pt was discharged on [**4-7**] and was found
this morning to have black guaic positive stools and increased
work of breathing.
.
In the ED, initial vs were: T 100.3 P 100 BP 102/48 R 30 O2 sat
of 100% on NRB. Pt triggered on arrival with diaphoresis and
tachypnea. He was noted to black guaic + stool and concentrated
urine. He was weaned from NRB and had a Tmax of 102 in the ED.
CXR showed worsening in bilateral infiltrates and he was given
Zosyn, Levofloxacin, Protonix and 1L IVF for possible PNA. PIV
was placed and blood was typed/crossed for GI bleed.
.
On arrival to the ICU, pt was oriented to person only and c/o
feeling tired and thirsty. Pt has mild shortness of breath but
denies cough, congestion or significant increased work of
breathing. He denies abd pain, nausea, vomiting, diarrhea,
bloody stools, changes in vision or sore throat but does report
decreased appetite.
Past Medical History:
Severe Dementia
Depression
CAD s/p MI in [**2162**] c/b VF with stenting of the L circ, PCI to R
PDA with DES in [**2169**]
COPD
Recent ARDS s/p appendectomy
Type II DM
Hypertension
Spinal Stenosis
Hyperlipidemia
CDiff
Zoster on rectal area
.
Surgical History
s/p CCY
s/p hernia repair
s/p appendectomy
Social History:
Former smoker approx 30 pack year history, retired post-officer.
Pt was living with wife but has been at rehab since complicated
admission in [**2173-2-8**]
Family History:
His father died of a myocardial infarction at 84. His mother
died of a myocardial infarction at 74. His three brothers, who
died one of a motor vehicle accident and one of leukemia.
Physical Exam:
T 97 HR 95 BP 98/41 RR 29 Sats 95% on 6LNC
General: NAD, comfortable, breathing comfortably with NC O2
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
Neck: no pre-cervical lymphadenopathy
Lungs: Bilateral inspiratory rales, no rhonchi, no congestive
cough
CV: Irreg, mildly tachy, intermittent S4. PMI non-displaced
Abdomen: soft, NT/ND, NABS, no rebound or guarding
Ext: cool hands, warm feet, good distal pulses
Pertinent Results:
[**2173-4-15**] 01:55AM BLOOD WBC-11.2* RBC-3.29* Hgb-10.4* Hct-31.2*
MCV-95 MCH-31.8 MCHC-33.4 RDW-17.2* Plt Ct-340
[**2173-4-14**] 07:15PM BLOOD WBC-11.4* RBC-3.49* Hgb-10.8* Hct-33.0*
MCV-95 MCH-30.9 MCHC-32.7 RDW-17.5* Plt Ct-372
[**2173-4-15**] 01:55AM BLOOD PT-16.1* PTT-28.8 INR(PT)-1.4*
[**2173-4-14**] 07:15PM BLOOD PT-14.8* PTT-28.8 INR(PT)-1.3*
[**2173-4-14**] 07:15PM BLOOD Glucose-166* UreaN-6 Creat-0.6 Na-133
K-3.7 Cl-93* HCO3-31 AnGap-13
[**2173-4-15**] 01:55AM BLOOD Glucose-168* UreaN-6 Creat-0.6 Na-135
K-3.3 Cl-97 HCO3-32 AnGap-9
[**2173-4-15**] 01:55AM BLOOD CK(CPK)-31*
[**2173-4-15**] 01:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2173-4-14**] 07:15PM BLOOD Albumin-2.6*
[**2173-4-15**] 01:55AM BLOOD Calcium-7.5* Phos-1.3* Mg-1.7
[**2173-4-14**] 10:50PM BLOOD Type-ART Temp-37.2 pO2-66* pCO2-45
pH-7.48* calTCO2-34* Base XS-8
[**2173-4-14**] 07:16PM BLOOD Lactate-2.4*
.
CXR [**2173-4-14**]: FINDINGS: AP upright portable chest radiograph is
obtained. As compared with the prior radiograph, there has been
no significant change. Motion artifact somewhat limits
evaluation. Bilateral extensive parenchymal opacities are again
noted, consistent with the provided history of ARDS. There has
been no significant interval change. Small bilateral pleural
effusions cannot be excluded. Heart size is difficult to assess.
No large pneumothorax is present. Bony structures appear intact.
Brief Hospital Course:
# Hypoxic Resp Distress: Pt with poor substrate given recent
ARDS who p/w fever, increased O2 requirement and worsening in
bilateral infiltrates concerning for PNA. Appeared clinically
euvolemic to dry and large A-a gradient on ABG. There was no
evidence of COPD exacerbation or acute CO2 retention.
Oxygenation remained poor despite broad spectrum antibiotics,
patient was unable to be weaned off O2, he remained on 6 L plus
facemask. After discussion with HCP and patient on [**4-15**],
decision was made to transition patient to CMO. IV antibiotics
were continued at the family's request because they wanted to
have some more time to spend with him. Patient passed away on
[**2173-4-18**].
.
# GI bleed: Pt presented with guaiac positive black stools, but
had stable hematocrit at his baseline. He likely has a slow
upper GI bleed. After patient was made CMO, morphine was used
to treat abdominal pain.
Medications on Admission:
Sitagliptin 50mg daily
Vancomycin 250mg po BID
Ipratropium neb q6hrs
Senna prn
Clotrimazole TP
Lasix 20mg IV
Insulin SS
Lactobacillus [**Hospital1 **]
Levalbuterol neb q6hrs
Omeprazole 40mg [**Hospital1 **]
Sertraline 50mg daily
Simvastatin 40mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 0389, 486, 2762, 5990, 496, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6707
} | Medical Text: Admission Date: [**2142-9-27**] Discharge Date: [**2142-10-4**]
Date of Birth: [**2063-3-27**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79F with h/o multiple UTIs c/b urosepsis p/w acute mental status
changes associated with cloudy urine with foul odor. Also noted
to have involuntary muscle twitches. She recently recovered from
an admission to [**Hospital1 **] [**Location (un) 620**] in late [**Month (only) 216**]
where she was diagnosed with a UTI with urine culture showing
VRE/E.Coli/Proteus and treated with linezolid and ertapenem.
In ED: T99.3 134/54 18 94%RA
U/A floridly +; given cefepime
<br>
Patient's family members currently not at bedside, but per
nursing report, her mental status appears to be at baseline
<br>
She currently denies any fevers, chills, cough, shortness of
breath, chest pain, palpiations, abdominal pain, change in
appetite. She does complain of feeling hot all of the time.
Past Medical History:
1. Chronic UTIs: Mulpiple prior admissions with urosepsis
2. Coronary artery disease: MI [**2135**] s/p stent placement
3. Peripheral vascular disease
4. Diabetes mellitus
5. Hypertension
6. Hyperlipidemia
7. Hypothyroidism
8. Anemia
9. Right renal staghorn calculus.
10. Polymyalgia Rheumatica
11. Dyspnea secondary to morbid obesity
12. Rheumatoid arthritis
13. Morbid obesity
14. Bladder diverticulum.
15. History of syncope secondary to poor glycemic control
16. History of C. difficile
17. Cholecystitis s/p cholecystostomy [**7-1**]
18. Status post sigmoidectomy with ileostomy
19. Groin abscess [**2141**] with non-healing wound
Social History:
Pt lives at [**Hospital **] Nursing Home. She is wheelchair-bound
secondary to lower back and lower extremity joint pain. She has
3 children who live locally and are active in her healthcare.
She has never smoked cigarettes.
Family History:
Non-contributory. Sister with [**Name (NI) 10322**] and colon cancer.
Physical Exam:
Physical Exam:
vitals - T 99.1, BP 112/80, HR 73, 95% on 2L.
gen - Obese female, lying flat in bed. Is sleeping but
arousable. A&Ox2; responding appropriately to questions,
speaking comfortably in full sentences
heent - Large neck. Could not assess JVP.
cv - RRR. No murmurs heard but heard sounds were distant.
pulm - Assessed anteriorly and clear.
abd - Soft and very obese. Non-tender. Non-healing wound in
right groin
ext - Warm; no edema; erythema without skin breakdown at site of
previous ulcer
Pertinent Results:
[**2142-9-26**] 10:00PM GLUCOSE-134* UREA N-33* CREAT-1.3* SODIUM-138
POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-31 ANION GAP-12
<br>
[**2142-9-26**] 10:00PM WBC-13.3* RBC-3.93* HGB-12.0 HCT-35.2* MCV-90
MCH-30.5 MCHC-34.0 RDW-16.6*
[**2142-9-26**] 10:00PM NEUTS-80.7* LYMPHS-11.9* MONOS-2.8 EOS-4.5*
BASOS-0.2
<br>
[**2142-9-26**] 10:53PM LACTATE-1.1
<br>
[**2142-9-26**] 10:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2142-9-26**] 10:20PM URINE BLOOD-MOD NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2142-9-26**] 10:20PM URINE RBC-0-2 WBC-[**11-15**]* BACTERIA-MANY
YEAST-NONE EPI-0-2 TRANS EPI-[**2-28**]
Brief Hospital Course:
79 F with known staghorn caliculi, h/o urosepsis, and multidrug
resistant UTIs, presenting from her nursing home with muscle
twitching and ?change in mental status.
.
Staghorn calculus: Pt has a h/o R staghorn calculus. She had a
recent UTI with urine culture showing VRE and she was placed on
linezolid and ertapenem to treat E. coli and proteus and VRE.
She was noted to have cloudy urine x 1 day at her nursing home,
and mental status slightly off baseline. She received a dose of
cefepime in the ED and then the following day was started on
meropenem based on prior urine culture results and
sensitivities. By the morning after admission, the pt felt she
was back to her baseline mental status. A renal ultrasound
showed a continued R staghorn calculus, but no L staghorn
calculus, no hydronephrosis, and no perinephric abscess.
Urology was consulted as the patient had been seen by Dr. [**Last Name (STitle) 3748**]
as an outpatient and he had been planning to treat the staghorn
calculus as an outpatient in [**11-3**], but elected to perform the
procedure while she is hospitalized.
Patient underwent lithotripsy on [**2142-10-1**]. Transferred to [**Hospital Unit Name 153**]
for further management and particularly due to post-procedure
risk of sepsis/DIC. Did extremely well in ICU - hemodynamically
stable with no evidence of active bleeding. Antibiotic coverage
with meropenem. WBC elevated, though febrile and with no
symptoms indicating active infection. Per urology recs on
[**2142-10-2**], removed Foley and started Flomax 0.4mg QHS to help pass
stones.
# Pannus Wound: Pt had ulcerations under left side of pannus.
This wound was recently examined by her [**Last Name (LF) 5059**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**], who
per report saw her several weeks ago at which time he thought
the wound looked alright, and was unlikely to ever heal. At that
time she had a fistula gram which did not clearly demonstrate a
track, rather the contrast terminated in the subcutaneous tissue
adjacent to the abdominal wall
Medications on Admission:
levothyroxine 150mg
ASA 81mg
prednisone 5mg
MVI
Colace
Loratadine
Prilosec
Cymbalta 20mg
Hydroxychloroquine 400mg
gabapentin 600mg tid
artifical tears
Morphine Sulfate 30mg CR
oxycodone 5mg tabs prn
metoprolol 25 mg
Senna
lidoderm patches 5%
lorazepam .5mg prn
albuterol/ipratropium
Humulin 48U qam/12Uqhs
nitro prn
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Urinary Tract Infection with sepsis
Acute Renal Failure
Right staghorn calculi
Non-healing left groin fistula
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a urinary tract infection. You were
treated with antibiotics for this. You also had acute kidney
failure, but this resolved with IV fluids.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2142-10-18**] 10:15
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2142-10-25**] 10:30
Provider: [**Name10 (NameIs) **] RM 1 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2142-10-25**]
11:30
ICD9 Codes: 0389, 5849, 5990, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6708
} | Medical Text: Admission Date: [**2167-7-16**] Discharge Date: [**2167-7-21**]
Date of Birth: [**2091-1-7**] Sex: F
Service: MEDICINE
Allergies:
Peanut
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
History of Present Illness:
76 yo F w/ h/o COPD on home O2 and multiple COPD flares in the
setting of non-compliance some of which required intubation
presents to the ER w/ SOB that has been worsening over the last
2 weeks. The daughter reported to the [**Name (NI) **] physicians that she is
not compliant w/ home O2, meds and is still smoking. Reported no
CP, nausea or vomiting.
In the ED, initial vs were: 98, 89, 133/68, R 30 O2 sat84 on 3L
O2 ->97 on NRB and was in acute resp distress. Initial ABG:
7.25/80/72/37. Patient received Magnesium, 125mg solumedrol,
nebs, ceftriaxone, and azithromycin. Put on bipap, repeat ABG:
7.2/94/457. Intubated and initially put on 500 X 16 with FiO2
100%, peep 7. I/E [**12-1**] and on those settings she had no autopeep
per respiratory and abg was: 7.27/67/398. OG tube in place. ETT
in place per latest XR. On Versed/fentanyl. repeat ABg:
7/27/67/400. Access is peripherals only. On transfer, VS were
98 64 129/83 19 99% on current vent settings: 500X 16 40% FIO2.
On the floor, patient was intubated and sedated on fent/midaz.
An A-line was placed under sterile conditions in the right
radial artery.
Review of systems: unable - intubated/sedated
Past Medical History:
COPD, on O2 at home (2L, recently increased to 4L) followed by
Dr. [**Last Name (STitle) 575**]
allergic rhinitis
Depression
Anxiety
Osteopenia
Tobacco Abuse
Social History:
Pt had been previously estranged from family and now has
re-established contact. [**Name (NI) **]-term and current smoker.
Family History:
NC
Physical Exam:
T: 97.3 BP:116/75 P:72 R: 19 O2: 98% on 470X19, 0.4, 8
General: Intubated/sedated
HEENT: Sclera anicteric, dryMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased breath sounds on the left
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: foley
Ext: warm, well perfused, 2+ pulses, No edema
neuro: sedated
Skin: no breakdown
Pertinent Results:
Labs:
CBC:
[**2167-7-16**] 08:00PM BLOOD WBC-6.4 RBC-5.73* Hgb-19.9*# Hct-58.1*#
MCV-101*# MCH-34.8*# MCHC-34.3 RDW-14.2 Plt Ct-143*#
[**2167-7-18**] 04:47AM BLOOD WBC-10.9# RBC-5.38 Hgb-17.7* Hct-55.5*
MCV-103* MCH-32.9* MCHC-31.9 RDW-14.1 Plt Ct-182
[**2167-7-21**] 05:20AM BLOOD WBC-8.1 RBC-5.60* Hgb-18.4* Hct-56.8*
MCV-101* MCH-32.7* MCHC-32.3 RDW-13.8 Plt Ct-154
Coagulation Studies:
[**2167-7-21**] 05:20AM BLOOD PT-11.3 PTT-32.3 INR(PT)-0.9
Chemistries:
[**2167-7-16**] 08:00PM BLOOD Glucose-183* UreaN-21* Creat-0.9 Na-146*
K-4.4 Cl-104 HCO3-34* AnGap-12
[**2167-7-21**] 05:20AM BLOOD Glucose-166* UreaN-32* Creat-0.8 Na-144
K-3.6 Cl-102 HCO3-35* AnGap-1108/24/10 05:20AM BLOOD Calcium-9.4
Phos-3.1 Mg-2.1
[**2167-7-17**] 03:52AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.2
Liver Function Tests:
[**2167-7-19**] 05:01AM BLOOD ALT-31 AST-19 LD(LDH)-153 AlkPhos-87
TotBili-0.3
Cardiac Enzymes:
[**2167-7-16**] 08:00PM BLOOD cTropnT-<0.01
[**2167-7-17**] 03:52AM BLOOD CK-MB-6 cTropnT-<0.01
ABGs:
[**2167-7-16**] 08:15PM BLOOD Type-ART pO2-72* pCO2-80* pH-7.25*
calTCO2-37* Base XS-4
[**2167-7-20**] 12:48PM BLOOD Type-ART Temp-35.8 FiO2-35 O2 Flow-3
pO2-51* pCO2-46* pH-7.44 calTCO2-32* Base XS-5
Microbiology:
blood, urine, sputum cultures no growth to date.
mrsa swab - negative.
.
CXR ([**7-16**]) -
FINDINGS: The study is limited secondary to positioning. The
patient was
imaged in a lordotic and rotated orientation. Within those
limitations, the lungs are clear without consolidation or edema.
The mediastinum is grossly stable. The cardiac silhouette is
within normal limits for size. No effusion or pneumothorax is
noted. Degenerative changes are noted throughout the mid and
lower thoracic spine.
IMPRESSION: Limited study with no definite acute pathology
identified.
KUB ([**7-19**]) -
INDICATION: Abdominal pain and hypoactive bowel sounds, concern
for ileus or obstruction.
TECHNIQUE: Portable supine and left lateral decubitus
radiographs of the
abdomen.
FINDINGS: Moderate amount of stool is seen in the large bowel
with an
otherwise unremarkable bowel gas pattern. There is no evidence
of
obstruction. There is no free intraperitoneal air seen. There is
no acute
fracture, or bony abnormality.
IMPRESSION: No evidence of ileus or obstruction. Moderate amount
of stool in the colon.
EKG ([**7-16**]) Sinus rhythm. Baseline artifact. Possible biatrial
abnormality.
QS deflections in leads V1-V2. Possible septal myocardial
infarction,
age indeterminate. Compared to the previous tracing of [**2165-10-2**]
artifact is
new. TRACING #1
Rate PR QRS QT/QTc P QRS T
79 150 74 392/425 71 5 55
Brief Hospital Course:
Assessment and Plan: Mrs. [**Known lastname 19376**] is a 76yo F with severe COPD
on 4 L home O2 admitted to the MICU with hypercarbic respiratory
failure.
.
# Hypercarbic respiratory failure: Patient's hypercarbic
respiratory failure was thought to be due to a COPD exacerbation
in the setting of medication non-compliance, resumption of
smoking. She was noted to be hypercarbic on admission on serial
ABGs. She is also likely a chronic retainer of CO2 given the
severity of her COPD and her chronically elevated bicarbonates,
and her serial ABGs demonstrating an underlying chronic
respiratory acidosis. She appeared clinically euvolemic on exam,
so acute heart failure exacerbation was less likely. Her sputum,
blood, and urine cultures showed no evidence of underlying
infection. She was admitted to the MICU, underwent intubation
and mechanical ventilation, received nebulizers with
ipratroprium and albuterol around the clock, IV steroids
(solumedrol). She also initially received Azithromycin and
Ceftriaxone for treatment of possible community acquired
pneumonia -- sputum returned without any growth so antibiotics
were tapered, and she completed 5 days of Azithromycin in the
hospital. She was eventually extubated to BiPAP. Her oxygen was
weanred to nasal cannula, with oxygen saturations between 88-95%
on [**3-3**] L NC. She occasionally desaturates down to 80% when
eating or beig turned, which returns to her baseline oxygen
saturations with repositioning and increased oxygen delivery.
She was weaned to prednisone and was discharged on an oral
prednisone taper. H2 blocker was started for GI prophylaxis and
aspirin was held in setting of steroids -- latter can be
restarted once prednisone taper is stopped. She will need
rehabilitation with focus on pulmonary treatment.
# Smoking cessation: Dicussed with patient, she will stop
smoking. Nicotine patch give in-house.
# Breast mass: Noted on left breast on physical exam. Recent
normal mammogram in [**2165**] with some fibrocystic changes. Would
defer this to outpatient primary care physician.
# Secondary Polycythemia: Elevated Hematocrit chronic, likely
from uncorrected hypoxemia and history of smoking. Would
recommend continued monitoring.
Medications on Admission:
Ocygen 4L NC with exertion and at night
Ketoconazole cream
Advair 250/50 [**Hospital1 **]
Spiriva 1puff daily
ASA 325mg daily
Clonazepam 0.5mg TID PRN
Nicotine patch
ProAir HFA 2 puffs QID PRN
lasix 20mg PO daily
Mucinex 600mg [**Hospital1 **]
Mupiricin ointment
Oxycodone-acetaminophen TID
Colace [**Hospital1 **]
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. Prednisone 20 mg Tablet Sig: 2.5 Tablets PO daily () for 2
days.
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO daily () for 2
days: After 50 mg dose has been given for 2 days.
5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO daily () for
2 days: After 40 mg dose has been given for 2 days.
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 2
days: After 30 mg dose has been given for 2 days.
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 2
days: After 20 mg dose has been given for 2 days.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q4H (every 4 hours).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q4H (every 4 hours) as
needed for wheezing.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation .
13. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Unit/mL Injection Injection TID (3 times a day).
15. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
16. Mupirocin Topical
17. Ketoconazole Topical
18. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis: COPD exacerbation
.
Secondary Diagnoses: Polycythemia, Stable Breast Mass, Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair advancing to Ambulatory with assistance as tolerated
from respiratory standpoint.
Discharge Instructions:
You were admitted to the hospital for a COPD exacerbation. You
were initially intubated and placed on a ventilator to help you
breathe. You were treated with antibiotics, steroids, and
nebulizer treaments. You were successfully extubated and weaned
to oxygen by nasal cannula only.
--------------
The following changes were made to your medications:
You should use Albuterol NEBULIZER and Ipratropium Bromide
NEBULIZER while in rehab instead of ADVAIR, PROAir, and SPIRIVA
INHALERS. You can return to using ADVAIR, PROAir, and SPIRIVA
INHALERS when you return home.
.
You were STARTED on a taper of PREDNISONE that will finish in 10
days.
.
Your Aspirin was HELD until you finish your PREDNISONE taper.
.
You were started on PEPCID (FAMOTIDINE) which you should
continue while you take PREDNISONE.
.
Your PERCOCET (OXYCODONE-ACETAMINOPHEN) was STOPPED as you were
not having any pain.
.
You should STOP SMOKING.
Followup Instructions:
You should follow-up with your PCP regarding your COPD within 1
week. You should continue your outpatient follow-up of your
breast mass.
Completed by:[**2167-7-21**]
ICD9 Codes: 2762, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6709
} | Medical Text: Admission Date: [**2172-5-19**] Discharge Date: [**2172-5-26**]
Date of Birth: [**2172-5-19**] Sex: M
Service: NEONATOLOGY
weighing 2485 gms and admitted to the NICU from L&D for
prematurity and respiratory distress. At the time of
discharge he is 7 days old and corrected age of 35 [**4-14**]
wks.
Mother is a 32 yr old gravida 8 para 1 now 2 with
Pregnancy was complicated by presence of anticardiolipin
antibodies which was treated with levonox. She also had low
platelets and pregnancy induced hypertension. [**Doctor First Name **] had apgars of
8,9.
His initial physical examination was temp of 98.9, HR of 140, RR
of 2485gms (75%), length 46.5 (50%) and head circumference of
limb pulses felt, mild
palpable, anus patent, no hip clicks, pink and well perfused.
Physical assessment at that time was 34 [**4-14**] wk neonate with
respiratory distress to rule out RDS.
HOSPITAL COURSE:
Respiratory: he was initially started on CPAP of 6, but
because of increasing oxygen requirement and distress he was
intubated and given one dose of survanta. After nine hours of
ventilation he spontaneously extubated and was put
back on CPAP. He remained on CPAP until [**5-22**] and then was
weaned to nasal cannula. He was quickly weaned to room air
and has been on room air since [**5-24**]. There has been no
episodes of apnea or bradycardia. Breath sounds are clear
and equal with baseline respiratory rate between 30s and 60s.
Cardiovascular:
A systolic murmur was noted soom after birth, which became softer
and resolved within a few days of life. The infant is pink and
well perfused.
Infectious disease: he was started on Ampicillin and
Gentamycin for 48 hour rule out pending blood cultures. CBC
was benign. Blood cultures revealed no growth. Antibiotics
were discontinued 48 hours later.
Fluid and nutrition: [**Doctor First Name **] was started initially on D10W at 80 cc
per kilogram, which was restricted to 60 cc/ kg on day two,
because of a sodium of 129. Subsequently fluids were increased
and now is on ad lib feeds of Neosure 20 or breast milk 20. His
last set of electrolytes on [**5-23**] were sodium 142, potassium
5.8, chloride 108, total CO2 of 23.
Bili: He was started on phototherapy on [**5-22**] for a bili of 9.8
subsequently bilirubin came down and his phototherapy was
discontinued on [**5-25**] with a bili of 8.1/.3. His rebound
bili on [**5-26**] was 7.5/.2. His highest bilirubin was 12.2/.3
on [**5-23**].
Heme: his initial hematocrit was 43 and platelet count
of 392.
Neurology: no issues.
Others: He has passed hearing screen both ears. He had a car
seat test, which he has passed. He also received his hepatitis B
vaccine. His newborn screen has been sent.
CONDITION ON DISCHARGE:
discharge weight: 2390 gm. Stable, preterm neonate with resolved
RDS now in room air and on ad lib feeds. The pediatrician is Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42720**], phone number is [**Telephone/Fax (1) 42721**].
CARE AND RECOMMENDATIONS: Feeds: he is on ad lib bottle
feeds every three to four hours with Neosure 20 or breast
milk of 20. He is on Fer-In-[**Male First Name (un) **]. Follow up appointment with
pediatrician on Thursday.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. RDS.
3. Rule out sepsis.
4. Indirect hyperbilirubinemia.
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Last Name (STitle) 42130**]
MEDQUIST36
D: [**2172-5-26**] 11:25
T: [**2172-5-26**] 11:37
JOB#: [**Job Number 42722**]
ICD9 Codes: V290, V053, 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6710
} | Medical Text: Admission Date: [**2183-1-5**] Discharge Date: [**2183-1-11**]
Date of Birth: [**2107-1-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization with DES to RCA and POBA to PDA
History of Present Illness:
75 M h/o severe CAD s/p CABG [**2167**], s/p recent complicated
admission ([**Date range (1) 107779**]/07) for NSTEMI with multiple interventions,
presented to ED after calling EMS c/o increased SOB. Patient
reports that he had noticed increased BLE edema over the last
few days PTA. Yesterday, he noted more SOB and diaphoresis. Pt
reported taking SLNTG x3 at home with some relief of these
symptoms. BP 160/80, RR 36, O2sat 91-92% in field per MICU note.
Patient reports being compliant with his medications and denies
any change in diet recently. He did have 1 week of a
nonproductive cough.
In the ED, HR 63, BP 143/77, SaO2 85% RA, increasing to 90-92%
on nonrebreather (no T recorded). Pt refused CPAP, stated that
he would prefer intubation, and was ultimately intubated for
increasing WOB/SOB. Pt then received furosemide 80 mg IV, nitro
gtt, and ASA 300mg PR. TropT 0.03 noted on first set of CE. He
put out only 200mL to the furosemide. He was transferred to the
MICU.
In the MICU, he received diuril 250mg and furosemide 100mg IV
once. To this he has continually put out urine to over 2.5L
negative thus far. He was awake and alert the morning after
admission and was extubated at 9am. Since then, he has not
received any more diuretics, but continues to make urine. He has
been on room air with sats in the 90's. Currently, he complains
of some bilateral leg pain secondary to the swelling. No CP, no
SOB, no n/v, no f/c, no diarrhea or abdominal pain. +sore throat
from intubation.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease
---CABG ([**2167**])
- LIMA-->LAD
- SVG-->RCA
- SVG-->OM
---PCI ([**11/2176**])
- Ostial LIMA-LAD stent --> restenosis and brachytherapy
([**5-/2177**])
- Stenotic LIMA to the LAD stented
- SVG to the PDA (patent)
- SVG to the RCA (occluded)
---PCI ([**1-/2180**])
- SVG-RCA and SVG-OM (occluded)
- LIMA-LAD (patent)
- RCA and r-PDA stented (DES)
---PCI ([**3-/2180**])
- rPDA stented stented (Taxus)
- r-PL balloon rescue
- ostial RCA stented (DES)
---PCI ([**5-/2180**])
- LMCA-LCx stented (DES)
- RCA stented (DES)
---PCI ([**5-/2181**])
- Left subclavian artery stented
- [**Name (NI) 107781**] PTCA
---PCI ([**8-/2182**])
- RPDA POBA
- RCA POBA
---PCI ([**8-/2182**])
- ostial LIMA stented (Cypher DES)
.
2. Congestive heart disease
- Systolic and [**Last Name (LF) 107778**], [**First Name3 (LF) **] 23% ([**9-16**])
3. Valvular disease
- 1+ AR
- 2+ MR
4. Atrial fibrillation
5. Episode of atrial tachycardia ([**2181**])
6. Episode of phase 4 block secondary to PVC ([**9-/2182**])
.
Cardiac Risk Factors:
(+) Diabetes
(+) Dyslipidemia
(+) Hypertension
.
OTHER PAST HISTORY
1. Peripheral [**Year (4 digits) 1106**] disease
- Right CEA ([**7-/2168**])
- Left fem-bk [**Doctor Last Name **] w/ ISSVG ([**8-/2168**])
- Left fem-pt w/ vein ([**12-11**])
- Right CFA-ak [**Doctor Last Name **] w/ NRSVG ([**1-11**])
- Bilateral 5th toe amps ([**1-11**])
- Successful atherectomy of the right anterior tibial and
popliteal
arteries ([**3-14**])
- Successful cryoplasty of the L fem-[**Doctor Last Name **] graft ([**4-13**])
2. Chronic kidney disease
3. Grade II internal hemrohrroids
4. Colonic diverticulosis
5. GERD
6. Acalculous cholecystitis s/p indwelling gallbladder catheter
7. Obstructive lung disease?
8. Low back pain
Social History:
No current tobacco use. 60+ pack-year history. Past heavy
drinker. Lives alone, son lives upstairs from him.
Family History:
No family history of sudden cardiac death or early coronary
artery disease.
Physical Exam:
Physical Exam:
VS: T 97.3, BP 104/54 (99-120/41-58), HR 80 (76-90), O2sat 96%
on RA RR 17. In 1030/Out 3476 net 2446 (LOS negative 2837mL)
Gen: tired appearing male with eyes closed but awakens to answer
questions appropriately
HEENT: NCAT, dry MM, clear OP, PERRL, EOMI, anicteric sclera,
non-injected conjunctiva.
Neck: Elevated JVP to edge of jaw
CV: difficult to hear secondary to upper airway secretions, but
RRR, could not appreciate m/r/g
Chest: clear bilaterally without w/r/r with mild crackles at R
base. Anterior breath sounds obscured with upper airway
secretion noises.
Abd: Soft, NT, ND, BS+.
Ext: 2+ BLE, very dry skin.
Pertinent Results:
[**2183-1-5**] 06:30PM BLOOD WBC-9.0 RBC-3.83* Hgb-10.8* Hct-34.7*
MCV-91 MCH-28.3 MCHC-31.2 RDW-15.6* Plt Ct-217
[**2183-1-7**] 03:05AM BLOOD WBC-4.7 RBC-3.29* Hgb-9.3* Hct-28.5*
MCV-87 MCH-28.3 MCHC-32.6 RDW-15.7* Plt Ct-167
[**2183-1-7**] 10:47AM BLOOD WBC-5.5 RBC-3.50* Hgb-10.1* Hct-30.4*
MCV-87 MCH-28.8 MCHC-33.1 RDW-15.9* Plt Ct-171
[**2183-1-10**] 06:07AM BLOOD WBC-3.6* RBC-3.13* Hgb-8.8* Hct-27.3*
MCV-87 MCH-28.1 MCHC-32.2 RDW-15.5 Plt Ct-164
[**2183-1-11**] 06:23AM BLOOD WBC-3.0* RBC-2.96* Hgb-8.1* Hct-25.8*
MCV-87 MCH-27.4 MCHC-31.4 RDW-15.4 Plt Ct-129*
[**2183-1-11**] 09:14AM BLOOD Hct-31.0*
[**2183-1-5**] 06:30PM BLOOD PT-14.1* PTT-27.1 INR(PT)-1.2*
[**2183-1-6**] 02:14AM BLOOD PT-12.7 PTT-20.7* INR(PT)-1.1
[**2183-1-11**] 06:23AM BLOOD PT-13.1 PTT-31.3 INR(PT)-1.1
[**2183-1-11**] 06:23AM BLOOD Ret Aut-2.1
[**2183-1-5**] 06:30PM BLOOD Fibrino-509*
[**2183-1-11**] 06:23AM BLOOD calTIBC-316 Hapto-207* Ferritn-79 TRF-243
[**2183-1-5**] 06:30PM BLOOD Glucose-207* UreaN-30* Creat-2.5* Na-141
K-5.8* Cl-105 HCO3-20* AnGap-22*
[**2183-1-5**] 09:35PM BLOOD Glucose-192* UreaN-31* Creat-2.5* Na-142
K-4.5 Cl-106 HCO3-22 AnGap-19
[**2183-1-8**] 06:00AM BLOOD Glucose-122* UreaN-44* Creat-2.9* Na-138
K-3.8 Cl-104 HCO3-24 AnGap-14
[**2183-1-11**] 06:23AM BLOOD Glucose-129* UreaN-32* Creat-2.6* Na-142
K-4.1 Cl-101 HCO3-28 AnGap-17
[**2183-1-5**] 06:30PM BLOOD CK(CPK)-146 Amylase-102*
[**2183-1-6**] 02:14AM BLOOD CK(CPK)-188*
[**2183-1-6**] 10:03AM BLOOD CK(CPK)-207*
[**2183-1-6**] 04:02PM BLOOD CK(CPK)-194*
[**2183-1-9**] 05:26AM BLOOD CK(CPK)-89
[**2183-1-11**] 06:23AM BLOOD LD(LDH)-247 TotBili-0.4
[**2183-1-5**] 06:30PM BLOOD CK-MB-4 cTropnT-0.03*
[**2183-1-6**] 02:14AM BLOOD CK-MB-13* MB Indx-6.9* cTropnT-0.20*
proBNP-8368*
[**2183-1-6**] 10:03AM BLOOD CK-MB-11* MB Indx-5.3 cTropnT-0.24*
proBNP-9154*
[**2183-1-7**] 10:47AM BLOOD CK-MB-4 cTropnT-0.21*
[**2183-1-5**] 09:35PM BLOOD Calcium-9.3 Phos-5.4*# Mg-2.3
[**2183-1-6**] 02:14AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.4
[**2183-1-11**] 06:23AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.2 Iron-37*
Notable labs:
143 104 35 133
-------------<
3.6 25 2.6* (elevated from baseline 1.8)
CK: 194 MB: 7 Trop-T: 0.25 *
([**2183-1-6**] 10am: CK: 207 MB: 11 MBI: 5.3 Trop-T: 0.24
[**2183-1-5**] 2am: CK: 188 MB: 13 MBI: 6.9 Trop-T: 0.20)
Ca: 9.3 Mg: 2.1 P: 3.4
proBNP: 9154
WBC 5.5 Hgb 11.5 HCT 34.4 PLT 172 MCV 88
PT: 12.7 PTT: 20.7 INR: 1.1
EKG: Rate 100bpm, rhythm, Axis LAD, RBBB, ST depressions at
V2-V3 new but ST depressions in V4-6 appear chronic.
STUDIES:
[**2183-1-5**] CXR: Cardiomegaly and moderate CHF
[**2183-1-6**]: no more fluid overload. ETT tube in place
.
Echo [**2183-1-6**]:
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is severe global left ventricular hypokinesis with best
preserved motion in the anteroseptum (LVEF = 25 %). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal. with
mild global free wall hypokinesis. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.6 cm2). Mild to
moderate ([**12-11**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is borderline pulmonary artery systolic hypertension. Mild
pulmonic regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2182-9-27**],
regional left ventricular dysfunction now extends to the
anterior and anterolateral walls. The overall ejection fraction
is likely decreased. The severity of aortic regurgitation may
have increased slightly.
[**2183-1-8**] Cardiac Cath:
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA-LAD
3. Stenting of ostial and mid RCA with DES and POBA to ostial
PDA.
[**2183-1-8**] ECG:
Sinus rhythm
Ventricular premature complex
Marked left axis deviation
Left atrial abnormality
RBBB with left anterior fascicular block
Since previous tracing of the same date, no significant change
Brief Hospital Course:
75 year old male with history of CAD s/p CABGx3 and multiple
PCI's, CHF with EF 30%, diastolic and systolic HF, CRI, HTN, now
presenting with SOB likely [**1-11**] CHF. Pt was intubated in ED and
sent to the MICU. He was extubated the following day and
transferred out to the Cardiology floor.
# Respiratory distress: Respiratory distress likely combination
of COPD and CHF, but more CHF given bilateral lower exttremity
edema, CXR finding of fluid overload, and overload on exam
initially. Mr. [**Known lastname 63208**] has a known LVEF of 25% based on ECHO
here. Patient was intubated in the ED and transferred to the
MICU. He was much improved the following day and was extubated
successfully. He was treated with IV Furosemide during this
time. He was transferred to the Cardiology Service and was
placed on a Lasix drip for further diuresis. Given his new
onset worsening left ventricular function, he was sent for
cardiac cath which was significant for 3VD and is now s/p
stenting of ostial and mid RCA with DES and POBA to ostial PDA.
#CHF: Systolic acute on chronic CHF exacerbation as above.
Patient was to continue carvedilol 12.5 mg [**Hospital1 **], isosorbide
dinitrate 20mg TID. Furosemide was incresed to 80mg [**Hospital1 **]
.
#CAD: CABG x 3 in [**2167**] (LIMA-LAD, SVG-OM, SVG-PDA) with only
LIMA-LAD
patent multiple PCI's and multiple stents placed. Patient has
tropopin leak up to 0.25 up from 0.03. This was thought to be
due to demand ischemia as CK levels were not elevated. Patient
was sent for Cardiac Cath as above. He is to continue home
regimen of clopidogrel 75mg daily, ASA 325mg daily, simvastatin
80mg daily, isosorbide dinitrate 20mg TID. Pt started on
Carvedilol 12.5 mg [**Hospital1 **].
# Rhythm: Atrial fibrillation: Pt not anticoagulated [**1-11**] massive
GI bleed; rate controlled only with nondihydropyridine
nifedipine at home. Switched to carvedilol this admission per
cardiology. Patient was monitored for bronchospasm given hx of
COPD. He did not have any adverse reaction and was discharged
on Carvedilol for management of his A-fib and CHF.
# COPD: Pt has known obstructive lung disease [**1-11**] extensive
smoking history. He is to continue on his home Combivent.
.
# CRI: Baseline Cr (1.7-2.2), now elevated to 2.6 and remained
there upon discharge. ACE-I was held and will be restarted by
Dr. [**First Name (STitle) 437**] in clinic if kidney function improves.
.
# HTN: Patient is to continue Carvedilol, Isosorbide dinitrate,
Amlodipine
# Diabetes mellitus: Cont home glipizide
.
# Dyslipidemia: Continued simvastatin 80 daily.
# Phase 4 Paroxysmal AV block: Patient has been seen by Dr.
[**Last Name (STitle) **] regarding ICD/PM placement. This should be follow up
by his PCP.
Medications on Admission:
MEDICATIONS ON ADMISSION: ([**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**2182-12-16**] OMR note):
Nifedipine 60 mg--one tablet by mouth once a day
ASPIRIN 325MG--Take one by mouth every day
Amlodipine 5 mg--one tablet by mouth once a day
CLOPIDOGREL BISULFATE 75MG--One by mouth every day
COMBIVENT 103-18 mcg/Actuation--take 2 puffs three times a day
as needed for wheezing
FUROSEMIDE 20 mg--three tablets by mouth once a day
GLIPIZIDE 5 mg--take 1 tablet(s) by mouth once a day 1 hour
after a meal
ISOSORBIDE DINITRATE 20 mg--one tablet by mouth three times a
day
NITROGLYCERIN 400 MCG (1/150 GR)--Take as directed as needed for
chest pain
PROTONIX 40 mg--take 1 tablet(s) by mouth once a day (20 minutes
before a meal)
ROXICET 5 mg-325 mg--take 1 tablet(s) by mouth four times a day
as needed for pain (twenty-eight day supply)
SIMVASTATIN 80 mg--take 1 tablet(s) by mouth at bedtime
***** Pt does not appear to be on LISINOPRIL per PCP [**2182-12-16**]
note, although he was discharged on lisinopril after his last
hospital admission. *****
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Isosorbide Dinitrate 10 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed.
Disp:*1 tube* Refills:*2*
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day: 1
hour after a meal.
8. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation TID PRN as needed for shortness of breath or
wheezing.
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual q5min PRN as needed for chest pain: one tablet every
5min for a total of 3 doses if needed for chest pain.
11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. Roxicet 5-325 mg Tablet Sig: One (1) Tablet PO QID prn as
needed for pain.
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Systolic Heart Failure Exacerbation
Coronary Artery disease s/p PCI with DES to RCA and POBA to PDA
Secondary:
- Coronary Artery Disease
- Atrial Fibrillation, not anticoagulated due to massive GI
bleed [**2176**]
- PVD with B fem to distal bypass
- Hypertension
- Hypercholesterolemia
- COPD
- DM2
- GERD
- Chronic renal insufficiency baseline 1.5 - 2.0
Discharge Condition:
Stable
Discharge Instructions:
You were admitted into [**Hospital1 69**] for
treatment of your Congestive Heart Failure. You were in severe
respiratory distress on arrival and you were intubated and
placed on a breathing machine for 24 hours. Your heart failure
has been treated successfully with Intravenous Diuretics. An
Ultrasound of the heart was done which showed worsening heart
function. A cardiac catheterization was done to evaluate your
arteries. You had a new occlusion of your right coronary artery
which was opened with a drug eluting stent. A balloon was also
used to open up a second artery.
Please stop taking your Lisinopril for the time being. Your
kidney function has slightly worsened with the diuresis and you
should not take your Lisinopril as it may contribute to
worsening kidney function. Your kidney function will be
reevaluated by Dr. [**First Name (STitle) 437**] at your visit with him.
Your Lasix has been increased from Lasix 60mg daily to Lasix
80mg twice per day.
Please continue with your remaining regular home medications.
Please attend recommended follow up below.
If you experience worsening chest pain, shortness of breath,
palpitations, nausea, vomiting, increased leg swelling,
dizziness, lightheadedness, fainting or any other concerning
symptoms then please call your doctor or report to the nearest
emergency room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please call your new Cardiologist, Dr. [**First Name (STitle) 437**] at [**Telephone/Fax (1) 3512**] to
set up an appointment to be seen on [**2183-1-23**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2183-1-22**] 8:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2183-3-5**] 8:20
ICD9 Codes: 4254, 5849, 5859, 4280, 4439, 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6711
} | Medical Text: Admission Date: [**2172-11-30**] Discharge Date: [**2172-12-5**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
woman status post myocardial infarction [**2172-11-14**] who
returned to the medical center for coronary artery bypass
graft. The patient had presented to an outside medical
center on [**2172-11-14**] with anginal equivalent symptoms
of diaphoresis and increased shortness of breath. She was
evaluated at the medical center and then transferred to the
[**Hospital6 256**] for further management.
The patient was discharged following her initial
hospitalization with plan to return to the [**Hospital6 1760**] for coronary artery bypass
graft on [**2172-11-30**].
PAST MEDICAL HISTORY: Myocardial infarction, congestive
heart failure, hypertension, nephrolithiasis, tuberculosis,
Pott's disease, anemia, coronary artery disease.
PAST SURGICAL HISTORY: Total abdominal hysterectomy/
bilateral salpingo-oophorectomy, left kidney surgeries, right
inguinal hernia repair, laminectomy for spinal infection
(tuberculosis).
ALLERGIES: Intravenous contrast, Morphine, Lasix (? the
patient believes this may have been an adhesive sensitivity).
MEDICATIONS ON ADMISSION: Labetalol 100 b.i.d.; Lipitor 40
q.d., Celebrex 200 q.d., Prilosec 20 b.i.d.; Tegretol 100 mg
q.h.s., Oxycontin 30 mg b.i.d., Lisinopril 5 mg q.d., Ecotrin
one tablet q.d., multivitamin one tablet q.d. Glucosamine
chondroitin one pill q.d.
HOSPITAL COURSE: The patient was admitted to the medical
center on [**2172-11-30**] and taken to surgery where she
had a four vessel bypass with left internal mammary artery
being grafted to the left anterior descending and a saphenous
vein graft to the right PL and also with a vein graft to the
obtuse marginal and diagonal sequentially. The surgery was
performed without complications and the patient thereafter
transferred to the CSRU for continued management. The
patient's stay in the CSRU was relatively uneventful. She
did require frequent chest tube site dressing changes for
some persistent drainage. Her hematocrit remained stable.
It was suspected that one or more of the tubes may have been
clogged with fluid, possibly escaping around the insertion
site. The patient was transferred to the Cardiothoracic
Surgery Floor on postoperative day #1 where she continued to
have persistent drainage from her chest tube sites with
frequent dressing changes required. Her hematocrit continued
to be monitored and remained stable. The patient was without
complaints. Late on postoperative day #1 the patient was
noted to be bradycardiac to the 40s following a dose of
Lopressor. The decision was made to discontinue the
patient's beta blockers and the patient's pacing box was left
in place and set to provide pacing if the patient's heartrate
was to go below 50 permanently. The patient remained alert
and oriented during the periods of bradycardia. After beta
blocker the patient's sinus rhythm stabilized in the 80s to
90s. Physical therapy was initiated but it was found that
the patient had some gait instability. Some of this was
attributable to the patient's known history of spine disease.
The patient was better able to ambulate with a brace which he
used prior to admission. The remainder of the patient's
hospitalization was uneventful. She did develop a rash on
her back which was suspected to be an allergic reaction to
the linen. The patient also had some erythema develop on
both sides of her mouth where tape was used to secure her
endotracheal tube during surgery.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Motrin 400 mg p.o. q. 8 prn
2. Atorvastatin 40 mg p.o. q.d.
3. Carbamazepine 100 mg p.o. q.h.s.
4. Celebrex 200 mg p.o. q.d.
5. Oxycodone sustained release 30 mg p.o. q. 12 hours
6. Dulcolax 10 mg p.r. prn
7. Milk of magnesia 30 ml p.o. q.h.s. prn
8. Percocet one to two tablets p.o. q. 4-6 hours prn
9. Enteric coated Aspirin 325 mg p.o. q.d.
10. Ranitidine 150 mg p.o. b.i.d.
11. Colace 100 mg p.o. b.i.d.
12. Potassium chloride 20 mEq p.o. q. 12 hours times ten days
13. Lasix 20 mg p.o. q. 12 hours times ten days
14. Lisinopril 2.5 mg p.o. q.d.
**The patient's blood pressure medications will need to be
titrated. The patient's Lisinopril was restarted on the day
of discharge.
FO[**Last Name (STitle) 996**]P: The patient is to follow up with Dr. [**Last Name (Prefixes) **]
four weeks following discharge. The patient is also to
follow up with her primary care physician in one to two weeks
following discharge.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2172-12-5**] 08:51
T: [**2172-12-5**] 09:02
JOB#: [**Job Number 44974**]
ICD9 Codes: 4280, 4271, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6712
} | Medical Text: Admission Date: [**2125-9-13**] Discharge Date: [**2125-9-18**]
Date of Birth: [**2055-6-5**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Aspirin
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 y/o lady with h/o recurrent C.diff colitis since [**Month (only) 958**] of
[**2124**] presenting worsening diarrhea. Patient has noticed
increased amount of bowel movements > 10 per day in the last two
days. She has noticed some bright blood and dark colored stool
occasionally. She has a hard time explaining the quality and
quantitiy of stool. Her appetite was very poor and did not eat
in the last two days. Denies nausea/vomitting. She had mild
abdominal pain prior to bowel movement yesterday. She felt very
tired and decided to come to the ED.
.
In the ED, initial vs were: T97.4 P95 BP128/65 R20 O292% sat in
RA. She spiked a temp to 102.4 approx 5 hours after
presentation. Patient recieved 1 gram of tylenol and became
afebrile. She initially recieved 1 L NS. Her SBP dropped to 80s
(per verbal signout) and she was started on peripheral levophed
and additional 2 L NS were given. Patient refused central line.
She had 2 PIV (18G) placed in ED per verbal signout. CXR was
concerning LLL PNA. Patient was also given 1 gram of IV
vancomycin, 500 mg IV flagyl, 750 mg IV levofloxacin and 2 grams
of IV calcium.
.
On the floor, patient was comfortable.
.
Review of sytems:
Denies fevers at home, chills, night sweats, headache,
rhinorrhea or congestion. Denied cough, shortness of breath.
Denied chest pain or tightness, palpitations. Denied arthralgias
or myalgias, new weakness or numbness. Has chronic right
shoulder weakness.
Past Medical History:
- Recurrent C Diff colitis beginning [**1-/2125**], last episode and
hospitalization [**2125-8-1**] to [**2125-8-10**], confirmed colitis on CT and
flex-sig without pseudomembranes and patient refused biopsy, was
treated with a pulse and taper dose of vancomycin (completed on
[**2125-9-2**]), Florastor [**Hospital1 **], and was started on rifaximin 400 mg
[**Hospital1 **] on [**2125-9-3**].
- RUE DVT following PICC Placement in [**2125-7-20**], on coumadin
- Anxiety
- HTN
- CAD s/p NSTEMI in the setting of demand ischemia in [**Month (only) 958**] of
[**2124**]
- s/p ORIF of R wrist in [**1-/2125**]
- Anemia
Social History:
Usually lives alone and is able to do activities of daily living
including driving herself but since her MI in [**Month (only) 958**] she has been
afraid to leave the house and her son has been living with her
to help with activities around the house. She has a neice who
works in the [**Name (NI) 13042**] at [**Hospital1 18**]. Quit tobacco in [**2-5**] but smoked for
50 years [**12-1**] ppd before that. No alcohol or other drug use.
Family History:
One brother with kidney tumor, CHF, OA, obesity. Dad had DM.
Physical Exam:
Vitals: T:97.3 BP:101/44 P:84 R: 18 O2: 96% on 2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 7cm
Lungs: distant BS diffusely, no wheezes, rales, ronchi
Heart: Regular rate and rhythm, normal S1 + S2, I/VI
holosystolic murmur at left lower sternal border
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, no clubbing, cyanosis or edema
Guaic negative in ED
Pertinent Results:
Admission Labs:
[**2125-9-13**] 03:09PM GLUCOSE-109* UREA N-18 CREAT-0.8 SODIUM-134
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-19* ANION GAP-14
[**2125-9-13**] 03:09PM ALT(SGPT)-29 AST(SGOT)-30 LD(LDH)-183 ALK
PHOS-170* TOT BILI-0.4
[**2125-9-13**] 03:09PM GGT-153*
[**2125-9-13**] 08:41AM GLUCOSE-109* UREA N-20 CREAT-0.9 SODIUM-135
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-22 ANION GAP-12
[**2125-9-13**] 08:41AM ALBUMIN-3.1* CALCIUM-7.6* PHOSPHATE-3.5
MAGNESIUM-1.6
[**2125-9-13**] 08:41AM WBC-4.5# RBC-3.04* HGB-9.2* HCT-28.2* MCV-93
MCH-30.1 MCHC-32.4 RDW-14.8
[**2125-9-13**] 04:35AM LACTATE-1.4 K+-5.0
[**2125-9-12**] 11:08PM CALCIUM-9.6 PHOSPHATE-3.4 MAGNESIUM-1.8
[**2125-9-12**] 11:08PM NEUTS-84* BANDS-9* LYMPHS-3* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
.
CT Abd/Pelvis:
IMPRESSIONS:
1. Wall thickening and stranding along the colon from the
splenic flexure
through the sigmoid colon, similar to that seen on [**2125-8-1**].
Findings again
represent nonspecific colitis, possibly ischemic, infectious or
inflammatory
in etiology. No free air, definite abscess, pneumatosis, or
portal gas seen.
2. Left kidney with hyperdense cyst and other subcentimeter
hypodensities.
3. Atherosclerotic disease.
.
Stool cx:
/15/09 1:55 am STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2125-9-17**]**
FECAL CULTURE (Final [**2125-9-14**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2125-9-15**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2125-9-13**]):
REPORTED BY PHONE TO [**Doctor Last Name **] KITCHEN ON [**2125-9-13**] AT 1:10PM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
Brief Hospital Course:
C. difficile colitis/Sepsis: Given history of recurrent C.
difficile colitis, diarrhea, and sepsis, etiology was presumed
to be CDAD, confirmed on stool cx. She was started on PO vanco,
IV flagyl empirically. CT scan demonstrated colitis. Patient
was admitted to the ICU for aggressive IVF, though patient
refused central line. She was briefly on peripheral levophed.
ID and GI were consulted. After adequate resuscitation, she
stabilized clinically and was transferred to the medical floor.
Her diarrhea improved, though her flagyl was stopped after she
developed parasthesias. Reviewing the record, it appeared that
she stopped her previous taper early. Therefore, a more
aggressive taper was pursued, deferring possible fecal
transplantation to the outpatient setting, as well as rifamixin.
.
ARF: Likely pre-renal. Resolved with IVF resusitation
.
h/o DVT: Coumadin was reversed initially. However, once she
stabilized it was restarted with lovenox bridge. She will need
close follow up to ensure her coumadin returns to therapeutic
range 2-3 and was dicharged on warfarin 4mg daily and lovenox
40mg SC q12 to bridge
.
Plexopathy: Continued coumadin
.
HTN, benign: will restart home antihypertensives on discharge
.
Chronic diastolic CHF: was euvolemic on exam. Continued home
medications
Medications on Admission:
Citalopram 40 mg daily
Gabapentin 100 mg TID
Alprazolam 1 mg TID prn
Lisinopril 10 mg daily
Metoprolol Tartrate 12.5 mg [**Hospital1 **]
Pantoprazole 40 mg daily
Oxycodone 5 mg q6h prn pain
Trazodone 50 mg qhs prn
Vitamin D-3 800 units daily
Calcium Carbonate 500 mg (1,250 mg) 2tabs daily
Multivitamin daily
Lidocaine HCl 5 % Ointment topical TID prn rectal pain
Warfarin 6 mg for the first day follwed by 4 mg in the next two
days
Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO as
directed: 125mg 4 times per day through [**2125-9-26**], 14 days, then
125mg 2 times per day through [**2125-10-3**], 7 days, then
125mg 1 time per day through [**2125-10-10**], 7 days, then
125mg every other day through [**2125-10-18**], 8 days, then
125mg every 3rd day through [**2125-11-2**], 15 days.
Disp:*90 Capsule(s)* Refills:*0*
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: please have INR checked 2 days after discharge and adjust
according to your PCP. [**Name10 (NameIs) 18303**] INR [**1-2**].
12. Outpatient [**Name (NI) **] Work
PT/INR on [**2125-9-20**], [**2125-9-22**].
to fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20561**]
Phone: [**Telephone/Fax (1) 26190**]
Fax: [**Telephone/Fax (1) 81080**]
13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous Q12 HR (): subcutaneously until INR 2.
Disp:*10 injection* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
# C-diff colitis, protracted
# Sepsis due to c-diff colitis
# acute exacerbation of diastolic heart failure
# Acute renal failure
# Right brachial plexopathy
# Peripheral neuropathy, new; likely d/t Flagyl
# Anticoagulation on coumadin
Discharge Condition:
stable, diarrhea, improved
Discharge Instructions:
You were admitted with recurrent diarrhea due to your c-diff
infection. Please take your medications as prescribed. It will
be very important to complete the full course of vancomycin,
even if you start feeling better. You will be tapered off this
medication. Please seek medical attention if you develop
worsened diarrhea, abdominal pain, blood in your stools, fevers,
chills, or any other concerns. Also, your coumadin is not in
the desired range. You will need to take Lovenox injections
until your coumadin level is therapeutic.
.
New medication:
Vancomycin, oral:
125mg 4 times per day through [**2125-9-26**], 14 days, then
125mg 2 times per day through [**2125-10-3**], 7 days, then
125mg 1 time per day through [**2125-10-10**], 7 days, then
125mg every other day through [**2125-10-18**], 8 days, then
125mg every 3rd day through [**2125-11-2**], 15 days
.
Lovenox 40mg subcutaneously twice daily until INR is 2.
.
Appointments have been made for you. Please return to the
hospital if you experience fevers/chills, worsening abdominal
pain, lightheadedness, or any other symptoms.
Followup Instructions:
Appointment #1
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20561**]
Specialty: Internal Medicine / PCP
Date and time: Monday, [**10-1**], 1:20pm
Location: One Pearl St, [**Hospital1 1474**] MA
Phone number: [**Telephone/Fax (1) 26190**]
Special instructions if applicable:
.
Appointment #2
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**]
Specialty: Gastroenterology
Date and time: Monday, [**10-15**], 11am
Location: [**Last Name (NamePattern1) **], [**Hospital Ward Name **] Buidling [**Location (un) **], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 463**]
ICD9 Codes: 0389, 5849, 412, 496, 2767, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6713
} | Medical Text: Admission Date: [**2164-12-20**] Discharge Date: [**2164-12-25**]
Date of Birth: [**2084-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Protamine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
DOE/CHF
Major Surgical or Invasive Procedure:
[**2164-12-20**] - Aortic Valve Replacement (19mm St. [**Male First Name (un) 923**] Mechanical
Valve)
History of Present Illness:
The patient is an 80-year-old woman with diabetes and renal
failure who presented with recurrent congestive heart failure.
She was noted to have severe aortic stenosis. Catheterization
showed normal coronary arteries. It was elected to proceed with
aortic valve replacement with mechanical valve.
Past Medical History:
1)History of GIB of unknown cause; numerous diverticula on
C-scope
2) L colectomy with transverse colostomy for GIB (D/C [**11-12**])
3) Diastolic CHF (EF 65-75%)
4) s/p trach placement after prolonged intubation in ICU (at
time
of colectomy)
5) Severe AS ([**Location (un) 109**] 0.7cm2, pk gradient 91mmHg, mean gradient
55mmHg
on [**6-13**] TTE
6) HTN
7) Elevated cholesterol
8) Diabetes type 2
9) CKD - baseline creat 2.5-3
10) Bilat total knee replacment
11) Multiple skin lesions removed by general and plastic surgery
12) Hypothyroid
Social History:
Lives at home with husband, [**Name (NI) **] 3 sons and 1 daughter. Is a
non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager. No h/o IVDU.
Family History:
No colon CA, otherwise unremarkable. Has 3 sons and 1 dtr.
Physical Exam:
63 sr 18 150/61 68" 222lbs
GEN: NAD
SKIN: Unremarkable
HEENT: Unremarkable
NECK: Supple, FROM
LUNGS: CTA
HEART: RRR, Loud SEM, NlS1-S2
ABD: Soft, NT/ND, NABS
EXT: 2+ LE edema, Pulses palp except nonpalp DP.
NEURO: Nonfocal, unsteady gait
Pertinent Results:
[**2164-12-24**] 08:15AM BLOOD WBC-4.5 RBC-3.25* Hgb-10.1* Hct-31.3*
MCV-96 MCH-30.9 MCHC-32.1 RDW-16.3* Plt Ct-183
[**2164-12-20**] 11:06AM BLOOD WBC-9.2# RBC-3.11*# Hgb-9.8*# Hct-29.3*#
MCV-95 MCH-31.4 MCHC-33.2 RDW-17.1* Plt Ct-177
[**2164-12-20**] 11:06AM BLOOD Neuts-62.2 Lymphs-36.5 Monos-0.5* Eos-0.7
Baso-0.1
[**2164-12-25**] 05:42AM BLOOD PT-16.1* PTT-70.5* INR(PT)-1.4*
[**2164-12-24**] 08:15AM BLOOD PT-13.9* PTT-35.5* INR(PT)-1.2*
[**2164-12-23**] 01:10PM BLOOD PT-12.9 INR(PT)-1.1
[**2164-12-22**] 06:38AM BLOOD PT-13.7* PTT-30.9 INR(PT)-1.2*
[**2164-12-20**] 12:12PM BLOOD PT-14.8* PTT-47.3* INR(PT)-1.3*
[**2164-12-20**] 11:06AM BLOOD PT-15.7* PTT-48.0* INR(PT)-1.4*
[**2164-12-24**] 08:15AM BLOOD Glucose-109* UreaN-45* Creat-5.0*# Na-137
K-3.9 Cl-101 HCO3-27 AnGap-13
[**2164-12-20**] 12:12PM BLOOD UreaN-21* Creat-2.9* Cl-105 HCO3-28
[**2164-12-24**] 08:15AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.5
[**2164-12-24**] 09:00AM BLOOD PTH-290*
Cardiology Report ECG Study Date of [**2164-12-24**] 7:58:44 AM
Sinus rhythm. Compared to previous tracing of [**2164-12-20**] no
diagnostic
change.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
79 124 104 422/455 57 20 71
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2164-12-24**] 2:59 PM
CHEST (PORTABLE AP)
Reason: evaluate effusion - in HD please check with RN that pt
on fl
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with s/p avr
REASON FOR THIS EXAMINATION:
evaluate effusion - in HD please check with RN that pt on floor
INDICATION: Followup.
FINDINGS: Comparison to [**2164-12-22**]. The right-sided
sheath in the jugular vein has been removed. All other invasive
and monitoring devices are in unchanged position. The effusions
are small and limited to the very area of the pleural sinuses.
In unchanged manner, the silhouette of the heart is enlarged.
Slight aortic calcification. Subtle signs of fluid overload.
IMPRESSION: Cardiomegaly with signs of fluid overload, unchanged
extent of bilateral pleural effusions.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2164-12-24**] 5:14 PM
RADIOLOGY Preliminary Report
[**Numeric Identifier **] PICC W/O PORT [**2164-12-24**] 12:01 PM
Reason: no IV access
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with s/p AVR w/ chronic renal failure, on HD
REASON FOR THIS EXAMINATION:
no IV access
PICC LINE PLACEMENT
INDICATION: IV access needed for antibiotics.
The procedure was explained to the patient. A timeout was
performed.
RADIOLOGISTS: Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 4686**] performed the
procedure. Dr. [**Last Name (STitle) 4686**], the Attending Radiologist, was present
and supervised the entire procedure.
TECHNIQUE: Using sterile technique and local anesthesia, the
right brachial vein was punctured under direct ultrasound
guidance using a micropuncture set. Hard copies of ultrasound
images were obtained before and immediately after establishing
intravenous access. A peel-away sheath was then placed over a
guidewire and a 5 French double-lumen PICC line measuring 35 cm
in length was then placed through the peel-away sheath with its
tip positioned in the SVC under fluoroscopic guidance. Position
of the catheter was confirmed by a fluoroscopic spot film of the
chest.
The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile
dressing applied.
The patient tolerated the procedure well. There were no
immediate complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French double-lumen PICC line placement via the right brachial
venous approach. Final internal length is 35 cm, with the tip
positioned in SVC. The line is ready to use.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name (STitle) **] [**Name (STitle) **]
PreliminaryApproved: MON [**2164-12-24**] 4:48 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 2995**] [**Hospital1 18**] [**Numeric Identifier 97470**] (Complete)
Done [**2164-12-20**] at 10:14:31 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2084-10-17**]
Age (years): 80 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Aortic valve disease. Congestive heart
failure. Dizziness. Hypertension. Left ventricular function.
Pulmonary hypertension.
ICD-9 Codes: 428.0, 402.90, 786.05, 440.0, 424.1
Test Information
Date/Time: [**2164-12-20**] at 10:14 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 45% to 55% >= 55%
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *40 mm Hg < 20 mm Hg
Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Mildly depressed LVEF.
RIGHT VENTRICLE: RV hypertrophy. Mildly dilated RV cavity.
Borderline normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Simple atheroma in ascending aorta. Normal aortic arch diameter.
Simple atheroma in aortic arch. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. No masses or vegetations on aortic valve.
Moderate-severe AS (area 0.8-1.0cm2). Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Calcified tips of
papillary muscles. Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler.
2. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45-50%).
3. The right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated. Right ventricular systolic
function is borderline normal.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. No masses or vegetations are
seen on the aortic valve. There is moderate to severe aortic
valve stenosis (area 0.8-1.0cm2). Trace aortic regurgitation is
seen. The annulus is heavilyb calcified and measures 19 mm.
6. The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
7. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusions of epinephrine and levophed. Well-seated
mechanical valve in the aortic position. No AI. AS gradient 20
peak, 13 mean at Cardiac Output of 7 L/min. Preserved LV
systolic function on inotropic support. Mild inferior
hypokinesis. LVEF=50%. Flow seen in LMCA and RCA.
Protamine reaction with hypotension and CCO=8-9 L/min. Rx'd epi
boluses. LV SAX shows underfilled LV with good systolic
function. Aorta intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2164-12-20**] 16:50
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2164-12-20**] for surgical
management of her aortic valve disease. She was taken directly
to the operating room where she underwent an aortic valve
replacement using a 19mm St. [**Male First Name (un) 923**] Mechanical valve. Please see
operative note for details. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
she underwent dialysis to remove volume. On postoperative day
two, she awoke neurologically intact and was extubated. Coumadin
was started for anticoagulation. She was later transferred to
the step down unit for further recovery. The physical therapy
service was consulted for assistance with her postoperative
strength and mobility. The renal service continued to follow her
and she continued with hemodialysis as prior to surgery. She was
started on heparin while her INR was subtherapeutic. The heparin
should continue until her INR is 2. She is due for HD Wednesday
[**12-26**].
Medications on Admission:
lasix 100", fluticasone 50', diovan 160", levothyroxine 75',
hydrazaline 50"', Labetolol 400", Procrit [**Numeric Identifier 961**] q mon, protonix
40', simvastatin 20', iron 325'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig:
1000 (1000) units/hr Intravenous ASDIR (AS DIRECTED): goal PTT
60-80
do NOT bolus
discontinue when INR > 2.0 .
4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. PICC line
PICC line care per protocol
7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Warfarin 1 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO DAILY
(Daily) as needed for mech AVR: please dose based on INR result
- goal INR 2.5-3.0 with PT/INR checked daily until off heparin
and then mon/wed/fri for continued dosing .
She has received 3mg coumadin [**12-22**] and [**12-23**] 5mg coumadin
[**12-24**] and [**12-25**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital/Radius
Discharge Diagnosis:
Aortic stenosis s/p avr
s/p Aortic valvuloplasty
CHF (Diastolic dysfunction LVEF 65%
Diabetes mellitus
CRI baseline creatinine 3.0
Hypothyroid
GIB
Obesity
s/p vein stripping
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**First Name (STitle) 437**] after discharge from rehab
Follow-up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] after discharge from rehab
[**Telephone/Fax (1) 608**]
Follow up with Dr [**Last Name (STitle) 4883**] [**Telephone/Fax (1) 20422**]
Please call all providers for appointments.
Scheduled Appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**]
Date/Time:[**2165-3-20**] 10:40
Dialysis - please refer back to [**Location (un) **] [**Location (un) **] when dc from
rehab
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2165-1-3**] 9:20
Completed by:[**2164-12-25**]
ICD9 Codes: 4241, 5856, 4280, 2720, 2449, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6714
} | Medical Text: Admission Date: [**2163-3-3**] Discharge Date: [**2163-3-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
fever, altered metal status
Major Surgical or Invasive Procedure:
Left Internal Jugular Central Line Placement
History of Present Illness:
[**Age over 90 **] y/o M with PMH sig for dementia, bladder CA, h/o chronic C
diff diarrhea, who presents from NH after being found to have
altered mental status. History obtained through family and his
personal nurse. The patient currently a resident at Heathwood NH
and his recent history begins one day prior to admission when he
was found to have pulled out his chronic indwelling foley
catheter. Through the remainder of the day, he had progressive
deterioration in his mental status. In the evening, the pt was
noted to have episodes of emesis and loose stools. His
temperature was checked and was found to be 101.1. In addition,
patient noted to have hematuria. Per ED notes, pt is normally
high functioning, but has had significant change in mental
status over the course of past 24-48 hours.
.
In ED, VS were 101.8, hr of 70, BP 91/30, was 100% on
non-rebreather, lactate 9.4 and WBC 31. Pt was placed on sepsis
protocol, sepsis CVL placed, given levo/vanc/flagyl, decadron
and albumin. Patient received 11 L of fluid, but only had 100 cc
of urine output. U/A showed large LE, 21-50 wbc, >50 rbc. Pt was
initially placed on levophed, but SVO2 remained 50-58%. Pt then
changed to dobutamine, with increase of SVO2 to >70%, dobutamine
then titrated to 1.3 mcg..
Upon arrival to MICU, patient's lactate had improved to 3.5,
temp resolved to 98.9. Pt was still on 1.3 of dobutamine w/ SVO2
in 70's.
.
MICU COURSE:
Pt was admitted to unit with improved lactate and SvO2 of 71%.
The dobutamine was weaned off, but his CVP was [**5-12**] so another
500cc of fluids were administered. His levaquin/vanc/flagyl were
continued, but around midnight his blood cultures came back
positive for gram negative rods so his coverage was broadened to
ceftaz to better cover for pseudomonas/klebsiella.
.
Unable to give meaningfull/reliable history. Per son-in-law,
last week he was much more alert and eating fine. Secretions and
difficulty swallowing, as well
Past Medical History:
1) Bladder CA , last cystoscopy [**6-8**] with no evidence of
recurrence
2) Atonic bladder
3) s/p TURP
4) Chronic C diff since [**6-8**] treated with PO Flagyl and
Vancomycin intermittently since [**6-8**]
5) ? of history of DVT vs. thrombophlebitis, recently on
coumadin
Social History:
Retired plastic surgeon.
Family History:
Noncontributory
Physical Exam:
Gen: awake, responsive but oriented only to person, not place or
year.
VS: T 97 BP: 133/100 HR 65 RR 25 Sat 100% on RA
HEENT: PERRL, sclera anicteric
Neck: no JVD, no carotid bruits, no LAD
Chest: Upper airway secretions audible, coughing, rhonchi b/l
anteriorly, Palpable lymph node in right axilla.
Heart: RRR. Distant heart sounds, no M/G/R
Abd: NABS, soft, NT, ND, no palpable masses
Ext: No edema. DP pulses faint B/L.
Neuro: mild tremor of upper ext. [**4-8**] distal muscle strenth in
LE. 4/5 strength with handgrips.
Pertinent Results:
[**2163-3-3**] 9:40 am BLOOD CULTURE LINE OR SITE NOT NOTED.
**FINAL REPORT [**2163-3-7**]**
AEROBIC BOTTLE (Final [**2163-3-6**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 106616**]
([**2163-3-3**]).
ANAEROBIC BOTTLE (Final [**2163-3-7**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 106616**]
([**2163-3-3**]).
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
[**2163-3-3**] 11:50 am BLOOD CULTURE VENIPUNCTURE #2.
**FINAL REPORT [**2163-3-6**]**
AEROBIC BOTTLE (Final [**2163-3-6**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM
ANAEROBIC BOTTLE.
ANAEROBIC BOTTLE (Final [**2163-3-5**]):
[**2163-3-4**] REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 106617**] AT 1:00 AM.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2163-3-5**] 3:44 pm URINE
**FINAL REPORT [**2163-3-8**]**
URINE CULTURE (Final [**2163-3-8**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. 2ND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 32 S <=16 S
VANCOMYCIN------------ =>32 R <=1 S
[**2163-3-6**] 9:57 am URINE
**FINAL REPORT [**2163-3-9**]**
URINE CULTURE (Final [**2163-3-9**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- <=16 S
VANCOMYCIN------------ =>32 R
[**2163-3-6**] 7:14 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2163-3-8**]**
FECAL CULTURE (Final [**2163-3-8**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2163-3-8**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2163-3-7**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2163-3-9**] 12:07 am STOOL CONSISTENCY: LOOSE Source:
Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Final [**2163-3-11**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2163-3-9**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Brief Hospital Course:
[**Age over 90 **] y/o M w/ history of transitional cell ca, chronic c.diff,
urinary retention with chronic indwelling catheter, had
Urosepsis from E. Coli/Proteus/VRE likely from UTI. The pt's
status continued to decline despite treatment of all of his
medical problems. A family meeting was held, and, based on his
previous expressed wishes prior to illness and his families
desires to avoid further suffering with a baseline poor quality
of life, he was made comfort measures only and expired on
[**2163-3-12**]. His isues during his stay were as follows:
.
1. E. Coli/Proteus Sepsis: Treated originally with Levo based on
culture and sensitivities showing levo sensitive E. Coli.
Changed to Ceftriaxone to cover Proteus and E coli.
.
1b. VRE in UTI: Grew out of UCx. Resistant to
ampicillin/vancomycin. Treated with Linezolid (started [**2163-3-8**]).
Was on VRE precautions.
.
2. h/o C.Diff: Chronic C. Diff carrier. He was on PO vanco and
flagyl at the nursing home. At [**Hospital1 18**], C. diff toxin was negative
x2. He was kept on C. Diff contact precautions.
.
3. ARF: He had a creatinine of 3.8 on admission due to pre renal
azotemia from hypovolemia in the setting of sepsis. He has a h/o
BPH w/ TURP, but Renal U/S showed no evidence of hydronephrosis
or chronic obstruction. He has an indwelling foley catether at
baseline. He responded well to aggressive fluid hydration.
.
4. BPH: H/o in past. Likely reason for his chronic foley in
addition to bladder atonia/h/o turp/bladder Ca. We held his
flomax, proscar as he had a foley in.
.
5. Dementia: He has been off his baseline for 5 years. We held
his outpatient regimen of aricept as he was unable to take PO's.
.
6. Non Gap Hypercholeremia Acidosis: Likely due to aggressive
normal saline hydration. He had hypernatremia which resolved.
.
7. Leukocytosis: Improved from 31 on admission to 11. Likely due
to UTI/Sepsis. Stool studies were negative.
.
8. Anemia: Likely due to bone marrow suppresion from sepsis.
Baseline Hct of 39 on admission. Last Hct 25.
.
9. Thrombocytopenia: Likely Marrow supression from sepsis.
Baseline Plt count of 165. HIT Ab negative. Returned to
baseline.
.
10. Elevated INR: Likely due to poor nutrition and antibiotics.
Given 1 mg SQ vit K with improvenment.
.
11. LFT elevation: Likely due to sepsis. Hep B neg, Hep C neg,
Hep A Ab positive (indicating past exposure to Hep A). Resolved.
.
12. F/E/N: NPO except medications given secretions. Failed
Speech and swallow eval. Unable to place Fluro guided post
pyloric NG tube. Patient would not want PEG or long term
feeding.
.
Code: DNR/DNI
.
Communication: [**First Name4 (NamePattern1) 6480**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 106618**] (h), [**Telephone/Fax (1) 106619**] (c).
Medications on Admission:
Vitamin c 1 tab [**Hospital1 **]
ferrous sulfate 1 tab
aricept 10mg po qd
prilosec 20mg qd
flomax 0.4 mg po qd
proscar 5mg po qd
vancomycin 125mg po bid (x2wks from [**2-16**])
lactobacillus 1 pkt [**Hospital1 **]
remeron 22.5mg hs
coumadin 6.5mg po qd (d/c [**2-13**])
fleets enema PRN
tylenol prn
dulcolax prn
cholestyramine
foley cath check twice qShift
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain for 1 weeks.
Disp:*56 Tablet(s)* Refills:*0*
2. Scopolamine Base 1.5 mg Patch 72HR Sig: Two (2) Patch 72HR
Transdermal every seventy-two (72) hours for 1 months.
Disp:*20 Patch 72HR(s)* Refills:*0*
3. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1H
(every hour) as needed for discomfort, RR> 20.
Disp:*QS mg* Refills:*0*
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for discomfort, RR>20.
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
E. Coli and Proteus Sepsis
Vancomycin Resistant Enterococcal Urinary Tract infection
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2163-3-29**]
ICD9 Codes: 5849, 5990, 2762, 2760, 2875, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6715
} | Medical Text: Admission Date: [**2109-5-24**] Discharge Date: [**2109-6-4**]
Date of Birth: [**2044-4-23**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycodone
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
CVVH with line placed [**2109-5-25**], subsequently removed [**2109-5-28**] with
placement of temporary HD line for initiation of HD
A line placed [**2109-5-25**], subsequently removed
Temporary HD line removed for tunnelled HD line [**2109-6-3**]
History of Present Illness:
65 y/o F with h/o CABG and DM2 presented with fever, malaise,
cough since Monday and severe weakness today. Per husband she
has had chronic DOE with inability to walk for long periods of
time without resting. She has been seen by a cardiologist for
this but not a pulmonologist. On Monday she started having a
cough productive of green sputum without blood. She also had
shaking chills and fevers. Yesterday she started having diffuse
muscle aches and profound weakness as well as diarrhea. Today
she attempted to get out of bed and fell and could not get up so
her husband called 911.
She was brought to the ER at NWH where she told them she also
had not urinated since thursday morning ([**2109-5-23**]). At NWH she
appeared mottled and lips were blue. O2 Sat was 93% on 2L NC.
Because she appeared blue she was placed on NRB. Also originally
SBP 140sand reportedly was borderline hypotensive her lowest
systolic pressure being 105, which responded to fluids (2L NS).
She was also incontinent of stool and had numerous foul smelling
loose BMs. A CXR showed "right paratracheal soft tissue density"
and a repeat CXR showed persistent right soft tissue density and
right apical consolidation. Since she had a markedly elevated
white cell count 20 so she was treated with
CTX/Vanc/Flagyl/Azithro. Labs also revealed acute renal failure,
lactate of 6.6 and a markedly elevated AST. There were no unit
beds there and so she was thransfered here.
.
In the ED, initial vs were: T:100.6 HR:106 BP:96/74 RR:22
O2Sat:88RA. Spiked temp to 102.8, RR was 40. Placed on NRB and
sats up to 100%. On exam guaiac pos brown stool from below. ED
got history that patient had been taking two tabs apap 2Xdaily
for the last week and thought she may have APAP OD so started
NAC per recs from ED physician who is [**Name Initial (PRE) **] tox attending. APAP
level was negative. Received 2.5L in the ED and then noted to be
tachypneic and rhonchorus so was placed on CPAP.
VS prior to transfer to floor: Hr 113 RR 35 Sat 98 BP 128/74
(stable in ED)
.
On the floor, patient was initially tachypneic to 40 with tidal
volumes of 110 on Bipap 10/5. She appeared uncomfortable but was
able to talk to us. She denied chest pain but endorsed severe
muscle aches, worse in her legs that had started yesterday. She
also endorsed severe muscle weakness causing her to crawl on the
floor to get to the bathroom and making it hard for her to get
out of bed. She denied urinary symptoms. Endorsed diarrhea X 1
day. Also endorsed cough productive of green sputum X 1 week. no
hemoptysis.
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations.
Denies nausea, vomiting, constipation, abdominal pain. Denies
dysuria. Denies rashes or skin changes.
Past Medical History:
Diabetes Type 2
CABG [**2095**] (triple bypass)
TTP 30 years ago
breast cancer s/p lumpectomy and XRT on left
Social History:
Works as a secretary for a senior living center. Lives at home
with husband
- [**Name (NI) 1139**]: Quit 25 years ago
- Alcohol: Occasional
- Illicits: None
Family History:
Daughter healthy
Physical Exam:
Vitals: T: 101.2 BP:111/71 P:117 R: 30 O2:90% on Shovel mask
General: Alert, oriented, tachypneic
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles at bases with occasional expiratory wheeze
CV: Tachycardic and regular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
skin: erythematous, non-tender 6cm nodule on right shoulder. No
other rashes.
Neuro: A+OX 3 but repeats herself and per husband not all
history is entirely accurate
Pertinent Results:
Admission labs:
[**2109-5-24**] 06:10PM BLOOD WBC-20.0* RBC-4.25 Hgb-14.1 Hct-42.8
MCV-101* MCH-33.2* MCHC-33.0 RDW-16.6* Plt Ct-227
[**2109-5-24**] 06:10PM BLOOD Neuts-67 Bands-24* Lymphs-5* Monos-3
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2109-5-24**] 06:10PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL
[**2109-5-24**] 06:10PM BLOOD PT-15.0* PTT-26.7 INR(PT)-1.3*
[**2109-5-24**] 06:10PM BLOOD Plt Ct-227
[**2109-5-24**] 06:10PM BLOOD Glucose-86 UreaN-42* Creat-2.3* Na-138
K-4.0 Cl-108 HCO3-13* AnGap-21*
[**2109-5-24**] 06:10PM BLOOD ALT-741* AST-3533* LD(LDH)-4185*
CK(CPK)-[**Numeric Identifier 86085**]* AlkPhos-148* TotBili-2.3*
[**2109-5-24**] 06:10PM BLOOD Lipase-14
[**2109-5-24**] 06:10PM BLOOD cTropnT-1.46*
[**2109-5-24**] 06:10PM BLOOD Albumin-2.6* UricAcd-5.9*
[**2109-5-24**] 10:05PM BLOOD Calcium-6.7* Phos-6.1* Mg-2.1
[**2109-5-24**] 10:05PM BLOOD TSH-1.5
[**2109-5-24**] 06:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2109-5-24**] 06:16PM BLOOD Type-ART Temp-39.3 FiO2-100 pO2-113
pCO2-31* pH-7.33 calTCO2-17* Base XS--8 AADO2-565 REQ O2-94
Intubat-NOT INTUBA Comment-NRB
[**2109-5-24**] 06:16PM BLOOD Glucose-87 Lactate-2.6* Na-135 K-3.4*
Cl-108
[**2109-5-26**] 02:50PM BLOOD O2 Sat-86
[**2109-5-24**] 06:16PM BLOOD freeCa-0.98*
.
.
CXR ([**5-24**]):
1. Thickening of the right paratracheal stripe, can represent
mass or vascular structures. This can be further evaluated by
CT.
2. No evidence of pneumonia or overt pulmonary edema.
.
CXR ([**5-24**]):
1. Widening of the upper right mediastinal contour, incompletely
characterized, and requiring a dedicated chest CT for more
complete assessment when the patient's condition allows.
2. Fluctuating right upper lobe opacity is possibly due to
aspiration or
atelectasis.
3. Small right effusion.
.
CXR ([**5-25**]):
Previously described abnormality in right mediastinal contour is
unchanged and could potentially represent lymphadenopathy.
Slight worsening of opacities in right upper lobe concerning for
pneumonia. New interstitial opacities likely reflect
interstitial edema. Unchanged small right effusion.
.
CXR ([**5-29**]):
Multifocal pneumonia has worsened and mild pulmonary edema has
developed since [**5-27**]. Moderate cardiomegaly increased. Pleural
effusions are small, if any. The previous right upper
paratracheal fullness is no longer evident. I wonder if this
patient has had a gastric pull-up or has an otherwise normal
esophagus to account for the change over such a short interval.
Alternatively, a mediastinal abscess could have drained
internally.
.
TTE ([**2109-5-25**]):
Suboptimal image quality.The left atrium is mildly 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. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded (although
inferior and infero-lateral severe hypokinesis is suggested).
Overall left ventricular systolic function is probably mildly
depressed (LVEF= 40-45 %). The right ventricular cavity is
mildly dilated with depressed free wall contractility. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mitral regurgitation is present but cannot be
quantified. The tricuspid valve leaflets are mildly thickened.
Tricuspid regurgitation is present but cannot be quantified. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
Abdominal US ([**2109-5-25**]):
1. Limited evaluation. Increased hepatic echogencity is
suggested, which is non-specific but may be due to fatty
infiltration. However, more serious forms of liver disease such
as significant cirrhosis/fibrosis cannot be excluded on this
study.
2. Patent portal vein with appropriate direction of flow.
3. Normal-appearing kidneys bilaterally with no evidence of
hydronephrosis.
.
Upper Extremity US ([**5-27**]):
No ultrasound evidence of deep venous thrombosis of the right
upper extremity.
Brief Hospital Course:
Ms. [**Known lastname **] is a 65yo F with h/o CABG, treated BrCA, and HL on
statin admitted with hypoxia, fever and rhabdomyolysis of
unclear etiology.
.
# Hypoxia: The patient was hypoxic on admission in the MICU with
A-a gradient 560. She reported having a cough productive of
green/yellow sputum, and CXR showed evidence of multifocal
pneumonia. She was started initially on Vanc, Flagyl, Cefepime,
Azithro which was switched to Vanc and Levofloxacin [**2109-5-26**] and
then switched to only Cefepime. Pt was initially on face mask
in ICU which was then titrated to NC prior to transfer to the
floor. Pt's respiratory status improved with antibiotics as well
as removal of fluid with CVVH. Of note, nursing did note some
wheezing at night and thought pt might have some element of OSA
as well. The patient was transferred to the floor, and went
into respiratory distress in the setting of atrial fibrillation
with rapid ventricular rate. Her rate was controlled with use of
metoprolol and a one time diltiazem dosing with improvement of
her respiratory status. She underwent ultrafiltration with
dialysis and was weaned on her oxygen. On subsequent transfer
to the floor, the patient was breathing comfortably. She had
one episode of dyspnea on laying down to sleep. EKG was
unchaged and symptoms improved with sitting. She underwent
hemodialysis the following day with improvement of her
respiratory status, and was able to be weaned to room air.
.
# Rhabdomyolysis/Myositis: On admission, pt's CK was 200K. Rheum
was consulted and believed the etiology was [**2-26**] myositis and
noted that lung involvment gives worse prognosis. Suggested
sending viral studies including flu swab and aldolase to check
if its really muscle (send out). They also recommended a non-con
CT scan of the chest to eval the parenchyma for myositis however
pt was not stable enough for this. Aldolase was not sent but
CMV and EBV both returned IgG positive but IgM negative. [**Doctor First Name **]
returned negative. The pt's rhabdomyolysis was believed to be
[**2-26**] myositis +/- contribution of statin (pt had been on
atorvastatin for a long period of time with chronically
elevating doses but not recent dose change). Statin was held
this admission. With CVVH, the pt's CK gradually decreased.
Physical therapy was consulted and saw the patient while
in-house. She was discharged to rehab with PT services.
.
# Strep pneumo bacteremia: 1/4 bottles grew Srep pneumo from OSH
blood cultures ([**5-23**]). Pt was initially covered on vanco and
cefepime. Vanco was d/c'd [**5-27**] and pt remained on cefepime for
coverage at time of transfer out of ICU on [**5-28**]. OSH
sensitivities returned resistant to oxacillin, sensitive to PCN
with MIC 0.094, and sensitive to ceftriaxone with MIC 0.064. The
patient was discharged on a 14 day course of cefepime.
.
# Multifocal pneumonia: The patient presented with a multifocal
pneumonia. Sputum culture did not reveal any organisms. She was
broadly covered with vancomycin, cefepime and
levofloxacin/azithromycin. She was discharged on a 14 day course
of Cefepime.
.
# Liver Disease: Patient had elevated ALT, AST, LDH on admission
which was attributed to myositis/rhabdo and hypotension (shock
liver). APAP level was negative. With treatment and resolution
of the underlying issues, LFTs trended down. The patient also
had an elevated INR and TBili on admission which was more
consistent with a primary liver abnormality. Of note, the pt
did have an abd U/S on [**5-25**] which showed: "Increased hepatic
echogencity, which is non-specific but may be due to fatty
infiltration. However, more serious forms of liver disease such
as significant cirrhosis/fibrosis cannot be excluded on this
study." Hepatitis serologies were sent and showed no exposure to
Hep B or Hep C including no immunity to Hep B from vaccination.
In the end, the pt's LFTs abnormalities were thought [**2-26**] rhabdo
and trended down over the course of admission.
.
# Acute Renal Failure: Pt was anuric on admission, and was found
to be in ATN [**2-26**] rhabdomyolysis. Renal was consulted and placed
a femoral line for CVVH on [**2109-5-25**]. Renal ultrasound [**2109-5-25**]
showed no hydronephrosis and normal-appearing kidneys. She was
transitioned from CVVH to HD on [**2109-5-28**]. The patient's femoral
line was removed and a temporary HD line was placed by IR. The
patient continued to be anuric and a tunnelled HD line was
placed on [**2109-6-3**] with the hope that her renal function would
improve over the next several weeks as an outpatient.
.
# Arrhythmia: Pt had frequent ectopy with PACs and NSVT on
admission. On [**5-27**], she was noted to have A fib with RVR which
improved with fluid removal. She was started on ASA. Given her
CHADS score of 3, she should discuss the initiation of coumadin
for outpt anticoagulation with her PCP or [**Name Initial (PRE) **] cardiologist to
lower her long-term risk. However, she did not have any further
episodes of a fib on telemetry and anti-coagulation was not
initiated in-house given her one episode of afib was in the
setting of fluid overload. Her metoprolol was uptitrated to 50
TID for rate control.
.
# Diarrhea: Per report from OSH, patient had profuse diarrhea at
OSH which had resolved on arrival to [**Hospital1 18**] ICU. She was briefly
on flagyl but this was d/c'd on [**5-26**] when C diff was negative.
.
# Elevated Cardiac Enzymes: Patient did not have chest pain,
but did have dyspnea as described above. CK and Trop were
initially elevated on admission but this was attributed to
severe rhabdomyolysis and ARF. CE's down-trended subsequently.
Of note, TTE on [**5-25**] showed LVEF 40-45% and inferior and
infero-lateral severe hypokinesis. EKG showed no acute ST
changes concerning for ischemia.
.
# DM2: Pt was continued on ISS while hospitalized.
.
# Communication: Patient, husband and daughter, [**Name (NI) 1060**]
C:[**Telephone/Fax (1) 86086**] H:[**Telephone/Fax (1) 86087**]
# Code: Full (discussed with patient and ICU consent signed)
Medications on Admission:
Medications at home:
Ambien 5mg QHS
Lipitor 80mg daily
Norvasc 10mg daily
Diovan 80mg daily
Metoprolol 100mg [**Hospital1 **]
Aspirin 81mg daily
Lasix 20mg daily
Allopurinol 300mg daily
Humulin 40units QAM, 34units QPM,
Humalog 24 units at supper
.
Discharge Medications:
1. Heparin (Porcine) 1,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
2. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob, wheeze.
7. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: Forty (40)
units Subcutaneous qAM: with breakfast.
8. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: Thirty Four
(34) units Subcutaneous qPM: with dinner.
9. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous as directed: please see attached sliding scale.
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: Please taper as tolerated.
Disp:*30 Tablet(s)* Refills:*0*
11. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 5 days: Last dose on [**6-9**].
Disp:*5 Recon Soln(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Rhabdomyolysis
Multifocal Pneumonia
Acute Renal Failure
Secondary Diagnosis:
Diabetes
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 to the hospital with pneumonia, rhabdomyolysis
(breakdown of your muscles), and acute renal failure (kidney
injury). You were treated with antibiotics for your pneumonia.
Blood tests showed your rhabdomyolysis resolved during your
hospital stay. Because of your renal failure, you underwent
hemodialysis and will continue dialysis sessions as an
outpatient.
The following changes to your home medications:
- Cefepime was added for a total 14 day course, last dose on
[**6-9**]
- Pantoprazole was added
- Albuterol nebulizers were added
- Tramadol was added for pain, to be decreased as tolerated and
discontinued when possible
- Metoprolol was switched from 100mg twice daily to 75mg three
times daily
- Humalog 24mg with supper was switched to a Humalog sliding
scale
- Aspirin was increased to 325mg daily
- Amlodipine was stopped
- Valsartan was stopped
- Lasix was stopped
- Allopurinol was stopped; please discuss the possibility of
re-starting this medication with your primary care physician on
[**Name9 (PRE) 702**]
- Atorvastatin was stopped
Followup Instructions:
You will be followed by the Renal team for dialysis at rehab.
You should follow up with a Nephrologist within 1-2 weeks, or as
directed by the Renal team, to monitor your kidney function.
Please follow up with your primary care physician [**Name Initial (PRE) 176**] [**2-27**]
weeks.
ICD9 Codes: 5845, 486, 2762, 4271, 5990, 4280, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6716
} | Medical Text: Unit No: [**Numeric Identifier 71119**]
Admission Date: [**2185-3-9**]
Discharge Date: [**2185-5-12**]
Date of Birth: [**2185-3-9**]
Sex: M
Service: NB
HISTORY: This is a 28-2/7 week gestation twin A delivered
preterm by cesarean section due to progressive preterm labor.
The mother is a 31-year-old primigravida with an estimated
date of confinement of [**2185-5-29**]. Prenatal screens were
as follows: Blood type O positive, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella immune, GBS unknown. The pregnancy was conceived by
IVF, complicated by gestational diabetes, growth discrepancy,
then shortened cervix. She was admitted to [**Hospital1 346**] 1 month prior to delivery, beta
complete. On the morning of delivery the mother was noted to
be 6 cm dilated, and she was therefore delivered by cesarean
section.
No intrapartum antibiotic prophylaxis was given. In the
operating room, the baby had spontaneous cry. He required
brief blow-by oxygen for pallor and mild cyanosis. Heart rate
was always greater than 100. Apgars were 8 and 9. He was
transferred to the Neonatal Intensive Care Unit for further
evaluation and management of prematurity.
PHYSICAL EXAMINATION AT DISCHARGE:
The discharge weight is 2495 grams, about 25th percentile. The
baby is [**Name2 (NI) **] and comfortable in open crib. HEENT: Anterior
fontanelle is open and flat. Mucous membranes moist. No neck
masses. No cleft palate. Red reflex is present bilaterally.
Cardiovascular: Regular rate and rhythm. No murmur heard.
Strong femoral pulses. Respiratory: Breath sounds are clear to
auscultation bilaterally. There are no retractions. Abdomen is
soft, nontender, nondistended. No masses are palpated.
Extremities are [**Name2 (NI) **] and well perfused. He is moving all
extremities equally. Hips are stable. Back is straight with no
[**Hospital1 **] or dimples. GU: Baby is circumcised with improved penile
edema. Bruise at base of penis. Testes are descended. Anus is
patent. Neuro: Patient is active and alert with a strong suck
and grasp. Tone is appropriate for age. Skin is intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: The baby was initially intubated for respiratory
distress. He received Survanta x1. He was weaned to CPAP by
day of life 2. On day of life 27, he was transitioned to nasal
cannula oxygen for about 3 days and then restarted on CPAP on
day of life 31. He remained on CPAP for another 6 days and
then transitioned to room air on day of life 37. He was
initially started on caffeine. That was discontinued on day
of life 52. Following discontinuation of caffeine, he had a
few self resolved quick spells with feedings, last reported on
[**5-2**]. He has had not had any spells in room air since
that time.
Cardiovascular: The baby remained stable throughout
hospitalization.
Fluids, electrolytes and nutrition: The baby was initially
made n.p.o. He was started on trophic feeds on day of life 3
and slowly advanced on feedings. He worked up to full volume
by day of life 7. Calories were gradually increased as
tolerated to a maximum of breast milk 30 calories per ounce
with beneprotein. On [**4-20**], he had bloody stools and a
necrotizing enterocolitis (NEC) evaluation was initiated .
Blood culture, stool culture, clinical exams, and abdominal
xrays were all reassuring. He underwent bowel rest and was
given Zosyn for about 5 days. Breastmilk was restarted
without any further difficulties. He is currently on breast
milk 24 calories per ounce. He has been taking all p.o. feeds
for about 6 days. The length on [**5-9**] was 48 cm (about 50
%ile) and head circumference was 31.5 cm (about 25 %ile).
Gastrointestinal: The baby was on phototherapy for about a
week in the first 10 days of life. It was discontinued on day
of life 11. The maximum total bilirubin was 6 on day of life
9.
Hematology: The baby's initial hematocrit was 40.3. He was
started on ferrous sulfate and vitamin E on day of life 13.
Follow up hematocrit on day of life 30 was 26.2 with a retic
of 4.7. Iron was increased to 6 mg per kilo per day at that
time. Follow-up hematocrit on day of life 43 was 24.6. Repeat
hematocrit on the day of discharge was 25.9 with a retic of
3.9. The baby was never transfused.
Infectious disease: The baby was initially started on
ampicillin and gentamicin which was discontinued after 48
hours of negative blood cultures. The baby underwent another
sepsis evaluation on [**4-20**] for bloody stools and rule out
necrotizing enterocolitis. Please refer to Fluids,
electrolytes and nutrition section for additional details. On
routine surveillance cultures, the baby was found to be
colonized with MRSA. He has been on contact precautions
throughout the remainder of his hospitalization.
Neurology: Head ultrasounds on [**3-17**] and [**4-7**] were
both normal.
Sensory:
1. Audiology: Hearing screening was performed with automated
auditory brainstem responses. The baby passed the hearing
screen prior to discharge.
2. Ophthalmology: Eyes examined most recently on [**2185-5-9**] revealed immaturity of the retinal vessels on the right
side, but no ROP as of yet. The retinal vessels in the left
eye were mature. A follow-up exam is recommended 3 weeks from
the last exam.
Condition at discharge: Stable with good growth.
Discharge disposition: Home
Name of primary pediatrician: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17562**]
Phone [**Telephone/Fax (1) 42639**]
Fax [**Telephone/Fax (1) 71120**]
Care/recommendations:
1. The baby will be discharged home on breastmilk 24 Cal/oz
(with Similac Powder)
2. Medications are ferrous sulfate- concentration 25 mg/ml- 10
mg Q24H (= 0.4 ml or 4mg/kg/day) and multivitamins 1 ml po
Q24H.
3. Iron and Vitamin D supplementation:
- iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age.
- all infants fed predominantly breast milk should receive
vitamin D supplementation at 200 International Units (may be
provided as a multivitamin preparation) daily until 12 months
corrected age.
4. The baby passed his car seat test prior to discharge.
5. The last state newborn screen on [**2185-4-20**] was normal.
6. The baby received his first hepatitis B vaccine on [**2185-4-8**]. His 2 month vaccinations were also given. Pediarix and
HIB were given on [**5-10**] and Prevnar given on [**5-11**].
7. Immunizations recommended:
- Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: 1) born at <32 weeks; 2) born between 32 and 35
weeks with 2 of the following: daycare during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings; 3) chronic lung
disease; or 4) hemodynamically significant CHD.
- 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.
-This infant has not received rotavirus vaccine. The
American Academy of Pediatrics recommends initial vaccination
of preterm infants at or following discharge from the
hospital if they are clinically stable and at least 6 weeks
but fewer than 12 weeks of age.
Follow-up Appointments:
- Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17562**] on Friday [**2185-5-13**]
- Recommended follow-up eye exam on [**2185-5-30**]
- VNA has been scheduled
- referral to early intervention made
Discharge Diagnoses:
- prematurity
- infant of diabetic mother
- respiratory distress syndrome
- apnea of prematurity
- anemia of prematurity
- hyperbilirubinemia
- sepsis evaluation, ruled-out
- necrotizing enterocolitis evaluation, ruled out
- MRSA colonization
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 71121**]
MEDQUIST36
D: [**2185-5-11**] 19:10:42
T: [**2185-5-11**] 19:57:28
Job#: [**Job Number 71122**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6717
} | Medical Text: Admission Date: [**2135-1-9**] Discharge Date: [**2135-1-14**]
Date of Birth: [**2059-1-19**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 41915**] was in her usual
state of health until approximately four days prior to
admission when she began to have upper respiratory symptoms.
On the evening of admission, she apparently fell and hit her
head.
On the day of admission to [**Hospital3 **], she developed
moderate epigastric pain and some pain in her chest. She was
admitted to the hospital and ruled out for a myocardial
infarction. Serum sodium was 116 on her admission. Her
mental status was noted to deteriorate after the admission,
and she was sent to the Intensive Care Unit to correct her
sodium. Sodium increased to 119. She appeared to be come
more alert. A CAT scan was done which showed a suprasellar
mass, and she was transferred to [**Hospital1 190**] for further care.
REVIEW OF SYSTEMS: Headaches for the last week, double
vision in the morning for the last week, nausea, and
occasional chest pain.
PAST MEDICAL HISTORY: Remarkable for GERD, hypertension,
osteoarthritis, type 2 diabetes, and increased cholesterol.
MEDICATIONS ON ADMISSION: Avandia 4 mg twice daily, folic
acid 1 mg twice daily, aspirin 81 mg once daily, Lipitor 10
mg once daily, Protonix 40 mg once daily, niacin 500 mg once
daily, Cardizem CD 240 mg once daily, and Celebrex 200 mg
once daily.
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: She lives with her daughter and husband.
She is not a smoker and drinks no alcohol.
PHYSICAL EXAMINATION ON PRESENTATION: The blood pressure was
127/46, the heart rate was 66, and 100 percent on room air.
She had a hematoma over the right occiput area. Pupils were
pinpoint. She had a goiter on the right side. The lungs
were clear bilaterally. Heart showed a regular rate and
rhythm. Normal S1 and S2. A 2/6 systolic murmur. The
extremities showed no edema. Gastrointestinal examination
showed the abdomen to be soft and nontender. On neurologic
examination, she was awake, alert, and oriented times three.
She followed commands. She was in no acute distress. She
was lightheaded. No diplopia. The pupils were pinpoint.
Extraocular movements were full. The visual fields were
intact. She had slight left droop. Sensation was intact to
light touch. Motor examination showed her to be [**4-7**]
throughout the upper and lower extremities. Unable to elicit
reflexes, and the toes were downgoing. Name and
comprehension were intact.
SUMMARY OF HOSPITAL COURSE: She was admitted to Neurosurgery
and was to have neurologic checks every hour. Her sodium was
to be checked every 4 hours, and she was started on salt
tablets 2 grams three times per day. She was also ordered to
have a MRI with and without contrast. She was also given
Venodyne's, subcutaneous heparin, and Protonix.
She was seen by Dr. [**First Name (STitle) **] who felt that she had a pituitary
adenoma and wanted her evaluated by Endocrine, who did see
the patient, who recommended laboratory work; all of which
was done, and to start her on steroids. She also had formal
visual field testing. She was also seen by Dr. [**First Name (STitle) **] of ENT
who will perform elective surgery with Dr. [**First Name (STitle) **]. The patient
is to undergo a transsphenoidal resection of the pituitary
tumor.
DISCHARGE STATUS: She was discharged to home.
DISCHARGE FOLLOWUP: She is scheduled to follow up with
Endocrine laboratories in one week and then follow up in the
[**Hospital 1800**] Clinic. She will then have
her surgery scheduled electively and will likely be done in
the beginning of [**Month (only) 958**] by both Drs. [**First Name (STitle) **] and [**Name5 (PTitle) **].
CONDITION ON DISCHARGE: The patient was discharged to home
in stable condition.
MEDICATIONS ON DISCHARGE: Folic acid, atorvastatin,
famotidine, niacin, diltiazem, levothyroxine, Bactrim,
ferrous sulfate, sodium chloride, and Percocet.
DISCHARGE DIAGNOSES:
1. Pituitary adenoma.
2. Urinary tract infection.
3. Anemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2135-1-14**] 14:08:52
T: [**2135-1-14**] 17:19:40
Job#: [**Job Number 41916**]
ICD9 Codes: 5990, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6718
} | Medical Text: Admission Date: [**2165-12-23**] Discharge Date: [**2165-12-26**]
Date of Birth: [**2120-9-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Metastatic Melanoma
Major Surgical or Invasive Procedure:
[**2165-12-23**]: Left Craniotomy for Mass Resection
History of Present Illness:
Patient is a 45F with history of metastatic melanoma, and known
metastasis to tbe brain, who presents for elective admission for
left sided cranitotomy.
Past Medical History:
Oncology History:
Metastatic melanoma - resection of a right shoulder lesion with
pathology revealing a 0.47 mm thick, [**Doctor Last Name 10834**] level II melanoma
in 01/[**2159**]. She underwent wide local excision at that time. She
was well until late [**2162**] when she developed a forehead nodule
with eventual biopsy in [**8-/2163**] revealing melanoma.
- PET CT scan revealed uptake in the right frontal bone, a 2 cm
soft tissue mass in the ascending colon and in the right tibia.
- S/p cyber-knife radiation to the skull on [**2163-10-11**] and began
HD IL-2 therapy on [**2163-11-14**].
- S/p XRT to the right tibia completed on [**2164-3-15**].
- [**10-1**] developed frontal HA's and forgetfullness, found to have
right frontal heterogeneously enhancing mass suggestive of a
metastasis. Underwent resection with Dr. [**Last Name (STitle) **] followed by
Cyberknife radiosurgery to the resection cavity from [**2164-11-6**] to
[**2164-11-8**]. The pathology was metastatic melanoma.
[**2164-12-26**] - Curettage and cementing R tibia metastatic lesion.
[**2165-2-19**] - new bony prominence in the right orbital region,
evaluated with MRI that also revealed three new small brain
parenchymal metastases in the left posterotemporal lobe, left
cerebellum, and left inferior frontal lobe.
- PET/CT on [**2165-2-27**] revealed an FDG-avid mass arising from the
stomach wall and an FDG-avid soft tissue area adjacent to the
right ureter
- [**2165-3-6**] C1WK1 Ipilimumab #08-062 (CTLA-4 Ab)
Social History:
She lives with her husband and two children. She lives on the
[**Location (un) **]. She was a teacher. No tobacco. She rarely drinks
alcohol.
Family History:
Mother had pancreatic cancer and diabetes at 63. Her
grandmother's brother died of melanoma and her great grandmother
died of colon cancer.
Physical Exam:
On Discharge:
Alert, oriented to person place and date with some prompting.
PERRL, face is with slight left NL fold flattening. Full
strength in upper and lower extremities. Wound is clean, dry and
intact without reddness, or drainage.
Pertinent Results:
Labs on Admission:
[**2165-12-23**] 05:45PM BLOOD WBC-8.6 RBC-3.91* Hgb-11.0* Hct-33.6*
MCV-86 MCH-28.2 MCHC-32.9 RDW-14.4 Plt Ct-597*
[**2165-12-24**] 01:50AM BLOOD PT-11.9 PTT-24.9 INR(PT)-1.0
[**2165-12-23**] 05:45PM BLOOD Glucose-126* UreaN-14 Creat-0.6 Na-142
K-3.9 Cl-104 HCO3-27 AnGap-15
[**2165-12-23**] 05:45PM BLOOD Calcium-9.5 Phos-2.7 Mg-2.0
Labs on Discharge:
[**2165-12-25**] 04:40AM BLOOD WBC-8.9 RBC-3.77* Hgb-10.7* Hct-33.5*
MCV-89 MCH-28.5 MCHC-32.0 RDW-14.4 Plt Ct-486*
[**2165-12-25**] 04:40AM BLOOD PT-11.6 PTT-26.4 INR(PT)-1.0
[**2165-12-25**] 04:40AM BLOOD Glucose-93 UreaN-11 Creat-0.6 Na-138
K-4.1 Cl-101 HCO3-29 AnGap-12
[**2165-12-25**] 04:40AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.0
Imaging:
Post-op MRI Head:
IMPRESSION:
1. Status post resection of the left parietotemporal lobe
lesion, with post- surgical changes as detailed above. There are
no findings specific for residual or recurrent neoplasm,
although continued followup as the hemorrhage resolves will help
further evaluate this region. There is an increase in the
surrounding edema post surgery.
2. Stable right frontal lobe resection cavity, with areas of
nodular
enhancement and decreased diffusion. The findings may represent
post-
radiation treatment, although continued followup will help
ensure that there is no evidence of residual or recurrent
neoplasm.
3. Stable focus of enhancement in the left cerebellar
hemisphere, without a new focus of abnormal enhancement.
4. Stable right frontal calvarial lesion without interval
change.
5. Mucosal sinus disease, with air-fluid levels and debris in
the maxillary sinuses bilaterally.
Brief Hospital Course:
Patient is a 45F with history of metastatic melanoma, with know
metastasis to the brain. She was admitted to the neurosurgery
service on [**2165-12-23**] for elective left craniotomy for adjunct
treatment. Post-operatively, she was returned to the neuro
intensive care until for close monitoring and surveillance.
After being observed to be stable, she was transferred to the
neuro floor. On POD#2, she also received her planning session
for cyberknife, and was tranported to the [**Hospital Ward Name **], where CK
treatment was carriede out to her cerebellar lesion. She was
seen and evaluated by physical therapy and occupational therapy.
It was determined that she would be appropriate for disposition
to home with services. This was arranged, and she was discharged
on [**2165-12-26**], with appropriate pain medication, with pain in good
control.
Medications on Admission:
Dexamethasone 2mg"',Keppra 500mg",Docusate 100mg",Lovenox
40mg',y
Fexofenadine 60mg", MVI,Pantoprazole 40mg',Ranitidine 150mg"
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*0*
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. 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:*0*
6. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain: for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 19700**] Nursing Association
Discharge Diagnosis:
Metastatic Melanoma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in 10-14days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2166-1-20**]
12:35pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will need an MRI of the brain. This has been scheduled for
you on Date/Time:[**2166-1-20**] 12:35pm. Please call
Phone:[**Telephone/Fax (1) 327**] if you need to change this appointment.
Completed by:[**2165-12-26**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6719
} | Medical Text: Admission Date: [**2178-7-16**] Discharge Date: [**2178-7-30**]
Date of Birth: [**2099-9-16**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
worsening SOB and chest pressure
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
78 M with PMH HTN, hypercholesterolemia, Parkinson's Disease,
CRF (baseline Cr 1.2-1.5), presents with worsening SOB, chest
pressure, N/V, sweating. Pt denied fever, chills or cough. He
notes PND and orthopnea. Recieved Lasix 80IV, and NTG at HebReb
with some relief. No cough, no sputum, no F/C. +PND, +orthopnea,
worsening SOB since discharged from [**Hospital1 18**].
.
Pt was recently discharged 1 wk ago for sepsis secondary to MRSA
aspiration pneumonia (requiring pressors, intubation), stress
dose steroids (adrenal insufficiency). Hospital course
complicated by hypertensive episodes and acute renal failure.
He was treated with and discharged on Vanco/Levo/Flagyl.
.
In the [**Name (NI) **], pt was found to be tachypneic, tachycardic, BP
199/113. Pt was started on NTG drip, given Lasix 80 IV x1, which
improved his SOB. Pt's chest pressure improved on NTG, and he
had good urine output. EKG showed rate 116, 0.[**Street Address(2) 1755**] elevations
in V2-V3 (J point elevation), troponin 2.09.
Past Medical History:
[**Last Name (un) 3562**] disease
Hypertension
Chronic lower back pain
Chronic renal insufficiency (baseline creat 1.2-1.5)
CAD
h/o melanoma s/p resection 20yrs ago
Gerd
BPH
Social History:
Lives at [**Hospital 100**] Rehab with his wife. A former International
Relations professor. independent in most ADLs. Smoked
previously, but quit 45 years ago, had 5 years of 1ppd.
Occasional alcohol at special occasions, dinner. No IVDA.
Family History:
son and daughter have renal cysts
Physical Exam:
Vitals: BP: 160/104 P: 98 RR: 24 Oxygen sat: 96% on RA FS 172
Gen: NAD in bed, not acutely SOB
HEENT: JVD to 10 cm, no LAD
Lungs: Rales in bases bilaterally
Heart: [**1-11**] apical SEM, no r/g
Abd: Distended, +BS, obese, soft, diffusely mildly tender, 3+
hip/sacral edema, scars. Guiaic negative.
Neuro: [**3-10**] motor LUE, [**4-9**] motor RUE, [**2-7**] motor LEs, 3+ lower
extremity edema
Pertinent Results:
CXR [**7-16**]:
1. Moderate congestive failure.
2. Unchanged parenchymal opacities bilaterally within the lower
lobes. These were previously described as aspiration pneumonia.
3. Small bilateral pleural effusions.
.
Echo [**7-10**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. LV systolic function appears depressed however views are
technically suboptimal for assessment of regional wall motion.
Resting regional wall motion abnormalities include mid to distal
septal/anterior, apical and basal inferior hypokinesis
(estimated ejection fraction ?35-40%. No definite apical
thrombus seen but cannot exclude. The aortic valve leaflets (3)
are mildly thickened. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. Compared with the
report of the prior study (tape unavailable for review) of
[**2177-1-16**], left ventricular systolic function is now significant
impaired and mitral regurgitation is now more prominent.
.
Stress MIBI [**7-10**]:
Moderate fixed inferior wall perfusion defect. Transient
ischemic dilatation of the left ventricle. Moderate global
hypokinesis with LV EF of 38%.
.
Cardiac catheterization [**7-10**]:
1. Selective coronary angiography in this right dominant
circulation
demonstrated three vessel disease. The LMCA was very short
versus dual
ostia. The LAD was calcified and diffusely diseased. There was a
50%
proximal stenosis and then a 70% stenosis after the takeoff of
the D1.
The distal LAD had moderate diffuse disease. The D1 had moderate
diffuse
disease proximally. The LCx had a 60% ostial stenosis and then a
serial
70% stenosis in the proximal segment. There was moderate diffuse
disease
in the distal LCx. The OM1 had an 80% stenosis at its origin.
The L-PL
had mild diffuse disease. The RCA was totally occluded which
appeared
chronic. There were moderate left to right collaterals.
2. Resting hemodynamics from right heart catheterization
demonstrated
mildly elevated right and left heart filling pressures
(RVEDP=13mmHg,
mean PCWP=17mmHg). There was moderate pulmonary and systemic
arterial
hypertension (PA=47/17mmHg, Ao=170/67mmHg). The calculated
cardiac
output by the Fick method was 6.4 L/min with a cardiac index of
2.8.
Moderate hypoxemia was noted with an arterial oxygen saturation
of 88%
on 2L O2 by nasal cannula.
3. A cardiothoracic surgery evaluation is recommended. However,
given
that this patient may not be an ideal surgical candidate given
his
comorbidities, a persantine MIBI may be consider. This would
allow
identification of a major area at risk for ischemic which then
can
potentially be intervened upon via PCI.
Brief Hospital Course:
A/P: 78 M with PMH of HTN, hypercholesterolemia, Parkinson's ds,
CRF (with baseline Cr 1.2-1.5), discharged 1 wk ago for MRSA
aspiration pna (requiring pressors, intubation), d/ced on
Vanco/Levo/Flagyl, presented on [**2178-7-16**] with worsening SOB,
chest pressure, N/V, sweating, found to have NSTEMI.
.
1. NSTEMI: Though it was a NSTEMI, his echo shows a large area
of hypokinesis which is new. He was pain free after admission
and his CK trended downward. His cath was initially deferred
secondary to worsened CRI. During this time, he was maintained
on ASA/BB/heparin/statin. He was originally started on a nitro
drip but this was d/c in favor of hydralazine and isordil during
this time period. His ace-i was held secondary to his worsening
renal function but restarted once his kidney function
normalized. As his creatinine improved he was taken to cath
where he was seen to have 3VD. He was evaluated by cardiac
surgery who felt that he was too high risk to intervene on. He
had a stress MIBI showing global hypokinesis with transient
ischemic dilitation suggesting that a focused PCI would not be
effective. It was decided to medically manage the patient.
.
2. SOB: On admission he was volume-overloaded by exam and CXR
and was unable to lie flat for any period of time. This was
also complicated by an infectious picture. He was originally
maintained on a nitroglycerin drip that was titrated off over
his admission and replaced by hydralazine and isordil. Because
of his previous admission for PNA, vancomycin/flagyl/ceftazidime
were continued for a 10d course. His CXR gradually improved and
he began autodiuresing. He was able lie flat and his O2
requirement was weaned. His hydralazine and isordil were
switched to an ace-i prior to d/c.
.
3. Anemia: On admission, the pt had a baseline HCT of 27-33 and
iron studies c/w an anemia of chronic disease. Secondary to his
ischemia, he was transfused x3 units over three days to maintain
his HCT over 30. He remained guaiac negative throughout his
admission and was maintained on GI prophylaxis.
.
4. Tachyarrhythmia: He had an episode of afib on the day after
admission that was self limited and never recurred. He was
maintained on bblocker for rate control throughout his admission
and had no further episodes.
.
5. Hypertension: His hypertension was initially managed with
metoprolol which was titrated up to 75tid but further titration
was limited by HR. He was initially also maintained isordil and
hydralazine but these were switched to lisinopril as his
creatinine normalized. His lisinopril was titrated up to 40qd
on the day of discharge as his SBP was still in the 160s. He
will need continued outpatient management of his blood pressure
meds and will need to have his BP checked at his rehab facility.
.
6. Hypercholesterolemia: He was maintained on a statin
throughout his admission.
.
7. Lower back pain: He received his outpatient oxycodone doses
while hospitalized.
.
8. Parkinson's Disease: He was maintained on carbidopa/levadopa
at home doses.
.
9. GERD: He was fed a cardiac diet and kept on a PPI.
.
10. BPH: He remained on his outpatient meds and had a foley
throughout his stay in the CCU.
.
11. FEN: Lytes were repleted prn.
.
12. CODE: He is a full code
.
Medications on Admission:
aspirin 325
senna 17.2bid
gabapentin 600
zoloft 100
zocor 80
oxycodone 20bid
tamsulosin 0.4
imdur 60
docusate 100bid
toprol 50
lisinopril 20
carbidopa/levodopa 25/100 qid
amlodipine 10
tolterodine 4
prevacid 30
finasteride 5
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
7. 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:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Tolterodine Tartrate 2 mg Tablet Sig: Two (2) Tablet PO QHS
(once a day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
11. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
15. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
16. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
17. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Take 1 tab po qd. #30. Refills: 3
18. Furosemide 20 mg PO DAILY #30. Refills: 3
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
NSTEMI
Discharge Condition:
Stable
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all appointments with physicians as below.
3. Please return to the emergency room if you experience chest
pain, shortness of breath, palpitations.
Followup Instructions:
Primary Care Appointment: [**Name6 (MD) 8741**] [**Name8 (MD) 9529**], MD Where: [**Hospital 273**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-8-12**] 2:30
Cardiologist Appointment: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Where: [**Hospital 273**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2178-9-7**]
2:30
Completed by:[**2178-7-30**]
ICD9 Codes: 4280, 5070, 2762, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6720
} | Medical Text: Admission Date: [**2140-2-1**] Discharge Date: [**2140-2-9**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 89 year old
female with a history of coronary artery disease status post
remote history of MI who presented to [**Hospital3 4527**] in the
a.m. of [**2-1**] with severe substernal chest pain radiating to
her back since [**46**]:00 p.m. the night before. She reported
shortness of breath and orthopnea overnight. She said that
her symptoms were reminiscent of her prior angina several
months ago. At [**Hospital3 4527**] her heart rate was 115,
blood pressure 140/83. EKG showed [**Street Address(2) 4793**] depression in lead
1 and questionable J point elevation in V2 and V3. She also
had [**Street Address(2) 4793**] elevation in lead 3. She was 91 to 92 percent on
4 liters nasal cannula at this time. She received 5 mg of IV
Lopressor, aspirin, Lovenox, Integrilin, nitropaste, Benadryl
25 and prednisone 40. She [**Street Address(2) 4351**] had relief of her pain
with these interventions. Chest x-ray at [**First Name (Titles) 4527**]
[**Last Name (Titles) 4351**] showed no evidence of CHF or infiltrate. She had
a CT of the thorax and abdomen which was negative for
dissection. She was pain free on arrival to [**Hospital1 18**].
In the cath lab at [**Hospital1 18**] she received 20 mg of IV Lasix,
Integrilin and nitroglycerin drip. Cardiac cath revealed
multivessel disease including left main coronary artery with
a mid 60 to 70 percent lesion, LAD with a proximal 70 percent
lesion, 90 percent mid-lesion, 40 percent mid-lesion. Left
circumflex had a 60 percent ostial lesion and 60 to 70
percent mid-lesion. She also had proximal RCA subtotal
occlusion. Her cardiac index was 2.12. Her PA pressures
were 45/27 with a wedge of 33.
PAST MEDICAL HISTORY: Spinal stenosis. Abdominal aortic
aneurysm infra-renal approximately 4 cm. Coronary artery
disease with a distant history of MI in [**2130**].
Hyperlipidemia. Poor balance. Borderline hypertension on no
medications.
SOCIAL HISTORY: The patient reports that her husband died
two weeks ago here in the MICU at [**Hospital1 18**]. She denies any
tobacco or drug use. She reports occasional alcohol use.
FAMILY HISTORY: Noncontributory.
ALLERGIES: Bactrim, codeine, Naprosyn, apples, pears, tuna,
"antibiotics," fish, iodine.
MEDICATIONS: Medications on transfer included Lopressor,
Lovenox, Integrilin drip, aspirin 325, prednisone 40 mg q.d.,
Benadryl, Lipitor, nitroglycerin drip, heparin drip,
Mucomyst. Home medications included B-12, Lipitor at an
unknown dose, aspirin.
PHYSICAL EXAMINATION: On presentation the patient had a
temperature of 95.5, heart rate 91, blood pressure 160/90,
respirations 18, oxygen saturation 96 percent on 100 percent
nonrebreather. In general, she was in no acute distress,
alert and oriented times three. HEENT exam revealed pupils
that were equally round and reactive to light. Extraocular
muscles were intact. Oropharynx was without lesions or
exudate and she had moist mucous membranes. Neck exam
revealed JVP approximately half way to the angle of the jaw.
Lungs were clear anteriorly, however, she was not able to sit
up. Abdomen was soft, nondistended, nontender. There were
good bowel sounds. She had a palpable pulsatile mass in the
mid-abdominal region consistent with abdominal aortic
aneurysm. It was nontender to palpation, but pulsatile.
Stools were OB negative at [**Hospital3 4527**]. Heart was
regular and there was a 2/6 systolic ejection murmur heard
best at the left upper sternal border. She had no gallop or
rubs. Extremities were thin without cyanosis, clubbing or
edema. She had 1 to 2+ dorsalis pedis pulses bilaterally.
LABORATORY DATA: Laboratories at [**Hospital3 4527**]: CBC with
white count 6.5, hematocrit 33.3, platelets 170. Chemistries
revealed sodium 138, potassium 4.7, chloride 103, bicarb 24,
BUN 22, creatinine 1.3, glucose 106. She had an INR of 1.2,
PTT 27. ALT 123, AST 85, t-bili 0.5, lipase 135, amylase 33.
CK 109, MB 8.9, MBI 8.2, troponin 5.2. Cardiac cath results
are as mentioned above. EKG at [**Hospital3 4527**] revealed
sinus tachycardia with a rate of 103 beats per minute. She
had normal axis and normal intervals. She had 1 mm S
elevations/J point elevations in leads V2 and V3. She had
flipped T waves in V5 and V6. She had [**Street Address(2) 4793**] depression in
lead 1. She had [**Street Address(2) 4793**] elevation in lead 3 and a Q wave in
lead 3.
HOSPITAL COURSE:
1. Cardiovascular. In regard to ischemia and CAD, the
patient presented with unstable angina with three vessel
disease by cath with LAD lesion being the likely culprit of
her symptoms. She was given aspirin, heparin, Integrilin and
subsequently started on a beta blocker after her congestive
heart failure improved. She was also started on a statin.
She was initially resistant to the idea of CABG and there was
plan for PTCA of LAD the morning after admission. Serial CKs
and troponins were followed which peaked and then began to
decline. The night of admission she received 2 mg of Haldol
and 0.5 mg of Ativan and subsequently became very lethargic
and somewhat unarousable. Her waxing and [**Doctor Last Name 688**] mental
status delayed her repeat cardiac cath, however, she
subsequently underwent cardiac cath on [**2140-2-5**] which revealed
90 percent mid-LAD lesion with mild proximal OM disease. She
had successful PTCA and stenting of the LAD. Final diagnosis
was three vessel coronary artery disease with successful
stenting of the mid-LAD. As mentioned above, she was
continued on aspirin, a beta blocker, a statin and ACE
inhibitor was held due to elevated creatinine, however, it
was restarted on the day of discharge.
In regard to her pump function, she had evidence of elevated
filling pressures in the cath lab here. She was diuresed
with Lasix overnight the first night of admission to
desaturate her wedge to 15 to 20. She was continued on nitro
drip which was stopped the following morning. She had a
chest film the day after admission which revealed evidence of
congestive heart failure. She had an echo on [**2140-2-1**] which
revealed severe global left ventricular hypertrophy
consistent with multivessel CAD or another diffuse process.
She had mild aortic regurgitation. Her pulmonary artery
systolic pressures were elevated. She had mild mitral
regurgitation. She had an ejection fraction of 20 percent.
She was subsequently diuresed for several days until she
became euvolemic. At this time she experienced an elevation
in her creatinine to 2.2, which was felt to be a combination
of diuresis in the setting of two exposures to contrast. She was
started on lisinopril 2.5 mg q.d. on the day of
discharge.
Rhythm. The patient had no rhythm issues throughout
admission.
2. Renal. As mentioned above, the patient experienced some
renal failure during her admission with peak creatinine of
2.2. It was felt this was most likely secondary to diuresis
in the setting of exposure to dye in someone with a known
iodine allergy. She was premedicated prior to both
catheterizations with Benadryl and steroids as well as
Mucomyst. Her creatinine continued to decline prior to
discharge as she began to auto-diurese. It was felt safe to
start an ACE inhibitor with lisinopril 2.5 mg p.o. q.day on
the day of discharge.
3. Neurologic. As mentioned above, the patient was given
Haldol and Ativan the night of admission for agitation and
combativeness. She was given a very small dose, however, in
the setting of likely renal failure, she became extremely
sedated and unresponsive on these medications. A neurology
consult was obtained and it was felt that her mental status
changes were most likely multifactorial in the setting of
underlying dementia and poor substrate. She had a CAT scan
of her head which was negative. She had TSH which was
slightly elevated with normal free T4. She had normal B-12
and folate. It was not felt necessary to perform an LP,
given her improving mental status and lack of fever and white
cell count. It was felt most likely that her mental status
changes were due to medication effect and sedating meds were
thereon avoided. On the day of discharge she was awake,
alert and oriented times three intermittently with some
waxing and [**Doctor Last Name 688**] confusion.
4. Musculoskeletal. The patient became extremely weak
throughout admission and was seen by physical therapy the day
prior to discharge. It was felt that she would most likely
benefit from subacute rehabilitation.
5. Hypernatremia. It was noted the day before discharge
that the patient was hypernatremic to 152. It was felt that
this was most likely secondary to aggressive diuresis in the
setting of lack of access to free water. Her free water dose
was adjusted and she was replaced with D5W with half of her
deficit being replaced in the first 24 hours. It was also
felt that her hypernatremia was possibly responsible for some
of her mental status changes.
6. Endocrine. In the workup of the patient's mental status
changes, it was noted that she had an elevated TSH with a
normal free T4, possibly reflecting subclinical
hypothyroidism. It was recommended that this be followed up
as an outpatient.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post stent to LAD.
2. Dementia.
3. Hypernatremia.
DISCHARGE MEDICATIONS:
1. Lisinopril 2.5 mg q.d.
2. Toprol XL 100 mg q.d.
3. Plavix 75 mg q.d.
4. Lipitor 10 mg q.d.
5. Aspirin 325 mg q.d.
6. Multivitamin.
CONDITION ON DISCHARGE: At the time of discharge the patient
was with improved spirits, was denying chest pain or
shortness of breath. She was having waxing and [**Doctor Last Name 688**] mental
status changes with intermittently being confused and
disoriented to place. However, she was in good spirits and
felt ready to go to rehab and then subsequently home
following rehab.
FOLLOWUP: The patient will be discharged to [**Hospital **] Rehab
and will require followup with a cardiologist and with her
PCP at the time of discharge.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-426
Dictated By:[**Last Name (NamePattern1) 9820**]
MEDQUIST36
D: [**2140-2-8**] 13:19
T: [**2140-2-8**] 13:32
JOB#: [**Job Number 49863**]
ICD9 Codes: 4280, 2760, 5849, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6721
} | Medical Text: Admission Date: [**2127-2-10**] Discharge Date: [**2127-2-14**]
Date of Birth: [**2088-11-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
38 M with PMH ARDS [**2122**], presents with SSCP x 2 days. SSCP
started suddenly on Sat (time unknown), [**6-16**], pt holds up
clenched fist to describe chest pressure, constant but worse
with exertion, no noticed relief with rest, no association with
food, radiated to back of L shoulder which ached. Pt has had
severe fatigue, sore throat, diffuse myalgias. No
F/C/N/V/diaphoresis, no SOB. SSCP was relieved at 1 am on Sun
AM, and pt slept to see if CP would resolve by Sun morning. Pt
woke up on Sun AM and still had SSCP. He went to [**Hospital 47**]
Hospital, where he was found to have STE in anterolateral leads,
NSR 92. Pt was placed on ASA, heparin, integrilin, and was
taken to emergent cath.
.
At cath, pt was found to have 100% proximal LAD occlusion, RCA
generally patent, LCX generally patent. Was able to pass wire
down LAD, but LAD took a sharp U-turn anteriorly, and had no
flow in LAD on contrast injection. Stented mid-LAD, with
minimal flow to LAD. Wire was maneuvered more distally into LAD
and contrast injection showed perforation into distal LAD, with
contrast flowing into ventricle (likely LV). Perforation
appeared to be into the ventricle, not into the pericardium.
Balloon was inflated for relatively prolonged periods at 2 sites
near perforation, which was successful in diminishing contrast
leakage from LAD. Pt was airlifted to [**Hospital1 18**], hemodynamically
stable with HR 80s, BP 110-120s, for further management of LAD
perforation.
Past Medical History:
Was hospitalized for 2.5 mo with intubation at [**Hospital3 **]
for ARDS and a "mold lung infection" in [**2122**], was in coma for 1
month. Otherwise has never been hospitalized.
Hypercholesterolemia
Social History:
Used to be heavy EtOH user but last drink few mo ago. 23 pky
smoking hx per one person's history, 46 pky smoking hx per
another person's history. +marijuana use, last 1.5 weeks ago,
never tried cocaine, heroin. Lives with father and stepmother.
Family History:
Father had MI at 52, quintuple bypass at 66.
Physical Exam:
97.0 / 101/68 / 94 / 16-24 / 100% 2.5L nc
Gen: Sleepy in bed
HEENT: JVD difficult to assess, no LAD, dry mm
Lungs: Rales diffuse bl
Heart: [**2-10**] holosystolic blowing murmur heard best at apex, no
r/g, regular, tachy
Abdomen: Soft, ND, NT, +BS, mildly obese
Extr: No c/c/e, 2+ DP bilaterally, minimal bleeding
Neuro: [**4-11**] motor in UE, sensation equal and intact bl
Skin: No ecchymoses, no rash
Pertinent Results:
EKG: STE in anteroseptal leads
.
CXR: Swan ends in PA, mediastinum little wide, focal indentation
in trachea around L clavicle area (narrowed trachea 15-20%
likely from intubation)
.
Echo:
Conclusions:
The left atrium is elongated. The left ventricular cavity size
is normal. LV systolic function appears moderately to severely
depressed. Resting regional wall motion abnormalities include
anteroseptal hypokinesis/akinesis, mid to distal anterior
akinesis, apical akinesis/dyskinesis. No definite apical
thrombus seen but cannot exclude. Right ventricular chamber size
is normal. There is focal hypokinesis of the apical free wall of
the right ventricle. The aortic root is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no regurgitation. There is no aortic valve
stenosis. The mitral valve leaflets are structurally normal.
Mild (1+) mitral regurgitation is seen. There is a small
pericardial effusion.
There are no echocardiographic signs of tamponade.
.
Cath at OSH:
Proximal 100% LAD occlusion, poor flow upon opening LAD, LAD
Class III perforation with extravasation of contrast into RV.
RCA and LCX are patent.
.
[**2127-2-10**] 11:36PM CK(CPK)-137
[**2127-2-10**] 11:36PM CK-MB-13* MB INDX-9.5* cTropnT-2.07*
[**2127-2-10**] 12:09PM CK(CPK)-142
[**2127-2-10**] 12:09PM CK-MB-17* MB INDX-12.0* cTropnT-2.03*
[**2127-2-10**] 12:09PM HCT-35.1*
[**2127-2-10**] 09:30AM ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG
[**2127-2-10**] 09:30AM URINE HOURS-RANDOM
[**2127-2-10**] 09:30AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2127-2-10**] 09:23AM HCT-33.8*
[**2127-2-10**] 06:19AM O2 SAT-71
[**2127-2-10**] 05:06AM TYPE-ART PO2-136* PCO2-35 PH-7.35 TOTAL
CO2-20* BASE XS--5
[**2127-2-10**] 05:06AM O2 SAT-97
[**2127-2-10**] 05:06AM freeCa-1.06*
[**2127-2-10**] 04:42AM GLUCOSE-98 UREA N-20 CREAT-1.0 SODIUM-136
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-19* ANION GAP-16
[**2127-2-10**] 04:42AM CK(CPK)-127
[**2127-2-10**] 04:42AM CK-MB-12* MB INDX-9.4* cTropnT-2.25*
[**2127-2-10**] 04:42AM CALCIUM-7.2* PHOSPHATE-4.8* MAGNESIUM-1.6
[**2127-2-10**] 04:42AM WBC-13.7* RBC-3.90* HGB-11.7* HCT-34.4*
MCV-88 MCH-30.1 MCHC-34.0 RDW-12.5
[**2127-2-10**] 04:42AM PLT COUNT-204
[**2127-2-10**] 04:42AM PT-14.1* PTT-38.9* INR(PT)-1.2*
Brief Hospital Course:
38 M with PMH ARDS [**2122**], presents with STEMI and perforated LAD
post-stenting, with partial revascularization.
.
# Cardiac:
Ischemia: Subacute anteroseptal STEMI upon presentation, likely
3-5 days old. Proximal 100% LAD occlusion with mid-LAD stent,
but LAD flow was not restored, LAD territory likely unable to be
recovered. LAD was perforated during procedure. Post-cath, hemos
were CO: 5.9, Index: 2.76, Wedge 17, PAP 28/15. On ASA, plavix,
statin, ACE, BB. Will follow up for repeat TTE to assess EF for
possible ICD in 1 month.
.
Pump: EF 30% on TTE after STEMI, wedge 21-22, severe
anteroseptal and inferior hypokinesis, small anterior
pericardial effusion. Pt was discharged on coumadin for 1 month
for large anteroseptal infarct with apical hypokinesis. He needs
INR checks for goal INR 2.0-3.0, and was discharged on lovenox
for bridge to coumadin. Immediately post-cath, patient had a
murmur on exam, but after 24 hrs, pt did not have a murmur for
the remainder of admission.
.
Rhythm: Pt was in NSR on tele.
.
# Class III LAD perforation:
LAD was perforated into LV at the location of distal LAD. LAD
perforation complications include: pericardial tamponade, MI,
intramural hematoma, arrhythmia, coronary dissection,
cardiogenic shock. Treatment is either CABG for emergent
revascularization or prolonged inflation with PTCA balloon or
perfusion catheter or stent.
.
The PTCA balloon was put up for extended period in 2 sites in
the LAD, to inhibit extravasation of contrast post-LAD
perforation. Perforations are classified into:
Class I - extraluminal crater without extravasation
Class II - pericardial or myocardial blushing
Class III - perforation 1 mm in diameter with contrast streaming
and cavity spilling
.
Serial pulsus checks were negative. CABG was not recommended to
patient because MI likely occurred 3-4 days before presentation
(according to presenting cardiac enzymes) so myocardium cannot
be reperfused with revascularization.
Medications on Admission:
Medications on Admission:
Lipitor
Wellbutrin
.
ALL: PCN
Discharge Medications:
1. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. 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*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Start taking this medication on [**2127-2-17**].
Disp:*30 Tablet(s)* Refills:*2*
7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime for
3 days: Take one tablet on [**2127-2-14**], [**2127-2-15**], and [**2127-2-16**], then
start taking Warfarin 5 mg by mouth every night instead.
Disp:*3 Tablet(s)* Refills:*0*
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-9**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
10. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg
Subcutaneous Q12H (every 12 hours).
Disp:*20 20 syringes ([**2120**] mg total)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Large ST elevation Myocardial Infarction
LAD perforation into left ventricle
Discharge Condition:
hemodynamically stable
Discharge Instructions:
1. Please eat a low salt diet. No more than 2 mg per day.
2. Weigh yourself daily. If you have a weight gain > 3 lbs,
please call your doctor.
3. Please take all medications as prescribed. ALWAYS take your
aspirin and plavix.
4. Please keep all follow-up appointments. You have an
appointment for an echocardiogram in 1 month followed by an
appointment with an electrophysiology cardiologist, Dr.
[**Last Name (STitle) **].
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2127-3-11**] 2:30. [**Hospital1 **] [**Last Name (Titles) 516**],
[**Hospital Ward Name 23**] 7
2. Please make a followup appointment with Dr. [**Last Name (STitle) 1655**]. INR
check Monday morning in Dr.[**Name (NI) 64536**] office.
Completed by:[**2127-2-14**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6722
} | Medical Text: Admission Date: [**2112-8-9**] Discharge Date: [**2112-8-25**]
Date of Birth: [**2066-11-3**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 45-year-old
gentleman who is status post inferior wall MI on [**2112-7-1**].
At that time, he underwent a PTCA stent to his RCA. At the
time of his cardiac catheterization, it was noted that he had
multiple LAD and LCX lesions. It was elected to discharge
the patient to home and have the patient come back to the
Cardiac Catheterization Laboratory at a later date for
treatment of those lesions. The patient was admitted on
[**2112-8-9**] for repeat cardiac catheterization.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Type 2 diabetes, now insulin-dependent.
4. Coronary artery disease, status post myocardial
infarction.
5. Status post kidney surgery, type unknown, as a child.
ALLERGIES: Penicillin.
PREOPERATIVE MEDICATIONS:
1. Plavix 75 mg p.o. q.d.
2. Enteric coated aspirin 325 mg p.o. q.d.
3. Zestril 5 mg p.o. q.d.
4. Lipitor 20 mg p.o. q.d.
5. Lopressor 100 mg p.o. b.i.d.
6. Protonix 40 mg p.o. q.d.
7. NPH insulin 18 units subcutaneously b.i.d.
8. Humalog sliding scale.
PREOPERATIVE LABORATORY DATA: Significant for a hematocrit
of 40.7, potassium 4.5, BUN 18, creatinine 0.9.
HOSPITAL COURSE: The patient was taken to the Cardiac
Catheterization Laboratory on [**2112-8-9**] where he was started
on an Integrelin infusion and given a heparin bolus. During
the cardiac catheterization, an attempted PCI of the LAD was
undertaken. During the PCI, the patient began to develop
chest pain and ST segment elevations. There was no flow
through the LAD and no improvement in the flow with
vasodilators. Due to the patient's continued chest pain, an
intra-aortic balloon pump was inserted in the Cardiac
Catheterization Laboratory and the patient was taken
emergently to the Operating Room by Dr. [**Last Name (STitle) **] for coronary
artery bypass.
In the Operating Room, the patient underwent a CABG times
three with SVG to LAD, SVG to diagonal, and SVG to OM. Due
to the patient's coagulation status preoperatively with the
patient being on Plavix and Integrelin, the patient had a
large amount of chest tube output in the Operating Room and
postoperatively. The patient was transferred to the
Intensive Care Unit on a large amount of pressors due to a
low blood pressure.
In the Intensive Care Unit, the patient had approximately 2
liters of chest tube drainage in the first hour in the
Intensive Care Unit. The patient was quickly taken back to
the Operating Room. In the Operating Room, there were found
only small areas of bleeding which were repaired. The
patient's coagulopathy was corrected and the patient was
again transferred back to the Intensive Care Unit on
epinephrine and Amiodarone in stable condition. Please see
the operative note for further details.
On the evening of postoperative day number one, the patient
required large amounts of blood products. The patient
continued on his intra-aortic balloon pump. It was elected
to keep the patient intubated on the night of postoperative
day number one. The patient's chest tube output was
considerably decreased. The patient was moderately hypoxic.
The chest x-ray showed volume overload.
By postoperative day number two, the patient's coagulopathy
had been corrected and he was hemodynamically stable. The
intra-aortic balloon pump was removed without complications.
The patient required large amounts of diuresis over the next
several days for the patient's oxygenation and enable the
patient to wean on the ventilator.
On postoperative day number three, it was noted that the
patient had a large right-sided pleural effusion. A right
pleural chest tube was inserted with 1,500 cc of old dark
blood and improvement in the patient's chest x-ray. After
the chest tube was inserted, the patient began complaining of
the sensation of shortness of breath and became tachypneic.
A repeat chest x-ray was performed which showed no
pneumothorax, no effusion; however, the patient's
endotracheal tube was noted to be high. This was advanced.
However, the patient continued to remain anxious. The
patient's oxygenation improved with sedation.
By postoperative day number four, the patient had been weaned
off of his pressors and was started on a low-dose beta
blocker. The patient was noted to have a dropping platelet
count. A heparin antibody test was sent which was
subsequently negative. The patient had been started on
Plavix as he still had a stent to his RCA. It was
recommended by Dr. [**Last Name (STitle) **] that the patient be transfused
platelets and given Plavix as the concern for keeping the
stent patent.
On the evening of postoperative day number four, the patient
began draining large amounts of bloody fluid from his sternal
incision which was thought to be a liquefying hematoma. On
postoperative day number five, the patient continued to have
a large amount of drainage and Dr. [**Last Name (STitle) **] decided to return
the patient to the Operating Room for tightening of the
sternal wires as he thought the drainage was due to a sternal
dehiscence. The patient tolerated this procedure well and
returned to the Intensive Care Unit and remained intubated
throughout.
On the evening of postoperative day number five, the patient
was weaned and extubated from mechanical ventilation and
required vigorous chest PT to maintain oxygen saturation, had
a moderate productive cough. It was also noted on the
evening of postoperative day number five that the patient had
icteric sclerae. A bilirubin was sent which was noted to be
elevated at 6.8.
A right upper quadrant ultrasound was obtained on
postoperative day number eight which showed evidence of
increased echogenicity consistent with fatty infiltration of
the liver. No focal liver lesions. No evidence of
intrahepatic or extrahepatic biliary ductal dilatation,
common bile duct normal in size, unremarkable gallbladder
without stones. Limited view of the pancreas due to
overlying bowel gas.
The patient continued on IV vancomycin prophylactically for
the multiple reoperations and the sternal drainage. The
patient was transferred from the Intensive Care Unit to the
floor on postoperative day number seven. The patient was
again noted to have a moderate amount of serosanguinous
drainage from the sternal incision as well as a moderate
amount of drainage from his right lower extremity vein
harvest site.
On postoperative day number nine, Dr. [**Last Name (STitle) **] evaluated the
patient and applied Dermabond to the sternal incision;
however, on postoperative day number ten, the patient
continued to drain serosanguinous fluid from his incisions.
It was decided by Dr. [**Last Name (STitle) **] that the patient would return to
the Operating Room for sternal rewiring. At this time, the
patient had begun complaining of nausea and abdominal pain.
The patient was noted to have elevated amylase and lipase.
The patient was changed to clear liquids and made n.p.o. for
the Operating Room.
The patient's Operating Room was delayed due to scheduling.
On the evening of postoperative day number nine, the
patient's sternal drainage became very minimal so it was
elected to delay surgery. With the patient becoming n.p.o.,
the patient's amylase and lipase were decreased. The patient
continued to be n.p.o. and subsequently his nausea and left
upper quadrant pain subsided. His amylase and lipase
continued to decrease. His sternal incision drainage
decreased to nothing. The patient continued on his
vancomycin.
On postoperative day number 14, the patient's amylase and
lipase had decreased sufficiently. The patient had tolerated
clear liquids. The patient was started on a regular diet.
On the night of postoperative day number 14, after one meal,
the patient had again elevated amylase and lipase. The
patient was switched to a low-fat diet and the patient's
amylase and lipase continued to trend down. The patient's
sternal drainage had stopped and by postoperative day number
16, the patient was cleared for discharge to home.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post emergent coronary artery bypass graft.
3. Status post reoperation for bleeding.
4. Postoperative sternal drainage.
5. Status post sternal rewire for sternal dehiscence.
6. Postoperative pancreatitis.
7. Insulin-dependent diabetes mellitus.
CONDITION ON DISCHARGE: T maximum 98.6, pulse 90, sinus
rhythm, blood pressure 106/60, respiratory rate 14, room air
oxygen saturation 96%. The patient was awake, alert,
oriented times three, ambulating independently with a
nonfocal neurological examination. The heart revealed a
regular rate and rhythm without rub or murmur. The lungs
were clear bilaterally. The abdomen was with positive bowel
sounds, soft, nontender, nondistended. He was tolerating a
low-fat diet. He had no nausea or vomiting. He was having
regular bowel movements. The sternal incision showed peeling
Dermabond. No drainage. No erythema. The sternum was
stable. The right lower extremity showed resolving
ecchymosis with a small amount of serosanguinous drainage
from the medial knee and a small amount of resolving erythema
at the distal incision right above the ankle.
LABORATORY/RADIOLOGIC DATA: White blood cell count 7.7,
hematocrit 40, platelet count 279,000. Sodium 135, potassium
4.4, chloride 98, bicarbonate 26, BUN 22, creatinine 1.0,
glucose 120. AST 64, ALT 93, alkaline phosphatase 129,
amylase 168, lipase 247, total bilirubin 2.1.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg p.o. b.i.d.
2. Colace 100 mg p.o. b.i.d.
3. Enteric coated aspirin 325 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Protonix 40 mg p.o. q.d.
6. Lipitor 20 mg p.o. q.d.
7. Combivent MDI two puffs q. six hours p.r.n.
8. Levofloxacin 500 mg p.o. q.d. times two weeks.
9. Lasix 20 mg p.o. b.i.d. times seven days.
10. Potassium chloride 20 mEq p.o. b.i.d. times seven days.
11. Guaifenesin elixir 10 cc p.o. q. six hours p.r.n.
12. NPH insulin 18 units subcutaneously b.i.d.
13. Humalog sliding scale per the patient to maintain a blood
sugar of 120 or less.
DISPOSITION: The patient is to be discharged to home in
stable condition.
FOLLOW-UP: The patient is to follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12491**], in one week for recheck of his
amylase and lipase. The patient was instructed to call Dr.[**Name (NI) 12492**] office immediately if he has any abdominal
pain,nausea, or any drainage from his sternal or leg
incisions. The patient is to follow-up with Dr. [**Last Name (STitle) 911**] in two
to three weeks. The patient is to follow-up with Dr. [**Last Name (STitle) **]
in three to four weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2112-8-25**] 02:48
T: [**2112-8-25**] 16:57
JOB#: [**Job Number 12493**]
ICD9 Codes: 4111, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6723
} | Medical Text: Admission Date: [**2179-1-19**] Discharge Date: [**2179-1-28**]
Date of Birth: [**2138-1-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
[**Doctor Last Name 15532**] esophagus with intramucosal
cancer of the distal esophagus.
Major Surgical or Invasive Procedure:
transhiatal esophagectomy
History of Present Illness:
Mr. [**Known lastname **] is a 40-year-old gentleman with
longstanding reflux disease status post a Nissen
fundoplication in the remote past. He has gone on to develop
[**Doctor Last Name 15532**] esophagus, and on serial biopsies has been found to
have high-grade dysplasia and by pathologic review evidence
for intramucosal cancer.
Past Medical History:
Barrett's esophagus, HTN, small bowel resection, splenorrhaphy
[**2159**], Nissen [**2162**]
Physical Exam:
general: well appearing male in NAD
HEENT: unremarkable
chest: CTA bilat,
COR RRR S1, S2
abd: soft, round, NT, ND, +BS w/ prev well healed abd scar.
extrem: No C/C/E
neuro: alert and oriented x3
Pertinent Results:
[**2179-1-24**] CXR IMPRESSION:
Slight decrease in left-sided pleural effusion. Airspace disease
at the left base. Patchy increase in density at the right base
may represent some subsegmental atelectasis or early airspace
disease.
[**2179-1-19**] Pathology Tissue: ESOPHAGUS AND PROXIMAL [**2179-1-19**]
[**Last Name (LF) **],[**First Name3 (LF) 2389**] M. Not Finalized
Brief Hospital Course:
pt was admitted and taken to the OR for transhiatal
esophagectomy and J-tube placement. An NGT for gastric
decompression and JP drain to bulb sxn at neck anastomosis to
facilitate drainage. An epdiural was placed for pain control. Pt
was admitted to the ICU overnoc and extubated on POD#1 and
transferred from the ICU.
Post op course was uneventful -Trophic tube feeds were started
on POD#3 and remained on IVF for hydration while NPO. NGT was
d/c'd on POD# 4. Pt was ambulating independently in hallway w/
sats mid 90's on roomair. Epidural was d/c'd on POD#6 and
transitioned to PCA for apin control. On POD # 7 pt given trail
of po grape juice w/o any evdience of grape juice via the [**Doctor Last Name **]
at the neck anastomotic site. Pt was then started on clear
liquids and tube feed was slowly increased to goal. Pain was
controlled on po roxicet. Pt was d/c'd to home on POD# 9 w/
continous tube feeds, full liqs to soft solid diet and VNA
services.
Medications on Admission:
lisinopril, prevacid
.
Discharge Medications:
1. Replete/Fiber Liquid Sig: Seventy (70) ml PO per hour:
may cycle as [**Last Name (un) 1815**].
Disp:*QS x 1 month QS x 1 month* Refills:*11*
2. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO once a day.
Disp:*30 tabs* Refills:*2*
3. Lopressor 50 mg Tablet Sig: [**11-24**] Tablet PO twice a day.
Disp:*15 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*420 ML(s)* Refills:*0*
5. Motrin 100 mg/5 mL Suspension Sig: Four Hundred (400) mg PO
every eight (8) hours.
Disp:*600 ml* Refills:*2*
6. feeding pump
feeding pump and supplies
one month supply with 11 refills
7. tube feeding flush
flush with 50cc water every 8 hours while in use, before and
after instillation of liquid medications, before and after tube
feed discontinuation, or when not in use.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Androscroggin VNA
Discharge Diagnosis:
Barrett's esophagus, HTN, small bowel resection, splenorrhaphy
[**2159**], Nissen [**2162**]
transhiatal esophagectomy
Discharge Condition:
good-requires tube feeds to meet nutritional needs
Discharge Instructions:
Please call Dr.[**Doctor Last Name 4738**] office if you develop chest pain,
shortness of breath, fever, chills, redness or drainage from
your incision sites, Also call if you have difficulty swallowing
or do not tolerate tube feeding (diarrhea, vomiting)or if the
feeding tube becomes loose or falls out. If your feeding tube
falls out, bring the tube and immediately go the nearest ER and
have it replaced. Call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 170**] and
update us regarding the feeding tube.
Continue on a soft solids diet until you are seen in follow up.
Followup Instructions:
Please report to [**Hospital Ward Name 23**] 4 at [**2179-2-11**] 10:30am for a barium
swallow then proceed to your follow up appointment with Dr.
[**Last Name (STitle) **]. You have a follow up appointment with Dr. [**Last Name (STitle) **] on
[**2179-2-11**] at [**Hospital Ward Name **] clinical center [**Location (un) **].
Completed by:[**2179-1-28**]
ICD9 Codes: 5180, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6724
} | Medical Text: Admission Date: [**2128-7-21**] Discharge Date: [**2128-7-27**]
Date of Birth: [**2067-1-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / E-Mycin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
diabetic foot ulcer, hypotension
Major Surgical or Invasive Procedure:
I+D of R diabetic foot ulcer
History of Present Illness:
61yo M with h/o DM, dementia, MR admitted to podiatry with
diabetic right foot ulcer s/p I+D in OR on [**2128-7-21**] transferred
from PACU to MICU for hypotension. Per records and ED attending
patient was found down at [**Hospital3 **] this morning in feces
and urine. He was brought to the ED where he had a temp to 101,
sinus tach to 150s, WBC 18, and cellulitis on right foot with
purulent ulcer and streaking up leg to groin with track. Mental
status was "alittle out of it" but at baseline per family. Got
4L NS in the ED and APAP and HR down to 120s. XR foot didnt show
evidence of osteo but had track with pus through ulcer. Broad
spec abx were given (vanc/ctz/cipro/flagyl) and he was evaluated
by podiatry and vascular surgery who recommended sending him to
the OR for I+D.
.
In the OR the patient underwent I+D, received fent (75mg)/midaz
(3mg), esmolol and metoprolol for sinus tach in the 150s and neo
for hypotension (100s/50s) and 5L drained 10cc pus from right
foot, EBL 50mL, packed with saline wet-dry dressing change. Per
anesthesia he's had tachycardia treated with esmolol and
hypotensive (100s/50s). superficial culture taken in ED and deep
cultures taken in OR as well. Will likely need debridement and
head of Metatarsal removed over the next few days by podiatry.
.
On the floor, patient is sleeping but arousable. Denies pain.
Denies chest pain and denies palpitations.
Past Medical History:
DM2
Vascular dementia
Asthma
Hypertension
Barretts esophagus
.
PAST SURGICAL HISTORY: (per OMR) Open reduction and internal
fixation
fracture both bones of the forearm [**6-/2117**], pheochromocytoma [**2110**]
Social History:
(per OMR)
Smoking: Nonsmoker. ETOH: Social drinking.
Physical Exercise: Patient has been moderately physically
active.
Family History:
non-contributory
Physical Exam:
Vitals: T:97.1 BP:91/40 P:140 R:25 O2:97 on 5L NC
General: somnolent but arousable, answers questions
appropriately but falls asleep mid-interview
HEENT: Sclera anicteric, very dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Upper airway snoring sounds but otherwise Clear to
auscultation bilaterally, no wheezes, rales, ronchi anteriorly
CV: tachycardic but regular
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
GU: foley
Ext: warm, well perfused, no edema, bandage on right foot with
marker line on leg and inside marker line no erythema
Pertinent Results:
[**2128-7-21**] 08:05PM BLOOD WBC-18.1*# RBC-4.26* Hgb-11.0* Hct-33.0*
MCV-78* MCH-25.9* MCHC-33.5 RDW-16.8* Plt Ct-269
[**2128-7-21**] 08:05PM BLOOD Neuts-88.5* Lymphs-4.4* Monos-6.4 Eos-0.2
Baso-0.5
[**2128-7-23**] 12:58AM BLOOD WBC-6.3 RBC-3.40* Hgb-8.8* Hct-25.8*
MCV-76* MCH-25.8* MCHC-34.1 RDW-16.7* Plt Ct-219
[**2128-7-21**] 08:05PM BLOOD PT-16.4* PTT-29.3 INR(PT)-1.5*
[**2128-7-22**] 12:54AM BLOOD Fibrino-640*
[**2128-7-21**] 08:05PM BLOOD Glucose-434* UreaN-34* Creat-1.3* Na-127*
K-4.6 Cl-92* HCO3-22 AnGap-18
[**2128-7-21**] 08:05PM BLOOD ALT-41* AST-49* LD(LDH)-332* AlkPhos-90
TotBili-0.8
[**2128-7-22**] 12:54AM BLOOD Albumin-2.4* Calcium-7.0* Phos-3.2 Mg-1.8
[**2128-7-22**] 12:54AM BLOOD Hapto-182
[**2128-7-21**] 08:05PM BLOOD Osmolal-296
[**2128-7-22**] 12:54AM BLOOD TSH-0.92
[**2128-7-23**] 12:58AM BLOOD Cortsol-13.5
[**2128-7-22**] 01:05AM BLOOD Type-[**Last Name (un) **] pO2-56* pCO2-50* pH-7.23*
calTCO2-22 Base XS--6
[**2128-7-22**] 01:40AM BLOOD Type-ART pO2-96 pCO2-51* pH-7.23*
calTCO2-22 Base XS--6 Intubat-NOT INTUBA
[**2128-7-21**] 08:13PM BLOOD Glucose-386* Lactate-2.1* K-4.6
[**2128-7-22**] 09:37AM BLOOD freeCa-1.06*
[**2128-7-21**] 09:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.023
[**2128-7-21**] 09:45PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-1000 Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2128-7-21**] 09:45PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
.
[**2128-7-22**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2128-7-22**] SWAB GRAM STAIN-FINAL; WOUND
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
[**2128-7-22**] SWAB GRAM STAIN-FINAL; WOUND
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
[**2128-7-22**] URINE URINE CULTURE-FINAL INPATIENT
[**2128-7-21**] SWAB GRAM STAIN-FINAL; WOUND
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2128-7-21**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2128-7-21**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2128-7-21**] ECG: Narrow complex tachycardia which may be due to
sinus tachycardia or an atrial flutter or atrial tachycardia
with 2:1 conduction. Compared to the previous tracing of [**2124-5-20**]
the rate has increased substantially and there may be an atrial
arrhythmia present.
.
[**2128-7-21**] CT Head W/Out Contrast: 1. No acute intracranial
pathology. 2. Parenchymal atrophy and small vessel microvascular
disease.
.
[**2128-7-21**] R Foot AP,LAT & OBL X-Ray: : Soft tissue ulceration and
swelling at the medial forefoot at the level of the great toe
with soft tissue ulceration. Markedly limited study for
evaluation for osteomyelitis and if clinically warranted, MRI
may be obtained to further assess.
.
[**2128-7-21**] CXR: No evidence of pneumonia. Equivocal evidence of
mild congestion.
.
[**2128-7-22**] 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 spontaneous echo
contrast is seen in the left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 40 cm from the
incisors. The aortic valve leaflets (3) are mildly thickened. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion. .
.
[**7-24**]:
xray
HISTORY: Foot ulcer status post debridement.
FINDINGS: In comparison with the study of earlier in this date,
there has
been extensive debridement about the first MTP joint with bony
resection.
Area of gas in soft tissues could merely be trapped under the
bandage.
Further information can be gathered from the operative report.
Brief Hospital Course:
61yo M with DM2, vascular dementia found down at [**Hospital3 **]
with infected foot ulcer s/p I+D in OR with hypotension likely
from sepsis.
.
# Sepsis/ right foot osteomyletis: - Resolved following
aggressive IVF. Lactate normalized and he had improved mentation
and urination. Covered broadly for infected diabetic foot ulcer
with Vanc/Ceftaz/Cipro/Flagyl initially. Cultures showed
multiple organisms. Was followed by vascular and podiatry.On
wound culture: UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH
OF SWARMING PROTEUS.STAPH AUREUS COAG +=RARE GROWTH. ANAEROBIC
CULTURE (Preliminary):NO ANAEROBES ISOLATED. Blood pressures are
currently stable. Status post podiatric surgery ([**7-24**])-Resection
of first metatarsophalangeal joint. Radical debridement of skin,
muscle and subcutaneous tissue, right foot. Delayed primary
closure, right foot. Will be discharged on levofloxacin which
will cover the MSSA which grew from his wound culture.
.
# Tachycardia: A flutter, s/p D/C cardioversion after
amiodarone loading, and beta blocking. TEE did not show
thrombus. Now in sinus with improved BP. Pt started on heparin
gtt which was transitioned to lovenox and coumadin. Has remained
in sinus rhythm. Currently being rate controlled with Metoprolol
75mg TID. Lovenox should be DC'd after INR therapeutic between
[**12-31**]. Anticoagulation should be continued until [**8-24**].
At that time need for anticoagulation should be reassessed.
.
# Acid/Base disturbance: had respiratory acidosis and non gap
met acidosis on admission to MICU. Thought to be secondary to
sepsis with procedural sedation. This issue has resolved since
and on the floor his acid/base status was stable.
.
# Hyponatremia: Hypovolemic hyponatremia likely [**12-30**] either tea
and toast diet/poor po intake from being on floor for unknown
number of days vs adrenal insufficiency vs insensible losses
from fevers, infection etc. Improved with hydration (normal
TSH, random cortisol was 13.2 ?????? equivocal).His sodium level on
the floor were normal.
.
# Anemia: Hct were 25-26 which is low for his baseline of
30s-40s. guaiac negative, hemolysis labs were negative.
Continued to trend Hct. Iron studies were obtained.
Iron: 25 calTIBC: 176 Ferritn: 871 TRF: 135, suggestive of
anemia with chronic disease. This should be followed by the
patient's primary care physician.
# Elevated INR: unclear etiology, patient not on coumadin,
heparin. Possibly nutritional deficiency but with anemia
concerning for hemolysis. INR is now coming down and has been
stable at around 1.4. No evidence of hemolysis. Started on
heparin gtt during stay which was transioned to lovenox and
coumadin bridge.
.
# [**Last Name (un) **]: Likely [**12-30**] hypotension/pre-renal given sepsis. Now
resolved.
# conjunctivitis: Found to have conjunctivitis on [**7-22**]. Started
on erythromycin drops. Resolving. Erythromycin stopped prior to
discharge.
# Dementia/MR: sedating meds were being held initially because
of low BP. Otherwise issue stable during admission.
# COPD: Standing atrovent and PRN albuterol nebs while in ICU
and floor. Breathing status has been stable and he is tolerating
room air well. Continued on home [**Month/Year (2) **] at discharge.
.
# DM: Standing insulin sliding scale.
.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
-The patient will need at least 1 month of anticoagulation after
having atrial flutter cardioversion. The potential continuation
of anticoagulation will have to be assessed as an outpatient.
Medications on Admission:
HCTZ 25', metformin 1000', lisinopril 40', remeron 45'qhs,
simvastatin 40', mertazipine 30'qhs, celexa 40', [**Last Name (LF) **], [**First Name3 (LF) 130**]
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice
a day.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. [**First Name3 (LF) 4010**] Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Acetaminophen 500 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for pain/fever.
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehabilitation & [**Hospital **] Care Center - [**Location (un) **]
Discharge Diagnosis:
1.Osteomyelitis, right first metatarsophalangeal joint.
2. Abscess and cellulitis, right foot.
3. Atrial flutter which was cardioverted
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to care for you as your doctor.
.
You were brought to the hospital because of a foot infection.
You developed low blood pressure and spent a couple of days in
the intensive care unit. After intravenous fluids, antibiotics,
and surgery on your foot you improved and were transferred to
the regular floor. Your admisison was complicated by a abnormal
heart rhythm which required electrial conversion to a regular
heart rhythm.
.
We made the following changes to your home medication list:
-We added Coumadin which is a blood thinner you will need to
take because of the irregular heart rhythm you experienced.
Please take this medication as directed by your outpatient
physician.
-We added lovenox which is a blood thinner you must take for
your irregular heart rhythm you experienced, please take this
medication as directed by your physician at rehab. This will be
stopped once your INR is between [**12-31**].
-We started levofloxacin which is an antiobiotic for your foot
infection which you had surgery.
- Lisinopril and HCTZ were stopped during admission.
.
Please follow up with the outpatient appointments below:
Followup Instructions:
Department: PODIATRY
When: THURSDAY [**2128-8-5**] at 8:05 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: HMFP
When: THURSDAY [**2128-9-9**] at 2:10 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Department: [**State **]When: MONDAY [**2128-9-27**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
ICD9 Codes: 5849, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6725
} | Medical Text: Admission Date: [**2190-9-2**] Discharge Date: [**2190-9-7**]
Date of Birth: [**2115-7-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2190-9-2**] Minimally Invasive Off-Pump Coronary Artery Bypass
Graft x 1 (LIMA to LAD)
History of Present Illness:
75 y/o male c/o dyspnea on exertion who had a cardiac CT that
revealed plaque on his LAD. Underwent cardiac cath which
revealed a totally occluded LAD.
Past Medical History:
Coronary Artery Disease, Hypertension, Hyperlipidemia, Aortic
Insufficiency, s/p Appendectomy, s/p Hernia Repair x 2, Benign
Prostatic Hypertrophy
Social History:
Retired. Quit smoking 50 years ago. Drink [**12-1**] glasses
whiskey/night.
Family History:
Non-contributory
Physical Exam:
Admission: VS: 81 16 148/76 5'[**93**]" 170#
Gen: WD/WN male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM , -JVD
Chest: CTAB
Heart: RRR
Abd: Soft, NT/ND
Ext: -c/c/e, -varicosities
Neuro: A&O x 3, MAE, non-focal
Discharge: VS: T98.4 HR81 BP126/68 RR18 O2sat93%RA
Gen: NAD
Neuro: A&Ox3, nonfocal exam
Pulm: CTA-bilat
CV: Irreg-Irreg, left thoracotomy incision w/steri's CDI
Abdm: soft, NT/ND/NABS
Ext: warm, well perfused. [**12-1**]+pedal edema
Pertinent Results:
[**9-2**] Echo: 1, The left atrium is moderately dilated. No
spontaneous echo contrast is seen in the body of the left
atrium. No thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. 2, Right
ventricular chamber size and free wall motion are normal. Right
ventricular chamber size is normal. 3. There are simple atheroma
in the ascending aorta. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. No masses or vegetations are seen
on the aortic valve. There is no aortic valve stenosis. Moderate
(2+) aortic regurgitation is seen. The aortic regurgitation jet
is eccentric, directed toward the anterior mitral leaflet. There
is no flow reversal in the descending aorta. 4. The mitral valve
appears structurally normal with trivial mitral regurgitation.
Trivial mitral regurgitation is seen. 5, There is a
trivial/physiologic pericardial effusion. 6. LV systolic
function is normal . LVEF= 55%. During occlusion of LAD, there
was akinesis of mid and distal anterior wall with preserved
ejection fraction. Upon release of LAD occlusion, there is
improvement of anterior wall, but some residual anterior
hypokinesis.
[**9-5**] CXR: PA and lateral views of the chest are obtained on
[**2190-9-5**] at 1553 hours and compared with the prior radiograph
performed on [**2190-9-2**]. The patient is status post CABG. He has
been extubated and the Swan-Ganz catheter and pleural tubes have
been removed. Increased density is seen in the right base which
is likely a combination of fluid and atelectasis in the right
lower lobe. Patchy increased density is seen in the retrocardiac
area on the left side consistent with a degree of
atelectasis/airspace disease of the left base. Bilateral small
pleural effusions are present.
[**2190-9-2**] 03:05PM BLOOD WBC-14.6*# RBC-3.01* Hgb-10.1* Hct-28.6*
MCV-95 MCH-33.6* MCHC-35.3* RDW-13.4 Plt Ct-141*
[**2190-9-5**] 02:02AM BLOOD WBC-10.9 RBC-2.90* Hgb-10.1* Hct-28.1*
MCV-97 MCH-34.7* MCHC-35.8* RDW-13.1 Plt Ct-148*
[**2190-9-2**] 03:05PM BLOOD PT-14.5* PTT-31.4 INR(PT)-1.3*
[**2190-9-5**] 02:02AM BLOOD PT-11.8 PTT-27.1 INR(PT)-1.0
[**2190-9-2**] 04:30PM BLOOD UreaN-10 Creat-0.7 Cl-115* HCO3-22
[**2190-9-5**] 02:02AM BLOOD Glucose-113* UreaN-11 Creat-0.8 Na-135
K-4.0 Cl-105 HCO3-24 AnGap-10
[**2190-9-5**] 02:02AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.2
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
07 [**2190-9-5**] 02:02AM 148*
Source: Line-art
[**2190-9-5**] 02:02AM 11.8 27.1 1.0
[**2190-8-30**] 02:02AM 10.9 2.90* 10.1* 28.1* 97 34.7* 35.8* 13.1
148*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2190-9-5**] 02:02AM 113* 11 0.8 135 4.0 105 24 10
Brief Hospital Course:
Mr. [**Known lastname 73692**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On day admission he was
brought to the operating room where he underwent a minimally
invasive off-pump coronary artery bypass graft x 1. Please see
operative report for surgical details. Following surgery he was
transferred to the CVIICU for invasive monitoring in stable
condition. Later on op day he was weaned from sedation, awoke
neurologically intact and extubated. He required Neo-Synephrine
for hemodynamic support until early post-op day three when it
was weaned off. Lasix and beta blockers were initiated and he
was gently diuresed towards his pre-op weight. Chest tubes were
removed on post-op day three and he was transferred to the SDU
for further care. Also on this day his heart rhythm went into
atrial fibrillation and he was started on Amiodarone and
Coumadin. He continued to progress in his activity and on POD 5
it was decided he was ready for discharge home with visiting
nurse visits
Medications on Admission:
Aspirin 81mg qd, Amlodipine 3.75mg qd, Finasteride 5mg qd,
Flomax o.4mg qd, Lasix 20mg qd, Lisinopril 5mg qd, Plavix 75mg
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:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): [**Hospital1 **] x 10 days then QD x 14 days.
Disp:*34 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours): [**Hospital1 **]
x 10 days then
QD x 14 days.
Disp:*68 Capsule, Sustained Release(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] x 7 days then 400 mg QD x 7 days then 200 mg
QD.
Disp:*60 Tablet(s)* Refills:*2*
12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 3 weeks.
Disp:*65 Tablet(s)* Refills:*0*
13. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day:
Target INR 1.5-2.0.
Disp:*75 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1
PMH: Hypertension, Hyperlipidemia, Aortic Insufficiency, s/p
Appendectomy, s/p Hernia Repair x 2, Benign Prostatic
Hypertrophy
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 11493**] in [**1-2**] weeks
Dr. [**Last Name (STitle) 17029**] in [**12-1**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2190-9-7**]
ICD9 Codes: 4241, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6726
} | Medical Text: Admission Date: [**2114-10-22**] Discharge Date: [**2114-11-16**]
Date of Birth: [**2064-6-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfur / Demerol / Amphotericin B / Allopurinol /
Vicodin / Percocet
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Scheduled admission for chemotherapy
Major Surgical or Invasive Procedure:
s/p antegrade nephrostogram
s/p PICC line placement
History of Present Illness:
Ms. [**Known lastname **] is a 50 year old woman with history of AML, allogenic
transplant in [**2110-8-4**], and recent admissions for right-sided
hydronephrosis ([**Month (only) 116**]), donor lymphocyte infusion in (discharged
[**8-24**]), and left-sided hydronephrosis (discharged [**10-4**]). She
has been admitted for chemotherapy in preparation for donor
lymphocyte infusion vs. second bone marrow transplant.
.
She reports feeling "lousy" for the past several weeks, with
feelings of fatigue and lack of stamina. She has had increased
bruising. Her steroids were increased last Friday to 40mg daily
from 30mg daily. She reports a headache and fever to 100.5 last
night which came down with Tylenol.
Past Medical History:
ONCOLOGY HX:
- Acute myelogenous leukemia s/p allo transplant
- [**2110-8-4**]: 5 of 6 matched family member allogenic BMT for AML.
Father was her donor. She has remained in complete remission; no
GVHD. Her performance status was 100%.
- mid-[**7-10**] found to have peripheral blasts and host cells in
marrow, suggestive of relapsed AML, planning for DLI
.
PMH:
1. AML- as above
2. Allergic rhinitis
3. Depression
Social History:
Married, lives with her husband and three children ages 13, 8,
6. Works as a controller. No tobacco or EtOH.
Family History:
Both parents living. Mother with HTN, MI, SLE; father with HTN.
Father (donor) recently had MI. Siblings with hypertension.
Physical Exam:
Vitals: T 98.6 BP 107/67 P 98 RR 18 O2sat 98%
Gen: Well-appearing, no acute distress
HEENT: PERRL, EOMI, OP clear, MMM
Neck: No LAD
Card: RRR, normal S1/S2, no m/r/g
Pulm: CTA bilaterally
Back: No CVAT, mild tenderness around percutaneous nephrostomy
insertion site, ecchymoses
Abd: Soft, non-distended, RUQ and epigastric tenderness
Ext: No clubbing or cyanosis, 1+ non-pitting edema bilaterally,
2+ pulses bilaterally
Skin: Some ecchymoses, no rashes
Neuro: A&Ox3, responds appropriately
Pertinent Results:
Urine cytology : NEGATIVE FOR MALIGNANT CELLS.
.
RUQ U/S [**10-23**]: Mildly distended gallbladder. Mildly distended
common bile duct. Negative [**Doctor Last Name 515**] sign. HIDA can be performed
for further evaluation if clinically warranted.
.
CT Abd/Pelvis [**10-23**]: 1. Ascites and edema of the small and large
bowel. The appearances may be consistent with enteritis or a
graft versus host disease. 2. No evidence of perforation. 3.
Left nephrostomy tube. 4. Moderate dilation of right kidney. 5.
Unchanged appearance of low attenuation lesions in pancreas and
liver.
.
Abd X-Ray [**10-23**]: FINDINGS: Left nephrostomy tube is present. No
dilated bowel loops are identified. Stool and air is present in
the colon. The osseous structures are unremarkable. IMPRESSION:
No obstruction.
.
[**2114-11-5**] BONE MARROW CORE BIOPSY:
DIAGNOSIS: Markedly hypocellular bone marrow with extensive
fibrosis and focal increased blasts, see note.
Note: The aspirate material is aspicular. The core biopsy shows
extensive areas of grade 3 reticulin fibrosis. An
immunohistochemical stain for CD34 highlights a focal area with
increased interstitial blasts within the extensively fibrotic
background, which likely represents minimal residual disease.
This was reviewed in consultation with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] who concurs.
Compared to the previous biopsy, the current biopsy shows a
marked reduction in cellularity.
MICROSCOPIC DESCRIPTION.
Peripheral Blood Smears:
Red blood cells show hypochromasia and anisopoikilocytosis with
rare microcytes, red cell fragments and dacrocytes.
The white blood cell count appears markedly decreased. Platelet
count appears markedly decreased. Large/giant forms are not
seen.
A limited 25 cell differential shows 100% lymphocytes.
Aspirate Smears:
The aspirate material is inadequate for evaluation due to a lack
of spicules, hemodilution, and clotted sample.
Clot Section and Biopsy Slides:
The biopsy material is fragmented, but adequate for evaluation.
One bony piece is hypocellular with new bone formation and
likely represents previous biopsy site.
A second bony core fragment contains diffuse background fibrosis
occupying more than half the length of this piece. In the
remaining half, the cellularity is variable (overall 10%) and is
comprised predominantly of plasma cells, lymphocytes, and
hemosiderin-laden macrophages. A small lymphoid aggregate is
seen. Maturing myeloid and erythroid precursors are extremely
scant.
A CD34 immunohistochemical stain is performed to better assess
presence of blasts, given the architectural distortion by
background fibrosis. The CD34 stain highlights scattered
interstitial mononuclear cells within the fibrotic areas overall
comprising ~10% of marrow cellularity (the remaining being
lymphocytes and plasma cells).
Special Stains:
Iron stain is inadequate for evaluation due to lack of spicules.
Reticulin stain shows extensive Grade 3 reticulin fibrosis.
Trichrome stain does not show any collagen fibrosis.
ADDENDUM: Additional immunohistochemical studies with antibodies
against favor VIII-related antigen highlights endothelial cells.
Definite staining amongst blasts is not seen, however, scant
tissue remains on deeper sections used for immunohistochemical
staining.
.
Renal U/S: IMPRESSION: No definite evidence of hydronephrosis.
Left-sided nephrostomy tube is seen in place. Likely right-sided
ureteral jet. No left ureteral jet identified.
.
[**2114-11-15**] Antegrade Nephrostogram:IMPRESSION: Persistent
narrowing of the distal left ureter, probably from the extrinsic
compression, unchanged from the study from one month ago
Brief Hospital Course:
#) AML. She was admitted for scheduled MEC with initial plans
for either second DLI vs. second BMT. She tolerated MEC, but her
course was complicated by severe mucositis. pain was controlled
with Fentanyl PCA. She also developed diarrhea (C. diff and
other stool cultures negative and symptomatically treated with
immodium).
Day 14 marrow revealed markedly hypocellular bone marrow with
extensive fibrosis and focal increased blasts. On discharge, she
is to follow-up with her outpatient oncologist for a repeat bone
marrow bx and further discussion of additional chemotherapy/mini
transplant.
.
#) Abdominal pain: Patient was admitted with complaints of mild
abdominal discomfort. Then, on AM of [**10-23**], developed worsening
abdominal pain, diffuse, worse in LLQ. KUB negative for free air
and obstruction. She was given lorazepam 1g IV for anxiety and
sent for CT abd/pelvis without contrast. After returning from
CT, BP was found to be 70/40 with continued progression of her
pain. She also had some associated nausea. She was mentating
normally throughout. She was given a 1L NS bolus with transient
improvement of her blood pressure to 95/50s. She was also given
aztreonam 2g IV, vancomycin 1g IV, and metronidazole 500mg IV.
She also received morphine 1mg IV for pain with little relief.
Surgery was consulted and she was transferred to the ICU. Abd CT
revealed ascites and edema of the small and large bowel. The
appearances may be consistent with enteritis or a graft versus
host disease with no evidence of perforation. Ultimately, this
was felt not to be an acute surgical abdomen. Once her blood
pressure stabilized and she was aggressively diuresed. Following
diuresis, her abdominal pain also subsided. By the time of
discharge, she was feeling well without abdominal discomfort.
.
#) Hypotension: In the setting of severe abdominal pain, she was
found to have SBP in 80's, which responded well to fluid
boluses. Initially, there was concern for sepsis, and she was
started on stress dose steroids, which were ultimately tapered
down. Afterwards, her BP remained stable. She was discharged on
a tapered down dose of 5 mg prednisone QD.
.
#) Fevers: Beginning on [**11-7**], she developed fevers to 101. She
was empirically covered with aztreonam, vancomycin and
caspofungin. There was concern for a line infection from her
left IJ, which waspulled. The tip was sent for culture, but no
organisms grew. Blood cx subsequently grew out Lactobacillus X3.
ID was consulted and suggested starting meropenam. Given she has
a hx of hives to penicillins, she was premedicated and tolerated
the meropenam without incident. She was discharged to complete a
total of 14 day course of meropenam. Ertapenam as QD antibiotic
was discussed, but as there was no literature to support its
efficacy against lactobacillus, she was discharged with VNA
services to help administer her IV meropenam. By dicharge, she
had been afebrile for greater than 72 hours.
.
#) Hydronephrosis: Patient has a history of obstruction of her
ureters. The etiology remains unclear as the ureters behave as
if there is external compression, but there are no compressing
masses seen on any imaging. She was s/p urgent placement of L
nephrostomy tube, and had been responding well. On [**11-10**], she
developed R flank pain (very mild and intermittent) as well as
decreased urine output. There was concern for right ureteral
obstruction as well, but Abd U/S revealed normal flow through R
ureter. Urology was consulted regarding taking out her left
nephrostomy tube prior to discharge. She had a antegrade
nephrostogram, which revealed essentially unchanged partial
obstruction of left ureter with only minimal and slow flow. the
decision was made for her to follow-up with her urologist, Dr.
[**Last Name (STitle) 770**], as an outpatient to further assess in 2 weeks.
.
#) F/E/N: IVF, bolus as needed, replete electrolytes as needed.
She was started on TPN for nutrition given her abdominal pain
and was gradually weaned off. By discharge, she was tolerating
PO's.
Medications on Admission:
Ciprofloxacin 250mg [**Hospital1 **]
Ritalin 20mg QD
Citalopram 20mg QD
Loratadine 20mg QD
Beclonase [**Hospital1 **]
Fluconazole 200mg QD
Acyclovir 400mg [**Hospital1 **]
Protonix 40mg [**Hospital1 **]
Sudafed 30 mg QD
Potassium 20mEq powder
Fluconazole QD
Prednisone 40mg (increased on Friday)
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Loratadine 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Beclomethasone Diprop Monohyd 42 mcg (0.042 %) Aerosol, Spray
Sig: One (1) Nasal [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO Q4H (every 4
hours) as needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*1*
9. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
10. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 7 days: Please premedicate
with Tylenol.
Disp:*21 Recon Soln(s)* Refills:*0*
11. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a
day.
Disp:*30 packets* Refills:*2*
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Line care
Please flush and care for line as per IV network protocol
Discharge Disposition:
Home With Service
Facility:
VNS of [**Location (un) 7188**] and [**Location (un) 16221**] County
Discharge Diagnosis:
Primary:
AML
lactobacillus bacteremia
ureteral stricture
Discharge Condition:
good
Discharge Instructions:
You have AML and received induction chemotherapy during this
admission. During this hospital course, you have some narrowing
of your left ureter requiring the nephrostomy tube to be in
place. You will need to address this issue with your urologist,
Dr. [**Last Name (STitle) 770**]. Also, you have a bacteria called Lactobacillus
growing in your blood. To treat this bacteria, you will need to
take an antibiotic called Meropenam IV every 8hours for one
week.
Please attend all follow-up appointments and take all
medications as prescribed.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] at [**Hospital1 18**] [**2114-11-19**] at
12:30.
.
Also, please follow-up with your urologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**]
to discuss when you can have your nephrostomy tube removed. Your
appointment with him is on [**2114-11-29**] 2:50PM in [**Hospital Ward Name 23**] Building
[**Location (un) 436**], [**Hospital1 18**] [**Hospital Ward Name **].
ICD9 Codes: 7907, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6727
} | Medical Text: Admission Date: [**2135-2-27**] Discharge Date: [**2135-3-2**]
Date of Birth: [**2079-12-3**] Sex: F
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
SOB, hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55F with COPD, paranoid schizophrenia, seizure disorder presents
with episode of SOB at her group home with hypoxia to the 70s,
increasing cough productive of yellow sputum. Patient reports
that she got up to go to the bathroom and felt SOB. She has had
a productive cough for months but has recently had more sputum
production. Denies sick contacts (although she lives in a group
home), hemoptysis, chills, fevers, unwanted weight loss. She has
had some night sweats and has been having episodes of vertigo
which have been controlled with anivert. She continues to smoke
[**2-15**] PPD.
.
In the ED, T 97.3, HR 109, BP 101/69, RR 20 O2 98% on 6 L to 94
% on RA. She had 2 episodes of hypotension to SBP high 70s-80s
which initialy responded to IVF, but given second episode, was
tranferred to the ICU for close monitoring. She recieved
combivent nebs x3, 5 L NS, levofloxacon 500 mg IV x 1 and
solumedrol 125 mg IV x1.
.
Per discussion with PCP; baseline BP runs in the 90s-100s.
.
ROS: Denies diarrhea, constipation, headache, CP. She has had a
10 lb intentional weight loss over the past months. Slight sore
throat 2 days ago which resolved. She continues to hear voices.
Most recently last night when people were trying to "slay her."
She also sees "faces" and feel people are talking to her from
the TV. Denies HI, SI.
Past Medical History:
Paranoid Schizophrenia
Seizure disorder-unclear history
COPD - no PFTs in [**Hospital1 **] system, patient's Pulmonologist is Dr.
[**Last Name (STitle) 3278**] at [**Hospital **] Hospital. CXRs at [**Hospital1 18**] however demonstrate
interstitial changes c/w ILD
Vertigo
Hypercholesterolemia
Foot pain - unclear etiology
Urinary incontinence s/p "bladder surgery" 8 years ago
Social History:
Patient lives in a group home. Smokes [**2-15**] ppd. Before this
smoked PPD since age 13. Denies illicit drug use. Has 2
duaghters.
Family History:
2 daughter with "mental health problems." Did not want to speak
about her parents. Denies any family history of CAD or stroke.
Did have a grandfather with COPD.
Physical Exam:
Vitals:Tm 100.5
General: Middle aged female lying flat in bed breathing
comfortably in NAD
HEENT: MMM, OP clear, PERRL
Neck: no cervical LAD, no JVD
CV: RR, nl S1, S2 no m/g/r
Pulm: diffusely rhonchorous with occasional wheezes
Abd: NABS, soft, NT/ND
Ext: + clubbing right>>left, no LE edema, no calf tenderness, 2
+ DP pulses, right forearm with slight erythema at site of PPD
but no induration
Neuro:AAOx3, CN intact, strength in upper and LE [**6-18**] and equal
b/l
Psych: reports auditory and visual hallucinations as above. No
HI/SI. Somewhat flattened affect
Skin: No rashes
Pertinent Results:
EKG: Sinus tachy, rate 100, nl axis, nl interval, <1mm St
depressions in II, II, avF
.
CXR: b/l lateral interstitial changes. Unchanged from [**2130**]. No
evidence of PNA.
.
[**2135-2-27**] 12:09PM BLOOD Lactate-1.6
[**2135-2-27**] 06:03PM BLOOD Phenyto-9.8*
[**2135-2-27**] 09:20AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2135-2-27**] 06:03PM BLOOD CK-MB-2 cTropnT-<0.01
[**2135-2-27**] 09:20AM BLOOD CK(CPK)-48
[**2135-2-27**] 06:03PM BLOOD CK(CPK)-61
[**2135-2-27**] 09:20AM BLOOD Glucose-135* UreaN-22* Creat-0.8 Na-141
K-4.0 Cl-102 HCO3-30 AnGap-13
[**2135-2-27**] 09:20AM BLOOD WBC-17.7* RBC-4.83 Hgb-14.4 Hct-43.7
MCV-91 MCH-29.9 MCHC-33.1 RDW-13.4 Plt Ct-290
[**2135-3-1**] 07:50AM BLOOD WBC-11.4* RBC-4.24 Hgb-12.3 Hct-36.6
MCV-86 MCH-29.0 MCHC-33.5 RDW-13.5 Plt Ct-228
Brief Hospital Course:
55 yo female with h/o COPD, paranoid schizophrenia, seizure
disorder presenting with episode of increasing SOB and cough
likely [**3-18**] bronchitis v COPD exacerbation v PNA.
.
# Dyspnea and hypoxia: The patient carries the dx of COPD,
however, PA/Lat during this admission demonstrated unchanged
interstitial pattern compared to [**2130**]. No PFTs in [**Hospital1 18**] system.
She may have a component of both COPD and ILD.
Nevertheless,there was a ? of a retrocardiac opacity on the
lateral film. Pt to complete 7 day course of Levofloxacin for
CAP. She should have her ECG monitored every few days as there
is a theoretical interaction between Quinolones and her
antipsychotics. She was started on Spiriva and advair for more
agressive COPD regimen, and will complete a quick steroid taper.
Should f/u with her Pulmonologist, Dr [**Last Name (STitle) 3278**].
.
# Hypotension: Patient reports that he SBP run in high 80 to
110s usually. She may have been mildly dehydrated on admission
as she says she has not been drinking much and felt dry. She
receievd 5.5 L IVF. Was not truly orthostatic on the floor.
Lasix held upon discharge.
.
# Schizophrenia: Has hallucinations at baseline. No current
SI/HI. Continued abilify, clozaril, lexapro, diazepam
.
# Seizure disorder: Unclear history. No recent seizures.
Dilantin level at goal corrected for albumin
.
# ST depressions: Patient had no CP, no increasing DOE and no
cardiac history and is not diabetic. Very slight <1mm ST
depression in the inferior leads. 2 sets CE's negative.
.
# Vertigo: Patient says that she has been having feeling that
the "room is spinning" for the past couple of weeks. Improved
with antivert.
Medications on Admission:
Clozaril 600 mg PO QHS
Abilify 30 mg PO QAM
Lexapro 15 mg PO QAM
Diazepam 5 mg PO TID
Vitamin E 400 mg PO BID
Prednisone 10 mg PO BID x 7 days (day 2)
Azmacort 4 puffs Po BID
Claritin 10 mg Po QD
Colace 100 mg PO BID
Dilantin 200 mg Po BID
Lasix 40 mg Po QAM
Antivert 25 mg PO BID:PRN vertigo
Lipitor 10 mg PO QD
MVI PO QAM
DDAVP 0.4 mg PO QHS
PPD placed (needs to be read [**2-28**])
C-Pap with 1.2 liters O2 overnight
Relafen 500 mg QD PRN
Albuterol nebs PRN
Albuterol MDI PRN
Robitussion 100 cc PO Q4H PRN
Tylenol PRN
Ibuprofen PRN
MOM PRN
Nicotine gum PRN
Trazadone 50 mg Po QHS PRN sleep
Lidomantle cream [**Hospital1 **] for foot pain
Ditropan XL 15 daily
Discharge Medications:
1. Clozapine 100 mg Tablet Sig: Six (6) Tablet PO HS (at
bedtime).
2. Aripiprazole 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Escitalopram 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
5. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. Desmopressin 0.1 mg Tablet Sig: Four (4) Tablet PO QHS (once
a day (at bedtime)).
14. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
16. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhl
Inhalation Q4H (every 4 hours) as needed.
18. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day for 2 days: Please take 20 mg on [**3-2**] and 10 mg on [**3-3**] then
stop.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
1. COPD vs ILD exascerbation
2. ?Community Acquired PNA
Secondary Diagnoses:
Paranoid Schizophrenia
Seizure disorder-unclear history
Vertigo
Hypercholesterolemia
Urinary incontinence s/p "bladder surgery" 8 years ago
Discharge Condition:
stable
Discharge Instructions:
Please come back to the emergency room should you develop any
worsening shortness of breath, fevers, chills, worsening cough,
or any other serious concerns.
Followup Instructions:
Please call to make appiontments for the patient with the
following providers.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 42596**], M.D.
Specialty: Pulmonary Medicine
Address 1: [**Hospital 42597**] Medical Building
[**Apartment Address(1) 42598**]
[**Hospital1 **], [**Telephone/Fax (1) 42599**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42600**], M.D.
Specialty: Family Practice
Address 1: Family Medicine Associates, PC
38R [**Hospital1 42601**], [**Telephone/Fax (1) 42602**]
ICD9 Codes: 486, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6728
} | Medical Text: Admission Date: [**2138-4-10**] Discharge Date: [**2138-5-4**]
Date of Birth: [**2091-2-17**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 47 year old
male, with end stage liver disease secondary to hepatitis C
cirrhosis diagnosed about 5 years prior to admission. The
patient had undergone treatment with interferon and
Ribavirin. He had been admitted to the [**Hospital1 18**] multiple times
early in [**2137**] for management of encephalopathy and ascites.
The patient had been discharged from the [**Hospital1 18**] on [**2138-4-7**],
but was readmitted on [**2138-4-10**] when noted to have worsening
renal function. The patient's serum creatinine on the day of
discharge, on [**2138-4-7**], was 1.9, but was noted to increase to
3.2 on [**2138-4-9**], and was further elevated to 3.6 on [**2138-4-10**].
The patient was admitted with concern for hepatorenal
syndrome.
PAST MEDICAL HISTORY:
1. Hepatitis C cirrhosis for which the patient was on the
liver transplant list.
2. Hypertension.
3. Nephrolithiasis.
4. Hemorrhoids.
5. Knee surgeries.
6. Back surgery.
MEDICATIONS:
1. Miconazole nitrate powder tid prn for groin rash.
2. Protonix 40 mg po bid.
3. Lactulose 30 ml tid (titrated to 4 to 5 bowel movements
qd).
4. Vancomycin 1 gm IV bid.
SOCIAL HISTORY: The patient is married with no children. He
works as a counselor at an alcohol and drug treatment
facility for teenagers. The patient was previously a heavy
alcohol user, but had been sober since [**2120**]. The patient had
also used cocaine in the past, but had also stopped in [**2120**].
HOSPITAL COURSE: (Part of the patient's chart from the
period [**2138-4-10**] to [**2138-4-24**] is currently unavailable, and
this dictation will mainly cover the period from [**2138-4-24**] to
[**2138-5-4**])
As previously mentioned, the patient's creatinine at the time
of admission was up to 3.6 from 1.9 at the time of his
discharge 3 days prior. Over the following 5 days, the
patient's creatinine improved marginally to 2.7.
Optimization of his fluid balance was managed by the medical
service in consultation with hepatology and renal. The
patient's INR on admission was 2.4, with his PT level being
18.9. The patient periodically required transfusions of
fresh frozen plasma, as well as platelets and red cells. The
patient was thrombocytopenic with a platelet count of 49 on
the 23. The patient was continued on vancomycin therapy for
his previously diagnosed Methicillin resistant, coagulase
negative Staph bacteremia. The patient's nutrition was
suboptimal, and the patient was started on tube feeding.
The patient underwent diagnostic and therapeutic paracentesis
on [**2138-4-17**], [**2138-4-22**], and [**2138-4-25**]. He had no evidence of
spontaneous bacterial peritonitis.
On [**2138-4-26**], a liver became available for transplant to the
patient. The patient was taken to the operating room and
underwent an orthotopic liver transplant. In order to aid in
optimization of the patient's fluid status, the patient was
on continuous [**Last Name (un) **] [**Last Name (un) **] dialysis during the procedure. His
estimated blood loss was 2 liters. The patient received 5
liters of crystalloid, 9 units of fresh frozen plasma, 9
units of red cells, 6 units of platelets, as well as 1 liter
of Cell [**Doctor Last Name **]. The procedure proceeded without
complications, and the patient was transferred to the
intensive care unit while still intubated following the
procedure.
The patient underwent an uncomplicated recovery in the
intensive care unit. By postop day 1, the patient was awake,
in no distress, and appeared lucid prior to extubation. The
patient was extubated on postop day 1 without any problems.
The patient was on a Lasix drip to aid in diuresis, and was
ultimately converted to oral Lasix on postop day 1. The
patient's pain control was with morphine. The patient
required 2 units of fresh frozen plasma on the night
following surgery, and 1 unit of platelets on postop day 1,
but otherwise required no blood products following the liver
transplant. The patient was started on sips on postop day 2,
and advanced to clear liquids on postop day 3. He was
advanced to a regular house diet later on postop day 3. The
patient was advanced per protocol to an immunosuppressive
regimen of prednisone, Neoral, and CellCept.
The patient's mental status remained essentially clear
throughout the entire postoperative period. The patient
started ambulating with the assistance of physical therapy
following transfer to the surgical floor. At the time of
discharge, the patient was independent, ambulating, and
functioning well. The patient's appetite improved
significantly, and at the time of discharge the patient was
on a regular diet with no tube feed supplements deemed
necessary. The patient's liver function tests all improved
appropriately by the time of discharge.
The patient's surgical incision was also healing well by the
time of discharge with no evidence of infection. The patient
was ultimately deemed ready for discharge on postoperative
day 8.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Bactrim single strength 1 tablet po qd.
2. Protonix 40 mg po qd.
3. Metoprolol 25 mg po bid.
4. Fluconazole 200 mg po qd.
5. CellCept 1 gm po bid.
6. Prednisone 20 mg po qd.
7. Dilaudid prn.
8. Neoral 500 mg po bid.
9. Valcyte 450 mg po qod.
10.Lasix 40 mg [**Hospital1 **] x 21 days.
11.Colace 100 mg po bid.
FOLLOW UP:
1. The patient was to follow-up with Dr. [**First Name (STitle) **] in the
Transplant Center 3 days following discharge.
2. The patient was to follow-up with Dr. [**Last Name (STitle) 497**] of hepatology
following discharge.
MAJOR SURGICAL PROCEDURES: Liver transplant on [**2138-4-26**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 25452**]
Dictated By:[**Last Name (NamePattern1) 17694**]
MEDQUIST36
D: [**2138-5-7**] 08:29:54
T: [**2138-5-8**] 10:40:21
Job#: [**Job Number 25453**]
ICD9 Codes: 5849, 5715, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6729
} | Medical Text: Admission Date: [**2121-10-15**] Discharge Date: [**2121-10-19**]
Date of Birth: [**2048-10-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Aortic valve replacement with a 27-mm [**Company 1543**] Ultra
Mosaic aortic valve bioprosthesis, serial number
[**Serial Number 99679**].
2. Coronary bypass grafting x1 with a reverse saphenous
vein graft from the aorta to the posterior left
ventricular coronary artery.
3. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
72 yo M with h/o CAD s/p BMS in LAD
and PTCA of D2 ostium, MR [**First Name (Titles) **] [**Last Name (Titles) **] presented today for
pre-admission testing. Patient reports feeling well overall
with
occasional
SOB with exertion (walking). He reports occasional palpitation.
However, there has not been any chest pain, orthopnea, PND,
swelling in the LE, syncope or pre-syncope. He is pre-op for
AVR/CABG.
Past Medical History:
Aortic Insufficiency
Coronary Artery Disease
s/p AVR, CABG this admission
PMH:
aortic insufficiency
mitral insufficiency
NSTEMI [**2113**]
coronary artery disease ( S/p BMS to LAD, PTCA to Diag)
mild normocytic anemia
chronic renal insufficiency ( baseline Cr 1.5)
hypertension
hyperlipidemia
pacemaker [**4-2**] ( first degree and type-1 second degree AVB)
Raynaud's syndrome
benign prostatic hypertrophy
RLL PNA [**2118**]
gastroesophageal reflux
left gynecomastia
right LE varicosities
Social History:
Lives with:wife
Occupation:investment manager
Tobacco:quit 50 yrs ago
ETOH:[**1-25**] glasses wine/day
Family History:
There is no family history of premature coronary artery disease,
unexplained heart failure, or sudden death.
Physical Exam:
Pulse: 60 Resp: O2 sat: 96% RA
B/P Right: 137/64 Left: 140/67
Height: 69" Weight: 140#
General:thin gentleman
Skin: Dry [x] intact [x]2 tiny bites at xyphoid area
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM []-no JVD noted
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur- [**3-29**] diastolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: RLE
Neuro: Grossly intact;nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2121-10-18**] 04:30AM BLOOD Hct-25.8*
[**2121-10-17**] 05:55AM BLOOD WBC-9.9 RBC-2.90* Hgb-9.5* Hct-27.6*
MCV-95 MCH-32.7* MCHC-34.3 RDW-13.3 Plt Ct-120*
[**2121-10-18**] 04:30AM BLOOD UreaN-21* Creat-1.1 Na-134 K-4.2 Cl-98
Intra-Op TEE [**2121-10-15**]
Conclusions
Pre CBP:
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 are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly depressed (LVEF= 50 %).
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 descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. Severe (4+) aortic regurgitation is seen. Flow
reversal was observed in the thoracic descending aorta.
Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
Post CPB:
The cardiac output is 4.8L/min, the patient is being AV paced.
There is mild MR.
There is a well seated bioprosthetic valve in the aortic
position, with a peak gradient of 10mmHg and a mean gradient of
6mmHg.
The thoracic aortic contours are intact.
The LVEF is 40% with mild hypokinesis in the inferior wall,
although it is difficult to assess wall motion abnormalities
accurately while pacing.
Brief Hospital Course:
The patient was brought to the operating room on [**2121-10-15**] where
the patient underwent CABG and AVR (27-mm [**Company 1543**] Ultra Mosaic
aortic valve bioprosthesis, serial number [**Serial Number 99679**]) with Dr.
[**Last Name (STitle) 914**]. See operative report for full details. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Cefazolin 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. His permanent pacemaker was interrogated
and pacing wires discontinued. 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 were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to home in good condition with
appropriate follow up instructions.
Medications on Admission:
atenolol 12.5 mg daily
ASA 162 mg daily
lipitor 20 mg daily
lisinopril 20 mg daily
MVI daily
Vit D2 1000 units daily
omeprazole 20 mg daily
flomax 0.4 mg daily
fish oil 1200 mg/144 mg daily
SL NTG prn
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 pain.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
9. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5
Tablets PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic Insufficiency
Coronary Artery Disease
s/p AVR, CABG this admission
PMH:
aortic insufficiency
mitral insufficiency
NSTEMI [**2113**]
coronary artery disease ( S/p BMS to LAD, PTCA to Diag)
mild normocytic anemia
chronic renal insufficiency ( baseline Cr 1.5)
hypertension
hyperlipidemia
pacemaker [**4-2**] ( first degree and type-1 second degree AVB)
Raynaud's syndrome
benign prostatic hypertrophy
RLL PNA [**2118**]
gastroesophageal reflux
left gynecomastia
right LE varicosities
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
No LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2121-10-24**]
11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8708**], M.D. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2121-11-13**] 4:00
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2121-11-4**]
4:00
Please call to make an appointment with Dr. [**Last Name (STitle) 914**] in [**2-26**] weeks
[**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**
Completed by:[**2121-10-19**]
ICD9 Codes: 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6730
} | Medical Text: Admission Date: [**2162-5-18**] Discharge Date: [**2162-5-27**]
Date of Birth: [**2087-5-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain/Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2162-5-21**] - Off pump CABG X 2 (Internal mammary to left anterior
descending artery, vein graft to obtuse marginal).
[**2162-5-18**] - Cardiac Catheterization
History of Present Illness:
This 75 year old female with a history of hypertension, smoking
and hyperlipidemia was recently referred to Dr. [**Last Name (STitle) **] for
evaluation of new onset chest pain. Two weeks ago, she awoke
from
sleep with chest pain that lasted for an hour. Since then, she
has had one further episode of chest pain, occuring at rest. She
took Mylanta at that time with relief of her symptoms. She has
also been experiencing new onset dyspnea with exertion. She has
dyspnea after walking about 2 blocks. She denies claudication,
orthopnea, PND, and lightheadedness. She has left ankle edema.
She was referred for a stress test, done at the [**Hospital1 882**] on
[**2162-5-10**]. She exercised for 6?????? [**First Name8 (NamePattern2) **] [**Doctor First Name **] protocol. Negative for
chest pain. Positive for 3mm downsloping ST segment depressions
in leads II, III, AVF and V4-V6. Nuclear imaging was significant
for a severe reversible anterior defect involving the mid and
apical segments of the anterior wall, mid and apical segments of
the upper septum and apical segment of the apex. EF 87%.
Past Medical History:
Hypertension
Hyperlipidemia
Glaucoma
hysterectomy
cyst removed from ovary
D&C
Cataract surgery to the right eye with a lens implant
Social History:
Social: Lives alone, works for the mass highway dept as an
administrative assistant. She has no children. Has a 40-80 pack
year history of smoking quitting 9 days Ago. Occassional alcohol
consumption.
Family History:
Father died of MI at age 56
Physical Exam:
57 SB 16 145/77 62" 148lbs
GEN: NAD
HEENT: NCAT, PERRL, Anicteric sclera, OP benign
NECK: supple, FROM
LUNGS: Mildly diminished breath sounds at left base
HEART: RRR, , No M/R/G
ABD: Soft, NT, ND, NABS
EXT: Warm, well perfused without edema. No varicosities noted on
standing
NEURO: Nonfocal
Pertinent Results:
[**2162-5-18**] 09:00AM PT-11.9 PTT-29.9 INR(PT)-1.0
[**2162-5-18**] 09:00AM WBC-8.8 RBC-4.24 HGB-12.0 HCT-35.4* MCV-84
MCH-28.2 MCHC-33.8 RDW-13.6
[**2162-5-18**] 09:00AM %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE
[**2162-5-18**] 09:00AM ALT(SGPT)-27 AST(SGOT)-23 CK(CPK)-86 ALK
PHOS-54 AMYLASE-30 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1
[**2162-5-18**] 09:00AM GLUCOSE-217* UREA N-18 CREAT-0.9 SODIUM-135
POTASSIUM-3.3 CHLORIDE-97 TOTAL CO2-31 ANION GAP-10
[**2162-5-18**] 11:27AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG
[**2162-5-18**] Cardiac Catheterization
1. Coronary angiography of this right dominant system
demonstrated 3
vessel coronary artery disease. The LMCA had no
angiographically
apparent flow-limiting disease. The LAD had a 90% proximal
stenosis and
a 70% mid-vessel stenosis. The diagonal-1 branch was small and
had a
40% distal stenosis. The LCx had a 70% mid-vessel stenosis.
The OM1
had diffuse disease with a 40% stenosis. The OM2 was occluded.
The RCA
had a proximal total occlusion. There were left to right
collaterals.
2. Limited resting hemodynamics revealed elevated left sided
filling
pressure with a LVEDP of 16 mmHg. The systemic arterial
pressure was
normal with a BP of 136/65 mmHg. There was no transaortic valve
gradient on pullback of the catheter from the LV to the aorta.
3. Left ventriculography demonstrated no mitral regurgitation.
The
calculated LVEF was 67%. There was normal LV systolic wall
motion.
[**2162-5-19**] ECHO
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is
11-15mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size and systolic function (LVEF>55%).
Regional left ventricular wall motion is normal. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated. Right ventricular systolic function is 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. Trace to
mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2162-5-19**] Carotid Ultrasound
Less than 40% stenosis of the proximal internal carotid arteries
bilaterally. This is a baseline examination at the [**Hospital1 18**].
Brief Hospital Course:
Ms. [**Known lastname 72388**] was admitted to the [**Hospital1 18**] on [**2162-5-18**] for a cardiac
catheterization. This revealed three vessel coronary artery
disease and given the severity of it, the cardiac surgical
service was consulted. Ms. [**Known lastname 72388**] was worked-up in the usual
preoperative manner including a carotid duplex ultrasound which
showed less then a 40% stenosis of the bilateral internal
carotid arteries. Given that her preoperative chest x-ray and
echocardiogram showed an atherosclerotic aorta, it was planned
to do her surgery off pump. On [**2162-5-21**], Ms. [**Known lastname 72388**] was taken
to the operating room where she underwent off pump coronary
artery bypass grafting to vessels. Postoperatively she was taken
to the cardiac surgical intensive care unit for monitoring. By
postoperative day one, Ms. [**Known lastname 72388**] had awoke neurologically
intact and was extubated. Gentle diuresis was initiated. The
physical therapy service was consulted for assistance with her
postoperative strength and mobility. On postoperative day four,
she was transferred to the step down unit for further recovery.
She developed atrial fibrillation which converted to normal
sinus rhythm with an increase in her beta blockade. As she
continued to have paroxysmal rate controlled atrial
fibrillation, coumadin was started for anticoagulation. Her
white blood cell count was mildly elevated however slowly
trended back towards normal. No evidence of infection was found
and a repeat white cell count will be checked [**2162-5-31**]. She
continued to make steady progress and was discharged to [**Hospital **]
Rehab on [**2162-5-27**]. She will follow-up with Dr. [**Last Name (STitle) **], her
cardiologist and her primary care physician as an outpatient.
Her coumadin will be managed by Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 53443**] upon
discharge from rehab for a goal INR of 2.0-2.5 for atrial
fibrillation.
Medications on Admission:
HCTZ 25mg daily
Atenolol 25mg daily
Simvastatin 20mg daily
Timolol eye gtts one drop both eyes [**Hospital1 **]
Aspirin 325mg 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
4. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 1 months.
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-9**]
Puffs Inhalation Q6H (every 6 hours) for 1 months.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5
days: Take for five days with potassium and then stop.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days: Take with lasix and stop when lasix stopped. .
13. Coumadin 1 mg Tablet Sig: Dose for goal INR of 2.0-2.5
Tablets PO once a day: Dose for goal INR of 2.0-2.5 for Atrial
fibrillation. Monitor daily PT/INR and dose accordingly. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
CAD
HTN
Glaucoma
AF
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeksfroom date of
surgery.
6)No driving for 1 month.
7)Take lasix 40mg once daily with potassium 20mEq once daily for
five days and then stop. Please monitor electrolytes and replete
as needed.
8)Take coumadin daily for goal INR of 2.0-2.5 for atrial
fibrillation. Please monitor daily PT/INR for appropriate
dosing. Dr. [**Last Name (STitle) 72389**] (PCP) [**Telephone/Fax (1) 6803**] or Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
(Cardiologist) ([**Telephone/Fax (1) 72390**] will manage her coumadin as an
outpatient. Please call to arrange follow-up appointment prior
to discharge from rehab. She received her coumadin dose (4mg)
for [**2162-5-27**].
9)Please check white blood cell count on Monday [**2162-5-31**].
10)Please call wih any questions or concerns.
Followup Instructions:
with Dr. [**Last Name (STitle) 53443**] (PCP) in [**3-13**] weeks [**Telephone/Fax (1) 6803**]
with Dr. [**Last Name (STitle) **] (Cardiologist) in [**3-13**] weeks [**Telephone/Fax (1) 57005**]
with Dr. [**Last Name (STitle) **] in [**5-13**] weeks (Cardiac Surgeon) ([**Telephone/Fax (1) 1504**]
Please call all providers for appointments.
Needs coumadin follow-up upon discharge from rehab. Likely Dr.
[**Last Name (STitle) 53443**] (PCP) [**Telephone/Fax (1) 6803**] or if patient prefers Dr. [**Last Name (STitle) **]
cardiologist [**Telephone/Fax (1) 57005**]. Please call to arrange when patient
discharged from rehab. Goal INR is 2.0-2.5 for AF.
Completed by:[**2162-5-27**]
ICD9 Codes: 4111, 2724, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6731
} | Medical Text: Admission Date: [**2169-7-7**] Discharge Date: [**2169-7-15**]
Date of Birth: [**2126-7-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
LEFT SUB-OCCIPITAL CRANIOTOMY
History of Present Illness:
41M with headaches x 1 month that are persistent and not
relieved by Advil. The patient reports blurred vision with the
"waves" of headache. He also was woken up 3 times this week in
the middle of the night with vomiting. Currently he does not
have nausea. He does not report gait disturbances. The patient
works full time as a dentist and has not taken any time off
since the onset of symptoms. He went to his PCP today who
ordered a head CT. It showed a new large left cerebellar brain
mass with ring enhancement. The patient does not take coumadin,
aspirin, or
plavix and has no history of cancer.
Past Medical History:
none
Social History:
works as a dentist; lives with his female partner and their 17
year old son
Family History:
non-contributory
Physical Exam:
Exam upon admission:
T:97.8 BP:140/92 HR:63 RR:16 O2Sats:99% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
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, 4 to 3 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-20**] throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin. No dysmetria noted.
Pertinent Results:
CT Head [**7-14**] prior to EVD removal:
FINDINGS: Again left-sided posterior fossa craniotomy is
identified with
small amount of blood products in the region. The previously
noted air within
the area has decreased. A small hypodensity is seen in the
region to the
surgery with small areas of blood products from surgery. No
large hematoma or
interval new blood products are seen. There remains some mass
effect on the
left side of the fourth ventricle, which is unchanged. A right
frontal
ventricular drain extends to the third ventricle which is
unchanged and
minimal prominence of temporal horns is also unchanged. The air
seen
previously within the right lateral ventricle and in the frontal
region has
resolved.
IMPRESSION:
1. Overall no significant change in the mass effect on the
fourth ventricle
without evidence of new hemorrhage.
2. Ventricular size is unchanged
3. Interval resorption of pneumocephalus.
MRI [**2169-7-11**]:
FINDINGS: The patient is post left occipital craniectomy with
mesh in place
overlying the left cerebellum. The previously seen left
cerebellar enhancing lesion has been resected. Small amount of
blood products are seen in the surgical bed. There is persistent
cerebellar edema and mass effect on the left ambient cistern
with evidence of upward transtentorial herniation. There is a
thin left subgaleal fluid collection, measuring up to 6 mm in
thickness, containing fluid and air. Again seen is a right
transfrontal ventriculostomy catheter with its tip in the region
of the foramen of [**Last Name (un) 2044**]. The ventricles are not dilated. There
is no shift of normally midline structures. Major flow voids are
unremarkable. There is susceptibility artifact within the right
lateral ventricle, consistent with air.
Following contrast administration, there is faint enhancement at
the edge of the resection cavity, which could be seen in the
postoperative setting,
however continued followup to rule out recurrence is
recommended.
IMPRESSION:
1. Status post resection of left cerebellar lesion with small
amount of blood products in the surgical bed and faint
enhancement at the edge of the cavity, which may be related to
post-surgical/inflammatory changes, however continued followup
is recommended to rule out residual tumor.
2. Small subgaleal postoperative fluid collection.
3. Persistent edema in the left cerebellum with a mass effect on
the ambient cistern.
Head CT [**7-10**]:
FINDINGS" There has been an interval left occipital craniectomy
with mesh in place overlying the left cerebellum. There is
expected pneumocephalus and high attenuation material within the
resection cavity consistent with blood products. There is a
right frontal approach ventriculostomy catheter with tip in the
region of the foramen of [**Last Name (un) 2044**]. There is expected pneumocephalus
and air within the right lateral ventricle. The ventricles
appear nondilated and basal cisterns are preserved. There is no
major midline shift. Outside of the resection site, there is a
now new hemorrhage. [**Doctor Last Name **]-white matter junction differentiation
is preserved. There is no edema outside the resection site. Air
is seen in the subcutaneous tissues overlying the right frontal
bone towards the vertex and in the operative site of the left
occipital region. Mastoid air cells are clear. Visualized
paranasal sinuses are unremarkable.
IMPRESSION: Expected postoperative changes with no significant
shift of
midline structures or abnormal dilatation of ventricles.
Brief Hospital Course:
Mr [**Known lastname **] was admitted to Neurosurgery service started on
Decadron for a new brain mass he underwent a torso CT to assess
for any sign of malignancy which was negative. He underwent a
sub occipital craniotomy for mass removal with EVD placement. He
was monitored in the ICU for three days, treated with
antihypertensives and slow EVD wean. He complained of neck pain,
from the incision fo which he was started on Valium. Post
operative MRI showed complete resection. Neur-Onc was consulted
and they recommended follow in one month. Differential diagnosis
included: hemangioblastoma, and pilocytic astrocytoma pathology
is pending. He was transferred to the regular floor on [**7-14**] his
drain was removed. Overnight he had no difficulties only neck
incision pain, he ambulated without difficulty and was
tolerating a regular diet.
Medications on Admission:
Advil
Discharge Medications:
1. Lisinopril 20 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).
Disp:*60 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for headache: No driving while on
this medication.
Disp:*50 Tablet(s)* Refills:*0*
4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for neck pain/spasm.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
LEFT CEREBELLAR MASS
Discharge Condition:
NEUROLOGICALLY STABLE
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
PLEASE SEE YOUR PCP REGARDING CT OF CHEST/ABD/PELVIS, IT
REQUIRES A REPEAT STUDY IN 3 MONTHS
You have both sutures and staples in the front of your head as
well as the back you will need those removed around [**7-20**]
call [**Telephone/Fax (1) 1669**] for an appointment with [**Name8 (MD) **] NP
You have a Brain [**Hospital 341**] Clinic appointment with [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD
Phone:[**Telephone/Fax (1) 1844**]. It is on [**2169-8-7**] at 3:00pm on [**Hospital Ward Name 23**] 8 on
the [**Hospital Ward Name 516**].
Completed by:[**2169-7-15**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6732
} | Medical Text: Admission Date: [**2199-5-3**] Discharge Date: [**2199-5-5**]
Date of Birth: [**2166-10-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Female First Name (un) 82171**]
Chief Complaint:
Tylenol PM overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
38 year old male with unknown past medical history (presumed
depression as of [**1-/2199**]) found unresponsive with three wine
bottles, suicide note and empty bottle of Tylenol PM (40
tablets) found next to him this evening. Receipt for the Tylenol
PM was for 9:21 pm, [**5-2**]. A third party called EMS who brought
him to [**Hospital1 18**] ED. No other drugs found at the scene. No signs of
trauma. Per report, patient was found wearing multiple T-shirts
from his bachelors party, with wife's wedding garter belt around
his neck. Had recently told a friend he wished to be cremated.
.
In the [**Hospital1 18**] ED, initial VS: T98.1, HR123, BP133/81, RR30, O2
sat 100% on RA. The patient was initially minimally verbally
responsive but protecting his airway, ABG 7.42/34/81. EKG showed
sinus tachycardia with QTc 438 and QRS 92. Urinalysis negative
for UTI and UTox negative for other substances. Labs were
generally unremarkable except for Creatinine 1.3, INR 1.2 and
serum alcohol level 56. LFTs currently normal. Serum tylenol
still pending upon arrival to MICU. The patient became very
agitated with Foley catheter placement, requiring Lorazepam 2mg
IV. Haldol was avoided to prevent QTc prolongation. The patient
also received Zofran 4mg for nausea and 3L IVF. Toxicology was
consulted and recommended empiric NAC, which was started (first
dose). They recommended against using activated charcoal since
the patient likely ingested hours earlier and would be at risk
for aspiration with his mental status. It was estimated that the
patient consumed ~20 grams of tylenol and 1 gram of benadryl
within the last 4.5 hours.
.
ROS: Patient arousable but garbled speech, does not endorse any
complaints.
Past Medical History:
- L thumb tip avulsion (kitchen knife, [**3-/2198**])
- Depression
Social History:
Denies tobacco, illicit drug use. Reports 1-2 drinks per week.
Of note, lived at home with wife until she recently moved out
after being threatened repeatedly by patient.
Family History:
Schizophrenia
Physical Exam:
ADMISSION
VS: Temp: 97.1 BP: 140/88 HR: 99 RR: 16 O2sat 99% on RA
GEN: Sleeping soundly but responsive to verbal stimuli, follows
commands, comfortable, NAD, garbled speech but appropriate
HEENT: PERRL - dilated, EOMI, anicteric, MMM, op without
lesions, no supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTA b/l with good air movement throughout, no
wheezing/rhonchi/rales anteriorly
CV: RR, S1 and S2 wnl, no murmurs/gallops/rubs
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAO. CN 2-12 intact. Moving all extremities.
DISCHARGE
VS: 97.9 80 125/80 15 99%RA
GEN: Well appearing, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTA b/l with good air movement throughout, no
wheezing/rhonchi/rales anteriorly
CV: RR, S1 and S2 wnl, no murmurs/gallops/rubs
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAO. CN 2-12 intact. Moving all extremities.
Pertinent Results:
Blood Counts
[**2199-5-3**] 01:10AM BLOOD WBC-7.0 RBC-4.49* Hgb-14.5 Hct-40.8
MCV-91 MCH-32.2* MCHC-35.4* RDW-12.9 Plt Ct-240
Coags
[**2199-5-3**] 01:10AM BLOOD PT-13.8* PTT-23.1 INR(PT)-1.2*
[**2199-5-3**] 10:06AM BLOOD PT-15.6* PTT-26.4 INR(PT)-1.4*
[**2199-5-5**] 07:25AM BLOOD PT-12.6 PTT-23.5 INR(PT)-1.1
Chemistry
[**2199-5-3**] 01:10AM BLOOD Glucose-97 UreaN-13 Creat-1.3* Na-143
K-3.8 Cl-104 HCO3-23 AnGap-20
[**2199-5-5**] 07:25AM BLOOD Glucose-98 UreaN-14 Creat-1.1 Na-139
K-4.0 Cl-99 HCO3-31 AnGap-13
LFTs
[**2199-5-3**] 01:10AM BLOOD ALT-23 AST-22 AlkPhos-56 TotBili-0.6
[**2199-5-3**] 05:35PM BLOOD ALT-18 AST-15 LD(LDH)-157 AlkPhos-51
TotBili-1.0
[**2199-5-5**] 07:25AM BLOOD ALT-16 AST-13 LD(LDH)-158 AlkPhos-58
TotBili-0.7
Tox
[**2199-5-3**] 01:10AM BLOOD ASA-NEG Ethanol-56* Acetmnp-210*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2199-5-3**] 10:06AM BLOOD Acetmnp-52*
[**2199-5-3**] 05:35PM BLOOD Acetmnp-6*
[**2199-5-4**] 12:40AM BLOOD Acetmnp-NEG
EKG [**2199-5-3**]
Sinus tachycardia. There are non-diagnostic Q waves in the
inferior leads.
Non-specific ST-T wave changes.
Brief Hospital Course:
HOSPITAL COURSE
This is a 38yo M who presented with a tylenol and benadryl
overdose w/o significant signs of toxicity, stable over 48hrs,
medically cleared, now being discharged to [**Hospital1 **] 4
Psychiatric Service.
.
ACTIVE
# s/p suicide attempt: Pt found unresponsive with a suicide
note, admitted to medical ICU for management of tylenol/benadryl
overdose as below, now stable and medically cleared. He was
monitored by 1:1 sitter, with social work and psychiatry
following patient regarding ongoing mental health and social
issues, including reports from wife of patient being
increasingly paranoid and "emotionally abusive". Patient
expressed regret re: suicide attempt. After evaluation by
Psychiatry service, patient is now being discharged to [**Hospital1 **]
4 Psychiatric Service.
.
# Tylenol overdose: Patient admitted with tylenol overdose,
estimated at 20g by toxicology service. Admission acetaminophen
level of 210 at (~4hrs post ingestion). Patient received NAC
and was monitored without major abnormality of LFTs, INR.
Patient without any signs of significant toxicity at 48hrs post
ingestion.
.
# Benadryl overdose: Patient admitted w delirium and agitation
thought to be [**1-2**] to bendryl overdose, but was without
significant QTc prolongation, hyperthermia, urinary retention.
His mental status cleared and was without any prolonged toxicity
at 48hrs post ingestion.
.
TRANSITIONAL
1. Code status - Patient remained full code
2. Pending - No labs/studies were pending at discharge
3. Transition of Care - Patient was medically cleared; after
evaluation by psychiatry service, patient was accepted to
[**Hospital1 **] 4 Psychiatric Service.
Medications on Admission:
-Vitamin D2
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY
Tylenol Overdose
Benadryl Overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Last Name (Titles) 82172**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for treatment of a tylenol
and benadryl overdose. You were monitored and did not
demonstrate any signs of lasting toxicity. You were medically
cleared and are now being discharged to the [**Hospital1 18**] Psychiatric
Service
Followup Instructions:
Please follow-up with the pschiatrists on the [**Hospital1 18**] Psychiatric
Service
[**Month (only) 6436**] ([**Month (only) **]) [**Name8 (MD) **] MD [**MD Number(2) 82173**]
ICD9 Codes: 5849, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6733
} | Medical Text: Admission Date: [**2138-4-6**] Discharge Date: [**2138-4-10**]
Date of Birth: [**2062-9-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
dyspnea, chest pressure on exertion
Major Surgical or Invasive Procedure:
Cardiac catheterization; cardiac electrophysiology study w/
ablation
History of Present Illness:
Mr. [**Known lastname 96278**] is a very pleasant 75 yo M w/ PMHx of HTN, moderately
dilated aorta, moderate aortic regurgitation, AV conduction
delay, who presnted to the ED after experiencing new onset
anginal symptoms this AM. According to the Pt he has been in his
usual state of health and this morning noted a sensation of
chest pressure and dyspnea while putting the dishes away after
eating breakfast. The episode resolved after rest and deep
breathing. The Pt then decided that he would climb the stairs in
his home so that he could check his BP and pulse on monitor he
has at home. When climbing the stairs, again he felt a sensation
of chest pressure and dyspnea. He noted that his BP was 150s/80s
and heart rate 97 which is very fast for him. The pressure
sensation again resolved spontaneously after rest and deep
breathing. The sensation felt the same on both occasions and was
not associated with any nausea, vomiting, diaphoresis, or
radiation. Each time the episode lasted approximately 2 minutes.
The Pt then called his PCP who recommended that he present to
the ED for further evaluation. According to the Pt, this
discomfort is new. Approximately 2-3 weeks ago, he resumed
working out regularly after not working out for a number of
weeks. He has been able to do regular exercise including weight
lifting and cardiovascular exercise without experiencing any
chest discomfort.
.
In the ER, vitals were 98.5 92 138/90 18 98 . Exam with 1+
LLE>RLE pitting edema (old), guiac negative. EKG showed LBBB
(old). He was given ASA 324mg and started on IV heparin.
.
On evaluation on the floor, he reported no discomfort and
specifically denied any chest discomfort or dyspnea. He was
without any complaints.
Past Medical History:
1. Hypertension.
2. Dyslipidemia.
3. S/p bilateral total knee replacement.
4. H/o prostate cancer.
5. Colonic adenoma [**2129**].
.
Cardiac Risk Factors:- Diabetes, +Dyslipidemia, +Hypertension
.
Cardiac History: No CABG
.
Percutaneous coronary intervention: none
.
Pacemaker/ICD: none
Social History:
Pt is married real estate investor who lives in [**Location 1887**], Ma with
his wife. [**Name (NI) **] has 3 daughters and 11 grandchildren and is a
former weightlifter who reports that he holds multiple
weightlifting records. He denied any hx of steroid use or
performance enhancing drugs. He denies tobacco or illicit drugs
and admits to social ETOH 3-4 times per week.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - T 98 BP 118/64 P 100 rr 20 O2 sat 97% 2L
Gen: Pleasant 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 with JVP of 4 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
On admission:
[**2138-4-6**] 01:30PM BLOOD WBC-7.8# RBC-5.19 Hgb-16.0 Hct-46.3
MCV-89 MCH-30.9 MCHC-34.6 RDW-13.9 Plt Ct-158
[**2138-4-6**] 01:30PM BLOOD PT-12.5 PTT-24.0 INR(PT)-1.0
[**2138-4-6**] 01:30PM BLOOD Glucose-96 UreaN-32* Creat-1.0 Na-140
K-3.5 Cl-101 HCO3-32 AnGap-11
[**2138-4-6**] 01:30PM BLOOD CK(CPK)-142
[**2138-4-6**] 01:30PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
.
On discharge:
[**2138-4-10**] 06:00AM BLOOD WBC-8.1 RBC-4.80 Hgb-14.4 Hct-42.7 MCV-89
MCH-29.9 MCHC-33.7 RDW-13.9 Plt Ct-136*
[**2138-4-9**] 06:05AM BLOOD Neuts-78.8* Lymphs-13.5* Monos-6.0
Eos-1.2 Baso-0.5
[**2138-4-10**] 06:00AM BLOOD PT-13.3 PTT-34.6 INR(PT)-1.1
[**2138-4-10**] 06:00AM BLOOD Plt Ct-136*
[**2138-4-10**] 06:00AM BLOOD Glucose-94 UreaN-26* Creat-1.0 Na-141
K-4.5 Cl-104 HCO3-30 AnGap-12
[**2138-4-7**] 05:10AM BLOOD CK(CPK)-119
[**2138-4-10**] 06:00AM BLOOD Mg-2.0
.
Cardiac catheterization ([**2138-4-8**]):
1. Selective coronary angiography of this right dominant system
demonstrated no significant coronary artery disease. The LMCA,
LAD, and
LCx were free of disease. The RCA had mild, non flow limiting
disease.
.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal ventricular function.
.
Brief Hospital Course:
Mr [**Known lastname 96278**] is a pleasant 75 yo M with hx of HTN, moderately
dilated aorta, moderate aortic regurgitation, AV conduction
delay, who presented to the [**Hospital1 18**] ED after experiencing new
onset anginal symptoms on the morning of admission. He was
subsequently admitted to the cardiology service on [**2138-4-6**] where
his anginal symptoms were evaluated. He underwent cardiac
catheterization on [**2138-4-7**] and cardiac electrophysiology study
with ablation on [**2138-4-8**]. He was discharged to home on [**2138-4-10**]
his brief hospital course was notable for:
.
#. CAD/angina: Pt did not have hx of known CAD but has multiple
risk factors including hypertension, hyperlipidemia, age, sex.
TIMI risk score is [**3-19**]. Pt history of new onset dyspnea on
exertion on morning of admission was conerning for unstable
angina. He did not have EKG changes or cardiac enzymes leak to
suggest NSTEMI. He was ruled out for myocardial infarction with
three sets of negative cardiac enzymes, and no EKG changes. He
underwent cardiac catheterization on [**2138-4-7**] to evaluate
unstable angina. The catheterization was tolerated well, and
demonstrated clean coronaries, with a normal ejection fraction,
and no intervention was performed.
.
Of note, during the cardiac cath the Pt was noted to have a
somewhat dilated and tortuous aorta. Prior to this
hospitalization he had a previously known history of aortic
dilation, presumed to be related to his history as a
weightlifter. Further imaging of the aorta such as CTA or MRI
could be considered as an outpatient.
.
# Wide complex tacchycardia: On the evening of admission, on two
separate occasions the Pt was noted to go into a wide complex
tacchycardia with a rate to 180-190s. Although there was initial
concern for ventricular tachycardia, after thorough review of
telemetry and 12-lead EKGs, it was thought that this arrhythmia
most likely represented a supraventricular tachycardia with
aberrancy. During both these episodes, the Pt was asymptomatic,
and maintained a blood pressure within normal limits. The first
episode lasted approximately 20 minutes and resolved after vagal
maneuvers and 5 mg IV metoprolol. The second episode lasted
approximately 5 minutes and resolved spontaneously. The Pt was
monitored on telemetry and had no other such events.
.
He underwent consultation by the cardiac electrophysiology
service and subsequent EP study, during which he was found to
have Right side atrial flutter with aberrancy of Left Bundle
Branch Block. The atrial flutter was pace terminated, but after
ablation, he had an 8 second pause and remained in a junctional
rhythm with HR in the 50s. He was briefly on isoproteronol,
which was weaned off, and a temporary pacing wire was placed
through a Right femoral line into the right atrium for backup
pacing. The patient was transferred to the CCU overnight for
monitoring on telemetery. He had no complaints of chest pain,
shortness of breath, or palpitations overnight. He was noted to
be in sinus bradycardia with rate in 40s-50s, intermittently
paced with frequent PACs and PVCs on presentation to the CCU; in
the morning, his sinus node appeared to have recovered, and he
was noted to be in sinus bradycardia with rate in 50s, not being
paced. The pacing wire and femoral line were removed, and he
was transferred back to the floor in stable condition. He was
discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Event Monitor and with
outpatient follow-up arranged.
.
#Anticoagulation: Pt [**Name (NI) 96278**] was initiated on Warfarin at the time
of discharge. He was also given a prescription for Lovenox 120
mcg qD to be taken [**Hospital1 **] until his INR is therapeutic. He was set
up with follow-up at the [**Hospital 191**] [**Hospital 197**] clinic, where he was
scheduled to visit on the day after discharge. After that time
they will assume responsibility for his anticoagulation.
.
All other chronic medical issues for this Pt were stable. No
further changes were made to this Pt's outpatient medication
regimen than those noted above. He was discharged to home in
good condition, ambulatory, with stable vital signs, and with
appropriate outpatient follow-up arranged.
Medications on Admission:
ASA 81 mg qD
Cholecalciferol 2,000 units 1 tab qD
Diovan 80 mg -12.5 qD
Fish oil 1200-144 qD
Lorazepam 1mg [**Hospital1 **] PRN anxiety
MVI 1 tab qD
Simvastatin 40 mg qD
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Five (5)
Tablet PO DAILY (Daily).
5. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
twice a day: Please take until advised to stop by [**Hospital 197**]
clinic.
Disp:*30 * Refills:*2*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 2 mg Tablet Sig: as dir Tablet PO once a day: Please
take these tablets as directed by the [**Hospital 197**] clinic.
*** Only fill this prescription if directed to do so by coumadin
clinic.
Disp:*30 Tablet(s)* Refills:*2*
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Outpatient Lab Work
Please have INR drawn on Saturday [**2138-4-12**] at [**Hospital3 18648**] and have the result paged to the [**Hospital1 18**] [**Company 191**] physician on
call. [**Hospital1 18**] main number [**Serial Number 20875**], Dr. [**First Name4 (NamePattern1) 1169**] [**Last Name (NamePattern1) **] will be
on call.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: atrial flutter s/p ablation
Secondary: hypertension, dyslipidemia
Discharge Condition:
Good, normotensive and in sinus rhythm, ambulatory, AOX3
Discharge Instructions:
You came into the hospital after developing chest pressure and
shortness of breath. We determined that your symptoms were not
caused by a heart attack. During your hospital stay, on two
occasions your heart was noted to go in a fast rhythm for a
brief period of time. You underwent a cardiac catheterization;
this test did not show any significant coronary disease. You
also underwent an electrophysiology study which showed that you
had an abnormal heart rhythm called atrial flutter, and you had
an ablation procedure to try to prevent this rhythm from coming
back.
.
You are being discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to
evaluate your heart rhythm at home. You have received
instructions on how to use this monitor.
.
You will also need to take a blood thinning medication
(warfarin, sometimes known as Coumadin) to reduce your risk of
stroke related to the atrial flutter. While taking warfarin,
close monitoring is essential to prevent the blood from becoming
too thin, increasing your risk of bleeding, or not thin enough.
The anticoagulation nurses will coordinate the dose of the
warfarin. You will need to get your first blood test (INR) on
Saturday [**2138-4-12**] at [**Hospital6 4620**]. It is very
important that the results of this test are paged to the [**Company 191**]
physician on call, available at phone [**Numeric Identifier 20875**].
.
The following changes have been made to your outpatient
medication regimen:
STARTED Warfarin 5 mg by mouth once daily. Please take this
medication daily as instructed by the [**Hospital 197**] clinic.
STARTED Enoxaparin 120mg injections twice daily. Please take
this medication until instructed to stop by the [**Hospital 197**] clinic.
.
Please continue to take your other medications as directed and
keep your followup appointments.
Followup Instructions:
Please follow up with your cardiologist Dr. [**Last Name (STitle) 171**] as
scheduled:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2138-5-28**]
1:20
.
Please call your primary care doctor, Dr.[**First Name (STitle) 216**], to schedule a
follow-up appointment within the next month [**Numeric Identifier 20875**]
.
You have been set-up for follow-up at the [**Hospital1 18**] Coumadin
(anti-coagulation) clinic. The clinic will call you tomorrow
[**4-11**] and assume care of your anticoagulation. If you do
not hear from them tomorrow, please call them at [**Telephone/Fax (1) 14650**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
ICD9 Codes: 2724, 4019, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6734
} | Medical Text: Admission Date: [**2102-4-8**] Discharge Date: [**2102-4-12**]
Date of Birth: [**2034-2-7**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Penicillins / Shellfish
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Pt is a 68 yo woman with PMH of tobacco use, RA presents to ED
today with chest pain, found to have inferior/posterior STEMI
with RV involvement. Patient was in her USOH until 2 week PTA
when developed sub-sternal chest pressure w/ radiation down both
arms while raking leaves. She rested after onset of pain, and
pain resolved after 5 minutes. 1 week prior to presentation,
patient again experienced these sxs after having "an emotional
phone call". Again, pt rested and pain resolved after [**10-29**]
minutes, but she was nervous about pain, so presented to [**Hospital 2538**] on [**2102-4-3**]. At that time she was r/o for MI with
negative cardiac enzymes and underwent stress ECHO that was
negative after going 7 minutes on [**Doctor First Name **] protocol, achieving 91%
of maximum HR. Therefore patient was discharged. She then
again had a similar episode of this pain last night, associated
w/ N/V x 1, but then was able to fall asleep without sxs.
Pt then reports this evening, developed same type of substernal
chest pressure, but more severe. Patient states she was baking
pies when had onset of [**9-24**] sub-sternal chest pressure, +
radiation down arms b/l, associated with N/V x 1 and
diaphoresis. Onset of sxs was 7:30pm. Therefore pt called
ambulanace and presented to [**Hospital1 18**].
On presentation to [**Hospital1 18**], pt was initially given NTG gtt and
morphine. Found to have EKG with ST elevations in inferior
leads with reciprical ST depressions in aVL, V1-V2. R sided EKG
demonstrated ST elevations in V4, indicating RV involvment.
Therefore nitro gtt d/ced, started on IVF - received a total of
1 L fluid bolus in ED. Also started on heparin gtt, integrilin
gtt, and given plavix load 300mg x 1 in ED. Also received
benadryl, solumedrol, pepcid prior to cardiac cath given hx of
dye allergy.
Patient presented to cath lab at 10:06 PM (therefore time of
onset of pain to cath lab was approximately 2.5 hours). In cath
lab, patient found to have lesion in RCA extending into PDA and
PL - patient had 1 x stent placed in RCA-to-PDA, jailing the PL,
which was then rescued with balloon angioplasty (TIMI 3 flow
demonstrated). Also noted to have 50% LAD lesion after D1, 70%
L Cx lesion, 40% proximal RCA lesion. Hemodynamics were noted
to be CO 3.48, CI 2.02, PCWP 20, RA mean 15, PAP 46/22, RV 46/8.
Cath course c/b some bradycardia, thought [**2-16**] vagal response,
responded to atropine. Also had hypotension with SBP = 90's
intra-cath, given fluid boluses for total of 1.8L in cath (2.8L
total with 1L fluid bolus in ED). Post cath pt noted to have
small groin hematoma. Post cath EKG notable for resolution of
ST elevations, q waves in leads III and aVF. Patient had
resolution of pain in cath lab.
Currently patient feels well. Denies any chest pain/pressure,
SOB, diaphoresis, nausea, any other complaints.
ROS also negative for orthopnea, PND, LE edema.
Past Medical History:
Rheumatoid arthritis
Social History:
smokes 1-1.5 ppd x 55 years (quit on thursday - got nicotine
patch), rare EtOH, no drug use. Lives alone, 2 daughters live
nearby, also has 2 sons.
Family History:
Mother alive and well, father died in his 60's in a car
accident, has 6 brothers, no FH of CAD or DM
Physical Exam:
Vitals - Afebrile, HR 89, BP 101/85, RR 12, O2 90-92% on RA (not
SOB) -> 96% 2L NC
General - lying supine, awake, alert, pleasant, NAD
HEENT - PERRL, EOMI, dry MM
Neck - could not assess JVP as pt lying flat, no carotid bruit
b/l
CVS - RRR, nl S1, S2, no M/R/G
Lungs - CTA anteriorly and laterally - could not assess
posterior lung fields as pt lying supine
Abd - soft, NT/ND, + BS
Groin - R sided groin w/ some eccymoses, mildy tender to
palpation, ?small hematoma although difficult to assess, no
bruit ascultated
Ext - no LE edema b/l, 2+ DP pulses b/l
Neuro - A+O x 3, FROM x 4 ext
.
EKG on presentation: ST elevations in leads II, III, aVF with
reciprical ST depressions in aVL, V1-V2. R sided EKG with ST
elevation in V4.
.
Post cath EKG: Resolution of ST elevation, q waves noted in
III, aVF
Pertinent Results:
[**2102-4-8**] 09:20PM WBC-12.4* RBC-4.75 HGB-14.7 HCT-42.6 MCV-90
MCH-31.0 MCHC-34.5 RDW-15.1
[**2102-4-8**] 09:20PM NEUTS-50.9 LYMPHS-41.1 MONOS-5.5 EOS-2.2
BASOS-0.4
[**2102-4-8**] 09:20PM PLT COUNT-279
[**2102-4-8**] 09:20PM PT-11.6 PTT-19.2* INR(PT)-1.0
[**2102-4-8**] 09:20PM GLUCOSE-156* UREA N-24* CREAT-1.0 SODIUM-135
POTASSIUM-3.0* CHLORIDE-95* TOTAL CO2-25 ANION GAP-18
[**2102-4-8**] 09:20PM LD(LDH)-224 CK(CPK)-87
[**2102-4-8**] 09:20PM cTropnT-0.01
[**2102-4-8**] 09:20PM CK-MB-NotDone
.
CXR ([**4-8**]): Prominence of bilateral vasculature, which may
represent
early volume overload versus mild CHF.
.
C.cath ([**4-8**]):
1. Selective coronary angiography of this right dominant system
revealed
two vessel coronary artery disease. The LMCA was patent. The LAD
had
50% stenosis after D1. The LCX had 70% OM2 stenosis. The RCA had
proximal 40% and 100% stenoses distally at the crux.
2. Resting hemodynamics demonstrated elevated right and left
sided
pressures (mean RA pressure was 15mmHg, mean PCWP 20mmHg). There
was
evidence of moderate pulmonary hypertension. The cardiac index
was
normal at 2.02 L/min/m2.
3. Successful PTCA/stenting of the distal RCA with a 3.0x18mm
Cypher DES
posted to 3.5mm in the proximal portion with excellent results
(see PTCA
comments).
.
TTE ([**4-10**]):
1.The left atrium is normal in size.
2. 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%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is
seen.
5.The mitral valve leaflets are structurally normal. Mild (1+)
mitral
regurgitation is seen.
6.There is borderline pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Brief Hospital Course:
Assessment/Plan: Patient is a 68 yo woman with PMH tobacco use,
presents with inferior/posterior STEMI with RV involvement.
.
# Cardiac:
A. Ischemia: Patient presents with inferior/posterior STEMI
with RV involvement. Course complicated by some hypotension
noted in cath lab, responsive to IVF boluses. PCWP noted to be
20 intra-cath. Initially monitored with Swan-Ganz catheter.
Received integrilin gtt x 18 hours. Cardiac enzymes trended
down.
Continued on ASA 325mg QD, Plavix 75mg QD, Lipitor 80mg QD.
Started on a beta blocker and discharged on Toprol XL. Started
on ACE-i and discharged on lisinopril. Further lipid management
deferred to outpatient setting. Discharged to follow up with
Cardiology, may need ETT-MIBI in the future. Encouraged smoking
cessation.
.
B. Pump: Patient with EF=65%, no wall motion abnormalities
noted on stress ECHO done at [**Hospital3 **] on [**2102-4-4**]. Intra
cath hemodynamics consistent with mild fluid overload, with
PCWP=20, RA=15, PAP=46/22. TTE on [**4-10**] with EF 70-75%, no wall
montion abnormality, 1+ MR, and borderline PA systolic
hypertension. Euvolemic on exam upon discharge. Discharged on
beta blocker and ACE-inhibitor as above.
.
C. Rhythm: Patient was in NSR. Given RV involvement, was felt
to be high risk for arrythmia. No signs of nodal block on EKG.
Had asymptomatic run of NSVT with stable vital signs.
Maintained and discharged on beta blocker.
.
# Hematoma: Small hematoma noted in groin site post-cath.
Remained hemodynamically stable, improved to just ecchymosis by
discharge. Hct stable.
.
# Rheumatoid Arthritis: Patient on prednisone as outpatient.
Continued on prednisone with prn Tylenol for pain.
.
# Code status: Full
.
Medications on Admission:
Prednisone 5mg [**Hospital1 **]
HCTZ 50mg QD
Advil
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Inferoposterior ST elevation MI
Right groin hematoma
Discharge Condition:
good
Discharge Instructions:
Please take all of your medications as prescribed.
If you experience chest pain, shortness of breath, or other
concerning symptoms, please call your doctor or go to the ER.
Followup Instructions:
1) PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3142**], [**2102-4-17**] at 2:30pm, ([**Telephone/Fax (1) 35385**].
2) Cardiology: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], [**2102-5-4**] at 10:00am,
([**Telephone/Fax (1) 11814**].
Completed by:[**2102-9-13**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6735
} | Medical Text: Admission Date: [**2189-9-14**] Discharge Date: [**2189-10-3**]
Date of Birth: [**2133-7-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
I/O line placement x 2 in right leg [**2189-9-14**] which was removed
on [**2189-9-15**]
Right femoral central line [**2189-9-15**] which was removed on
[**2189-9-17**]
Right IJ dialysis line placed by IR on [**2189-9-17**]
Right Tunneled Catheter placed by IR on [**2189-9-25**]
History of Present Illness:
56 obese M h/o gout, a-fib (INR 7.7) p/w multiple joint pain x 3
days. Pt was in USOH until 3 days ago when he developed b/l knee
and ankle pain, R>L (both). This has gradually worsened and was
accd by fever/chills over the weekend, resolving the morning
prior to admission. Pt states that this is similar to past gout
attacks, but more severe. The right knee has swollen and the
right ankle has been warm.
In the ED, initial VS were 98.6, 86, 148/98, 16, 98% RA. Labs
notable for WBC 16.1, INR 7.7 (given 2.5mg Vit K). RLE LENI neg
for DVT. X-ray R knee showed a large effusion and
osteoarthritis. Arthrocentesis was performed which showed
hemarthrosis (369k RBC), leukocytosis (26k) with both negative
and positively birefringent crystals.
On arrival to the floor, patient reports pain right knee and
ankle > left knee, ankle. He denies any systemic symptoms of
fever, chills, chest pain, dyspnea, light-headedness or syncope.
At baseline poor mobility.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Diabetes Mellitus (last Alc 7.3 [**4-19**])
- Dyslipidemia
- Hypertension
- Chronic Kidney Disease Stage IV
- Morbid obesity
- Chronic systolic congestive heart failure, EF 25-30% ([**9-/2187**])
- Coronary Artery Disease
- Atrial fibrillation: on coumadin
- Gout
- Sleep apnea
- Moderate Pulmonary Hypertension, secondary
- Cardiac Cath [**5-/2187**]: 1. Selective coronary angiography in this
left dominant system demonstrated no obstructive coronary
disease. The LMCA was large and normal. The LAD was large and
ectatic with slightly delayed flow into the distal vessel
without luminal irregularities. The LCx was large and ectatic
with delayed flow into the left PDA. The RCA had no significant
disease.
Social History:
-On disability. Had been living with his brother and his
sister-in-law in [**Name (NI) 2268**], prior to rehab stay
-Tobacco history: Denies
-ETOH: Admits to prior heavy drinking, unable to quantify. last
drink 8 months ago
-Illicit drugs: Denies
Family History:
Hypertension, mother with heart disease.
Physical Exam:
Admission Exam
VS: T 98.5, HR 70, BP 168/100, RR 16, SO2 98%@RA
GEN: pleasant, morbidly obese, NT/ND, NAD
HEENT: NCAT, MMM, sclera anicteric
NECK: supple, trachea midline
PULM: CTAB, no r/r/w
CV: faint heart sounds; irregular rhythm, normal rate, no m/r/g,
EXT: R knee swollen, R>L knee pain on active and passive ROM; R
ankle tenderness with active and passive ROM; no L ankle
tenderness with active or passive ROM; no erythema or obvious
swelling (difficult to assess due to adiposity)
ABD: soft, morbidly obese, non-tender, no r/g
NEURO: fluent, linear, prompt, moving all 4 spontaneously.
Discharge Exam:
VS - 97.9 122-133/79-80 81 16 97 ra
GEN Morbidly obese, oriented, NAD, laying in bed
HEENT: NCAT, MMM, EOMI, sclera anicteric, OP clear.
NECK: supple, no LAD, tunnelled IJ HD cath in place, C/D/I, no
oozing, mild pain to palpation around site of placement. No
erythema or edema around site.
PULM: Good aeration anteriorally, CTAB no wheezes, rales. Less
rhonci and crackles heard in lower lobes this AM. Venti mask on
4L.
CV: Irregular rhythm with normal rate, normal S1/S2, no m/r/g,
distant heart sounds
ABD Obese, soft, diffusely tender on soft and deep palpation,
ND, hypoactive bowel sounds, no r/g
EXT: WWP 2+ pulses palpable bilaterally. Trace edema under
knees bilaterally. Tender to palpation in bilateral LE below
the knee. Knees are mildly warmer than rest of legs bilaterally.
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: Small (~2 cm) scratch to buttock, covered with Mepilux. No
other rashes or lesions noted.
GU: no foley
Pertinent Results:
Admission Labs
[**2189-9-14**] 03:40PM BLOOD WBC-16.1* RBC-5.02 Hgb-13.4* Hct-42.6
MCV-85 MCH-26.7* MCHC-31.4 RDW-14.5 Plt Ct-158
Relevent Labs:
[**2189-9-15**] 05:00AM BLOOD WBC-33.0*# RBC-3.85* Hgb-10.4* Hct-34.7*
MCV-90 MCH-26.9* MCHC-29.8* RDW-14.3 Plt Ct-204
[**2189-9-15**] 09:54AM BLOOD WBC-43.0* RBC-3.20* Hgb-8.5* Hct-28.2*
MCV-88 MCH-26.6* MCHC-30.3* RDW-14.8 Plt Ct-202
[**2189-9-15**] 07:06PM BLOOD Hct-23.7*
[**2189-9-16**] 02:04AM BLOOD WBC-37.5* RBC-2.80* Hgb-8.1* Hct-24.0*
MCV-86 MCH-28.8 MCHC-33.7# RDW-15.3 Plt Ct-148*
[**2189-9-16**] 08:41AM BLOOD Hct-28.1*
[**2189-9-16**] 03:59PM BLOOD WBC-34.9* RBC-3.43* Hgb-10.2*# Hct-29.7*
MCV-87 MCH-29.7 MCHC-34.3 RDW-15.1 Plt Ct-119*
[**2189-9-16**] 10:11PM BLOOD WBC-35.3* RBC-3.24* Hgb-9.6* Hct-28.2*
MCV-87 MCH-29.6 MCHC-34.1 RDW-15.4 Plt Ct-106*
[**2189-9-17**] 04:39PM BLOOD Hct-25.9*
[**2189-9-18**] 03:58AM BLOOD WBC-24.1* RBC-2.94* Hgb-8.7* Hct-25.9*
MCV-88 MCH-29.5 MCHC-33.5 RDW-15.8* Plt Ct-84*
[**2189-9-18**] 03:44PM BLOOD Hct-25.1*
[**2189-9-14**] 03:40PM BLOOD PT-75.7* PTT-75.8* INR(PT)-7.7*
[**2189-9-15**] 09:54AM BLOOD PT-101.3* PTT-65.7* INR(PT)-10.4*
[**2189-9-15**] 03:52PM BLOOD PT-28.7* PTT-36.2 INR(PT)-2.8*
[**2189-9-15**] 09:04PM BLOOD PT-22.3* PTT-34.2 INR(PT)-2.1*
[**2189-9-16**] 02:04AM BLOOD PT-20.3* PTT-29.4 INR(PT)-1.9*
[**2189-9-17**] 02:54AM BLOOD PT-23.2* PTT-30.9 INR(PT)-2.2*
[**2189-9-18**] 03:44PM BLOOD PT-34.5* PTT-37.5* INR(PT)-3.4*
[**2189-9-15**] 05:00AM BLOOD Glucose-220* UreaN-37* Creat-2.7* Na-133
K-3.6 Cl-93* HCO3-13* AnGap-31*
[**2189-9-15**] 03:52PM BLOOD Glucose-265* UreaN-42* Creat-3.3* Na-131*
K-4.5 Cl-97 HCO3-12* AnGap-27*
Discharge Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2189-10-3**] 07:25 13.0* 3.27* 9.4* 30.1* 92 28.7 31.2
17.3* [**2078**]
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps
Metas Myelos
[**2189-10-3**] 07:25 83.5* 9.7* 4.5 1.7 0.4
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2189-10-3**] 07:25 NORMAL1 [**2079**]
[**2189-10-3**] 07:25 12.7* 31.5 1.2*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2189-10-3**] 07:25 125*1 63* 5.6* 133 3.9 96 27 14
Relevant Imaging:
CT Abdomen ([**2189-9-15**])
1. Large retroperitoneal hemorrhage involving the perirenal and
both anterior and posterior pararenal spaces. The right kidney
is also markedly enlarged. Suspect right renal subcapsular
hematoma which ruptured into the retroperitoneum. Evaluation
with contrast-enhanced CT would be helpful as permitted by
patient's renal function.
2. No evidence of bowel wall thickening to suggest ischemia.
3. Spontaneous reflux of contrast into the esophagus is
documented.
CTU Abdomen ([**2189-9-18**])
1. Expanded right renal contour with retroperitoneal fluid,
similar in size and extent to [**2189-9-15**], and compatible
with extension of a right renal subcapsular hemtoma into the
retroperitoneum. No new region of hemorrhage is identified.
2. Right renal hilum appears swollen and obliterated, which is
non-specific but may be seen with obstruction. Potential
etiologies include thrombosis within the collecting system or
obstruction of the collecting system by the retroperitoneal
hematoma. Neither etiology is well-evaluated on this
non-contrast exam.
3. Non-specific mild stranding adjacent to the left ureter in
the pelvis.
Slight interval increase in bilateral pleural effusions with
adjacent compressive atelectasis.
4. Right adrenal adenoma, similar to [**2187-9-27**].
TTE: Suboptimal image quality. Left ventricular cavity dilation
with low normal global systoilc function (the apical half of the
left ventricle is not visualized). Pulmonary artery
hypertension. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2188-7-1**],
the left ventricular cavity is now dilated and global systolic
function is slightly improved. The severity of mitral
regurgitation may be similar (better visualized on the prior
study). The heart rate is much faster.
Knee XR [**2189-9-24**]: 1. Moderate to large suprapatellar effusion,
stable. 2. Mild-to-moderate tricompartmental osteoarthritis.
Tunneled w/o Port [**2189-9-25**]: Conversion of a temporary to a
tunneled double-lumen hemodialysis catheter through the existing
right internal jugular vein approach. The catheter tip is
located in the upper right atrium. The catheter is ready for
use.
CT Chest w/o Contrast [**2189-9-29**]: Limited assessment of the
examination. Bilateral left more than right areas of atelectasis
in the lower lobes. No evidence of pneumonia. Mucus in the
trachea, potentially reflecting poor airway clearance. No
evidence of infectious lung disease, no lung nodules or masses.
Microbiology:
[**2189-9-14**] 3:55 pm JOINT FLUID JOINT FLUID.
**FINAL REPORT [**2189-9-17**]**
GRAM STAIN (Final [**2189-9-14**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2189-9-17**]): NO GROWTH.
Blood culture [**2189-9-14**]: negative
C. diff, stool culture [**9-20**], [**9-24**] negative
[**9-24**] Ucx [**2189-9-24**] 6:46 pm URINE Source: CVS.
URINE CULTURE (Final [**2189-9-27**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
Discharge Labs:
[**2189-10-3**] 07:25AM BLOOD WBC-13.0* RBC-3.27* Hgb-9.4* Hct-30.1*
MCV-92 MCH-28.7 MCHC-31.2 RDW-17.3* Plt Ct-190
[**2189-10-3**] 07:25AM BLOOD Neuts-83.5* Lymphs-9.7* Monos-4.5 Eos-1.7
Baso-0.4
[**2189-10-3**] 07:25AM BLOOD Glucose-125* UreaN-63* Creat-5.6*# Na-133
K-3.9 Cl-96 HCO3-27 AnGap-14
[**2189-10-3**] 07:25AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 11950**] is an obese 56 year old male with gout, a-fib on
coumadin, who was admitted for joint pain,
gout/pseudogout/hemarthrosis. Course complicated by subcapsular
right renal hemmorhage, RP bleed in the setting of INR 7.7, [**Last Name (un) **]
on CKD with initiation of dialysis, and Pseudomonas UTI.
Active Issues:
# Hypotension due to subcapsular right renal hemmorhage
complicated by retroperitoneal bleed in the setting of INR of
7.7. S/p volume and blood product resuscitation along with
reversal of coagulopathy. IR and Urology following and managed
conservatively. Hct remained stable at 25-30 s/p 8 units of
blood, and 4 units of FFP over 2 weeks on the floor.
# Gout/Pseudogout/Hemarthrosis. Cause of patient's bilateral
knee pain, L>R. Also, contractures and critical care myopathy
are possibilities at this point. Completed a course of
prednisone taper per Rheumatology. Changed allopurinol and
colchicine regimen to based on HD. Rheumatology considered IA
steroid injection but opted not to due to recent hemarthrosis.
Knee XR on [**9-24**] showed a slight decrease in joint effusion and
a stable joint. Patient continues to complain of leg pain at
discharge.
# ARF on CKD, now HD dependent: Baseline stage IV CKD due to DM,
HTN. R kidney likely damaged due to subcapsular bleed. Left
kidney likely damaged from extended hypotension. Pt was on renal
diet, all medications were renally dosed, and chemistries were
followed daily. We continued calcitriol and nephrocaps while
inpatient. Calcitriol was eventually switched to Doxerfericol.
Renal diet initially was receiving 2g K daily, but later reduced
1.0g per day. K has since been in stable range. Transplant also
would like to put in dialysis fistula for long-term access.
Cardiology consulted to make sure pt is at cardiac optimization
for such placement. Pt will continue outpatient with long-term
dialysis for the forseeable future per Nephrology.
# Atrial fibrillation in setting of supratherapeutic INR. Held
coumadin since hospital day 1. Tele was placed during duration
of hospital stay, with multiple episodes of VTach in the 150's
overnight. INR was re-assesed daily, trending to 1.6 by
discharge. Albumin level was 2.5 on [**9-28**]. Labetolol was
continued, but changed to 100mg TID to support ultrafiltration
and hemodialysis. Patient CHADS=3, however, in light of recent
supratherapeutic INR and major bleed, coumadin was not
reinitiated. Patient started on ASA 325mg. Will have
Cardiology follow up to determine further anticoagulation.
# Insomnia: pt reports not sleeping well for much of hospital
stay. Questioning pinpoints problem to sleep maintanence.
Experiences more lethargy as the day goes on. Doubled trazadone
dosage helped when he was not in pain.
# Elevated white count: Most likely due to steroids &
Pseudomonal UTI. Possible multifactorial since it was present,
but not as high, before steroid use. Unclear why WCB increased
so much in MICU (above 40). Trend of WBC 18.2 -> 18.2 -> 16.3
at discharge while on cefepime for UTI. Plan complete a 10d
course, last day on [**10-8**].
# Chronic systolic CHF. Some rales in lower lobes early on
morning physical exams. Pt would report SOB that would resolve
after dialysis. Pt was grossly fluid overloaded. CT showed no
evidence of pneumonia.
# Diabetes mellitus: HbA1C was 6.9% on [**2189-5-18**]. Complicated
by neuropathic pain and gastroparesis. Increased sliding scale
insulin when steroids began. Monitored glucose levels during the
day. Continued gabapentin and metaclopramide. Continue
prescribed sliding scale of insulin and standing doses in rehab
and adjust based on blood glucose. Would consider transition to
70/30 on discharge home for better compliance.
# Heartburn: Likely stress ulcer from ICU stay. Unlikely to be
cardiac pain as pt was worked up in ICU after hypotension with
no signs of ACS at that time and afterwards. Continued
sucralfate and omeprazole. Was given GI cocktail containing
maalox and lidocaine if persistant with positive results.
# Hyperparathyroidism: most likely [**3-12**] CKD and inc. phosphate.
Guidelines for pts on dialysis include Ca of 8.4-9.5, Ph of
3.5-5.5, and PTH of 150-300. Pt's values are 7.6, 5.5, and 589,
respectfully. Renal recommended Vit D analog during dialysis
rather than Sevelamer.
# Diarrhea: C. diff results negative. Has resolved. No
intervention needed.
Chronic Issues:
# Dyslipidemia: Stable. Continued simvastatin.
# Hypertension: Pt with history of hypertension, but not an
issue since major bleed. Continued on labetolol for rate
control.
Transitional Issues:
Pt will be discharged to rehab where he will continue dialysis,
physical therapy, and maintanence of care.
Status: Full Code
UTI: Cefepime 500mg IV q24h on [**2189-10-8**]
Medication Changes:
Stopped Calcitriol, Metoclopramide, Simvistatin, Torsemide,
Insulin NPH 70/30, Colace, Vit D, Ferrous Sulfate, Tramadol.
Started on Atorvastatin, Calcium Carbonate, Cepacol (Menthol),
Colchicine, Digoxin, Doxerfericol, Guaifenesin, HYDROmorphone
(Dilaudid), Ipratropium Brommide, Insulin SC Sliding Scale and
Fixed Dose, Labetolol, Nephrocaps, Ondansetron, Sucralfate,
Trazadone
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Allopurinol 100 mg PO EVERY OTHER DAY
2. Calcitriol 0.25 mcg PO DAILY
3. Digoxin 0.25 mg PO MWF
4. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
5. Gabapentin 300 mg PO BID
6. Metoclopramide 5 mg PO QIDACHS
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Simvastatin 40 mg PO DAILY18
10. Torsemide 100 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO TID:PRN pain
12. [**Doctor First Name 7096**] 3 mg PO DAILY
13. [**Doctor First Name 7096**] 1 mg PO ASDIR
1-2 tablets daily as directed
14. Ferrous Sulfate 325 mg PO BID
15. 70/30 12 Units Breakfast
70/30 10 Units Dinner
16. Aspirin 81 mg PO DAILY
17. Albuterol Inhaler [**2-9**] PUFF IH Q6H:PRN shortness of breath or
wheezing
Discharge Medications:
1. Allopurinol 100 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Digoxin 0.125 mg PO MWF
Please start Monday [**9-28**].
4. Gabapentin 100 mg PO DAILY
give after HD on HD days
5. 70/30 12 Units Breakfast
70/30 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Omeprazole 40 mg PO BID
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
9. Atorvastatin 80 mg PO DAILY
10. Calcium Carbonate 500 mg PO TID W/MEALS
11. CefePIME 500 mg IV Q24H
day 1= [**9-28**]
12. Cepacol (Menthol) 1 LOZ PO PRN cough, sore throat
13. Colchicine 0.6 mg PO EVERY OTHER DAY
14. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
15. Docusate Sodium 100 mg PO BID
hold for diarrhea
16. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
17. Guaifenesin [**6-18**] mL PO Q6H:PRN cough
18. Heparin 5000 UNIT SC TID
19. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
Please try prior to IV
RX *hydromorphone [Dilaudid] 4 mg [**2-9**] tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*1
20. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
21. Labetalol 100 mg PO TID
hold for SBP<100 or HR<60
22. Maalox/Diphenhydramine/Lidocaine 30 mL PO TID:PRN heartburn
23. Miconazole Powder 2% 1 Appl TP [**Hospital1 **] rash
24. Nephrocaps 1 CAP PO DAILY
25. Ondansetron 4 mg IV Q8H:PRN nausea
26. Senna 1 TAB PO BID:PRN constipation
27. Sucralfate 1 gm PO QID
28. traZODONE 100 mg PO HS insomnia
29. HYDROmorphone (Dilaudid) 1-2 mg IV Q4H:PRN pain
hold for sedation or RR<10
RX *hydromorphone 2 mg/mL 1-2mg every four (4) hours Disp #*20
Unit Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Retroperitoneal hematoma
Acute Renal Failure on Stage 4 Chronic Kidney Disease, on
Hemodialysis
Type II Diabetes Mellitus
Atrial Fibrillation
Gastroesophageal Reflux Disease
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 11950**],
As you know, you were initially admitted to the hospital for you
knee pain and elevated coumadin levels. However, on your first
night here you became very sick and had to go to the ICU. There
they found that you were bleeding very heavily into your right
kidney. You lost a lot of blood and required many transfusions
to keep your blood pressure up. However, you blood pressure was
very low for a long time. Your kidneys were already damaged
from your diabetes and high blood pressure, and this low blood
pressure very severely damaged this kidneys and you had to start
dialysis, which is likely permanent.
While you were very sick with did many other tests to keep you
healthy. We found that you had a urinary tract infection and
treated that first with a drug called ciprofloxacin and then
with a drug called Cefepime. We gave you steroids to try to
help the pain in your legs. We did chest xrays and a CT scan of
your chest to make sure you did not have pneumonia. We looked
at many EKGs of your heart and some blood tests to make sure
that you did not have a heart attack.
You were on [**Known lastname 7096**] before you came to the hospital, but your
blood levels were very high and likely contributed to your large
bleed. You were on this for your atrial fibrillation, but we
think that it is no longer safe to continue this medicine as you
may have a big bleed again. This is a risk, however, because as
long as you have a-fib (an irregular heart rhythm) you are at
risk of a stroke. We will give you aspirin, but this is not as
effective as the coumadine would be. You should discuss this
more with your primary care doctor and your cardiologist when
you are out of the hospital. We will continue your beta blocker
medicine Labetalol to keep your heart rate from going too fast
as is often a risk for people with irregular heart rhythms.
We realize that your legs are still causing you a great deal of
pain. We were hoping that getting a lot of the extra fluid off
your legs with dialysis would help. We also gave you steroids.
You have an appointment with the rheumatology doctors in a [**Name5 (PTitle) 15935**]
weeks to help treat your leg pain better.
We made the following changes to your medicines:
Stopped:
Calcitriol
Colace
Ferrous Sulfate
Metoclopramide
Simvistatin
Insulin NPH 70/30
Torsemide
Tramadol
Vit D
[**Name5 (PTitle) 7096**] (also known as Coumadin)
Started:
Atorvastatin
Calcium Carbonate
Cepacol (Menthol)
Colchicine
Doxerfericol
Guaifenesin
HYDROmorphone (Dilaudid)
Ipratropium Brommide
Insulin SC Sliding Scale and Fixed Dose
Labetolol
Nephrocaps
Ondansetron
Sucralfate
Trazadone
Changed Dose/Dosing: (medication and dose listed is NEW dose)
Allopurinol 100mg PO DAILY
Aspirin 325 mg PO/NG DAILY
Digoxin 0.125 mcg, PO, every MON, WED, and FRI
Gabapentin 100 mg, PO, DAILY
Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP below when you are ready for
discharge.
Name:Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]
Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 1265**]
Phone: [**Telephone/Fax (1) 7976**]
Department: RHEUMATOLOGY
When: WEDNESDAY [**2189-10-21**] at 11:00 AM
With: [**Doctor First Name 21204**] (RHEUM LMOB) [**Last Name (un) **] [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2189-10-26**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5845, 0389, 5856, 5990, 2851, 2761, 2724, 4280, 4168, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6736
} | Medical Text: Admission Date: [**2104-11-12**] Discharge Date: [**2104-12-1**]
Date of Birth: [**2034-9-18**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
ABG
History of Present Illness:
70 year old female with chief complaint of sob, weakness.
Started to feel ill on Thankgiving while she was in [**State 2690**]
visiting family and noted chills. Continues to have intermittent
sweats and chills, also devloped progressive fatigue and SOB. By
the time she arrived home [**11-7**], she could only take a few steps
without feeling short of breath. Minimal cough, but does feel
chest "tightness." Tm 100 at home. Other than "sitting still"
Ms. [**Known lastname 13751**] did not find anything that made her symptoms better.
Presented to OSH ED on Friday night (5 days ago) with these
complaints. CXR there showed a pneumonia, and she was d/c home
with a Z-pack which she finished last night. She had a scheduled
follow up at her PCP's office today where she was found to be
sating 83% on RA and was sent to the ED. In the [**Hospital1 18**] ED,
initial VS T 96.5, HR 80, BP 98/66, RR 21, O2 97% 4L NC. The
patient had a CXR that demonstrated a right lung consolidation,
received levofloxacin, and was admitted to the ICU for further
management. Labs in the ED were notable for a bicarb of 20 and
WBC count of 13.7 with 81% PMNs. Pt has no Hx of chronic lung
disease, but has had episodes of "bronchitis" in the past. No
previous ICU admissions. VS upon transfer to [**Hospital Unit Name 153**] were T 98, HR
74, BP 104/60, RR 19, O2 97%5L NC.
In the ICU, the patient felt much better since being placed on
nasal canula. Minimal cough. Denies drenching night seats or
high fevers. She has had a poor appetite, but no nausea or
vomiting.
.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [] All Normal
[ X] Fever [ ] Chills [ ] Sweats [ X] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] weight loss
HEENT: [X] All Normal
[ ] Blurred vision [ ] Blindness [ ] Photophobia
[ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums
[ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ]Tinnitus [ ] Other:
RESPIRATORY: [] All Normal
[ X] SOB [X] DOE [ X] Cough
[ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic
pain
[] no PND:
CARDIAC: [X] All Normal
[ ] Angina [ ] Palpitations [ ] Edema [ ] PND
[ ] Orthopnea [] Chest Pain [ ] Other:
GI: [X] All Normal
[ ] Blood in stool [ ] Hematemesis [ ] Odynophagia
[ ] Dysphagia: [ ] Solids [ ] Liquids
[ ] Anorexia [] Nausea [] Vomiting [ ] Reflux
[ ] Diarrhea [ ] Constipation [ ] Abd pain [ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Frequency [ ] Hematuria []Discharge
[]Menorrhagia
[]unable to urinate
SKIN: [X] All Normal
[] SKs + ecchymoses
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Temp subjectivity
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [X] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
.
[+]all other systems negative except as noted above
Past Medical History:
Hypertension
Hyperlipidemia
Depression
Obesity
60-69% left ICA stenosis
Osteopenia
Cholecystectomy [**2089**]
Social History:
Her social history is positive for one to two glasses of wine
a day and she did have a significant smoking history of two
packs per day for 30 years. She quit 20 years ago. Lives alone.
Retired.
Family History:
Her mother passed away last year. Mom had a MI and a TIA as well
as a CHF.
Physical Exam:
VS: T = 100.4 P = 88 BP = 116/64 RR = 24 O2Sat = 94% on 4L NC
GENERAL:
NAD (on O2)
Mentation: Alert, speaks in full sentences.
Eyes:NC/AT, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM,
Neck: supple
Respiratory: Diffuse rhonchi R lung
Cardiovascular: RRR, nl. S1S2
Gastrointestinal: soft, NT/ND, normoactive bowel sounds
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No edema.
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
Psychiatric: WNL
Pertinent Results:
[**2104-11-12**] 09:45AM WBC-13.7*# RBC-3.66* HGB-10.1* HCT-30.2*
MCV-83# MCH-27.5 MCHC-33.3 RDW-13.4
[**2104-11-12**] 09:45AM GLUCOSE-106* UREA N-16 CREAT-1.0 SODIUM-138
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-20* ANION GAP-20
[**2104-11-12**] 05:24PM TYPE-ART PO2-74* PCO2-32* PH-7.48* TOTAL
CO2-25 BASE XS-0
Brief Hospital Course:
70yo F with HTN and dyslipidemia who was sent to ED from PCP's
office for hypoxia in the setting of community aquired PNA x 2
weeks, refractory to outpatient azithromycin and was admitted to
the ICU for severe pneumonia and sepsis which were complicated
by multisystem failure including respiratory and renal failure.
.
She Presented to the ICU with a Pneumonia like picture.
Stabalized on 4 L 02, but continued to have tachypnea. Due to
difficulty maintaining respiratory rate, patient was electively
intubated. Had imaging consistent with severe right pulmonary
pneumonia as well as progressing rounded left lower lobe
opacities, likely infectious in nature. CT scan complimented
CXR, but was negative for pulmonary effusions. Started on broad
antibiotics including vancomycin, zosyn, and levofloxacin. As
pt had history of traveling to [**State 2690**] within the previous several
weeks multiple tests for fungus, EBV, legionella, AFB,
cryptococcus, sputum, blood, and urine cultures all were
negative. The patient had a BAL after intubation which was
negative for microorganisms including PCP. [**Name10 (NameIs) **] became
progressivley more hypoxic requriing increased PEEP and FiO2.
ARDSnet protocol was instituted as CXR was concerning for
possible ARDS. Trathoracic pressure monitoring was performed
via esophageal balloon manometry. Despite these efforts patient
showed no clinical or radiological improvement and continued to
have difficulty on the vent requiring increased FiO2 and PEEP to
maintain her oxygen saturation. She also developed oliguric
renal failure and CVVH was started. She was gradually weaned of
sedation but did not regain consciousness. Throughout her
hospital stay the ICU team worked closely with the patient's
family and HCP who were aware of the worsening prognosis in the
setting of multi-organ failure and lack of improvement. On
hospital day 20 in accordance with the family's wishes she was
terminally extubated. She expired shortly thereafter with the
family at the bedside.
.
Medications on Admission:
Simvistatin 40 mg Daily
FUROSEMIDE 20mg Daily
Metoprolol XL 25mg daily
OXYBUTYNIN CHLORIDE Extended Release 5mg Daily
RANITIDINE HCL 150 mg Daily
ASPIRIN 325 mg Tablet Daily
CALCIUM CARBONATE-VITAMIN D3 500 mg -400 unit Daily
CLARITIN-D 24 HOUR 240 mg-10 mg
MULTIVITAMIN once daily
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2105-4-2**]
ICD9 Codes: 0389, 486, 5845, 5856, 5070, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6737
} | Medical Text: Admission Date: [**2138-4-28**] Discharge Date: [**2138-5-3**]
Date of Birth: [**2080-1-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
58 y/o M with severe COPD with h/o mulitple intubations,
obesity, DM, h/o DVTs s/p IVC filter, who had respiratory
distress this morning. Wife called EMS for respiratory distress.
Pt intubated in the field. VS at OSH ED Temp 33.1, HR 76, RR 22,
BP 122/39, O2 Sat 98% intubated. Pt opened eyes to verbal
stimuli, foley placed; pt opened eyes to name. Pt became
hypotensive with SBP 68 so dopamine gtt started with improvement
to 137 mmHg. CXR confimred tube placement. Pt's urine output
noted to be 300-500cc, dopamine was weaned, IVF 1 L NS given.
Central line placed for access. Given plavix 300 mg, heparin
gtt, and protonix. Another 1 LS NS given. On transfer, pt given
vecuronium, fentanyl, and versed for sedation. Vent set at TV
450 cc, RR 12, FiO2 40%, PEEP 5. Transferred to [**Hospital1 18**] for
cardiac cath given STE in inferior leads. Cath showed 50% mid
LAD otherwise no flow limiting disease.
.
In the CCU, history obtained from wife. Pt was recently
discharge for PNA and COPD flare on [**4-15**]. Prednisone taper was
stopped last week. He had not been sleeping much, probably off
home BiPAP. Denied cough, chest pain, N/V or other symptoms. His
only c/o was poor sleep; no indicaiton that there was worsening
SOB or DOE. He uses oxygen and auto-BiPAP at baseline. He did
c/o some postural sxs with standing but no syncope.
.
Admitted to MICU service for hypercarbic resp distress.
Past Medical History:
severe COPD
-FEV1/FVC 29%, FEV1 0.69 (26%)
-h/o multiple intubations
-baseline co2 80's
-home home oxygen 3-5 L
RLL pulm nodule 4mm ([**2137-7-6**] at [**Hospital1 2025**])
s/p right facial burn
sleep apnea
-AHI 26.7, 79.8% sats, 6 L supplemental oxygen at night, BIPAP
[**11-20**]
allergic rhinitis
h/o DVT s/p IVC filter
-[**8-5**], then large RP bleed in [**12-7**] [**1-3**] coumadin
-RLE/RUE DVT at [**Hospital1 2025**]
-IVC [**2137-7-12**]
Chest pain with neg stress in [**11-5**]
PAF during resp distress
GERD with h/o PUD
h/o GIB in [**2137-7-14**]
hyperlipidemia
DM2
ventral hernia
obesity
chronic back pain
psoriasis
eczema
anemia
PTSD
s/p facial burn in Summer [**2136**] (care at [**Hospital1 2025**])
PVD c/b right foot ulcer
h/o [**Doctor Last Name 360**] [**Location (un) 2452**] exposure
Social History:
lived with wife, current [**Name2 (NI) 1818**] ([**2-3**] cigs/day), 1-1.5 ppd x
several years, no EtOH, no drugs, former auto mechanic, large
exposure to paint
Physical Exam:
97.0, HR 98-101, BP 109/64 on 2.5 mcg dopamine
FiO2 50%, PCV, 450 x 24, PEEP 5, compliance 13, 89-91%
intubated, not repsonisve to verbal stimuli, does not follow
commands
R pupil < L pupil, both sluggishly reactive, no blink to threat
RRR, distant heart sounds
mechanical BS
large obese abd, +BS, large reducible ventral hernia
R a-line in groin, L femoral line in place
2+ LE edema bilateral with chronic venous stasis changes,
flaking of skin
Pertinent Results:
[**2138-5-1**] 06:00AM BLOOD WBC-6.9 RBC-3.49* Hgb-10.6* Hct-34.2*
MCV-98 MCH-30.3 MCHC-30.9* RDW-15.8* Plt Ct-314
[**2138-5-1**] 06:00AM BLOOD PT-11.8 PTT-31.0 INR(PT)-1.0
[**2138-5-1**] 06:00AM BLOOD Glucose-273* UreaN-24* Creat-0.9 Na-142
K-4.2 Cl-94* HCO3-VERIFIED B
[**2138-5-1**] 06:00AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.5
[**2138-4-30**] 03:32AM BLOOD CK(CPK)-18*
[**2138-4-28**] 10:36PM BLOOD CK(CPK)-24*
[**2138-4-30**] 03:32AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2138-4-28**] 10:36PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2138-4-29**] 05:54AM BLOOD Type-ART Temp-36.7 pO2-75* pCO2-85*
pH-7.39 calTCO2-53* Base XS-21
Brief Hospital Course:
Mr. [**Known lastname **] is a 58 year old man with severe COPD, DM, chronic low
back pain, admitted for cath, which demonstrated one vessel
disease, and with hypercarbic respiratory failure, s/p
extubation on [**2138-4-30**].
Brief ICU course:
#) Hypercarbic resp failure. Thought to be likely secondary to
severe COPD exacerbation and residual community or
hospital-acquired pneumonia, with recent rapid steroid taper.
Pt. was intially intubated in the field and transferred to CCU
in stable condition on [**2138-4-28**]. CXR showed hyperinflated lungs
and mild generalized interstitial abnormality in lower lungs of
indeterminate chronicity. ABGs revealed pH 7.21, pCO2 128, pO2
58, HCO3 54. PCV was started w/ PEEP 10 due to auto-PEEP in
setting of COPD. Treatment was started w/ methylprednisolone IV
125mg IV q8h, ipratropium inh, albuterol inh, and
fluticasone-salmeterol inh. Levofloxacin 750mg IV daily was
also started for presumed pneumonia given CXR findings. A L
subclavian line was attempted, but found to be folded over in L
brachiocephalic vein, and subsequently removed. On [**2138-4-29**],
mechanical ventilation was switched from PCV to AC, and ABGs
revealed pH 7.39, pCO2 85. Vancomycin 1g IV q12 was initiated
later due to concerns for GPC in blood cx from OSH. On [**2138-4-30**],
ventilation was weaned from AC to PSV 16/10, which was tolerated
well by the patient. Sputum gram stain showed 1+ GPCs, and
blood/sputum cultures were drawn. Since pt did not show signs
of infection (Tmax 99.4, WBC 5.3) at this time, abx regimen was
continued. Pt was then weaned to PSV 5/5, and subsequently
extubated. By [**2138-5-1**], pt has tolerated 4L NC and BiPAP at
night, w/ O2Sat in the low 90's. Pt was subsequently
transferred from the MICU in stable condition.
.
#) ST elevations: Although pt reported no prodrome of chest
pain, EKG at OSH revealed STE in leads II, III, and AVF. On
transfer to [**Hospital1 18**], cardiac catheterization revealed only 50%
mid-lesion in LAD, but EF 63% and no wall motion abnormalities.
Cardiac enzymes were negative x2 (CK 25 cTnT 0.03 on [**2138-4-29**] and
CK 18 cTnT 0.02). No anti-coagulation was given, and pt never
reported any CP, SOB, or palpitations
.
#) Hypotension: Pt's low SBP unlikely related to sepsis due to
absence of fever, normal WBC and lactate. His BP stabilized
quickly with 2L NS bolus on [**2138-4-28**]. Pt was taken off dopamine
gtt, and SBPs have ranged from 100-150 for the remaining
duration of his MICU stay.
.
#) Mental status change: Pt initally very poorly responsive,
possibly secondary to paralytics and sedation en route on
[**2138-4-28**]. Pupils were unequal and sluggishly reactive to light.
On [**2138-4-29**], pt began to respond to verbal stimuli though not
following commands, pupils were less unequal. On [**2138-4-30**], pt
could follow commands, and pupils were equal and reactive. On
[**2138-5-1**], pt was awake, appropriately interactive, and began
asking for food.
.
#) Anemia: Pt's Hct initially dropped from 37.8 ([**2138-4-28**]) to
32.4 ([**2138-4-29**]) to 31.1 ([**2138-4-30**]), but stabilized to 34.4
([**2138-5-1**]).
.
#) Chronic back pain: Pt continued on home narcotics regimen.
.
#) DM: Pt on ISS especially while on steroids.
Once on the floor, he continued to receive his COPD medications
and nebulizers. His home glyburide was restarted on [**5-2**]. His
respiratory status continued to be stable, and he was discharged
home on [**5-3**] on a slow steroid taper and instructed to follow up
with his PCP.
Medications on Admission:
prednisone taper recently stopped
flovent IH 220 mcg/[**Hospital1 **]
combivent 14.7 gm 2 puffs q6 hrs
lasix 20 mg qam
MVI
Fe sulfate 325 mg qam
oscal + vit D 1 tab tid w/ meals
advair 1 puff [**Hospital1 **]
micronase 5 mg qd
colace 100 mg [**Hospital1 **]
MS contin 30 mg qid, morphine IR 30 mg q 6 prn
protonix 40 mg qd
diltiazem 90 mg (unclear [**Name2 (NI) **])
ASA 81 mg qd
lisinopril 2.5 mg (unclear [**Name2 (NI) **])
foradil 1 puff [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q6H (every 6 hours).
3. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q6H (every 6 hours).
14. PredniSONE 50 mg Tablet Sig: One (1) Tablet PO daily () for
3 doses.
Disp:*3 Tablet(s)* Refills:*0*
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 20 days: DIRECTIONS:
[**Date range (1) 28125**]: 5 tablets
[**Date range (1) 72937**]: 4 tablets
[**Date range (1) 63629**]: 3 tablets
[**Date range (1) 39587**]: 2 tablets
[**Date range (1) 17333**]: 1 tablet
[**Date range (1) **]: 0.5 tablet.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary Diagnosis
Respiratory Failure requiring intubation
Severe COPD (home oxygen 3-5L)
Community acquired pneumonia
Sleep Apnea on BiPap at night
Chronic Back Pain
Anemia
Type II Diabetes Mellitus
Secondary Diagnosis
h/o DVT s/p IVC filter
h/o PAF during resp distress
GERD
Hyperlipidemia
Ventral Hernia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hosptial with respiratory failure.
After discharge, you should continue to take all your
medications and follow up with your appointments as below.
If you notice that your oxygen saturation is low, have
difficulty breathing, cough, fevers, chills or chest pain please
go to the nearest emergency room.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] 1 week after discharge.
ICD9 Codes: 486, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6738
} | Medical Text: Admission Date: [**2156-1-8**] Discharge Date: [**2156-1-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
claudication
Major Surgical or Invasive Procedure:
peripheral angiography and stent placement in Left Superficial
Femoral Artery
History of Present Illness:
Pt is a [**Age over 90 **] yo man with htn, hyperlipidemia, PVD, experienced as
pain in both calves when walking one block and resolving with
rest, who presented for stenting of his femoral artery. He had
ABIs which were also diminished bilaterally
(0.82 right ankle, 0.66 left ankle). Lower extremity doppler
evaluation
showed triphasic waveforms in bilateral common femoral arteries
and
evidence of a left SFA occlusion.
Past Medical History:
1. PVD-s/p atherectomy and stenting of left SFA
2. Bilateral Renal Artery Stenosis
3. Hyperlipidemia
4. Hypertension
5. Knee and hip replacement surgeries
6. s/p PPM
Social History:
Lives alone in [**Location 8391**] in [**Hospital3 **]. One son. 50 pack
year history of smoking quit 50 yrs ago. Drinks accasional
highball. Retired from construction work.
Family History:
Mother with MI in 40's.
Physical Exam:
Afebrile 145/60 64 12 99% on RA
NAD. Alert. OP clear with MMM.
L carotid upstroke diminished with bilateral bruits.
RRR soft S1, normal S2. Soft systolic murmurs at RUSB and LLSB.
No rubs or gallops
Lungs clear to auscultation
Abd is soft NTND. Normal BS. No bruits
R groin without minimal ecchymoses no hematoma. No bruit and 1+
pulse.
No peripheral edema. Bilateral LE warm.
Pertinent Results:
Catheterization:
BRIEF HISTORY: [**Age over 90 **] yo man with hypertension and dyslipidemia
referred
for peripheral arteriography to evaluate significant bilateral
leg
claudication (L>R). He had ABIs which were also diminished
bilaterally
(0.82 right ankle, 0.66 left ankle). Lower extremity doppler
evaluation
showed triphasic waveforms in bilateral common femoral arteries
and
evidence of a left SFA occlusion.
INDICATIONS FOR CATHETERIZATION:
Peripheral vascular disease, claudication, positive noninvasive
ischemia
evaluation
PROCEDURE:
Peripheral Catheter placement was performed via the RFA.
Peripheral Imaging was performed of the AA and bilateral LE.
Peripheral PTA was performed of the R SFA.
Peripheral Stenting was performed of the R SFA.
Peripheral Atherectomy was performed of the R SFA.
**PTCA RESULTS
LSFA
**BASELINE
STENOSIS PRE-PTCA 100
**TECHNIQUE
PTCA SEQUENCE 1
GUIDING CATH [**Last Name (un) **]
GUIDEWIRES SPATRACO
INITIAL BALLOON (mm) 3.0
FINAL BALLOON (mm) 6.0
# INFLATIONS 7
MAX PRESSURE (PSI) 120
**RESULT
STENOSIS POST-PTCA 0
SUCCESS? (Y/N) Y
PTCA COMMENTS: Initial angiography revealed a 70% lesion at
the
origin of the SFA and a mid-segment occlusion of the SFA in the
left
lower extremity. Heparin was started prophylactically. A 7
French [**Last Name (un) 12297**]
sheath was advanced into the left CFA. The total occlusion of
the left
SFA was crossed with moderate difficuly using a Shinobi wire
followed by
an angled stiff Glidewire. Atherectomy was performed on th
eproximal SFA
using a Silverhawk LS device with good result. We were unable to
deliver
the Silverhawk device distal to the total occlusion, so the
occlusion
was dilated with a 3.0 x 20 mm Saavy balloon using 3 inflations
of 6
ATM. We were still unable to deliver the atherectomy device so
the
diecsion was made to proceed with stenting of the left SFA. A
7.0 x 56
mm Dynalink stent was deployed across the lesion and a 4.0 x 60
mm Saavy
balloon was used to dilate the stent at 120 ATM. Angiography
demonstrated a filling defect at the proximal edge of the stent
so a 7.0
x 100 mm Dynalink stent was deployed proximal to the first stent
in
overlapping fashion and both stents were dilated with the 4.0 x
60 mm
balloon using 3 inflations of 6 ATM. Final angiography revealed
no
residual stenosis, no apparent dissection, and normal flow.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 13 minutes.
Arterial time = 1 hour 13 minutes.
Fluoro time = 29 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 214 ml
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 5000 units IV
Other medication:
Fentanyl 50 mcg iv
Cardiac Cath Supplies Used:
- [**Company **], ANGLED GLIDEWIRE, 180
.014 GUIDANT, [**Location (un) **]/CORE, 130CM
.014 CORDIS, SHINOBI, 300CM
7F COOK, [**Last Name (un) 28712**], 55
7F FOXHOLLOW, SILVERHAWK ES
7 GUIDANT, DYNALINK 56, 80
7 GUIDANT, DYNALINK .018, 100
COMMENTS:
1. Access was obtained in retrograde fashion via the RFA using a
6
French short sheath.
2. Resting hemodynamics revealed no significant pressure
gradient
between AO and either common femoral artery.
3. Abdominal aortography revealed nild diffuse athersclerotic
disease.
4. The renal arteries were single bilaterally. The left renal
artery had
a 70% proximal stenosis and minimal blush was noted in the left
kidney.
The right renal artery had a proximal 70% stenosis.
5. Selective angiography of the right lower extremity revealed
no
significant disease in the CIA or EIA. The SFA was subtotally
occluded
at the adductor. The popliteal had no significant disease. The
AT and PT
were occluded with the PA filling the foot.
6. Selective angiography of the left lower extremity revealed no
significant disease in the CIA or EIA. There were mild luminal
irreguarities in the CFA. The SFA was totally occluded in its
mid
segment and reconstituted just above the popliteal artery. The
popliteal
artery was not obstructed.
7. Successful atherectomy of the proximal left SFA (see PTA
comments).
8. Successful PTA and stenting of the mid SFA with overlapping
7.0 x 100
mm and 7.0 x 56 mm Dynalink stents which were postdilated with a
6.0 mm
balloon. Final angiography revealed no residual stenosis, no
apparent
dissection and normal flow (see PTA comments).
FINAL DIAGNOSIS:
1. Bilateral SFA and infrapopliteal disease.
2. Bilateral renal artery stenosis.
3. Successful atherectomy, PTA, and stenting of the left SFA.
.
.
Right femoral vascular ultrasound:
Right common femoral artery and common femoral vein are widely
patent, without pseudoaneurysm or AV fistula. No large hematoma
is identified within the soft tissues of the right groin.
IMPRESSION:
No evidence of pseudoaneurysm, AV fistula or hematoma within the
right groin.
Brief Hospital Course:
Pt was taken to the catheterization lab and a stent was placed
in the left superficial femoral artery. At the end of the
procedure it was very difficult to attain hemostasis at the
right groin access site. As there was concern for development
of hematoma or pseudoaneurysm, pt was admitted to the CCU where
he was monitored closely and had multiple stable hematocrit
checks. A femoral vascular ultrasound was performed at the
right groins site and showed neither pseudoaneurysm or hematoma.
Pt was stable and was discharged to home with plan to return at
a later date for stenting of the right femoral artery.
Medications on Admission:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
2. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Prazosin HCl 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
2. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Prazosin HCl 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 30 days.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Outpatient Lab Work
please check potassium, BUN, creatinine and call into nurse
practitioner [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **] at [**Hospital1 336**] ([**State 59677**]) -
[**Telephone/Fax (1) 59678**].
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
2. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Prazosin HCl 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 30 days.
Disp:*30 Tablet(s)* Refills:*3*
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Outpatient Lab Work
please check potassium, BUN, creatinine and call into nurse
practitioner [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **] at [**Hospital1 336**] ([**State 59677**]) -
[**Telephone/Fax (1) 59678**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Peripheral Vascular Disease
Hyperlipidemia
Hypertension
Discharge Condition:
Good, stable.
Discharge Instructions:
Continue your medications as directed. We have started one new
medication called Plavix (clopidogrel) that you should take
everyday from now on.
You will have the other leg fixed on [**2156-1-22**]. You do not need
to see Dr. [**First Name (STitle) **] prior to this. You will see [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **]
at your primary care doctor's office this Tuesday for a blood
check.
Drink plenty of fluids at home.
Followup Instructions:
You have an appointment with [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) **] (Nurse
Practitioner) on Tuesday, [**1-13**], at 10:40 a.m. at your
Primary Care Doctor's office at [**Hospital1 336**] ([**State 59677**]).
You should have your blood drawn at that time to check on your
kidney.
You will also need to see Dr. [**First Name (STitle) **] as directed. You are
scheduled to have the same procedure on your other leg on
[**2156-1-22**].
Completed by:[**2156-1-28**]
ICD9 Codes: 4280, 4439, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6739
} | Medical Text: Admission Date: [**2191-7-24**] Discharge Date: [**2191-7-26**]
Date of Birth: [**2116-10-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
resp failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 yr old male with hx of metastatic lung cancer, prostate
cancer, transitional cell ca of the bladder, recent MRSA
pneumonia (completed Vanco course [**7-12**]), recent pseudomonas
pneumonia (on Zosyn since [**7-8**]) noted to be lethargic at his
nursing home with a RR 10. Per nursing home staff no recent
worsening in cough, fevers, complaints of chest pain or
shortness of breath. After several failed attempts at
intubation, an ABG was checked and pCO2 was found to be 115. Pt
was then brought to [**Hospital1 18**] ED with a laryngeal mask airway and
then successfully intubated by anesthesia. An ABG on the
ventilator was 7.32/57/241. In the ED, T 97, HR 86, bp 117/68,
resp 18, 100%. CXR showed new patchy right-sided infiltrates and
he received vancomycin 1 g IV X 1 and ceftazidime 1 g IV X 1 and
1.7 L of fluid. Patient then dropped his sbp to 60s and HR to
the 40s, for which he received 1 mg of atropine and was started
on a lephed gtt with recovery of his HR to 80s and sbp 130s.
Currently unable to obtain further information from patient as
he is intubated and sedated.
Past Medical History:
PUD
squamous cell lung cancer s/p XRT and left pneumonectomy (15
years prior to arrival)
TCCA bladder, diagnosed [**2190**] and not undergoing treatment
prostate CA T2bNxMx, grade [**8-24**] s/p XRT and hormone therapy with
biscalutamide
GERD
anemia of chronic disease
Left knee trauma [**2156**] s/p fusion with rod in left leg and now
left leg shorter than right
HTN
Social History:
Per daughter.. patient's pre-morbid situation included:
- living with girlfriend (67yo and an alcoholic) in home in
[**Location (un) 686**]
- home health aid once per week
- His girlfriends friends have been stealing his percocets so
PCP switched him to fentanyl patch
Family History:
NC
Physical Exam:
T97 HR 65, bp 143/66, resp 20 100%
AC 400/18 FiO2 100% PEEP 5
Gen cachectic, elderly African American male, intubated, sedated
HEENT: Pupils equal and minimally reactive to light, anicteric,
pale conjunctiva, OMMM, intubated, neck supple
Cardiac: irregularly irregular, II/VI SM at apex
Pulm: Decreased BS throughout left lung, crackles at right lung
base with diffuse ronchi. Occasional wheezes
Abd: concave, hypoactive BS, soft, NT
Ext: trace LE edema, warm with 1+ DP bilaterally. 2+ edema LUE.
Significant shortening of LLE
Neuro: Moves all 4 extremities in response to noxious stimuli,
2+ DTR throughout.
Access: L SC portocath, Right EJ
Pertinent Results:
[**2191-7-24**] 08:26PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2191-7-24**] 08:26PM URINE RBC->50 WBC-[**3-19**] BACTERIA-MOD YEAST-NONE
EPI-[**3-19**] TRANS EPI-0-2
[**2191-7-24**] 08:26PM URINE GRANULAR-0-2 HYALINE-0-2
.
[**2191-7-24**] 06:18PM TYPE-ART TEMP-36.7 PO2-241* PCO2-57* PH-7.32*
TOTAL CO2-31* BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED\
.
[**2191-7-24**] 05:49PM GLUCOSE-107* UREA N-18 CREAT-0.6 SODIUM-147*
POTASSIUM-VERIFIED B CHLORIDE-111* TOTAL CO2-31
[**2191-7-24**] 05:49PM ALT(SGPT)-20 AST(SGOT)-32 LD(LDH)-241
CK(CPK)-30* ALK PHOS-114 AMYLASE-17 TOT BILI-0.3
[**2191-7-24**] 05:49PM LIPASE-9
[**2191-7-24**] 05:49PM cTropnT-0.03*
[**2191-7-24**] 05:49PM CK-MB-NotDone
[**2191-7-24**] 05:49PM ALBUMIN-2.1* CALCIUM-11.2* PHOSPHATE-3.3
MAGNESIUM-1.9
.
[**2191-7-24**] 05:49PM WBC-14.2* RBC-3.49* HGB-9.8* HCT-30.3* MCV-87
MCH-27.9 MCHC-32.2 RDW-15.1
[**2191-7-24**] 05:49PM PLT SMR-NORMAL PLT COUNT-164
[**2191-7-24**] 05:49PM NEUTS-93.3* BANDS-0 LYMPHS-3.8* MONOS-2.0
EOS-0.7 BASOS-0.2
[**2191-7-24**] 05:49PM PT-14.4* PTT-26.0 INR(PT)-1.4
.
CTA:
1. No evidence for pulmonary embolism.
2. Interval opacification of the lung parenchyma within the left
hemithorax with minimal aeration of the left upper lung lobe
consistent with pneumonia. Interval worsening of the patchy
airspace opacities within the right lower, middle, and upper
lung lobes also consistent with pneumonia. Interval increase in
size of large right pleural effusion.
3. Unchanged bony lesions.
.
CT Head:
No evidence of hemorrhage, mass effect, or major vascular
territorial infarction.
.
CXR:
Persistent near complete opacification of the left lung. New,
multifocal patchy opacities within the right lung which may
represent infiltrate or CHF.
.
Upper ext doppler:
New non-occlusive thrombus within the left subclavian vein.
Brief Hospital Course:
Pt was intubated for hypercarbic respiratory failure. After a
meeting with the pt's daughter, his health care proxy, the
decision was made, by both the pt and his daughter, to extubate
the pt and make him CMO. The pt was extubated one day after
admission and he expired the following day. His daughter was at
his bedside. The following is a description of his brief
hospital course.
.
1) Hypercarbic respiratory failure: Pt intubated on arrival to
ED. Respiratory failure likely [**2-16**] COPD exacerbation
superimposed on persistent/recurrent pneumonia, possibly
post-obstructive. CTA in ED was negative for PE. CXR showed
near complete opacification of the left lung along with new
opacities in the right lung. He was given Vancomycin, cefepime
and flagyl for post-obstructive/aspiration pneumonia and
solumedrol with nebs for COPD. Sputum cx grew pseudomonas. As
above, pt was extubated after a family meeting and made CMO.
.
2) Hypotension: Briefly, around time of intubation, due to
propofol. Resolved.
.
3) Hypernatremia: Likely [**2-16**] decreased access to free water so
pt was given free water boluses down NGT.
.
4) Coagulopathy: INR 1.4, likely represents nutritional
deficiency so pt was given Vitamin K.
.
5) h/o CAD: recent NSTEMI with current nonspecific ST-T wave
changes. Pt was continued on cardiac meds.
.
6) LUE edema: Left upper ext ultrasound showed new subclavian
clot.
Medications on Admission:
1. Aspirin 325 mg qd
2. Lipitor 40mg qd
3. Thiamine HCl 100 mg qd
4. Folic Acid 1 mg qd
5. Ferrous Sulfate 325 qd
6. MS Contin 30 mg Tablet qd
7. Finasteride 5 mg qd
8. Acetaminophen 325-650mg q4 prn
9. Prochlorperazine 10 prn
10. Multivitamin Capsule qd
11. Atrovent
12. Fentanyl patch 100 mcg/hr
13. Lidocaine 5 % patch
14. Megestrol Acetate 40 mg [**Hospital1 **]
15. Morphine 15mg q4-6hrs prn pain
16. Piperacillin-Tazobactam 4.5 gm q8hrs (To complete a 21 day
course. Should end on [**2191-7-28**])
17. Senna
18. Albuterol Sulfate
19. Pantoprazole Sodium 40 mg qd
20. Metoprolol Tartrate 25 mg [**Hospital1 **]
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
hypercarbic respiratory failure
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 0389, 486, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6740
} | Medical Text: Unit No: [**Numeric Identifier 77715**]
Admission Date: [**2116-3-17**]
Discharge Date: [**2116-5-6**]
Date of Birth: [**2116-3-17**]
Sex: M
Service: NB
HISTORY: Baby boy [**Known lastname 77716**] was born at 28-5/7 weeks with a
birth weight of 1245 grams to a 39-year-old mom, [**Name (NI) **] P1-2.
Mom's prenatal labs include the following: Blood type O
positive, hepatitis B surface antigen negative, RPR
nonreactive, GBS unknown at the time of delivery and rubella
immune. Mom had spontaneous rupture of membranes on [**3-6**] for approximately 12 hours. She was treated with
betamethasone and antibiotics. However, on the day of
delivery, mom developed a low grade temperature and the
infant was born via spontaneous vaginal delivery after
induction for presumed chorioamnionitis in the mother.
The patient emerged vigorous and had Apgars of 7 and 8. The
patient did require oxygen and stimulation for poor
respiratory effort and was transitioned to the NICU on CPAP.
The weight on admission was 1245 grams which was equal to the
50-75 percentile. The length on admission was 39 cm which was
equal to the 50-75 percentile. The head circumference on
admission was 27.5 cm which was equal to the 50-75th
percentile.
Of note, this family is from [**Country 77717**] and mom has lived in the
United States since [**2106**].
PHYSICAL EXAMINATION: On discharge, the weight was 2.685
kilograms which is equal to the 50-75 percentile. The head
circumference at that time was 34 cm which is equal to the
75-90 percentile. The length upon discharge was 40 cms.
Generally, this patient was well appearing and alert on
physical exam. HEENT exam was significant for an anterior
fontanel that was open, soft and flat. Extraocular movements
intact with red reflex present bilaterally. Ears were normal
set and rotation. Palate was intact. No dysmorphic facies
were noted to the face. The neck was supple. Respiratory exam
was consistent with clear and equal breath sounds bilaterally
with no significant retractions or work of breathing. The
cardiovascular exam is consistent for a normal S1, S2,
regular rate and rhythm with no appreciable murmurs during
the exam. Femoral pulses were equal bilaterally. Abdominal
exam was consistent with a nontender, nondistended abdomen
and no masses were palpable. GU exam was consistent with
normal male genitalia. This patient, [**Last Name (un) **], did have a
circumcision. There is a small blood clot around the
circumference of the glans consistent with a normal healing
circumcision. The testicles are palpable bilaterally in the
mid inguinal canal. The testes can be pulled down into the
scrotal sac. There is a min or bulge in the proximal portion
of the inguinal canal area bilaterally. This bulge is thought
to be most consistent with the testicles in the mid canal.
There were no exam findings to suggest that there were bowel
loops in this area (hernia evaluation negative). The anus is
patent. The extremities are warm and well perfused and moving
symmetrically. The neurological exam is consistent with
normal tone and suck with a normal Moro reflex.
HOSPITAL COURSE:
Respiratory: This patient was initially brought from the
delivery room on nasal CPAP. The patient remained on CPAP
until day of life 5. The patient was then in room air until
day of life 22 when he was placed on nasal cannula of 25 cc.
The patient was then taken off of nasal cannula on day of
life 26 and remained in room air for the duration of the
hospitalization. This patient did have apnea of prematurity
and was placed on caffeine. Caffeine was discontinued on
[**2116-3-30**]. The patient was observed for 6-7 days prior
to discharge with no significant apnea or bradycardia events.
Cardiovascular: This patient had no significant appreciable
murmur during this hospitalization. This patient did not have
an echocardiogram to evaluate for a patent ductus arteriosis
during the hospitalization. It was noted that this patient
was often tachycardic with heart rates in the 170's-190's or
even low 200's at times. Caffeine was discontinued because it
was thought to exacerbate the tachycardia. The feedings were
also reduced in length because it was thought that possibly
the patient became more tachycardic near the end of the
feedings. Regardless of these possibilities, this patient's
heart rate remained stable in the 140's-170's for the last 2-
3 weeks of the hospitalization. An EKG was done that showed
normal sinus tachycardia during the hospitalization.
Fluids, electrolytes and nutrition: This patient was started
on enteral feedings on day of life 3 and the patient reached
full enteric feeds by day of life 10. The patient's maximum
caloric intake was PE 28 kcal per ounce. Upon discharge, this
patient was sent home with Enfamil 24 kcal per ounce feeding
ad lib. This patient was supplemented with iron for anemia of
prematurity during this hospitalization.
Hematology: As mentioned above, the patient did have anemia
of prematurity and was supplemented with iron. The most
recent hematocrit was done on [**4-29**] which was equal to day
of life 43 and the hematocrit value was 26.4. The
reticulocyte value was 4.2%. The patient was supplemented 4
mg of elemental iron per kilo per day. This patient also had
hyperbilirubinemia and the maximum bilirubin level was 6.5 on
[**2116-3-29**] which was equal to day of life 2. The patient
did receive phototherapy for this.
Infectious disease: This patient was placed on an ampicillin
and gentamicin for a sepsis workup for the first 48 hours of
life. These antibiotics were discontinued and the patient had
no other evaluations for sepsis during hospitalization.
Neurology: This patient had an initial head ultrasound on day
of life 8 that showed no intraventricular hemorrhage and
results were within normal limits. Followup head ultrasound on
day of life 30 or [**2116-4-21**] revealed bilateral germinal
matrix bleeding. A followup on [**5-5**] revealed resolving
bilateral germinal matrix hemorrhage. The film on [**5-5**]
also showed no evidence of periventricular leukomalacia.
This patient also had a retinopathy of prematurity screening
during the hospitalization. The initial exam was on [**2116-4-21**] which showed immature retina in zone 2 bilaterally. A
followup exam will performed on [**2116-5-6**] revealed the
same -- immature retina in zone 2 bilaterally. Follow-up is
recommended in 2 weeks.
Psychosocial: The [**Hospital1 69**] social
worker was involved with the care of this patient as they do
for all the patients in the neonatal intensive care unit. As
mentioned previously, this family is from [**Country 77717**] and mom has
lived in the United States since [**2106**]. Mom speaks [**Name2 (NI) 483**]
fluently.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Home.
PRIMARY CARE PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47710**] in [**Location (un) 55**]
Pediatrics. The address of the pediatrician is [**Apartment Address(1) **], [**Location (un) 55**], [**Numeric Identifier **]. Phone number is
[**Telephone/Fax (1) 47712**].
CARE/RECOMMENDATIONS:
Feedings on discharge are Enfamil 24 kcal per ounce ad lib.
Medications on discharge: Ferrous sulfate 4 mg of elemental
iron per kilo per day which is equal to 0.5 ml p.o. daily with
a concentration of 25 mg/mL.
Car seat position screening was performed prior to discharge
and the patient passed.
State newborn screening was performed on [**2116-3-20**] which
revealed an elevated phenylalanine level. Followup testing on
[**2116-3-31**] revealed a normal newborn screen. The last
screen was sent on [**2116-4-28**] and no abnormal results have
been reported.
Immunizations received during this hospitalization were
hepatitis B vaccine on [**2116-4-17**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following four criteria: 1: Born at less than or
equal to 32 weeks. 2: Born between 32-35 and 0/7 weeks with
two of the following: Daycare during RSV season, a smoker in
the household, neuromuscular disease, airway abnormalities or
school age siblings. 3: Chronic lung disease. 4:
Hemodynamically significant congenital heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months 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.
This infant has not received rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable and at least 6 weeks but fewer
than 12 weeks of age.
We recommend that the GU exam be followed clinically as an
outpatient. Due to his prematurity, [**Last Name (un) **] is at risk for
inguinal hernias. It is difficult to assess now if he has
inguinal hernias. We feel that [**Last Name (un) 40781**] physical exam is
consistent with descending testicles.
FOLLOWUP:
Primary care pediatric appointment on Thursday, [**2116-5-7**]
at 11:45 a.m.
Visiting nurse service on [**Last Name (LF) 2974**], [**2116-5-8**].
Followup referrals have been placed with early intervention
and infant followup clinic.
Family needs to schedule a follow-up appointment with
ophthlmology to follow the development of his retina.
DISCHARGE DIAGNOSES:
1. Preterm newborn
2. Respiratory distress syndrome
3. Apnea of prematurity
4. Sepsis evaluation
5. Hyperbilirubinemia
6. Anemia of prematurity
7. Bilateral germinal matrix hemorrhages
8. Immature retinal development
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern4) 76810**]
MEDQUIST36
D: [**2116-5-5**] 15:03:08
T: [**2116-5-5**] 16:02:42
Job#: [**Job Number 77718**]
ICD9 Codes: 7742, 769, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6741
} | Medical Text: Admission Date: [**2148-11-21**] Discharge Date: [**2148-11-25**]
Date of Birth: [**2091-2-25**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Biaxin / Ciprofloxacin
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
57-year old man with a history of HIV CD4 373 in [**2148-6-14**],
history of asplenia, history of strep viridans septic shock in
[**2148-6-14**] presents with fevers and rigors, lightheadedness, and
elevated WBC who is admitted to the ICU for hypotension and
fever. He was well until he woke up this morning with rigors and
feeling of lightheadedness without syncope. He took a hot shower
that did not warm him up and decided to present to the ED given
that these symptoms were similar to his prior Strep viridans
septic shock. He denies any other localizing symptoms including
cough, rhinorrhea, nausea, vomiting, diarrhea, myalgias, chest
pain/pressure, SOB, calf pain, or rash. He recently travelled to
[**Country 12649**] and to [**Location (un) **] where he engaged in protected anal and oral
sex, ate mussels, but no other changes in diet or habits. No
animal exposures other than his pet chihuahua. No known sick
contacts. [**Name (NI) **] had pneumovax and flu vaccines.
In the ED, initial vital signs were: T 98.1 P 122 BP 145/59 R 16
O2 sat 100%. His blood pressure dropped to 80's systolic and had
a temperature up to 103F. Vanco and zosyn were given in the ED.
Initial lactate was 2.2, elevated to 2.5 after 2nd liter of NS.
WBC was 21.3 with 88% neutrophils. CXR showed L retrocardiac
density concerning for pneumonia but later read as subsegmental
atelectasis. Received total 6L NS, central line was placed.
Upon leaving the ED, vitals were HR 111 BP: 114/52 O2: 98%2L RR
21
In the [**Hospital Unit Name 153**], T: 101.5 HR: 108 BP: 117/77 100% RA.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
HIV, CD4 379 [**6-22**], undetectable viral load and CD4 > 600 2 weeks
ago by report, never below 350 since diagnosis per patient.
Treated initially with Trisovir, now on Atripla (efavirenz-an
NNRTI, emtricitabine--a nucleoside RTI, and tenofavir--a
nucleoside RTI).
Hep B Diagnosed [**2117**]. ([**6-22**]: negative Hep B viral load; had
been on Atripla which includes emtricitabine and tenofovir, both
w anti-Hep B activity)
S/P Septic Shock with Xigris (activated protein C)
administration [**3-18**] strep viridans bacteremia c/b Acute Renal
Failure and CVVH, respiratory failure and thrombocytopenia in
[**6-22**]
History of splenic abscess s/p splenectomy in [**2135**]
DM type 2, on metformin
Obesity
Hypercholesterolemia, on lipitor
Asthma
R medial meniscal tear
History of severe bronchitis [**2146**]
Social History:
In long term relationship w/ partner x 30 years. Works in
software quality assurance for [**Location (un) 12650**]. No smoking. Very
occasional alcohol. No drugs. Recently travelled to Barcelona
[**Country 12649**] with + oral/anal sex, all protected. Recent travel also to
[**Location (un) **]. Ate mussels x 2 in [**Country 12649**], no unpasteurized cheeses, no
animal contacts other than pet chihuahua, no bites, no travel to
SW US or tropics, no significant tick exposure.
Family History:
Aunt with rheumatic fever, died [**2119**]
Mother with arrhythmia requiring pacemaker
Father died of lung ca, 60 year smoking history
Physical Exam:
Vitals: T: 101.5 HR: 108 BP: 117/77 100% RA
General: Alert, oriented, no acute distress. Interactive and
pleasantly conversant.
HEENT: Sclerae anicteric, MMM, oropharynx clear without thrush
Neck: Supple, JVP not appreciated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi.
CV: Tachycardic, regular, normal S1 + S2, grade 2/6 systolic
murmur at LUSB, no detectable radiation, no rubs or gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
well-healed laparotomy scar noted
GU: foley in place
Ext: +erythema, swelling, and tenderness in left anterior lower
leg. there are skin abrasions on dorsal surface of both halluxes
as well as onychomycosis of some toe nails.
Pertinent Results:
ADMISSION LABS:
[**2148-11-21**] 05:56PM LACTATE-1.8
[**2148-11-21**] 06:29PM URINE HOURS-RANDOM UREA N-681 CREAT-60
SODIUM-126
[**2148-11-21**] 05:56PM TYPE-[**Last Name (un) **] PH-7.36
[**2148-11-21**] 05:22PM GLUCOSE-125* UREA N-29* CREAT-1.4* SODIUM-140
POTASSIUM-4.3 CHLORIDE-111* TOTAL CO2-19* ANION GAP-14
[**2148-11-21**] 05:22PM CALCIUM-8.9 PHOSPHATE-2.4*# MAGNESIUM-1.7
[**2148-11-21**] 05:22PM WBC-28.1* RBC-3.63* HGB-11.2* HCT-34.6*
MCV-95 MCH-30.9 MCHC-32.4 RDW-15.1
[**2148-11-21**] 12:32PM LACTATE-2.5*
MICROBIOLOGY:
[**2148-11-21**] Blood Cx pending as of day of discharge
[**2148-11-21**] Urine Cx negative
[**2148-11-21**] GC / Chlamydia negative
[**2148-11-22**] Cdiff negative
[**2148-11-22**] Stool Cx negative
STUDIES:
[**2148-11-21**] CXR - Mild cardiomegaly with sub-segmental atelectasis
in the left
lower lobe.
Brief Hospital Course:
57 year old asplenic male with HIV (per pt. most recent
CD4=600), h/o strep viridans sepsis in [**Month (only) 547**]/[**2148-6-14**], was
admitted with sepsis, most likely secondary to left leg
cellulitis.
1. Sepsis
Patient presented with fevers, tachycardia, elevated WBC, and
hypotension responsive to fluids. Of note, the patient is
asplenic, so encapsulated organisms were of concern. There was
concern for another episode of Strep Viridans sepsis as with his
previous hospitalization in [**2148-6-14**], but his blood cultures
have been negative so far. Initial interpretation of CXR was
possible PNA, but the patient did not have any respiratory
symptoms to support it. A left lower extremity cellulitis was
the likely source of sepsis. The cellulitis had no induration,
but the erythema and swelling appeared to increase slowly in
size for a full 24 hours on the intravenous antibiotic regimen
before it stabilized.
Vancomycin and Zosyn were continued for treatment of his
cellulitis because of his history of MRSA and to cover for
encapsulated organisms. GC/Chlamydia swaps were negative. ID
consult recommended transition to PO Bactrim and Augmentin as
outpatient therapy. Will defer to PCP as to whether or not
patient should have penicillin prophylaxis because of his
asplenia.
2. Acute vs Chronic Renal Insufficiency:
Mr. [**Known lastname 12651**] creatinine was 1.3-1.4 on presentation. His
baseline creatinine is unclear. [**Name2 (NI) **] had acute renal failure
during his last hospitalization in [**Month (only) 116**], and it is unclear
whether his creatinine ever returned to his baseline.
3. HIV
Per patient, his last CD4 count was greater than 600, and his
viral load undetectable. During his hospitalization, he was
continued on Atripla.
4. Type 2 Diabetes Mellitus
He was initially maintained on insulin sliding scale but was
then transitioned to his home regimen of metformin.
5. Hypertension
His lisinopril was initially held during this admission and then
restarted once his blood pressure improved.
Medications on Admission:
Metformin 250mg PO BID
Atripla 1 tab PO daily
Lisinopril 15mg PO daily
Lipitor 10mg PO daily
ASA 81mg PO daily
Ibuprofen 3 tabs TID
Prilosec 20 mg daily (?)
supplements including fish oil, L carnitine, glucosamine
Discharge Medications:
1. Metformin 500 mg Tablet [**Month (only) **]: 0.5 Tablet PO BID (2 times a
day).
2. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO once a
day.
3. Lisinopril 5 mg Tablet [**Telephone/Fax (3) **]: Three (3) Tablet PO DAILY
(Daily).
4. Atorvastatin 10 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable [**Telephone/Fax (3) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Bactrim DS 160-800 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. Augmentin 875-125 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Cellulitis of the left lower leg.
SECONDARY DIAGNOSIS:
1. HIV
2. Asplenia
3. Type 2 Diabetes Mellitus
4. Hypertension
Discharge Condition:
Stable. Patient is ambulating, tolerating oral intake, and has
returned to his baseline condition.
Discharge Instructions:
You were admitted to the hospital with sepsis thought likely
related to your left lower leg cellulitis. You were started on
IV antibiotics with improvement in your blood pressure.
We have adding the following medications for treatment of your
cellulitis:
1. Bactrim DS one tablet twice daily for 10 days total
2. Augmentin 875mg one tablet twice daily for 10 days total
Please seek immediate medical attention if you develop fevers,
shaking chills, night sweats, light-headedness, dizziness,
passing out, worsened swelling in your left leg, shortness of
breath, abdominal pain, diarrhea, or cough.
Followup Instructions:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2148-11-27**]
3:15
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6164**], within the next 10 days.
ICD9 Codes: 0389, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6742
} | Medical Text: Admission Date: [**2196-11-30**] Discharge Date: [**2196-12-3**]
Date of Birth: [**2146-5-1**] Sex: F
Service: SURGERY
Allergies:
Baclofen
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
The patient was initially admitted for diarrhea and jaundice.
Major Surgical or Invasive Procedure:
Emergent exploratory laparotomy for control of life-threatening
intraperitoneal variceal hemmorhage [**2196-12-3**]
Transfusion of 35 units of packed red blood cells, 20 units of
FFP, 6 units of platelets, 2 units of cryoprecipitate, and one
dose of recombinant Factor VIIa over [**Date range (1) 71513**]/09
History of Present Illness:
This 50 year old lady with hepatitis C cirrhosis was initially
admitted for diarrhea and jaundice. The diarrhea had resolved
and jaundice with ARF secondary to volume depletion was
correcting early in her hospital course.
During the night of [**2196-12-2**], she transferred to the ICU for
abdominal pain, hemodynamically stable and repeat hematocrit
drops consistent with a bleed. Prior to transfer the patient
received 9 units of pRBCs, 4 units FFP, 3 units platelets and 1
Unit cryoprecipitate with appropriate hematocrit increase, but
without platelent increase or resolution of coagulopathy.
Diagnostic paracentesis revealed sanguinous fluid with a
hematocrit of 13. Tagged RBC scan was non-revealing. CT scan
suggested no retroperitoneal bleed (full report below). The
patient remained hemodynamically stable with systolic blood
pressures 90-100 and heart rate 70-80 while on Nadolol.
Past Medical History:
1.Cirrhosis [**12-26**] HCV (genotype 1) and EtOH
- h/o ascites, SBP, and encephalopathy
- currently listed for liver [**Month/Day (2) **]
- Abdominal CT [**5-/2196**] showed stable cirrhosis, portal
hypertension, and extensive variceal formation, patent portal
vein, cholelithiasis, splenomegaly, anterior pelvic midline
hernia containing a small bowel loop without obstruction,
ascites, and mild cecal thickening.
- Abdominal U/S [**5-/2196**] showed no liver mass, splenomegaly, and
patent main portal vein with hepatopetal flow and large patent
umbilical vein shunting portal venous flow (no flow detected in
right portal vein)
- EGD [**5-/2196**] showed grade 1 esophageal varices, grade 1
esophagitis, a small hiatal hernia, portal hypertensive
gastropathy, and an ulcer in the duodenal bulb
2.Asthma
3.mildly dilated left atrium, trace AR, trivial MR, EF>55%, no
[**Last Name (un) 6879**] on TTE [**12-1**]
4.No h/o diabetes, cancer, stroke, MI, epilepsy, seizures, high
cholesterol or hypertension
5.s/p fractured jaw repair [**2185**]
6.s/p ankle surgery [**2177**]
7.Endometriosis and right simple ovarian cyst s/p BSO [**3-/2195**]
Social History:
Lived with her sister, has a very supportive family. Formerly
employed in social work but currently unemployed [**12-26**] fatigue and
poor memory. Smokes 2 packs/week, used to smoke 1 PPD. Drank
heavily for 20 years, but no EtOH use since [**2194-2-22**]. +Prior
marijuana and intranasal cocaine use, but no h/o IVDU.
Family History:
Significant for the absence of any colon cancer or breast
cancer. No liver disease. Her mother is healthy. Her dad has
prostate cancer. She has three sisters and two brothers who are
all healthy.
Physical Exam:
Wt 90.6 kilograms, up from 86 kilograms. 02 sat is 100%.
HEENT -does reveal marked sclera icterus.
Heart normal rate and rhythm, no murmurs
Lungs clear to auscultation bilaterally,no wheezes.
Abdomen soft, distended, obvious ascites on exam. Extremities
reveal 1+ edema pitting edema bilaterally and there is increased
swelling in the left lower extremity with some bruises and cuts.
Neurologic exam: postivie for asterixis but she is alert and
oriented x3.
Pertinent Results:
[**2196-11-30**] 09:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-11-30**] 05:12PM GLUCOSE-123* UREA N-28* CREAT-1.6*
SODIUM-132* POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-28 ANION GAP-10
[**2196-11-30**] 05:12PM ALT(SGPT)-12 AST(SGOT)-68* LD(LDH)-413* ALK
PHOS-93 TOT BILI-10.7*
[**2196-11-30**] 05:12PM ALBUMIN-2.4* CALCIUM-8.4 PHOSPHATE-3.9
MAGNESIUM-2.2
[**2196-11-30**] 05:12PM WBC-3.8* RBC-1.96* HGB-7.0* HCT-20.4*
MCV-104* MCH-35.9* MCHC-34.5 RDW-17.8*
[**2196-11-30**] 05:12PM PLT COUNT-31*
[**2196-11-30**] 05:12PM PT-24.0* PTT-40.0* INR(PT)-2.3*
[**2196-11-30**] Abdominal ultrasound:
IMPRESSION:
1. Coarsening of the hepatic parenchyma, consistent with known
history of
cirrhosis. Portal hypertension is evidenced by massive
splenomegaly, moderate ascites, and recanalization of the
paraumbilical vein.
2. Unchanged cholelithiasis without son[**Name (NI) 493**] evidence for
cholecystitis. There is no intra- or extra-hepatic biliary
ductal dilatation. Mild gallbladder wall thickening and edema is
nonspecific, and can be seen in cirrhosis.
3. No focal liver lesions identified.
4. There is normal antegrade flow in the main portal vein,
dilation of the
left portal vein, and continuation into a recanalized
paraumbilical vein. The intrahepatic portal veins are difficult
to identify as discribed above but show likely flow reversal in
right anterior and posterior portal veins, an unchanged finding.
[**2196-12-1**] CT without contrast:
1. Moderate-to-large amount of ascites. Shrunken nodular liver
with numerous varices notably in the distal esophagus consistent
with cirrhosis and decompensated liver disease.
2. No retroperitoneal bleed.
3. Largely distended gallbladder with layering stones within the
lumen.
Evaluation is otherwise limited given surrounding ascities and
non-constrast enhanced evaluation. HIDA may be pursued as
indicated.
4. Tiny 3 mm non-obstructing renal calculus within the right
kidney.
5. 3.8 cm venous varix within the subcutaneous tissues of the
anterior
abdominal wall without change.
[**2196-12-2**] CT with contrast:
1. New layering high-density within large ascites concerning for
interval
bleeding into the ascitic fluid. While source of bleeding is not
identified on non-contrast study, note is made of slight higher
density material in the pelvis and near the gallbladder. No
retroperitoneal hematoma seen.
2. Fat-containing umbilical hernia, unchanged. Multiple fluid-
containing
ventral wall hernias, also containing fluid-fluid levels.
3. Cirrhotic liver with large ascites and extensive variceal
formation.
4. Anasarca, enlarged ascites, small left and tiny right pleural
effusions.
5. Largely distended gallbladder with layering gallstones as
seen one day
prior on CT. If clinically concerning for acute cholecystitis,
again HIDA may be performed.
6. Nonobstructing 2-mm right renal calculus
Brief Hospital Course:
Patient was transferred from [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] to MICU for increasing
abdominal pain and repeated hematocrit drop in the face of
multiple units of blood. The patient was transfused with 4
additional units as well as fresh frozen plasma and platelets to
achieve hemostasis. She remained hemodynamically stable and
pain controlled on morphine. At approximately 10am, the patient
experienced an acute drop in blood pressure to the 70s with
severe abdominal pain. At this time she had evidence of an
acute abdomen. Surgery and anesthesia were called immediately
and transfusions started. The patient was intubated, sedated
and central access was obtained. With multiple units of PRBCs
transfusing the patient was taken to the OR by [**Doctor Last Name **]
surgery.
Operative Course
Upon entering the abdomen, there was a tremendous amount of
bloody ascites. The liver was obviously cirrhotic and she had
extensive abdominal and subcutaneous
varices measuring greater than 1-2 cm in diameter. Uponentering
the peritoneal cavity, there was a very large amount of bleeding
with massive exsanguinating hemorrhage coming from the hilum of
the liver, which was ultimately found to come from a recanalized
umbilical vein. The vein itself measured about 3 cm in diameter
and there was a hole in the side of the umbilical vein that
measured about 1.5 cm. There was a significant hemorrhage coming
from this likely 500-600 mL a
minute. Control of this vein was achieved by ligating the
umbilical vein proximally and distally to the venotomy and this
essentially caused the hemorrhage to cease. At this time, the
abdominal closure was aborted due to furthing variceal bleeding
encounted upon attempted fascial closure. A [**Location (un) 5701**] bag was
placed into the abdomen as a temporary closure followed by two
19 [**Doctor Last Name 406**] drains above the [**Location (un) 5701**] bag and
[**Last Name (un) 71514**] laparotomy pads, blue sterile towel, and then an Ioban.
The patient was then returned to the surgical intensive care
unit in critical condition.
Hours after return from the OR, the patient experienced a
pulseless electrical activity cardiac arrest in the SICU. Chest
compressions were immediately initiated, resulting in a return
of heart rhythm.
Discussions were held with the patient's family regarding the
patient's overwhelmingly poor prognosis in light of the events
which had occured. The family elected to make patient no
compressions no shocks initally. Later on [**12-3**], the family
changed the patient's status to comfort measures only and
life-sustaining measures and treatments were discontinued. The
patient expired on [**2196-12-3**].
Medications on Admission:
Ciprofloxacin 250mg daily
Folate 1mg daily
Furosemide 40mg daily
Lactulose 30cc QID
Omeprazole 20mg daily
Rifaximin 600mg [**Hospital1 **]
Spironolactone 200mg daily
Multivitamin daily
Thiamine 250mg daily
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Death due to exsanguination and subsequent hypovolemic shock
from intraperitoneal variceal bleeding secondary to end stage
liver disease
Discharge Condition:
Expired
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
ICD9 Codes: 5849, 2851, 9971, 5715, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6743
} | Medical Text: Unit No: [**Numeric Identifier 56046**]
Admission Date: [**2129-7-10**]
Discharge Date: [**2129-8-30**]
Date of Birth: [**2129-7-10**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] was delivered on [**2129-7-10**] by
cesarean section at 30 weeks gestation to a 36 year old,
Gravida I, now Para 0 mother. This was a twin gestation,
resulting from in-[**Last Name (un) 5153**] fertilization. Mother's prental screens
include blood type is A positive, antibody negative, RPR
nonreactive, Rubella immune, hepatitis B surface antigen
negative, GBS unknown.
Pregnancy was complicated by twin gestation and HELLP
syndrome. Mother was treated with magnesium sulfate and was
treated with betamethasone on [**7-5**] and [**7-6**]. Baby was
delivered by cesarean section for worsening HELLP. Her
weight was 990 grams. Initially, she was blue with a weak
cry. Heart rate greater than 100. She was dried, suctioned
and provided positive pressure ventilation for one minute for
ineffective respiratory effort and this resulted in
improvement in color. She continued with facial C-Pap and
was noted to be centrally pink and crying. She was shown to
her parents briefly in the delivery room and transferred to
the Neonatal Intensive Care Unit for further management.
PHYSICAL EXAMINATION: Weight 990 grams, less than 10th
percentile. Length 36 cm. Head circumference 26.5 cm. She
had an anterior fontanel which was open, flat and soft; non
dysmorphic facial features. Nares were patent. Her palate
was intact. Her mucous membranes were moist and pink. Chest
was clear with decreased breath sounds. Heart rate was
regular rate and rhythm with no murmur, no rub, no gallop.
Pulses were plus 2 and equal. Abdomen was soft with active
bowel sounds. Her cord was clamped. She had spontaneous
range of motion of all extremities. Her neurologic
examination was nonfocal.
HOSPITAL COURSE: Respiratory: Infant was intubated upon
admission to the Neonatal Intensive Care Unit. She received
one dose of Surfactant with maximum pressures of 22 over 5
and a rate of 25. She was weaned after her dose of
Surfactant and was extubated on day of life one, at which
time caffeine was started. She remained on caffeine for the
next several weeks. Caffeine was discontinued on [**8-8**] on day
of life number 29, for apnea of prematurity and [**Known lastname **] has
remained free from spells for the last several days prior to
discharge. After being extubated on day of life one to CPAP,
[**Known lastname **] was placed in room air on day of life three which
she has subsequently remained. Her breathing is comfortable
and has noted occasional desaturations with feedings but no
true apnea for the last several days. [**Known lastname **] also received a
12 dose course of Vitamin A for lung disease.
Cardiovascular: [**Known lastname **] remained cardiovascularly stable, with
mean blood pressures on admission between 36 and 50. She
required no volume or pressor support. Vigilance for a
patent ductus arteriosus was maintained but there was no
clinical evidence of such. She had a PICC line placed which
was deemed to be non central and she received PN and intra
lipids through this. This line was discontinued on day of
life nine when feedings were advanced to full enteral volume.
She also had an initial UVC placed which was pulled on day of
life five, the time that the PICC line was placed.
She was noted to have some elevate blood pressure in the NIUC.
She had a renal ultrasound [**2129-8-29**] which was normal as
part of the work-up.
Fluids, electrolytes and nutrition: [**Known lastname 56047**] initial dextrose
stick was 54. She remained euglycemic on parenteral
nutrition and transitioning to enteral feeds. She was
maintained n.p.o. until day of life three, receiving
intravenous fluids and PN during that time. Enteral feeds
were introduced and gradually advanced to full enteral feeds on
day of life nine,
at which time calories were advanced to a maximum of breast
milk 30 with ProMod. She demonstrated good weight gain at
this caloric density and subsequently, calories were weaned.
At the time of discharge, [**Known lastname **] is taking breast milk 24
calories made with Similac powder for average intake of 180
cc per kg per day all p.o. or breast feeding. [**Known lastname **] had an
episode of abdominal distention on day of life 47, [**8-26**],
following administration of eye drops for an ophthalmic
evaluation. She had a KUB at that time which noted some
dilation of her bowel loops. She had a CBC and a blood
culture done concurrently which the blood culture remained
sterile and the CBC was benign. There was no further
treatment and her distention has resolved spontaneously. She
has a normal voiding and stooling pattern otherwise. Her weight
on the day of discharge was 2.37 kg, length 44 cm, head
circumference 32.5 cm.
Electrolytes were monitored throughout administration of PN
and remained in the normal range.
Gastrointestinal: [**Known lastname **] underwent phototherapy for
physiologic jaundice, with a peak bilirubin noted on day of
life four at 4.7 over 0.4. Phototherapy was discontinued on
day of life nine and rebound bilirubin was 3.8. The problem
was resolved at that time.
Hematology: Initial CBC was notable for white count of 5.5
with 25 polys and 1 band. Hematocrit of 59.4 percent.
Platelets of 281,000. [**Known lastname **] was started on iron and vitamin E
on day of life 11. She continues on iron at the time of
discharge. Vitamin E was discontinued. Her last hematocrit
was on [**8-26**] and was 37.1. She had a reticulocyte count of 9.2
percent a week prior to that. There were no blood products
received during this hospitalization.
Her state screens were notable for having FAS hemaglobin. She has
sickle cell trait. This was discussed with the parents. The
mother who has never had any hematological problems is being
screened for sickle cell. Hematology was consulted. There was no
furher work-up required.
Infectious disease: As part of her initial sepsis evaluation
at the time of admission, blood culture was obtained which
remained negative. [**Known lastname **] received 48 hours of Ampicillin and
Gentamycin during this time. She has remained clinically
well off antibiotics.
Neurologic: Head ultrasounds were performed for screening
purposes for intraventricular hemorrhage on day of life seven
and again at a month of age and both were noted to be within
normal limits.
Sensory: Audiology: Hearing screening was performed with
automated auditory brain stem responses. Hearing screen was
passed bilaterally.
Ophthalmology: Eyes were most recently examined on [**8-26**],
revealing ROP stage one, zone three bilaterally, four clock
hours on the left and seven clock hours on the right. It is
recommended that she have a follow-up examination two weeks
from [**8-26**] which would be the week of [**9-12**] as an
outpatient.
Psychosocial: [**Hospital1 69**] social
work was involved with this family. She may be reached at [**Telephone/Fax (1) 56048**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY CARE PHYSICIAN: [**First Name8 (NamePattern2) 5279**] [**Last Name (NamePattern1) 43699**], [**Name Initial (NameIs) **].D.
CARE AND RECOMMENDATIONS: Feedings: Breast feeding or
breast milk 24 calorie made with Similac powder, ad lib
demand.
MEDICATIONS: Iron.
Car seat positioning screening was passed on day prior to
discharge.
State newborn screening status: State newborn screens
included.
IMMUNIZATIONS: Received: Initial hepatitis B vaccine was
given on [**7-13**] and the second hepatitis B vaccine was
administered on [**2129-8-11**].
Recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) 359**] to
[**Month (only) 547**] for infants who meet any of the following three
criteria: 1. ) Born at less than 32 weeks. 2.) Born between
32 and 35 weeks with two of the following: Day care during
RSV season, a smoker in the household, neuromuscular disease,
airway abnormalities or school age siblings. Or, 3.) With
chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW UP: Follow-up with pediatrician is scheduled for
Thursday of this week on [**9-1**].
[**Hospital6 407**] will visit the family at home as
well this week.
She need opthomlogy follow-up the week of [**9-9**]-27.
DISCHARGE DIAGNOSES: Prematurity at 30 weeks, twin
gestation.
Surfactant deficiency.
Sepsis suspect.
Physiologic jaundice.
Apnea of prematurity.
Anemia of prematurity.
Retinopathy of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 54678**]
MEDQUIST36
D: [**2129-8-30**] 19:28:20
T: [**2129-8-30**] 20:15:29
Job#: [**Job Number **]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6744
} | Medical Text: Admission Date: [**2184-5-31**] Discharge Date: [**2184-6-28**]
Date of Birth: [**2114-11-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2184-5-31**] Aortic valve replacement(23mm CE Magma), two vessel
coronary artery bypass grafting(vein grafts to obtuse marginal
and PDA), and Aortic endarterectomy
[**2184-6-14**] Sternal re-exploration, Evacuation of mediastinal blood
and Sternal debridement.
[**2184-6-14**] Repair of sternal dehiscence and bilateral pectoralis
major musculocutaneous advancement flap.
[**2184-6-22**] Dobhoff tube placement
History of Present Illness:
Mr. [**Known lastname 1007**] is a 69 year-old male with a long history of aortic
stenosis followed by serial echocardiograms, recently found to
have coronary artery disease as well. He recently had been
complaining of dyspnea on exertion along with chest pain and
worsening fatigue. Therefore, he was referred for surgical
evaluation. Preoperative evaluation was notable for a cirrhotic
liver on CT scan. Workup was otherwise unremarkable and he was
admitted for aortic valve replacement and coronary artery bypass
grafting surgery.
Past Medical History:
- Aortic Stenosis/Coronary Artery Disease
- Type II Diabetes Mellitus
- Hypertension
- Cirrhosis, Portal Hypertension, with Splenomegaly, Varices and
Ascites
- Psoriasis
- Cataract Surgery
Social History:
Mr. [**Known lastname 1007**] is a custodian at a retail store. He reports smoking
cigars in the past. He denies drinking alcohol. He lives with
his wife.
Family History:
Noncontributory
Physical Exam:
At the time of admission, Mr. [**Known lastname 1007**] was found to be in no acute
distress.
65" 185#
Multiple psoriatic plaques were noted on his skin. His lungs
were clear to auscultation bilaterally. His heart was of
regular rate and rhythm and a III/VI murmur was noted. His
abdomen was soft, non-tender, and non-distended with bowel
sounds. His extremities were warm and well perfused.
Superficial varicosities were noted in his left lower extremity.
Neuro was grossly intact. There were 2+ bil. fem/DP/PT/radial
pulses. Murmur radiated to both carotids.
Pertinent Results:
[**2184-6-27**] 04:38AM BLOOD WBC-8.9 RBC-3.27* Hgb-10.4* Hct-32.7*
MCV-100* MCH-31.7 MCHC-31.7 RDW-16.7* Plt Ct-181
[**2184-6-28**] 03:04AM BLOOD PT-18.4* PTT-35.0 INR(PT)-1.7*
[**2184-6-27**] 04:38AM BLOOD PT-19.4* INR(PT)-1.8*
[**2184-6-26**] 06:13AM BLOOD PT-17.6* INR(PT)-1.6*
[**2184-6-28**] 03:04AM BLOOD Glucose-108* UreaN-34* Creat-1.7* Na-147*
K-4.2 Cl-113* HCO3-25 AnGap-13
[**2184-6-27**] 04:38AM BLOOD Glucose-114* UreaN-33* Creat-1.5* Na-149*
K-3.9 Cl-116* HCO3-24 AnGap-13
[**2184-5-31**] Intraop TEE
PRE-CPB: 1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the body of the left atrium. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. 2. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is mild regional left ventricular systolic
dysfunction with inferior hypokinesis. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-50 %). 3. There
are complex (>4mm) atheroma in the aortic root. There are simple
atheroma in the ascending aorta. There are complex (>4mm)
atheroma in the aortic arch. There are focal calcifications in
the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. An epiaortic scan was performed and
stored on a different machine. A single plaque was visualized in
the ascending aorta adjacent to the pulmonary artery.
4. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Trace aortic
regurgitation is seen. 5. The mitral valve leaflets are
moderately thickened. There is mild valvular mitral stenosis
(area 1.5-2.0cm2). Trivial mitral regurgitation is seen.
POST-CPB: On infusion of phenylephrine. AV pacing. There is a
well-seated bioprosthetic valve in the aortic position with no
regurgitation seen. A transvalvular gradient was not able to be
obtained but there was no evidence of residual stenosis by color
flow doppler. Biventricular systolic function is preserved. The
aortic contour is normal post decannulation with no alteration
seen of the plaque in the proximal aorta.
[**2184-6-4**] Abd/Chest CT Scan:
CT ABDOMEN: The lung bases demonstrate small bilateral pleural
effusions and associated relaxation atelectasis. Heart size is
normal. There is no pericardial effusion. The liver contour is
nodular consistent with history of cirrhosis. Ill defined
approximately 8 x 3 cm lesion in segment V demonstrates patchy
peripheral enhancement. The portal vein, SMV, and splenic vein
are patent. The gallbladder is unremarkable without evidence of
gallstones. There is no intra- or extra- hepatic biliary
dilatation. The spleen, pancreas, adrenals, kidneys are
unremarkable. The SMV, splenic and portal veins are patent.
Severe atherosclerotic calcifications at the origin of the
celiac artery and SMA are noted . A replaced right hepatic
artery arises from the SMA. Moderate splenic varices are noted.
The abdominal loops of small bowel are dilated to 3.4 cm without
evidence of pneumatosis, wall thickening or transition point to
suggest acute obstruction. Stool is seen to the level of the
rectum and there is mild colonic dilation to 5.5 cm. Scattered
mesenteric and retroperitoneal nodes do not meet CT size
criteria for enlargement. Stranding in the subcutaneous tissues
diffusely likely represents anasarca. The kidneys enhance and
excrete contrast symmetrically. CT PELVIS: The rectum, sigmoid,
and prostate are unremarkable. Air within the bladder is likely
secondary to foley catheterization.
[**2184-6-14**] Transesophogeal ECHO:
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. No
thoracic aortic dissection is seen. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis leaflets
appear to move normally. There is severe mitral annular
calcification. Physiologic mitral regurgitation is seen (within
normal limits). There is a large pericardial effusion. The
effusion appears circumferential. No right atrial diastolic
collapse is seen. No right ventricular diastolic collapse is
seen.
Brief Hospital Course:
In [**2184-5-31**], Mr. [**Known lastname 1007**] was admitted and underwent a coronary
artery bypass grafting times two (SVG to OM and SVG to PDA),
aortic valve replacement (23mm CE magna pericardial), aortic
endartarectomy. Please see the operative note for details. He
tolerated this procedure well and was transferred in critical
but stable condition. On the following day the hepatology
service was consulted secondary to a pre-operative CT suggesting
a cirrhotic liver. This consultation revealed cryptogenic
cirrhosis and portal hypertension with no liver failure. By post
operative day two he was extubated and weaned from pressors. He
was found to be lethargic and disoriented, but with a non-focal
exam. He had atrial fibrillation which was initially treated
with amiodarone but it then was stopped secondary to his poor
liver function. He was transfered to the step down floor on the
following day. A nasal-gastric tube was placed for a distended
abdomen and a CT scan revealed an ileus. On post-operative day
six, sips were initiated and a PICC was placed for access.
While his mental status and ileus improved initiatially, both
worsened on the 26th and he was returned to the intensive care
unit and the [**Last Name (un) **]-gastric tube was replaced. With time his
liver function tests improved and he passed his bowels. By
post-operative day ten he was transfered back to the step down
floor and TPN was begun to boost his nutrition. He had two
episodes of atrial fibrillation which resolved with
betablockers. His [**Last Name (un) **]-gastric tube was removed on the
following day and his diet was advanced.
On post-operative day 14 he was noted to have bloody drainage
from his mediastinal incision, hypotension, and decrease oxygen
saturation. A bedside echocardiogram revealed a circumferential
pericardial effusion, so he was taken to the operating room for
tamponade. The plastic surgery service joined the cardiac
surgery team in the operating room and plated his sternum,
performing bilateral myocutaneous advancement flaps. Please see
operative note for details. He was brought to the surgical
intensive care unit in critical but stable condition. ID
consult done for abx management as bone culture grew coag neg.
staph. Extubated again on [**6-16**]. Transferred back to the floor on
POD #18/13 to begin increasing his activity level. Jaundice
noted with elevated bilirubins. Serial C. Diff. cultures were
negative. A bedside swallowing evaluation was done on [**6-21**] and he
was cleared for ground solids and nectar thick liquids with a
chin tuck and strict supervision, but it was recommended that
ENT evaluate him first for his dysphonia. Since he was still
too drowsy to increase his intake adequately he was fed with TPN
and tube feeds for a couple of days. ENT felt on exam that Mr.
[**Known lastname **] vocal cords were inflammed but not compromised. He
removed his own Dobhoff tube and he began to take in food with
supervision. He was diuresed and given albumin for third
spacing. He was started on scheduled haldol and his mental
status improved markedly. The patient was found suitable for
transfer to rehab on POD 28/14. Vancomycin and rifampin are
continued for a total of 6 weeks per ID recommendations. The
patient was advised of appropriate follow-up.
Medications on Admission:
Aspirin 162, multivitamin, calcium 1200, B12 1000, omeprazole
20, lisinopril 5, zocor 40, metformin 500, lopressor 25,
glipizide 2.5, iron 325, humira pen 40, clobetasol propionate
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet [**Known lastname **]: One (1) Tablet PO BID
(2 times a day).
2. Haloperidol 1 mg Tablet [**Known lastname **]: One (1) Tablet PO BID (2 times a
day). Tablet(s)
3. Aspirin 81 mg Tablet, Chewable [**Known lastname **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Known lastname **]: One (1) Inhalation Q6H (every 6 hours).
5. Rifampin 300 mg Capsule [**Known lastname **]: One (1) Capsule PO Q12H (every
12 hours) for 4 weeks.
6. Glipizide 5 mg Tablet [**Known lastname **]: 0.5 Tablet PO BID (2 times a day).
7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
8. Furosemide 40 mg IV BID Start: In am
9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
12. Metoclopramide 10 mg IV Q8H:PRN nausea
13. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: 2.5 Intravenous Q 24H
(Every 24 Hours) for 4 weeks: trough goal 15-20, vancomycin
1250mg IV q24h.
14. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection ASDIR (AS DIRECTED): see attached sliding scale.
15. Outpatient Lab Work
weekly LFTs, CBC w diff, chem 7, ESR, CRP
results to Dr. [**Last Name (STitle) **] ([**Hospital **] clinic) fax: ([**Telephone/Fax (1) 1353**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Aortic stenosis
coronary artery disease
s/p aortic valve replacement,aortic endarterectomy & coronary
artery bypass graft X 2
sternal dehiscence and wound infection
atrial fibrillation
tamponade
hypertension
psoriasis
noninsulin dependent diabetes mellitus
hypercholesterolemia
prior IMI
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] (cardiac surgery)in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (PCP) in [**1-16**] weeks ([**Telephone/Fax (1) 3183**])
Dr. [**First Name (STitle) **] (plastic surgery) in 1 week [**Telephone/Fax (1) 1416**]
weekly labs to [**Hospital **] clinic
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2184-9-22**] 11:00
Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2184-7-19**]
1:30
Completed by:[**2184-6-28**]
ICD9 Codes: 5849, 2761, 2760, 4241, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6745
} | Medical Text: Admission Date: [**2200-10-21**] Discharge Date: [**2200-10-27**]
Date of Birth: [**2138-11-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
new onset chest pain with exertion
Major Surgical or Invasive Procedure:
s/p emergent CABG for 70% prox LAD occlusion [**10-21**]
History of Present Illness:
61 yo M p/w new onset chest pain . Cath showed clot in distal
LM, LAD and circ disease. Transferred for CABG.
Past Medical History:
Gout, HTN, Obesity, IBS, HZV (past) Hyperchol, Sq Cell CA, Bas
Cell CA, Skull frx, R knee
Social History:
works in real estate
quit tobacco 20 years ago
6 etoh/week
Family History:
NC
Physical Exam:
HR 78
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75282**] (Complete)
Done [**2200-10-21**] at 3:35:27 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2138-11-16**]
Age (years): 61 M Hgt (in): 66
BP (mm Hg): 180/801 Wgt (lb): 219
HR (bpm): 75 BSA (m2): 2.08 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 786.05, 440.0
Test Information
Date/Time: [**2200-10-21**] at 15:35 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Findings
LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. Results were reviewed with the
Cardiology Fellow involved with the patient's care. See
Conclusions for post-bypass data The post-bypass study was
performed while the patient was receiving vasoactive infusions
(see Conclusions for listing of medications).
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened. There is
no aortic valve stenosis. No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7. The tricuspid valve leaflets are mildly thickened.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine.
1. Biventricular systolic function is preserved.
2. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**].
3. Aorta is intact post decannulation
4. Other findings are [**Last Name (Titles) 1506**]
Brief Hospital Course:
He was taken to the operating room where he underwent a CABG x
3. He was transferred to the ICU in stable condition. He was
extubated later that same day. He was transferred to the floor
on POD #1. He did well postoperatively. His Chest tubes were
removed. Post cxr showed no sequele. POD 3 # Pacing wires were
removed.
PT worked with pt. Pt stable for DC.
To note pt did fail voiding trial. He is urinating on DC
Medications on Admission:
Miralax 17mg PRN, Levmid 0.375, Diovan 160, Amytiptyline 75 QHS,
Cochicine
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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
8. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12 hr
Sig: One (1) Capsule, Sust. Release 12 hr PO BID (2 times a
day).
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 4
days.
Disp:*8 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD now s/p CABG
Gout, HTN, Obesity, IBS, HZV (past) Hyperchol, Sq Cell CA, Bas
Cell CA, Skull frx, R knee
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 lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 1968**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 13175**] 2 weeks
Completed by:[**2200-10-26**]
ICD9 Codes: 4111, 2720, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6746
} | Medical Text: Admission Date: [**2124-1-19**] Discharge Date: [**2124-1-27**]
Date of Birth: [**2065-3-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
coronary arttery disease
Major Surgical or Invasive Procedure:
[**2124-1-21**] - Coronary artery bypass graft x5 (left internal mammary
artery to the ramus artery and saphenous vein grafts to left
anterior descending artery, diagonal, obtuse marginal, posterior
descending)
History of Present Illness:
This58 year old spanish speaking gentleman was found in atrial
fibrillation fibrillation following a colonoscopy. He was
admitted to [**Hospital3 **] and was found to have an elevated
troponin. A cardiac catheterization was perfomed which showed
severe three vessel disease. Given the severity of his disease,
he was transferred to the [**Hospital1 18**] for surgical management.
Past Medical History:
insulin dependent diabetes mellitus
Hypercholesterolemia
Diabetic retinopathy
Social History:
Occupation:unemployed
Cigarettes: Smoked no [n] yes [] last cigarette _____ Hx:
Other Tobacco use:denies
ETOH: < 1 drink/week [] [**12-28**] drinks/week [X] >8 drinks/week []
Illicit drug use
Family History:
Father MI < 55 [n]died resp illness.
Mother < 65 [n]MI age 82
Physical Exam:
Pulse: Resp:16 O2 sat:
B/P Right:122/60 Left:122/64
Height: Weight:145
General:WDWN in NAD
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [n] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [n] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2 Left:2
DP Right: 2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right: N Left:N
Pertinent Results:
[**2124-1-21**] - ECHO
PRE BYPASS The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. The left ventricular cavity size is normal. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person
of the results in the operating room at the time of the study.
POST BYPASS The patient is atrially paced. There is normal
biventricular systolic function. The mitral regurgitation is
worsened - now moderate, central regurgitation. The thoracic
aorta is intact after decannulation
[**2124-1-26**] 04:20AM BLOOD WBC-9.1 RBC-2.99* Hgb-9.1* Hct-26.1*
MCV-87 MCH-30.5 MCHC-35.0 RDW-13.5 Plt Ct-244
[**2124-1-19**] 07:30PM BLOOD WBC-8.4 RBC-4.58* Hgb-14.0 Hct-39.5*
MCV-86 MCH-30.4 MCHC-35.3* RDW-12.2 Plt Ct-230
[**2124-1-27**] 05:39AM BLOOD PT-30.8* INR(PT)-3.0*
[**2124-1-26**] 04:20AM BLOOD PT-52.3* INR(PT)-5.2*
[**2124-1-25**] 05:22AM BLOOD PT-33.6* INR(PT)-3.3*
[**2124-1-24**] 05:25AM BLOOD PT-15.7* INR(PT)-1.5*
[**2124-1-23**] 01:48AM BLOOD PT-12.1 PTT-26.0 INR(PT)-1.1
[**2124-1-22**] 02:53AM BLOOD PT-12.5 PTT-27.1 INR(PT)-1.2*
[**2124-1-21**] 12:40PM BLOOD PT-16.7* PTT-26.6 INR(PT)-1.6*
[**2124-1-27**] 05:39AM BLOOD Na-132* K-4.3 Cl-98
[**2124-1-25**] 05:22AM BLOOD Glucose-59* UreaN-26* Creat-1.0 Na-139
K-3.9 Cl-103 HCO3-33* AnGap-7*
[**2124-1-19**] 07:30PM BLOOD Glucose-225* UreaN-14 Creat-0.9 Na-138
K-4.0 Cl-104 HCO3-24 AnGap-14
[**2124-1-19**] 07:30PM BLOOD ALT-23 AST-24 LD(LDH)-199 AlkPhos-85
TotBili-0.3
Brief Hospital Course:
Mr. [**Known lastname 1004**] was admitted to the [**Hospital1 18**] on [**2124-1-19**] for surgical
management of his coronary artery disease. He was worked-up in
the usual preoperative manner. A radial duplex ultrasound was
obtained as a radial artery graft was desired given his younger
age. This revealed significant califications of the bilateral
radial arteries and thus the decision was made not to use a
radial artery for conduit.
On [**2124-1-21**], Mr. [**Known lastname 1004**] was taken to the Operating Room where he
underwent coronary artery bypass grafting to five vessels. As
the greater saphenous vein was very small in the left leg, an
extra length was harvested from his right thigh. Please see
operative note for details. Postoperatively he was taken to the
Intensive Care Unit for monitoring. Over the next several hours,
he awoke neurologically intact and was extubated. He was
transfused a unit of red blood cells for postoperative anemia.
He remained in atrial fibrillation which was treated with
Amiodarone. On postoperative day two, he was transferred to the
step down unit for further recovery. He was gently diuresed
towards his preoperative weight. The Physical Therapy service
was consulted for assistance with his postoperative strength and
mobility.
Anti-coagulation was initiated with Coumadin for atrial
fibrillation. He was extremely sensitive to dosing and his INR
rose to 5.2, nec3essitating an extra hospital day as the
Coumadin was held and the INR fell to 3. Arrangements were made
for his anticoagulation to be managed by his primary care
physician. [**Name10 (NameIs) 92592**] appointments were given and medications and
restrictions discussed.
He had converted to sinus rhythm at discharge and Amiodarone
will be tapered over the next 4 weeks.
Medications on Admission:
Lantus 15units daily,metformin 850mg [**Hospital1 **],Glipizide 20mg
daily,ASA 325mg daily,Lipitor 40mg daily, prn Naproxen
Discharge Medications:
1. Outpatient Lab Work
serial PT/INR
Coumadin for AFib
Goal INR [**12-24**]
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 73614**]
Results to phone [**Telephone/Fax (1) 82128**] fax [**Telephone/Fax (1) 92593**]
2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
7. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 400mg (2 tablets) twice daily for two weeks, then
200mg (one tablet) twiced daily for two weeks , then 200mg(one
tablet) daily until instructed to discontinue.
Disp:*100 Tablet(s)* Refills:*2*
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
Coronary artery disease
IDDM
Hypercholesterolemia
Diabetic retinopathy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema: trace
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2124-2-22**] at 1:15pm
Cardiologist: Dr. [**Last Name (STitle) 4922**] on [**2124-2-17**] at 1:30pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 73614**] ([**Telephone/Fax (1) 82128**]) in [**2-24**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for atrial fibrillation Goal INR 2-2.5
First draw [**1-28**] go to primary care clinic for blood draw with
presciption attached
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 73614**]
Results to phone [**Telephone/Fax (1) 82128**] fax [**Telephone/Fax (1) 92593**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2124-1-27**]
ICD9 Codes: 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6747
} | Medical Text: Admission Date: [**2170-4-14**] Discharge Date: [**2170-4-15**]
Date of Birth: [**2091-7-29**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
post operative ST elevation myocardial infarction
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
78 year old female with history of hypertension,
hypercholesterolemia, coronary artery disease with past
angioplasty x2, congestive heart failure, paroxysmal atrial
fibrillation, s/p aortic valve replacement and mitral valve
repair for rheumatic disease, who presented initially to [**Hospital1 **] on [**4-11**] for infected artificial knee
hardware and sepsis. After undergoing resection arthroplasty
[**4-14**] the patient was transferred to the ICU, where she became
hypotensive (SBP 48) with 3mm ST elevations seen in inferoseptal
leads on ECG. CK was elevated >1600 and Troponin T was >50.
Patient was transferred to [**Hospital1 18**] for urgent cardiac
catheterization. Levophed and dopamine infusions were started
and the patient was intubated upon arrival. In catheterization,
one drug eluting stent was applied to a 80% occluding right
coronary artery lesion without residual flow defect. The patient
became hypotensive and developed ventricular tachycardia during
the procedure requiring addition of a lidocaine infusion,
maximal levophed and dopamine delivery, and balloon pump
placement. She was transferred to the CCU for further management
since her cardiac output was low at 1.8 (CI 1.2 PCWP 18) and she
continued to be hypotensive. Of note, echocardiogram on [**2170-4-3**]
showed dilated LV, severe pulm HTN 70mmHg, moderate MR, mild TR,
LVH, and normally functioning porcine AV. Ejection fraction was
normal and no wall motion abnormalities were seen.
Past Medical History:
coronary artery disease with past angioplasty x2, congestive
heart failure, paroxysmal atrial fibrillation, s/p aortic valve
replacement and mitral valve repair for rheumatic disease,
chronic renal insufficiency and acute renal failure, paroxysmal
atrial fibrillation (retroperitoneal bleed on coumadin [**10-2**]),
chronic anemia, COPD, rheumatoid arthritis, lacunar infarct,
cortical atrophy, facial droop, peptic ulcer disease [**1-31**] NSAIDS,
diverticulosis, short bowel syndrome, neuropathy, recurrent
UTI/pyelonephritis caused by Serratia and Klebsiella, s/p
colectomy [**2167**] for bowel ischemia, s/p ileostomy for recurrent
lower GI bleeding, s/p bilateral total knee replacement c/b
recurrent infection of the right knee (s/p incision and drainage
[**5-2**] for infection with klebsiella, proteus, e.coli),
degenerative disc diasease, s/p appendectomy, s/p
cholecystectomy, s/p hysterectomy, s/p tracheostomy
Social History:
home health services living with daughter [**Name (NI) **]
Family History:
father and brother died of MI
Physical Exam:
The patient was unresponsive and found to be breathless,
pulseless, and without heart tones, blood pressure, and corneal
reflexes. The patient was pronounced dead at 0515 on [**2170-4-15**].
The patient's private physician and family were notified. They
refused anatomic gifts and autopsy.
Pertinent Results:
[**2170-4-14**] 10:50PM TYPE-ART O2 FLOW-100 PO2-404* PCO2-31*
PH-7.18* TOTAL CO2-12* BASE XS--15 INTUBATED-INTUBATED
[**2170-4-14**] 10:50PM GLUCOSE-100 K+-3.5
[**2170-4-14**] 10:50PM HGB-12.2 calcHCT-37 O2 SAT-96
[**2170-4-15**] 12:56AM BLOOD WBC-26.7* RBC-3.09* Hgb-9.5* Hct-28.2*
MCV-92 MCH-30.7 MCHC-33.5 RDW-15.1 Plt Ct-237
[**2170-4-15**] 12:56AM BLOOD PT-18.7* PTT->150* INR(PT)-2.2
[**2170-4-15**] 12:56AM BLOOD CK(CPK)-1416*
[**2170-4-15**] 12:56AM BLOOD CK-MB-242* MB Indx-17.1* cTropnT-20.53*
[**2170-4-15**] 12:56AM BLOOD Calcium-7.0* Phos-4.1 Mg-1.7
[**2170-4-15**] 03:02AM BLOOD Type-ART pO2-180* pCO2-38 pH-7.29*
calHCO3-19* Base XS--7
[**2170-4-15**] 01:03AM BLOOD Type-ART pO2-305* pCO2-25* pH-7.08*
calHCO3-8* Base XS--21
[**2170-4-14**] 10:50PM BLOOD Type-ART O2 Flow-100 pO2-404* pCO2-31*
pH-7.18* calHCO3-12* Base XS--15 Intubat-INTUBATED
[**2170-4-15**] 01:03AM BLOOD Glucose-110* Lactate-7.9* Na-134* K-3.8
Cl-112
[**2170-4-15**] 03:02AM BLOOD Lactate-7.6*
[**2170-4-15**] 01:03AM BLOOD freeCa-1.09*
Brief Hospital Course:
78 year old female with multiple medical problems who developed
an acute myocardial infarction after orthopedic surgery at [**Hospital1 **].
.
Cardiovascular-She had known coronary disease with prior
angioplasties as well as atrial fibrillation and valvular
disease. At the OSH, the patient became hypotensive with signs
of inferoseptal myocardial infarction on ECG. At [**Hospital1 18**], the
patient received one stent that fully opened an 80% lesion in
the proximal right coronary artery. No flow limiting disease was
seen in in the LCX or LAD. However, the patient developed
hypotension and required intubation plus pressure support with
monitoring in the ICU. In spite of aggressive care on levophed,
dobutamine, vasopressin, and lidocaine; the patient became
increasingly bradycardic and expired approximately 6 hours after
admission to [**Hospital1 18**]. She was given plavix and aggrastat. Calcium
and electrolytes were repleted.
.
Pulmonary-Intubated for airway protection. Fentanyl and versed
infusions for sedation. She developed lactic acidosis (lactate
7.9) with respiratory compensation. Bicarbonate supplementation
was given without significant improvement.
.
Renal- At baseline Cr 1.4. Medications were renally dosed.
.
Musculoskeletal- The patient was status post right knee
resection arthroplasty with drain in place for recurrent right
knee prosthetic infections. Fluid analysis identified many PMNs
but no organism on gram stain. Preliminary cultures grew gram
negative rods resembling Serratia. It was sensitive to
ceftriaxone, ceftazidime, cefepime, ciprofloxacin, gentamicin,
imipenem, levoquin, bactrim, and augmentin. Resistant to
ampicillin, piperacilliin, tetracycline, and cefazolin.
Infectious disease consultation at the OSH had started
ceftriaxone 2g IV and vancomycin 650mg IV daily, which was
continued at [**Hospital1 18**]. The patient did not have fever but developed
a post MI leukocytosis.
.
GI-Iliostomy care.
.
FEN: NPO, albumin at OSH 2.9, hypocalcemia cCa 7.9/free Ca
1.08(Ca 9.6->7), hypomagnesemia. Repleted Ca and Mg.
Supplemented sodium bicarbonate for acidosis.
.
MRSA and aspiration precautions.
.
Access: Femoral line and left portacath in place. Left radial
arterial line placed at [**Hospital1 18**].
.
Code: Full
.
HCP is her daughter, [**Name (NI) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 39202**] W[**Telephone/Fax (1) 39203**],
who was present at the time of death.
Medications on Admission:
Home Meds: protonix 40', neurontin 300''', lasix 40', lomotil
2.5'''', plavix 75', verapamil 40''', ultram
OSH added calan, tylenol, vicodin, tigan, phenergan, compazine,
senna, MVI, MOM, dulcolax, [**Name2 (NI) 13426**], magnesium
All: PCN (swelling), aspirin (PUD), egg and swordfish(swelling)
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired due to hypotension and shock in spite of aggressive
care. Thought due to acute anteroseptal myocardial infarction
after orthopedic surgery at an outside hosptial.
Secondary:
coronary artery disease with past angioplasty x2, congestive
heart failure, paroxysmal atrial fibrillation, s/p aortic valve
replacement and mitral valve repair for rheumatic disease,
chronic renal insufficiency and acute renal failure, paroxysmal
atrial fibrillation (retroperitoneal bleed on coumadin [**10-2**]),
chronic anemia, COPD, rheumatoid arthritis, lacunar infarct,
cortical atrophy, facial droop, peptic ulcer disease [**1-31**] NSAIDS,
diverticulosis, short bowel syndrome, neuropathy, recurrent
UTI/pyelonephritis caused by Serratia and Klebsiella, s/p
colectomy [**2167**] for bowel ischemia, s/p ileostomy for recurrent
lower GI bleeding, s/p bilateral total knee replacement c/b
recurrent infection of the right knee (s/p incision and drainage
[**5-2**] for infection with klebsiella, proteus, e.coli),
degenerative disc diasease, s/p appendectomy, s/p
cholecystectomy, s/p hysterectomy, s/p tracheostomy
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 9971, 496, 4271, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6748
} | Medical Text: Admission Date: [**2148-10-20**] Discharge Date: [**2148-10-28**]
Date of Birth: [**2098-6-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient has h/o chronic headche but complains of acute worsening
today. She describes constant [**11-5**] right sided throbbing
headahce that does not radiate. Denies photophobia but did
complain of some mild blurry vision. She took excedrin as usual
but did not help. Of note, patient is from DC and is here for
visiting her family. She had not been taking her
anti-hypertensive for 2 weeks. She never had such severe
headache before. Patient had not seen her PCP [**Name Initial (PRE) **] 2 years.
.
On arrival to ED, her initial VS T98.3 P110 BP 246/116 R17 99%on
RA. She received 20mg labetalol x1, 20mg hydralazine x1,
labetolol infusion, aspirin. She is currently on labetalol
1.5mg/min with BP in 160s/110s on transfer. She continues to
complain of HA, vomited x2 and received anzemet, phenergan 25mg
IVP, morphine 4mg and dilaudid 2mg. EKG show TWI V3-V6 and
inferior leads, ST depression inferior leads, repeat show
resolution of ST depression in inf leads.
.
Currently, patient denies chest pain, palpitation, shortness of
breath, abdominal pain. She does complain of nausea from
narcotic. She still complains of right sided headahce albeit
less.
.
Past Medical History:
diabetes on insulin
hypertension
chronic headahce s/p head injury [**12-1**]
s/p hysterectomy
Social History:
denies smoking/alcohol/drugs
.
Family History:
noncontributory
Physical Exam:
T 97 BP153/80 P73 R8 100% on 2L
Gen- sleepy, otherwise no apparent distress, African American
obese female
HEENT- anciteric, pin point pupils 1-2mm, reactive bilaterally,
EOMI, fundoscopic exam impossible because of pinpoint pupils, no
sinus tenderness, dry mucus membrane, no JVD at 45 degrees, neck
supple
CV- regular, no murmurs/gallop, PMI not displaced
RESP- clear bilaterally, no crackles
ABDOMEN- soft, nontender, nondistended, obese abdomen,
hypoactive bowel sounds
EXT- trace pedal edema, pedal pulses equal bilaterally
NEURO- A+O x3, CNII-XII intact, muscles strength 5/5 grossly,
sensation grossly intact, reflexes deferred.
SKin- no rashes/bruises
Pertinent Results:
[**2148-10-20**] 02:30PM WBC-8.6 RBC-3.86* HGB-10.5* HCT-30.8* MCV-80*
MCH-27.1 MCHC-33.9 RDW-14.5
[**2148-10-20**] 02:30PM PLT COUNT-324
[**2148-10-20**] 04:38PM GLUCOSE-170* UREA N-30* CREAT-2.5* SODIUM-139
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15
[**2148-10-20**] 02:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2148-10-20**] 02:30PM URINE RBC-0-2 WBC-[**3-31**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2148-10-20**] 11:15PM CK-MB-2 cTropnT-<0.01
[**2148-10-20**] 02:30PM CK-MB-2 cTropnT-<0.01
[**2148-10-21**]: serum/urine tox:
[**2148-10-21**]: serum erythopoietin:
.
[**2148-10-20**]: CT head: There is no evidence of hemorrhage, mass
effect, shift of normally midline structures, hydrocephalus, or
acute major vascular territorial infarction. The ventricles and
sulci are normal in size. The [**Doctor Last Name 352**]-white matter differentiation
is preserved. The visualized paranasal sinuses show
opacification of the right mastoid air cells and a small mucus
retention cyst in the right sphenoid sinus. Otherwise, the
surrounding osseous and soft tissue structures are unremarkable.
There is a nasopharyngeal mass on the right, perhaps crossing
the midline. The opacification of the mastoid air cells suggests
that this has been present for an extended period of time- i.e.
unlikely to be inflammatory nodal enlargement. These findings
are most concerning for nasopharyngeal carcinoma or other
malignancy.
..
MRI HEAD:
Lobulated right-sided nasopharyngeal soft tissue mass lesion,
which is highly suspicious for an underlying neoplastic process
or carcinoma as indicated on the patient's prior CT from
[**10-20**] and 25, [**2148**]. No acute territorial infarct seen
within the brain. Right-sided mastoiditis.
Brief Hospital Course:
1) HYPERTENSIVE EMERGENCY:
Pt was admitted to ICU. She was tried on multiple BP regimens.
At discharge, she is on lopressor, ACEI, amlodipine, and HCTZ.
On this regimen, her BP is within her short term goal though not
ideally controlled.
There was also one measurement of BP in her 2 arms that was
different. This was concerning for aortic dissection, but CXR
showed no widening of mediastinum. Repeat simultaneous b/l UE
BP measurements were equal so no further imaging was pursued.
.
2) RENAL FAILURE:
Creatinine ranged from 2.6-3.0 while in hospital but did not
change significantly. Baseline is unknown but is possible she
has CKD from DM and HTN. She did have proteinuria. Renal US
was suboptimal quality but did not show definitive RAS or other
pathology. Pt will require outpt renal f/u.
.
3) DM:
Seen by [**Last Name (un) **]. Regimen adjusted and now on NPH with SSI.
.
4) NASOPHARYNGEAL MASS: Incidental finding on head CT and MRI.
ENT consulted who stated these are usually benign but should
have outpt biopsy in next few months once acute issues resolved.
Biopsy not practical as inpatient given issues with
hypertension.
.
5) ANEMIA: Hct ranged widely but settled in low 20s. Baseline
unknown. [**Month (only) 116**] be due to chronic kidney failure. Should have
outpt w/u including colonoscopy given age.
Medications on Admission:
insulin 70/30
actos
lipitor
aspirin
blood pressure medicines (2)
excedrin migraine 3x/day
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*7 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*7 Tablet(s)* Refills:*2*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*7 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*21 Tablet(s)* Refills:*2*
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*7 Tablet(s)* Refills:*2*
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*7 Tablet(s)* Refills:*2*
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen
(16) units Subcutaneous daily at breakfast.
Disp:*10 mL* Refills:*2*
9. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per
SLIDING SCALE units Subcutaneous QACHS.
Disp:*3 ML* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Malignant Hypertension
.
Secondary:
Chronic renal failure
Diabetes mellitus type 2
Nasopharyngeal mass
Obesity
Hyperlipidemia
Urinary Tract infection
Anemia
Discharge Condition:
Good. blood pressure at short term goal. ambulating without
assist. tolerating oral medications and nutrition.
Discharge Instructions:
You have been evaluated and treated for very high blood
pressure, headaches, and acute kidney disease. While in the
hospital your blood pressure was controlled with a combination
of multiple medications. Your headaches improved with better
control of the headaches. Also, the kidney disease improved as
well but remains abnormal and needs to followed closely.
.
While you were in the hospital, we found that there is an
abnormal mass inside your sinuses. We did not complete all the
necessary testing as these should be done as an outpatient. The
mass could be something unimportant, but it also could be very
serious like a cancer. You should see the Ear-Nose-Throat
doctors as described below.
.
Also, while you were in the hospital, we found that you had a
urinary tract infection. You completed a 3 days cours of
antibiotics
.
The most important next step is for you to get regular medical
care. You must go see your primary doctor as soon as possible
in [**State 12000**]. I have given you enough prescriptions to last you
for about one week and we have arrange money for you to pay for
that, but beyond the one week you should discuss with Dr. [**Last Name (STitle) 22650**]
on how to obtain medications and care.
.
It is absolutely essential that you take your blood pressure
pills as prescribed.
.
When you meet with the doctors at the community health center
please give them this list of medical problems which is below.
.
After you meet with your new doctor, ask them to help arrange
for a follow-up appointment with the Ear-Nose-Throat doctors
here at [**Hospital3 **] Deaconness, to discuss the nasal mass.
If you have any trouble obtaining your medications, experience
recurrent HA, neurological symptoms, chest pain or any other
symptoms of concern to you, call Dr. [**Last Name (STitle) 22650**] or go to the nearest
ER.
Followup Instructions:
You need to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22650**] in [**State **]
within one week. Call [**Telephone/Fax (1) 68544**] to make an appointment. He
should be able to help you get access to your medications,
monitor your medical issues and make you the appropriate
referrals (see below).
.
You should have an appointment with the Ear-Nose-Throat doctors
[**Last Name (NamePattern4) **] [**3-1**] weeks to evaluate the mass inside your nose. The
appointment can be with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 **]
Deaconness the telephone number is [**Telephone/Fax (1) 41**]. If you return
to [**State 12000**], please ask Dr. [**Last Name (STitle) 22650**] to refer you to ENT.
You also need to see a kidney doctor. Ask Dr. [**Last Name (STitle) 22650**] to refer
you.
ICD9 Codes: 5849, 5859, 5990, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6749
} | Medical Text: Admission Date: [**2119-11-23**] Discharge Date: [**2118-12-7**]
Date of Birth: [**2119-11-23**] Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 68473**] was the [**2063**] gram product of a
37 and 2/7 weeks gestation born to a 31-year-old G1, P0
mother.
Prenatal screens - O positive, antibody negative, hepatitis
surface antigen negative, rubella immune, RPR nonreactive,
GBS negative.
This pregnancy was notable for intrauterine growth
restriction and spontaneous onset of labor. The infant
delivered vaginally with Apgars of 8 and 9. She was noted to
have dysmorphic features and developed stridor soon after
birth. On arrival to the newborn intensive care unit, the
infant with audible stridor and moderate subcostal
retractions.
PHYSICAL EXAMINATION: Weight [**2063**] grams, less than 10th
percentile; length 42 cm, less than 10th percentile; head
circumference 28 cm, less than 10th percentile. IUGR infant
with obvious dysmorphic features, large long filtrum, depressed
nasal bridge, small chin, short stubby hands and feet,
bilateral single palmar crease and two phalanx each finger.
Anterior fontanel at level, sutures normal, intact palate,
neck supple. Eyes with bilateral red reflex present.
Continues audible stridor even at rest, bilateral moderate
subcostal retractions with conducted sounds. CARDIOVASCULAR:
Pink, well perfused, S1, S2 normal. No murmurs. Femorals 2+.
ABDOMEN: Soft, nondistended. No hepatosplenomegaly.
GENITOURINARY: Normal female genitalia. Anus patent but
anteriorly displaced. NEUROLOGIC: Tone normal. Moving all 4
extremities. Spine with sacral dimple. The remainder is
normal. Hips stable.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The baby
was admitted to the newborn intensive care unit for
observation, and management of her IUGR status and her
respiratory stridor. She has remained stable in room air
throughout her hospital course and has not required any
methylxanthine therapy for apnea bradycardia. ORL evaluated
the infant and discovered severe laryngomalacia. Plan is to
have surgery to correct this issue at [**Hospital3 **] on
[**2119-12-7**].
CARDIOVASCULAR: The infant has an audible murmur. An
echocardiogram was obtained revealing patent foramen ovale,
small anterior muscular ventricular septal defect, small
patent ductus arteriosus. Cardiology was consulted and
recommended continued care.
FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was [**2063**]
grams. She is currently [**2033**] grams. She was initially started
on 80 cc per kg per day of D10W. Enteral feedings were
initiated on day of life 1. The infant is on full enteral
feedings, requiring PG feeding. She was evaluated by the
feeding team at [**Hospital3 **] this week and it was
recommended to continue offering PO feeds every other feed
knowing that the infant is at high risk for aspiration at
this time. Plan is to reevaluate the infant following her
surgery on Thursday. She is currently receiving 150 cc per kg
per day of breast milk 28 calorie with Beneprotein again an
average 10 to 30 grams per day.
GASTROINTESTINAL: Peak bilirubin was on day of life 3 of
9.1/0.4.
HEMATOLOGY: Hematocrit on admission was 42.6. She has not
required any blood transfusions.
INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC was benign and blood cultures remained
negative at 48 hours at which time ampicillin and gentamycin
were discontinued.
NEUROLOGIC: The infant has been appropriate for gestational
age.
GENETICS: Genetics was consulted to evaluate this infant for
dysmorphism. A chromosome analysis was performed revealing
normal 46 XX. FISH was performed for chromosome 22 and
chromosome 18 and those were normal. Genetics has seen the
infant most recently on [**12-5**] recommending a signature
CHIP being sent off which has not yet been done.
AUDIOLOGY: Hearing screen has not yet been performed but
should be done prior to discharge.
OPHTHALMOLOGY: The infant was seen by ophthalmology to rule
out ophthalmologic malformations. She was seen by Dr.[**First Name9 (NamePattern2) **]
[**Name (STitle) **] on [**11-27**] to reveal no colobomas, normal optic
nerves and retina.
PSYCHOSOCIAL: The family lives on [**Known lastname 6687**] and are
experiencing some financial strains due to housing in [**Location (un) 86**]
area. They are interested and involved and loved their
daughter.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 **].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **]. Telephone No.:
[**0-0-**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: She will be NPO at the time of
transfer to [**Hospital3 **], 130 cc per kg per day of
D10W with 2 of sodium chloride and 1 mEq of potassium
chloride.
2. Medications: Not applicable at the time of transfer but
prior to transfer she was on no medications.
3. State newborn screens have been sent per protocol and
have been within normal limits.
4. Immunizations received: The infant has not received any
immunizations to date.
DISCHARGE DIAGNOSES:
1. A 37 week infant, small for gestational age.
2. Laryngomalacia.
3. Dysmorphism.
4. Patent ductus arteriosus.
5. Muscular ventricular septal defect.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2119-12-6**] 21:43:57
T: [**2119-12-6**] 22:48:45
Job#: [**Job Number 68474**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6750
} | Medical Text: Admission Date: [**2192-5-4**] Discharge Date: [**2192-6-12**]
Date of Birth: Sex: M
This Dictation Summary will discuss the patient's course in
hospital. There will be an addendum detailing his initial
presentation.
1. Operative: The patient was taken to the Operating Room
hemicolectomy. Following his operation, his postoperative
course was complicated by a prolonged ileus which prohibited
the patient from taking p.o. Additionally, he was delirious.
He was started on TPN for nutrition on [**2192-5-14**].
from probable aspiration. He required intubation and
displayed septic physiology with hypotension, abnormal
cultures ultimately grew E. coli and Klebsiella. The source
was felt to be urinary, however, the patient also had
Methicillin sensitive Staphylococcus aureus in his sputum
along with copious thick secretion. He was treated initially
with Vancomycin, Ceftazidime and Levofloxacin and later
switched to Oxacillin and Levofloxacin when sensitivities
revealed that his organisms were sensitive to these
medications. He was extubated on [**2192-5-21**].
Following this, he had been slow to interact with others and
displayed continued inability to take oral feedings and
medications due to his sedation. This was initially
attributed to morphine and Propofol infusion received while
in the Surgical Intensive Care Unit. However, on [**2192-5-29**], the patient continued to exhibit poor interaction with
others and an inability to tolerate p.o. and at this point
the Geriatrics Team was consulted.
On [**2192-6-1**], the patient was transferred to the Medical
Service for further management.
2. Renal: At the time of transfer to the Medical Service,
the patient's creatinine had markedly increased. Concern was
raised for another septic episode given hypernatremia as well
as rising creatinine and hypotension and mild fevers. As
discussed initially, a septic picture was considered and the
patient was started on broad-spectrum antibiotics, however, a
Foley catheter was placed and the patient exhibited a large
post obstructive diuresis. He was diagnosed with
post-obstructive uropathy and was followed closely. He had
no further rises in creatinine throughout the remainder of
his hospital course.
3. Infectious Disease: As discussed, it was initially felt
that the patient was septic at the time of the rise in
creatinine. He was covered with Vancomycin, Ceftazidine, and
Clindamycin. When cultures remained negative over 48 hours,
those antibiotics were discontinued. However, on [**6-4**], the
patient spiked a temperature to 102.0 F. Cultures were sent
by Venipuncture and off of his central line. An Infectious
Disease consultation was obtained.
They recommended that Clindamycin and Vancomycin be
discontinued. Liver functions were checked and these were
mildly elevated. An abdominal ultrasound was obtained which
was mainly negative. Please see separate report for full
details.
The patient also had yeast growing in his urine, which they
recommended not to be treated by the Infectious Disease
Service. Throughout the remainder of the hospitalization,
the patient remained afebrile. Surveillance cultures were
checked and remained mainly negative with the exception of
one set of blood cultures taken off of the patient's central
line which grew Staphylococcus aureus, coagulase negative,
felt to be a contaminant, given no other blood cultures grew
this. This was not treated with any antibiotics. The
patient remained afebrile throughout the remainder of the
course of the hospitalization.
Access: His central line was changed and replaced with a
PICC line.
4. Cardiovascular: The patient had tachycardia which was
treated off and on with Lopressor. This was occasionally
held given concerns for hypotension and at this time is off
Lopressor.
5. Pulmonary: The patient had worsening O2 needs and
developed tachypnea on [**2192-6-5**]. An arterial blood gas
was consistent with respiratory alkalosis and chest x-ray was
negative. A VQ scan was obtained which revealed a pulmonary
embolism. Although the study was poor, the patient was felt
to be high probability for pulmonary embolism and he was
treated with heparin. It was also known that he had a
thrombus in the right internal jugular from an old central
line which could also be the source of his embolus. Hypoxia
resolved, and at the time of this dictation, he is on room
air with no oxygen needs. He was ultimately changes to
Lovenox 60 mg subcutaneously q. 12. Coumadin was not started
because of fluctuating nutritional status.
6. Endocrine: Although he had no prior history of diabetes
mellitus, the patient was noted to be hyperglycemic while on TPN
and was managed with a regular insulin sliding scale, and insulin
in his TPN.
7. Gastrointestinal: On rounds on [**2192-6-6**], the patient
was found to be distended and tympanitic. An abdominal x-ray
was obtained which revealed a partial small bowel obstruction
versus ileus. An NG tube was placed and over the course of
the next several days, the patient's distention resolved
slowly. His NG tube was removed on [**6-9**], and the patient
remained stable since. Repeat abdominal x-ray showed
resolution of his small bowel obstruction/ileus.
Given his past history, it was felt that the most likely
cause of this was ileus as opposed to obstruction.
8. Fluids, Electrolytes and Nutrition: When initially
transferred to the Medical Service, the patient was
hypernatremic. This was repleted with free water and
adjustments in his TPN. Ultimately, the patient became
hyponatremic and required further TPN adjustments. At the
time of this dictation, his hyponatremia and hypernatremia
are both controlled and he has normal natremic and continues
to receive TPN. The patient was not started on enteral feedings
given his profound delirium and ileus problems. Since he had
not yet "woken up" and continued to be somnolent much of the
time, even after about a month after surgery, the prognosis was
quite guarded, so the decision for a PEG tube in this elderly
confused gentleman was deferred. At this time, he continued on
TPN.
9. Prophylaxis: The patient received Zantac in his TPN on
[**2192-6-11**]. This was changed to Protonix as Zantac can
interfere with mental status in the elderly.
ADDITIONAL STUDIES: During the course of this
hospitalization:
1. Abdominal ultrasound: Which revealed a simple cyst in
the liver and a small amount of pleural effusion on the right
(please see full report).
2. CT scan of the neck on [**2192-6-5**]: Revealed a filling
defect in the right internal jugular vein consistent with
non-occlusive thrombus and a left subclavian line which was
felt to be coiled upon itself. Following discovery of this,
his line was discontinued and changed to a PICC line.
3. CT scan of the abdomen and pelvis on [**2192-5-19**]: Full
transit of oral contrast through the GI tract; not unchanged
from the [**5-18**] CT scan of the abdomen which revealed no
evidence for pulmonary embolism in the main pulmonary
arteries and intussusception and small bowel obstruction.
4. Echocardiogram on [**2192-5-18**], ejection fraction greater
than 55%, left atrium moderately dilated; left ventricular
wall thickness, cavity size, and systolic function normal; an
left ventricular ejection fraction of greater than 55%; right
ventricular cavity dilated, right ventricular systolic
function appears depressed; aortic root moderately dilated.
Aortic leaflets three and mildly thickened, or at least mild
aortic regurgitation, mitral leaflets mildly thickened.
Presence/absence of mitral valve prolapse cannot be
determined. There is at last mild mitral regurgitation.
There is moderate pulmonary hypertension and no pericardial
effusion.
DISCHARGE STATUS: Stable for discharge to rehabilitation
facility.
DISCHARGE INSTRUCTIONS:
1. He should follow-up with his primary care physician upon
discharge.
2. Routine PICC line care with heparin and saline flushes.
3. Continue total parenteral nutrition.
DISCHARGE MEDICATIONS:
1. Lovenox 60 mg subcutaneously q. 12.
2. Regular insulin sliding scale.
3. Protonix 40 mg p.o. q. day.
4. Total parenteral nutrition as directed.
FINAL DIAGNOSES:
1. Colon cancer status post right hemicolectomy.
2. Sepsis.
3. Urosepsis.
4. Pulmonary embolus.
5. Obstructive uropathy.
6. Diabetes mellitus.
7. Ileus.
8. Small bowel obstruction.
9. Hypernatremia.
10. Hyponatremia.
11. Delirium.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 45008**]
Dictated By:[**Name8 (MD) 2665**]
MEDQUIST36
D: [**2192-6-12**] 09:57
T: [**2192-6-12**] 10:03
JOB#: [**Job Number 37508**]
ICD9 Codes: 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6751
} | Medical Text: Admission Date: [**2180-12-2**] Discharge Date: [**2180-12-11**]
Date of Birth: [**2105-9-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
L ankle pain
Major Surgical or Invasive Procedure:
ORIF for left distal fib/tib fx
History of Present Illness:
75 year old female with history of COPD on home O2 (2L)who
presents with left ankle pain. Patient had fallen asleep on the
sofa. When she awoke, she tried to get up to go to the kitchen.
When she stood on her feet and turned to walk, she felt a sharp
pain in her left ankle. She felt as if her foot were "caught on
something." She felt as if her ankle "popped" and then she fell
to the ground. She denies LOC, trauma to head, syncope.
Past Medical History:
-COPD on home O2 (pulmonologist at [**Hospital1 112**]- Fanta)
-h/o Syncope 3 years ago (negative w/u)
--Echo [**3-4**]: EF 60%, mild pulm HTN (28), E/A 0.78, no WMA, no
LVH, trace MR
[**Name13 (STitle) **] Knee Cyst
-Anxiety
-osteoporosis
Social History:
Widowed x 5 years. Has 2 children. Lives alone in a studio
apartment in [**Location (un) **]. Has person to help clean 2x week. Son
lives one block away. Formerly worked in newspaper advertising.
~120 pack year smoking history (quit [**2145**]), per patient 2
glasses of EtOH with evening meal. Per son, mother drinks quite
a bit more.
Family History:
Mother c anxiety d/o, fa was alcoholic. Sister and 2
children all in psychiatric tx (details unknown).
Physical Exam:
VS: Tc & max: 98.3, HR: 105 (80-105), BP: 125/71 (124-155/53-78)
HEENT: EOMI, anticteric, dry MM, neck supple, JVP not elevated
Lungs: Decreased breath sounds, no audible wheezes or rhonchi
Heart: Soft heart sounds, tachycardic, s1, s2, no m/g/r
auscultated
abd: Soft NT, ND, +BS
ext: -edema, left ankle in bandage, good distal cap refill
neuro: alert and oriented to hospital, but not to floor.
Year=[**2179**]
Pertinent Results:
[**2180-12-2**] 02:30PM GLUCOSE-90 UREA N-31* CREAT-0.7 SODIUM-142
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-27 ANION GAP-13
[**2180-12-2**] 02:30PM WBC-11.5*# RBC-3.76* HGB-11.4* HCT-33.0*
MCV-88 MCH-30.5 MCHC-34.7 RDW-14.0
[**2180-12-2**] 02:30PM NEUTS-84.6* BANDS-0 LYMPHS-9.7* MONOS-3.4
EOS-2.2 BASOS-0.2
[**2180-12-2**] 02:30PM PLT COUNT-321
[**2180-12-2**] 02:30PM PT-12.2 PTT-23.7 INR(PT)-1.0
[**2180-12-2**] EKG: Baseline artifact. Sinus rhythm. Modest
non-specific ST-T wave changes. Poor R wave progression - cannot
rule out old anteroseptal myocardial infarction. Compared to the
previous tracing of [**2180-7-20**] no significant diagnostic change.
[**2180-12-2**] Ankle/tib/fib films: horizontally oriented fracture
through medial malleolus. Associated obliquely oriented fracture
through the anterior corner of the tibia. Obliquely oriented
fracture through the distal fibula with slight posterior
angulation of the distal fracture fragment. Disruption of the
ankle mortise with slight lateral subluxation of the distal
tibia.
[**2180-12-5**] CTA chest: Multiple small, nonocclusive pulmary emboli in
the subsegmental branches of the left lung. Emphysematous
changes. Several small, ill-defined nodular pulmonary opacities,
nonspecific in
appearance; followup in several months could be obtained to
ensure resolution.
Brief Hospital Course:
75 year old female with history of COPD presents with left
tib/fib fracture and COPD exacerbation, subsequently found to
have multiple pulmonary embolisms.
1) Left Ankle Tib/Fib Fracture: When patient came to the ED, her
x-ray noted fractures through tibula, fibula and medial
malleolus. She was admitted to the ortho service and medically
cleared for surgical repair. However, overnight she had MS
changes (discussed below)and adamantly refused surgery
recommended the next morning. Several days later, the patient
consented to surgery, and underwent an ORIF without
complications. She was fitted for a bivalve cast and cleared for
rehab. She will follow-up with orthopedics in 2 weeks following
discharge
.
2) Mental Status Changes: After the patient's admission to the
ortho service, she was noted to be agitated and tremulous, and,
according to the staff, appeared to be having auditory
hallucinations. The patient refused surgery the AM after
admission. Psychiatry service was called to assess capacity. She
was found to be in a confusional state and to lack capacity to
make a decision. They recommended waiting until the delirium
cleared to proceed with the therapy. Because of the patient's
reported EtOH abuse and elevated CIWA scores, she was placed on
a CIWA protocol. Prn benzos (other than CIWA protocol) and
morphine were d/c'd. The patient was given a 1:1 sitter for
safety. Patient was ordered for Haldol prn. Imipramine was
briefly discontinued, to be replaced by nortriptyline (due to
its lack of anti-cholinergic side effects), however, the patient
became upset about the change and was returned to her original
medication. Over the next days, the patient's mental status
improved. She consented to the surgery, and was treated with
tramadol and morphine for pain relief. After the operation, her
mental status was mostly at baseline, except for a few reports
of increased agitation and nervousness, usually correlated to
larger doses of morphine.
.
3) Pulmonary: Patient has a long standing history of COPD is on
constant home 02 2L n/c and is treated with nebs. Upon
admission, she was noted to be 87% on RA and up to 98% on 2L.
Lung exam revealed rhonchi and expiratory wheezes. The patient
did not have a fever or observed cough. While on the ortho
service, the patient had episodes of dropping O2 sat to 76 and
80 on RA when nasal cannula was partially or fully removed by
patient while delirius. When nasal cannula was repositioned,
SpO2 recovered. Later, the patient became progressively
tachypneic and had worsening hypoxia with ABG 7.42/45/56 on 2L
of room air. Chest XR was negative for infiltrate or pleural
effusions. Chest CT revealed bilateral non-obstructive thrombi
of unclear age. The patient was begun on heparin gtt for PE,
which was later switched to coumadin and lovenox after her
surgery. She is currently on coumadin with a lovenox bridge; she
will need to continue lovenox until she is therapeutic on
coumadin (INR [**1-5**]) for 48 hrs. Next INR check is due [**2180-12-12**].
She was also felt to have a COPD exacerbation and was started on
solumedrol, subsequently transitioned to a prednisone taper.
Discussion with her PCP suggested that she had not been taking
prednisone daily prior to admission, as originally thought.
Albuterol/atrovent nebulizer treatments and advair were
continued throughout her hospital stay. At time of discharge,
her oxygen saturation was stable 94% on 2L nasal cannula.
.
4) Hypertension: Over the course of her hospital stay, the
patient's home dose of Lisinopril was increased and a B1
selective BB was added. Good control was achieved (120-130's
systolic)on this regimen. Patient was also placed on a low salt
diet.
.
5) Anemia: Over the first several days of her admission, the
patient's hematocrit dropped significantly from baseline. She
was transfused with 2 units of blood and her hematocrit
stabilized in the low 30s.
.
6) Hyperglycemia. Patient has no known history of DM. Her high
sugars throughout her hospital stay were most likely secondary
to steriod use. Patient was placed on a SSI.
Medications on Admission:
Albuterol, Advair, Atrovent, Excedrin 325 mg
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) newb
Inhalation Q2H (every 2 hours) as needed for shortness of breath
or wheezing.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Enoxaparin 60 mg/0.6mL Syringe Sig: Sixty (60) mg
Subcutaneous Q12H (every 12 hours): continue until patient has
been therapeutic on coumadin (INR [**1-5**]) for 48 hours.
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Haloperidol 1 mg Tablet Sig: 1-2 mg PO TID (3 times a day) as
needed for severe agitation or confusion.
9. Imipramine HCl 25 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Please hold if sedated.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Prednisone 20 mg Tablet Sig: Forty (40) Tablet PO DAILY
(Daily): for 2 days, then 30 mg PO daily for 2 days, then 20 mg
PO daily for 2 days, then 10 mg PO daily for 2 days, then 10 mg
PO every other day for 3 days.
16. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
18. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: chronic obstructive pulmonary disease exacerbation
Secondary: left tibial/fibular fracture, pulmonary embolism,
ansiety, osteoporosis, delirium, steroid-induced hyperglycemia
Discharge Condition:
Stable.
Discharge Instructions:
Please follow-up with chest pain, shortness of breath, or other
symptoms that concern you.
Followup Instructions:
1) Orthopedics
- please call [**Telephone/Fax (1) 1228**] to schedule an appointment to see Dr.
[**Last Name (STitle) 1005**] within 10-14 days following discharge
2) Primary care
- please call to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1313**]
([**Telephone/Fax (1) 355**]) within 1-2 weeks following discharge from rehab
Completed by:[**2180-12-11**]
ICD9 Codes: 4019, 2930, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6752
} | Medical Text: Admission Date: [**2193-2-14**] Discharge Date: [**2193-2-16**]
Date of Birth: Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 70 year-old
male admitted to the MICU with sepsis, hypertension, status
post episode of ventricular tachycardia now on pressors. The
patient was admitted to the Vascular Service between [**12-30**]
and [**2193-1-17**]. He has an extensive history of peripheral
vascular disease and status post left femoral popliteal
bypass with a jump graft and a left second toe amputation and
revision. The patient was found to have a gangrenous wound
with involvement of the left third toe with purulent
discharge and breakdown of the incision site and underwent
further debridement and revision. He was evaluated by his
vascular surgeon Dr. [**Last Name (STitle) **] and thought to be stable for
rehab and that the wound was viable and without need for
further surgical intervention. The patient was at rehab when
he started complaining of difficulty swallowing and coughing
up dried blood on [**2193-2-13**] and neck pain.
Rehab doctor was called to evaluate the patient for same
complaints and blood pressure was noted to be 70/40 with a
heart rate of 92, white count 33.6. Blood cultures from
[**2193-2-12**] had four out of four bottles growing gram positive
cocci while on Vancomycin and Levaquin and the patient was
febrile to 102. The patient was transferred to [**Hospital1 346**], but on route developed ventricular
tachycardia while on Dopamine and was diverted to [**Hospital3 11531**]. Apparently ventricular tachycardia spontaneously
resolved and the patient was stable in their Emergency
Department and he was sent to [**Hospital1 188**] Emergency Department while awaiting MICU bed. In the
Emergency Department here his blood pressure was 60/palp.
The patient was started on neo-synephrine, fluid boluses and
Flagyl was added to his antibiotic regimen.
PAST MEDICAL HISTORY: Coronary artery disease status post
myocardial infarction in [**2169**], status post coronary artery
bypass graft in [**2183**], status post catheterization in [**11-8**]
with patent left internal mammary coronary artery to left
anterior descending coronary artery, patent supraventricular
tachycardia to obtuse marginal two and occluded saphenous
vein graft to right coronary artery. Exercise MIBI on
[**2192-11-22**] showed fixed apical defects, severe fixed distal
anterior wall defect with minimal reversible defect in distal
inferior wall, global left ventricular hypokinesis and apical
akinesis, EF of 22%. Paroxysmal atrial fibrillation, type 2
diabetes, end stage renal disease on hemodialysis since
[**11-8**], hypercholesterolemia, renal cell carcinoma status post
right nephrectomy in [**2182**] with metastasis to bone treated
with radiation therapy in [**10/2192**] with metastasis to
gallbladder status post cholecystectomy and status post
abdominal wall dissection. Hypothyroidism, peripheral
vascular disease status post above surgeries.
MEDICATIONS: Colace, Nephrocaps, Lopressor 12.5 b.i.d.,
Amiodarone 200 q day, Synthroid 100 micrograms q day, Pepcid
20 mg q day, Senna, vitamin C, Levaquin 250 mg po after
hemodialysis. Zocor 40 q.d., NPH 16 units in the a.m. and 3
units in the p.m. Calcitriol, Reglan, zinc, aspirin,
Coumadin 1 mg po q day, Vancomycin dose with hemodialysis.
ALLERGIES: Ativan makes the patient "go crazy."
SOCIAL HISTORY: No tobacco. Rare alcohol.
PHYSICAL EXAMINATION: Vital signs 60/palp increased to 97/36
on neo-synephrine. Pulse 97. Respiratory rate 22. Sating
98% on 2 liters nasal cannula. In general the patient is in
bed in no acute distress. HEENT oropharynx clear. Sclera
anicteric. Neck mildly swollen and full, nontender, no
lymphadenopathy. No JVD. Lungs with decreased breath sounds
at the bases. Cardiovascular irregular irregular rhythm.
Normal S1 and S2. Abdomen was soft, nontender, nondistended
with normoactive bowel sounds. Extremities left lower
extremity with TMA frankly necrotic, but no purulence.
INITIAL DATA: White blood cell count 27.6 with 97%
neutrophils, 3 lymphocytes, 3 monocytes, hematocrit 29.5,
platelets 537, INR 3.1, liver function tests within normal
limits. Chem 7 143, 4.8, 106, 23, 29, 4.2, glucose 73.
Initial CK negative. Rhythm strip with sustained ventricular
tachycardia. Electrocardiogram subsequently showed atrial
fibrillation rate of 97, Q waves in 3 and V1, poor R wave
progression, no ST or T wave changes, unchanged from [**2193-1-30**].
Chest x-ray showed possible right lower lobe infiltrate with
obscured right hemidiaphragm. CT of the neck showed
degenerative changes of the cervical spine, but no pharyngeal
fluid collections.
HOSPITAL COURSE: 1. Vascular surgery evaluated the patient
and they determined when the patient was medically stable
that he would require bilateral below the knee amputations.
In the interim the patient's left TMA wound received bedside
debridement.
2. The patient was also complaining of new onset right sided
blindness. Ophthalmology evaluated the patient in the
Emergency Department. There is no evidence of septic emboli.
The patient's blindness was consistent with AION.
3. The patient was also seen by the Infectious Disease
Service for his staph aureus bacteremia, which is likely
secondary to his gangrenous foot. Other sources of infection
could hve included his dialysis catheter. The patient was
continued on Vancomycin and Ciprofloxacin as well as Flagyl.
4. Cardiovascular, the patient continued to be persistently
hypotensive. He was started on neo-synephrine to which
Levophed was also added. The patient also started to become
dyspneic for which he was intubated. Immediately after his
intubation the patient became increasingly hypotensive and
also had an episode of ventricular tachycardia and also had
several episodes of supraventricular tachycardia. Both of
his arrhythmias resolved spontaneously. The patient also had
a metabolic acidosis, which was being poorly compensated. At
that time a family meeting was held and the gravity of his
situation was explained. On [**2193-2-16**] the patient's family
decided to withdraw care. The patient was extubated and
started on a morphine drip and the patient expired shortly
thereafter. The time of death was 7:30 p.m. on [**2193-2-16**].
CAUSE OF DEATH:
Respiratory failure secondary to sepsis.
No postmortem was performed.
[**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**]
Dictated By:[**Doctor Last Name 10735**]
MEDQUIST36
D: [**2193-7-15**] 14:59
T: [**2193-7-17**] 08:15
JOB#: [**Job Number **]
ICD9 Codes: 4271, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6753
} | Medical Text: Admission Date: [**2113-3-20**] Discharge Date: [**2113-3-26**]
Date of Birth: [**2045-4-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril / Diltiazem
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath, dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2113-3-20**]:
1. Bentall procedure with a 29-mm [**Company 1543**] Freestyle valve
graft, serial #[**Serial Number 59432**], with coronary button
reimplantation.
2. Hemi-arch replacement and replacement of ascending aorta
with a 28-mm Vascutek Gelweave single side-arm graft,
catalog #[**Numeric Identifier 31950**], lot #[**Serial Number 59433**], serial number
[**Serial Number 59434**].
History of Present Illness:
Mr. [**Known lastname **] is a 67 year male with known aortic aneurysm
involving the root and ascending portion. His PMH is notable for
COPD and hypertension. His aneurysm has been followed with
yearly
echocardiograms and CT scans. Given current size of 5.7
centimeters, he was referred by Dr. [**Last Name (STitle) **] for cardiac surgical
intervention. Patient denies chest and back pain. He has
longstanding shortness of breath and dyspnea on exertion
secondary to his COPD. He does experience palpitations with
exertion.
Past Medical History:
ascending aortic aneurysm, s/p Bentall Procedure [**2113-3-20**]
PMH:
chronic obstructive pulmonary disease
Hypertension
Hypercholesterolemia
supra-ventricular tachycardia [**2103**]
Intention Tremor, mostly right hand
Chronic Back Pain
Renal Cyst
peptic ulcer disease [**2073**]
Arthritis
gastroesophageal reflux disease
Social History:
Retired machinist. Recently seperated, lives
alone. Active smoker - about 3 cigs/day. Admits to 45 pack year
history of tobacco. Rare ETOH.
Family History:
Non-contributory
Physical Exam:
Height: 6'3" Weight: 196 lbs
General: Appears well, lying flat post cath, in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Clear with some ronchi bilaterally
Heart: RRR [x] Irregular [] - distant heart sounds
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Trace edema LLE
Varicosities: None [x]
Neuro: Alert and oriented, CN 2-12 grossly intact, no focal
deficits
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
Pre-bypass:
1. The left atrium and right atrium are normal in cavity size.
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. The aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. There are simple atheroma
in the descending thoracic aorta. There are three aortic valve
leaflets. There is no aortic valve stenosis. Moderate (2+)
aortic regurgitation is seen.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation.
7. There is no pericardial effusion.
Post-bypass: AV paciong. On infusion of phenylephrine.
Well-seated bioprosthetic valve in the aortic position. No AI;
systolic gradient is trivial. Ascending graft visible in the
aortic positoion. No dissection seen. Aortic contour is normal
in the descending aorta. Biventricular systolic function is
preserved.
[**2113-3-25**] 06:00AM BLOOD WBC-7.6 RBC-2.65* Hgb-7.8* Hct-24.5*
MCV-93 MCH-29.6 MCHC-32.0 RDW-13.4 Plt Ct-146*
[**2113-3-20**] 12:09PM BLOOD WBC-12.0* RBC-2.85*# Hgb-9.2*# Hct-26.6*#
MCV-93 MCH-32.4* MCHC-34.7 RDW-12.9 Plt Ct-139*
[**Known lastname 8034**],[**Known firstname **] [**Medical Record Number 59435**] M 67 [**2045-4-27**]
Radiology Report CHEST (PA & LAT) Study Date of [**2113-3-23**] 1:36 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2113-3-23**] 1:36 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 59436**]
Reason: pl.eff
[**Hospital 93**] MEDICAL CONDITION:
67 year old man s/p Bentall/hemiarch
REASON FOR THIS EXAMINATION:
pl.eff
Final Report
TWO-VIEW CHEST OF [**2113-3-23**]
COMPARISON: [**2113-3-21**].
INDICATION: Evaluate pleural effusion in postoperative patient.
FINDINGS: Cardiomediastinal contours are stable in appearance
compared to
previous postoperative radiographs. Small pleural effusions,
right greater
than left, are unchanged from the two most recent radiographs.
Minor
atelectatic changes persist at the bases. On the lateral view,
retrosternal
gas and fluid is likely related to the recent sternotomy. Due to
patient
obliquity, it is difficult to exclude small loculated anterior
hydropneumothorax, but no visible apical pleural line is evident
on the
corresponding frontal view. High-grade compression deformity in
the mid
thoracic spine is unchanged since the preoperative study.
IMPRESSION: Small pleural effusions, right greater than left
with adjacent
basilar atelectasis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: [**Doctor First Name **] [**2113-3-23**] 2:18 PM
Imaging Lab
[**2113-3-20**] 01:30PM BLOOD PT-15.0* PTT-45.7* INR(PT)-1.3*
[**2113-3-20**] 12:09PM BLOOD PT-16.0* PTT-43.2* INR(PT)-1.4*
[**2113-3-25**] 06:00AM BLOOD Glucose-97 UreaN-11 Creat-0.7 Na-133
K-4.1 Cl-93* HCO3-32 AnGap-12
[**2113-3-21**] 03:31AM BLOOD Glucose-111* UreaN-12 Creat-0.7 Na-135
K-4.8 Cl-104 HCO3-25 AnGap-11
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2113-3-20**] where he underwent Bentall procedure
as well as ascending aorta and hemi-arch replacement. See
operative note for further details. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. He awoke neurologically intact and was
extubated without difficulty. Weaned off Nitroglycerin.
Beta-Blocker/Aspirin/Statin/diuresis was initiated. Preoperative
meds were resumed. All lines and drains were discontinued in a
timely fashion. POD#1 he was transferred to the step down unit
for further monitoring. Physical therapy was consulted to
evaluate mobility and strength. He continued to progress
although he was not able to be weaned off of supplemental oxygen
completely. As discussed with his pulmonologist, Mr.[**Known lastname **]
continued his inhalers and diuresis, and would require O2
arranged for discharge to home. Postoperatively he had transient
hyponatremia requiring free water restriction and diuresis to
correct his electrolytes. On POD# 6 he was cleared by Dr.[**Last Name (STitle) 914**]
for discharge to home. All follow up appointments were advised.
Medications on Admission:
HCTZ 25 qd, Atenolol 100 qd, Amiodarone 200
qd, Nifedipine 30 qd, Pravastatin 40 qd, Advair prn, Trazadone
150 qd, Oxycontin 20-60 TID, Alendronate 70 qweek, Spiriva 18mcg
daily, ASA 81mg po daily, Fluticasone 50mcg 2 sprays each
nostril
daily, Albuterol PRN
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for insomnia.
5. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours) as needed
for pain.
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-28**]
Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea.
Disp:*qs * Refills:*0*
14. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
15. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
18. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
19. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
21; Home oxygen arranged for nasal cannula
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
ascending aortic aneurysm, s/p Bentall Procedure [**2113-3-20**]
PMH:
chronic obstructive pulmonary disease
Hypertension
Hypercholesterolemia
supra-ventricular tachycardia [**2103**]
Intention Tremor, mostly right hand
Chronic Back Pain
Renal Cyst
peptic ulcer disease [**2073**]
Arthritis
gastroesophageal reflux disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with ** prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Home oxygen arranged for nasal cannula
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) 914**] #[**Telephone/Fax (1) 170**], appointment arranged for
[**2113-4-25**] at 1:30pm
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 58937**] in [**1-28**] weeks
Cardiologist Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 16005**] in [**1-28**] weeks
Pulmonologist Dr [**Last Name (STitle) 26225**] in [**3-2**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2113-3-26**]
ICD9 Codes: 4241, 2761, 5180, 496, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6754
} | Medical Text: Admission Date: [**2193-12-30**] Discharge Date: [**2194-1-8**]
Date of Birth: [**2167-11-21**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old
female with a new diagnosis of dilated cardiomyopathy with an
ejection fraction of 10%. The patient was admitted to the
Coronary Care Unit for management of her congestive heart
failure and cardiomyopathy.
The shortness of breath started approximately two to three
years. At that time, she was diagnosed with asthma by
pulmonary function tests. Six months ago, the patient noted
new shortness of breath with exertion and pleuritic chest
pain that was nonexertional and accompanied by nausea,
vomiting, and nonbloody diarrhea.
Approximately one month ago the patient noted she was waking
up from sleep gasping for air. The patient went to her
primary care physician and was then admitted to [**Hospital 1474**]
Hospital. In early [**2193-12-7**], an echocardiogram there
showed an ejection fraction of 10%. She was seen by
Cardiology and started on medications for cardiomyopathy.
She was discharged on [**2193-12-13**].
The patient's symptoms worsened at home, and she was getting
more short of breath with exertion. She could only go a few
steps prior to becoming short of breath. She was returned to
[**Hospital 1474**] Hospital and was transferred to the [**Hospital1 346**] for further management.
PAST MEDICAL HISTORY:
1. Idiopathic cardiomyopathy.
2. Asthma.
3. Hypertension.
4. Cesarean section four years ago; postpartum hemorrhage.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.25 mg by mouth once per day.
2. Lasix 40 mg by mouth once per day.
3. Lisinopril 2.5 mg by mouth once per day.
4. Toprol-XL 12.5 mg by mouth once per day.
5. Potassium chloride 10 mEq by mouth once per day.
ALLERGIES:
SOCIAL HISTORY: The patient works as a bus driver. She
lives with her son and sister. She has one child. She quit
smoking one month ago; however, she had smoked half a pack
per day for eight years. She denies alcohol and intravenous
drug use.
FAMILY HISTORY: Her family history is significant for a
brother with asthma. Her mother has hypertension and
diabetes. Her son has an "arrhythmia" and asthma.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
with vital signs which revealed the patient's temperature was
95.9 degrees Fahrenheit, her heart rate was 103, her blood
pressure was 144/81, her respiratory rate was 22, and her
oxygen saturation was 100% on 2 liters via nasal cannula. In
general, the patient was pleasant and in no acute distress.
Head, eyes, ears, nose, and throat examination revealed the
pupils were equal, round, and reactive to light. The
extraocular movements were intact. There was bilateral
tonsilar enlargement. The mucous membranes were moist.
Jugular venous pressure at the angle of jaw. There was no
lymphadenopathy. Chest examination revealed the lungs were
clear to auscultation bilaterally. There were no crackles.
Cardiovascular examination revealed tachycardia with a
regular rhythm. There were no murmurs. Positive third heart
sound and fourth heart sound. The abdominal examination
revealed the abdomen was obese, nontender, and nondistended.
there were positive bowel sounds. Extremity examination
revealed no clubbing, cyanosis, or edema. Dorsalis pedis and
posterior tibialis pulses were 2+ bilaterally. Neurologic
examination revealed the patient was alert and oriented times
three. Grossly intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed the patient's hematocrit was 39.6, and her platelets
were 261. The patient's sodium was 142, potassium was 3.6,
chloride was 104, bicarbonate was 28, blood urea nitrogen was
10, creatinine was 0.9, and her blood glucose was 114. Her
creatine kinase was 59. Troponin was 0.06. Urinalysis at
the outside hospital was negative. Digoxin level was less
than 0.2. Her INR was 1.3, her prothrombin time was 14, and
her partial thromboplastin time was 26.1. Cardiac transplant
workup laboratories revealed the patient's total iron-binding
capacity was 361, her ferritin was 58, TRF was 278, her
hemoglobin A1c was 6.1. Her low-density lipoprotein was 80,
cholesterol/HD was 3.3, her high-density lipoprotein was 42,
her triglycerides were 90. Her thyroid-stimulating hormone
was 2.5. Her free T4 was 1.3. Hepatitis B surface antigen
was negative. Hepatitis B surface antibody was positive.
Hepatitis B core antibody was negative. Hepatitis A virus
antibody was negative. Antinuclear antibody was negative.
Hepatitis C virus antibody was negative. Human
immunodeficiency virus antibody was negative. Toxo IgG was
negative. IgM was negative. [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus viral capsid
antigen IgG antibody positive. [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus viral
capsid antigen IgG antibody positive. [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus
[**Doctor Last Name 3271**]-[**Doctor Last Name **] nuclear antigen IgG antibody positive.
[**Doctor Last Name 3271**]-[**Doctor Last Name **] virus viral capsid antigen IgM antibody
negative. Cytomegalovirus IgG positive. Cytomegalovirus IgM
negative. Varicella zoster negative. Herpes simplex virus
II IgG negative. Herpes simplex virus I IgG negative. The
patient's aspartate aminotransferase was 16, her
alanine-aminotransferase was 20, and her bilirubin was 1.6,
her alkaline phosphatase was 63. Her magnesium was 2.3, her
calcium was 8.9, and her phosphorous was 4.3. Her albumin
was 3.2. Her amylase was 47. Her lactate dehydrogenase was
317. Purified protein derivative was negative.
Guaiac-negative.
PERTINENT RADIOLOGY/IMAGING: A posterior/anterior and
lateral chest x-ray revealed no cardiomegaly but no evidence
of cardiac failure or pneumonia.
Impression from a computed tomography angiogram revealed the
examination was greatly limited due to the patient's body
habitus. There was no pulmonary embolus identified. There
was bilateral dependent atelectasis. Findings were
consistent with congestive heart failure.
Impression from an ultrasound of the abdomen (complete study)
revealed (1) gallstones and (2) normal liver Doppler, but
right hepatic artery not visualized due to technical
limitations.
An electrocardiogram revealed a normal sinus rhythm at 98
beats per minute, normal axis, normal intervals, right atrial
enlargement, and left atrial enlargement. There were Q waves
in V5 and V6. No changes. Consistent with prior
electrocardiogram.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR ISSUES: The patient was admitted to the
hospital and taken directly to cardiac catheterization.
During the procedure, the patient went into an
atrioventricular nodal reentrant tachycardia arrhythmia and
was given adenosine with good results.
On the evening of night of [**1-2**] to [**1-3**], the
patient went into a heart rate in the 190s.
Electrocardiogram at that time was taken and showed
atrioventricular nodal reentrant tachycardia arrhythmia.
Vagal maneuvers were attempted without success. Blood
pressure was stable in the 100s. The patient was
asymptomatic; however, when the patient was woken up she
complained of chest pain, right arm pain, diaphoresis, and
lightheadedness. The symptoms resolved when the patient was
given adenosine with good resolution of atrioventricular
nodal reentrant tachycardia.
On cardiac catheterization the patient was shown to have
dilated cardiomyopathy and high cardiac pressures, elevated
central venous pressure, pulmonary artery pressure (both
systolic and diastolic), and elevated pulmonary capillary
wedge pressure. Henceforth, the patient was started on a
Lasix drip initially and then taken off for fear of pushing
the patient into prerenal failure. She was then started on
milrinone. An ACE inhibitor was then added in addition to a
beta blocker with good pressure control.
Despite medical management, the patient continued to be
tachycardic since admission secondary to her heart failure.
She was started on a workup for cardiac transplantation and
without followed by Dr.[**Name (NI) 23312**] Congestive Heart Failure
Service.
Electrophysiology was consulted for ablation of the
atrioventricular nodal reentrant tachycardia. The
Electrophysiology team spoke with the patient and mother.
They obtained consent and performed atrioventricular nodal
reentrant tachycardia ablation without any complications.
The team was unable to re-induce atrioventricular nodal
reentrant tachycardia. The patient was then weaned off the
milrinone drip. The central lines were pulled, and the
patient was transferred to the floor for one and then
discharged home. The patient was to have Heart Failure
Service followup and further transplant evaluation.
2. PULMONARY ISSUES: The patient had desaturations to 88%
on room air. The patient was tried on different levels of
oxygen until finally placed on a nonrebreather face mask with
saturations stabilizing to the 90s. At that time, the
patient was tachycardic but was not complaining of any chest
pain. Arterial blood gas showed a pH of 7.38, PCO2 was 49,
and PO2 of 52 on a nonrebreather.
Respiratory Therapy was consulted for suspected obstructive
sleep apnea. The patient was placed on [**Hospital1 **]-level positive
airway pressure with good results. The patient's oxygen
saturation at that point were 98%.
The following day, attempts to take off the [**Hospital1 **]-level positive
airway pressure were unsuccessful. The next thought was that
the patient might have had a pulmonary embolism. A computed
tomography angiogram was performed, and the results were
negative. Attempted to wean off the [**Hospital1 **]-level positive airway
pressure slowly over the course of two days and were able to
place the patient back on 2 liters nasal cannula with oxygen
saturations stable at 98%. The patient subsequently did well
off any oxygen requirements with oxygen saturations stable
from 95% to 98%.
3. HYPERGLYCEMIA ISSUES: Likely due to apparent glucose
intolerance secondary to obesity. Spoke at length regarding
dietary modification and had Nutrition see the patient.
4. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
placed on a low-sodium cardiac diet.
5. PROPHYLAXIS ISSUES: Subcutaneous heparin was
administered throughout the entire hospitalization.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Acute-on-chronic congestive heart failure (systolic and
diastolic).
2. Left congestive heart failure.
3. Dyspnea.
4. Hypertension.
5. Atrioventricular nodal reentrant tachycardia arrhythmia.
6. Status post atrioventricular nodal reentrant tachycardia
radioablation.
7. Hyperglycemia.
MEDICATIONS ON DISCHARGE:
1. Warfarin 5-mg tablets one tablet by mouth at hour of
sleep.
2. Metoprolol succinate 50-mg tablets one tablet by mouth
once per day.
3. Lisinopril 20-mg tablets two tablets by mouth every day.
4. Digoxin 350-mcg tablets one tablet by mouth every other
day.
5. Digoxin ? 250-mg tablets 1.5 tablets by mouth every other
day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient had an exercise stress test appointment on
[**2194-1-15**] at 9:30 a.m. The patient was to call
telephone number [**Telephone/Fax (1) 1566**] for any questions or concerns.
2. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at the [**Last Name (un) 469**] Center Cardiac Services on [**2194-1-21**] at 10 a.m. The patient was to call telephone number
[**Telephone/Fax (1) 2550**] for questions or concerns.
3. The patient was instructed to follow up with her primary
care physician at [**Name9 (PRE) 53941**]. She was to call her physician
in one to two weeks to schedule an appointment at telephone
number [**Telephone/Fax (1) 3183**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2814**]
Dictated By:[**Last Name (NamePattern1) 9622**]
MEDQUIST36
D: [**2194-2-25**] 18:14
T: [**2194-2-26**] 11:04
JOB#: [**Job Number 53942**]
ICD9 Codes: 4280, 4254, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6755
} | Medical Text: Admission Date: [**2179-12-23**] Discharge Date: [**2179-12-28**]
Date of Birth: [**2131-7-11**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 48 year old male with
the history of AIDS, coronary artery disease, status post
cardiac catheterization on [**2179-12-7**] with percutaneous
transluminal coronary angioplasty to his left anterior
descending coronary artery and balloon angioplasty. He
presents to the emergency room on [**2179-12-23**] with dyspnea on
exertion since discharge. He reported he had initial
symptoms on his previous presentation where bilateral upper
extremity pain and substernal chest pain "like somewhat is
sitting on my chest." Since then he has had severe dyspnea
on exertion with minimal activity, occasionally with chest
pain without upper extremity pain. He reported no weight
loss, fever, vomiting, diarrhea. He does complain of night
sweats, nausea and gas. He has no lower extremity edema, no
paroxysmal nocturnal dyspnea and stable two to three pillow
orthopnea. He reported that he did start smoking again after
his last hospitalization and that he recently had some
"bumps" popping up over his shoulder and back over ten days.
They are nonpruritic. Currently on examination he is chest
pain free with no shortness of breath.
PAST MEDICAL HISTORY:
1. HIV positive requiring retroviral therapy. Last CD4 count
66 on [**8-4**].
2. Hypercholesterolemia.
3. Coronary artery disease.
4. Depression.
5. Congestive heart failure with both diastolic and systolic
dysfunction.
6. Right middle lobe 9 mm nodule noted on a CT angio of his
chest [**2179-12-4**].
7. Shingles.
8. Gastroesophageal reflux disease.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lopinavir-Ritonavir 133.3-33.3 caps, dosing 3 caps by
mouth twice a day.
2. Lamivudine-Zidovudine 150-300 mg tablets 1 tablet P.O.
twice daily.
3. Abacavir 300 mg P.O. twice a day.
4. Plavix 75 mg P.O. once a day for 30 days starting [**2179-12-8**]
status post stent placement.
5. Aspirin 325 mg P.O. once a day.
6. [**Month/Day/Year **] 20 mg P.O. once a day.
7. Atenolol 50 mg P.O. once a day.
8. Lisinopril 5 mg P.O. once a day.
9. Bactrim SS 1 tablet once a day.
10. Famotidine 20 mg P.O. twice a day.
11. Sublingual nitroglycerine.
12. Senna PRN
13. Colace.
14. Prozac 40 mg P.O. once a day and nicotine
transdermal patch 14 mg, application every 24 hours.
SOCIAL HISTORY: Admitted to smoking one pack a day,
occasional alcohol, no current drug use at all.
FAMILY HISTORY: Had a positive family history. His father
died of myocardial infarction at age 47.
PHYSICAL EXAMINATION: On admission temperature 98.9, blood
pressure 143/64, heart rate 62, regular, saturating 99
percent on room air. Head, eyes, ears, nose and throat
examination was unremarkable. He had jugular venous
distension, no lymphadenopathy palpable. Heart was regular
rate and rhythm with S1, S2, tones no murmur, rub or gallop.
Lungs were clear bilaterally with distant breath sounds
bilaterally. Abdomen had some mild epigastric tenderness, no
distention, no masses, no hepatosplenomegaly. Extremities
had no edema. He had some rare 1 mm scabbed over papules on
his left shoulder and back, nontender, nonpruritic.
Chest x-ray showed no infiltrate, no congestive heart failure
or effusion. His electrocardiogram showed normal axis with
sinus rhythm at 75 with 1 to [**Street Address(2) 37964**] elevations in V1
through V3. Biphasic T waves in V2 through V3 consistent
with his prior electrocardiogram on [**2179-12-8**]. Only the T wave
changes were new. Please refer to his electrocardiogram done
on [**2179-12-23**] for official report. Cardiac catheterization on
[**2179-12-7**] did show three vessel disease. He received three
stents to his left anterior descending coronary artery and
balloon angioplasty to his third obtuse marginal, AV groove
circumflex and left posterior descending coronary artery.
His ejection fraction at that time was 46 percent with an
left ventricular ejection fraction of 13.
He was admitted through the emergency room. Laboratories
prior to the catheterization were as follows; troponin T
0.02, saturation of 35, potassium of 5.6. Chloride 99,
bicarb 21, BUN 24, creatinine 1.0, blood sugar 101, anion gap
21, CK 135 with MB of 3. White count of 5.9, hematocrit
31.6, platelet count 357,000. PT 12.2, PTT 24.4, INR 0.9.
Urinalysis was negative. Given his current symptoms the
patient went to the cardiac catheterization laboratory on the
cardiology service which showed a clot in the left anterior
descending coronary artery, restenosis in the circumflex and
he was referred to Dr. [**Last Name (STitle) 70**] for emergent coronary artery
bypass graft. On the 23rd he went to the operating room for
emergent coronary artery bypass grafting times two with a
left internal mammary artery to the left anterior descending
coronary artery, a vein graft to the obtuse marginal and a
vein graft sequentially to the posterior descending coronary
artery. He was transferred to the cardiothoracic Intensive
Care Unit in stable condition on a Neo-Synephrine drip at 0.8
mcg per kilogram per minute and titrated propofol drip.
On postoperative day one he was hemodynamically stable on a
Neo-Synephrine drip at 2.5 mcg per kilograms per minute. He
was restarted on his aspirin and Plavix and continued with
his perioperative vancomycin. His white count was 8.3,
hematocrit 31.8, platelet count 286,000, potassium 4.5, BUN
17, creatinine 0.9. He remained intubated. He was stable
and remained in the cardiothoracic Intensive Care Unit. He
was seen by his [**Hospital6 **] Center physician who
made suggestions for his antiretroviral therapy protocol and
his HIV medications were restarted. On postoperative day two
he had no events overnight. He was extubated. His maximum
temperature was 100. He was hemodynamically stable in sinus
rhythm, saturating 94 percent on 2 liters nasal cannula. His
creatinine and white count were stable. He was doing well.
His Swan was discontinued. His Neo-Synephrine continued to
be weaned. Chest tubes were discontinued and his Foley was
pulled and he was encouraged to ambulate.
On the 26th his Cordis was discontinued. Peripheral
intravenous was placed. He was transferred out to the floor.
His examination was unremarkable. His incisions were clean,
dry and intact. He continued to be seen every day by Dr.
[**Last Name (STitle) 37965**], his [**Hospital1 778**] staff physician. [**Name10 (NameIs) **] was encouraged to
continue using the incentive spirometer and work on pulmonary
toilet as well as ambulation with physical therapy and the
nursing staff. On postoperative day four he had a blood
pressure of 124/76 with sinus rhythm at 78. His beta
blockage with Lopressor continued as well as Lasix diuresis.
He continued on his triple antiviral therapy as well as his
Plavix. His examination was relatively unremarkable.
Incisions were clean, dry and intact. His epicardial pacing
wires were to be removed during the day that day. He was
saturating 95 percent on room air. He had somewhat of a flat
affect but otherwise appeared to be alert and oriented with a
nonfocal examination. Psychiatry consult was requested and
done by Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 16293**] for his history of depression
and the assessment was based on his current examination and
he appeared safe for discharge with outpatient follow up and
they recommended that his Prozac be continued. He was also
seen by case management and patient's desire was to be
discharged to home and his roommate will be with him.
Patient would be discharged with [**Hospital6 407**]
services. On the day of discharge he was receiving Percocet
PRN and ibuprofen for P.O. pain control. He had good bowel
sounds. Discharge planning was done. His examination was
unremarkable. Incisions were clean, dry and intact. He was
performing all of his activities of daily living and his last
laboratories were hematocrit of 27.3. The patient was deemed
well enough to be discharged to home with Visiting Nurse
Associates services and was discharged with the following
diagnoses.
FINAL DIAGNOSES:
1. Status post emergent coronary artery bypass grafting times
three.
2. Coronary artery disease, status post triple vessel
stenting [**12-4**].
3. HIV positive on retroviral therapy.
4. Hypercholesterolemia.
5. Depression.
6. Congestive heart failure.
7. Right middle lobe nodule.
8. Gastroesophageal reflux disease.
DISCHARGE FOLLOW UP APPOINTMENTS: Were scheduled. Patient
was requested to make an appointment with Dr. [**Last Name (STitle) 2392**] for
approximately one to two weeks post discharge, to make
appointment for a psychiatric referral at [**Hospital 778**] Health
Center one week after discharge and make appointment to see
Dr. [**Last Name (STitle) 70**], his surgeon in the office for postoperative
surgical visit in approximately six weeks. He also has an
appointment scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] from cardiology
for [**2180-1-14**] at 11:30.
DISCHARGE MEDICATIONS:
1. Percocet 5/325 one to two tablets P.O. PRN q 4 hours for
pain.
2. Plavix 75 mg P.O. once daily.
3. Aspirin 81 mg enteric coated P.O. once daily.
4. Abacavir Sulfate 300 mg P.O. twice daily.
5. Lamivudine - zidovudine 150-350 mg tablet, 1 tablet P.O.
twice daily.
6. Lopinavir-ritonavir 133.3 - 33.3 mg capsule, 3 capsules
twice a day.
7. Flexitime 40 mg P.O. daily.
8. Metoprolol 25 mg P.O. twice a day.
9. Lasix 20 mg P.O. twice a day for seven days.
10. Potassium chloride 20 mEq P.O. twice a day for seven
days.
11. Pepcid 20 mg P.O. once a day.
12. Ibuprofen 600 mg P.O. q 6 hours PRN for pain.
The patient was discharged home with [**Hospital6 1587**] services on [**2179-12-28**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2179-12-29**] 15:35:12
T: [**2179-12-29**] 18:06:34
Job#: [**Job Number 37966**]
ICD9 Codes: 4111, 4019, 3051, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6756
} | Medical Text: Admission Date: [**2187-7-24**] Discharge Date: [**2187-8-2**]
Date of Birth: [**2133-10-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD on [**2187-7-24**]
1. Hemigastrectomy with Billroth II reconstruction.
2. Feeding jejunostomy
History of Present Illness:
53M with a PMHx of HTN, DMII, COPD, developed dizzyness with
nausea, stomach pain, and vomitting 3-4 days prior to admission.
Emesis was dark black. Melanotic stools began on saturday and
continued for three days until admission. This morning dizzyness
and weakness progressed, he called 911 and was brought to ED by
EMS. In the ambulance, was noted to have inferior ST elevations
(got ASA 325 by EMS). These resolved on the ED 12-lead and were
attributed to machine calibration; he does not have a cardiac hx
and had no chest pain. Trop on arrival 0.05, CK=28 (Cr at 1.6,
baseline unknown).
.
In the ED, initial vs were: T=96.8 P=99 BP=90/29 R=20 O2 sat
95%. Patient was pale and diaphoretic at presentation c/o
weakness. His initial Hct was 23.7 (unknown baseline) with WBC
of 20, normal plts, normal coags. His pants were stained with
melanotic stool. NG drainage was drak red and did not clear with
lavage. He was given 4L NS (1 prior to Hct, 3 post) and
erythromycin for motility prior to EGD. Pressure transiently as
low as 81/28 in the ED, at time of transfer (POST 4L), HR=86,
BP=105/60, R=20, 96%ra. One unit of blood given in transit and
second unit given over one hour in MICU.
.
EGD in MICU showed clot in fundus with no active bleeding.
Currently feels weak but significatly better than earlier today.
Denies ever having had chest pain. Denies GIB hx, ulcer hx, etoh
abuse, denies excess NSAID use. Never had stomach pain before 4
days PTA.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. No dysuria. Denied arthralgias or
myalgias. PCP informed of admission; has not seen him in one
year.
Past Medical History:
Chronic pain on home opiates
s/p MVA with femur fx 20+ years ago
R knee OA
HTN
COPD/asthma
Hypercholesterolemia
Hospitalization for PTX s/p bleb rupture several years ago.
Social History:
The patient is married, has two children. Denies alcohol or drug
use. He currently smokes 2 packs of cigarettes per day. He works
and owns a pizza shop in [**Location (un) 745**]. Wife is travelling in [**Country 5881**]
and has been updated.
Family History:
non-contributory, no CAD hX, NO ONCOLOGIC HX
Physical Exam:
Vitals: T:97.4 BP:109/58 P:95 R:22 O2:98ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, distant BS, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, DISTANT 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
Brief Hospital Course:
# Upper GI Bleed - In the emergency department, the patient
received two peripheral 16 gauge IV's. Overall, he received 5
liters of normal saline and 3 units of blood. After receiving
these fluids, his tachycardia resolved and his blood pressure
returned to the low-normal range. After the patient was
transferred to the emergency department, an EGD was performed.
When he received sedation for his EGD, he did have an episode of
hypotension that required a saline bolus. The EGD showing
significant clot in stomach with no active bleeding. The
patient had no additional melena or emesis. Hematocrits were
followed throughout the night and remained stable around 25 (up
from his initial hematocrit of 23.7). He was also maintained on
an IV PPI. Overnight, he remained normotensive. The day after
his admission, he was transferred out of the MICU to the floor
with plans for a repeat EGD after 48 hours. Pt had repeat EGD
on [**2187-7-26**] which showed a fungating, ulcerated and infiltrative
5-7cm mass with stigmata of recent bleeding of malignant
appearance at the stomach body, with a ventral vessel. Surgery
was consulted and the decision was made to go to the OR on
[**2187-7-27**] with Dr. [**Last Name (STitle) 519**]. A hemigastrectomy with Billroth II
reconstruction was performed along with a feeding jejunostomy.
Metastatic gastric adenocarcinoma was diagnosed on biopsy. The
patient recovered from his surgery in the unit before being
transferred to the floor. He was discharged on post-operative
day 5 and hospital day 9.
Medications on Admission:
HCTZ 25',lisinopril 20', atenolol 50', simvastatin 10',
oxycontin 20", advair diskus 250/50, spiriva, fenofibrate cap
200mg (1 cap PO daily with meals), metformin 500"
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atenolol 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 1 months: Take with
pain meds.
Disp:*60 Capsule(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks: Maximum of
4gm of APAP daily. .
Disp:*45 Tablet(s)* Refills:*0*
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation once a day.
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Upper gastrointestinal hemorrhage with gastric mass.
Adenocarcinoma of the stomach
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications.
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 pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow up appointment.
-Steri-strips will be applied and will fall off on their own.
Please remove any remaining strips 7-10 days after application.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
J-TUBE:
Please continue to flush J-TUBE with 30-60 cc of water daily.
Please continue to change dressing daily and as needed.
Please continue to assess site for s/s of infection.
Followup Instructions:
1. Please call Dr.[**Name (NI) 1745**] office, [**Telephone/Fax (1) 6554**], to make a follow
up appointment in 1 week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 5789, 5849, 2762, 486, 496, 2851, 4019, 2720, 4589, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6757
} | Medical Text: Admission Date: [**2112-7-25**] Discharge Date: [**2112-8-13**]
Date of Birth: [**2057-6-4**] Sex: F
Service: Surgery
CHIEF COMPLAINT: Recurrent sigmoid diverticulitis,
postoperative anastomotic leak.
MAJOR SURGICAL PROCEDURES: Sigmoid colon resection on [**2112-7-25**], exploratory laparotomy, and diverting ileostomy on
[**2112-8-2**], and removal of retained drain on [**2112-8-11**].
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
woman with a history of recurrent diverticulitis. Since [**2110**],
she had at least 3 documented episodes of acute
diverticulitis. Patient was now admitted for elective sigmoid
resection.
Patient underwent a sigmoid colon resection on [**2112-7-25**].
Patient had a postoperative complication with an anastomotic
leak which necessitated exploratory laparotomy and diverting
ileostomy. Subsequently, 1 of the drains that was placed at
the 2nd operation was retained and could not be removed at
bedside. Therefore, patient required an additional procedure
in the operating room with extraction of the drain.
After that procedure, the patient was doing well, and she
could be discharged home on [**2112-8-13**].
DISCHARGE STATUS: On discharge, the patient was in good
general condition. She was afebrile. Her ileostomy was
working well.
DISCHARGE FOLLOWUP: Patient will follow up in Dr.[**Name (NI) 109160**] office in approximately 10 days.
[**Name6 (MD) 5183**] [**Last Name (NamePattern4) 5184**], [**MD Number(1) 5185**]
Dictated By:[**Last Name (NamePattern4) 95468**]
MEDQUIST36
D: [**2112-11-10**] 11:18:39
T: [**2112-11-11**] 09:55:24
Job#: [**Job Number 109161**]
ICD9 Codes: 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6758
} | Medical Text: Admission Date: [**2198-5-22**] Discharge Date: [**2198-6-15**]
Service: MEDICINE
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension, Unresponsiveness
Major Surgical or Invasive Procedure:
Endotracheal (through stoma) intubation
History of Present Illness:
85 year old man with a hx of laryngeal CA s/p laryngectomy
w/permanent tracheostomy p/w decreased responsiveness and
hypotension. Pt. had been suffering through a cough and likely
COPD exacerbation with pneumonia based on pervious pulmonary
records. According to family, patient was being suctioned when
suddenly became unresponsive, was found to be flaccid by EMS
with cold extremities. Intubated through his stoma in ED with
resultant return of color and
In the ED, VS 99.6 115/46 59 100%RA 12, CXR demonstrated right
sided consolidation, received Vancomycin, Zosyn, rectal ASA.
EKG seen by cardiology with no plans for cath but would echo
instead, trop's negative. Pt. was subsequently paralyzed with
vecuronium (for an unknown reason) with resultant hypotension to
60's, ETT repositioned. Lactate initially at 4.0, down to 0.6
after fluids, initial ABG was 7.25/68/417/31 Fi02 100%. Was
started on levophed with resultant increase in BP, given 1L NS
and weaned off prior to arrival to MICU. IJ placed. Also
received decadron 10mg IV x 1.
.
In MICU, pt. required boluses, though responsive initially to
command, nodding head to questions. Started on vanc/zosyn,
given MDI's. Placed patient again on levophed due to lower
blood pressures.
.
Of note, was febrile to 102.7 the week before this admission,
with green sputum and shortness of breath. Was placed on
azithromycin and steroids by Dr. [**Last Name (STitle) 575**].
.
Past Medical History:
(1) Chronic obstructive pulmonary disease (COPD).
(2) Status post laryngeal cancer with permanent tracheostomy
placed in [**2180**].
(3) Status post right upper lobectomy for lung cancer in [**2186**].
(4) Left ventricular dysfunction with inferior akinesis on echo.
(5) Monoclonal gammopathy of unknown significance.
(6) Prior polio with right lower extremity weakness.
(7) Kyphoscoliosis.
(8) Hypertension.
Social History:
Pt. lives with wife and daughter. Extensive smoking history,
social drinking, no IVDU.
Family History:
Non contributory
Physical Exam:
VS: T 36, BP 115/52 (on levophed), 52, 100%, 24 (on vent)
Gen: Occasionally responsive to commands
HEENT: PERRLA, EOMI, clear OP, MMM
Neck: supple
CV: RRR, -m/r/g, nl S1/S2
Lungs: Decreased BS on R side, slightly wheezing, coarse breath
sounds from mechanical ventilation.
Abd: S/NT/ND/nabs, -HSM
Ext: -c/c/e, slightly cool extremities
Pertinent Results:
[**2198-5-22**] 04:00PM BLOOD WBC-12.9* RBC-3.97* Hgb-12.1* Hct-39.7*
MCV-100* MCH-30.6 MCHC-30.6* RDW-15.9* Plt Ct-340
[**2198-5-22**] 08:43PM BLOOD WBC-8.0 RBC-3.25* Hgb-10.1* Hct-32.6*
MCV-100* MCH-30.9 MCHC-30.9* RDW-15.8* Plt Ct-224
[**2198-5-24**] 02:22AM BLOOD WBC-5.7 RBC-3.12* Hgb-9.5* Hct-29.7*
MCV-95 MCH-30.5 MCHC-32.0 RDW-15.6* Plt Ct-220
[**2198-5-29**] 03:00AM BLOOD WBC-9.4 RBC-3.38* Hgb-10.2* Hct-31.3*
MCV-93 MCH-30.1 MCHC-32.5 RDW-15.5 Plt Ct-305
[**2198-5-29**] 03:00AM BLOOD PT-14.0* PTT-69.4* INR(PT)-1.2*
[**2198-5-22**] 08:43PM BLOOD Glucose-174* UreaN-35* Creat-0.6 Na-145
K-4.5 Cl-115* HCO3-27 AnGap-8
[**2198-5-25**] 03:58PM BLOOD Glucose-151* UreaN-29* Creat-0.7 Na-145
K-3.7 Cl-104 HCO3-33* AnGap-12
[**2198-5-29**] 03:00AM BLOOD Glucose-119* UreaN-18 Creat-0.6 Na-141
K-3.7 Cl-98 HCO3-39* AnGap-8
[**2198-5-22**] 04:00PM BLOOD ALT-40 AST-51* CK(CPK)-74 AlkPhos-64
TotBili-0.3
[**2198-5-22**] 08:43PM BLOOD ALT-157* AST-263* LD(LDH)-386*
AlkPhos-140* TotBili-0.3
[**2198-5-23**] 01:00AM BLOOD ALT-266* AST-370* LD(LDH)-389*
CK(CPK)-33* AlkPhos-222* TotBili-0.3
[**2198-5-23**] 04:38PM BLOOD ALT-204* AST-178* LD(LDH)-177
AlkPhos-184* TotBili-0.3
[**2198-5-24**] 02:22AM BLOOD ALT-161* AST-116* LD(LDH)-143
AlkPhos-154* TotBili-0.3
[**2198-5-25**] 02:42AM BLOOD ALT-132* AST-63* LD(LDH)-187 AlkPhos-148*
TotBili-0.4
[**2198-5-27**] 01:48PM BLOOD CK(CPK)-65
[**2198-5-27**] 08:17PM BLOOD CK(CPK)-77
[**2198-5-28**] 02:25PM BLOOD CK(CPK)-65
[**2198-5-22**] 04:00PM BLOOD Lipase-120*
[**2198-5-23**] 04:38PM BLOOD Lipase-40
[**2198-5-22**] 04:00PM BLOOD cTropnT-<0.01
[**2198-5-23**] 01:00AM BLOOD cTropnT-<0.01
[**2198-5-23**] 10:09AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2198-5-27**] 06:48AM BLOOD CK-MB-3 cTropnT-<0.01
[**2198-5-27**] 01:48PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2198-5-27**] 08:17PM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2198-5-28**] 02:25PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2198-5-22**] 04:00PM BLOOD Calcium-8.9 Phos-5.4* Mg-2.4
[**2198-5-25**] 02:42AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.2
[**2198-5-29**] 03:00AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.9
[**2198-5-27**] 06:48AM BLOOD TSH-2.0
[**2198-5-22**] 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2198-5-22**] 05:39PM BLOOD Tidal V-450 FiO2-100 pO2-417* pCO2-68*
pH-7.25* calTCO2-31* Base XS-0 AADO2-249 REQ O2-48
Intubat-INTUBATED Vent-IMV
[**2198-5-23**] 02:53AM BLOOD Type-ART Temp-36 Rates-24/24 Tidal V-400
PEEP-5 FiO2-50 pO2-128* pCO2-55* pH-7.26* calTCO2-26 Base XS--2
Intubat-INTUBATED Vent-CONTROLLED
[**2198-5-23**] 11:00AM BLOOD Type-ART Temp-36.6 Rates-24/ Tidal V-434
PEEP-5 FiO2-40 pO2-115* pCO2-46* pH-7.33* calTCO2-25 Base XS--1
-ASSIST/CON Intubat-INTUBATED
[**2198-5-24**] 02:09PM BLOOD Type-ART Rates-/29 Tidal V-395 PEEP-5
FiO2-30 pO2-78* pCO2-48* pH-7.42 calTCO2-32* Base XS-5
Intubat-INTUBATED Vent-SPONTANEOU
[**2198-5-25**] 03:49AM BLOOD Type-ART Temp-36.6 Rates-/24 Tidal V-250
PEEP-5 FiO2-30 pO2-62* pCO2-52* pH-7.39 calTCO2-33* Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2198-5-26**] 12:48AM BLOOD Type-ART Temp-35.4 O2 Flow-30 pO2-124*
pCO2-78* pH-7.27* calTCO2-37* Base XS-6 Intubat-NOT INTUBA
[**2198-5-22**] 04:15PM BLOOD Glucose-243* Lactate-4.5* Na-145 K-5.0
Cl-103 calHCO3-28
[**2198-5-22**] 04:21PM BLOOD Lactate-4.0*
[**2198-5-22**] 06:53PM BLOOD Lactate-0.6
[**2198-5-24**] 02:44AM BLOOD Lactate-0.9
[**2198-5-22**] 04:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2198-5-22**] 04:00PM URINE RBC-21-50* WBC-[**12-14**]* Bacteri-FEW
Yeast-NONE Epi-0-2
[**5-22**] Urine culture negative. Blood cultures x2 negative.
[**5-23**] Sputum
[**2198-5-23**] 12:33 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2198-5-26**]**
GRAM STAIN (Final [**2198-5-23**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2198-5-26**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Please contact the Microbiology Laboratory ([**7-/2495**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**5-26**] Sputum culture: contaminated
[**5-23**] Echo
IMPRESSION: Suboptimal image quality. Moderate pulmonary artery
systolic hypertension. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function.
Compared with the report of the prior study (images unavailable
for review) of [**2191-5-26**], moderate pulmonary artery systolic
hypertension with mild right ventricular enlargement is now
identified. Regional left ventricular systolic function now
appears preserved.
This constellation of findings is suggestive of a primary
pulmonary process.
[**5-22**] CXR
IMPRESSION:
1. Low positioned ET tube approximately 3 cm retraction for
optimal
positioning is recommended.
2. Fluffy left mid and lower lung opacity could reflect
infectious/post-
obstructive or aspiration pneumonitis. Given history of
malignancy,
lymphangitic carcinomatosis remains a differential
consideration; however, no
prior comparisons for accurate assessment are available.
3. Right hemithorax volume loss, but otherwise not evaluable due
to
rotation.
[**5-24**] CXR
IMPRESSION:
Interval worsening of left basilar airspace disease and stable
left upper lobe
airspace disease concerning for infection. Interval placement of
tracheostomy
tube terminating 4.7 cm above the carina. Stable right-sided
post-surgical
changes.
[**5-26**] CXR
IMPRESSION: Background COPD. Superimposed infectious infiltrate
or CHF
cannot be excluded. However, no significant change is detected
compared with
one day earlier.
[**5-27**] CXR
[**Known lastname **],[**Known firstname **] [**Medical Record Number 24814**] M 85 [**2112-10-17**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2198-5-27**] 3:53
AM
[**Doctor Last Name **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MED MICU [**2198-5-27**] 3:53 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 24815**]
Reason: eval for interval change
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with pneumonia, intubated, ?fluid overload
REASON FOR THIS EXAMINATION:
eval for interval change
Final Report
HISTORY: Pneumonia, intubated, question fluid overload interval
change.
CHEST, SINGLE AP VIEW
Despite provided history, no ET tube is identified.
The lungs are hyperinflated, consistent with COPD. There is
considerable
respiratory motion blurring detail. Allowing for this, the right
lung
appearance is grossly unchanged compared with 5/1 and [**5-26**].
However, even
allowing for differences in technique, the degree of opacity
along the lateral
aspect of the left chest appears more pronounced and confluent,
particularly
at the left lung base. The appearance is more suggestive of
parenchymal
consolidation than of layering fluid and the opacity does not
extendto
directly abut the chest wall.
Although much of the abnormal appearance could relate to the
patient's
background COPD, the possibility of an acute superimposed
pneumonic infiltrate
must be considered.
Brief Hospital Course:
Mr. [**Known lastname 10132**] is an 85 year old gentleman with a PMH significant for
laryngeal CA s/p laryngectomy and trach, COPD, CAD admitted with
unresponsiveness, dynamic ST-T wave abnormalities, shock, and
respiratory failure. Patient remained vasopressor and vent
dependent with BAL growing Pseudomonas. After family meeting,
patient's code status was changed to Comfort Measures Only. All
medications were stopped and the patient was started on morphine
gtt for comfort. He expired shortly thereafter with family at
bedside.
.
# Respiratory failure, requiring mechanical ventilation: The
patient presented with respiratory distress that was intially
thought to be secondary to pneumonia in conjuction with volume
overload. He was managed with antibiotics, including vancomycin
and zosyn as well as diuresis with furosemide, which was later
limited by hypotension. He also had underlying COPD, an
exacurbation of which was thought to contribute as well. This
was managed with nebulizers and steroids, initially IV followed
by [**Doctor Last Name 2949**] to a standing regimen of rednisone 5 mg daily. His
overall respiratory status was tenous and effors to wean off the
ventilation were unsucessfull.
# Unresponsiveness: This was intially noted in the setting of
desaturation to mid to high 70s, and EKG demonstrating ST
elevations. Cardiology was consulted and [**Hospital 24816**] medical
management for possible ACS. An EEG was performed showing
nonspecific findings. Head CT was negative for bleeding. His
prognosis for recovery remained poor. The family was updated
throughout the patients course. Ultimately a family meeting was
conducted to evaluated the goals of care. The family decided to
focus towards comfort measures.
# Troponin leak and ST elevations: These were most likely
consistent with ACS. This was managed medically with ASA, BB,
statin and ACEi. Initially he received heparin IV but this was
held given concern for active bleeding in the setting of HCT
drop (requiring multiple transfusions) and skin echymosses. His
BB and ACEi course was intermittent, given his hypotension. His
cardiac status was also associated with intermittent
bradycardia, also hindering management of his ACS.
# Hypotension: This was attributed to ACS and likely cardiogenic
shock. He required pressors (at times more than one, including
dopamine, norepinephrine and phenylephrine) throughtout most of
his ICU stay. His antihypertensive medications were held. CTA
chest negative for PE. CT abd/pelvis showed some free fluid in
abdomen but no blood. Also, bilateral renal cysts evident.
Initially thought to be urine from bladder perforation, CT
cystogram obtained which demonstrated no contrast extravasation
into peritoneum.
Medications on Admission:
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth once a day
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth at
bedtime
FINASTERIDE [PROSCAR] - 5 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 (Two)
puffs inhaled once or twice a day as needed for periods of mild
exacerbation
GABAPENTIN - (Prescribed by Other Provider) - 300 mg Capsule -
1
(One) Capsule(s) by mouth two times a day
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 3 puffs inhaled up to four times a day
and as needed, up to 14 puffs daily
LEVOTHYROXINE [SYNTHROID] - 100 mcg Tablet - 1 (One) Tablet(s)
by
mouth once a day brand name only, medically necessary. No
substitutions - No Substitution
LISINOPRIL - (Prescribed by Other Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) - 5
mg Tablet - 2 Tablet(s) by mouth daily
OXYGEN - - 2 L/min at night
SODIUM CHLORIDE - (Prescribed by Other Provider: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]) - 0.9 % Solution for Nebulization - 1 (One) 3ml(s)
inhaled via nebulizaiton twice a day in this pt with COPD as
needed
.
Medications - OTC
ASPIRIN [ENTERIC COATED ASPIRIN] - (Dose adjustment - no new
Rx)
- 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth
once a day
HYDROCOLLOID DRESSING [DUODERM CGF DRESSING] - 4" X 4" Bandage -
apply to area on buttock every 2-3 days apply to area on buttock
and change every 2-3 days
NEBULIZER & COMPRESSOR FOR NEB - Device - Use to aerosolize 3
ml of saline into permanent tracheostomy stoma twice a day in
this pt with COPD
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
Completed by:[**2199-3-26**]
ICD9 Codes: 486, 5070, 5849, 0389, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6759
} | Medical Text: Admission Date: [**2109-11-13**] Discharge Date: [**2109-11-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a [**Age over 90 **] yo Asian male from NH with multiple medical problems
who presents with shortness of breath and hypoxia. Per NH
records and family patient had developed cold-like symptoms [**2-22**]
days ago. He had a nasal/sinus congestion, cough with yellow
sputum, and increasing lethargy. Today at NH he was noted to
have PNA on CXR. He was started on Levo/Flagyl but had not
received any dosages. He was then seen in the afternoon by his
family who found him SOB, gurgling, and disoriented. At this
time his O2 sats were noted to be in the 60-70 range. Therefore
family asked that the patient be sent to the hospital.
.
Pt is currently pain free, denies any abd pain, chest pain,
diarrhea, nausea, vomiting.
.
In the ED he was found to be hypoxic with O2 sat of 79% on RA.
He was given combivent with minimal improvement and placed on
NRB. His lactate was found to be 7.4 and after 3L of fluid came
down to 2.4. He was given levofloxacin and clindamycin in the
ED.
Past Medical History:
PMH:
Hypothyroid
Dementia
A.fib
h/o CVA
BPH
Depression
Dysphagia
CHF- EF 30%
CRI- Baseline cr 1.7
Anemia
h/o bilateral renal stones(uric acid)
h/o GIB (duodenal/gastric ulcers)
Social History:
Currently lives in a NH. Per old records no ETOH/tobacco use.
Family History:
NC
Physical Exam:
PE
T 97 BP 97/50 [**Last Name (un) **] 69 HR 88 RR 20 O2sats 96% 70% Shovel
Gen: Awake, following commands, A&O times 2(did not know date)
HEENT: Unequal pupils, both reactive to light Lt 5mm Rt 3mm,
EOMI, dry mm, anicteric
Neck: no JVD
Lungs: Signficant upper airway sounds, gurgling, bilateral
basilar crackles
Heart: Irregularly, irregular
Abd: Soft, NT, ND hypoactive BS, + abd scar
Ext: No edema, cyanosis
Neuro: A& O times 2, CN 2-12 intact, strength 5/5 bilaterally in
UE/LE
Pertinent Results:
SPUTUM GRAM STAIN (Final [**2109-11-14**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final [**2109-11-16**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH.
.
CXR: [**2109-11-13**]:
IMPRESSION: Development of bilateral pulmonary opacities. The
differential includes multifocal pneumonia versus atypical
pattern of CHF, given underlying emphysema.
.
ECG: Afib at 81, LAD, no ST/T wave changes
.
ECHO '[**06**]- Conclusions:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is moderately dilated. There
is mild symmetric left ventricular hypertrophy with normal
cavity size. There is moderate global left ventricular
hypokinesis. No masses or thrombi are seen in the left
ventricle. The right ventricular cavity is dilated with moderate
global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
not stenotic. Mild to moderate ([**12-23**]+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Biventricular hypokinesis. Moderate-severe mitral
regurgitation. Pulmonary artery systolic hypertension.
Moderate-severe tricuspid regurgitation.
.
[**2109-11-13**] 05:30PM CK-MB-4 cTropnT-0.04* proBNP-[**Numeric Identifier 14891**]*
[**2109-11-13**] 11:39PM ART PO2-299* PCO2-40 PH-7.34* TOTAL CO2-23
BASE XS--3
[**2109-11-13**] 11:39PM LACTATE-4.7*
[**2109-11-13**] 06:06PM LACTATE-7.4*
[**2109-11-13**] 05:30PM GLUCOSE-94 UREA N-44* CREAT-2.3* SODIUM-145
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-21* ANION GAP-23*
[**2109-11-13**] 05:30PM WBC-10.5 RBC-4.60 HGB-12.7* HCT-40.5 MCV-88
MCH-27.6
.
[**2109-11-18**] Video Swallowing Study: FINDINGS: Oral and pharyngeal
swallowing videofluoroscopy was performed in collaboration with
the speech therapist. Two teaspoons of nectar thick liquid
barium were administered. The patient aspirated both times
without spontaneous coughing. Cued cough was ineffective in
clearing the aspirated material. [**Known lastname **] tuck position did not
prevent aspiration. The exam was subsequently discontinued given
the patient's tenuous respiratory status.
Brief Hospital Course:
In the ED the pt was found to be hypoxic with O2 sat of 79% on
RA. He was given Combivent with minimal improvement and placed
on NRB. CXR on admission showed bilateral lower lung field
infiltrates, and he was given levofloxacin and clindamycin in
the ED. On admission, his lactate was also found to be 7.4 and
after 3L of fluid came down to 2.4.
.
The patient was admitted to the MICU, where Levo/Flagyl were
started for tx of presumptive aspiration pneumonia; Vancomycin
was also started for empiric coverage for MRSA as pt is a
nursing home resident. The pt received aggressive chest
physiotherapy, albuterol/atrovent nebulizers PRN, O2 by face
tent (pt is a mouth breather). Sputum was sent for culture
[**11-14**]. Speech and swallow consult was obtained, and pt was
deemed to be at high risk for aspiration, and pt was made NPO
with NGT recommended for nutrition/hydration.
.
The pt's hypoxia was also thought to be also due in part to CHF,
as pt's EF 30% per [**9-23**] Echo, and BNP [**Numeric Identifier 14892**]. However, pt
appeared intravascularly depleted, with reported poor PO's and
thirst; diuresis was also held given h/o CRI, with increased Cr
on admission thought to be secondary to pre-renal azotemia. Pt
received gentle boluses of NS, then LR (given low bicarbonate)
for intravascular fluid repletion as well as for tx of low UOP.
.
The patient was called out of the ICU to regular inpatient floor
[**11-15**], as his O2 saturation had improved greatly to 95-96% with
blow-by O2 (face tent not on face, lying on chest).
.
HOSPITALIZATION COURSE - REGULAR INPATIENT FLOOR:
1) ID/ PNA:
Pt with initial hypoxia, has transitioned from face tent to O2
by NC, with improved O2 sats on NC to 99-100% on 2L, 93-95%RA;
productive cough improved and ultimately resolved, pt appears
much more comfortable with respiration. Pt was continued on
Vancomycin, Levo, Flagyl until sputum culture came back; as no
evidence of MRSA, Vancomycin was discontinued. He ultimately
completed a 2 week total course of Levaquin and Flagyl, ending
with doses given on [**11-28**]. The patient was never febrile; his
WBC increased transiently to 18, but quickly decreased to WNL.
He was maintained on aspiration precautions, daily chest
physiotherapy for loosening of secretions, and daily
albuterol/atrovent nebulizers. He had negative blood cultures,
UCx negative [**11-18**], [**11-20**], C. diff negative [**11-17**]
.
2) CHF: Pt has EF of 30%, BNP [**Numeric Identifier 14892**]. Pt had evidence of
pulmonary edema on exam with lung crackles and LE edema. He was
started on Lasix 10 mg IV given [**11-18**], pt responded with good
diuresis; he was transitioned to 10 mg per G/J tube on [**11-27**].
His Cr was monitored cloesly and actually normalized while on
diuresis, as he was simultaneously hydrated and given gentle
free water repletion IV for dehydration and intravascular
depletion and hypernatremia, then per G/J tube when placed. He
is not on an ACEI, but one was not started at this time given
ARF.
.
3) ARF:
Pt with baseline creatinine of 1.7 from [**2106**], increased up to
2.3 on admission. Likely pre-renal, as the patient had had poor
PO intake prior to admission, and the pt consistently
complained of thirst and requested water. Urine Na 19, also sign
of sodium avidity. With gentle hydration, the pt's Cr gradually
improved to 1.3
.
4) Afib:
Rate controlled on metoprolol IV - then per G/J tube for rate
control. Metoprolol given w/ holding parameters given low BP.
Pt has not been on anti-coagulation, per NH. Had been on
coumadin in the past, but discontinued [**1-23**] GI bleed
.
5) FEN- NPO given aspiration risk. Pt failed both bedside and
video speech and swallow, and was found to have no gag reflex
and silent aspiration. The patient was NPO w/ aspiration
precautions, then given PPN for a short course prior to
receiving G/J tube placement by IR [**11-26**]. He was started on tube
feeds, Probalance 15 cc-> 55 cc/hr, with 150 cc H20 boluses.
This was increased to 200 cc boluses as UOP slightly decreased
and concentrated on day of discharge. He tolerated tube feeds
with low residuals and no leakage. **NOTE**: G/J tube held in
place w/ T- fasteners sutured to skin - will need these d/c'd in
[**6-30**] days, can be done by RN in NH, just need to cut sutures
holding fasteners in place (NOT sutures holding PEG in place)
The patient also required care for oral hygiene, slightly wet
sponges for oral comfort given thirst.
.
6) Coagulopathy:
- The pt was found to have increased INR from baseline of
1.3-1.6, up to 2.0. The pt had not been on coumadin, per NH.
LFT's normal, no evidence of DIC, normal platelets, possible
nutritional deficiency. He received 3 day courses of Vitamin K
x 2 during admission. INR on discharge was 1.6
.
7) Anemia:
- Uncertain etiology, normal MCV so B12/Folate deficiency
unlikely, pt has h/o GI bleeds, guaiac negative. Hcts were
stable during admission, Hct on day of discharge 34.8.
.
8) Lactate
- Lactate initially elevated on admission, likely due to
dehydration/hypoperfusion, hypoxia, subsequently improved w/
hydration.
.
9) Hypothyroidism
- Levothyroxine per home regimen
.
10) BPH
- Possible traumatic foley placement, with hematuria (now
resolved).
11) Dementia:
- Initially on Doxepin; Zyprexa PRN/HS, however, pt never
demonstrated any agitation or confusion, and did not receive
these medications, and they were discontinued.
12) Peripheral neuropathy:
- Pt seen by neurology consult, initially for evaluation of
limited speech. Found to be able to verbalize with no focal
deficits and normal cranial nerve exam - and that pt does not
like to speak secondary to oral dryness and discomfort.
However, pt found to have a distal sensory polyneuropathy, for
which he had a negative work-up, with negative ESR, A1C, RPR;
only abnormal TSH given hypothyroidism.
- Pt followed by PT during admission, and deemed to be safe to
be discharged. Able to ambulate with assist. Only requires
further PT for mobility.
13) Code- DNR/DNI; confirmed by Dr. [**Last Name (STitle) 1266**] and son [**Name (NI) **]
[**Name (NI) **].
Medications on Admission:
Meds: Furosemide 10mg qday, metoprolol 12.5mg [**Hospital1 **], MVI,
synthroid 50 mcg qday, Vit C, zyrtec 10mg qday, colace,
ranitidine 150mg [**Hospital1 **], doxepin 10mg qhs, tylenol prn, albuterol
nebs, Urocit-K 5meQ qday
.
All: NKDA
Discharge Medications:
1. NURSING ORDER
To RN:
PLEASE D/C FASTENER'S HOLDING G/J TUBE TO SKIN IN 7 DAYS - these
are the barrel shaped pieces of cotton with protruding wires.
Please cut wires, they will recede into abdomen and will be
resorbed. Please do not cut sutures tied directly around G/J
tube! Thank you
2. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
3. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
4. Furosemide 40 mg/5 mL Solution [**Hospital1 **]: Ten (10) mg PO DAILY
(Daily).
5. Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
9. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: One (1) Cap PO DAILY
(Daily).
10. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
11. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed.
12. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
13. Docusate Sodium 150 mg/15 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day) as needed.
14. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Presumed aspiration pneumonia, chronic renal insufficiency/acute
renal failure, dehydration, anemia, atrial fibrillation,
congestive heart failure
Discharge Condition:
Stable
Discharge Instructions:
Please take your medications as written. Call your primary care
physician with worsening cough, chest pain, fever, shortness of
breath, confusion, any other worrisome symptoms
Followup Instructions:
Please call for an appointment to follow up with Dr. [**Last Name (STitle) 1266**]
in [**12-23**] weeks ([**Telephone/Fax (1) 8417**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
Completed by:[**2109-11-28**]
ICD9 Codes: 5070, 5849, 5859, 2760, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6760
} | Medical Text: Admission Date: [**2167-5-14**] Discharge Date: [**2167-5-21**]
Date of Birth: [**2107-6-10**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Propofol Analogues / Cefazolin
Attending:[**Last Name (NamePattern1) 13129**]
Chief Complaint:
left knee pain
Major Surgical or Invasive Procedure:
left total knee replacement/cardiac catheterization
History of Present Illness:
Ms. [**Known lastname 6633**] is a 59 yo woman with PMH significant for asthma
(FEV1 39% predicted, FVC 44% predicted) s/p multiple intubations
after operations, presents after left total knee arthroplasty
for DJD with hypoxia and tachypnea.
.
Initial exam notable for marked prolonged expiratory phase,
limited air movt, and wheezing. She received [**3-27**] albuterol
nebulizer and a racemic epi nebulizer in the PACU with some
improvement of her symptoms. She initially described chest
pressure and once her air movt improved described [**5-3**] SSCP
worse with cough and expiration. OF note, she received 1800 cc
in OR with minimal blood loss.
.
ABG s/p several nebulizer treatments was 7.3/60/108 with RR~25,
HR 70, BP 127/63 and FiO2 60-70% by face mask. EKG notable for
sinus rhythm with significant artifact and no ischemic changes
compared to a prior two weeks old. After several nebulizer
treatments, air movement improved and she was noted to have
crackles to the mid lung fields bilaterally. She was given 40
IV lasix on arrival to the MICU. She has no documented hx of
heart failure. She does have CAD s/p PTCI in [**2165**] and held her
plavix preoperatively.
.
Of note, she had an almost identical episode after her last TKR
in [**2162**] during which she was re-intubated post-op and also had
SSCP which was evaluated with serial cardiac enzymes and
ultimately a dobutamine stress test.
Past Medical History:
1)Asthma/reactive airway disease for the past 15 years with a
history of at least five intubations, with at least two this
year
after minor operations on her right lower extremity.
2)status post-right knee arthroscopy in [**Month (only) 547**] of this year,
which
is complicated by respriatory failure and two days intubation in
the [**Hospital Unit Name 153**] at [**Hospital3 **].
3) Status post-right toe bunionectomy, complicated by a
respiratory failure at [**Hospital 487**] Hospital earlier this year.
4) s/p cardiac catheterization at [**Hospital3 **] with a
question of coronary artery stenting at that time in
approximately [**Month (only) 205**] of this year.
5)anemia
6)hyperlipidemia
7)hepatic steatosis noted on imaging
8)hypertension, with a history of hypertensive urgency in [**Month (only) 547**]
of this year, an echo in [**Month (only) 547**] of this year showed an EF of 65%
and 1 to 2+ MR.
9) status post-hysterectomy.
10)Status post- appendectomy
11)Status post-perforated colon? cancer, requiring ostomy in the
past.
Social History:
per OMR: She lives in [**Hospital1 487**], alone. She is retired. She has a
30 pack year history of smoking, which she quit smoking five
years ago. She had started smoking at the age of 15. She denies
alcohol or elicit drug use. She has no history of asbestos
exposure.
Family History:
per OMR: Non-significant for any pulmonary problems. [**Name (NI) **] father
did have an MI at age 60.
.
Physical Exam:
well appearing, well nourished 59 year old female
alert and oriented
no acute distress
RLE:
-dressing-c/d/i
-incision-c/d/i
-+AT, FHL, [**Last Name (un) 938**]
-SILT
-brisk cap refill
-calf-soft, nontender
-NVI distally
Discharge Physical Exam:
Temp: 99.4 BP: 80-110/40-80 HR 70-80's 18 96% RA.
Gen: NAD, not-uncomfortable, able to lay on her side
General: MMM, CVL site on R neck, C/D/I. Bandage in place
non-tender to palpation
Res: Decreased air movement bilaterally, but no wheezes,
crackles or rhonchi
CV: Normal S1, and S2, with II/VI systolic murmur at LSB,
radiating to LUSB.
ABD: Soft, NT, ND +BS, no rebound or guarding
Ext: L knee, sutures in place, DP2+, PT 2+ bilaterally, with L
pre-tibial edema, and L thigh ecchymosis and L thigh edema. No
point tenderness over the knee. R leg without edema. Her LUE
had a PICC line that was c/d/i without any erythema.
Pertinent Results:
Admission:
[**2167-5-14**] 08:30PM BLOOD WBC-16.9*# RBC-3.95* Hgb-12.0 Hct-35.6*
MCV-90 MCH-30.4 MCHC-33.7 RDW-11.9 Plt Ct-177
[**2167-5-15**] 01:41AM BLOOD Neuts-91.8* Lymphs-5.3* Monos-2.6 Eos-0.1
Baso-0.1
[**2167-5-14**] 08:30PM BLOOD Plt Ct-177
[**2167-5-14**] 08:30PM BLOOD Glucose-244* UreaN-19 Creat-1.0 Na-141
K-3.5 Cl-102 HCO3-29 AnGap-14
[**2167-5-14**] 08:30PM BLOOD CK(CPK)-66
[**2167-5-14**] 08:30PM BLOOD CK-MB-2 cTropnT-<0.01
[**2167-5-14**] 08:30PM BLOOD Calcium-8.7 Phos-4.0 Mg-2.0
[**2167-5-17**] 05:55AM BLOOD calTIBC-267 Ferritn-167* TRF-205
[**2167-5-15**] 01:41AM BLOOD %HbA1c-6.9* eAG-151*
.
Imaging:
.
ECHO showed: mildly dilated L atrium, with normal left
ventricular wall thicknesses and size. Left ventricular systolic
function is hyperdynamic (EF 80%). There is a mild resting left
ventricular outflow tract obstruction. RV wnl. Study is
inadequate to exclude significant aortic valve stenosis.
Moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated single vessel coronary artery disease. The first
diagonal
contained a 60% lesion that appeared to be hazy on angiography.
The
right coronary, circumflex and left main were all free of
angiographically apparent flow limiting disease. The circumflex
arose
from a separate origin in the right coronary cusp.
2. The patient had a hazy first diagonal lesion. Her pain was
ongoing
and was made worse during balloon inflation. It was better after
stenting.
FINAL DIAGNOSIS:
1. Successful BMS to diagonal lesion
2. Single vessel coronary artery disease
3. Normal systemic blood pressures.
.
CXR (ICU):FINDINGS: In comparison with the study of [**4-30**], there
is ill-defined opacification at the left base silhouetting the
hemidiaphragm and descending aorta. Although this could merely
reflect atelectasis, in the appropriate clinical setting, an
infectious process must be considered.
.
Right IJ catheter extends to the lower portion of the SVC. No
evidence of
vascular congestion.
.
CT Knee: Large left knee hemarthrosis. Additional focus of
hyperdensity
seen around the deep sutures may represent hematoma as well.
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for total knee replacement.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following acute
hypoxic respiratory failure with a Transfer to [**Hospital Unit Name 153**] for acute
respiratory distress which was multifactorial: asthma
exacerbation and possible flash pulmonary edema.
[**Hospital Unit Name 13533**]:
Patient was transferred to [**Hospital Unit Name 153**] given concern for increased work
of breathing after extubation in PACU. Initial exam was notable
for poor air movement and bilateral wheezing. Air movement
improved with multiple nebulizer treatments and lung exam then
revealed wheezing. Patient was treated with Albuterol and
Ipratropium nebs in the [**Hospital Unit Name 153**] and was weaned to NC. She was also
given IV Lasix for concern for volume overload contributing to
her symptoms. Her respiratory distress was thought to be most
likely due to bronchospasm from ETT, given hx of asthma and
repeated history of respiratory distress after similar episodes.
However, she was also given a short steroid taper for potential
asthma exacerbation.
.
Interestingly, the patient had elevated lactate in
post-operative setting, attributed to albuterol. This trended
down without intervention.
.
Of note, the patient had chest pain on night of admission, as
well as two episodes the following day. During all episodes,
she had normal EKG and serial cardiac enzymes were negative.
She was treated with sublingual nitro without response, but pain
dissipated with morphine. Cardiology was consulted given past
history and outpatient symptoms consistent with increasing
anginal pain. Cardiology elected to cath her, and thus, at the
time of discharge from the ICU, she was transferred to the
medicine service.
.
Upon arrival to the medicine/cardiology service the patient was
chest pain free. Her case was discussed with the interventional
cardiologist who felt she should undergo cardiac catheterization
for crescendo angina. The night before catheterization she was
trasnsitioned from subcutaneous lovenox to heparin drip for
anti-coagulation. At that time she did not report any knee
pain. Subsequently she went to Catheterization which revealed
CAD (see report for specific details, in brief: she had single
vessel CAD and a BMS was placed to a diagonal lesion). Post
Cath she began to complain of increasing knee pain and chest
pain. A CT of her R knee showed a hematoma and her case was
discussed with Orthopedics. The orthopaedics service
recommended aggressive pain control, compression, ice,
compression stockings, PCM, but did not recommend a surgical
intervention. She was also restarted on lovenox daily for DVT
prophylaxis. Her knee pain persisted despite escalating dose of
short acting PO narcotics, until long acting narcotics were
initiated. Additionally, her chest pain resolved, after
administration of pain medication, and serial ECG's did not
demonstrate in-stent thrombosis. She also had serial cardiac
enzymes which remained normal. Of note, at the time of her
chest pain she had a drop in her Hgb which was believed to be
secondary to the development of her large knee hematoma. She
was transfused 1 unit of PRBC, and her HgB remained stable. She
also had a persistent leukocytosis that was attributed initially
to her steroid taper, and then to a stress response after the
development of the hematoma. Prior to discharge, and her pain
was well controlled. She was kept on Lantus and an ISS for
hyperglycemia which was secondary to DMII given her HgBAIC was
6.9%.
Transitional Issues:
- Patient was discharged on Post-Op day #7.
- Follow up hemoglobin/hematocrit
- Blood pressure: Her systolic pressure in the morning after
administration of long acting nitrates was in the morning was in
the mid 80's. She was asymptomatic. She may need titration of
her blood pressure medications. Her beta blocker was not
increased due to concern that she had a bronchospasm post cath.
Her beta blocker may need to be titrated as an outpatient.
- Anticoagulation:
1-3 weeks post discharge: ASA 325 daily, Plavix 75 daily,
Lovenox 40 mg subq daily
4-6 weeks post discharge: ASA 325 [**Hospital1 **], Plavix 75 daily
After 7 weeks post discharge: ASA 325 daily, Plavix daily
- The patient has had a low grade fever 99 for several days
prior to discharge. She has been cultured without evidence of
infection. Her CXR does not show a PNA. If the patient spikes
please re-culture.
Outpatient Follow up:
1) PCP: [**Name10 (NameIs) **] need to help start oral medications for her new
diagnosis of DMII, follow up blood cultures
2) Cardiologist: Will need to up-titrate her beta-blocker in the
setting of her recent stent placement and progressive angina.
3) Orthopedics
Patient was discharged to:
Extended Care Facility: Wood Mill Care and Rehab Ctr
Medications on Admission:
albuterol, amlodipine, ASA, atrovent, claritin, colace, flovent,
metoprolol, nitrostat, restasis, hydrocortisone cream, percocet,
plavix, pravachol, serevent
Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 3 weeks: Take until [**2167-6-11**].
Please take your ASA and plavix.
Disp:*21 syringe* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
Disp:*60 Tablet(s)* Refills:*2*
4. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice
a day for 3 weeks: AFTER completing all lovenox injections,
please take as directed with food. once you have finished the 3
weeks of twice daily aspirin, you may resume your preoperative
regimen of plavix 75mg and aspirin 81mg daily.
Disp:*42 Tablet(s)* Refills:*0*
5. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
8. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
9. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
11. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please take while taking your lovenox injections. Once you
finish your lovenox injections, please take [**Hospital1 **] as intructed for
3 weeks and then resume once weekly dosing.
13. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day).
14. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. insulin glargine 100 unit/mL Cartridge Sig: One (1) variable
Subcutaneous at bedtime: Please see attached ISS.
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
18. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
19. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
20. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
21. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
22. lisinopril 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
23. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2)
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
24. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
25. Flovent Diskus 250 mcg/Actuation Disk with Device Sig: Two
(2) Inhalation twice a day.
26. salmeterol 50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
27. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
Wood Mill Care and Rehab Ctr
Discharge Diagnosis:
left knee osteoarthritis
CAD s/p stent
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed (see
below). Please take Lovenox as prescribed, plavix, and aspirin
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out by the visiting nurse (VNA) or rehab
facility two weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for three (3)
weeks to help prevent deep vein thrombosis (blood clots). After
completing the lovenox, please take Aspirin 325mg TWICE daily
for an additional three weeks. Once you have completed the 3
weeks of aspirin therapy twice a day, you may resume your
pre-operative regimen of plavix 75mg and aspirin 325 mg daily.
[**Male First Name (un) **] STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. ROM as tolerated. No strenuous exercise or heavy
lifting until follow up appointment. Mobilize.
13. You were given a new diagnosis of DM during your hospital
stay, and you will be given insulin at rehab, but should be
transitioned to metformin before you go home.
14. The pain in your R knee is from a hematoma that developed
after you under went cardiac catheterization. This will
resolved after a few weeks.
The following medication changes where made:
DO NOT STOP: Aspirin daily or [**Hospital1 **] (please see medication
worksheet), Plavix, or Lovenox (only three weeks)
ADDED: Imdur, senna, bisacodyl, morphine SR, dilaudid, alum-mag
hydroxide-simeth, albuterol nebs PRN, ipratropium nebs PRN,
lisinopril, insulin, acetaminophen, multivitamin, zofran
CHANGED: Metoprolol, Aspirin
STOPPED: percocet
Followup Instructions:
-Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2167-6-12**] 11:00
-Please have the rehab facility call your PCP prior to discharge
to set up an appointment regarding your new diagnosis of DM.
-Please have the rehab facility call your cardiologist prior to
discharge to arrange an appointment regarding your coronary
artery disease. You had a bare metal stent placed in your heart
to help with your symptoms of chest pain.
Completed by:[**2167-5-27**]
ICD9 Codes: 4111, 2762, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6761
} | Medical Text: Admission Date: [**2195-10-19**] Discharge Date: [**2195-10-22**]
Date of Birth: [**2152-8-22**] Sex: M
Service: MEDICINE
Allergies:
Tegretol / Valproic Acid And Derivatives
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
endotrachial intubation
suture of right brow laceration
reduction of nasal fractures
History of Present Illness:
43 yo man with h/o epilepsy, psychogenic polydipsia, mental
retardation with multiple nasal fractures s/p fall who was
electively intubated in the ED due to agitation.
.
Per ED notes, the patient was running to catch a bus, fell down
and hit his face. Upon presentation to the ED, initial VS: 88 18
96%. He complained of severe facial pain and had multiple facial
lacerations. CT scan sinus/head/spine revealed multiple
communited nasal and maxillofacial fractures; no spine fx or
acute intracranial event.
.
Throughout ED course, he was agitated and received in total 25mg
halidol, 10mg ativan. He transiently desaturated to 88% on 100%
NRB with concern for possible aspiration event. Due to continued
agitation, he was electively intubated. Plastic surgery was
consulted and repaired lacerations, reduced fractures. He also
received levofloxacin 500mg x 1 for possible aspiration
pneumonia
Past Medical History:
- Developmental delay / Mental Retardation
- Seizure Disorder
- Mood disorder (? type)
- Hypertension
- Chronic Hyponatremia
- Left ventricular hypertrophy
- History of pulmonary edema and ascites
- Dyslipidemia
- Obstructive sleep apnea, unable to tolerate CPAP
Social History:
Unable to live independently, non-smoker. No drug use.
Independent in basic activities of daily living. Has a guardian
responsible for health care decisions
Attends a day program, but the program is not very active,
patient probably sits most of the day
Family History:
unknown to staff, unable to obtain from patient
Physical Exam:
VS: Temp: afebrile BP: 129/84 HR: 93 RR: 12 O2sat: 100%
GEN: intubated, responds to sternal rub
HEENT: b/l orbital ecchymoses, nasal splint in place; right brow
laceration with sutures c/d/i; midface stable to palpation; poor
dentition with ET tube in place
NECK: in c-spine collar
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: b/l knee abrasions, left elbow abrasion
NEURO:PERRL, face symmetric; moves all extremities
Pertinent Results:
Labs:
[**2195-10-19**] 10:00AM WBC-10.9 RBC-5.04 HGB-15.8 HCT-45.9 MCV-91
MCH-31.3 MCHC-34.4 RDW-14.0
[**2195-10-19**] 10:00AM NEUTS-81.9* LYMPHS-11.4* MONOS-5.1 EOS-0.6
BASOS-0.9
[**2195-10-19**] 10:00AM PLT COUNT-170
[**2195-10-19**] 10:00AM PT-12.6 PTT-26.0 INR(PT)-1.1
[**2195-10-19**] 10:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2195-10-19**] 10:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2195-10-19**] 07:40PM TYPE-ART TEMP-39.0 O2-100 PO2-252* PCO2-48*
PH-7.40 TOTAL CO2-31* BASE XS-4 AADO2-431 REQ O2-73
INTUBATED-INTUBATED
[**2195-10-19**] 10:00AM GLUCOSE-135* UREA N-19 CREAT-0.9 SODIUM-141
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-30 ANION GAP-14
Imaging:
MRI cervical spine:
Study is limited due to patient motion. Within this limitation,
there is no definite abnormal cord signal identified.
Specifically, there is no evidence of cord contusion or
extra-axial fluid collection to suggest epidural hematoma. There
is no abnormal STIR signal identified on sagittal imaging to
suggest ligamentous injury or acute fracture. Small amount of
increased fluid signal anterior to the vertebral bodies likely
represents fluid within the nasal and oropharynx due to recent
intubation rather than prevertebral or retropharyngeal edema.
This exam was not tailored for degenerative changes, although
there is no significant canal stenosis identified at any level.
IMPRESSION: No evidence of ligamentous injury or cord injury
identified
CT maxillofacial/ mandible/ sinus: B/L Nasal bone fractures with
postero-medial displacement of right sided distal fracture
fragment. Comminuted fracture of the nasal septum with right
sided displacement of fracture fragments. Significant sinus
disease.
CT spine:
No cervical spine fractures. Endotrachial and OG tubes. B/L lung
consolidations consistent with aspiration
CT head w/o contrast:
No hemorrhage, large territorial infarct, or mass effect. Nasal
bone
fractures as described in facial CT.
CXR:
Single AP supine portable view of the chest is obtained.
Endotracheal tube is in place with its tip located approximately
3.4 cm above the carina. An NG tube is seen extending into the
left upper quadrant. The lungs appear clear despite low lung
volumes. Cardiomediastinal silhouette appears grossly
unremarkable.
IMPRESSION: Adequate position of the ET and NG tubes
Brief Hospital Course:
43 yo man with h/o epilepsy, psychogenic polydipsia, mental
retardation with multiple nasal fractures s/p fall who was
electively intubated in the ED due to agitation
Nasal and maxillofacial fractures: Presented with communited
fractures of nasal septum that were reduced by plastic surgery
in the emergency department. A nasal splint was alos placed and
keept in place until [**10-22**]. Per plastic surgery
recommendations, patient was placed on 7 day course of augmentin
to end [**10-26**]. Maintained sinus precautions i.e. nothing by
straw, avoidance of nose blowing, sneezing with open mouth,
throughout hospitalization. Follow up arranged with plastic
surgery as an outpatient.
status post mechanical fall: Presented following a mechanical
fall with multiple lacerations and nasal fractures (see above).
Patient was placed in a cervical collar until c-spine was
cleared by CT spine and MRI (performed due to inability to
clinically clear given underlying mental retardation and
sedating medication side effects). Intubated in emergency
department due to agitation for laceration repair and reduction
of fractures. Trauma team followed patient with secondary and
tertiary survey and determined no further evidence of injury.
status post intubation: As above, patient intubated in emergency
department mostly due to agitation. Reportedly had episode of
hypoxia to 88% on 100% NRB in the ED in the setting of
agitation. Although there was initial concern that this may
have represented aspiration of oropharyngeal secretions, no
clear infiltrate was seen CXR and vent settings were able to be
weaned quickly. Sputum cx did grow GPC in chains and clusters
and patient was continued on augmentin per plastic surgery
recommendations for laceration/ nasal fractures. Patient was
extubated without difficulty and had no further oxygen
requirements.
Mood disorder: per ED, agitated and violent, requiring multiple
sedatives and eventual intubation. Patient was restarted on all
of his home medications (risperidol was substituted for home
paliperidone while intubated due to inability to give down
orogastric tube). Following extubation, patient required no
further doses of ativan or halidol.
Seizure d/o: stable, continued on home lamotrigine and
gabapentin
Medications on Admission:
gabapentin 1600mg TID
- dilantin 130mg qam, 160mg qpm
- nadolol 240mg qam
- lamotrigine 75mg [**Hospital1 **]
- furosemide 40mg qam
- MVI
- docusate 100mg [**Hospital1 **]
- senna 8.6mg qpm
- calcium/ vitamin D
- olanzipine 40mg QHS
- cogentin .5mg [**Hospital1 **]
- paliperidone 9mg qam
chlorhexidine, sodium fluoride, debrox
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. nadolol 80 mg Tablet Sig: Three (3) Tablet PO QAM (once a day
(in the morning)).
5. benztropine 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO twice a
day.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. paliperidone 9 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 days.
Disp:*9 Tablet(s)* Refills:*0*
10. gabapentin 400 mg Capsule Sig: Four (4) Capsule PO TID (3
times a day).
11. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**3-31**]
hours as needed for pain: do not exceed 4 grams acetaminophen
daily. Do not drink or drive with this medication .
Disp:*15 Tablet(s)* Refills:*0*
12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-31**]
hours as needed for pain: do not exceed 4 grams daily.
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a
day.
15. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
three times a day.
16. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO twice a day.
17. Dilantin 30 mg Capsule Sig: One (1) Capsule PO twice a day.
18. Dilantin 30 mg Capsule Sig: One (1) Capsule PO Qpm.
Discharge Disposition:
Home
Discharge Diagnosis:
Communited nasal fractures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital following a mechanical fall
with a broken nose and several cuts that needed to be sutured.
In the emergency department you were very agitated, probably
because you were in pain. To fix the fractured bones and repair
the cuts, you were given sedation and intubated. Your cuts were
sutured and your fractures reduced. You had a CT scan and MRI
of your cervical spine to ensure that you had not injured your
neck: these were normal. You were able to have the breathing
tube removed.
You will need to take antibiotics for a total of 7 days to
protect your cuts from becoming infected. You will need to
follow up with the plastic surgeons on Friday (see below).
Prior to seeing the plastic surgeons make sure that you keep
your wounds clean and dry, apply bacitracin ointment to your
wounds and do NOT drink through a straw or blow your nose.
Please make the following changes to your medications:
- please take augmentin 875mg twice daily for a total of 7 days
(last day [**2195-10-26**])
Please take your other medications as previously prescribed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22438**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2196-1-5**] 10:00
Please follow up with your primary care provider [**Last Name (NamePattern4) **] [**12-27**] weeks
ICD9 Codes: 5070, 4019, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6762
} | Medical Text: Admission Date: [**2146-6-4**] Discharge Date: [**2146-7-11**]
Date of Birth: [**2066-7-17**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Perforated duodenum s/p laparoscopic cholecystectomy in OSH
Major Surgical or Invasive Procedure:
[**2146-6-4**]:
1. Exploratory laparotomy with repair of enterotomy in the
jejunum.
2. Placement of lateral duodenostomy tube for duodenal
perforation.
3. Placement of feeding jejunostomy tube and drainage.
.
[**2146-6-10**]: Placement of a 10Fr internal-external biliary drain
through the right posterior biliary tree.
.
[**2146-6-16**]: Replacement of 10 French internal-external biliary
drainage catheter.
History of Present Illness:
79yM s/p laparoscopic cholecystectomy [**2146-6-2**] @ [**Hospital3 **]
with intraoperative drain placement for bleeding and mild bile
spillage who developed bilious drainage on POD1. He was sent to
[**Hospital1 18**] from [**Hospital1 392**] for ERCP and was found to have a duct of
Luschka leak and is now s/p CBD stent. He returned to [**Hospital1 **] [**2146-6-3**] in the evening and began to develop some
vague abdominal pain. He also became distended. He was
tachycardic to HR: 130's overnight. A CXR this AM showed free
air and a subsequent CTscan showed free extravasation of
contrast into the gallbladder fossa likely from the duodenal
stump as well as a large amount of free air, pneumomediastinum
and subcutaneous emphysema.
Upon transfer to the ICU, he continued to complain of diffuse
abdominal pain. He was tachycardic upon presentation to the
TSICU and his BP was stable from 107-110 systolic without
vasopressors. He had an NGT in place with bilious output and a
foley in place with 40cc over 2 hours.
Past Medical History:
Past Medical History: HTN, prostate CA, duodenal ulcer
Past Surgical History: partial gastrectomy with BII
reconstruction, prostatectomy with bilateral inguinal node
dissection, laparoscopic cholecystectomy
Social History:
Lives at home with wife who has alzheimer's, and is retired. No
EtOH, no tobacco x 20yrs
Family History:
non-contributory
Physical Exam:
At time of discharge:
Vitals: T 98.2, HR 68, BP 112/55, RR 26, O2sat 96%RA
General: Appears well, in no acute distress, alert and oriented
to person and place but not to time. Obeys simple commands,
awakens and responds to voice and touch.
Cardiac: RRR, holosystolic murmur.
Pulmonary: Diminished breath sounds in the bilateral lung bases,
no rales or rhonchi appreciated. Otherwise, the rest of the lung
fields were CTAB.
Abdomen: 3 drains in place: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube connected to a JP bulb,
a T-tube draining the duodenum connected to a JP bulb, and a
PTBD drain. All three drains are putting out green, billous
appearing discharge. Abdomen was soft, non-tender,
non-distended. Drain sites appeared C/D/I, no erythema or
discharge. Patient has a small wound open to air inferior to the
umbilicus which is healing well. There is no erythema,
discharge, or warmth surrounding the wound. Patient has +BS.
Skin: Multiple areas of skin breakdown due to tape on abdomen
and neck
Ext: No lower extremity edema
Pertinent Results:
[**2146-6-13**] ABD CT:
IMPRESSION:
1. Small 1.4 x 3.7 cm focus of peri-hepatic fluid along the
course of the
duodenostomy tube.
2. Small 2 x 2 x 3cm fluid collection interposed between colon
and duodenal stump.
3. Small bilateral pleural effusions and atelectasis.
4. Mild wall thickening of pelvic loops of ileum, cannot exclude
enteritis.
5. Subcentimeter left thyroid lobe hypodensities. Consider
thyroid
ultrasound if clinically appropriate.
6. Indeterminate left renal lesion
[**2146-6-15**] PA/LAT:
Interval resolution of pulmonary edema with mild persistent
bibasilar atelectasis and small right pleural effusion.
[**2146-6-15**] LENI: No evidence of deep vein thrombosis in either the
right or left lower extremity.
[**2146-6-15**] CTA CHEST:
IMPRESSION:
1. Apart from an equivocal filling defect in the left lower lobe
superior
segmental branch there are no filling defects in the main, lobar
or segmental branches concerning for pulmonary embolism.
2. Mild paraseptal emphysema.
3. Mild-to-moderate non-serous right pleural effusion
accompanying adjacent atelectasis.
4. Bilateral pleural plaques with small nodular calcification
suggest prior asbestos exposure.
5. Extensive esophagotracheal aspiration or retained
tracheobronchial
secretion.
[**2146-6-20**] G/GJ/GI TUBE CHECK:
1. Contrast filling the [**Doctor Last Name 406**] drain is worrisome for a leak from
the
duodenum.
2. Duodenostomy tube appears to be in satisfactory position and
unchanged
from prior.
[**2146-6-21**] ECHO:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is small.
Left ventricular systolic function is hyperdynamic (EF 80%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular free wall
is hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. The aortic valve is not well
seen. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. Mitral
stenosis is present, most likely secondary to severe annular
calcification. Tricuspid regurgitation is present but cannot be
quantified. There is no pericardial effusion.
MICRO:
[**2146-6-20**] PERITONEAL FLUID
ENTEROBACTER CLOACAE COMPLEX - Resistent to Zosyn, sensitive to
cipro
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA - Sensitive to Zosyn
ACINETOBACTER BAUMANNII - Sensitive to Zosyn, sensitive to cipro
[**2146-6-25**] Sputum Cx
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
GRAM NEGATIVE ROD #3. RARE GROWTH.
YEAST. SPARSE GROWTH.
Diagnostic:
TTE [**6-21**]- LVEF 80%, mild symmetric LVH, PCWP>18mmHg, RV dilation
with depressed free wall contractility, mitral stenosis present
& is most likely secondary to severe annular calcification.
[**2146-6-25**] CT Abdomen
IMPRESSION:
1. Interval decrease in size of the right upper quadrant fluid
loculation
adjacent to the duodenostomy tube; no discrete wall seen
surrounding this
fluid.
2. Bilateral pleural effusions, slightly increased on the left.
3. Multiple small calculi in the right kidney, the largest
measures 6 mm.
4. Extensive atherosclerotic calcification in the abdominal
aorta and
calcification of the mitral valve.
5. Bilateral pleural plaques consistent with prior asbestos
exposure.
[**2146-6-25**] CT Head
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema,
large
vessel territorial infarction, shift of normally midline
structures. The
ventricles and sulci are prominent, likely representing
age-related cortical atrophy. Mild bilateral periventricular
white matter hypodensities are identified and likely sequela of
chronic small vessel ischemic disease. No acute fractures are
identified. Mucosal thickening is noted in bilateral maxillary
sinuses as well as the sphenoidal sinuses. Mucosal thickening is
also noted in the right mastoid air cells.
[**2146-7-6**] EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of moderate diffuse background slowing and frequent runs
of frontal intermittent rhythmic delta activity. These findings
are indicative of moderate diffuse cerebral dysfunction which is
etiologically non-specific. There is focal slowing over the left
hemisphere indicative of more prominent focal dysfunction in
this region. No epileptiform discharges or electrographic
seizures are present. Compared to the prior day's recording,
there is no significant change.
[**2146-7-8**] CXR
As compared to the previous radiograph, there is no relevant
change. Mild elevation of the right hemidiaphragm, borderline
size of the
cardiac silhouette without pulmonary edema. Unchanged left PICC
line. No
larger pleural effusions. No pneumothorax. No evidence of
pneumonia.
Brief Hospital Course:
The patient was transferred emergently from [**Hospital3 5365**] on
[**2146-6-4**] for duodenal perforation and bile leak s/p laparoscopic
cholecystectomy. He was taken immediately to the OR where he
underwent exploratory laparotomy with placement of lateral
duodenostomy tube for duodenal perforation, repair of enterotomy
in the jejunum, and placement of feeding J-tube. He also had an
NG tube in place, as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain placed
intraoperatively and a JP drain from his cholecystectomy at the
outside hospital. He was transferred back to the ICU intubated
and sedated. In the morning he was weaned from the ventilator
and extubated on [**2146-6-5**]. His pain was initially controlled with
IV dilaudid, however he had confusion and agitation and all
narcotics and benzos were stopped. He required restraints and
intermittent haldol to protect his lines. He remained agitated
the next night and pulled out his NG tube, which was replaced on
[**2146-6-6**]. He remained in the ICU for close monitoring. Tube feeds
were started through his J-tube and advanced to goal. Overnight
he had an episode of tachypnea and respiratory distress for
which he received IV lasix with appropriate diuresis. He also
received nebulizer treatments and with improved respiration.
During this time his creatinine increased to 1.3 and no further
diuresis was performed at this time. He continued to be
intermittently confused and on [**6-8**] the geriatric surgery service
was consulted and felt he was having delirium. He was changed to
seroquel as necessary for agitation given his history of
possible Parkinson's disease. His respiratory status was stable
and he was transferred to a regular floor bed.
On [**6-9**] increased biliary drainage was noted from the [**Doctor Last Name **] drain
near the duodenostomy tube, while decreased drainage was
observed from the duodenostomy tube. It was felt there was a
continued bile leak and on [**6-10**] he underwent placement of
percutaneous transhepatic biliary drainage catheter by IR. This
was performed under general anesthesia and the patient tolerated
it well. He was returned to the floor. His foley catheter was
removed and a condom cath was placed.
on [**6-11**] the NG tube was removed and the patient was out of bed to
chair with assistance. He continued to have intermittent
confusion but was not agitated. His creatinine increased to 1.3
with an eventual maximum of 1.5 and his lisinopril was held due
to concern for kidney injury. He was seen by PT who recommended
rehab when ready for discharge.
on [**6-13**] the patient was afebrile but had a rising WBC. He had a
CT torso with IV and po contrast that showed several small fluid
collections believed to be consistent with normal post-operative
changes.
on [**6-14**] he had a speech and swallow evaluation in which he was
cleared for nectar thick liquids and pureed solids, although he
was unable to take in much by mouth. His labs were checked and
his WBC was noted to be increasing.
on [**6-15**] he continued to be tachypneic with respiratory rate in
the high 20s-30s. A blood gas showed respiratory alkalosis. He
underwent lower extremity ultrasound studies which were negative
for DVT, and a CTA was negative for pulmonary embolism. He
remained hemodynamically stable.
on [**6-16**] the patient's T-tube continued to have low output while
the [**Doctor Last Name **] drain output had increased. The PTC drain output
continued to be appropriate. He underwent a repeat cholangiogram
which again showed a bile leak from an accessory bile duct. No
leak was observed from the cystic duct stump.
on [**6-17**] the patient had longer periods of clarity. His labs were
checked and his WBC decreased.
on [**6-18**] the bilious output from the PTC drain was returned to
the patient via the J-tube feeds. He continued to have a weak
voice which had not improved significantly over the past several
days. ENT was consulted and reported that his vocal cords moved
symmetrically, but were atrophic. It was felt that his
difficulty with phonation could be due to deconditioning.
[**6-19**] the patient was noticed to have dicreased urine output,
and his Cre increased to 1.8 (1.3 day before). He received 500
cc LR boluses x 2 and his free H2O was increased via J-tube.
Patient was started on 1 to 1 fluid repletions, and his PTBD
output was given back via J-tube.
[**6-20**] Cre up to 2.1, patient was given IV Bicarb. His
respiratory rate remained within 30-36. The patient underwent
T-tube study, which demonstrated leak around t-tube captured by
[**Doctor Last Name 406**] drain.
[**6-21**] Nephrology was consulted for climbing Cre (3.0) and
metabolic acidosis, ATN most like s/t recent contrast
administration. Nephrology recommendations were followed. The
patient underwent cardiac echo, which revealed LVEF 80% and
depressed RV function.
[**6-22**] Pulmonary was consulted for persisent tachypnea, which
thought to be compensatory for metabolic acidosis. The patient's
urine output improved, Cre 3.5. The patient received one unit of
RBC for HCT 22.6. [**Doctor Last Name 406**] fluid gram stain positive for GNRs,
continued Zosyn, Vanc and Fluconazole (renal dose).
[**6-24**] Neurology was consulted for altered mental status,
tachypnea, and new onset acidosis. Patient was transferred to
the ICU and intubated. CT scan of head without contrast revealed
no acute process. CT scan of abdomen revealed interval decrease
in RUQ fluid loculation, seen on previous CT scan.
[**6-27**] His creatinine improved to 2.6, from peak value of 3.8.
Patient was taken off of zosyn and cipro and switched to
levofloxacin instead, as all three speciated organisms from
[**Doctor Last Name **]-tube fluid were shown to be sensitive to levofloxacin.
[**6-30**] Patient was extubated.
[**7-1**] Patient's stool output remained high (~2L) a day, lomotil,
tincture of opium, and imodium were initiated.
[**7-2**] Patient received a PICC line.
[**7-3**] Due to high stool output, rather than re-feed his bile
output through his J-tube, he was replenished with 1cc LR per IV
per cc bile output. The patient received [**Hospital1 **] BMP's to monitor
his electrolyte status. His stool output responded to this
change, resulting in a daily stool output of <300cc.
[**7-4**] His CXR's suggested that he might be fluid overloaded, and
he continued to be tachypneic. Thus, he was gently diuresed to
decrease his net fluid balance.
[**7-7**] Patient had a 48-hour EEG which revealed that he was not
suffering from seizures. Patient remained on chest physical
therapy, but nebulized saline and guaifenisin were added to his
regimen in an attempt to improve his respiratory status. He had
a bedside swallow evaluation performed by speech language
pathology - patient failed to pass the swallow test. His
creatinine plateaued at 1.4.
[**7-8**] Patient was weaned off of supplemental oxygen.
[**7-10**] Patient's stool output has decreased to 200cc/day.
[**7-11**] Patient had a high potassium of 5.7 and was given a dose of
kayexelate. The patient's potassium decreased to 5.4. His
tubefeeds were changed to Nepro@55cc/hr due to concern regarding
the high potassium. He was also given a second dose of
kayexelate. Patient was deemed stable and ready for discharge to
a long term care facility.
Medications on Admission:
lisinopril 20 mg
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB., wheeze
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb every six (6)
hours Disp #*120 Unit Refills:*1
2. Aspirin 324 mg PO DAILY
crush 4 81mg tablets administer through j tube
RX *aspirin 81 mg 4 Tablet(s) Jtube once a day Disp #*120 Tablet
Refills:*1
3. Culturelle *NF* (lactobacillus rham.
GG-inulin;<br>lactobacillus rhamnosus GG) 10 billion cell Oral
qd Reason for Ordering: increased stool output despite
modifications of tube feeding, addition of opium, lomotil
RX *Probiotic 10 billion cell 1 Capsule(s) Jtube once a day Disp
#*30 Capsule Refills:*1
4. Guaifenesin 5 mL PO Q6H
RX *guaifenesin 100 mg/5 mL 5 mL Jtube every six (6) hours Disp
#*60 Milliliter Refills:*1
5. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
RX *heparin lock flush 10 unit/mL every six (6) hours Disp #*30
Syringe Refills:*1
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
RX *dextrose 50% in water (D50W) 50 % q15min Disp #*30 Syringe
Refills:*1
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
RX *glucagon (human recombinant) 1 mg q15min Disp #*3 Syringe
Refills:*1
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 Capsule(s) Jtube once a day Disp #*30
Capsule Refills:*1
9. Metoprolol Tartrate 25 mg PO TID
Hold for SBP < 95, HR < 55
RX *metoprolol tartrate 25 mg 1 Tablet(s) J tube three times a
day Disp #*90 Tablet Refills:*1
10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
11. Heparin 5000 UNIT SC TID
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
RX *Humalog KwikPen 100 unit/mL Up to 8 Units per sliding scale
four times a day Disp #*80 Unit Refills:*2
RX *Humalog KwikPen 100 unit/mL Up to 8 Units per sliding scale
four times a day Disp #*60 Unit Refills:*1
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Perforated duodenum.
2. Bile leak after laparoscopic cholecystectomy
3. Acute renal failure
4. Persistent tachypena with respiratory alkalosis
5. Post op delirium
Discharge Condition:
--
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for perforated
duodenum and bile leak following a laparoscopic cholecystectomy
at an outside hospital. You are now safe to complete your
recovery at an extended care facility with the following
instructions:
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-12**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. You have an
appointment scheduled on [**2146-8-5**], 9:30 AM. Location:
[**Hospital Ward Name 23**] building, [**Location (un) 470**], [**Hospital Ward Name 516**]. [**Location (un) **],
[**Location (un) 86**], MA. Phone: [**Telephone/Fax (1) 2998**]
ICD9 Codes: 5845, 2760, 2762, 9971, 2930, 2851, 5990, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6763
} | Medical Text: Admission Date: [**2153-2-15**] Discharge Date: [**2153-2-19**]
Date of Birth: [**2086-3-24**] Sex: F
Service: MEDICINE
Allergies:
Flagyl / Iodine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Acute Blood Loss Anemia due to Gastric Ulcers with Bleeding
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
66 year old Female with ESRD on peritoneal dialysis due to
hypertensive nephropathy, and h/o NSCLC on Tarceva and
nephrolithiasis who presents with symptomatic anemia. The
patient typically adjusts her weekly EPO injections between
4000-6000 units depending on her symptoms of fatigue and
dyspnea. Two and a half weeks ago her dialysis nurse had her
terminate EPO in the setting of an elevated hmg > 12 per her
report. She has been waiting to hear back from her dialysis
clinic regarding when to restart her EPO. She titrates her own
EPO, given a similar episode of severe symptomatic anemia. In
the interim she developed excruciating flank pain earlier this
week for which she presented to the ED, a CT demonstrated
bilateral stones. She was given toradol and vicodin and
discharged home with total resolution of her pain. However, as
the week progressed, she has become progressively constipated
and fatigued with suprapubic abdominal pain. She reports her PD
fluid has been clear. She had an episodic visit at [**Company 191**] on
Thursday which prompted referral to the ED. Her blood pressure
was 112/72 laying and 94/68 standing. Blood cultures were taken,
but patient denied any fevers or chills. She got IVF
(approximately 500 cc). Her labs were significant for a
hematocrit of 27, down from 36 on [**2-13**]. She was guiac negative.
Her potassium was elevated at 6, she was given kayexalate. She
had an abdominal CT which showed nothing acute. A CXR was
negative for acute processes. Repeat orthostatics were: lying HR
75 BP 135/63, standing HR 85 BP 127/61. On transfer to the
floor her abdominal pain had completely resolved in the setting
of a large dark brown bowel movement after receiving kayexalate.
She did not receive PD o/n.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, vomiting, diarrhea, BRBPR, hematochezia.
She makes trace amounts of urine. She notes acid reflux for the
past 3 days that has been constant. She has only been eating
peppermints do to her poor appetite.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- NSCLC on erlotinib
- ESRD on PD
- recurrent nephrolithiasis
- depression
- insomnia
- seasonal rhinitis
- papillary thyroid CA s/p excision
Social History:
Divorced, lives in same house as 3 friends ([**Name (NI) 11894**], [**First Name3 (LF) **],
[**Name (NI) **]). 2 adult sons.
Remote tobacco (quit 20 years ago)denies EtOH or illicit drug
use.
Family History:
Mother- diabetes
Father with kidney disease
Physical Exam:
ADMISSION:
VS: 98.7 143/69 85 18 100 RA
GENERAL - in NAD, comfortable, appropriate, pale
HEENT - NC/AT, MMM
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
HEART - RR, no MRG, nl S1-S2
ABDOMEN - soft/NT/slightly distended, no rebound/guarding, PD
catheter in lower abdomen with clean bandage, skin without
erythema, non-tender
EXTREMITIES - trace LE edema, WWP, 1+ peripheral pulses
NEURO - awake, A&Ox3, gait intact
DISCHARGE:
GENERAL: NAD, comfortable, upright in pain, returned color
LUNGS: Decreased breath sounds and mild crackles at left lower
lung base
HEART - RR, no MRG, nl S1-S2
ABDOMEN - soft/NT/slightly distended, no rebound/guarding, PD
catheter in lower abdomen with clean bandage, skin without
erythema, non-tender
EXTREMITIES - trace LE edema, WWP, 1+ peripheral pulses
Pertinent Results:
CHEST XRAY [**2153-2-15**]
PA AND LATERAL VIEWS OF THE CHEST: The cardiac silhouette is
normal in size. The mediastinal and hilar contours are stable.
Chain sutures within the left lower lobe are again demonstrated.
Pulmonary vascularity is not engorged. Left lower lobe mass is
again noted, better seen on the prior CT, but similar compared
to the prior study. Nodular opacity within the left upper lobe
appears relatively unchanged from prior. Small left pleural
effusion persists. The right lung is grossly clear. No
pneumothorax is identified. Multiple clips are demonstrated
within the thyroid bed. Left proximal humeral fracture appears
chronic.
IMPRESSION: No significant interval change in appearance of left
lower lobe lung mass, and nodule in the left upper lobe.
Persistent small left pleural effusion.
CT ABDOMEN w/out contrast [**2153-2-15**]
CT OF THE ABDOMEN:
There is unchanged left lower lobe round nodule with associated
surgical
material and small left pleural effusion and mild bibasilar
atelectasis.
Unchanged multiple pulmonary nodules at the right lung base.
Segment III liver hypodensity is stable and was previously
characterized as a hemangioma. Adjacent sub-cm hypodensity in
the left lobe is also unchanged. The gallbladder, spleen,
bilateral adrenal glands and pancreas are normal. Unchanged
splenic artery calcifications. The kidneys are atrophic with
numerous calcifications, likely vascular, and cysts, unchanged
from priors. The stomach, duodenum, small bowel are normal.
A peritoneal dialysis (PD) cathether is visualized in the left
lower quadrant with unchanged small 17 x 8 mm seroma in the
subcutaneous soft tissues and moderate amount of ascites.
Unchanged calcification of the aorta and its major branches.
There is no retroperitoneal or mesenteric lymphadenopathy.
CT OF THE PELVIS:
The urinary bladder is normal. There is no pelvic
lymphadenopathy, no pelvic hernias.
BONES: There are moderate degenerative change at L5-S1 with
intervertebral
disc disease.
.
IMPRESSION: No acute process or interval change from 2 days
prior, including no evidence of diverticulitis or appendicitis.
.
PORTABLE CHEST XRAY [**2153-2-18**]
IMPRESSION: AP chest compared to [**3-15**]:
Mild interstitial abnormality in the right lung is probably
edema. Moderate left pleural effusion is increasing. Large left
lung lesions also appear grown since [**2-15**], though this is
probably mostly a function of projection between the PA and AP
orientations. Heart size top normal. Mediastinal veins and upper
lobe pulmonary vessels are slightly dilated.
PERTINENT LABS
[**2153-2-19**] 06:55AM BLOOD WBC-8.3 RBC-3.48* Hgb-10.9* Hct-31.1*
MCV-90 MCH-31.5 MCHC-35.1* RDW-14.2 Plt Ct-227
[**2153-2-18**] 07:15AM BLOOD WBC-7.9 RBC-3.38* Hgb-10.6* Hct-29.5*
MCV-87 MCH-31.3 MCHC-35.9* RDW-14.5 Plt Ct-211
[**2153-2-17**] 07:10AM BLOOD WBC-8.4# RBC-3.23* Hgb-10.0* Hct-28.5*
MCV-88 MCH-31.1 MCHC-35.2* RDW-14.3 Plt Ct-231
[**2153-2-17**] 07:10AM BLOOD WBC-8.4# RBC-3.23* Hgb-10.0* Hct-28.5*
MCV-88 MCH-31.1 MCHC-35.2* RDW-14.3 Plt Ct-231
[**2153-2-16**] 04:15PM BLOOD WBC-17.0*# RBC-3.02* Hgb-9.3* Hct-26.8*
MCV-89 MCH-30.8 MCHC-34.8 RDW-14.1 Plt Ct-249
[**2153-2-16**] 09:00AM BLOOD WBC-8.4 RBC-2.59* Hgb-8.0* Hct-22.7*
MCV-88 MCH-31.1 MCHC-35.5* RDW-14.0 Plt Ct-295
[**2153-2-16**] 02:40AM BLOOD Hct-22.8*
[**2153-2-16**] 01:20AM BLOOD WBC-10.9 RBC-2.58* Hgb-7.9* Hct-22.5*
MCV-87 MCH-30.6 MCHC-35.2* RDW-14.1 Plt Ct-308
[**2153-2-15**] 05:27PM BLOOD WBC-10.9 RBC-3.09* Hgb-9.5* Hct-27.2*
MCV-88 MCH-30.8 MCHC-35.1* RDW-14.1 Plt Ct-347
[**2153-2-15**] 05:27PM BLOOD Neuts-83.7* Lymphs-12.1* Monos-1.3*
Eos-2.2 Baso-0.7
[**2153-2-17**] 07:10AM BLOOD PT-12.7 INR(PT)-1.1
[**2153-2-19**] 06:55AM BLOOD Glucose-88 UreaN-81* Creat-12.2* Na-140
K-5.4* Cl-100 HCO3-26 AnGap-19
[**2153-2-17**] 07:10AM BLOOD Glucose-83 UreaN-95* Creat-10.7*# Na-138
K-4.8 Cl-101 HCO3-25 AnGap-17
[**2153-2-16**] 01:20AM BLOOD Glucose-92 UreaN-108* Creat-11.5* Na-141
K-4.6 Cl-102 HCO3-24 AnGap-20
[**2153-2-18**] 07:15AM BLOOD ALT-22 AST-27 LD(LDH)-174 AlkPhos-218*
TotBili-0.4
[**2153-2-16**] 09:00AM BLOOD TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2153-2-15**] 05:27PM BLOOD ALT-26 AST-23 AlkPhos-263* TotBili-0.2
[**2153-2-19**] 06:55AM BLOOD Calcium-7.8* Phos-5.2* Mg-2.1
[**2153-2-17**] 07:10AM BLOOD Calcium-7.9* Phos-5.2* Mg-2.1
[**2153-2-15**] 05:27PM BLOOD Albumin-3.3* Calcium-9.3 Phos-3.6# Mg-2.5
[**2153-2-16**] 09:00AM BLOOD Hapto-180
[**2153-2-16**] 02:40AM BLOOD Hapto-198
[**2153-2-18**] 03:17PM BLOOD IgA-122
[**2153-2-18**] 03:17PM BLOOD tTG-IgA-4
[**2153-2-15**] 07:45PM BLOOD Lactate-0.9 K-5.4*
[**2153-2-15**] 05:29PM BLOOD Lactate-1.1
[**2153-2-16**] 05:48AM OTHER BODY FLUID WBC-34* RBC-1* Polys-4*
Lymphs-16* Monos-0 Macro-79* Other-1*
[**2153-2-16**] 5:48 am DIALYSIS FLUID IMPROPER SPECIMEN
COLLECTION.
INTERPRET RESULTS WITH CAUTION.
**FINAL REPORT [**2153-2-19**]**
GRAM STAIN (Final [**2153-2-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2153-2-19**]): NO GROWTH.
[**2153-2-18**] 3:17 pm SEROLOGY/BLOOD
**FINAL REPORT [**2153-2-19**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2153-2-19**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
EGD: [**2153-2-16**]
Impression: Multiple superficial ulcers in the stomach antrum
Few cratered ulcers in the pre-pyloric region
A single cratered ulcer with stigmata of recent bleeding in the
pre-pyloric region (injection)
Bulbar duodenitis
Brunner's gland hyperplasia in the duodenal bulb
Scalloping folds on the mucosa of the second and third parts of
the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: The findings account for the symptoms, and the
distribution of the gastric ulcers suggests that they are
NSAID-induced.
Continue PPI, avoid all aspirin or NSAID products.
Follow serial Hcts, transfuse PRBCs to Hct >30. Consider DDAVP
and/or platelet transfusion for uremic platelets.
Check H.pylori serology, treat if positive.
Check TTG and IgA to exclude Celiac disease.
If re-bleeds will need repeat EGD.
Brief Hospital Course:
HOSPITAL COURSE
Ms. [**Known lastname 92380**] is a 66 year old woman with ESRD on PD, NSCLC, anemia,
and thyroid cancer who presented with an upper GI bleed. She
required multiple transfusions and transfer to the MICU where
upper endoscopy revealed bleeding gastric ulcers secondary to
recent NSAID use.
ACTIVE ISSUES
# Acute Blood Loss Anemia due to Gastric Ulcers with Bleeding,
Duodenitis:
Symptomatic anemia in the setting of a significant drop in Hct
over a three day period. (36->27->22) Etiology initially
concerning for discontinuation of weekly epogen in setting of
elevated hmg on routine lab draw. The patient has past history
of dramatic hct drop off epo. She received 1x dose of tordol
during ED visit on Monday. No other NSAID use or history of
GERD. Most recent colonscopy in [**2146**] demonstrated multiple
polyps. Follow up colonoscopy deferred given NSCLC. Initially no
evidence of acute bleed, guaic negative stool in the ED prior to
transfer, however on the morning of admission the patient passed
four melanolic stool, guaic positive. Her hct dropped to 22,
she was transfused 1 unit of pRBC and given desmopressin. Two
PIVs were placed, she was started on PPI gtt and 1 more unit
pRBC and transferred to MICU for EDG and further management. EGD
revealed multiple gastric ulcers in antrum, one of which had
stigmata of recent bleed with overlying dark area. This area was
injected. There was no evidence of active bleeding. The
duodenal bulb was acutely inflammed and edematous w/o discrete
ulcer or bleeding. Patient received additional 2 units pRBCS
after procedure, with subsequent stabilization in HCT and
hemodynamics. Her diet was advanced to clears, and she was
stable to be transferred back to the general medicine floor.
Her hematocrit continued to be stable. Pantoprazole was changed
to PO BID dosing which she will continue on for 6 weeks. She
will discuss further epoitin dosing with her outpatient
nephrologist. Hpylori negative. IgA at normal levels.
# Flank Pain:
The patient has was admitted to the ED prior to admission for
left sided plank pain for which she was prescribed vicodin for
pain managment. An episode of this flank pain recurred on
admission. Physical exam demonstrated left flank tenderness to
palpation. CT abdomen on [**2-13**] demonstrated bilateral stones and
CT abdomen two days later demonstrated calcified atrophic
kidneys. Unclear if pain is secondary to stones as patient is
PD dependant and almost anuric. Would consider outpatient MRI to
investigate for nerve impingement. Her pain was treated with
vicodin.
# Abdominal Pain Diffuse:
Completely resolved in setting of large bowel movement on night
of admission. She was afebrile, but given her history of
peritonitis and PD, fluid sent for culture and gram stain. Gram
stain revealed 1+ polys and no microorganisms, culture was
negative. Blood cultures were negative at the time of discharge.
# ESRD:
Renal fellow contact[**Name (NI) **] regarding admission. Peritoneal dialysis
was started per home regimen. Epoetin dosing to be discussed
with outpatient nephrologist. The patient became mildly fluid
overloaded in setting of multiple transfusions and clear diet.
CXR demonstrated small pleural effusion. Her PD dialsylate was
adjusted as indicated.
# Hyperkalemia:
Hyperkalemic on admission. She received kayexalate with
improvement in her potassium. No peaked T waves.
# Hypothyroidism:
Continued home levothyroxine dose.
# NSCLC: On Tarceva every three days. Patient stated she will
not take until appetite improved. Heme/onc was called, and
placed orders for patient to continue on Tarceva as per home
regimen.
TRANSITIONAL ISSUES
Medical Management: Pantoprazole 40mg [**Hospital1 **] for 6 weeks, Vicodin
for 3 days
Code Status: Full (Was DNR but do Intubate on admission.)
Medications on Admission:
CALCITRIOL - - 0.25 mcg Capsule - 1 Capsule(s) by mouth three
times a week (MWF)
EPOETIN ALFA [EPOGEN] - - 4,000 unit/mL Solution - 6000 weekly
ERLOTINIB [TARCEVA] - 25 mg Tablet - 1 Tablet(s) by mouth Q3
days on an empty stomach
LEVOTHYROXINE [LEVOXYL] - 150 mcg Tablet - 1 Tablet(s) by mouth
once a day and extra [**12-17**] tablet once weekly.
SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 5 Tablet(s) by
mouth TID w/ food
ZOLPIDEM - 5 mg
B COMPLEX-VITAMIN C-FOLIC ACID [[**Doctor First Name **]-VITE] - 0.8 mg Tablet - 1
Tablet(s) by mouth once a day
CAMPHOR-MENTHOL [SARNA ANTI-ITCH] - 0.5 %-0.5 % Lotion - apply
on
the skin as needed for itch three to four times daily as needed
Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR
(Monday -Wednesday-Friday).
2. epoetin alfa 4,000 unit/mL Solution Sig: One (1) Injection
once a week.
3. erlotinib 25 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday
-Wednesday-Friday).
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
5. levothyroxine 150 mcg Capsule Sig: One (1) Capsule PO once a
day.
6. sevelamer carbonate 800 mg Tablet Sig: Five (5) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
take for 6 weeks and then decreased to once daily.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for pain for 3 days.
Disp:*qS Tablet(s)* Refills:*0*
11. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for itching.
Discharge Disposition:
Home
Discharge Diagnosis:
NSAID induced Gastric Ulcers
End Stage Renal Disease
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted for management of an upper GI bleed. An upper
endoscopy demonstrated multiple ulcers in your stomach. It is
likely that the tordol you received during your prior ED visit
precipitated the development of these ulcers. A small injection
of epinephrine in one of the bleeding ulcers was made which
stopped the bleeding. You required multiple blood transfusions.
You were started on pantoprazole twice daily. You will need to
continue this medication for six weeks and then may take it just
once daily.
You developed left sided flank pain that appears to be an
intermittant chronic issue. Please discuss with your primary
care physician, [**Name10 (NameIs) **] MRI to explore the cause of your intermittant
spasms.
Please discuss with your nephrologist how much epoetin you
should be taking.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2153-2-28**] at 10:10 AM
With: [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**], MD. [**Company 191**] POST [**Hospital 894**] CLINIC
[**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Nephrology Appointment: PENDING
**We are working on a follow up appointmentt in the
NEPHROLOGY DEPARTMENT with DR.[**Last Name (STitle) **] [**Doctor Last Name **] for you to be seen
with in 2 weeks from your discharge. You will be called at home
with the appointment. If you have not heard from [**Doctor First Name **] in his
office by WED., [**2-21**] or have questions, please her at
[**Telephone/Fax (1) 721**].
ICD9 Codes: 5856, 2851, 5119, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6764
} | Medical Text: Admission Date: [**2104-1-6**] Discharge Date: [**2104-1-17**]
Date of Birth: [**2046-10-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
57 yoM w/ HepC cirrhosis w/ known varices EGD [**7-/2103**] presented
with one day of coffee-ground and then bright red emesis (<1L);
+ nausea; no melena/BRBPR. No prior episodes of GIB. Baseline
Hct in the low to mid-30's.
.
Pt. reports not taking medications, including insulin, home BG
of 411 last checked on day PTA. Pt. states that he has been
non-adherent w/ diabetic diet on [**3-5**] days PTA. Denies SOB, CP,
or worsening abdominal girth. States that this actually
improved. Recently had Spironolactone dose increased to 100mg qD
by PCP. [**Name10 (NameIs) 17613**] sadness, but no hopelessness, anhedonia or SI.
.
BP was 100/palp with EMS en route; was given 250 cc bolus with
improvement. In the ED he was HD stable with VS 118/68, 82, 16,
98% RA. He was given protonix and ocreotide.
.
Was admitted to ICU, where he underwent an EGD, showing grade I
and II non-bleeding ulcers and [**Doctor First Name **]-[**Doctor Last Name **] tear. Pt. received
2U PRBCs and 2U of FFPs. HCT stable.
.
ROS: Denies melena, BRBPR, previous hematemesis, CP, SOB,
encephalopathy hx.
Past Medical History:
#. Multiple gallbladder stones w/o cholecystitis
#. Hepatocellular Carcinoma
- two bx lesions c (+) path
- s/p RFA [**2103-8-29**]
#. Hospitalization x2 over last 2-4 months for severe
cellulitis of lower extremities
#. Hep C Genotype 1
- Pegylated interferon, ribavirin ([**2096**]): Viral relapse
- Liver bx ([**2099**]): Stage 3 fibrosis, grade 2 inflammation
- EGD ([**7-/2101**]): Esophagitis, varices
- AFP 9.8
#. Hypertension
#. DMII: c/b neuropathy
#. Psoriasis
#. Anxiety
#. GERD
#. Chronic anemia
#. s/p laminectomy ([**11/2095**])
#. Chronic pain [**2-4**] laminectomy managed by methadone
#. s/p right ankle surgery ([**2089**])
Social History:
Lives at home alone in [**Location (un) **], has girlfriend. has no social
supports, most family lives far away and has no one to call in
case of emergency. Currently on disability (formerly employed in
communications/IT); no tobacco; no hx of recreational drug use;
very occasional EtOH
Family History:
Both parents alive and in good health. Overweight/obesity, DM
and HTN in multiple family members. Denies hx Ca, CAD, Liver Px.
Physical Exam:
VS on arrival to the ED: 118/68, 82, 16, 98% RA
VS on arrival to the ICU: 80, 152/75, 13, 100% RA
General: comfortable and well nurished appearing
HEENT: non-icteric sclera; dry MM
Lungs: CTA b/l
Cardio: RRR, no m.r.g., no JVD
Abd: + BS, soft, NTND
Extremities: right leg external rotation > left at rest;
Skin: no rashes; WWP
Neuro: AA, OX3, no asterixis
By [**2104-1-7**] patient developed loss of attention and prominent
asterixis.
Pertinent Results:
Labs on admission:
[**2104-1-6**] 02:15AM BLOOD WBC-11.7* RBC-2.77* Hgb-8.9* Hct-26.5*
MCV-96 MCH-32.3* MCHC-33.8 RDW-14.5 Plt Ct-153
[**2104-1-6**] 11:19AM BLOOD WBC-10.5 RBC-2.61* Hgb-8.4* Hct-23.6*
MCV-90 MCH-32.1* MCHC-35.6* RDW-15.8* Plt Ct-117*
[**2104-1-7**] 02:54AM BLOOD WBC-13.2* RBC-3.11* Hgb-9.6* Hct-28.7*
MCV-92 MCH-31.0 MCHC-33.6 RDW-15.9* Plt Ct-127*
[**2104-1-6**] 02:56AM BLOOD PT-18.6* PTT-31.2 INR(PT)-1.7*
[**2104-1-7**] 02:54AM BLOOD PT-16.8* PTT-30.2 INR(PT)-1.5*
[**2104-1-6**] 02:15AM BLOOD Glucose-257* UreaN-70* Creat-4.3*#
Na-124* K-7.1* Cl-89* HCO3-20* AnGap-22*
[**2104-1-7**] 02:54AM BLOOD Glucose-61* UreaN-62* Creat-3.2* Na-131*
K-4.5 Cl-102 HCO3-22 AnGap-12
[**2104-1-6**] 02:15AM BLOOD ALT-63* AST-151* CK(CPK)-853*
AlkPhos-176* TotBili-1.6*
[**2104-1-7**] 02:54AM BLOOD ALT-59* AST-120* AlkPhos-147*
TotBili-2.2*
[**2104-1-6**] 11:19AM BLOOD Calcium-7.4* Phos-4.6*# Mg-1.6
[**2104-1-7**] 02:54AM BLOOD Albumin-2.7* Calcium-8.1* Phos-4.0 Mg-1.6
[**2104-1-7**] 04:59PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006
[**2104-1-7**] 04:59PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-TR
[**2104-1-6**] 02:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2104-1-6**] 02:56AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-5.0 Leuks-NEG
[**2104-1-6**] 02:56AM URINE RBC-[**6-11**]* WBC-[**3-6**] Bacteri-FEW Yeast-NONE
Epi-[**3-6**] RenalEp-[**3-6**]
.
.
Imaging/Studies:
.
CXR [**2104-1-6**] - PORTABLE UPRIGHT CHEST RADIOGRAPH: The heart size
and mediastinal contours
remain normal. The lungs are well inflated and remain clear. No
pneumothorax
or pleural effusion is seen. Degenerative changes of the
thoracic spine as
before.
IMPRESSION: No evidence of acute intrathoracic process seen.
.
EGD [**2104-1-6**]: Summary: [**Doctor First Name **]-[**Doctor Last Name **] tear. Varices grade I/II at
the gastroesophageal junction and lower third of the esophagus.
Blood in the fundus
.
RUQ U/S: [**1-8**]
.
IMPRESSION:
1. Segment IV s/p RFA cystic and solid lesion with mural nodules
concerning
for tumor recurrence.
2. Segment III lesion also raises the possibility of recurrence.
3. Persistent ascites and gallstones.
4. Normal son[**Name (NI) 493**] exam of the portal venous system.
5. Mild left renal pelviectasis
.
Colonoscopy - see brief hospital course.
.
MRI of abdomen - Pending.
.
Microbiology:
.
URINE CULTURE (Final [**2104-1-11**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
.
Peritoneal fluid, blood cultures negative.
.
Labs on discharge:
.
[**2104-1-17**] 05:35AM BLOOD WBC-8.9 RBC-2.92* Hgb-9.5* Hct-27.8*
MCV-95 MCH-32.4* MCHC-34.1 RDW-15.4 Plt Ct-126*
[**2104-1-17**] 05:35AM BLOOD PT-18.7* PTT-38.6* INR(PT)-1.7*
[**2104-1-17**] 05:35AM BLOOD Glucose-126* UreaN-27* Creat-1.8* Na-129*
K-4.0 Cl-99 HCO3-23 AnGap-11
[**2104-1-17**] 05:35AM BLOOD ALT-33 AST-73* LD(LDH)-232 AlkPhos-137*
TotBili-1.0
[**2104-1-17**] 05:35AM BLOOD Albumin-2.6* Calcium-7.8* Phos-3.6 Mg-1.6
[**2104-1-10**] 08:45AM BLOOD calTIBC-294 VitB12-1338* Folate-9.0
Ferritn-219 TRF-226
Brief Hospital Course:
57 year old man w/ history of HCV and HCC s/p RFA in [**8-/2103**], w/
Grade I/II varices, not on nadolol was admitted w/ episode of
hematemesis/UGIB [**2-4**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, diagnosed on emergent
endoscopy. Patient received 2U of PRBCs and FFP and was
transfered from ICU to the floor for further care.
.
#) GIB and anemia. Patient initially presented with a GIB due
to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear diagnosed via EGD. Patient was also noted
to have grade I/II non-bleeding varices. No banding was
performed. Patient was started on protonix 40 mg [**Hospital1 **] and Nadolol
20mg QD. He received 2U of PRBCs and HCT nadired at 24, 26 on
admission and was 30 after transfusions. No further frank
upper GI bleeding was noted. Patient had intermittently guiac
positive stools with HCT dropping to 26 on HD#7. This was felt
to be due to possible dilutional effect (Pt had received 50g of
albumin) vs. LGIB. He underwent a colonoscopy which showed
three polyps, with one maximum size of 1cm. No polypectomy was
performed due to agitation by the patient and INR of 1.6. No
sites of bleeding were noted. Patient received 2 additional
units of PRBCs. HCT increased to 30 and remained stable until
discharge. He will require a repeat colonoscopy for polypectomy
and pathology evaluation. He is currently scheduled for this
with Dr. [**Last Name (STitle) **]. Chronic anemia could not be further
characterized and patient had received transfusions. He will
require outpatient evaluation including iron studies,
reticulocyte count and vitamin studies. TSH was nl in [**2103**].
HCT on discharge was 28.
.
#) ESLD, HepC cirrhosis/HCC s/p RFA in [**8-9**]. Patient is
currently being worked up for liver transplantation (seen [**11-9**]
by Dr.[**Name (NI) 948**] office). HCV tx by Ribavarin, interferon in
[**2096**], w/ relapse and VL of 465K [**11-9**]. His EGD showed Grade
I/II varices. Prior to this admission, he had no hx of
encephalopathy. Liver ultrasound showed coarsened liver
echotexture, segment IV s/p RFA cystic and solid lesion with
mural nodules concerning for tumor recurrence, segment III
lesion also raises the possibility of recurrence, persistent
small asictes, gallstones, normal portal venous system. On
admission to the floor, patient was noted to have asterexis and
impaired attention and memory. He was started on lactulose and
rifaximin. WBC count was elevated and a diagnostic tap was
performed which failed to show SBP, 200 PMNs. Other infectious
work up was negative including CXR, BCx, C.difficile antigen and
contaminated UA. Due to persistent ecephalopathy and elevated
WBC, patient was started on ceftriaxone for possible SBP. On
HD8 patient grew enterococcus in from urinary source. He was
started on ampicillin IV on [**1-11**] and ceftriaxone was
discontinued. With this treatment, encephalopathy improved
significantly, including improved attention (days of the week
and months of the year backwards, and nearly resolved
asterixis). As part of liver [**Month/Day (4) **] work up, patient
underwent an echocardiogram, which showed normal PAP and LVEF of
70%. Due to concern for recurrent bleeding, patient's nadolol
was increased to 40mg daily. His lactulose was titrated to [**3-5**]
BMs per day and Rifaximin was continued at 400mg TID.
From social work perspective, patient has had difficulties
getting to appointments due to transportation and financial
issues. The day of discharge, patient underwent an MRI of
abdomen to assess the recurrence of HCC. This study will
require follow up by PCP and [**Hospital1 1388**] Dr. [**Last Name (STitle) 497**] and [**Doctor Last Name **].
.
#) ARF on CKD. Baseline Cr reported as 1.5 to 2.0, was 4.3 on
admission. CKD was felt to be likely due to DM and HTN. ARF on
admission was likely pre-renal in setting of N/V and hemorrhage.
Diuretics were held. Patient responded to IVF in ICU with Cr
improving to 3.2. However, improvement ceased as WBC began to
climb. Urine lytes were intially consistent with intrinsic
disease, Na of 105, FeNA > 1%, however eventually showed
pre-renal state w/ Na 18, FeNA <1%. UA did not show casts,
eosinophils were negative. Cr. improved after albmuin
administration and PRBC transfusions. Given this and lack of
hypotension, hepatorenal syndrome was felt unlikely and cause
was felt to be pre-renal. Renal team was consulted who agreed
with above assessment. At time of discharge Cr improved to 1.8.
With this treatment, patient's LE edema re-accumulated,
approximately 1+ at time of discharge with 5kg wt gain over last
4 days of hospitalization. Reported as baseline by patient.
Patient was restarted on Lasix 40 QD and Spironolactone of 50mg
qd at time of discharge.
.
#) Chronic RLE pain and back pain. This was unchanged during
admission. Pt. on methadone 40 mg QAM and 30 mg QPM as
outpatient. These were continued. Pain was reported as [**2105-2-5**].
Patient was evaluated by physical therapy was deemed to require
rehabilitation for further gait and strength training.
.
#) Liver nodule. see above for ultrasound results and further
work up performed with MRI on day of discharge. This will
require follow up.
.
#) T2DM, Hyperglycmeia. Improved, still not consistently < 150.
Has had some hypoglycemia in AM, [**2-4**] NPO. Likely presented in
DKA w/ trace ketones in urine, and elevated BG at home and N/V.
A1C 5.9 in [**10-9**], thus relatively well controlled. Pt. on 85
lantus as OP. This scale was restared with BG ranging between
110-220s, w/ occasional 60s during periods of NPO. Pt. was
discharged w/ HISS and Lantus 85U QHS.
.
#) Hypertension. Blood pressures ranging 130-150 systolic
throughout hospital stay. he was restarted on home Diltiazem CR
at 120 QD on HD#5 and Spironolactone at discharge. Goal SBP
130/80 or less.
0
#) PPX: PO protonix; pneumoboots
.
#) COMMUNICATION: with patient and Son [**Name (NI) 17614**] [**Name (NI) 805**] ([**Telephone/Fax (1) 17615**] OR [**Telephone/Fax (1) 17616**] OR [**Telephone/Fax (1) 17617**]. Multiple discussions
were held with family and it was felt that patient would benefit
from transient rehabilitation stay as well as recommeneded by
PT.
.
Patient was discharged in a hemodynamically stable condition,
afebrile.
.
Issues requiring follow up:
- Completion of ABx for UTI
- Titration of diuretics for optimal volume status
- Electrolyte monitoring with restarting of diuretics, 2d after
discharge
- Blood pressure regimen optimization
- HCT labs 2d after discharge
- MRI abdomen at [**Hospital1 18**] follow up
- PCP and Liver Clinic follow up as arranged.
Medications on Admission:
VS 98.6F 140/90 94 18 100% RA
General: comfortable and well nurished appearing
HEENT: non-icteric sclera; MMM
Lungs: CTA b/l, nl movement
Cardio: RR, no m.r.g., no JVD
Abd: obese, + BS, soft, NT/ND, no shifting dullness.
Extremities: right leg external rotation > left at rest; flat
solar surfaces, onychomycosis, no ulceration. Trace edema b/l.
Skin: no rashes.
Neuro: A&OX3, intact repetition, strength 5/5 in UE, [**5-6**] in LE
proximally, [**4-6**] RLE at foot [**2-4**] pain.
? asterixis vs. intention tremor. No pronator drift, FTN intact.
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Eighty Five (85)
units Subcutaneous at bedtime.
2. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO QAM (once a day (in the morning)).
3. Methadone 10 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
7. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for SBP < 90, HR < 60, page house officer if holding.
10. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO QMON
(every Monday): SBP prophylaxis
.
11. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous see sliding scale: see sliding scale.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Hold
for SBP < 90.
13. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day: Hold for SBP < 100.
14. Outpatient Lab Work
CBC, chem 10, PTT/PT, AST/ALT/Tbili/AP two days after discharged
and weekly there after. Please fax results to PCP and Dr.
[**Last Name (STitle) **] at [**Hospital1 18**].
15. MRI follow up
Patient had undergone and MRI at [**Hospital1 18**] on day of discharge.
This will require follow up by PCP.
16. Nitrofurantoin Macrocrystal 100 mg Capsule Sig: One (1)
Capsule PO every six (6) hours for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear with hemorrhage, acute kidney
injury, hepatic encephalopathy, urinary tract infection
Secondary: Hepatitis C and Hepatocellular Carcinoma, Cirrhosis,
Anemia of chronic disease, Esophageal Varices, Hypertension,
Diabetes.
Discharge Condition:
Hemodynamically stable, improved encephalopathy and afebrile.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with nausea and bloody vomiting. You
underwent an endoscopy that showed a tear in a part of your
esophagus as well as varices (blood vessel outpouchings in your
esophagus due to your liver disease). You received blood
transfusions for this and your blood levels stabilized. You
also underwent a colonoscopy that showed several polyps (see
below for follow up).
.
Because of the varices in your esophagus, you were started on a
medication called nadolol to prevent bleeding.
.
In addition, you were found to have developed encephalopathy (an
abnormality in the brain chemistry, due to liver disease or
infection) that to you felt like confusion. Because of this you
were started on two medications: lactulose and rifaximin. In
addition, you were found to have a urinary tract infection,
which was treated with intravenous antibiotic.
.
Finally, you stay was complicated by acute kidney failure on top
of your chronic kidney failure. This was felt to be due to
blood loss and infection. With blood transfusions and
intravenous fluids your kidney function recovered. You were
restarted on your diuretics the day of discharge at lower doses,
50mg daily of Spironolactone and Lasix at 40mg daily.
.
Should you experience any further or worsening confusion,
fevers, chills, nausea, vomiting, bloody or black stools,
coughing up blood, worsening swelling in your legs or abdomen,
please call your primary care doctor or go to the nearest
emergency room.
.
Your medications were adjusted. Please see list below and only
take medications you were prescribed.
.
While at the hospital your liver was imaged. A small lesion in
your liver was found concerning for recurrence of your cancer.
You will require an outpatient CT scan to evaluate this further.
In addition, you will require a repeat colonoscopy to remove
the polyps in your colon.
Followup Instructions:
You have an appointment with your PCP, [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. #
[**Telephone/Fax (1) 7538**], on [**2-4**] at 6.15pm.
You also have an appointment on Saturday, [**1-19**] with your
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], please call above number to confirm your
appointment.
Dr. [**Last Name (STitle) 497**], Liver center, [**2105-2-5**]:40 am, ([**Telephone/Fax (1) 1582**].
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB)
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2104-1-23**] 9:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 9394**] (ST-3) GI ROOMS Date/Time:[**2104-1-25**] 9:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2104-1-25**] 9:30. For repeat colonoscopy and
polypectomy.
Completed by:[**2104-1-17**]
ICD9 Codes: 5849, 5990, 3572, 5715, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6765
} | Medical Text: Admission Date: [**2124-3-10**] Discharge Date: [**2124-4-5**]
Date of Birth: [**2048-1-2**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 74-year-old female,
recently diagnosed with a right femur osteosarcoma, status
post 1 cycle of neoadjuvant chemotherapy with adriamycin and
cisplatinum on [**2-28**], and a history of ulcerative colitis,
status post total colectomy and ileostomy in the past, who
presented to the Emergency Room with acute sharp abdominal
pain, nausea and vomiting.
PAST MEDICAL HISTORY:
1. Melanoma, right lower extremity, in [**2097**].
2. Hyperthyroidism.
3. Migraines.
4. Proctocolectomy.
5. Total abdominal hysterectomy.
6. Cholecystectomy.
7. Hemithyroidectomy.
8. Appendectomy.
9. Ulcerative colitis.
10.Hypertension.
MEDS AT HOME:
1. Aspirin 81.
2. OxyContin.
3. Norvasc.
4. Colace.
5. Compazine.
6. Cipro.
7. Propranolol.
8. Percocet.
9. Valium.
10.Ambien.
11.Imitrex.
12.Vioxx.
ALLERGIES: No known allergies.
SOCIAL HISTORY: Significant for 1-pack of cigarettes per
day. No alcohol.
EXAM ON ADMISSION: Temperature 97.6, heart rate 120-90,
blood pressure 132/54, respiratory rate 18, sats 95percent on
room air. In significant pain. Heart regular rate and
rhythm. Chest clear to auscultation bilaterally. Abdomen
tender on the right side with guarding. Stoma was
digitalized. There was no gross blood, and it was heme
positive. Extremities were warm.
LABS: White count 0.1, hematocrit 27.6, platelets 88.
Chemistries - sodium 132, potassium 3.6, chloride 101, bicarb
16, BUN 41, creatinine 1.7, glucose 131, lactate 1.7. UA was
negative for infection. EKG showed sinus tachycardia. Chest
x-ray showed COPD with no pneumonia or congestive heart
failure. CT of the abdomen was done and showed thickening
and stranding of the distal ileum with some fluid in the
abdomen. There was little progression of contrast into the
small bowel. The SMA and celiac were open.
HOSPITAL COURSE: Over the few hours after presenting to the
Emergency Room, her clinical picture worsened. She became
tachycardic and intermittently hypotensive. In view of these
symptoms and her very concerning CT scan, it was decided to
take her the operating room. On [**2124-3-10**], she
underwent an exploratory laparotomy. She was found to have
ischemia of the distal small bowel to the stomach from
previous adhesions and small bowel obstruction. The
adhesions were taken down, as well as the stoma. The distal
small bowel was resected, and a new ileostomy was
constructed. Her long postoperative course is summarized as
follows:
1. NEURO: Initially, her pain was controlled, and she was
sedated with a fentanyl drip. This was later weaned and
changed to prn morphine as needed, and prior to discharge
her pain was well-controlled on Roxicet prn, and very
small amounts of Ativan prn. On postoperative day 19, as
she was beginning to wake-up and drips were weaned off,
she was noted not to be moving her left side as well, and
had left side neglect with right-sided gaze. A CT was
done and showed recent infarctions in the middle cerebral
arterial territory and left occipital territory. Further
work-up for what seemed to be embolic strokes included an
echo which did not show any source of emboli. She was
seen by the neurology team and was started on aspirin.
1. CARDIOVASCULAR: Her immediate postop course was
significant for septic shock and need for vasopressors
which were gradually weaned as she stabilized. She
developed atrial fibrillation which was converted back to
sinus on an amiodarone drip. Prior to discharge, she was
on amiodarone through her G-tube. She has remained in
sinus and stable hemodynamically for many days.
1. RESPIRATORY: She had prolonged respiratory failure and
vent dependency. This required a tracheostomy which was
done on [**2124-3-30**]. Prior to discharge, she was
gradually weaning off the vent on a pressure support mode,
and had been on a trach mask for the last 48 hours prior
to transfer to rehab. She still required some suctioning
and chest physical therapy, but had been stable with good
saturations, and normal respiratory rate, and seemed very
comfortable on the trach mask.
1. GI: Initial postop nutrition was provided through TPN.
Once her new ileostomy began to function, she was started
on tube feeds, and on [**3-30**] a PEG was placed, and the
tube feeds were then given through this access. She has
been tolerating tube feeds at goal with 1 episode of
vomiting 2 days prior to discharge. After starting her on
Reglan, tube feeds were restarted, and she seemed to be
tolerating it well. She was receiving Prevacid for
prophylaxis.
1. GU: After her initial resuscitation around surgery, the
patient significantly volume overloaded. Once stabilized
hemodynamically, this required gentle diuresis. Her
creatinine was slightly elevated to peak of 1.4, but had
returned to [**Location 213**] prior to discharge. She was still 6 kg
up. Her last weight on [**4-5**] was 70 kg. Her baseline
was 64 kg. It was recommended still to continue gentle
diuresis as we had been doing, and she seemed to be
tolerating it well.
1. HEME: As noted on admission, the patient was
significantly neutropenic and just needed to be supported
by G-CSF. Blood counts, thereafter, improved. Her last
white count was 15.2 on [**4-5**]. Her hematocrits have
remained stable around 29/30 over the last few days.
Throughout her hospitalization, she did require
intermittent transfusions of blood and platelets, but none
in the period prior to discharge.
1. ID: Of note, her immediate postop course was significant
for sepsis and septic shock. She was broadly covered with
antibiotics, including vancomycin, Levaquin, Flagyl, and
fluconazole. Her OA positive culture was 1 out of 2
bottles of blood culture from the 22, the day of her
admission, which grew presumptive Clostridium septicum.
Once afebrile and her white counts were normal, this
regimen was stopped. On [**3-28**], she had a low-grade temp
and a slight elevation in her white count. At that point,
cultures were taken, and a central line that she had in
her IJ was removed. Her catheter, as well as 1 out of 4
bottles of blood grew Staph coag-negative, and her sputum
on that day grew Pseudomonas and MRSA. She was,
therefore, treated with Zosyn and vancomycin. She is now
7 days on these antibiotics, and the plan was to complete
a 10-day course for suspected possible bacteremia. She
has remained afebrile, hemodynamically stable, with a mild
and stable elevation of her white count over the last few
days.
1. MUSCULOSKELETAL: Because of her CVA, she was not moving
her left side, and her left side seemed to be slightly
more swollen. Work-up for that included an ultrasound
which was negative for DVT. She will probably need
occupational therapy to be involved in her care with a
question of splints for her left upper extremity. She was
seen by the oncology service, radiation oncology service
and the orthopedic service here for questions regarding
further treatment of her osteosarcoma. It was felt that
at this point treatment, the patient would not be a good
surgical candidate for an amputation, but would possibly
benefit, at least initially, from radiation treatment, but
even that should wait until the patient further recovers.
She will need to follow-up with the oncology service in
the future who will coordinate her care between radiation
oncology and possibly orthopedics later on. She was
discharged to rehab in stabile condition and with the
following recommendations.
DISCHARGE RECOMMENDATIONS:
1. Continue meds as listed in .
2. Continue PT, OT and respiratory rehabilitation.
3. Follow-up with oncology in 2 weeks.
4. Follow-up with surgery and scheduling on the same date
would be optimal.
DISCHARGE DIAGNOSES:
1. Small bowel obstruction.
2. Ischemic small bowel.
3. Exploratory laparotomy, status post small bowel resection
and ileostomy.
4. Sepsis.
5. Bacteremia.
6. Respiratory failure, status post tracheostomy.
7. Status post percutaneous endoscopic gastrostomy.
8. Osteosarcoma, right lower extremity.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **]
Dictated By:[**Last Name (NamePattern1) 28297**]
MEDQUIST36
D: [**2124-4-5**] 10:01:56
T: [**2124-4-5**] 11:17:09
Job#: [**Job Number 28298**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6766
} | Medical Text: Admission Date: [**2188-4-19**] Discharge Date: [**2188-4-23**]
Date of Birth: [**2107-4-2**] Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
Bradycardia and seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81yoM with h/o HTN, PR prolongation; otherwise no other
significant cardiac history; also with R sided GBM s/p complete
resection and XRT in [**7-7**], VPS for hydrocephalus and stroke
(found per imaging in [**2-/2188**]) who is admitted to CCU for
syncopal episode this morning, bradycardia, and with GTC seizure
in the ambulance en route to hospital.
.
Most of the history is provided by the pt's wife due to the pt's
minimal verbal interaction, and also per reports. She relates
that she was downstairs this morning when he woke up, when she
heard him fall down upstairs. Apparently the pt was up for at
least 10 mins (on his feet), showering, shaving, getting
dressed, when she heard him fall and went upstairs. He was on
the ground a little dazed, and not moving much, but verbal. She
and her daughter endorse that he hit his head, but was conscious
at this point. After several minutes, he started crawling to,
then got into, his bed.
.
The wife called EMS. They came and found his pulse to be in the
20's and reportedly in a junctional rhythm. She doesn't know any
further vitals or his finger stick. They took him by EMS to
[**Hospital3 10310**]. In the ambulance, she reports he was in the
front seat and the EMS in the back noted he was seizing
(reportedly grand mal) for about 3.5 mins that broke with 5mg IV
Valium.
.
In the [**Hospital1 18**] ED: 97.2 154/78 60 12 99% on 15L (?) NC.
Code stroke called for pt not moving his L side, normal strength
on R. CT head done with prelim report showing: minimally
increased MTT with decreased CBF globally of the right cerebral
hemisphere and no intracranial hemorrhage. Neuro was consulted
in the ED and felt the L sided paralysis to be consistent with
[**Doctor Last Name 555**] Paralysis and that the hypoperfusion seen on the CT scan
was not consistent with a vasculature territory (vessels were
all patent), and so therefore more consistent with a seizure
activity. His L sided "densely hemiplegic" deficits began to
improve by the time the imaging was done in the ED, also more
consistent with seizure.
Also of note in the ED: CXR normal, WBC 10.5 (N86, L9), Hct
45.9, plts 174. Coags normal with slight elevation of PTT,
chemistries normal, CE's negative x1, UA with blood but negative
for infxn.
.
He is admitted to the CCU for workup of his bradycardia; he was
apparently supposed to see Dr. [**Last Name (STitle) 7965**] on Monday (in 2 days)
for evaluation of this bradycardia that has been noted by PCP
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**], who had sent him for Holter, carotid u/s, and echo,
and was down titrating his antihypertensives. His story is
complicated by the fact that he can't get a permanent pacemaker
in light of his frequent MRI's to monitor his brain malignancy.
.
He had some bradycardia and vomiting on arrival to the CCU,
however by evaluation, his hr was in the 50's, bp stable in the
160-170's, satting and breathing OK, and he was not vomiting.
.
ROS is positive as above, also for ataxic gait, occasional
"confusion" characterized as worsening short term memory, and
weight loss from 185 to <150 now, all felt to be consistent by
the family with his known GBM. At his baseline, his family
reports he functions "perfectly," is totally conversant, can
walk, was a practicing attorney until last [**Month (only) 216**], some weakness
on his L side at baseline.
ROS is negative extensively for all other major systems,
including potential sources of infection, etc. to explain
syncopal episode. His wife states he has never had problems with
seizures, or with cardiac dysrhythmias (other than PR
prolongation).
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, hyperlipidemia
2. CARDIAC HISTORY: Has PR prolongation per wife
-CABG: NONE
-PERCUTANEOUS CORONARY INTERVENTIONS: NONE
-PACING/ICD: NONE
3. OTHER PAST MEDICAL HISTORY:
- Brain tumor, glioblastoma. S/p resection [**2186**], by Dr. [**Last Name (STitle) 4887**] at
[**Hospital1 112**]. Also s/p radiation and chemoTx. Has been followed by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 30318**]. Complicated by normopressure hydrocephalus, s/p
shunt, with improvement in his gait disturbance, but still with
problems with memory and executive fxn. Recent admissions in
[**State 108**], [**Location 30319**], [**Hospital1 112**].
- Had small stroke noted on MRI brain per Dr. [**Last Name (STitle) 30318**] in the
field of his prior radiation therapy, with subclinical stroke.
- Residual L sided weakness and gait disorder
- Chronic bradycardia with two syncopal episodes, most recent
before this admission in [**1-/2188**] in [**State 108**], ? due to UTI?
- Hyperlipidemia, currently on Zetia, h/o myalgias with statins
Social History:
Never smoker, no drugs or EtOH.
He is back in his home on the [**Location (un) 1121**]. He had prolonged
hospitalization and rehab stays. He has a supportive family with
physician family members. [**Name (NI) **] has many grandchildren. He formerly
worked as an attorney and an officer of a bank. He has not been
able to work for many months.
Family History:
No family history of sudden cardiac death
Physical Exam:
99.8 R 161/81 L 173/62 p50's 100% on RA
Thin, elderly male in no distress but appears exhausted and
dazed, which apparently is not his baseline. His eyes are open
but he stares, but can be redirected with conversation. He
answers with quiet, simple one word answers but answers
appropriately.
EOMI are grossly intact but cannot follow a finger. Sclera are
clear, not icteric.
Carotid pulsations present bilaterally. No JVD noted, no
hepatojugular reflux. Radiation of AS type murmur heard in L
neck, not in R (sounds more like AS murmur than carotid bruit)
Lungs CTAB but poor air movement. No grossly adventitious lung
sounds.
Heart sounds barely perceptible but best heard at LLSB. A slight
AS type murmur is heard. RRR. PMI is not felt.
Abd soft, NT ND. BS diminished.
BLE without edema, DP's barely palpable. Bilateral radials
fairly thready but palpable.
Has apparent L facial droop. Unable to follow my finger with
eyes, bc not following the commands. His speech is soft but
clear and not grossly dysarthric. He states he has sensation in
his face bilaterally and can hear my fingers snapping
bilaterally. His shoulder shrug is strong bilaterally. He is
spontaneously moving all 4 extremities. L biceps and triceps are
[**4-2**] compared to R, however L hand grip is noticeably weaker than
the R, perhaps [**2-1**] compared to R [**4-2**]. His L arm is tonic/rigid,
but then he moves it spontaneously and the muscular tone is
normal. He can flex at the hip but is slightly weak, 4- to 4+
bilaterally. Distal flexion and extension of LE's is [**4-2**]. Biceps
and triceps reflexes are normal to slightly hyperreflexic.
Patellar and Achilles are bilaterally diminished.
Pertinent Results:
ADMISSION LABS:
[**2188-4-19**] 04:50PM BLOOD WBC-10.5 RBC-4.77 Hgb-15.0 Hct-45.9
MCV-96 MCH-31.4 MCHC-32.6 RDW-12.8 Plt Ct-174
[**2188-4-19**] 04:50PM BLOOD Neuts-85.6* Lymphs-9.1* Monos-4.6 Eos-0.3
Baso-0.4
[**2188-4-19**] 04:50PM BLOOD PT-12.2 PTT-20.2* INR(PT)-1.0
[**2188-4-20**] 04:36AM BLOOD Glucose-116* UreaN-17 Creat-0.8 Na-140
K-3.8 Cl-104 HCO3-29 AnGap-11
[**2188-4-19**] 04:50PM BLOOD ALT-19 AST-23 LD(LDH)-157 CK(CPK)-41*
AlkPhos-62 TotBili-0.6
[**2188-4-20**] 04:36AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
[**2188-4-19**] 04:50PM BLOOD Prolact-26*
[**2188-4-20**] 04:36AM BLOOD Phenyto-11.8
[**2188-4-19**] 05:00PM BLOOD Glucose-124* Na-142 K-3.9 Cl-102
calHCO3-18*
.
Cardiac enzymes:
[**2188-4-19**] 04:50PM BLOOD ALT-19 AST-23 LD(LDH)-157 CK(CPK)-41*
AlkPhos-62 TotBili-0.6
[**2188-4-19**] 04:50PM BLOOD CK-MB-NotDone
[**2188-4-19**] 04:50PM BLOOD cTropnT-<0.01
[**2188-4-20**] 04:36AM BLOOD CK(CPK)-52
[**2188-4-20**] 04:36AM BLOOD CK-MB-NotDone cTropnT-<0.01
.
Urinalysis
[**2188-4-21**] 02:54AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2188-4-21**] 02:54AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2188-4-19**] 04:50PM URINE RBC-21-50* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2188-4-19**] 04:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2188-4-19**] 04:50PM URINE Blood-LG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Labs on discharge:
[**2188-4-23**] 05:25AM BLOOD WBC-6.3 RBC-4.29* Hgb-13.5* Hct-40.2
MCV-94 MCH-31.4 MCHC-33.6 RDW-13.3 Plt Ct-143*
[**2188-4-21**] 03:40AM BLOOD Neuts-76.7* Lymphs-13.4* Monos-7.1
Eos-2.5 Baso-0.4
[**2188-4-23**] 05:25AM BLOOD PT-12.3 PTT-30.1 INR(PT)-1.0
[**2188-4-23**] 05:25AM BLOOD Glucose-85 UreaN-17 Creat-0.9 Na-139
K-3.8 Cl-102 HCO3-32 AnGap-9
[**2188-4-23**] 05:25AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9
.
[**2188-4-19**] CTA head
IMPRESSION:
1. The patient is status post right temporal craniotomy. Shunt
catheter is
visualized via right frontal burr hole and terminating at the
level of the
foramen of [**Last Name (un) 2044**]. There is no evidence of significant
enhancement to suggest recurrence or tumor activity. There is no
evidence of acute intracranial hemorrhage. Chronic microvascular
ischemic disease is visualized.
.
2. Mild increased mean transit time with decreased cerebral
blood flow
globally is noted in the right cerebral hemisphere, possibly
consistent with mild ischemia or recent seizure activity.
.
3. Calcified plaques are visualized in the carotid siphons, more
significant on the left with moderate stenosis.
.
4. Pulmonary nodule is identified in the left lung, correlation
with CT of
the chest is recommended for further characterization of this
nodule.
This finding was notified in the critical radiology findings
dashboard.
.
[**2188-4-19**] CXR
.
SINGLE FRONTAL VIEW OF THE CHEST: Lungs are clear without
consolidation or
pleural effusion. There is no pneumothorax. The heart size is
normal. There is no hilar or mediastinal enlargement. The aorta
is mildly tortuous. Pulmonary vascularity is normal.
.
IMPRESSION: No acute cardiopulmonary abnormality.
[**2188-4-21**] CT Chest:
Impression:
The spiculated nodule in the left apex is concerning for a
primary lung cancer and could be further assessed with a PET/CT.
Brief Hospital Course:
81M with history of hypertension, hyperlipidemia, glioblastoma
multiforme s/p resection and XRT in [**7-7**], VPS for hydrocephalus
and stroke admitted to the CCU for syncopal event, bradycardia,
and generalized tonic clonic siezure.
.
#BRADYCARDIA: The patient was admitted to the CCU on telemetry.
He was noted to have 2 further episodes of bradycardia, once in
the setting of nausea and vomiting, and another in the setting
of carotid palpation during physical exam, however his pulse
recovered without intervention. His symptoms were thought to be
vasovagal. The patient was evaluated by the electrophysiology
service with the recommendation being conservative management
given it was not felt that a PPM would not prolong his life or
improve his symptoms in this setting. There was also concern
given that he requires serial MRIs to track his glioblastoma
which would not be possible with a pacemaker. His heart rate was
monitored with pulses maintained in the fifties, normotensive,
with no concerning symptoms (dizziness, syncope). Upon transfer
to the medical floor it was decided that no aggressive
intervention would be implemented to treat his bradycardia.
Telemetry was discontinued per family wish. Decision that no
atropine or pacer pads would be used. Fortunately these were
not necesary during his hospitalization.
# SEIZURE: Pt had a witnessed 3 minutes GTC seizure in the
ambulance which broke with 5mg IV Valium. Neuro consulted in the
ED for L sided paralysis, which was thought to be Toddy's
paralysis. Left sided weakness improved over the course of the
hospitalization. He was initially started on dilantinbut there
was concern about worsening fatigue. He was changed to Keppra,
which he will continue as an outpatient, in consultation with
his outpatient neurologist. Follow up with neurology was also
arranged.
.
# GBM: The pt's neuro-oncologist was made aware of the pt's
admission. CT head/neck noted a lung nodule which was further
characterized on CT Thorax. PET scan was recommended as follow
up for potential primary lung cancer. Family was aware of the
nodule at time of discharge. Radiology was placed on CD and
given to family at time of discharge.
#Goals of care: Discussion of palliative care was brought up by
Dr. [**Last Name (STitle) 1007**] prior to discharge. Family is presently considering
options regarding further treatment vs palliative care. This
will be a continuing discussion as outpt.
Medications on Admission:
Reconciled with wife's home list.
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth daily
DONEPEZIL [ARICEPT] - (Prescribed by Other Provider) - 5 mg
Tablet - 1 Tablet(s) by mouth daily
ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth daily
EZETIMIBE [ZETIA] - 10 mg Tablet - 1 Tablet(s) by mouth daily
.
LOSARTAN [COZAAR] - 100 mg Tablet - 1 Tablet by mouth daily
--> reduced dose to 50mgs on [**2188-3-25**]
.
PREDNISONE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth daily
TESTOSTERONE [ANDROGEL] - (Prescribed by Other Provider) - 1.25
gram per Actuation (1 %) Gel in Metered-dose Pump - 2 squirts
daily
.
Medications - OTC
ASPIRIN [BABY ASPIRIN] - (OTC) - 81 mg Tablet, Chewable - 1
Tablet(s) by mouth daily
B COMPLEX VITAMINS - (OTC) - Capsule - 1 Capsule(s) by mouth
daily
BISACODYL [DULCOLAX] - (OTC) - 5 mg Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth daily
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) -
Tablet - 1 Tablet(s) by mouth daily
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO twice a day: From [**Date range (1) **], please give 1 capsule in morning
and 1 at night. From [**Date range (1) 30320**], give 1 capsule in morning only.
then stop.
Disp:*8 Capsule(s)* Refills:*0*
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aricept 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. B Complex Vitamins Capsule Sig: One (1) Capsule PO once
a day.
13. AndroGel 1.25 g/Actuation Gel in Metered-dose Pump Sig: Two
(2) squirts Transdermal once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
primary:
bradycardia
grand mal seizure
secondary:
Gliobastoma Multiforme
NPH with VPL
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 30321**] - It was a pleasure to care for you during your
hospitalization. You were admitted with low heart rate and
seizure.
After discussion with Dr. [**Last Name (STitle) 30318**] and our neurology consultants
here, the decision was made to taper on a new anti-seizure
medication, called Keppra (or Levetiracetam). Please take:
1) Keppra 500mg twice a day. You will need this medication for
the rest of your life.
.
Continue to take dilantin (phenytoin) as follows:
1. Dilantin 100 mg po at morning and night on [**4-23**]
2. Dilantin 100 mg po at morning on [**4-26**]
Then stop taking dilantin
Please continue to take all your prior medications as
prescribed. Please keep all your follow up appointments.
Followup Instructions:
Department: INTERNAL MEDICINE
When: WEDNESDAY [**2188-4-30**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD [**Telephone/Fax (1) 10492**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 24**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: Neuro-oncology, [**Hospital3 328**] Cancer Institute
When: Wednesday [**2188-4-30**] 9:00am
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 30318**], MD [**Telephone/Fax (1) 30322**]
Address: [**Hospital Ward Name 30323**], [**Location (un) 86**] MA
Department: NEUROLOGY
When: MONDAY [**2188-5-5**] at 4:30 PM
With: DRS. [**Name5 (PTitle) 162**] & [**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
Completed by:[**2188-4-24**]
ICD9 Codes: 2720, 311, 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6767
} | Medical Text: Admission Date: [**2160-8-19**] Discharge Date: [**2160-8-23**]
Date of Birth: [**2104-8-13**] Sex: M
Service:
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Coronary artery disease status post myocardial infarction
in [**2147**].
PAST PSYCHIATRIC HISTORY:
1. Knee surgery.
2. Appendectomy.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 q.d.
2. Lipitor ....................
3. Atenolol 100 q.d.
ALLERGIES: The patient has no known drug allergies.
HISTORY OF THE PRESENT ILLNESS: The patient is a 56-year-old
man status post myocardial infarction in [**2147**],
catheterization of one vessel and now a catheterization in
[**2150**]. The patient has recently been having chest discomfort
symptoms, similar to his previous myocardial infarction. The
patient was referred to [**Hospital1 69**]
for further follow up and treatment. The patient had
positive echocardiogram and EKG from an outside hospital.
PHYSICAL EXAMINATION: Examination revealed the following:
Vital signs: Blood pressure 161/65. CARDIOVASCULAR:
Regular rate and rhythm, no murmur. Chest was clear to
auscultation bilaterally. ABDOMEN: Soft, nontender,
nondistended, bowel sounds positive. EXTREMITIES: Warm and
perfused.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2160-8-19**] at which time coronary artery bypass graft times
three with LIMA to LAD, SVG to RCA and left radial to OM1 was
performed. The procedure was without complications. Pacing
wires. as well as mediastinal and pleural chest tubes were
placed intraoperatively. The patient was transferred in good
condition.
On postoperative day #1, the patient was extubated without
complications. The patient was afebrile. Vital signs were
stable. He was started on oral Lopressor and transferred to
the floor in stable condition. On postoperative day #2, the
patient had a low grade fever of 100.3. Vital signs were
stable. The wires were removed without complication. The
patient was ambulating and working with PT. The temperature
decreased with extensive pulmonary toilette. On
postoperative day #3, the patient was afebrile. The vital
signs were stable. The patient passed step 5 of PT. There
were no issues. No active concerns. The patient will be
sent home on postoperative day #4.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient should follow up with Dr. [**Last Name (STitle) 1537**]
in one month for postoperative check.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg PO b.i.d.
2. Lasix 20 mg PO b.i.d. times 7 days.
3. Potassium chloride 20 mEq one tablet PO b.i.d. times 7
days.
4. Docusate sodium 100 mg PO b.i.d.
5. Enteric coated aspirin 325 mg PO q.d.
6. Tylenol 650 mg q.6h.p.r.n.
7. Motrin 400 mg, one tablet PO q.8h.p.r.n.
8. Percocet one tablet to two tablets PO q.4h. to 6h.p.r.n.
for pain.
9. Isosorbide mononitrate ....................mg PO q.d.
10. Atorvastatin 20 mg PO q.d.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. Hypercholesterolemia.
3. Coronary artery disease status post myocardial infarction
status post coronary artery bypass graft.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 15509**]
MEDQUIST36
D: [**2160-8-22**] 13:12
T: [**2160-8-22**] 13:34
JOB#: [**Job Number 44444**]
ICD9 Codes: 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6768
} | Medical Text: Admission Date: [**2196-5-24**] Discharge Date: [**2196-6-1**]
Date of Birth: [**2128-3-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Codeine / Iodine
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Surgical reconstruction of metastatic Breast Cancer to sternum
Major Surgical or Invasive Procedure:
Left breast CA in past s/p left dorsi/gel implant. Now with
metastatic breast Cancer to sternum. S/P sternectomy and
reconstruction with [**Doctor Last Name **]-tex mesh to chest wall by Thoracic [**Doctor First Name **]
with pedicled left dorsi flap by plastic surgery, 4 [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] drains, 2 chest tubes
History of Present Illness:
68yo female with h/o L breast CA in past s/p left dorsi/gel
implant. Now with metastatic breast CA to sternum. S/P
sternectomy and reconstruction with [**Doctor Last Name **]-tex mesh to chest wall
by CT [**Doctor First Name **] with pedicled l dorsi flap by us. 4 drains, 2 Chest
tubes
Past Medical History:
Left breast cancer s/p mastectomy and reconstruction,
Hypertension, dyslipidemia
Social History:
Husband died in [**2195-11-30**]. Six children.
50 pk year smoker. ETOH [**5-4**] drinks/wk- now decreased to 4
drinks/wk.
Family History:
Breast cancer in 2 sisters. One sister deceased from bone
cancer.
Physical Exam:
General: well appaering female in NAD.
HEENT: Atraumatic. PEERL. EOMI. Sclera white. Throat -no
erythema.
Heart: RRR No murmur, no rub.
LUNGS: CTA bilat. Chest -ridge noted to left of midline of
sternum post surgery.
ABD: soft, NT, ND, +BS
Extrem: no C/C/E.
Pertinent Results:
[**2196-5-24**] 07:05PM GLUCOSE-125* UREA N-13 CREAT-0.5 SODIUM-141
POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-21* ANION GAP-13
[**2196-5-24**] 07:05PM WBC-8.4 RBC-3.82* HGB-11.3* HCT-32.8* MCV-86
MCH-29.5 MCHC-34.3 RDW-13.5
[**2196-5-24**] Pathology Tissue: STERNAL MARGIN,PARTIAL [**2196-5-24**]
[**Last Name (LF) **],[**First Name3 (LF) 2389**] M. Not Finalized
Brief Hospital Course:
68 yo female with T2 N1 stage IIB carcinoma of the left breast
with mastectomy and immediate reconstructionin [**2181**] who presents
with adeno carcinoma of sternum.
Pt was taken to the OR 4/ 26/05 for sternal resection and
reconstruction.
operative course was uneventful. Pt was kept intubated until
POD#1 then weaned to extubate. Pain was managed w/ epidural
Bup/Dilaudid). Sternal flap was well profused. Kefzol for JP
drain prophylaxis. Chest tubes right/left placed in OR to SXN w/
serosang drainage. JP drains x4 to bulb sxn.
POD #3 JP #1 d/c'd and chest tube to water seal. Right chest
tube d/c'd and left chest tube clamped then d/c'd on POD#4. Left
chest tube and two additional JP's d/c'd on POD #7.
Flap continued to heal well. Progressed w/ ambulation, po's and
epidural transitioned to po pain med.
POD #8 pt d/c'd to home with one remaining JP drain in place and
on po keflex until follow up appointment with plastics [**2196-6-10**]
for JP drain removal.
Medications on Admission:
Atenolol 25", Lovastatin, Xanax, Wellbutrin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 weeks: continue taking until the JP drain is
removed AND you have [**Doctor First Name **] told to stop taking the antibiotic.
Disp:*56 Capsule(s)* Refills:*0*
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Amoxicillin 500 mg Capsule Sig: Four (4) Capsule PO times one
for once days: take all 4 pills one hour prior to your dental
appointment.
Disp:*4 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Breast CA
sternal resection and flap reconstruction
Discharge Condition:
good.
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] for: shortness of breath,
fever, chest pain, or redness or discharge from incision sites.
Call Plastic Surgery office for issues with your JP drain
[**Telephone/Fax (1) 274**]. for: a follow up appointment
Resume medications as previous to hospitalization.
Take all medications as directed.
Obtain medical alert bracelet to indicate lack of sternal bone.
You may shower on thursday; no tub baths for 3-4 weeks.
Chest tube dressings may be removed on thursday and replaced
with a bandaid.
Followup Instructions:
Call Dr.[**Doctor Last Name 4738**] office for appointment in [**1-31**]
weeks-[**Telephone/Fax (1) 170**]. Please arrive to your Dr. [**Last Name (STitle) **] appointment
45 minutes prior for a follow up Chest XRAY- [**Location (un) **] radiology
[**Hospital Ward Name 23**] Clinical Center.
You have a Plastic Surgery Clinic appointment on [**2196-6-10**] at
1:30pm- [**Telephone/Fax (1) 274**].
Dr. [**Last Name (STitle) 1435**] office: [**Street Address(2) **]., [**Location (un) **], Ma. Phone
[**Telephone/Fax (1) 1416**]
Completed by:[**2196-6-3**]
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6769
} | Medical Text: Admission Date: [**2154-6-3**] Discharge Date: [**2154-6-8**]
Date of Birth: [**2107-5-11**] Sex: F
Service: VSU
CHIEF COMPLAINT: Aortoiliac disease.
HISTORY OF PRESENT ILLNESS: 47-year-old non-diabetic white
female with hypertension, hypercholesterolemia, seizure
disorder, schizo-affective disorder, gastroesophageal reflux
disease, asthma, who continues to smoke two packs of
cigarettes per day complained of bilateral hip and thigh
claudication and rest pain.
The patient had been admitted to the hospital in [**Month (only) 547**] and
had undergone an aortogram with bilateral run off via the
left brachial artery on [**2154-5-13**]. The study showed severely
diseased infrarenal aorta with complete occlusion of
bilateral external and internal iliac arteries. There was
reconstitution of the common femoral artery bilaterally with
severe disease at the common femoral artery level. Both
profunda arteries were patent.
The cardiology service cleared the patient for surgery after
an exercise Thallium stress test was done which was normal
and showed an ejection fraction of 77%
Several days after discharge the patient was readmitted with
complaints of left upper arm hematoma with numbness and
tingling of the left fingers. Her left radial and ulnar
arteries were not palpable. An ultrasound confirmed
occlusion of the left brachial artery. The patient underwent
a left brachial artery thrombectomy and primary repair on
[**2154-5-17**].
The patient now presents for an elective aortobifemoral
bypass graft.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Gastroesophageal reflux disease.
4. Migraine headaches.
5. Schizo-affective disorder.
6. Seizure disorder; most recent episode one month ago.
7. Asthma; last exacerbation was one year ago.
8. History of goiter.
9. Chronic low back pain following trauma.
10. Vertigo.
11. Cystocele causing urinary incontinence.
PAST SURGICAL HISTORY:
1. Tonsillectomy.
2. Ovarian cyst [**2144**].
3. Excision of benign right axillary mass.
4. Right tibial fracture.
5. Thrombectomy of the left brachial artery on [**2154-5-17**] by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
FAMILY HISTORY: Significant for myocardial infarction.
Maternal aunts two sons diagnosed with myotonia congenita.
SOCIAL HISTORY: The patient lives alone. She has been
smoking two to three packs of cigarettes per day for almost
30 years. Currently she smokes two packs of cigarettes per
day. She ambulates independently. She is divorced times
two. She has two adult sons and a stepdaughter, who is
supportive.
ALLERGIES: Penicillin.
Demerol.
Pistachios.
MEDICATIONS:
1. Lisinopril 10 mg p.o. q day.
2. Lipitor 20 mg p.o. q h.s.
3. Topamax 200 mg p.o. twice a day.
4. Prolixin 5 mg p.o. q AM.
5. Seroquel 50 mg p.o. q h.s.
6. Nexium one capsule p.o. q day.
7. Vicodin p.r.n. pain.
PHYSICAL EXAMINATION: Vital signs: Pulse 110, respirations
20, blood pressure 126/74. Height 4 feet, 11 inches, weight
154 pounds. General: Alert, cooperative white female in no
acute distress. Chest: Heart regular rate and rhythm without
murmur. Lungs clear bilaterally. Abdomen soft, nontender,
bowel sounds active. No masses or bruits. Extremities:
Left brachial artery incision well healed. Feet equally
warm. Right foot has rubor with mildly dusky toes. Pulse
oximetry, carotid pulses 1+ bilaterally without bruits.
Right radial pulse is nonpalpable but has a Doppler signal.
Left radial pulse is 1+. Femoral pulses and pedal pulses
have Doppler signals bilaterally. Neurologic examination:
Alert and oriented times three. Cranial nerves 2 through 12
intact. Motor and sensory function intact. Romberg
negative.
LABORATORY FINDINGS: White blood cells 10.6, hemoglobin
13.6, hematocrit 40.2. Platelets 267,000. Prothrombin 12.2,
PTT 25.6, INR 1.0. Sodium 139, potassium 4.1, chloride 107,
bicarbonate 19, BUN 15, creatinine 0.6, glucose 94. Calcium
9.6, phosphorus 4.5, magnesium 2.0. Urinalysis negative.
Chest X-ray showed no acute pulmonary disease. EKG showed a
normal sinus rhythm at a rate of 90. Abnormal R-wave
progression present.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2154-6-3**]. On [**2154-6-4**] the patient underwent an uneventful
aortobifemoral bypass graft with right profundoplasty. At
the end of surgery the patient had equally warm feet with
dopplerable pedal pulses bilaterally. She received
Vancomycin perioperatively.
Postoperative pain was managed with a Dilaudid PCA. The
Acute Pain Service followed the patient.
On postop day two, the patient's nasogastric tube was
removed. She was started on clear liquids the following day
and advanced to a regular diet without difficulty.
Physical Therapy evaluated the patient and recommended short-
term rehabilitation stay initially. However, patient had no
insurance benefits for rehabilitation stay. Physical therapy
worked with the patient until she was able to ambulate well
on her own. They recommended home physical therapy at
discharge.
Lopressor was started for heart rate control. The patient
continued on her Lisinopril as well.
During hospitalization the patient said that she wanted to
stop smoking and was ordered the nicotine patch. By postop
day four she had removed the Nitroglycerin patch and had been
found smoking in the patient room bathroom. She was reminded
again of the dangers of wearing the nicotine patch and
smoking at the same time. She planned to continue using the
nicotine patch and not resuming smoking cigarettes.
At the time of discharge the patient's abdominal and groin
incisions were clean, dry and intact. She had dopplerable
pedal pulses bilaterally. She was instructed to follow-up
with Dr. [**Last Name (STitle) **] in the office in one to two weeks for
surgical staple removal.
DISCHARGE MEDICATIONS:
1. Lisinopril 10 mg p.o. q day, to be restarted at home.
2. Lipitor 20 mg p.o. q h.s, to be restarted when home.
3. Lopressor 50 mg p.o. twice a day.
4. Topamax 200 mg p.o. twice a day.
5. Prolixin 5 mg p.o. q AM.
6. Seroquel 50 mg p.o. q h.s.
7. Pepcid 20 mg p.o. twice a day.
8. Nicotine patch 21 mg/24 hour apply q day.
9. Percocet one to two tabs p.o. q 4 to 6 hours p.r.n. pain.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: Home with VNA services.
PRIMARY DISCHARGE DIAGNOSIS:
1. Aortoiliac disease.
2. Aortobifemoral bypass graft and right profundoplasty on
[**2154-6-4**].
SECONDARY DIAGNOSIS:
1. Current cigarette smoker; quitting smoking using the
nicotine patch.
2. Hypertension.
3. Hyperlipidemia.
4. Schizoaffective disorder.
5. Seizure disorder.
6.
Asthma.
7. Gastroesophageal reflux disease.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Dictated By:[**Last Name (NamePattern1) 7259**]
MEDQUIST36
D: [**2154-6-11**] 10:59:27
T: [**2154-6-11**] 11:49:21
Job#: [**Job Number 98001**]
ICD9 Codes: 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6770
} | Medical Text: Admission Date: [**2136-7-8**] [**Month/Day/Year **] Date: [**2136-7-24**]
Date of Birth: [**2064-2-24**] Sex: F
Service: MEDICINE
Allergies:
Streptomycin / Versed / Fentanyl
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest Pain and SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP:[**Name Initial (NameIs) 7274**]: [**Last Name (LF) 8682**], [**Name8 (MD) **] MD
Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL
GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 133**]
Fax: [**Telephone/Fax (1) 445**]
Email: [**University/College 12500**]
Date : [**2136-7-8**]
Time 4:48 am
History obtained from Russian interpreter over the telephone.
72yo Russian speaking F with h/o diastolic CHF recently
discharged 2 weeks ago here with 5 lb weight gain, SOB,
worsening LE edema and CP x 3 days. Similar to previous
admission. She been taking meds at home as prescribed- asked the
interpretor this many times. She has a home VNA that assists her
with her pills 2x per day. Neg cath for CAD [**1-15**]. She only CP
and SOB when she walks around and not at rest. She also has R
sided abominal pain. CD improved with 1 SLNG. Received lasix 80
mg IV with diuresis. She is not very active at baseline because
of leg swelling and leg pain. She can only walk 10 yards. She
uses CPAP at home. She has a VNA who comes and checks her
weight/BP twice per week. She does not have daily weight and BP
monitoring daily.
Discussed diet with daughter with daughter who confirms that she
is has a low salt diet. Her husband cooks for her.
In ER: (Triage Vitals: 98.4, 104/48, 77, 20, 97% RA)
Meds Given: SLNG x T, lasix 80 mg IV x T
Fluids given: none/380 cc out
[**Month/Year (2) **] Studies: portable CXR, increased pulmonary vasculature
consults called: none
PAIN SCALE: [**10-14**] in both legs
She also developed pin point 5/10 chest pain in the L chest
without radiation worse with palpation during the encounter.
________________________________________________________________
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [] All Normal
[] Fever [+] Chills 1 week ago [ ] Sweats [ ] Fatigue [ ]
Malaise [ ]Anorexia [ ]Night sweats
[+] _5___ lbs. wt gain over _2____weeks
HEENT: [] All Normal
[ ] Blurred vision [-] Blindness [ ] Photophobia
[ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums
[ ] Oral ulcers [- ] Sore throat [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ]Tinnitus [ ] Other:
RESPIRATORY: [] All Normal
[+ ] SOB [ ] DOE [+] Can't walk 2 flights [+] Dry
cough x 1 day
[ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic
pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Angina [ ] Palpitations [+] Edema [ ] PND
[ ] Orthopnea [+] Chest Pain [ ] Other:
GI: [] All Normal
Last BM - [**2136-7-7**]
[ ] Blood in stool [ ] Hematemesis [ ] Odynophagia
[ ] Dysphagia: [ ] Solids [ ] Liquids
[ ] Anorexia [-] Nausea [-] Vomiting [ ] Reflux
[ ] Diarrhea [+] Constipation [+] Abd pain [ ] Other:
GU: [] All Normal
[ ] Dysuria [ ] Frequency [ ] Hematuria [][**Month/Day/Year **]
[]Menorrhagia
SKIN: [] All Normal
[ ] Rash [ ] Pruritus
MS: [] All Normal
[X]B/L leg pain[ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [] All Normal
[ ] Headache [-] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [+ ] Dizziness/Lightheaded with
standing[+]Vertigo [ ] Headache [+]Dizziness when she moves her
head from side to side
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Temp subjectivity
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [X] All Normal
[] Mood change []Suicidal Ideation [ ] Other:
[X]all other systems negative except as noted above
Past Medical History:
1. Atrial fibrillation
2. Hypertension
3. Dyslipidemia
4. Obstructive sleep apnea with secondary pulmonary HTN (on
CPAP)
5. Chronic diastolic heart failure
6. Type 2 Diabetes Mellitus
- [**2135-1-31**] HbA1c 7.7 [**2135-8-24**]
7. Chronic Renal Failure
8. S/p lap appy ([**9-11**])
9. Diabetic neuropathy
10. Osteoporosis
11. h/o cataract surgery
Social History:
Lives with her husband. Denies alcohol, tobacco, or illicit drug
use.
Family History:
Non-contributory. Mother: died of 'old age' at 73, Father:
killed during the war.
No other family members with heart disease.
Physical Exam:
PAIN SCORE [**5-14**]
VS T = 97.3 P = 67 BP = 106/60 RR = 20 O2Sat =100% RA Wt, ht,
BMI
GENERAL:Obese female laying in bed. She is in NAD.
Nourishment: good
Grooming: good
Mentation: Alert, speaking in full sentences
Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory:Decreased BS throughout, not moving a great deal of
air.
Cardiovascular: RRR, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
2+ edema b/l. DPP pulses barely appreciatd b/l.
Xerosis of b/l feet noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or
inguinal lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
Psychiatric: Appropriate full affect
Pertinent Results:
EKG: Atrial fibrillation at 91 bpm, no acute changes
Admission CXR: Increased interstitial markings, ? L pleural
effusion
Admission Labs:
[**2136-7-8**] 01:19AM PT-23.1* PTT-24.7 INR(PT)-2.2*
[**2136-7-8**] 12:40AM GLUCOSE-278* UREA N-47* CREAT-2.4* SODIUM-133
POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-32 ANION GAP-15
[**2136-7-8**] 12:40AM estGFR-Using this
[**2136-7-8**] 12:40AM cTropnT-<0.01
[**2136-7-8**] 12:40AM proBNP-3101*
[**2136-7-8**] 12:40AM WBC-5.8 RBC-2.81* HGB-7.8* HCT-25.2* MCV-90
MCH-27.7 MCHC-30.9* RDW-18.8*
[**2136-7-8**] 12:40AM NEUTS-74.3* LYMPHS-18.6 MONOS-4.6 EOS-2.1
BASOS-0.4
[**2136-7-8**] 12:40AM PLT COUNT-166
[**2136-7-8**] 12:40AM BLOOD TSH-7.9*
Labs on [**Month/Day/Year **]:
[**2136-7-24**] 06:10AM BLOOD WBC-4.8 RBC-3.52* Hgb-10.0* Hct-31.5*
MCV-90 MCH-28.6 MCHC-31.9 RDW-21.4* Plt Ct-156
[**2136-7-24**] 06:10AM BLOOD PT-20.6* PTT-26.9 INR(PT)-1.9*
[**2136-7-24**] 06:10AM BLOOD Glucose-181* UreaN-46* Creat-1.8* Na-140
K-3.9 Cl-97 HCO3-34* AnGap-13
[**2136-7-24**] 06:10AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.2
Other Notable Labs:
[**2136-7-11**] 07:08AM BLOOD ALT-15 AST-26 CK(CPK)-43 AlkPhos-69
TotBili-0.5
[**2136-7-16**] 12:05PM BLOOD Type-ART pO2-84* pCO2-64* pH-7.49*
calTCO2-50* Base XS-21 Intubat-NOT INTUBA
[**2136-7-16**] 12:05PM BLOOD Lactate-0.9
[**2136-7-10**] BLOOD Cr 3.2
[**2136-7-13**] BLOOD Cr 1.5
[**2136-7-21**] BLOOD Cr. 2.6
TTE [**2136-7-11**]:
The left atrium is mildly 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. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is probably normal (LVEF>55%). There is no ventricular
septal defect. The right ventricular cavity is dilated with
depressed free wall contractility. 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. Mitral
regurgitation is present but cannot be quantified. The tricuspid
valve leaflets are mildly thickened. At least 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 [**2136-1-30**],
the degree of TR seen has probably increased.
Right Cardiac Cath [**2136-7-13**]:
1. Invasive hemodynamics using swan-ganz catheter demonstrated
elevated
ventricular filling pressures, and normal cardiac output.
2. The pulmonary vascular resistance was high-normal.
FINAL DIAGNOSIS:
1. Elevated ventricular filling pressures.
2. Normal cardiac output.
Brief Hospital Course:
Floor Course:
Admitted to [**Hospital1 18**] for chest pain and shortness of breath, and an
acute diastolic CHF exacerbation. On the floor she was given
Lasix with initially good urine output. However, she became
oliguric and increasingly dyspneic, hypotensive in the setting
of decompensated heart failure. She was transfered to the [**Hospital Ward Name 332**]
ICU for close management.
[**Hospital Ward Name 332**] ICU course:
#Atrial Fibrillation/A Flutter: Decompensated heart failure was
likely driving A. fib. She was rate controlled with Diltiazem
and Metorpolol and home. EP assessed patient and recommended we
start Amiodarone drip which showed some rate control.
#Hypotension: Pt was hypotensive upon arrival to ICU. She was
started on empiric antibiotics (Vanco and Cefepine) for coverage
of possible sepsis. All cultures came back negative.
Hypotension likely attributed to decompensated heart failure
with intravascular hypovolemia. She had cardio-renal syndrome
and was put on both pressors and lasix drip.
#Acute Renal Failure: Cr increased, secondary to pre-renal and
poor forward flow. Renal was consulted and encouraged lasix.
#Diabetes: Had a few hypoglycemic episodes, given D5W.
#Hypothyroidism: Continued her home thyroid medications.
#Sleep Apnea: Has sleep apnea, uses CPAP at home.
CCU Course:
The patient is a 72yo female with h/o dCHF, DM2, a fib and
recent CHF exacerbation who was admitted to [**Hospital1 18**] on [**2136-7-8**] with
chest pain, SOB, and acute on diastolic CHF exacerbation. She
was transferred to the [**Hospital Ward Name 332**] ICU for hypotension in the setting
of decompensated heart failure. EP recommended cardiac cath to
evaluate whether patient's hypotension was cardiogenic in
nature. The patient was started on amiodarone and diltiazem for
a flutter/a fib. She required pressors to maintain BP while she
underwent aggressive diuresis as treatment for her heart
failure.
#) Hypotension: The differential for the patient's hypotension
included worsening dCHF, intravascular volume depletion, and
acute blood loss in setting of supratherapeutic INR. She was
aggressively diuresed, initially on a Lasix gtt. She had a CVL
and Swan catheter placed to monitor the cardiogenic portion of
her hypotension. Right cath on [**2136-7-13**] revealed elevated
ventricular filling pressures and normal cardiac output. The
pulmonary vascular resistance was high-normal. She required
pressors initially to maintain her BP while she underwent
aggressive diuresis for diastolic CHF, but was able to be weaned
off pressors with more stable blood pressures by [**2136-7-12**]. Swan
catheter was removed on [**2136-7-16**].
#) Acute on Chronic Heart Failure: Thought to be diastolic heart
failure, and a TTE obtained during the admission revealed LVEF
of 55-60%. Right heart cath findings were consistent with dCHF,
revealing elevated ventricular filling pressures and LVEF of
55%. The patient was thought to be up to 30 pounds over her dry
weight, and was aggressively diuresed. She was initially on a
lasix gtt, and was later transitioned to IV Lasix boluses. She
also received a course of diamox in the setting of increased
bicarb/metabolic alkalosis, part of a mixed acid-base status
with a concurrent respiratory acidosis. The patient's diuretic
regimen was gradually tailored back, with close monitoring of
her hemodynamics, fluid balance, and renal function.
#) Atrial Fibrillation: Patient was in a fib on admission, and
was monitored on telemetry throughout her hospital course. Her
Coumadin was initially held as her INR was supratherapeutic, but
was later resumed. She was on a heparin gtt at the time. She
received both diltiazem and metoprolol for rate control during
her hospital course, and was started on an amiodarone load. She
underwent a DC cardioversion on [**2136-7-20**], after which she was
temporarily in a rhythm felt to be sinus bradycardia (rate 40s)
with junctional escape and rate in the 60s. Her amiodarone was
continued, but her metoprolol was temporarily held given her
lower HR. She reverted back to a fib prior to [**Date Range **], and
her metoprolol was re-started. She may benefit from a repeat
cardioversion in the future.
#) Acute Kidney Injury: The patient was noted to have poor urine
output and rising Cr, which peaked at 3.2 on [**2136-7-10**]. Her [**Last Name (un) **]
was thought to pre-renal in setting of hypotension/poor forward
flow, and less likely to be intrinsic renal failure. Renal
consult involved early in hospital course. The patient did not
require ultrafiltration, and her Cr trended back to near
baseline at 1.5 on [**2136-7-15**]. However, her Cr rose again to as
high as 2.6 on [**2136-7-21**], likely secondary to continued diuresis
and poor forward flow. Urine electrolytes were not suggestive
of an intrinsic renal etiology. Renal continued to follow, and
recommended decreasing the amount of diuresis as the patient was
nearing her weight prior to her CHF exacerbation.
#) Anemia - The patient's HCT dropped to a low of 21 on
[**2136-7-13**], down from her baseline of 26. In the setting of a
supratherapeutic INR and concern for possible blood loss, she
was transfused one unit PRBCs on [**2136-7-13**]. Per renal recs, she
was also started on epo 3x/week for her anemia. She was also
started on iron prior to [**Date Range **]. Her HCT remained stable for
the rest of the admission.
#) Diabetes Type 2 - She was on an insulin sliding scale during
her hospital course. For her diabetic neuropathy, she received
renally dosed neurontin.
#) Hypothyroidism: She was continued on levothyroxine.
#) Sleep apnea: She was encouraged to use CPAP at night during
her CCU admission.
Medications on Admission:
The patient could not tell the team any of the names of any
pills that she is taking. Her family brought in her medications
and this list is the result of direct inspection of her pill
bottles reviewed on [**2136-7-8**].
ECASA 81mg qd
Torsemide 20mg 2 tabs [**Hospital1 **]
Metoprolol XL 150mg (1.5 tabs 100mg) qd
Gabapentin 300mg tid
Glipizide 5mg [**Hospital1 **]
Spironolactone 25mg qd
Pantoprazole 40mg qd
Warfarin 5mg tabs ([**1-7**] tab Saturday, 1 tab qSunday-[**Month/Day (2) 2974**])
Senna 2 tabs [**Hospital1 **]
Docusate 100mg qd
Vitamin D [**Numeric Identifier 1871**] one dose qweek (husband thinks started a few
weeks PTA)
Folic acid 1mg qd
Diltiazem CD 180mg [**Hospital1 **]
TRICOR 145mg qd
atorvastatin 10mg qhs
Levothyroxine 125 mcg qd
Insulin 70/30 ?15 units (25units qam/15 units qpm)
Nocturnal Oxygen (2L/min) with CPAP at bedtime Please follow up
for Sleep Study for further instructions. [**2131-7-12**]
These medications were not provided by the patient's family, but
appear in her recent records per OMR:
Cyanocobalamin 1,000 mcg/mL Solution 1 ml once a month IM
[**2136-5-7**]
[**Year (4 digits) **] Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: Last day [**7-28**].
Disp:*20 Tablet(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: take on [**7-25**] and [**7-26**], then Dr. [**Last Name (STitle) **] will tell you
what to take.
11. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
12. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for pruritus.
14. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) ml
Injection once a week.
15. Levothyroxine 125 mcg Capsule Sig: One (1) Capsule PO once a
day.
16. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Twenty
Five (25) units Subcutaneous once a day: in the am.
18. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Fifteen
(15) units Subcutaneous at bedtime.
19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
20. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
21. Tuberculin Syringe 1 mL Syringe Sig: One (1) syringe
Miscellaneous once a week.
Disp:*4 syringes* Refills:*2*
22. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
23. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) ml
Injection once a week.
Disp:*4 ml* Refills:*2*
24. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day.
Disp:*30 packets* Refills:*2*
25. Outpatient Lab Work
Please check INR, Chem 7 on thursday [**2136-7-26**] and call results to
Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 133**]
26. Torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
[**Telephone/Fax (1) **] Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
[**Hospital1 **] Diagnosis:
Acute on chronic Diastolic congetive Heart Failure
Acute on chronic Kidney Disease
Fe deficiency Anemia
Atrial Fibillation with rapid ventircular response/Atrial
tachycardia
Diabetes Mellitus type 2
[**Hospital1 **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Hospital1 **] Instructions:
You had an acute exacerbation of your congestive heart failure
and required aggresive diuretics to take off the fluid. Your
kidney function worsened temporarily because of the diureteics
but is improving now. We had some kidney doctors follow [**Name5 (PTitle) **]
[**Name5 (PTitle) 1028**] you were here and they will see you after [**Name5 (PTitle) **] as
well. We cardioverted you to try to restore a normal rhythm to
your heart. This was not effective but we started a new
medicine, Amiodarone, to try to control your heart rate. We may
try another cardioversion in the future. it is very important
that you weigh yourself every morning, call Dr. [**Last Name (STitle) 171**] if
weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days.
You must not eat salt. A low sodium diet was described to you.
Eating too much salt will cause you to be readmitted to the
hospital and will worsen your kidney function.
.
Medication changes:
1. Start taking amidarone to control your heart rate and rhythm.
You will take 2 pills twice a day until Saturday [**7-28**], then
decrease to 1 pill daily. Dr. [**Last Name (STitle) 18542**] will follow your liver and
thyroid function while on this medicine.
2. Increase Toprol to 200 mg daily
3. Decrease Gabapentin to 300 mg daily because of your kidney
function, this may be increased later.
4. Decrease Tricor to 48 mg daily because of your kidney
function, this may be increased later.
5. Discontinue your Lisinopril, spironolactone and Diltiazem
because of your kidney function.
6. Start Epoetin injections every week to help your body make
more red blood cells. Your kidney doctors [**Name5 (PTitle) **] adjust the dose.
7. Start ferrous sulfate (iron) tablets to treat your anemia.
Make sure you take colace and Miralax as this medicine is very
constipating.
8. Decrease your Torsemide to 20 mg daily. Dr. [**Last Name (STitle) 171**] will tell
you when to increase the dose.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2136-8-6**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name 706**]
When: WEDNESDAY [**2136-8-8**] at 3:15 PM
With: [**Year (4 digits) 706**] [**Telephone/Fax (1) 327**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2136-11-12**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],MD
Department: Internal Medicine
When: [**Last Name (NamePattern1) 2974**] [**7-27**] at 10:45am
Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL
GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 133**]
Department: WEST [**Hospital 2002**] CLINIC, NEPHROLOGY
When: THURSDAY [**2136-8-30**] at 8:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2136-7-27**]
ICD9 Codes: 5849, 2851, 2762, 5990, 4280, 2449, 2724, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6771
} | Medical Text: Admission Date: [**2126-10-31**] Discharge Date: [**2126-11-7**]
Date of Birth: [**2063-9-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Lisinopril
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
altered mental status, hyperglycemia, renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 yof with IDDM c/b nephropathy, neuropathy and retinopathy,
htn, and anemia who presents with three days of nausea,
vomiting, cough, and high blood sugars. On the night prior to
admission her sugars where critically high, > 600. She was
evaluated by Dr. [**First Name (STitle) 216**] at her home who recommended 20U of NPH
at night and 40U lispro. She became altered overnight and was
brought into the ED in the AM for hydration. PCP recommended
adjustment of BP medications while hospitalized.
.
In the ED, vs were T101 BP126/60 HR56 RR16 O2 sat 100% 2L.
Her mental status had improved at this point and she was alert
and oriented X 3. She was given Ceftriaxone 1gm, Tylenol 1mg
and Azithromycin 500mg. She refused Levofloxacin. She was
given 2L normal saline. Labs were notable for normal
electrolytes, AG of 15, ketones in the urine. CXR showed left
lower lobe infiltrate.
.
On the floor, pt is refusing to answer questions, affirms
thirst, nausea, vomiting. Admits to low po intake and low urine
output for three days. Asks that all questions be directed to
her husband.
Past Medical History:
DM1, last A1c 8.5% on [**4-/2123**], c/b gastroparesis, retinopathy,
and neuropathy
Hypertension
Depression
Anemia
OSA on CPAP 11 CM
Legally blind
h/o pneumonia x2
h/o MSSA bacteremia
h/o T10-T11 discitis
s/p lap cholecystectomy
s/p ORIF left ankle
Social History:
Lives w/ husband. [**Name (NI) 1403**] as an administrator at BU. Walks w/
cane. Never smoked. [**1-26**] glass wine daily. No illicits.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: T 98.9 BP 151/56 P 61 RR 18 SaO2 97 RA
Blood glucose 133-440
General: mildly fatigued elderly woman with left eye closed
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP flat, no LAD, thyromegally
Lungs: Reduced breathsounds at LL base, otherwise clear
bilatearlly without wheezes, rales or rhonchi.
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
Labs:
WBC 11.7 Hct 30.3 Plt 220
N:80.3 L:12.1 M:7.1 E:0.2 Bas:0.3
.
133 92 69
---------------181
4.3 26 3.9
[**2126-10-31**] 01:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-150
GLUCOSE-1000 KETONE-50 BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2126-10-31**] 02:21PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2126-10-31**] 02:21PM URINE HOURS-RANDOM
[**2126-10-31**] 03:37PM URINE OSMOLAL-355
[**2126-10-31**] 12:10PM GLUCOSE-181* UREA N-69* CREAT-3.9*#
SODIUM-133 POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-26 ANION GAP-19
[**2126-10-31**] 12:10PM estGFR-Using this
[**2126-10-31**] 12:10PM CK(CPK)-90
[**2126-10-31**] 12:10PM CK-MB-3 cTropnT-0.06*
[**2126-10-31**] 12:10PM OSMOLAL-306
[**2126-10-31**] 12:10PM WBC-11.7*# RBC-3.17* HGB-10.2* HCT-30.3*
MCV-96 MCH-32.3* MCHC-33.8 RDW-14.5
[**2126-10-31**] 12:10PM NEUTS-80.3* LYMPHS-12.1* MONOS-7.1 EOS-0.2
BASOS-0.3
[**2126-10-31**] 12:10PM PLT COUNT-220
CXR: [**10-30**]: Minimal left basilar atelectasis. Unchanged right
minor fissural thickening.
CXR: [**10-31**]: In comparison with the study of [**10-30**] there is little
overall
change. Continued low lung volumes with mild engorgement of
pulmonary vessels and atelectatic changes primarily in the
retrocardiac region. Minimal blunting of both costophrenic
angles could reflect some small pleural effusions. There is
slight asymmetric opacification in the left perihilar region
when compared to the right. This could merely reflect slight
differences in pulmonary vascular engorgement. However, if there
is strong clinical concern for infection, this could be an area
of developing consolidation.
CXR [**11-5**] 1. Interval improvement in vascular congestion.
2. Trace atelectasis at the left costophrenic angle. No evidence
of
aspiration.
Brief Hospital Course:
63 year old female with IDDM, who presents with DKA c/b
worsening dysphagia.
.
# DKA/hyperglycemia - The patient presented with DKA, perhaps
precipitated by an acute viral syndrome. On admission she was
sent to the ICU. Her anion gap was small and likely atleast
partially contiributed to by her acute on chronic renal failure.
However, there were ketones in the urine, though these may also
be secondary to poor po intake. HONK was also on the
differential initially but her serum osms were within normal
limits. Her blood glucose on presentation was 184, which had
been increasing slowly. She was started on insulin drip
administered with D5, 1/2NS when sugars < 200. This was stopped
once glucose was controlled. Once anion gap was closed and
sugars were under better control the patient was switched to ISS
and home NPH (qAM) and transferred to the floor. Despite being
on the home regimen, pt's sugars continued to have some high
elevations with episodes of hypoglycemia. Given the patient had
been hard to manage diabetic, [**Last Name (un) **] was consulted and
recommended lantus and changing sliding scale. The patient's
sugars were better managed however did continue to experience
some elevations. The patient will follow-up with [**Last Name (un) **] as an
outpatient.
.
# Inability to swallow: Speech and Swallow evaluated the patient
and found she was at aspiration risk for solids and liquids. The
cause was unclear, could be recrudescence of deficits from [**2-3**]
lacunar infarct [**2-26**] hypovolemia. The patient was made NPO but
was adamant that she could eat full diet. The patient and
husband were counseled about the risks of aspiration and
potential morbidities associated with it and agreed that they
were willing to accept the risk of aspiration. On repeat S&S the
following recommendations were made: 1. Safest recommendation
would be videoswallow study for better objective assessment of
swallow function 2. If pt remains uninterested in discussion of
aspiration risk,
modified diet, and further testing, would return her to regular
diet with thin liquids at her own risk. 3. If pt is to take PO,
aspiration precautions including: a) feed only when awake/alert
b) sit fully upright for all PO c) remain upright at least 30
minutes after meals d) do not lower HOB below 30 degrees.
.
# LLL infiltrate - The patient had a CXR questionable for LLL
infiltrate, along wiht cough, fever, and leukocytosis. She was
started on ceftriaxone and azithro given suspicion for CAP.
However given the inconclusiveness of the xray, the fact that
the patient was asymptomatic, and her slight leukocytosis on
admission was likely [**2-26**] DKA, we stopped antibiotics and the pt
continued afebrile, stable on ra. Repeat PA and lateral showed
interval improvement. UA negative, blood cx neg.
.
# Acute on chronic renal failure: Pt shows evidence of volume
depletion from hyperosmolar state suggesting a prerenal
azotemia. No sediment on UA to suggest intrinsic renal
pathology. No evidence of outflow obstruction. She was treated
with IVF and Cr improved to baseline.
.
#Hypertension - Dr. [**First Name (STitle) 216**] had been concerned about her blood
pressure for some time and recommended titration while
hospitalized. However, in the ICU she was normotensive, likely
due to volume depletion. Chlorthalidone 25mg daily was held due
to acute on chronic renal failure, and reduced diltiazem to 30mg
qid (120mg daily vs 540mg home dose)changed atenolol 25mg daily
to metoprolol tartrate 12.5mg tid given renal failure and
continued clonidinen 0.1mg qAM and 0.2mg qPM. On the floor,
Diltiazem was uptitrated to 360mg, she was continued on
metoprolol 25mg TID, continued clonidine and started on
hydralazine 25mg PO TID, as well as restarted on chlorthalidone
home dose.
.
#Elevated troponins - without elevation in CK/MB, no ECG
changes, there was very low suspicion for MI.
.
# Anemia: Hct trended from 34 to 27 this admission, likely
secondary volume resuscitation. Now 30. Baseline anemia is
likely due to CKD.
.
# Depression: Psych was consulted and signed off due to
patient's lack of interest in talking to them further. She was
continued on home fluoxetine
.
#HL - continued home simvastatin
Medications on Admission:
Atenolol 25mg daily
Chlorthalidone 25mg daily
Clonidine 0.1mg qAm and 0.2mg qpm
Diltiazem 540mg daily
Fluoxetine 40mg daily
Lispro 4 units tid for BG > 200
Metoclopramide 5mg daily
Omprazole 20mg daily
Percocet 0.5-1 tab q6h prn pain
Simvastatin 40mg qhs
ASA 81mg daily
Calcium + vit D [**Hospital1 **]
Vit D 100 U daily
MVI
NPH 20mg daily
Fish oil 1000mg daily
.
Allergies:
Codeine
Lisinopril
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO qAM.
12. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
14. hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
15. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO once a
day.
16. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO qPM.
17. M.V.I. Adult 1-5-10-200 mg-mcg-mg-mg Solution Sig: One (1)
Intravenous once a day.
18. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
19. insulin glargine 100 unit/mL Cartridge Sig: Eighteen (18)
unit Subcutaneous at bedtime.
Disp:*1 month supply* Refills:*2*
20. insulin lispro 100 unit/mL Cartridge Sig: sliding scale
insulin units per ss Subcutaneous qachs: BREAKFAST: <80 give 4,
80-130 give 7, 131-180 give 8, 181-230 give 9...increase 1unit
lispro every 50 increase of sugar. LUNCH and DINNER: <80 give
3u, 80-130 give 5u, 131-180 give 6u, continue to increase
insulin 1u for every 50 increase of blood sugar. BEFORE BED: if
blood sugar 181-230 give 2u lispro, continue to increase 1u
insulin per 50 increase sugar. .
Disp:*1 month supply* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1) DKA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were admitted for diabetic ketoacidosis (very high blood
sugars) likely precipitated by a respiratory illness probably
from a virus. You were in the intensive care unit where they
brought down your sugars with an insulin drip and then
transitioned you to the general wards. While here you were
consulted by [**Last Name (un) **] Diabetes Center and they changed your
insulin sliding scale and switched you from NPH to Lantus
(insulin glargine). You will follow up with a doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]
as an outpatient to further optimize your diabetes management.
You were also found to have difficulty swallowing and were
evaluated by speech and swallow. They found that you do aspirate
some food and liquids while eating and drinking, especially thin
liquids. However, in consultation with you and your husband, you
decided to accept the risks of eating in order to have an
unrestricted diet. If you decide in the future that you want
more specific recommendations on diet in order to decrease the
risk of aspirating, further imaging can be done to better
identify the source of this difficulty swallowing.
If you develop increased pain, sugars >500 that are not
being controlled with insulin, or other symptoms that concern
you, please call Dr. [**First Name (STitle) 216**] or return to the ED.
*********
Please START the following medications:
Lantus 18u at bedtime
Metoprolol 25mg every 8h
Hydralazine 25mg every 8h
Senna, Colace, Miralax as needed for constipation
.
Please STOP the following medications:
Atenolol
NPH insulin
.
The following medications have been CHANGED:
Take Diltiazem at 360mg daily
The Lispro sliding scale has changed
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2126-11-13**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Last Name (un) **] Diabetes Center will call you with an appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
ICD9 Codes: 5849, 3572, 5859, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6772
} | Medical Text: Admission Date: [**2114-2-23**] Discharge Date: [**2114-3-15**]
Date of Birth: [**2060-4-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Intractable Seizures
Major Surgical or Invasive Procedure:
placement of left hemisphere grid ([**2-23**]) and removeal of grid
([**2-26**])
History of Present Illness:
53yo RH woman s/p left partial frontal lobectomy and VNS
placement, with extensive history of seizure comes to [**Hospital1 18**] for
elective placement of grid for seizure focus localization.
Seizures started when patient was 13yo. Observers noted that
the patient would stare blankly and then her head would slowly
slump to her chest. These seizures last only a few moments and
then the patient would become aware and usually laugh as if
embarrassed by the event. Patient also has partial complex
seizures, starting at age 13 where she loses tone and
consciousness, falling to the ground. Had to wear a helmet in
later years for this. These tend to last less than a minute. A
third type of seizure is noted in previous notes where the
patient has altered consciousness and shaking of the left arm
(family denies). These three types of seizure are not preceded
by an aura, or any other sign that the patient recognizes (no
warning). The family thinks that the patient may have been hit
in the head with a shovel when she was 6 years old by her
cousin. Also, Forceps were used on the patient when she was
born. In [**2091**] the patient had a left partial frontal lobe
resection. However, seizures returned following the procedure
and have continued to this day. Patient had a VNS placed in
[**2106**], which decreased the frequency of seizures. Recently, the
frequency of seizures had increased coincident with the battery
failing on the VNS. The battery was replaced; however the VNS
never provided the same level of seizure protection as prior to
the battery replacement.
Currently the patient experiences [**3-20**] seizures per day, with
and average of 8 seizures per day. Approximately 2 of these
seizures are partial complex involving loss of tone and falling.
The remaining seizures are of the blank stare type. She has
never had a grand mal seizure or bit her tongue during a
seizure. She has been incontinent as a result of the partial
complex seizures.
The patient??????s seizures occur with a fairly stable frequency.
The patient wanted grid placement for localization and an
eventual removal of the seizure focus. The seizure focus has
been localized with SPECT scan to the left hippocampus, followed
by Dr. [**Last Name (STitle) **].
At baseline, patient has always had memory difficulties, which
she attributes to the seizures; however she was able to
graduated from nursing school and work as a nurse [**First Name (Titles) **] [**Last Name (Titles) 1281**]
Hospital. Her seizures eventually stopped her from working as a
nurse [**First Name (Titles) **] [**2113-3-7**] and recently she has been living at the
[**Hospital 1456**] [**Hospital **] Rehab Center. She has had to wear a helmet and use
a wheel chair due to frequent falls. Some of these falls have
resulted in head trauma.
Past Medical History:
-Seizure disorder: The patient first developed epilepsy at the
age of 8 when she had staring spells. She then developed complex
partial seizures at the age of 13. She had been intermittently
treated with several anticonvulsants, none of which fully
controlled her seizures. She had a presurgical evaluation that
showed a left temporal lobe focus of her seizures over 20 years
ago. She underwent left temporal lobe resection in [**2091**] with
mild improvement of her symptoms for a short period of time
before her seizure activity returned to baseline. The patient
had a vagus nerve stimulator placed in [**2106**]. She has had an
increased in her seizure activity over the last year. Her
seizures appear now as drop attacks that come without warning.
She loses consciousness and is awakes anywhere from right away
to 45 seconds later. They are brought on by stress. She states
that she has had 4 seizures/day for the last year. She was
recently admitted to the [**Hospital1 18**] for medication adjustment, as
above.
-S/P Cholecystectomy
-S/P Benign breast mass removal
-Hypercholesterolemia
Social History:
Currently lives at [**Hospital 1456**] Rehab facility, had a boyfriend, no
children, former nurse [**First Name (Titles) **] [**Last Name (Titles) 1281**] Hospital, no drinking, no
alcohol no drug use.
Family History:
No seizures in other family members.
Physical Exam:
T 97.5 BP 124/64 HR 72 RR 22 O2Sat 100% RA
Gen: Lying in bed, eyes initially closed, arouses to stimulus
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, supple, neg brudzinskis
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: CTAB
aBd: +BS soft
ext: no edema, wwp
Neurological examination:
Mental status: Somnolent but rousable to voice and pain.
Intermittently follows simple commands. Verbal output minimal,
attempted to speak a number of times was frustrated when unable
to find words. At one point was able to form a phrase of words,
but did not make sense. Unable to name. Unable to use hands
well enough to assess writing. Patient tends to turn head to
the left and will drift back to left after the head is
repositioned. Possible neglect of right side.
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally.
III, IV, VI: Lateral eye movements appear intact. Left eye was
slightly slower tracking and caused disconjugate movement.
However, stationary gaze was conjugate
V: unable to assess, + corneals bilaterally
VII: mild lower facial droop on right side, no involvement of
forehead
VIII: unable to assess
IX, X: unable to assess
[**Doctor First Name 81**]: unable to assess
XII: Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. Had difficulty following commands due to aphasia. Was
essentially full strength on the left and had right leg
externally rotated.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R ? 4 5 ? ? ? 5 5 4 5 ? ? 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to painful stimuli all 4 extremities,
withdrawls but less vigorously on the right side.
Reflexes:
B T Br P A
R 2 2 2 0 0
L 2 2 2 0 0
Toes upgoing bilaterally
Coordination: Not assessed
Gait: Not assessed
Romberg: Not assessed
Pertinent Results:
[**2114-2-23**] 03:53PM PLT COUNT-166
[**2114-2-23**] 03:53PM WBC-6.9# RBC-3.16* HGB-10.1* HCT-28.4* MCV-90
MCH-31.8 MCHC-35.4* RDW-14.8
[**2114-2-23**] 03:53PM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.4*
[**2114-2-23**] 03:53PM GLUCOSE-177* UREA N-15 CREAT-0.7 SODIUM-147*
POTASSIUM-3.7 CHLORIDE-118* TOTAL CO2-18* ANION GAP-15
[**2114-2-23**] 08:21PM CK-MB-6 cTropnT-<0.01
[**2114-2-23**] 08:21PM CK(CPK)-300*
HEAD CT: [**2-23**] postop;
Interval placement of a grid in the left frontoparietal area
with mass effect and slight contralateral shift of normally
midline structures. Mild-to-moderate amount of subarachnoid
hemorrhage also present in the basilar cisterns and left sylvian
fissure.
CT HEAD W/O CONTRAST [**2114-2-25**] 9:13 AM
[**Hospital 93**] MEDICAL CONDITION:
53 year old woman with epilepsy s/p grid placement on the left.
Small amount of shift and subarachnoid blood.
REASON FOR THIS EXAMINATION:
please assess for progression of blood, shift.
INDICATION: Status post grid placed on the left, epilepsy,
assess for progression of bleed and shift.
CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: The patient is
status post left craniotomy with metallic grid in place
overlying the left convexity. There is continued pneumocephalus,
approximately unchanged in degree since [**2-24**].
Since the examination of one day prior, there is increase in
mass effect, with increased left to right subfalcine shift,
previously 2 mm and now approximately 12 mm. The degree of
subarachnoid blood within the suprasellar cistern appears
approximately unchanged. Visualization of the brain parenchyma
is limited by streak artifact arising from the metallic density
structures overlying the left hemisphere, however, there is
diffuse sulcal narrowing within the right hemisphere and
probably within the left convexity as well. The left temporal
[**Doctor Last Name 534**] is effaced, a new finding. Encephalomalacic change in the
left frontal lobe appears unchanged. There is questioned mild
diffuse loss of [**Doctor Last Name 352**]-white differentiation, although no focal
vascular territorial areas of loss of differentiation are
identified to suggest a major vascular territorial infarct.
The osseous structures appear unchanged. There is a question of
increased displacement of the grid from the inner table of the
calvarium on the left, a finding that could indicate increase in
the extra-axial fluid.
CT HEAD W/O CONTRAST [**2114-2-26**] 7:51 PM
[**Hospital 93**] MEDICAL CONDITION:
53 year old woman s/p postop brain grid removal
HISTORY: 53-year-old woman status post brain grid removal.
FINDINGS: There has been interval removal of the left-sided
grid. There are small amounts of left frontal and temporal
intraparenchymal, subarachnoid, and subdural blood.
Pneumocephalus is also identified. Hypodensity in the frontal
and temporal lobes are again noted. There is decreased mass
effect and shift of normally midline structures to the left.
Less compression on the left lateral ventricle is also
identified. The patient is status post left frontal, parietal,
and temporal craniotomy. A small extra-axial drainage catheter
is identified as are skin staples. The paranasal sinuses are
clear.
IMPRESSION: Status post grid removal with small amounts of
intracranial hemorrhage and pneumocephalus. Overall decreased
mass effect and shift of normally midline structures compared to
prior examination.
EEG FINDINGS: [**2114-3-6**]
ABNORMALITY #1: A broad area of low and slow voltage activity
was seen
from the left anterior quadrant, with predominantly low voltage
delta
seen throughout much of the record.
ABNORMALITY #2: Focal discharges were seen from the left
anterior
sylvian to mid-temporal to posterior temporal region which from
extension to left central seen most notably during waking with
left
posterior quadrant fast activity followed by several second
bursts of
wicket-like 10 Hz rhythmic activity from the temporal region
with a
persisting rhythmic theta lasting several additional seconds
from the
left anterior quadrant. Occasional scattered spike and sharp
discharges
were seen from the same left temporal region with left ventral
extension
in both waking and drowsiness.
BACKGROUND: Somewhat unevenly modulated 10 Hz activity was seen
in the
brief most alert portions of the record without significant
asymmetry.
SLEEP: The patient appeared to be drowsy throughout much of the
record
with only brief waking. Stage II sleep was not, however, seen.
No
abnormalities of sleep architecture were seen in Stage I sleep.
CARDIAC MONITORING: No abnormalities noted.
IMPRESSION: Abnormal EEG, due to left anterior quadrant voltage
reduction and slowing indicative of a structural obstructive
process
with evidence of increased irritability and discharges from
surrounding
regions on the left.
Brief Hospital Course:
The patient was admitted on [**2114-2-23**] for a scheduled left
craniotomy revision with
implantation of subdural strip and grids by Dr. [**Last Name (STitle) 739**]
(please see operative note for details). The operation went
well with no complications. A post-operative CT scan showed
interval placement of a grid in the left frontoparietal area
with mass effect and slight contralateral shift of normally
midline structures, with a mild-to-moderate amount of
subarachnoid hemorrhage also present in the basilar cisterns and
left sylvian fissure. On POD 1, she was transfused one unit of
red blood cells for blood loss anemia. A follow-up CT of her
head showed no interval change. She was placed on dexamethasone
for 24 hours. She was also on Cefazolin for post operative
empiric coverage. On POD 2, she was opening her eyes to pain.
she followed commands on her left. She was transferred to the
Neurology service. Throughout the day, she became more
lethargic. A CT scan showed an interval increase in the mass
effect in comparison with [**2114-2-24**], with increased left to
right subfalcine shift and mass effect upon the left lateral
ventricle. Mannitol was started to decrease edema. Steroids
were deferred due to the risk of infection. She was transferred
to step-down for more frequent neurologic checks. On POD 4, she
was taken to the OR for a craniotomy for removal of grid and
strip electrodes and removal of peg electrodes (please see
operative note for details). She had been nonresponsive to
mannitol.
Postoperatively, her CT showed an overall decreased mass effect
and shift of normally midline structures compared to prior
examination. She was transferred to the ICU while intubated.
Antiepileptic drugs were continued. Mannitol was to continue as
long as her sodium was kept over 130 and her serum osmolarity
was kept above 310. She was opening her eyes to voice. She had
no spontaneous movements or movements to commands. She
localized her left UE to pain. Dexamethasone was continued. On
POD 1, her mannitol and dexamethasone were decreased and then
stopped the next day. Her JP drain was discontinued. She was
tansfused 2 unitis of red blood cells for blood loss anemia.
Tube feeds were slowly advanced to goal via her NG tube. On POD
2, her CT scan showed persistent edema of the left frontal and
temporal lobes. She was transfused 2 more units of red cells
for blood loss anemia. Cefazolin was discontinued. On POD 3,
she was openinge her eyes. she followed commands on her left
side. On POD 4, a CT showed no evidence of new hemorrhage, and
the degree of edema as well as its attenuation pattern within
the left frontal lobe is unchanged. Mannitol was discontinued.
On POD 6, she was started on Zosyn for pseudomonas in her
sputum, enterococcus in her urine, a WBC of 16, and a low grade
fever of 100. On POD 7, her Tmax was 101.5. She was moving her
left side well and withdrawing her right side to pain. Surgical
staples were removed. On POD 8 she was more alert than the day
before. She was moving her left side well and withdrawing her
right lower extremity to pain. An EEG was done and was abnormal
due to left anterior quadrant voltage reduction and slowing
indicative of a structural obstructive process with evidence of
increased irritability and discharges from surrounding regions
on the left. Her Tmax was 100.5 and her antibiotics were
changed to ampicillin and meropenem for her Kelbsiella and
Pseudomonas in her sputum. She was following some commands but
was still rather lethargic. Physical therapy saw her for
balance and gait training. On POD 9, her vagus nerve stimulator
was tested and found to be working properly. The ICU team tried
to wean her vent but she had some thick secretions. On POD 10 a
CT of her head was unchanged. She was extubated successfully.
She was following commands with both lower extremities. PT got
her out of bed to a chair. Gentamycin was started for
persistent low grade fevers and a WBC of 20 the day before. On
POD 11, her right upper extremity was rather flaccid. Her WBC
decreased from 17 (the day before) to 11. A speech and swallow
evaluation was done- she failed due to decreased mental status,
so she was kept NPO with hydration and nutrition via her NG
tube. On POD 12, she was more lethargic, but had some tone in
her right upper extremity. On POD 13, she was more awake. Her
WBC was down to 8. She was following commands with all 4
extremities, although her right upper extremity strength was [**3-11**]
only. She was transferred to stepdown care. On POD 14, another
speech and swallow evaluation was done- although her mental
status was improved, she was still to be kept NPO. Her
gentamycin and ampicillin were discontinued and Levaquin was
started as per ID recommendations. On POD 15 a 14-French
gastrojejunostomy tube was successfully placed by interventional
radiology. On POD 16, she was transferred to regular floor
status. Tube feeds were tolerated through her GJ tube. On POD
17, her antibiotics were stopped. She was alert and was
regaining strength in her extremities. She was doing very well
and was discharged to [**Hospital3 **] later that day.
Medications on Admission:
vit D, keppra 1500'', zonegram 300'', clorazepate [**7-11**]'',
clorazepate 15 Qpm, lipitor, tylonol PRN, ativan PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Oxycodone-Acetaminophen 5-325 mg Tablet [**Month/Day (1) **]: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
3. Atorvastatin 40 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 150 mg/15 mL Liquid [**Month/Day (1) **]: One (1) PO BID (2
times a day).
5. Senna 8.6 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO BID (2 times a
day) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (1) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day (1) **]: Two (2)
Tablet, Chewable PO QAM (once a day (in the morning)).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (1) **]: One (1)
Tablet PO DAILY (Daily).
9. Clorazepate Dipotassium 3.75 mg Tablet [**Month/Day (1) **]: Four (4) Tablet
PO HS (at bedtime).
10. Clorazepate Dipotassium 3.75 mg Tablet [**Month/Day (1) **]: Two (2) Tablet
PO BID (2 times a day).
11. Levetiracetam 500 mg Tablet [**Month/Day (1) **]: Three (3) Tablet PO BID (2
times a day).
12. Zonisamide 100 mg Capsule [**Month/Day (1) **]: Three (3) Capsule PO BID (2
times a day).
13. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (1) **]: One (1)
Injection twice a day.
14. Insulin Regular Human 100 unit/mL Solution [**Month/Day (1) **]: One (1)
Injection ASDIR (AS DIRECTED).
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) Injection Q4H (every
4 hours) as needed for seizures.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
intractable seizures, blood loss anemia, post operative fever,
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please call or come to the ED for fevers > 101, decreased mental
status, decreased motor function, uncontrollable seizures,
nausea, vomiting, or any other worrisome issues.
Please do not use heat, diathermy, electrostimulation or any
procedures on patient without speaking to epilepsy neurologist -
could damage vagal nerve stimulator.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) 739**] in 6 weeks for a
follow-up appointment with Head CT
Also call Dr[**Name (NI) 3536**] office for seizure management and FU
appointment
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2114-3-15**]
ICD9 Codes: 2859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6773
} | Medical Text: Admission Date: [**2198-9-30**] Discharge Date: [**2198-10-2**]
Date of Birth: [**2164-11-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Upper endoscopy x 2
History of Present Illness:
Mr. [**Known lastname 26808**] is a 33 year old male without any significant past
medical history who was in his usual state of health until the
day prior to admission. He reports that he awoke around 1 am, at
which time he had a loose, black bowel movement. Shortly
thereafter, he felt nauseus and began to vomit bright red blood
with clots. He felt slightly lightheaded and drove himself to
the emergency room. He denies any associated abdominal pain at
the time or in the weeks prior to hematamsis/melena - just occ
vague ache associated with hunger that was slightly stronger
than previously.
Of note, patient had been taking 2 full strength aspirin every
4-6 hours for relief of discomfort from a cold sore that began
over two weeks ago, and had taken this dosing for about 10 days.
He last took aspirin about 10 days ago.
In the emergency room, his presenting vital signs were
temperature 97.0, heart rate 77, blood pressure 144/86,
respiratory rate of 17, and 100% on room air. As laboratories
were being drawn, the patient became acutely diaphoretic and his
heart rate went down to the 40's. His blood pressure dipped to a
systolic of 90. Two 18 gage peripheral IV's were placed, and a
NG tube was placed, at which time the patient vomitted bright
red blood. NG lavage was completed with bright red blood and
clots that did not clear. Rectal exam was notable for melena in
the vault. He was given a bolus of protonix 80 mg and then
continued on a protonix drip. He was type and crossed for 4
units of packed red blood cells.
Upon arrival to the ICU, he received 4 units pRBC's, fluids and
IV protonix infusion. EGD performed by GI: Diffuse friability,
erythema and congestion of the mucosa were noted in the whole
stomach. A single ulcer was found in the stomach body with
evidence of a visible vessel. Epinephrine 1/[**Numeric Identifier 961**] injections and
cauterizations were applied for hemostasis with success. A
second endoscopy was performed the next day which revealed
sucessful hemostasis.
The patient had no further melena or hematemasis. He currently
reports feeling well.
Past Medical History:
1)Hyperlipidemia
2)Status post tonsillectomy [**5-/2197**]
Social History:
Patient works in the bio-technology field. He has a supportive
husband who is at the bedside. He does not smoke or use ilicit
drugs. He drinks a [**12-27**] alcoholic drinks a few nights a week,
sometimes more on a weekend while out with friends. [**Name (NI) **] enjoys
gardening.
Family History:
Non-contributory.
Physical Exam:
VS 96.9 120/65 71 20 99% RA
General: Pleasant male, in NAD, resting comfortably in bed.
HEENT: NC/AT. MMM, clear oropharynx, no scleral icterus. PERRL
Neck: Supple
Cardiac: Regular rate & rhythm, no rubs or gallops, possible
soft systolic murmur, although not heard consistently
Lungs: CTAB no w/r/r
Abdomen: Soft, NT, ND, +BS
Extr: Warm, well perfused, capillary refill WNL
Neuro: A&Ox3, CN's sym and intact. Speech fluent and coherent
Skin: No lesions or rashes
Pertinent Results:
[**2198-9-30**] 08:15AM BLOOD WBC-5.4 RBC-4.50* Hgb-14.0 Hct-38.3*
MCV-85 MCH-31.1 MCHC-36.6* RDW-12.3 Plt Ct-225
[**2198-10-1**] 12:10AM BLOOD WBC-10.1 RBC-3.20*# Hgb-10.6*# Hct-27.7*
MCV-87 MCH-33.2* MCHC-38.3* RDW-12.3 Plt Ct-205
[**2198-10-2**] 07:00AM BLOOD Hct-33.2*
[**2198-9-30**] 08:15AM BLOOD PT-12.7 PTT-22.5 INR(PT)-1.1
[**2198-9-30**] 08:15AM BLOOD Glucose-116* UreaN-28* Creat-0.8 Na-140
K-3.9 Cl-107 HCO3-24 AnGap-13
[**2198-9-30**] 08:15AM BLOOD ALT-13 AST-15 AlkPhos-52 TotBili-0.4
[**2198-9-30**] 08:15AM BLOOD Albumin-4.3 Calcium-9.0 Phos-3.8 Mg-1.9
Relevant Imaging:
1)Cxray ([**9-30**]): NG tube is in the first portion of the duodenum.
Cardiomediastinal contours are normal. The lungs are clear.
There is no pleural effusion.
2)EGD:
[**2198-9-30**]: Mixture of red and clotted blood was seen in the
stomach. Extensive washout was performed to obtain better
visualization. Residual clot remained, but we were able to see
the majority of the gastric mucosa by repositioning patient.
Diffuse friability, erythema and congestion of the mucosa were
noted in the whole stomach. Excavated Lesions A single ulcer was
found in the stomach body with evidence of a visible vessel.
[**2198-10-1**]: Gastritis in the entire stomach. Non-bleeding gastric
ulcer s/p cautery from previous EGD.
Brief Hospital Course:
Mr. [**Known lastname 26808**] is a 33 year old male without past medical history
who presents with hematemesis and melena in setting of
significant aspirin use 10 days ago.
1)Upper GI Bleed: Patient presented with melena and NG lavage in
the ED was positive. Likely in the setting of Aspirin use. Hct
on admission was 38.3 but dropped to 27.7. He received a total
of 4 units pRBCs. He was initially transferred to the MICU for
closer monitoring. An IV PPI was started at this time. GI was
consulted and the patient underwent an upper endoscopy which
revealed gastritis with a single bleeding ulcer, which was
cauterized. He was rescoped the next day which showed no further
bleeding. H. pylori serologies were sent and returned positive.
He was started on Prevpak. IV PPI was transitioned to PO and his
diet was advanced. Hct at time of discharge was approximately
~33. He is scheduled in [**Hospital **] clinic for follow-up in 3 weeks with
Dr. [**Last Name (STitle) 4539**].
2)Positive blood cultures: [**12-29**] blood culture bottles positive
for GPC's in clusters. Thought to be a contaminant but he was
started on Vancomycin which was stopped the next day. He has no
murmurs on exam and no other focal findings. Repeat blood
cultures were obtained prior to discharge. Patient is scheduled
for follow-up in [**Company 191**] at the end of this week. In addition, he
will be contact[**Name (NI) **] day after discharge to inform him of his
results.
Medications on Admission:
Aspirin 650mg PO q4-6 hours for 10 days, last taken about 1-1.5
weeks ago
Acyclovir (only recently for cold sore)
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. PrevPak
Please use as directed for 14 day course.
Dispense 1 pack, no refills.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Upper GI Bleed
H. Pylori infection
Discharge Condition:
Stable
Discharge Instructions:
1) You were admitted because you were found to have an upper
gastrointestinal bleed likely due to Aspirin use. You had an
upper endoscopy which showed a single bleeding ulcer within your
stomach. The bleeding was stopped via cauterization and on
repeat endoscopy the following day, there was no evidence of
additional bleeding. Due to the fact that you've had a GI
bleed, you are to avoid using aspirin or NSAIDs (ibuprofen,
naproxen).
2) You were also diagnosed with H. pylori, which is an infection
of the lining of your stomach. For this infection, you were
started on two antibiotics, amoxicillin and clarithromycin along
with an anti-acid medication.
3) As part of your laboratory evaluation, blood cultures were
obtained. You were found to have bacteria in one of the blood
cultures. We believe that this may be a contaminant. As a
precaution, an additional set of blood cultures were obtained
immediately prior to discharge. However, you should call your
primary care physician's office tomorrow ([**2198-10-3**]) for the
results of the first set of blood cultures. You will need to
follow-up the results of the most recent set of blood cultures
at your follow-up appointment with your primary care physician
on Thursday, 10/09/[**Numeric Identifier 12623**].
4) You were started on several new medications during your
hospital course. You were started on pantoprazole which you
should continue taking until you are seen in follow-up by your
gastroenterologist. You were also started on two antibiotics for
your H. pylori infection, which you will continue taking for 14
days. Please take all other medications as listed below.
5)Please attend all appointments as listed below.
6) If you have shortness of breath, difficulty breathing, chest
pain, fevers, chills, or any other concerning symptoms, please
seek immediate medical attention.
Followup Instructions:
1) You will need to follow-up the results of the 1st set of
blood cultures by calling your primary care physician's office
tomorrow ([**2198-10-3**]).
2) You have a follow-up appointment with your primary care
physician on Thursday, [**2198-10-4**] at 2:20 pm.
3) You have a follow- up appointment with your
gastroenterologist, Dr. [**Last Name (STitle) 4539**], on [**2198-10-23**] at 2:00 pm.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8718**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2198-10-23**]
2:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
ICD9 Codes: 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6774
} | Medical Text: Admission Date: [**2123-1-24**] Discharge Date: [**2123-2-3**]
Date of Birth: [**2044-5-7**] Sex: M
Service: MEDICINE
Allergies:
Darvocet A500
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
ETOH withdrawl
Major Surgical or Invasive Procedure:
intubation [**1-24**], extubation [**1-25**]
EGD on [**2123-2-2**]
History of Present Illness:
78 yo M with PMHx of ETOH use and HTN, was transferred to our ED
from the OSH ED for management of frostbite of hands, knees and
feet. He was in his USOH until yesterday evening when he had a
few drinks in the bar, then was unable to open the door to his
house and fell asleep in his doorsteps last night. ? fall from
the porch. He woke this morning, got into the house, slept
some more, then woke up with increasing pain in his hands, feet
and knees. He presented to the OSH ED on [**2123-1-24**] where his work
up was significant only for the abovementioned frostbite, for
which he was trasnferred to the [**Hospital1 18**] ED.
.
In our ED, he was evaluated by plastics (conservative
management). He was also found to be withdrawing from ETOH
(tachycardic, hypertensive, hyperthermic and tremulous). He was
given a total of 30 mg of Valium. His respirations were noted
to be coarse, his O2 sat was 91% on RA, then 95% on a few liters
NC, then 100% on NRB. CXR showed bibasilar atelectasis vs PNA.
His Tm was 102 rectally during a withdrawal episode. He was
given empiric ABXs (Vanc and Levofloxacin) here (got Unasyn at
the OSH). Head CT neg.
.
For the first several hours of the ED stay he was found to have
no UOP. He got a total of 3.5 L fluids. Bladder scan showed
significant urinary retension. Foley was changed to 20F: he put
out 1 L (with some hematuria and clots), then his SBP dropped to
70s--> spont back up to 100s. Repeat CXR in the ED without
significant change. The pt then began to have coffee ground
emesis and the pt was intubated for airway protection (copious
oral secretions noted).
ROS prior to intubation: raspy voice; coughing up thick sputum;
loss of sensation in his fingers and his R great toe.
In the [**Hospital Unit Name 153**] [**2123-1-24**] pt initially hypotensive upon arrival w/ SBP
70s but responded to IVFs without pressor requirement. Pt had
[**Hospital1 **] dressing changes for his frostbite wounds and was by
plastics. He was extubated without complications on [**2123-1-25**].
Due to refusal to eat his NG tube was continued for medication
administration. As his ankle was notes to be painful, X-rays
were performed and showed ankle fracture - ortho was contact[**Name (NI) **]
for evaluation with plans to cast. Due to hypertension
metoprolol was started. Out of concern for cellulitis
associated with frostbite as well as to cover possible
aspiration pneumonia, Unasyn was initiated. Regarding bloody
emesis, hct remained stable, GI consulted with plan to perform
EGD once stable.
.
ROS prior to intubation: raspy voice; coughing up thick sputum;
loss of sensation in his fingers and his R great toe.
.
Meds in the ED: Dilaudid (3 mg IV); Fentanyl (100 mcg); Versed
(4 mg); Propofol gtt, Levofloxacin
Past Medical History:
Varicous veins
HTN
Social History:
ETOH of approx 5 beers per day; neg tobacco and illicit drugs
Family History:
NC
Physical Exam:
PE: 98.5 160/90 95 17 100% RA
HEENT: MMM
Neck: no JVD
CV: RRR; distant heart sounds
Lungs: CTA anteriorly
Ab: obese; + BS; no organomegaly; visible superficial veins;
redusible umbilical hernea
Extrem: escars B knees w/ surrounding erythema; moves all toes.
pulses by doppler only. hands with extensive blistering and
discolaration. loss of sensation distal to PIP all 5 digits B
and B great toes per chart; 2+ edema B LEs
.
Pertinent Results:
ABDOMEN ULTRASOUND: The liver is diffusely echogenic consistent
with fatty infiltration. No nodular outer contour is
appreciated. There is no intra or extrahepatic ductal
dilatation. The common bile duct measures 3 mm. The gallbladder
contains several stones. There is no gallbladder wall
thickening. There is a large cyst in the upper pole of the right
kidney, measuring up to 9 cm in diameter. A single thin
septation is seen within the cyst. The right kidney is otherwise
unremarkable. Two simple cysts are present within the left
kidney, with the largest at the lower pole measuring 1.8 cm in
diameter. The spleen is unremarkable. The pancreatic head is
normal.
IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. Cholelithiasis.
.
RIGHT ANKLE: AP, oblique, and lateral views. Osseous detail is
obscured by the overlying cast. The distal fibular fracture is
again seen, with minimal distraction of the fracture fragments.
The ankle mortise is preserved. Pes planus is again noted.
Vascular calcifications are also again noted.
.
EGD ([**2123-2-2**]): ulceration of esophagus and stomache, antral
gastritis
.
ECHO:
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.7 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 70% (nl >=55%)
Aorta - Valve Level: 2.2 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 2.0 m/sec (nl <= 2.0 m/sec)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded. Hyperdynamic LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No
valvular AS. The
increased transaortic gradient related to high cardiac output.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Left ventricular
systolic function is hyperdynamic (EF>75%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets are mildly
thickened. There is no valvular aortic stenosis. The increased
transaortic gradient is likely related to high cardiac output.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. There is no
pericardial effusion.
Brief Hospital Course:
Briefly, this is a 78 yo with h/o ETOH abuse who presented with
frostbite on hands, broken right ankle, and hematemesis
secondary to stomach/esophageal ulcers and gastritis. On arrival
the pt was admitted to the [**Hospital Unit Name 153**] s/p intubation in the ED for
respiratory distress and airway protection.
.
1)ETOH abuse: He was written for CIWA protcol but never required
any valium. He was started on daily thiamine and folate. He
was started on metoprolol 12.5 mg po tid for likely both
underlying baseline HTN and perhaps minor withdrawl. Social work
was consulted
.
2)Respiratory Distress: Initially in the [**Name (NI) **] pt had appearance of
increased resp. distress but was satting at 100% on NRB;
subsequently was intubated for airway protection in the setting
of coffee ground emesis. Pt may have had another aspiration
event or had flash pulmonary edema s/p fluid resuscitation at
that time. The pt was extubated [**1-25**] without diffficulty,
satting 100% on 50% shovel mask. TTE showed some mild diastolic
dysfunction with EF >70%, mild symmetric LVH; perhaps explaining
flash edema on admission. Given mild rales on exam and 3L
positive fluid balance on HD3, the pt was given Lasix 20 mg IV
x1. Over the course of the hospitalization pt was diuresed with
good effect, no longer requiring supplemental oxygen.
.
3)Fever/Elevated WBC: WBC on admission 20.1 with 6%bands. WBC
on HD3 was down to 10 with no bands. Most likely source of fever
and elevated WBC was either ETOH withdrawl/stress demargination
vs. aspiration pneumonitis vs pneumonia vs skin infection in
light of frostbite. The pt was initially started on levo and
flagyl on admission; however Unasyn was started also on the
night of admission to cover the pts skin given his frostbite,
and levo/flagyl were discontinued given redundant coverage. Pts
wbc count returned to [**Location 213**], no fevers, was switched to
Augmentin for antibiotic prophylaxis against skin infection.
.
4)Ankle fracture: The pt c/o medial R ankle pain. XR on [**1-26**]
revealed oblique fx of distal fibula likely secondary to
eversion injury. Ortho was consulted and casted ankle. Knee
films obtained demonstrated no fracture at knee. Ortho team
suggested weight bearing as tolerated and follow up with Dr.
[**Last Name (STitle) **] 2 weeks from dicharge. Appointment made and listed in
discharge plan.
.
5)Stomach/esophagheal ulcers and gastritis: The pt had an
episode of coffee ground emesis in the ED. Hct remained stable
throughout course. On [**2123-2-2**] EGD performed and showed
stomach/gastric ulcers and gastritis. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 2161**] and Dr. [**Last Name (STitle) **].
[**Doctor Last Name 3815**] of [**Hospital1 18**] GI department recommended protonix [**Hospital1 **] for 8
weeks followed by repeat EGD. Appointment made and listed in
discharge plan. Biopsies obtained and pending.
.
6)Frostbite: The pt sustained extensive frostbite injury to his
hands and fet with sensory loss distal to all PIPs and in his BL
1st toes. The pt was seen by plastics in the ED who recommended
xerofrom dressings [**Hospital1 **] and volar splints. The pt was covered
for potential infection with Unasyn which was switched to
Augmentin.
.
7Episode of Hypotension: The pt has one episode of hypotension
in the ED of unclear etiology, but self-limited (likely
contribution from sedatives received in the ED). His hypotension
quickly resolved with 1 L fluid bolus on admission to the [**Hospital Unit Name 153**]
and he never required pressors. In fact, the pt became
hypertensive by HD2.
.
8)Traumatic foley placement: Bleeding with foley placment
resolved. Four days prior to day of discharge foley removed, pt
voiding w/o difficulty.
.
9)Abdominal distension: Given unknown hx and alcohol abuse,
ultrasound obtained. LFTs normal. No ascities by ultrasound.
Liver with fatty infiltrations c/w alcoholic damage.
.
10) HTN: Difficult to control, typically 160-200/80-100 once off
ICU. Titrated up Lisinopril to max, Toprol started, Amlodopine
started ([**2123-2-2**]). Will need further titration at rehab.
.
Medications on Admission:
? Lisinopril
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 4 days.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: one treatment
Inhalation Q6H (every 6 hours) as needed.
9. Albuterol Sulfate 0.083 % Solution Sig: one treatment
Inhalation Q6H (every 6 hours) as needed.
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
13. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day. Tablet Sustained
Release 24HR(s)
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
frostbite
ankle fracture
CHF
GI bleed
Discharge Condition:
stable
Discharge Instructions:
Please call your PCP or return to emergency room with chest
pain, difficulty breathing, fever, increased pain in your hands.
Please call your PCP or return to emergency room with chest
pain, difficulty breathing, fever, increased pain in your hands.
Followup Instructions:
1) Regarding the ulcers in your stomach and esophagus, you will
need a repeat EGD to ensure that these have healed. You are
scheduled for [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2123-3-31**] 10:30; Place: SUITE GI ROOMS on the [**Hospital Ward Name 5074**] of [**Hospital1 **] Hospital.
2)Please follow up with the Plastic Surgeons. You have make an
appointment to be seen in two weeks phone number ([**Telephone/Fax (1) 65943**].
Completed by:[**2123-2-2**]
ICD9 Codes: 5070, 4280, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6775
} | Medical Text: Admission Date: [**2136-6-5**] Discharge Date: [**2136-6-12**]
Date of Birth: [**2136-6-5**] Sex: F
Service: Neonatology
HISTORY: This is a 2255-gram product of a 34-6/7 week twin
gestation pregnancy to a 36-year-old G6, P2-4 mother, whose
pregnancy was complicated by pregnancy induced hypertension
and preterm labor prompting transfer from [**Hospital **] Hospital
to the [**Hospital1 69**] at 34 weeks.
Mother was treated here with tocolysis. She had received
betamethasone when evaluated for preterm labor at 31 weeks.
This is spontaneous diamniotic-dichorionic twins pregnancy.
She was also noted to have increased liver function tests,
increased uric acid.
She gradually weaned off of her magnesium sulfate, but on day
of delivery was noted to have increasing blood pressures and
uterine activity. Due to a vertex-breech presentation, a
cesarean section was performed. This baby emerged vigorous
with [**Name (NI) **] of 8 and 9. Was given blow-by oxygen and
stimulation, and brought to the NICU after visiting with the
parents. Also notable prenatal screens: Blood type A
positive, antibody negative, rubella immune, RPR nonreactive,
hepatitis B surface antigen and group B Strep positive.
SOCIAL HISTORY: Notable for 12 year old and 10-year-old
siblings.
PHYSICAL EXAMINATION ON ADMISSION: Pink, active,
nondysmorphic infant. Skin is without any rash or lesions.
HEENT is within normal limits. Heart sounds are normal,
regular, rate, and rhythm, normal S1, split S2, no murmur.
Pulses are plus 2 and equal. Respirations are comfortable.
Lungs are clear. Abdomen is benign, no hepatosplenomegaly.
Spine is intact. Hips are normal to examination.
Extremities: Moves all equally, warm, and well perfused.
Neurologic: Nonfocal and appropriate for gestational age.
On the physical examination, the birth weight was 2.255 kg,
50th percentile for gestational age. Length 42.5 cm, 20th
percentile and head circumference 31 cm, 30th percentile.
HOSPITAL COURSE BY SYSTEMS:
Respiratory: Initially was comfortable in room air.
Continued to have respiratory rates noted in the 30s-40s with
O2 saturations greater than 95.
Cardiovascular: AP is noted to be 130s-150s with mean blood
pressures in the 40s. Last blood pressure 72/43 with a mean
of 53. Has remained hemodynamically stable. Has not
required any IV access.
Fluid, electrolytes, and nutrition: Initially had D sticks
of 40s, 44, then 67. Was started on premature Enfamil 20
calories formula or breast milk and required gavage feeding.
She currently is all p.o. feeding and is also feeding at the
breast. Intake over the last 24 hours was 139 cc/kg plus
breast feeding. Baby has had a normal stooling pattern and
is voiding.
Gastrointestinal: Bilirubin was noted to be elevated with a
peak bilirubin on [**6-11**] of 10.5/0.2 (it has been stable in
this range for several days). This baby has not required any
phototherapy.
Hematologic: Initial CBC was done on admission, and revealed
a white blood cell count of 11.2 with 40 polys and 0 bands,
53.2 percent hematocrit, and 217,000 platelets. Baby
received no blood products during the hospitalization.
Infectious disease: The blood culture was obtained on
admission and has remained negative. Baby was not started on
antibiotic and has remained clinically well. Temperature is
stable in an open crib.
Neurologic: Baby has appropriate exam for gestational age.
Maintains her temperature in an open crib.
Sensory: Audiology. A hearing screen was performed on [**6-9**]
and baby passed the automated auditory brain stem response
hearing screen.
Ophthalmology examination is not indicated at this time.
Social worker has been involved with this family. The social
worker's name is [**Name (NI) 553**] and she may be reached at [**Telephone/Fax (1) 55529**].
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 55413**], [**Street Address(1) **] Pediatrics, [**Location (un) 56138**] ([**Telephone/Fax (1) 56139**], FAX ([**Telephone/Fax (1) 56140**].
CARE AND RECOMMENDATIONS: Feedings: Continue breast and
bottle feeding ad lib demand. There were no medications at
this time. Car seat screening passed. State newborn
screening was sent on day of life three. Results at this time
are pending. Immunizations received is hepatitis B vaccine,
initial vaccine on [**6-9**].
Follow-up appointment is recommended for week of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 34-6/7 weeks twin number one.
2. Sepsis suspect ruled out.
3. Physiologic jaundice.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 55876**]
MEDQUIST36
D: [**2136-6-12**] 04:26:01
T: [**2136-6-12**] 06:46:01
Job#: [**Job Number 56141**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6776
} | Medical Text: Admission Date: [**2123-5-11**] Discharge Date: [**2123-5-18**]
Date of Birth: [**2041-2-23**] Sex: F
Service: SURGERY
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Ischemic ulcer and rest pain of the left foot.
Major Surgical or Invasive Procedure:
[**2123-5-12**]
Thrombectomy L iliac stent w/ restenting x 2, L CFA/Profunda
endarterectomy w/ SFA patch/venous patch angioplasty
History of Present Illness:
This 82-year-old lady with severe peripheral
[**Month/Day/Year 1106**] disease and end-stage kidney disease (on
hemodialysis) has rest pain of her left foot with a small
ulceration. She has previously undergone a left external
iliac artery angioplasty and stent via a percutaneous
approach. Recent CT angiography showed the stent to be
occluded with complete thrombosis of her common femoral
artery. Her superficial femoral artery is chronically
occluded, and the profunda femoris artery is patent. We are
attempting to reopen the previously placed covered stent
graft in the iliac and then revise the problem.
Past Medical History:
-ESRD on HD, had renal artery stenosis, s/p stent
-Afib
-Controversial dx of SCLCA
-Hypothyroid
-Hx GI bleed in the past
-Hx old foot drop (presumed left based on exam)
-s/p bilateral cataract surgeries
Social History:
She formerly worked for Gilette in financial controls
department; divorced; smoked 1ppd x 50 yrs, quit in [**2116**] at time
of ca dx. She does not drink or use drugs.
Family History:
The patient's father died secondary to coronary artery disease
at the age 66. The patient's sister died at age 51 secondary to
myocardial infarction. The patient's mother has diabetes
mellitus.
Physical Exam:
PHYSICAL EXAMINATION
Vitals: BP: 109/70 mmHg supine, HR 132 bpm, RR 25 bpm, O2: 93 %
on 2LNC.
CONSTITUTIONAL: No acute distress, mildly sedated.
EYES: No conjunctival pallor. No icterus.
ENT/Mouth: MMM. OP clear.
THYROID: No thyromegaly or thyroid nodules.
CV: Nondisplaced PMI. Normal rate. irregular rhythm. nl S1, S2.
No extra heart sounds. No appreciable murmurs (limited by loud
rhonchi, [**Year (4 digits) 13042**] noise)
LUNGS: Coarse rhonchorous breath sounds bilaterally. No
crackles,
wheezes.
GI: NABS. Soft, NT, ND. No HSM.
MUSCULO: Supple neck. Normal muscle tone. Full strength grossly.
HEME/LYMPH: No palpable LAD. Trace peripheral edema.
Dopplerable
distal pulses bilaterally.
SKIN: Cool extremities.
NEURO: A&Ox3, although mildly lethargic. Grossly normal without
any significant focal deficits
PSYCH: Mood and affect were appropriate.
Pertinent Results:
[**2123-5-17**] 07:40AM BLOOD
WBC-6.4 RBC-3.43* Hgb-10.6* Hct-32.0* MCV-93 MCH-30.9 MCHC-33.1
RDW-16.3* Plt Ct-150
[**2123-5-17**] 07:40AM BLOOD
Calcium-9.4 Phos-3.4 Mg-1.8
CT SCAN IMPRESSION:
1. No evidence of hematoma.
2. Renal cysts.
3. Small pleural effusions with atelectasis and right lower lobe
infiltrate.
Brief Hospital Course:
Mrs. [**Known lastname 27974**],[**Known firstname 27975**] [**Last Name (NamePattern1) 27976**] admitted on [**5-11**] with Ischemic
ulcer and rest pain of theleft foot.
She agreed to have an elective surgery. Pre-operatively, she was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preperations were made.
It was decided that she would undergo a:
Left external iliac thrombectomy with common and deep femoral
artery endarterectomy and patch angioplasty using
endarterectomized superficial femoral artery and
saphenous vein with selective left iliac angiography, stenting
of proximal common/external iliac and distal external
iliac/common femoral arteries, and completion arteriography.
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, she was extubated and transferred to the [**Month/Year (2) 13042**]
for further stabilization and monitoring. While in the [**Name (NI) 13042**] pt
went into Atrial fibrillation. A cardiology consult was
obtained. They recommended to hold amiodaron, Give IV lopressor
and fluid resusitation. To note pt did have history of
tachybrady syndrome and has a PPM in place.
A renal consult was alos obtained. for HD. She did recieve HD on
her scheduled days while here.
Pt was also noted to have a HCT of 19. She did recieve blood
products. A stat cat scan was obtained. She did not have a
retroperitoneal bleed. Her HCT was stable post operative period.
She was admitted to the CVICU for further care. A EP consult was
also obtained. They agreed with cardiology plans. They also
recommended to hold amiodarone and to titrated BB as needed.
She was then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care. When stable she was
delined including her aline. Her diet was advanced. A PT consult
was obtained.
To note her troponins were followed, she plateued. EP and
cardiology signed off. They recommended no amiodarone and to
titrate the BB as necessary.
When she was stabalized from the acute setting of post operative
care, she was transfered to floor status
On the floor, she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility.
Also on the floor her abdomen became distended. KUB demonstarted
an ileus. Her pain meds were held. Made NPO. Reglan and
erthromycin were started.
She also had a coughing episode where the expectorant was
purulent. This was sent for gram stain. Antibiotics were then
started. CXR revealed atelectasis vs PNA.
GRAM STAIN (Final [**2123-5-14**]):
[**12-6**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2123-5-16**]):
SPARSE GROWTH Commensal Respiratory Flora.
Pt afebrile, no WBC. After sputum cx showed Commensal
Respiratory Flora, her antibiotics where then stopped.
Her ileus resolved with conservative treatment. She is taking PO
without difficulty.
She continues to make steady progress without any incidents. She
was discharged to a rehabilitation facility in stable condition.
Medications on Admission:
levothyroxine 88', oxezepam 15 qhs, plavix, amiodarone 200', asa
81'
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
PMH:
tachybrady syndrome s/p PPM placed [**11-20**]
PVD
CHF
Afib
ESRD on HD
Renal artery stenosis
Hypothyroidism
GI bleed
PSH: -[**11-20**] stenting of the left external iliac artery and
Balloon angioplasty of the left profunda femoris artery.
-[**5-22**] Left external iliac thrombectomy with common and
deep femoral artery endarterectomy and patch angioplasty,
stenting of proximal common/external iliac and distal external
iliac/common femoral arteries,
-renal artery stent - bilateral cataracts
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Division of [**Month/Year (2) **] and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
except amiodarone
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home/rehab:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**3-17**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-15**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2123-6-7**] 1:00
Completed by:[**2123-5-18**]
ICD9 Codes: 5856, 2449, 496, 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6777
} | Medical Text: Admission Date: [**2184-8-18**] Discharge Date: [**2184-9-3**]
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Lower GI bleed
Major Surgical or Invasive Procedure:
NGT placement (now d/c'd).
PICC placement (now d/c'd).
CXR.
EKG.
Blood transfusion.
Left upper extremity ultrasound.
Incision and drainage of small left upper extremity abscess.
History of Present Illness:
This is a [**Age over 90 **] year-old woman with history of stroke seven weeks
ago, atrial fibrillation, hypertention, CAD s/p MI, and BRBPR in
[**2182-1-15**] with colonscopy at [**Hospital6 2561**] revealing
extensive diverticulosis and internal hemorrhoids who presents
with copious BRBPR at home on [**2184-8-18**]. The patient noted
a large amount BRB in her undergarments with large clots and BRB
noted on the toilet seat. No melena was noted. In addition to
starting aspirin and aggrenox seven weeks ago, she was also
taking celebrex. She was prescribed Fosamax at the time as well,
but had refused to take it since her stroke. She had BRBPR in
[**2182**] while on celebrex and fosamax.
Past Medical History:
1. [**6-18**]: small acute lacunar infarct: right periventricular
white matter, started on ASA and aggrenox
2. Diverticulosis/int hemorrhoids seen on colonscopy in [**2182**] and
abdominal CT [**2181**]
Colonscopy [**Hospital3 **] [**1-16**] for guiac postive stool/LGIB:
-- Two right colon polyps, excised.
-- Extensive diverticulosis of the distal colon.
-- No blood encountered.
-- Internal hemorrhoids.
3. AFIB- not on coumadin as fall risk
4. HTN
5. CAD s/p MI
6. Depression
7. GERD/HH
8. Hip surgery [**2178**] and [**2179**]
9. s/p shoulder fracture and surgery in [**2182**]
10. glaucoma s/p eye surgery
[**91**]. Lumbar stenosis
12. BPPV
13. 7-beat run of asymptomatic ventricular tachycardia on Holter
monitor in [**2182**].
Social History:
Widowed and lives alone on [**Location (un) 453**] of 2-family apartment.
Daughter lives above. Two sons (one in [**Name (NI) **], one in CT) also
involved. Retired bookkeeper. Distant history of tobacco and
rare ETOH.
Family History:
Sister w/ breast CA, urinary CA
Parents with PVD
Physical Exam:
PE on admission:
T98 BP 96/53 --> 70/p --> 100/75 HR 101-118 RR18-22 O2sat 94-97%
RA
gen- elderly frail woman in NAD
HEENT-L surgical pupil, R pinpoin but reactive, OP moist
NECK- supple, no LAD
CHEST- bibasilar crackles - very poor effort/cooperation with
exam (Bowel sounds at left base)
CV- irreg irreg no m/r/g
ABD- hyperactive BS, soft, NT/ND, frank gross blood noted in ED
EXT- no c/c/e, 2+ DP b/l, warm
Neuro- alert, follows some commands, oriented x 1 (self), moving
all extremities, ? right facial drop
PE on discharge:
T97 BP 130/70 HR 75-93 RR1 18 O2sat 93-97% RA
gen- elderly frail woman in NAD
HEENT-L surgical pupil, R reactive, OP moist
NECK- supple, no LAD
CHEST- bibasilar crackles - poor cooperation with exam
CV- irreg irreg no m/r/g
ABD- nl BS, soft, NT/ND
EXT- WWP; no c/c/e, 2+ DP b/l
Neuro- poor attention; alert, oriented to person only; follows
commands intermittently, moving all extremities symmetrically
Pertinent Results:
[**2184-9-2**] 08:45PM BLOOD WBC-10.3 RBC-3.92* Hgb-11.9* Hct-36.3
MCV-93 MCH-30.3 MCHC-32.7 RDW-15.1 Plt Ct-373
[**2184-9-1**] 07:30AM BLOOD WBC-7.6 RBC-3.88* Hgb-12.2 Hct-35.3*
MCV-91 MCH-31.4 MCHC-34.5 RDW-15.7* Plt Ct-377
[**2184-8-31**] 07:00AM BLOOD WBC-9.4 RBC-3.99* Hgb-12.1 Hct-37.6
MCV-94 MCH-30.3 MCHC-32.2 RDW-15.0 Plt Ct-374
[**2184-8-30**] 07:00AM BLOOD WBC-12.1* RBC-3.96* Hgb-12.1 Hct-36.8
MCV-93 MCH-30.6 MCHC-32.9 RDW-15.3 Plt Ct-439
[**2184-8-29**] 06:55AM BLOOD WBC-9.7 RBC-3.67* Hgb-11.0* Hct-34.2*
MCV-93 MCH-30.0 MCHC-32.2 RDW-15.0 Plt Ct-304
[**2184-8-28**] 06:45AM BLOOD WBC-10.9 RBC-3.83* Hgb-11.7* Hct-35.2*
MCV-92 MCH-30.5 MCHC-33.2 RDW-15.2 Plt Ct-342
[**2184-8-27**] 07:00AM BLOOD WBC-11.4* RBC-4.19* Hgb-12.9 Hct-38.1
MCV-91 MCH-30.9 MCHC-34.0 RDW-16.0* Plt Ct-337
[**2184-8-26**] 09:37PM BLOOD WBC-9.9 RBC-4.11* Hgb-12.8 Hct-36.4
MCV-89 MCH-31.1 MCHC-35.2* RDW-16.1* Plt Ct-308
[**2184-8-26**] 09:30AM BLOOD WBC-11.4* RBC-4.29 Hgb-13.2 Hct-38.7
MCV-90 MCH-30.7 MCHC-34.0 RDW-15.6* Plt Ct-305
[**2184-8-25**] 04:48AM BLOOD WBC-8.6 RBC-4.04* Hgb-12.4 Hct-36.3
MCV-90 MCH-30.8 MCHC-34.3 RDW-15.9* Plt Ct-277
[**2184-8-24**] 06:26AM BLOOD WBC-9.0 RBC-4.07* Hgb-12.5 Hct-36.4
MCV-90 MCH-30.7 MCHC-34.3 RDW-15.4 Plt Ct-237
[**2184-8-23**] 10:30PM BLOOD Hct-35.2*
[**2184-8-23**] 11:59AM BLOOD WBC-8.1 RBC-4.04* Hgb-12.2 Hct-36.0
MCV-89 MCH-30.3 MCHC-34.0 RDW-15.4 Plt Ct-216
[**2184-8-23**] 07:00AM BLOOD Hct-39.0
[**2184-8-23**] 06:00AM BLOOD WBC-9.5 RBC-3.93* Hgb-12.5 Hct-35.5*
MCV-90 MCH-31.8 MCHC-35.2* RDW-15.9* Plt Ct-208
[**2184-8-22**] 10:25PM BLOOD Hct-35.9*
[**2184-8-22**] 05:34AM BLOOD WBC-9.5 RBC-4.28# Hgb-13.3# Hct-38.9
MCV-91 MCH-31.0 MCHC-34.1 RDW-15.3 Plt Ct-191
[**2184-8-21**] 02:41PM BLOOD Hct-37.1#
[**2184-8-21**] 03:12AM BLOOD WBC-8.2 RBC-3.31* Hgb-10.1* Hct-29.2*
MCV-88 MCH-30.6 MCHC-34.6 RDW-15.2 Plt Ct-164
[**2184-8-20**] 08:17PM BLOOD Hct-29.8*
[**2184-8-20**] 03:40PM BLOOD Hct-31.6*
[**2184-8-20**] 09:55AM BLOOD Hct-34.7*
[**2184-8-20**] 03:23AM BLOOD WBC-13.0*# RBC-3.98* Hgb-11.9* Hct-37.5
MCV-94 MCH-30.0 MCHC-31.9 RDW-14.7 Plt Ct-219
[**2184-8-19**] 08:04PM BLOOD Hct-37.9
[**2184-8-19**] 12:50PM BLOOD WBC-7.5 RBC-3.91* Hgb-11.9* Hct-36.1
MCV-93 MCH-30.4 MCHC-32.8 RDW-14.7 Plt Ct-193
[**2184-8-19**] 05:19AM BLOOD WBC-7.4 RBC-4.00* Hgb-12.0 Hct-37.3
MCV-93 MCH-30.0 MCHC-32.1 RDW-14.6 Plt Ct-177
[**2184-8-19**] 01:05AM BLOOD Hct-35.2*
[**2184-8-18**] 11:35AM BLOOD WBC-7.2 RBC-4.25 Hgb-12.8 Hct-39.0 MCV-92
MCH-30.2 MCHC-32.8 RDW-14.8 Plt Ct-234
[**2184-9-1**] 07:30AM BLOOD Neuts-74.9* Lymphs-18.5 Monos-4.4 Eos-1.1
Baso-1.1
[**2184-8-31**] 07:00AM BLOOD Neuts-71.6* Lymphs-20.1 Monos-5.9 Eos-1.9
Baso-0.4
[**2184-8-30**] 07:00AM BLOOD Neuts-76.7* Lymphs-17.1* Monos-5.0
Eos-0.8 Baso-0.4
[**2184-8-22**] 05:34AM BLOOD Neuts-77.2* Lymphs-17.6* Monos-3.8
Eos-1.0 Baso-0.4
[**2184-8-18**] 11:35AM BLOOD Neuts-67.9 Lymphs-26.4 Monos-3.6 Eos-0.7
Baso-1.4
[**2184-8-31**] 07:00AM BLOOD Hypochr-1+ Macrocy-1+
[**2184-8-30**] 07:00AM BLOOD Hypochr-1+ Macrocy-1+
[**2184-9-2**] 08:45PM BLOOD Plt Ct-373
[**2184-9-1**] 07:30AM BLOOD Plt Ct-377
[**2184-8-31**] 07:00AM BLOOD Plt Ct-374
[**2184-8-30**] 07:00AM BLOOD Plt Ct-439
[**2184-8-29**] 06:55AM BLOOD Plt Ct-304
[**2184-8-28**] 06:45AM BLOOD Plt Ct-342
[**2184-8-27**] 07:00AM BLOOD Plt Ct-337
[**2184-8-26**] 09:37PM BLOOD Plt Ct-308
[**2184-8-26**] 09:30AM BLOOD Plt Ct-305
[**2184-8-25**] 04:48AM BLOOD Plt Ct-277
[**2184-8-24**] 06:26AM BLOOD Plt Ct-237
[**2184-8-23**] 11:59AM BLOOD Plt Ct-216
[**2184-8-23**] 06:00AM BLOOD Plt Ct-208
[**2184-8-22**] 05:34AM BLOOD Plt Ct-191
[**2184-8-22**] 05:34AM BLOOD PT-12.6 PTT-25.2 INR(PT)-1.1
[**2184-8-21**] 03:12AM BLOOD Plt Ct-164
[**2184-8-20**] 03:23AM BLOOD Plt Ct-219
[**2184-8-20**] 03:23AM BLOOD PT-12.9 PTT-37.4* INR(PT)-1.1
[**2184-8-19**] 12:50PM BLOOD Plt Ct-193
[**2184-8-19**] 05:19AM BLOOD Plt Ct-177
[**2184-8-19**] 05:19AM BLOOD PT-12.7 PTT-25.2 INR(PT)-1.1
[**2184-8-18**] 11:35AM BLOOD Plt Ct-234
[**2184-8-18**] 11:35AM BLOOD PT-14.8* PTT-25.8 INR(PT)-1.5
[**2184-9-2**] 08:45PM BLOOD Glucose-105 UreaN-18 Creat-1.1 Na-144
K-4.6 Cl-106 HCO3-28 AnGap-15
[**2184-9-1**] 07:30AM BLOOD Glucose-97 UreaN-16 Creat-0.8 Na-142
K-3.7 Cl-104 HCO3-30* AnGap-12
[**2184-8-31**] 07:00AM BLOOD Glucose-122* UreaN-17 Creat-0.9 Na-140
K-4.1 Cl-101 HCO3-30* AnGap-13
[**2184-8-30**] 07:00AM BLOOD Glucose-100 UreaN-23* Creat-1.0 Na-146*
K-4.3 Cl-104 HCO3-30* AnGap-16
[**2184-8-29**] 06:55AM BLOOD Glucose-103 UreaN-24* Creat-0.8 Na-144
K-4.2 Cl-105 HCO3-30* AnGap-13
[**2184-8-28**] 06:45AM BLOOD Glucose-109* UreaN-22* Creat-0.8 Na-145
K-4.6 Cl-106 HCO3-30* AnGap-14
[**2184-8-27**] 07:00AM BLOOD Glucose-170* UreaN-25* Creat-0.7 Na-145
K-4.7 Cl-107 HCO3-29 AnGap-14
[**2184-8-26**] 09:37PM BLOOD Glucose-140* UreaN-24* Creat-0.8 Na-145
K-4.4 Cl-108 HCO3-27 AnGap-14
[**2184-8-26**] 09:30AM BLOOD Glucose-116* UreaN-23* Creat-0.8 Na-144
K-4.6 Cl-108 HCO3-25 AnGap-16
[**2184-8-25**] 04:48AM BLOOD Glucose-113* UreaN-22* Creat-0.7 Na-144
K-4.3 Cl-111* HCO3-25 AnGap-12
[**2184-8-24**] 06:26AM BLOOD Glucose-93 UreaN-18 Creat-0.8 Na-145
K-3.4 Cl-110* HCO3-26 AnGap-12
[**2184-8-23**] 06:00AM BLOOD Glucose-124* UreaN-14 Creat-1.0 Na-145
K-3.8 Cl-114* HCO3-21* AnGap-14
[**2184-8-22**] 05:34AM BLOOD Glucose-133* UreaN-15 Creat-1.0 Na-145
K-3.9 Cl-117* HCO3-20* AnGap-12
[**2184-8-21**] 03:12AM BLOOD Glucose-132* UreaN-19 Creat-1.0 Na-143
K-3.3 Cl-116* HCO3-16* AnGap-14
[**2184-8-20**] 03:23AM BLOOD Glucose-133* UreaN-23* Creat-1.0 Na-146*
K-3.9 Cl-113* HCO3-16* AnGap-21*
[**2184-8-19**] 05:19AM BLOOD Glucose-84 UreaN-26* Creat-0.8 Na-147*
K-4.3 Cl-119* HCO3-19* AnGap-13
[**2184-8-18**] 11:35AM BLOOD Glucose-108* UreaN-32* Creat-1.0 Na-144
K-4.8 Cl-112* HCO3-24 AnGap-13
[**2184-8-26**] 09:37PM BLOOD CK(CPK)-190*
[**2184-8-24**] 06:26AM BLOOD CK(CPK)-183*
[**2184-8-23**] 10:30PM BLOOD CK(CPK)-230*
[**2184-8-23**] 11:59AM BLOOD CK(CPK)-224*
[**2184-8-22**] 05:34AM BLOOD CK(CPK)-320*
[**2184-8-21**] 03:12AM BLOOD CK(CPK)-489*
[**2184-8-20**] 08:17PM BLOOD CK(CPK)-484*
[**2184-8-19**] 05:19AM BLOOD CK(CPK)-32
[**2184-8-26**] 09:37PM BLOOD CK-MB-6 cTropnT-<0.01
[**2184-8-24**] 06:26AM BLOOD CK-MB-6 cTropnT-0.02*
[**2184-8-23**] 10:30PM BLOOD CK-MB-7 cTropnT-0.02*
[**2184-8-23**] 11:59AM BLOOD CK-MB-8 cTropnT-0.03*
[**2184-8-22**] 05:34AM BLOOD CK-MB-10 MB Indx-3.1
[**2184-8-21**] 03:12AM BLOOD CK-MB-11* MB Indx-2.2
[**2184-8-20**] 08:17PM BLOOD CK-MB-9 cTropnT-0.02*
[**2184-8-19**] 05:19AM BLOOD CK-MB-4 cTropnT-<0.01
[**2184-8-18**] 11:35AM BLOOD cTropnT-<0.01
[**2184-9-2**] 08:45PM BLOOD Calcium-8.8 Phos-4.3 Mg-2.3
[**2184-9-1**] 07:30AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.1
[**2184-8-31**] 07:00AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.1
[**2184-8-30**] 07:00AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.2
[**2184-8-29**] 06:55AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.2
[**2184-8-28**] 06:45AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2
[**2184-8-27**] 07:00AM BLOOD Calcium-8.9 Phos-2.2* Mg-2.1
[**2184-8-26**] 09:37PM BLOOD Calcium-8.8 Phos-2.4* Mg-2.2
[**2184-8-26**] 09:30AM BLOOD Calcium-8.2* Phos-2.1* Mg-2.1
[**2184-8-25**] 04:48AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.1
[**2184-8-24**] 06:26AM BLOOD Calcium-7.7* Phos-1.8* Mg-1.8
[**2184-8-23**] 06:00AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.8
[**2184-8-22**] 05:34AM BLOOD Calcium-7.4* Mg-1.9
[**2184-8-21**] 03:12AM BLOOD Calcium-6.6* Phos-2.2* Mg-1.6
[**2184-8-19**] 05:19AM BLOOD Calcium-7.0* Phos-3.1 Mg-1.8
[**2184-8-20**] 12:27PM BLOOD Type-ART Temp-37.2 O2-21 pO2-79* pCO2-27*
pH-7.36 calHCO3-16* Base XS--8 Intubat-NOT INTUBA
[**2184-8-20**] 12:27PM BLOOD Lactate-1.8
[**2184-8-18**] 11:55AM BLOOD K-4.7
[**2184-8-18**] 04:37PM BLOOD Hgb-10.7* calcHCT-32
[**2184-8-29**] 11:24AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2184-8-21**] 05:35PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2184-8-19**] 05:12PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2184-8-19**] 08:12AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.021
[**2184-8-29**] 11:24AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2184-8-21**] 05:35PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2184-8-19**] 05:12PM URINE Blood-LGE Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2184-8-19**] 08:12AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2184-8-29**] 11:24AM URINE RBC-0 WBC-2 Bacteri-MANY Yeast-NONE Epi-1
[**2184-8-21**] 05:35PM URINE RBC-[**12-4**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-<1
[**2184-8-19**] 05:12PM URINE RBC-17* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2184-8-19**] 08:12AM URINE RBC-[**3-19**]* WBC-[**3-19**] Bacteri-FEW Yeast-NONE
Epi-0
[**2184-8-19**] 08:12AM URINE CastHy-0-2
[**2184-8-29**] 11:24AM URINE Mucous-RARE
[**2184-8-19**] 05:12PM URINE Hours-RANDOM
[**2184-8-19**] 05:12PM URINE Hours-RANDOM Creat-110 Na-59
[**2184-8-29**] 11:24 am URINE Site: NOT SPECIFIED
**FINAL REPORT [**2184-8-31**]**
URINE CULTURE (Final [**2184-8-31**]):
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
2ND ISOLATE. <10,000 organisms/ml.
[**2184-8-19**] 8:12 am URINE
**FINAL REPORT [**2184-8-20**]**
URINE CULTURE (Final [**2184-8-20**]): NO GROWTH.
Brief Hospital Course:
Mrs. [**Known lastname 96619**] was brought to the ED by EMS. Her SBP was 80/palp
en route but improved to 95/63 on arrival. It fell to the 70s
after Valium was given and improved to the 100s with 4L IVF.
Mrs. [**Known lastname 96619**] was persistently tachycardic (110-115). She had
[**2-17**] more episdoes of BRBPR in the ED and was evaluated by GI.
Her HCT fell from 39 on arrival to 32. An NGT was placed by IR
(large hiatal hernia present) and gastric lavage was negative.
In total she was transfused 2 units PRBCS.
Mrs. [**Known lastname 96619**] was admitted to the MICU for close monitoring and
resuscitation. Colonscopy was declined by the patient and
family. As her vital signs stabilized and as no intervention
was planned, Mrs. [**Known lastname 96619**] was transferred from the MICU to the
floor on [**2184-8-22**], for further management.
Neuro/delirium: Her mental status waxed and waned with
intermittent agitation that responded to Zyprexa. Her delirium
is likely multifactorial related to her recent CVA, infection,
electrolyte imbalance, ICU stay on top of her underlying
dementia. In regard to her recent CVA, on [**9-1**] she was
started on a baby aspirin and had no evidence of bleeding or
fall in her hematocrit as a result. She will f/u with neurology
as outpatient
CV: She was in atrial fibrillation chronically with episodic
tachycardia to the 160s that was controlled acutely with IV
metoprolol and diltiazem. Over time, her daily medications were
adjusted such that po atenolol and diltiazem XR kept heart rate
below 100 with acceptable blood pressure. She was also started
on lisinopril and remained normotensive.She experienced
recurrent asymptomatic 5-12 beat runs of ventricular tachycardia
that self-resolved. There is evidence of these episoded dating
back to [**2182**]. She had episodes of chest pain when her heart
rate was elevated but did not have evidence of MI by EKG changes
or by troponin elevation.
GI: ASA and aggenox were held as well as all blood thinners.
She did not experience any further bleeding, and, with
assistance and encouragement, was able to take an adequate po
diet. On [**8-31**], her NGT was removed
FEN: pt requires assistance with PO diet since discontinuation
of tube feeds
ID: On [**2184-8-29**], she developed a urinary tract infection
that was treated with oral antibiotics. . On [**9-2**] she
developed a cellulitis with small abscess at the former site of
an IV on her left arm. Absence of vascular involvement was
confirmed by ultrasound. The abscess was drained by surgery (no
pus was seen) and she was started on levofloxacin on [**9-3**]
for treatment of cellulits (PCN allergy)
PT: She was encouraged to work with PT and get out of bed to a
chair.
Code status: DNR/DNI
Medications on Admission:
ASA 81mg po qd
Aggrenox 1 tab [**Hospital1 **]
Protonix 40mg po qd
Megace 40mg po qd
Celebrex 100mg po qd
Paxil 30mg po qd
Lopressor 25mg po bid
Trazodone 50mg po qhs
Lipitor 10mg po qd
Vitamin D 400 IU po qd
Calcium 500mg po qd
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
2. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO QD
(once a day).
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest pain.
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
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 [**Hospital1 **] (2 times a day).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO HS (at bedtime).
9. Atenolol 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO every eight (8) hours as needed for agitation.
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
14. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QD (once a day): Hold for SBP<100,
HR<60.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for t>101.
16. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days.
17. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.
18. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
Lower GI bleed
Secondary diagnoses:
Left upper extremity cellulitis s/p I&D
Urinary tract infection
Atrial fibrillation with rapid ventricular response
Dementia/delerium
Episodic nonsustained ventricular tachycardia
Failure to thrive
hx CVA [**7-18**]
Discharge Condition:
Afebrile , hemodynamically stable, no evidence of ongoing
bleeding (stable Hct)
Discharge Instructions:
Please take all medications as prescribed. Continue
levofloxacin for six days as an outpatient. Continue diltiazem,
atenolol, lisinopril, and zyprexa as prescribed. Continue your
glaucoma medications as prior to hospitalization. Take one baby
aspirin daily. Change dressings on left arm wound twice daily
(wet to dry) until healed.
Please return to the hospital if you have bleeding, chest pain,
shortness of breath or any other worrisome symptoms.
Followup Instructions:
Follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**], on
Friday [**9-10**] at 1:30pm or reschulde if necessary
[**Telephone/Fax (1) 2660**]
Follow up with your neurologist in the next 2 weeks.
([**Telephone/Fax (1) 44**])
Follow up with your cardiologist, Dr. [**Last Name (STitle) **], in the next 2
weeks .
Completed by:[**2184-9-3**]
ICD9 Codes: 2851, 5990, 2765, 4280, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6778
} | Medical Text: Admission Date: [**2184-8-23**] Discharge Date: [**2184-8-28**]
Service: NEUROLOGY
HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
right-handed woman with hypertension, high cholesterol, who
had a large left MCA territory stroke. She was last known to
be in her usual state of health on [**2184-8-22**] at 4:00
p.m. On [**2184-8-23**] at 11:00 a.m. she apparently fell
and then called a family member. The family member then
found her at 1:30 p.m. to be confused with slurred speech.
She was taken to the [**Hospital6 256**]
Emergency Department. Her initial examination at
approximately 5:00 p.m. noted her to be nonfluent with a
right facial droop and a right pronator drift. MRI/MRA was
done and showed decreased flow in the left internal carotid
artery. There was a suggestion of a subacute to chronic
infarct in the right periatrial white matter.
Upon returning from MRI, at approximately 7:30 p.m., she had
the acute onset of global aphasia and left gaze preference
and right hemiplegia. A stat head CT and CTA showed absent
flow in the left internal carotid artery. Her vessel imaging
and examination findings were felt to be consistent with a
large left MCA territory acute stroke. Due to the unclear
onset of her symptoms, she was felt not to be a TPA candidate
after discussion with the family as well. She was admitted
to the Intensive Care Unit.
HOSPITAL COURSE IN THE INTENSIVE CARE UNIT: 1. NEUROLOGY:
A carotid ultrasound was suggestive of distal left ICA
occlusion. A repeat head CT on [**2184-8-24**] showed a
large acute left MCA stroke in the left frontal lobe
extending into the insula as well as the left parietal lobe
with a blurred [**Doctor Last Name 352**]-white junction. She was initially loaded
on Dilantin for concern of seizure but this was then
discontinued.
A transthoracic cardiogram was performed and showed left
ventricular systolic dysfunction consistent with coronary
artery disease. There was no visualized thrombus. She was
started on aspirin for secondary prophylaxis.
2. CARDIOVASCULAR: The patient ruled out for a myocardial
infarction based on enzymes.
3. RESPIRATORY: The patient had chest x-rays performed
which were consistent with mild pulmonary edema. She had
normal saturations on 3 liters nasal cannula.
4. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
kept n.p.o. with IV fluids running.
5. INFECTIOUS DISEASE: The patient was started on
levofloxacin for pyuria with urine culture pending.
6. CODE STATUS: The patient was made DNR, DNI by the
family. On [**2184-8-24**], the patient was transferred to
the Neurology floor. Her examination at that time showed a
temperature of 97.2, blood pressure 120/58, pulse 61,
respiratory rate 22, oxygen saturation 97% on 3 liters.
General: She is an elderly appearing female with her eyes
closed in no apparent distress. Her neck showed no carotid
bruits. The lungs had bilateral basilar crackles. Her
cardiac examination showed a regular rate and rhythm with a
II/VI systolic murmur at the left sternal border. Her
abdomen was soft. On neurological examination, on mental
status examination, her eyes were closed. She did not open
her eyes to voice or to painful stimuli. She had no speech
production. She was not following commands. Cranial nerve
examination: There was deviation of gaze to the left but she
was able to cross the midline with doll's maneuver. The
pupils were 3 mm bilaterally and reacted to 2 mm. The left
corneal reflex is present. Right corneal reflex is absent.
There is a right facial droop. On motor examination, there
was decreased tone in the right upper and lower extremity.
There was spontaneous movement of the left upper and lower
extremity. There was extensor posturing of the right upper
extremity in response to noxious stimuli. There was triple
flexion response of the right lower extremity in response to
painful stimuli. Reflexes were 1+ and symmetric. Toes were
upgoing bilaterally.
The patient was continued on supportive care with IV fluids,
aspirin prophylaxis, respiratory monitoring, and
levofloxacin. Her urine culture returned with no growth to
date and the levofloxacin was discontinued. Her chest x-ray
showed progressive pulmonary edema and her IV fluids were
decreased.
On [**2184-8-26**], after extensive discussions with the
Neurology Team, her family decided to redirect care towards
comfort measures only. At this point in time, the next step
would have been a PEG tube placement, but the patient had
previously discussed this with the family that she would not
have wanted this invasive measure. Therefore, the patient
was placed on comfort measures only. Her nasogastric tube
was discontinued. Laboratories and chest x-rays were
discontinued. Accu-Cheks were discontinued.
Her neurologic examination showed her to be slightly more
alert with eyes open. However, she did not have any speech
production and was not following any commands. Her right
upper and lower extremity remained hemiplegic. She was seen
by the palliative care service and placed on medications as
needed for comfort, including morphine, Ativan, Scopolamine
and Tylenol. She was screened for hospice care and will
likely be transferred to hospice within the next one to two
days to continue on comfort measures.
CONDITION ON DISCHARGE: Poor.
DISCHARGE STATUS: Hospice.
DISCHARGE DIAGNOSIS: Left middle cerebral artery territory
stroke.
DISCHARGE MEDICATIONS:
1. Morphine 5 to 20 mg sublingually q. four hours p.r.n.
distress.
2. Ativan 0.5 to 1 mg sublingually q. four hours p.r.n.
agitation.
3. Scopolamine 1.5 mg patch transdermally q. 72 hours p.r.n.
secretions.
4. Tylenol 650 mg p.r. q. four hours p.r.n. fever.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**]
Dictated By:[**Name8 (MD) 33494**]
MEDQUIST36
D: [**2184-8-27**] 05:31
T: [**2184-8-27**] 18:43
JOB#: [**Job Number 98869**]
ICD9 Codes: 5990, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6779
} | Medical Text: Admission Date: [**2106-7-25**] Discharge Date: [**2106-8-6**]
Date of Birth: [**2031-5-28**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Shellfish / Ace Inhibitors
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75-yr-old male with PAF (on amio), HTN, AAA, CRI (Cr baseline
1.4), SCLC with brain and spinal mets (diagnosed in [**7-19**],
treated with five cycles of carboplatin/Taxol + chest XRT) s/p
recent whole brain radiation, who presented to the ED with LE
swelling but was found to have hypotension and fever.
.
Pt noted mild b/l LE swelling over the last two days which he
has never experienced before. He denies any CP, SOB but noted
some dizziness and lightheadedness over the last few days. He
continued to take his BP meds despite these symptoms. Per his
report, he developed the LE swelling after his last whole brain
radiation on Friday and was told by his radiation-oncologist
that it might be related to that and the steroids he is
currently receiving. However, he was concerned and called his
daughter in [**Name (NI) 108**] who came up to [**Name (NI) 86**] and brought him to the
ED.
.
In the ED, his BP was found to be 65/40. He was tachy to the
120s and had a Temp of 100.6. Lactate of 2.1. A UA was negative.
However, a CXR revealed an infiltrate below his lung mass in
line with post-obstructive pneumonia. He received 4L IVF with
only transient effect on his BP. He was started on Levo and
Clindamycin for presumed postobstructive pneumonia. Code Sepsis
was called and a right IJ was placed. Levophed was started given
hypotension that was resistant to fluid resuscitation. His
Levophed drip was at 0.75 mcg/kg on transfer to the ICU.
.
On ROS, he endorsed a mildly productive cough over the last two
weeks. Sputum has only been whitish to clear. No F/C/N noted. No
sick contacts. [**Name (NI) **] CP or SOB as above. No urinary symptoms or
abnormal bowel movements. No blood in stool or urine noted. No
nosebleeds but easy bruising. Chronic back pain from spinal mets
with no change in severity.
.
Oncologic History (per onc notes from [**6-25**] and [**7-13**]): Dx in
8/[**2104**]. Initially presentation with bulky disease and near
complete tracheal obstruction s/p Y stenting (removed again in
10/[**2104**]). S/p chemo with carboplatin and etoposide on
[**2105-8-11**]. His first cycle of chemotherapy was complicated by
S. bovis endocarditis; completed 4 weeks of IV penicillin in
early [**Month (only) 359**]. Initially, believed to have extensive stage
disease, with metastases in the left adrenal gland and liver.
However, follow-up CT scans revealed no change in the adrenal
lesion while his pulmonary lesions decreased in size. In
addition, the hepatic lesions seen on his initial CT were not
seen on later exams were felt to be an artifact and not
metastatic spread. Mr. [**Known lastname 4401**] completed five cycles of
chemotherapy and radiation therapy to the chest.
Past Medical History:
- PAF, on Amio, not on anticoagulation (has been on coumadin
prior to his first round of chemo in [**2104**]); followed by Dr.
[**Last Name (STitle) 73**] (last seen on [**2106-7-7**])
- HTN
- Hyperlipidemia
- CRI, Cr baseline 1.4
- PVD
- AAA S/P repair over one year ago
- ? Etoh abuse
- H/o S. bovis endocarditis (during first cycle of chemo); s/p 4
wks of penicillin in [**9-/2105**]
- Colonoscopy on [**2105-9-1**]: fragments of adenoma with high grade
dysplasia and focal intramucosal carcinoma but no invasive
carcinoma.
- SCLC as above
Social History:
Lives alone. Family lives in [**State 38104**] and [**State 108**]. Has five kids and
many grandchildren. Divorced. Quit smoking over two years ago.
Smoked 1 pack per week for 50 years. Remote EtOH use in the past
(1-2 drinks per month). No drug use.
Family History:
Son died of brain tumor at age 16. Did not know parents, was
raised by step parents.
Physical Exam:
VS: Temp: 97.0, BP: 119/76 (on NE), HR: 97, RR: 18, O2sat 94% on
2L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, dry MM
NECK: no supraclavicular or cervical lymphadenopathy, no jvd,
right IJ in place
RESP: coarse BS at both bases, no wheezes, rhales or rhonchi
CV: Tachy, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 1+ LE edema b/l, cold feet but good pulses
SKIN: bruises b/l on UEs, no jaundice
NEURO: AAOx3. 5/5 strength throughout.
Pertinent Results:
141 106 62
============117
4.6 25 1.8
.
CK: 290 MB: 7 Trop-T: 0.04
.
WBC 5.1, Hct 45.0, Plt 58
N:93 Band:2 L:4 M:1 E:0 Bas:0
.
PT: 12.4 PTT: 26.0 INR: 1.1
.
Lactate 2.1
.
.
EKG: Afib at HR of 101, normal axis, no ST changes
.
Imaging:
CXR [**2106-7-25**]: Comparison was made with a prior chest radiograph
dated [**2106-3-9**]. Again note is made of opacity in the right
upper lobe extending from the right hilum, representing
post-radiation change
as seen on prior torso CT dated [**2106-5-27**]. Thoracic aorta is
tortuous. Cardiac contour is unchanged. Linear atelectasis in
right upper lobe with pleural thickening is again noted. There
is atelectasis in the right lower lobe. Overall appearance of
the chest is unchanged. Left lung is clear. IMPRESSION: Overall
unchanged appearance of the chest with post-radiation change and
volume loss of the right lung.
.
MRI spine [**2106-7-19**]: Diffuse leptomeningeal metastases involving
the lower thoracic cord, the conus medullaris, and the cauda
equina.
Abdominal aortic aneurysm just above the aortic bifurcation
measuring
approximately 3.1 cm in size.
Mild degenerative changes of the lumbar spine with multilevel
mild bilateral foraminal stenoses, but without canal stenosis.
.
MRI brain [**2106-6-25**]: Multiple, new metastatic lesions (left
parietal;
left medial temporal lobe; met extending from the pituitary
infundibulum into the hypothalamus; right lateral pons; left
cerebellar tonsil and the left cerebellar hemisphere; right
frontal leptomeningeal metastasis).
Brief Hospital Course:
75-yr-old male with PAF (on amio), HTN, AAA, CRI (Cr baseline
1.4), SCLC with brain and spinal mets (diagnosed in [**7-19**],
treated with five cycles of carboplatin/Taxol + chest XRT) s/p
recent whole brain radiation, who presented to the ED with LE
swelling but was found to have hypotension, fever and RLL
infiltrate.
.
# Fever/hypotension: Met SIRS criteria given BP, HR and temp.
Lactate of 2.1 in the ED. Normal AG. Left-shift on differential
with 2% bands. Likely source is lungs given RLL infiltrate on
CXR, which was confirmed on CT. UA was negative and no urinary
symptoms. No lines as entry sites. No open wounds on skin or
mucosa. No abdominal tenderness and LFTs wnl. Thus, no other
obvious sources making pneumonia most likely reason for his
fever/hypotension. Pt received 4L IVF in the ED and was started
on Levophed after CVL placement. Antihypertensive meds were
held. Levophed was weaned off, as well as supplemental O2.
Received Levo/Clinda x1 in the ED. Started Vanc/Zosyn in ICU.
Hemodynamically stable off pressors. Likely component of
dehydration contributing to hypotension as out of proportion of
other clinical picture.
Patient was transfered to the oncology floor when he was
stabilized. Was stepwise titrated down off antibiotics to levo,
and patient completed [**9-26**] day course. He remained off
suppelmental oxygen and was afebrile with normal WBC. Patients
blood pressure's returned to [**Location 213**] normal, and patient returned
to baseline hypertension. HTN meds were restarted, and patient
was well controlled. Towards the end of hospitalization,
patient developed presumed herpetic oral ulcers. Patient had
continued hypotension, HTN meds held, believed to be due to poor
PO intake. Pressures maintained w/ IVF. Patient should have PO
intake enouraged, and IVF if necessary. Patients SBP has ranged
from 90-105 at time of discharge, and patient is asymptomatic.
.
# Thrombocytopenia, now leukocytopenia: Plt of 58 on admission.
H/o easy bruising but no overt bleeding. Last Plt count was 214
one month ago. Baseline around 100-200 indicating chronic
thrombocytopenia, likely due to current radiation therapy. Coags
unremarkable. HIT ab negative. Patient was transfused with one
unit of platelets, increasing count from 21 to 54. Patient w/
leukocytopenia, but ANC > 1000. Should have continued
monitoring.
.
# LE swelling: new onset per patient. LE minimal on exam today.
Preserved EF on Echo from [**2104**]. Possibly due to steroids per
radiation-oncologist. Lenis negative. Consider Echo as well once
stable and euvolemic, in order to assess EF.
.
# Acute on CRF: CRI due to HTN per OMR. Cr baseline around 1.4.
Cr of 1.8 on admission. Likely prerenal given dehydration and
recent orthostatic hypotension as outpatient. Received IVF for
septic picture and Cr down to 0.9 today.
.
# Cardiac:
PAF, on Amio, not on anticoagulation since first cycle of chemo
in [**2104**]; followed by Dr. [**Last Name (STitle) 73**], last seen on [**2106-7-7**]. Found
to be in Afib on admission EKG but not in RVR. Pt between Afib
and tachy sinus on tele, but hemodynamically stable. Patient
was continued on amioderone for rhythem control, and BB was held
at times due to hypotension.
.
# SCLC: SCLC with brain and spinal mets. Diagnosis in [**7-/2105**]
with bulky disease and near complete tracheal obstruction s/p Y
stenting and removal. S/p five cycles of chemotherapy and
radiation therapy to the chest in [**2104**]. Patient completed whole
brain radiation to treat brain disease. Was complaining of back
pain radiating down buttocks. Patient completed spinal XRT
during this hospitalization with a significant improvmeent in
pain. Dexamethasone was increased during this XRT therapy, and
is now being tapered.
.
# Chronic anemia: Hct baseline around 26-36. Normal B12/folate
in [**2105-10-14**], but high Ferritin in line with ACD due to
malignancy. Hct of 45 on admission, likely due hemoconcentration
in setting of dehydration/infection.
.
# Oral Ulcers- Believed to be herpetic in appearence. Patient
started on acyclovir and given lidocain gel for pain relief.
Patient with poor PO intake due to ulcers causing hypotension.
PO intake must be encouraged utill ulcers heal.
Medications on Admission:
amiodarone 200 daily
aspirin 81 daily
dexamethasone 8mg daily, per tapering protocol (OMR note from
[**2106-7-16**])
Diovan 80 per day
metoprolol tartrate 50 mg twice a day
Percocet 5/325 mg twice a day for pain
Protonix 40 once a day
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO once a day
for 8 days: Take 4mg every day on [**8-5**], then take 2mg every day
for three days until [**8-8**], then take 2mg every other day for
three days until [**8-13**], then stop taking.
Disp:*8 Tablet(s)* Refills:*0*
6. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
Disp:*1 ML(s)* Refills:*1*
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-15**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*1 bottle* Refills:*2*
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*250 ML(s)* Refills:*0*
9. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours) for 4 days.
Disp:*12 Capsule(s)* Refills:*0*
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day
for 8 days: Take 2mg every day for three days until [**8-9**], then
take 2mg every other day for three days until [**8-15**], then stop
taking.
Disp:*0 Tablet(s)* Refills:*0*
4. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
Disp:*1 ML(s)* Refills:*1*
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-15**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*1 bottle* Refills:*2*
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*250 ML(s)* Refills:*0*
7. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours) for 4 days.
Disp:*12 Capsule(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
9. Oral Wound Care Products Gel in Packet Sig: One (1)
Mucous membrane tid ().
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Saliva Substitution Combo No.2 Solution Sig: One (1)
Mucous membrane [**3-23**] x day () as needed for use prior to eating
for mouth pain.
12. Artificial Saliva 0.15-0.15 % Solution Sig: One (1) ML
Mucous membrane QID (4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1456**] [**Hospital **] Health Care Center
Discharge Diagnosis:
Pneumonia
Small Cell Lung Cancer
sepsis
acute renal failure
hypotension
Pneumonia
Small Cell Lung Cancer
sepsis
acute renal failure
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after an admission
for fevers and low blood pressure. You were found to have
pneumonia. This pneumonia was so serious that it required
hospitalization to the intensive care unit. We have
successfully been treating this infection with antibiotics, and
your blood pressures have returned to [**Location 213**]. If you develop
fevers, SOB, CP, confusion, or any other concerning symptoms
call your doctor.
You have also developed oral ulcers which has made it
difficult for you to eat/drink. We are giving you medication to
treat the source of the ulcers, as well as medication to numb
the pain. It is important that you drink at least 8 glasses of
water of day, as poor water intake has caused low blood
pressure.
You are being discharged from the hospital after an admission
for fevers and low blood pressure. You were found to have
pneumonia. This pneumonia was so serious that it required
hospitalization to the intensive care unit. We have
successfully been treating this infection with antibiotics. If
you develop fevers, SOB, CP, confusion, or any other concerning
symptoms call your doctor.
You have also developed oral ulcers which has made it
difficult for you to eat/drink. We are giving you medication to
treat the source of the ulcers, as well as medication to numb
the pain. It is important that you drink at least 8 glasses of
water of day, as poor water intake has caused low blood
pressure. If you develop light headedness, dizziness,
confusion, or faint, call your doctor.
You have also developed low blood counts, believed to be due
the the radiation. If you develop bleeding, SOB/weakness, or
fevers, call your doctor.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2106-8-26**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2503**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2106-8-26**] 2:30
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
ICD9 Codes: 486, 5849, 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6780
} | Medical Text: Admission Date: [**2198-10-28**] Discharge Date: [**2198-10-31**]
Date of Birth: [**2139-12-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1945**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
Intubation/ Self-Extubation
History of Present Illness:
Mr. [**Known lastname 88114**] is a 58M with h/o ulcers and GIB, who presented s/p
intubation from OSH with massive hematemesis. History obtained
through outside records, girlfriend, and mother.
.
The patient was seen at [**Hospital3 **] for 2 day h/o hematemesis
and melena per EMS note. Also with c/o abdominal pain. Pt was
AOx3 and speaking in full sentences at that time. In the ED, he
started vomiting frank blood and became "hypotensive + barely
responsive", so was intubated presumably for airway protection.
Initial HCT was 25.5, INR 1.6. He was given Protonix 80mg,
Pepcid 40mg, Morphine 4mg, Thamine, Folate, Ativan, Etomidate,
Succ, and started on a Fentanyl/Versed gtt. He was transfused
2units pRBCs en route. Two attempts at fem line were
unsuccessful.
.
In the ED, initial vs were: T 96.4 P 133 BP 133/78 RR 19 O2sat
99%. Pt noted to be moving all 4 extremities when sedation
lightened. NGL positive >1.5L. Labs notable for WBC 16.4, HCT
29.0, INR 1.8, lactate 7.3. ABG 7.26/49/121. Patient was given
CTX, Octreotide, and Pantoprazole. Cordis was placed in RIJ. He
was transfused 4 units pRBCs, 1unit FFP, 4LNS. BP transiently
dropped to SBP 80s. Vitals prior to transfer: P 103 BP 103/65 RR
22 O2sat 100%.
.
On the floor, the patient remains intubated and sedated at this
time.
Past Medical History:
Ulcers, + h/o bleeding
Social History:
Lives alone. Has a partner - [**Name (NI) 7019**] [**Name (NI) 1193**].
- Tobacco: + tobacco use
- Alcohol: + EtOH use
- Illicits: none
Family History:
Unable to assess
Physical Exam:
On admission:
Vitals: T 95.6 P 106 BP 105/64 RR 22 O2sat 100%
General: intubated, sedated
HEENT: pupils 2mm sluggish
Neck: supple, JVP not elevated
Lungs: CTA b/l anteriorly
CV: tachycardic, S1S2
Abdomen: mildly distension, +bs
GU: foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2198-10-28**] 07:05PM BLOOD WBC-16.4* RBC-2.78* Hgb-9.7* Hct-29.0*
MCV-105* MCH-34.9* MCHC-33.4 RDW-21.7* Plt Ct-183
[**2198-10-28**] 07:05PM BLOOD PT-19.5* PTT-27.5 INR(PT)-1.8*
[**2198-10-28**] 07:05PM BLOOD Fibrino-163
[**2198-10-28**] 07:05PM BLOOD UreaN-17 Creat-1.0
[**2198-10-28**] 07:05PM BLOOD ALT-34 AST-47* AlkPhos-67 TotBili-0.8
[**2198-10-28**] 07:05PM BLOOD Lipase-12
[**2198-10-28**] 10:59PM BLOOD Calcium-6.8* Phos-3.1 Mg-1.0*
[**2198-10-28**] 08:06PM BLOOD Type-ART pO2-121* pCO2-49* pH-7.26*
calTCO2-23 Base XS--5
[**2198-10-28**] 07:11PM BLOOD Glucose-187* Lactate-7.3* Na-143 K-4.3
Cl-110 calHCO3-19*
[**2198-10-28**] 07:11PM BLOOD Hgb-9.9* calcHCT-30
[**2198-10-28**] 07:11PM BLOOD freeCa-0.98*
[**2198-10-28**] 07:05PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2198-10-28**] 07:05PM URINE Blood-SM Nitrite-NEG Protein-75
Glucose-TR Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2198-10-28**] 07:05PM URINE RBC-0-2 WBC-0 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2198-10-28**] 07:05PM URINE CastHy-0-2
.
ECG [**2198-10-28**]:
Regular supraventricular tachycardia, likely sinus given age.
Diffuse
non-specific ST-T wave abnormalities, likely secondary to rapid
rate. No
other diagnostic abnormalities. No previous tracing available
for comparison.
.
Chest X-ray [**2198-10-28**]:
FINDINGS: Single supine AP portable view of the chest was
obtained. There is an endotracheal tube is seen, terminating
approximately 5 cm above the level of carina. A nasogastric tube
is seen, coursing below the diaphragm,
terminating in the expected position of the stomach. There are
relatively low lung volumes. Medial right base opacity may
relate to low lung volumes and prominent vasculature, although
an underlying consolidation from pneumonia or aspiration cannot
be entirely excluded. No focal consolidation, pleural effusion
or pneumothorax is seen. No displaced fracture is appreciated.
IMPRESSION:
1. Endotracheal and nasogastric tubes in appropriate position.
2. Low lung volumes. Medial right base opacity may relate to
prominent
vasculature, although an underlying consolidation cannot be
entirely excluded, which could be due to aspiration or
pneumonia.
Labs at discharge:
[**2198-10-31**] 06:47AM BLOOD WBC-8.4 RBC-3.61* Hgb-11.8* Hct-35.3*
MCV-98 MCH-32.8* MCHC-33.5 RDW-20.9* Plt Ct-89*#
[**2198-10-31**] 03:05AM BLOOD Hct-29.5*
[**2198-10-31**] 06:47AM BLOOD Plt Ct-89*#
[**2198-10-31**] 06:47AM BLOOD PT-13.8* PTT-23.0 INR(PT)-1.2*
[**2198-10-31**] 06:47AM BLOOD Glucose-103* UreaN-10 Creat-0.9 Na-139
K-3.5 Cl-104 HCO3-23 AnGap-16
[**2198-10-31**] 06:47AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.0
Brief Hospital Course:
MICU Course:
Pt was admitted from OSH with massive hematemesis and had been
intubated. He underwent EGD upon arrival to MICU. EGD showed
blood in stomach body and fundus and two small areas of likely
NG trauma. There were no varices. There was edema and erythema
at GE junction and on gastric mucosa and patchy area of columnar
epithelium suggestive of barrett's. Biopsies were obtained.
One lesion that could be a dieulafoye's was clipped. He was
initially kept on IV PPI gtt that was transitioned to IV PPI [**Hospital1 **]
and then to po PPI [**Hospital1 **]. He was also put on octreotide and
ceftriaxone which were also d/c-ed when esophageal varices was
ruled out. Hct remained stable in low 30s. He had no further
episodes of hematemesis while on floor and was hemodynamically
stable. He was doing well on pressure support ventilation and
self-extubated on [**2198-10-29**]. He tolerated self-extubation well
with oxygen saturations consistently above 90. He was monitored
on CIWA for alcohol/benzo withdrawal and received one dose
diazepam for insomnia. Per family, pt has had recent decrease
in mental status and self-medicating with aspirin, alcohol, and
ativan. Pt was noted to be speaking inappropriately at times
and having conversations with himself. Psych consult was
obtained who suggested Haldol 1mg at night and 1mg PRN
agitation.
On the floor the pt was hemodynamically stable and had a stable
HCT at 35.3. He continued to exhibit slightly pressured speech
and his thought pattern appeared tangential. He did not have
repeat emesis or black/bloody stool.
He was deemed stable for discharge home on Omeprazole with
follow-up at [**Company 191**] and follow-up with gastroenterology
Medications on Admission:
Ativan
Aspirin
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Upper GI bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 88114**],
You were admitted to the [**Hospital3 **] Medical center for vomiting
blood and passing blood in your stool. You were intubated in the
ICU to protect your airway. You received blood transfusions and
an endoscopy to evaluate the source of your bleeding. We did
find a lesion in your esophagus but this lesion was not actively
bleeding. You were extubated and watched closely for 2 days.
During these 2 days time you did not have repeat episode of
bleeding either through vomiting or in your stool. Your red
blood cell level remained stable. We feel that you are stable
for discharge home with follow-up appointments with a primary
care physician.
You should START the following medications:
- Omeprazole 40mg twice a day
- Folic Acid
- Vitamins
- Ativan as needed for anxiety
You should take all your other medications as prescribed in this
discharge packet.
You should call your doctor and return to the Emergency
immediately if you vomit blood or if you have bloody stools.
Followup Instructions:
Please note the following appointments:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2198-11-7**] at 3:50 PM
With: [**Last Name (NamePattern5) 65657**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This is your new Primary Care Physician within [**Hospital **].
Department: GASTROENTEROLOGY
When: FRIDAY [**2198-12-7**] at 9:30 AM
With: [**Name6 (MD) 81**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 2930, 2875, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6781
} | Medical Text: Admission Date: [**2108-2-28**] Discharge Date: [**2108-3-15**]
Date of Birth: [**2037-10-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
increased SOB, lower extremity edema
Major Surgical or Invasive Procedure:
AVR (25mm [**First Name8 (NamePattern2) **] [**Male First Name (un) **] tissue), CABGx3(SVG>PDA, SVG>LAD, SVG>Diag)/
Lt CEA [**3-8**]
tooth extraction [**3-3**]
History of Present Illness:
70 yo M who has not received medical care for most of his life
presented to ED on [**2-23**] with SOB, edema. Received lasix gtt with
some relief, cath at OSH with 2 VD, ech with AS and EF 10%.
Past Medical History:
DM, ischemic cardiomyopathy-new dx, etoh abuse, s/p cyst removal
from tailbone as child
Social History:
worked in plumbing and heating
quit tobacco [**2060**]
quit etoh 25 years ago
Family History:
NC
Physical Exam:
NAD HR 86, R 14 BP 87/56
HEENT teeth in poor repair
Lungs decreased t/o
Heart RRR 2/6 SEM
Abdomen benign
Extrem with 1+ edema to knees
No varicose veins, 1+ dp/pt pulses
Left carotid with loud bruit
Pertinent Results:
[**2108-3-15**] 06:55AM BLOOD WBC-9.7 RBC-3.44* Hgb-9.7* Hct-30.0*
MCV-87 MCH-28.0 MCHC-32.2 RDW-17.1* Plt Ct-319
[**2108-3-15**] 06:55AM BLOOD Plt Ct-319
[**2108-3-13**] 07:15AM BLOOD PT-14.9* INR(PT)-1.3*
[**2108-3-15**] 06:55AM BLOOD Glucose-128* UreaN-26* Creat-1.5* Na-140
K-4.2 Cl-101 HCO3-29 AnGap-14
[**2108-3-13**] 07:15AM BLOOD Glucose-137* UreaN-36* Creat-2.0* Na-134
K-4.2 Cl-99 HCO3-26 AnGap-13
[**2108-3-12**] 01:15PM BLOOD UreaN-33* Creat-1.9* K-4.9
CHEST (PA & LAT) [**2108-3-14**] 2:35 PM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
70 year old man s/p AVR CABG
REASON FOR THIS EXAMINATION:
eval for pleural effusions
PROCEDURE: Chest PA and lateral on [**2108-3-14**].
COMPARISON: [**2108-3-12**].
HISTORY: 70-year-old man status post AVR and CABG, evaluate for
pleural effusions.
FINDINGS: In the interim, there is a gradual decrease in the
bilateral pleural effusions with gradual decrease in the
bibasilar lower lobe atelectasis. Persistent stable
cardiomegaly. There is no evidence of pulmonary edema.
IMPRESSION:
1. Gradual decrease in the bilateral bibasilar pleural effusions
which are small to moderate on today's examination along with
gradual decrease of the bilateral bibasilar lower lobe
atelectasis.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 77685**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77686**] (Complete)
Done [**2108-3-8**] at 9:22:59 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2037-10-7**]
Age (years): 70 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG/AVR
ICD-9 Codes: 428.0, 402.90, 435.9, 786.05, 786.51, 799.02,
440.0, 424.1, 424.0
Test Information
Date/Time: [**2108-3-8**] at 09:22 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW-1: Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 10% to 15% >= 55%
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *30 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 23 mm Hg
Aortic Valve - LVOT pk vel: 0.50 m/sec
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Severely depressed LVEF.
RIGHT VENTRICLE: Severe global RV free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate (2+) 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
severely depressed (LVEF= 10 - 15%). RV also with severe global
free wall hypokinesis. There are simple atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion.
Post- CPB: The patient is in SR, with infusions of milrinone and
epinephrine.
A well-seated and functioning aortic valve prosthesis is seen,
with no AI, and no perivalvular leak. Mean gradient is 15.
Aorta intact.
MR is 1+.
Biventricular systolic fxn is still moderately depressed.
Brief Hospital Course:
He was admitted to cardiac surgery. Carotid duplex showed Left
CCA stenosis of 80-99%, he was seen by vascular surgery. CT scan
showed very calcified aortic arch and carotid arteries and CEA
was recommended. He was seen by dentistry and tooth extraction
was recommended. He underwent 1 tooth extraction on [**3-4**]. On
[**3-8**] he was taken to the operating room where he underwent an
AVR, CABG x 3 and Left CEA. He was transferred to the ICU in
critical but stable condition on epinephrine, nitroglycerine,
and milrinone. He was extubated on POD #1. He was weaned from
his milrinone over several days and transferred to the floor on
POD #3. He required extensive diuresis. he was seen by [**Last Name (un) **]
for preoperative HbA1c of 9 and uncontrolled diabetes postop. He
was started on lantus and humalog sliding scale. He was seen by
PT and cleared for home over several days. He was ready for
discharge on POD #7.
Medications on Admission:
aspirin
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*qs 1 month* Refills:*0*
9. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
Disp:*qs 1 month* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days: then 40 mg daily.
Disp:*60 Tablet(s)* Refills:*0*
11. Diabetic Supplies
one touch ultra glucometer,
Test strips for one touch ultra, Insulin syringes,
Lancets
QS 1 month
Refills per PCP
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6011**] Care
Discharge Diagnosis:
AS/CAD now s/p AVR/CABG
uncontrolled diabtes
acute on chronic systolic heart failure
L carotid stenosis now s/p CEA
DM, ischemic cardiomyopathy-new dx, etoh abuse, s/p cyst removal
from tailbone as child
Discharge Condition:
Stable
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 lifting more than 10 pounds for 10 weeks, no driving until
follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 1 week
Dr. [**Last Name (STitle) 914**] 2 weeks
Dr. [**Last Name (STitle) 39975**]/[**Last Name (un) 55499**] 4 weeks
Dr. [**Last Name (STitle) 77687**] 6 weeks
Completed by:[**2108-3-15**]
ICD9 Codes: 4241, 4254, 4280, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6782
} | Medical Text: Admission Date: [**2118-2-24**] Discharge Date: [**2118-3-8**]
Date of Birth: [**2062-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Decompensated cirrhosis
Major Surgical or Invasive Procedure:
Multiple paracenteses
EGD
History of Present Illness:
Mr. [**Known lastname 99200**] is a pleasant 55 yo man with recently-diagnosed
presumed alcoholic cirrhosis who presents from clinic today with
gross volume overload.
He had not seen a doctor for 10-15 years until about 1 month
prior toadmission, at which time he found a primary care
physician for generalized malaise and fatigue. He was apparently
sent from her office to an OSH for evaluation. During that
admission, he was diagnosed with cirrhosis and what appears to
be acute alcoholic hepatitis, as he was discharged on
prednisone.
He returned to the OSH with abdominal pain and chills. He was
found to be in renal failure, which was thought to be secondary
to a combination of obstruction and contrast-induced
nephropathy, and he was discharged with a Foley catheter after
being started on tamsulosin and finasteride.
He has had loose stools for about 6 months, and he was
apparently started on an empiric course of vancomycin PO for C.
difficile, although D/C summaries from the second
hospitalization showed no evidence of C. diff in his stool. In
addition, he has been on a course of amoxicillin-clavulanic acid
for an unknown indication. He has also been taking levofloxacin
qweek for his chronic Foley catheter.
He presented to liver clinic today, and was admitted for
management of decompensated liver failure.
He reports increasing lower extremity swelling and abdominal
girth since being discharge [**2-11**]. Over the past few days, he also
reports lower back pain that is both positional and worse with
movement. He has been having trouble ambulating because of the
swelling in his legs and his increasing weight. He has not
weighed himself since his last discharge.
He denies fevers, chills, night sweats, cough, nausea, vomiting,
hematemesis, coffee-ground emesis, melena, abdominal pain. He
does report mild abdominal distension. He does report
blood-streaked light-brown stool but he does have a h/o
hemorrhoids.
ROS was otherwise essentially negative.
Past Medical History:
Cirrhosis
Alcoholism
BPH
Social History:
Drank 1.5L of wine per day for 10-15 years; has been abstinent
for about one month now; denies tobacoo or drug use; no h/o
transfusions; no tattoos; no h/o incarceration or homelessness;
no IVDU
Family History:
No h/o liver disease
Physical Exam:
Vitals: T: 96.5 BP: 109/80 P: 115 R: 18 SaO2: 98%
General: Awake, alert, NAD, pleasant, appropriate, cooperative
HEENT: NCAT, PERRL, EOMI, mild scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, bibasilar rales, no wheezes or
ronchi
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: Distended, nontender, + shifting dullness, normoactive
bowel sounds, no masses or organomegaly noted
Extremities: Deep pitting edema to midcalf, with edema evident
to thighs bilaterally
Lymphatics: No cervical, supraclavicular lymphadenopathy noted
Skin: no spider angiomata, no gynecomastia
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor. 2+ biceps, triceps, brachioradialis, patellar
reflexes and 2+ ankle jerks bilaterally. Plantar response was
flexor bilaterally.
Pertinent Results:
[**2118-2-24**] 12:40PM URINE RBC-398* WBC-2 BACTERIA-NONE YEAST-MANY
EPI-0
[**2118-2-24**] 12:40PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-TR
[**2118-2-24**] 12:40PM URINE COLOR-LtAmb APPEAR-SlCloudy SP
[**Last Name (un) 155**]-1.018
[**2118-2-24**] 12:40PM PT-17.7* PTT-34.2 INR(PT)-1.7*
[**2118-2-24**] 12:40PM PLT COUNT-107*
[**2118-2-24**] 12:40PM NEUTS-88.8* LYMPHS-6.0* MONOS-5.1 EOS-0.1
BASOS-0.1
[**2118-2-24**] 12:40PM WBC-20.8* RBC-3.90* HGB-13.5* HCT-42.2
MCV-108* MCH-34.4* MCHC-31.9 RDW-14.6
[**2118-2-24**] 12:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG marijuana-NEG
[**2118-2-24**] 12:40PM URINE HOURS-RANDOM
[**2118-2-24**] 12:40PM HCV Ab-NEGATIVE
[**2118-2-24**] 12:40PM ETHANOL-NEG
[**2118-2-24**] 12:40PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-NEGATIVE
[**2118-2-24**] 12:40PM TSH-2.1
[**2118-2-24**] 12:40PM TOT PROT-5.9* ALBUMIN-3.2* GLOBULIN-2.7
CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.4
[**2118-2-24**] 12:40PM LIPASE-76*
[**2118-2-24**] 12:40PM ALT(SGPT)-441* AST(SGOT)-293* ALK PHOS-267*
AMYLASE-66 TOT BILI-6.2* DIR BILI-3.6* INDIR BIL-2.6
[**2118-2-24**] 12:40PM LIPASE-76*
[**2118-2-24**] 12:40PM ALT(SGPT)-441* AST(SGOT)-293* ALK PHOS-267*
AMYLASE-66 TOT BILI-6.2* DIR BILI-3.6* INDIR BIL-2.6
[**2118-2-24**] 12:40PM estGFR-Using this
[**2118-2-24**] 12:40PM UREA N-45* CREAT-1.8* SODIUM-133
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-19* ANION GAP-17
[**2118-2-24**] 12:40PM GLUCOSE-146*
[**2118-2-24**] 05:51PM ASCITES WBC-51* RBC-51* POLYS-18* LYMPHS-16*
MONOS-46* MESOTHELI-2* MACROPHAG-18*
[**2118-2-24**] 05:51PM ASCITES TOT PROT-0.4 GLUCOSE-181 LD(LDH)-39
ALBUMIN-<1.0
[**2118-2-24**] 06:01PM URINE HOURS-RANDOM UREA N-806 CREAT-66
SODIUM-18
Brief Hospital Course:
55 yo man with newly-diagnosed cirrhosis and BPH who presented
with decompensated cirrhosis and renal failure and subsequent
shock.
.
On presentation, patient was found to be in shock with MRSA
bacteremia. He was started on Vancomycin and his blood pressure
was supported with pressors and steroids. He eventually became
hemodynamically stable and pressors were being weaned off.
However, his overall prognosis was poor with decompensated
cirrhosis and resultant renal failure and pulmonary edema/ARDS.
Patient was also very sedated and even off sedating medications,
had a depressed mental status, likely from hepatic
encephalopathy. Discussions with the family about goals of care
eventually caused the patient to become CMO. All unnecessary
medications were discontinued. The patient passed away on
[**2118-3-8**] with his family at the bedside.
Medications on Admission:
lactulose
Tamsulosin
Finasteride
Prednisone 20 [**Hospital1 **]
Pantoprazole
.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cirrhosis
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 0389, 5849, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6783
} | Medical Text: Admission Date: [**2174-8-1**] Discharge Date: [**2174-8-4**]
Date of Birth: [**2116-11-12**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Direct admission for paracentesis and blood transfusion in
anticipation of TIPS
Major Surgical or Invasive Procedure:
TIPS
mechanical ventilation
central line placement
therapeutic paracentesis
History of Present Illness:
57 year old man with alcoholic cirrhosis and resultant portal
hypertension and ascites scheduled for TIPS this week who
presented to Dr.[**Name (NI) 948**] clinic today with reaccumulated
ascites. He has had multiple large volume paracenteses in the
past month most recently 2 days ago in the ED when he had 6
liters tapped from his abdomen (he was given 50g albumin at that
time). In addition, Hemoglobin was noted to be 8.4 (down from
10.2 on [**7-19**]). He was discharged home from the ED with
planned TIPS scheduled for [**8-2**]. However, in clinic today,
his fluid had reaccumulated and given his recent drop in
Hemoglobin, per Dr. [**Last Name (STitle) 497**], he is being admitted today for
paracentesis of reaccumulated fluid as seen in clinic today and
a 2 unit blood transfusion in anticipation of TIPS planned for
tomorrow.
.
His ascites has been recurrent since [**Month (only) 547**] and has been
refractory to diuretics. Prior to that, his last episode of
ascites was a few years ago. The differential of his worsening
ascites was initially thought to include progression of liver
disease, portal vein thrombosis, HCC, hepatic mets, peritoneal
carcinomatosis. During an admission in [**Month (only) 116**], he had a RUQ US
with normal vasculature and no liver lesions. AFP was within
normal limits. Fluid from paracenteses has been negative for
SBP and cultures have also been consistently negative. He has
known esophageal varices that were visualized on 3 EGDs in [**Month (only) 116**]
and were found to be nonbleeding. He had no evidence of
encephalopathy and was maintained on prophylactic
lactulose. The team was initially considering performing a TIPS
procedure in [**Month (only) 116**], however, when he developed bacteremia, it was
felt to be safer to administer 2 weeks of antibiotics and then
plan for TIPS scheduled for this week.
.
He denies fever, chills, abdominal pain, N/V, constipation,
BRBPR/melena, hematemesis, cough, SOB, LE edema, headache, neck
stiffness, confusion, pruritus, change in BMs. He does report
some daytime somnolence and mild nighttime insomnia. He reports
he first developed ascites approximately 4y ago, for which he
underwent paracentesis. He states he had no further ascites
until last month.
Past Medical History:
1. EtOH cirrhosis: decompensated with ascites and varices, on
transplant list
2. Colonic adenoma: polypectomy in [**2171**]
3. Esophageal varices: grade 1 on last EGD in [**8-26**], s/p banding
of grade II varices in [**10-25**], h/o hematemesis in the past
4. Cholelithiasis
5. Partial colectomy: at [**Hospital3 **] in [**2158**] [**2-24**] severe GI
bleed after polypectomy
6. hernia repair
Social History:
[**Month/Day (2) **] Priest. [**Name (NI) **] children. No tobacco. Currently no EtOH.
Formerly a heavy drinker (cannot quantify). Currently living
with parents
Family History:
no fam hx of cirrhosis/liver disease; 6 siblings, all healthy.
parents both alive and healthy
Physical Exam:
T 97.8 BP 98/62 HR 83 RR 20 Sat 100% ra
Gen: thin man lying in bed in NAD
HEENT: no scleral icterus; nasogastric feeding tube in place
with small amount of dried blood
Neck: no LAD, no JVP
Pulm: cta bilaterally
CV: reg rate, nl s1s2, no murmurs
Abd: moderately distended; nontender; normoactive bowel sounds;
(+)shifting dullness; no liver edge or spleen tip palpated
Extr: 2+ PT pulses
Skin: no jaundice; no rashes
Neuro: alert, oriented, nonfocal
Pertinent Results:
REPORTS:
.
Procedure [**2174-8-2**]:
1. Ultrasound-guided paracentesis.
2. Transjugular intrahepatic portosystemic shunt placement
(TIPS).
3. Single coronary vein varix ablation with absolute alcohol.
4. Quadruple lumen central venous line, right internal approach.
PRESSURE MEASUREMENTS:
Initial direct portal vein pressure = 22 mmHg.
Initial free hepatic vein pressure = 4 mm.
Post TIPS direct portal vein pressure = 17 mm.
Post TIPS free hepatic vein pressure = 14 mm.
Post TIPS inferior vena cava pressure = 8 mm.
A single coronary vein was ablated with a bolus of 5 cc of
absolute alcohol.
IMPRESSION:
1. Status post paracentesis. 1500 cc of clear amber acetic fluid
was collected.
2. Status post TIPS procedure with deployment of the 10 mm x 68
mm wall stent in the transparenchymal tract. Initial
portosystemic gradient was 19 mm. Subsequent to stent creation,
portosystemic gradient was 9 mm
3. Status post single coronary vein varix ablation with absolute
alcohol.
4. Status post quadruple lumen central venous line placement.
.
DUPLEX DOPP ABD/PEL [**2174-8-3**] 2:05 PM
IMPRESSION: Patent TIPS with flow rates from 122.1 to 226.6
cm/sec. The velocites are upper limits of normal and follow-up
is recommended. Patent and appropriate direction of flow within
the anterior right and left portal veins, hepatic veins, left
and main hepatic artery.
.
LABS:
.
[**2174-8-4**] 01:57AM BLOOD WBC-7.4 RBC-3.06* Hgb-9.4* Hct-26.7*
MCV-88 MCH-30.9 MCHC-35.3* RDW-16.8* Plt Ct-49*
[**2174-8-3**] 08:02AM BLOOD Hct-27.6*
[**2174-8-3**] 03:30AM BLOOD WBC-9.4 RBC-3.08* Hgb-9.5* Hct-26.9*
MCV-87 MCH-30.7 MCHC-35.1* RDW-17.0*
[**2174-8-2**] 11:50PM BLOOD WBC-7.8 RBC-3.15* Hgb-9.7* Hct-27.4*
MCV-87 MCH-30.8 MCHC-35.5* RDW-17.0*
[**2174-8-2**] 08:47PM BLOOD WBC-8.3 RBC-3.26* Hgb-9.9* Hct-28.2*
MCV-87 MCH-30.5 MCHC-35.2* RDW-16.9*
[**2174-8-2**] 04:55PM BLOOD WBC-8.4 RBC-3.15* Hgb-9.8* Hct-27.3*
MCV-87 MCH-31.1 MCHC-35.8* RDW-17.0* Plt Ct-74*
[**2174-8-2**] 02:24PM BLOOD WBC-7.5# RBC-3.33* Hgb-10.1* Hct-29.0*
MCV-87 MCH-30.2 MCHC-34.7 RDW-17.4* Plt Ct-76*
[**2174-8-2**] 04:25AM BLOOD WBC-4.9 RBC-2.72* Hgb-8.3* Hct-24.5*
MCV-90 MCH-30.6 MCHC-34.0 RDW-16.5* Plt Ct-86*
[**2174-8-2**] 12:00AM BLOOD Hct-22.9*
[**2174-8-1**] 12:45PM BLOOD WBC-7.3 RBC-2.32* Hgb-7.3* Hct-21.5*
MCV-92 MCH-31.5 MCHC-34.1 RDW-16.7*
[**2174-8-4**] 01:57AM BLOOD Neuts-76.9* Lymphs-8.4* Monos-9.5
Eos-4.9* Baso-0.3
[**2174-8-2**] 04:55PM BLOOD Neuts-82.9* Lymphs-3.8* Monos-9.7 Eos-2.9
Baso-0.7
[**2174-8-1**] 12:45PM BLOOD Neuts-79.3* Lymphs-6.7* Monos-8.1
Eos-5.3* Baso-0.5
[**2174-8-4**] 01:57AM BLOOD Plt Smr-VERY LOW Plt Ct-49*
[**2174-8-4**] 01:57AM BLOOD PT-16.7* PTT-36.1* INR(PT)-1.5*
[**2174-8-3**] 08:02AM BLOOD Plt Smr-UNABLE TO
[**2174-8-3**] 08:02AM BLOOD PT-15.9* PTT-36.1* INR(PT)-1.5*
[**2174-8-3**] 03:30AM BLOOD Plt Smr-VERY LOW Plt Ct-69*
[**2174-8-3**] 03:30AM BLOOD Plt Smr-UNABLE TO LPlt-1+
[**2174-8-3**] 03:30AM BLOOD PT-14.9* PTT-34.4 INR(PT)-1.3*
[**2174-8-3**] 01:48AM BLOOD Plt Smr-LOW Plt Ct-81*
[**2174-8-2**] 11:50PM BLOOD Plt Smr-UNABLE TO
[**2174-8-2**] 11:50PM BLOOD PT-15.2* PTT-33.9 INR(PT)-1.4*
[**2174-8-2**] 08:47PM BLOOD Plt Smr-VERY LOW Plt Ct-79*
[**2174-8-2**] 08:47PM BLOOD Plt Smr-UNABLE TO
[**2174-8-2**] 08:47PM BLOOD PT-15.5* PTT-35.9* INR(PT)-1.4*
[**2174-8-2**] 04:55PM BLOOD PT-15.8* PTT-36.0* INR(PT)-1.4*
[**2174-8-2**] 02:24PM BLOOD Plt Smr-VERY LOW Plt Ct-76*
[**2174-8-2**] 02:24PM BLOOD PT-16.1* PTT-58.0* INR(PT)-1.5*
[**2174-8-1**] 12:45PM BLOOD Plt Smr-UNABLE TO
[**2174-8-1**] 12:45PM BLOOD PT-15.9* PTT-33.7 INR(PT)-1.5*
[**2174-8-2**] 04:25AM BLOOD PT-16.0* PTT-36.8* INR(PT)-1.5*
[**2174-8-3**] 03:30AM BLOOD Fibrino-254
[**2174-8-2**] 11:50PM BLOOD Fibrino-241
[**2174-8-2**] 08:47PM BLOOD Fibrino-236
[**2174-8-2**] 02:24PM BLOOD Fibrino-221
[**2174-8-2**] 02:24PM BLOOD Ret Aut-4.5*
[**2174-8-4**] 01:57AM BLOOD Glucose-128* UreaN-30* Creat-1.1 Na-133
K-4.2 Cl-105 HCO3-21* AnGap-11
[**2174-8-3**] 03:30AM BLOOD Glucose-88 UreaN-39* Creat-1.1 Na-132*
K-4.0 Cl-99 HCO3-22 AnGap-15
[**2174-8-2**] 11:50PM BLOOD Glucose-92 UreaN-40* Creat-1.1 Na-132*
K-4.1 Cl-99 HCO3-22 AnGap-15
[**2174-8-2**] 04:55PM BLOOD Glucose-91 UreaN-42* Creat-1.1 Na-130*
K-4.1 Cl-98 HCO3-22 AnGap-14
[**2174-8-2**] 02:24PM BLOOD Glucose-92 UreaN-43* Creat-1.1 Na-127*
K-4.3 Cl-98 HCO3-19* AnGap-14
[**2174-8-2**] 04:25AM BLOOD Glucose-100 UreaN-52* Creat-1.3* Na-125*
K-4.6 Cl-94* HCO3-21* AnGap-15
[**2174-8-2**] 12:00AM BLOOD K-4.9
[**2174-8-1**] 12:45PM BLOOD Glucose-102 UreaN-50* Creat-1.3* Na-125*
K-5.3* Cl-94* HCO3-22 AnGap-14
[**2174-8-4**] 01:57AM BLOOD ALT-29 AST-39 AlkPhos-88 TotBili-1.9*
[**2174-8-3**] 03:30AM BLOOD ALT-26 AST-37 LD(LDH)-153 AlkPhos-85
TotBili-3.0*
[**2174-8-2**] 04:55PM BLOOD ALT-23 AST-35 LD(LDH)-145 AlkPhos-79
TotBili-3.5*
[**2174-8-2**] 02:24PM BLOOD ALT-23 AST-37 LD(LDH)-151 AlkPhos-77
TotBili-3.7*
[**2174-8-2**] 04:25AM BLOOD ALT-18 AST-26 LD(LDH)-136 AlkPhos-80
TotBili-2.3*
[**2174-8-1**] 12:45PM BLOOD ALT-21 AST-30 LD(LDH)-154 AlkPhos-97
TotBili-1.4
[**2174-8-4**] 01:57AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
[**2174-8-3**] 03:30AM BLOOD Albumin-3.5 Calcium-8.8 Phos-4.0 Mg-2.1
[**2174-8-2**] 11:50PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.1
[**2174-8-2**] 04:55PM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.8 Mg-2.1
[**2174-8-2**] 04:25AM BLOOD Albumin-3.7 Calcium-8.6 Phos-4.5 Mg-2.1
[**2174-8-1**] 12:45PM BLOOD Albumin-3.8 Calcium-8.7 Phos-3.7 Mg-2.2
[**2174-8-2**] 02:24PM BLOOD Hapto-<20*
[**2174-8-2**] 04:25AM BLOOD AFP-2.1
[**2174-8-3**] 05:39AM BLOOD Type-ART Temp-36.1 Rates-/16 PEEP-5
FiO2-50 pO2-150* pCO2-33* pH-7.46* calTCO2-24 Base XS-1
Intubat-INTUBATED
[**2174-8-2**] 05:13PM BLOOD Type-ART Temp-37.2 Rates-/14 Tidal V-450
PEEP-5 FiO2-50 pO2-161* pCO2-36 pH-7.42 calTCO2-24 Base XS-0
Intubat-INTUBATED Vent-SPONTANEOU
[**2174-8-2**] 02:35PM BLOOD Type-ART pO2-153* pCO2-32* pH-7.42
calTCO2-21 Base XS--2
[**2174-8-2**] 05:48PM BLOOD HEPARIN DEPENDENT ANTIBODIES: negative
[**2174-8-1**] 04:38PM ASCITES TOT PROT-0.6 LD(LDH)-19 ALBUMIN-LESS
THAN
[**2174-8-1**] 12:30PM ASCITES WBC-105* RBC-1085* POLYS-11*
LYMPHS-33* MONOS-47* EOS-7* MESOTHELI-2*
.
MICRO:
.
Time Taken Not Noted Log-In Date/Time: [**2174-8-1**] 4:38 pm
FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL.
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
.
Time Taken Not Noted Log-In Date/Time: [**2174-8-1**] 4:38 pm
FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Brief Hospital Course:
On admission, pt was transfused 2 U PRBC's, with minimal bump in
hct from 21.5 to 24.5. He also underwent therapeutic
paracentesis, and 5L of fluid was removed. Pt was placed on Hep
SC for DVT ppx. Pt then underwent TIPS procedure, which was
successful. A therapeutic paracentesis of 1600cc was also
performed during the TIPS. However, after the procedure, he was
found to have blood pooling in his oropharynx, as well as oozing
of blood from his nares and R IJ site. There was ? of coffee
ground aspirated from NG tube. He was kept intubated for airway
protection, and labs were sent. He was then given 2L NS, 1 U
PRBC's, 2U FFP, and 1 bag of platelets. Pt had been on
Neosynephrine briefly during the TIPS procedure, but did not
require pressors after the procedure. He remained
hemodynamically stable in the PACU, and was transferred to the
MICU for further management. His hct remained stable s/p
initial transfusion, and he remained hemodynamically stable
throughout his stay in the MICU. He was given Vitamin K 10mg SC
to treat an INR of 1.5. Pt's platelets dropped during the
admission, and a HIT Ab test was negative. The platelet drop
was of unclear etiology. The pt was started on protonix for GI
ppx, but this was started after the platelet drop, and this med
was subsequently d/c'd (although not thought to be cause of
inital platelet decrease). Heparin products were held after his
initial episode of bleeidng. He had fibrinogen levels >200, so
DIC was thought unlikely. He had an episode of increased
bleeding from his nasal passage overnight in the ICU, so he was
given an additional 2 [**Location 16678**] and treated with Afrin. The
bleeding then ceased, and the pt was successfully extubated on
[**8-3**]. It was believed that the initial episode of bleeding s/p
TIPS was due to epistaxis from possible NGT trauma, in the
setting of dysfibrinoginemia and coagulopathy from liver
disease. GI bleed or bleeding from his airway were thought much
less likely. Pt's diuretics and lactulose were held during his
MICU stay and on discharge. His hct remained stable s/p
extubation, and he was discharged directly from the ICU in good
condition.
Medications on Admission:
1. omeprazole 30mg daily
2. Folic Acid 1mg daily
3. Multivitamin one tab daily
4. Bupropion SR 100mg qAM
5. Benzonatate 100mg TID
6. Hydroxyzine 25mg [**Hospital1 **]
7. Furosemide 60mg [**Hospital1 **]
8. Spironolactone 100mg [**Hospital1 **]
10. Lactulose 30 ML PO TID
11. Metoclopramide 10mg TID prn
12. Ferrous Sulfate 325mg daily
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. Lactulose (for Encephalopathy) 10 g/15 mL Solution Sig:
Thirty (30) ml PO three times a day.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
cirrhosis requiring TIPS procedure
Secondary diagnosis:
epistaxis requiring intubation and ICU monitoring
Discharge Condition:
stable
Discharge Instructions:
please seek medical attention immediately if you experience
bleeding, chest pain, shortness of breath, fevers, chills,
nausea, vomiting, diarrhea, dizziness, or any other concerning
symptoms.
Please take all medications as prescribed.
Please attend all follow-up appointments.
Followup Instructions:
You have the following appointment scheduled:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2174-8-10**] 8:20
Please follow-up with your PCP [**Last Name (NamePattern4) **] 1 week as well.
Completed by:[**2174-8-5**]
ICD9 Codes: 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6784
} | Medical Text: Admission Date: [**2164-10-16**] Discharge Date: [**2164-11-9**]
Date of Birth: [**2087-7-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2164-10-22**]:
1. Aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna Ease
aortic valve bioprosthesis, model #3300TFX, serial
#[**Serial Number 87002**].
2. Mitral valve replacement with a 27-mm St. [**Male First Name (un) 923**] Epic
mitral bioprosthesis, reference #[**Serial Number 87003**], serial
#[**Serial Number 87004**].
3. Coronary bypass grafting x1 with reverse saphenous vein
graft from aorta to distal right coronary artery.
History of Present Illness:
77 year old female that presented to OSH with worsening dyspnea
on exertion x 3 days with known murmur. She was found to be in
failure and echocardiogram
revealed severe aortic stenosis with [**Location (un) 109**] 0.5. She received
lasix
for diuresis and was transferred in for surgical evaluation and
cardiac catheterization
Cardiac Catheterization: Date: [**2164-10-16**] Place: [**Hospital1 18**]
Revealed three vessel disease. The LMCA was normal without
stenosis. The
LAD has a 50% proximal stenosis. The LCx has a 40% proximal
stenosis with a 40% distal stenosis. The RCA has an 80%
proximal stenosis. Resting hemodynamics demonstrated elevated
left and right sided filling pressures with RVEDP of 13 mmHg and
mean PCWP of 28 mmHg. There is moderate pulmonary arterial
hypertension of 53/23 mmHg as well as persistent systemic
arterial hypertension (151/61 with a mean of 101 mmHg). The
cardiac index was preserved at 2.93 l/min/m2 (using an assumed
oxygen consumption)
Past Medical History:
Hypertension
Hyperlipidemia
Aortic Stenosis [**Location (un) **] 0.5
Hodgkin's stage IIIB s/p chemotherapy and radiation ( was from
level of ears to pelvis done in [**2137**])
Breast Cancer
diverticulosis stage III - found on colonscopy [**2164-9-8**]
Upper airway obstruction secondary to papillomas - although
multiple areas note home oxygen - she states that she does not
wear oxygen at home
Epitaxis every 2-3 months left nares only
Glaucoma s/p laser in left eye to reduce pressure
Past Surgical History
splenectomy
hysterectomy
laryngeal papillomas removal - last attempt [**2164-5-9**]
Left mastectomy [**2162**]
Social History:
Race: caucasian
Last Dental Exam: long time ago
Lives with: daughter
Occupation: health clinic in school
Tobacco: denies
ETOH: denies
Family History:
grandfather deceased 65 MI
brother deceased 74 MI
Grandmother stroke deceased 60
Physical Exam:
Pulse: 94 Resp: 20 O2 sat: 100% 2 l nc
B/P Right: 132/49 Left: not done due to mastectomy
General: pleasant, no acute distress
Skin: Dry [x] intact [x] right groin cath site, left subclavian
surgical scar, left chest surgical scar
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] non palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: multiple bilateral lower extremities
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit transmitted murmur
Pertinent Results:
Admission:
[**2164-10-17**] 06:35AM BLOOD WBC-10.4 RBC-3.90* Hgb-10.9* Hct-33.6*
MCV-86 MCH-27.9 MCHC-32.4 RDW-14.5 Plt Ct-494*
[**2164-10-17**] 06:35AM BLOOD Plt Ct-494*
[**2164-10-17**] 06:35AM BLOOD Glucose-98 UreaN-36* Creat-1.3* Na-142
K-4.2 Cl-100 HCO3-29 AnGap-17
[**2164-10-18**] 03:11PM BLOOD ALT-24 AST-21 AlkPhos-110* TotBili-0.3
[**2164-10-17**] 06:35AM BLOOD CK(CPK)-154
[**2164-10-18**] 03:11PM BLOOD Lipase-31
Discharge:
[**2164-11-8**] 11:32AM BLOOD Vanco-26.0*
[**2164-11-8**] 05:01AM BLOOD WBC-12.0* RBC-2.92* Hgb-8.6* Hct-26.3*
MCV-90 MCH-29.3 MCHC-32.5 RDW-16.2* Plt Ct-349
[**2164-11-8**] 05:01AM BLOOD Plt Ct-349
[**2164-11-8**] 05:01AM BLOOD PT-22.3* PTT-30.3 INR(PT)-2.1*
[**2164-11-8**] 05:01AM BLOOD UreaN-25* Creat-1.0 Na-132* K-4.8 Cl-103
[**2164-11-6**] 04:57AM BLOOD Glucose-141* UreaN-23* Creat-0.8 Na-134
K-5.0 Cl-104 HCO3-25 AnGap-10
[**2164-11-1**] 05:56AM BLOOD ALT-66* AST-48* AlkPhos-209* TotBili-0.7
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of
[**2164-11-7**]
[**Hospital 93**] MEDICAL CONDITION: 77 year old woman with s/p AVR,
MVR, CABG
REASON FOR THIS EXAMINATION: evaluate dysphagia
Final Report
FINDINGS: Multiple consistencies of barium were administered.
Barium passed freely through the oropharynx without evidence of
obstruction. Mild
penetration was seen with rapid swallows of thin barium;
otherwise, there is no evidence of aspiration. For more
information, please see the speech and swallow division note in
the online medical record.
Radiology Report CHEST (PA & LAT) Study Date of [**2164-11-6**] 2:46 PM
[**Hospital 93**] MEDICAL CONDITION: 77 year old woman s/p AVR/CABG/ex
lap
REASON FOR THIS EXAMINATION: assess for infiltrates
There has been little interval change in bilateral pleural
effusions, right greater than left, with marked retrocardiac
opacity. Upper lungs remain relatively well aerated without new
focus of consolidation. There is no pneumothorax. The
cardiomediastinal silhouette is grossly unchanged.
IMPRESSION: Little change in bilateral pleural effusions with
retrocardiac
opacity. Superimposed consolidation at the lung bases cannot be
excluded.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
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: 5.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.5 cm
Left Ventricle - Fractional Shortening: *0.18 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.1 cm <= 3.0 cm
Aorta - Ascending: 2.6 cm <= 3.4 cm
Aorta - Arch: 2.4 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *3.6 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *52 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 32 mm Hg
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Mitral Valve - MVA (P [**1-28**] T): 2.0 cm2
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 1.00
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Normal LV cavity
size. Low normal LVEF. [Intrinsic LV systolic function likely
depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Simple atheroma in
aortic arch. Normal descending aorta diameter. Complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Mild to moderate ([**1-28**]+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe
mitral annular calcification. Mild valvular MS (MVA 1.5-2.0cm2).
Moderate to severe (3+) MR.
TRICUSPID VALVE: Moderately thickened tricuspid valve leaflets.
Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The patient appears to be in sinus rhythm.
patient.
Conclusions
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50-55%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the aortic arch.
There are complex (>4mm) atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild to moderate
([**1-28**]+) aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. There is severe mitral annular
calcification. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Moderate to severe (3+) mitral regurgitation is
seen. The tricuspid valve leaflets are moderately thickened.
Moderate [2+] tricuspid regurgitation is seen. Dr. [**Last Name (STitle) 914**] was
notified in person of the results in the operating room at the
time of the study.
POST BYPASS The patient is receiving epinephrine by infusion.
Biventricular systolic function appears normal. There is a
bioprosthesis located in the mitral position. It appears well
seated. The leaflets are seen to be moving normally. There is
trace, central, valvular mitral regurgitation. The maximum
gradient through the mitral valve was 16 mmHg with a mean
gradient of 7 mmHg at a cardiac output around 3.5 liters/minute.
There is a bioprosthesis located in the aortic position. It also
appears well seated and displays normal leaflet movement. There
is trace, central valvular aortic regurgitation. The maximum
gradient through the aortic valve was 16 mmHg with a mean
gradient of 8 mmHg at a cardiac ouput of 3.5 liters/minute. The
thoracic aorta appears intact after decannulation. The tricuspid
regurgitation may be slightly improved - now closer to mild to
moderate.
Brief Hospital Course:
Patient was initially admitted to cardiology service after being
seen at OSH for chest pain and dyspnea. An echo showed aortic
stenosis and she was referred to [**Hospital1 18**] for cardiac
catheterization. Her catheterization revealed 3 vessel coronary
disease. Cardiac surgery was consulted. After the usual
preoperative workup the patient was brought to the operating
room on [**2164-10-22**]. Please see operative report for details, in
summmary she had:
1. Aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna Ease
aortic valve bioprosthesis, model #3300TFX, serial #[**Serial Number 87002**].
2. Mitral valve replacement with a 27-mm St. [**Male First Name (un) 923**] Epic mitral
bioprosthesis, reference #[**Serial Number 87003**], serial #[**Serial Number 87004**].
3. Coronary bypass grafting x1 with reverse saphenous vein graft
from aorta to distal right coronary artery.
4. Endoscopic left greater saphenous vein harvesting.
5. Epiaortic duplex scanning.
Her bypass time was 160 minutes with a crossclamp time of 136
minutes.
She tolerated the operation well and was transferred
post-operatively to the cardiac surgery ICU in stable condition.
The patient woke from anesthesia with tachycardia and
hypertension and was resedated. On the morning of POD1 she was
extubated. Over the next few days she remained hemodynamically
stable but had generalized complains aof pain with some
localization to the abdomen. On POD2 her lactate rose from 1.2
to 2.1 and general surgery was consulted. She was brought to the
operating room by general surgery on [**10-25**] for Exploratory
laparotomy, cholecystectomy. Please see operative report for
details. She again was brought to the cardiac surgery ICU in
stable condition. She extubated the day after surgery but
remained in the ICU for hemodynamic monitoring. During this time
she had several episodes of atrial fibrillation and was treated
with Beta blockers, amiodarone and anticoagulation.
She was very deconditioned and her activity was minimal in this
initial period, she failed a swallow evaluation and a feeding
tube was placed.
She slowly gained strength and on POD 9 and 6 she was
transferred from the ICU to the cardiac stepdown floor. Once on
the floor she was started on some oral nutrition and appeared to
have aspirated, with a leukocytosis and chest XRay the revealed
a right lower lobe infiltrate. She was started on broad spectrum
antibiotics and her leukocytosis gradually resolved. She worked
with physical therapy and the nursing staff to regain strength
and mobility, again the progress was slow. ON POD 18 she was
transferred to rehabilitation at Life Care Center of [**Location (un) **] for
continued recovery.
Medications on Admission:
Torsemide 20 mg daily - will increase to 40 mg if weight
increased
Metoprolol 25 mg [**Hospital1 **]
Atorvastatin 10 mg daily
Aspirin 81 mg daily
Multivitamin 1 daily
Lumigan 0.03% 1 drop each HS
Klor-con 20 meq daily
Plavix - last dose: none
Allergies: shellfish - vomiting
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Yx Inhalation Q6H (every 6 hours) as
needed for wheezing.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**5-1**]
hours as needed for fever, pain.
10. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg [**Hospital1 **] x7 days then 200mg QD.
13. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
14. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous QD and PRN as needed for line flush.
15. vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) for 8 days: please check
trough after 3rd dose.
16. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush: 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. .
17. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 8
days.
18. warfarin 1 mg Tablet Sig: as directed to keep INR 2-2.5
Tablets PO Once Daily at 4 PM: Target INR 2-2.5(AFib)
[**11-8**] dose 1mg.
19. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
20. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
1. Aortic stenosis/aortic regurgitation. s/p AVR
2. Mitral stenosis/mitral regurgitation. s/p MVR
3. Coronary artery disease. s/p CABG
4. s/p Cholecystectomy
PMH: Hypertension, Hyperlipidemia, AS, MS, CVD, PVD, Hodgkin's
stage IIIB s/p chemo and radiation,Upper airway obstruction
secondary to papillomas, on Home O2 2 liters, splenectomy,
hysterectomy, laryngeal papillomas, tubular adenoma,
diverticulosis stage III
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with asssistance
Incisional pain managed with Ultram and Tylenol
Incisions: Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage. 1+ Edema
Exploratory Laporotomy wound- no eryhtema 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**]
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: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:
[**2164-11-27**] 2:45PM
Cardiologist: Dr [**First Name (STitle) 7756**] on [**11-26**] at 2:15PM
General Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (abdominal
surgeon)Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2164-11-23**] 2:20
Please call to schedule appointments with your
Primary Care Dr [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] in [**4-30**] weeks [**Telephone/Fax (1) 28262**]
****Pulm nodules on Chest CT needs f/u study in 6 mo**
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2.0-2.5
First draw [**2164-11-10**]
Completed by:[**2164-11-9**]
ICD9 Codes: 5070, 4280, 4019, 2859, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6785
} | Medical Text: Admission Date: [**2136-8-30**] Discharge Date: [**2136-9-11**]
Date of Birth: [**2058-7-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Md-76 R
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2136-9-5**] Urgent coronary artery bypass graft x5: Left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to diagonal, posterior descending artery and
saphenous vein sequential grafts to obtuse marginal 1 and 2
[**8-30**] Cardiac Cath
History of Present Illness:
78 yo M with PMH significant for hypertension, diabetes, and
known CAD s/p BMS to LCx who presented to [**Hospital6 33**]
with exertional substernal chest pain. EKG showed slight ST
depressions and patient requested transfer to [**Hospital1 18**]. Cardiac
catheterization showed 3VD and we are asked to evaluate for
surgical revascularization.
Past Medical History:
Coronary Artery Disease
PMH:
Hypertension
Hyperlipidemia
NSTEMI [**8-/2126**] s/p BMS to LCx
Diabetes Mellitus-Type II
Benign Prostatic Hypertrophy
Osteoarthritis
Essential Tumor
PNA with empyema as child s/p rib resection
Glaucoma
Social History:
Lives with:wife
Occupation:Retired
Tobacco:quit 45 years ago; smoked 1ppd x 15 yrs
ETOH:occasional beer
[**Location (un) 686**] native and a a graduate of [**Location (un) 86**] Tech, no college.
He used to work at [**Location (un) 511**] Telephone as an installer.
Married for 53 yrs with 4 adult children: 3 girls and 1 boy.
Enjoys playing golf daily. He has a remote history of tobacco
use, DC'ing this in the mid-60s. He consumes an occasional beer,
and there is no history of injecting or other drug use. Exercise
consists of walking both on and off the golf course. The patient
remains quite active. He adheres to relatively [**Name2 (NI) **] diet
although does acknowledge still a sweet tooth. Recent death of
his son from advanced renal failure against the backdrop of
hypertension, diabetes and previous closed head injury. This has
been quite devastating to the patient and his wife.
Family History:
Notable for malignancy of undetermined type in an aunt, HTN and
CHF in son, and ETOH abuse in an uncle. There is no family
history of premature coronary artery disease or sudden death.
Physical Exam:
Pulse:58 Resp:16 O2 sat:94%RA
B/P Right:187/ Left: 226/87
Height:5'[**37**]" Weight:205lbs (93 kg)
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] umbilical hernia
Extremities: Warm [x], well-perfused [x] Edema 0 Varicosities:+
R knee incision
Neuro: Grossly intact
Pulses:
Femoral Right: dressing Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**8-30**] Cath: 1. Selective coronary angiography in this right
dominant system
demonstrates three vessel disease. The LMCA was a short vessel
with no angiographically apparent disease. The LAD was heavily
calcified proximally with diffuse disease in the proximal
portion of the vessel. The ostium of the LAD had a 90% stenosis,
the mid LAD had a 50% stenosis and the distal LAD had a 70%
stenosis. The Cx had a proximal 50% stenosis. OM1 had a 60%
stenosis, the origin of OM2 had a 50% stenosis and the origin of
OM3 had a 40% stenosis. The RCA was known occluded and not
injected. However, the RCA was seen to fill via robust left
sided collaterals and only mild disease was seen in the vessel
after the known total occlusion. 2. Limited resting hemodynamics
revealed a central aortic pressure of 179/80 mmHg.
[**8-31**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
40-59% .
[**8-31**] Vein mapping: Duplex and color Doppler demonstrate wide
patency of both greater saphenous veins. Please see digitized
image on PACS for formal sequential measurements of these
vessels
[**9-5**] Echo: PRE BYPASS The left atrium is mildly dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricle displays normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
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 a trivial/physiologic pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the study.
POST BYPASS The patient is a-paced. Normal biventricular
systolic function. No change in valvular function. The thoracic
aorta appears intact status post decannulation.
[**2136-9-11**] 05:30AM BLOOD Hct-32.3*
[**2136-9-10**] 05:05AM BLOOD WBC-8.7 RBC-3.73* Hgb-11.1* Hct-33.6*
MCV-90 MCH-29.6 MCHC-32.9 RDW-14.6 Plt Ct-227
[**2136-9-11**] 05:30AM BLOOD PT-12.7 INR(PT)-1.1
[**2136-9-10**] 05:05AM BLOOD PT-11.8 PTT-25.7 INR(PT)-1.0
[**2136-9-5**] 02:15PM BLOOD PT-13.5* PTT-29.8 INR(PT)-1.2*
[**2136-9-11**] 05:30AM BLOOD UreaN-29* Creat-1.2 Na-143 K-4.3 Cl-106
[**2136-9-10**] 05:05AM BLOOD Glucose-142* UreaN-33* Creat-1.2 Na-142
K-3.9 Cl-107 HCO3-28 AnGap-11
[**2136-9-9**] 06:50AM BLOOD Glucose-144* UreaN-28* Creat-1.3* Na-143
K-3.9 Cl-106 HCO3-29 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 26172**] presented to [**Hospital6 33**] with exertional
substernal
chest pain. EKG showed slight ST depressions and patient
requested transfer to [**Hospital1 18**]. On [**8-30**] he underwent a cardiac cath
which revealed severe three vessel coronary artery disease. He
underwent appropriate work-up which included carotid ultrasound
and bilateral vein mapping. He received medical management while
awaiting Plavix washout. On [**9-5**] he was brought to the operating
room where he underwent a coronary artery bypass graft x 5.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. On post-op
day one chest tubes were removed and he was transferred to the
telemetry floor for further care. Beta-blockers and diuretics
were initiated and he was diuresed towards his pre-op weight.
He did develop rapid atrial fibrillation and was treated with
amiodarone and titration of beta blocker. He was started on
coumadin.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 6 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to home in good condition with
appropriate follow up instructions. Dr. [**Last Name (STitle) **] will follow
coumadin/INR through [**Hospital 191**] [**Hospital 2786**] clinic.
Medications on Admission:
Medications at home:
Lipitor 20mg po daily
Imdur 60mg po daily
Lisinopril 40mg po daily
NTG
Tamsulosin 0.4mg po daily
Metformin 850mg po BID
Avodart
ASA 325mg po daily
HCTZ 25mg po daily
Carvedilol 25mg [**Hospital1 **]
Transfer meds:
Lipitor 20mg po daily
ASA 325mg po daily
Carvedilol 25mg [**Hospital1 **]
Lisinopril 40mg po daily
HCTZ 25mg po daily
Tamsulosin 0.4mg po daily
Imdur 60mg po daily
Finasteride 5mg po daily
Topamax 25mg po BID
Plavix - last dose: 300mg [**2136-8-30**]
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR
Coumadin for atrial fibrillation
Goal INR [**2-22**]
First draw day after discharge, [**2136-9-12**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) **]
Results to [**Hospital 191**] [**Hospital3 **] phone: [**Telephone/Fax (1) 2173**]
2. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: dose
will change daily for goal INR [**2-22**], managed by [**Hospital 191**]
[**Hospital 2786**] clinic.
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. 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*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO once a
day.
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily until further instructed.
Disp:*120 Tablet(s)* Refills:*2*
9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO QID (4
times a day) as needed for phlebitis for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
PMH:
Hypertension
Hyperlipidemia
NSTEMI [**8-/2126**] s/p BMS to LCx
Diabetes Mellitus-Type II
Benign Prostatic Hypertrophy
Osteoarthritis
Essential Tumor
PNA with empyema as child s/p rib resection
Glaucoma
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
edema 2+ bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Surgeon Dr. [**First Name (STitle) **] on [**2136-10-1**] at 1PM [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr. [**Known firstname 449**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**] in [**1-21**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] in [**1-21**] weeks
Labs: PT/INR
Coumadin for atrial fibrillation
Goal INR [**2-22**]
First draw day after discharge, [**2136-9-12**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) **] (conf. with
[**Doctor Last Name **])
Results to [**Hospital 191**] [**Hospital3 **] phone: [**Telephone/Fax (1) 2173**]
**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:[**2136-9-11**]
ICD9 Codes: 5849, 4111, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6786
} | Medical Text: Admission Date: [**2201-6-26**] Discharge Date: [**2201-7-5**]
Date of Birth: [**2134-1-31**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
[**2201-6-27**]: Cerebral Angiogram with coiling
History of Present Illness:
67F fell off step stool 2 days ago and possible LOC. Had
laceration on back of head with much bleeding. Did not seek
medical attention at that time. Has been nauseaous and vomiting
since that time. Daughters brought to OSH, found diffuse SAH
and
possible R MCA distribution, loaded with dilantin and
transferred
to [**Hospital1 18**] ED.
Past Medical History:
High cholesterol
Social History:
Married, has three children.
Family History:
Parents deceased, sister and 3 children alive and well
Physical Exam:
On admission:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: grade 1 [**Doctor Last Name **]:2 GCS 15 E:4 V:5 Motor:6
O: T:98.6 BP: 148/66 HR:57 R18 O2Sats96
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 EOMs
Neck: in hard collar
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: [**4-9**] 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, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to 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 [**6-11**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally
Toes downgoing bilaterally
On the day of Discharge: [**2201-7-5**]
alert and oriented to person, place and time
patient has full strength and sensation
EOMs are intact 3-2mm with brisk reaction bilaterally
No pronator drift.
The patient ambulate with a steady gait and is out of bed to the
chair this morning eating breakfast.
Pertinent Results:
CTA Head [**2201-6-26**]:
IMPRESSION: Subarachnoid hemorrhage seen on head CT. CT
angiography of the
head demonstrates a 3.5 x 5.5 mm aneurysm at the anterior
communicating artery with irregular contour.
Study Date of [**2201-6-26**] 2:33:56 PM
Sinus bradycardia. Non-diagnostic inferior Q wave pattern may be
a normal
variant but cannot exclude prior inferior myocardial infarction.
Left
ventricular hypertrophy with marked repolarization abnormalities
consistent
with left ventricular strain pattern. No previous tracing
available for
comparison.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
52 [**Telephone/Fax (3) 88997**]/502 47 54 -147
CT Cspine [**2201-6-26**]:
IMPRESSION: No evidence of acute fracture or dislocation of the
cervical
spine.
CHEST (PORTABLE AP) Study Date of [**2201-6-26**] 6:20 PM
IMPRESSION:
Mild lingular and bibasilar atelectasis. No focal consolidation.
CT Head [**2201-6-27**]:
Impression: post-embolization of the ACOMM aneurysm. SAH stable.
CTA Head [**6-28**]: IMPRESSION: 1. Interval coiling of anterior
communicating artery aneurysm. There is no evidence of large
vessel occlusion or significant vasospasm. The coil pack
obscures the aneurysm itself and some adjacent vessels of the
anterior circle of [**Location (un) 431**].
2. Persistent moderate hydrocephalus with intraventricular
hemorrhage.
ECHO [**6-29**]: The left atrium is elongated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a very mild resting left ventricular outflow tract obstruction.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
CTA HEAD W&W/O C & RECONS Study Date of [**2201-7-2**] 11:05 AM
IMPRESSION:
1. No evidence to suggest vasospasm in the intracranial arterial
vasculature.
2. Further evolution of the subarachnoid and intraventricular
hemorrhage.
Brief Hospital Course:
Ms. [**Known lastname **] is a 67 year old woman who was admitted to the NSICU
under the care of Dr. [**Last Name (STitle) 739**] on [**2201-6-26**] after a fall with
CT findings of SAH and ACOMM aneurysm. She was on dilantin for
seizure prophylaxis.A UA showed a UTI and she was started on
Cipro. Seh had some heart block on EKG and some bradycardia in
the ICU. She received a dilantin bolus for a low drug level. On
[**6-27**] she underwent a cerebral angiogram with coiling.
Immediately Post-angio she was lethargic, a head CT was obtained
which was stable, as patient awoke from sedation her exam was
stable. On [**6-28**] her dilantin level was 11.3. Cardiology consult
was called for persistant HTN and bradycardia. They noted <3sec
sinus pauses & episodes of sinus arrest with ventricular escape
with heart rate to 30s, but SBP was stable at 140. EKG showed
changes consistent with Left Ventricular Hypertrophy vs cerebral
T waves consistent with SAH. They felt that her bradycardia and
HTN were consistent with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] effect from her SAH. They
asked that her calcium channel blocker be stopped which it was
on [**6-29**]. On [**6-28**] at 1330 she was noted to have a new left facial
droop and she was lethargic. She had some right deltoid and
grasp weakness, this strength exam has varied during her
admission. CTA was ordered, there was no increase in ventricular
size and no concern for vasospasm. She was transfered to Dr.
[**Last Name (STitle) **] service on [**6-29**].
Her ICU course was uneventful. She had serial TCDs as of [**7-1**]
which have showed no evidence of vasospasms. Nimodipine was
discontinued secondary to bradycardia and hypotension. She
completed her course of Cipro for Urinary tract infection. The
patients serum sodium was 136 and her serum BUN of 16.
On [**7-2**], patient was transferred to the step down unit in stable
condition.The patient has a CTA consistent with no evidence to
suggest vasospasm in the intracranial arterial vasculature and
further evolution of the subarachnoid and intraventricular
hemorrhage.The patient's serum sodium was 134 and her serum BUN
of 16.
On [**7-3**], The patients serum sodium was 133 and her serum BUN of
17.
On [**7-4**], routine laboratory blood work was sent and a serum
sodium was 130* and her serum BUN of 24. sodium chloride tablets
2 grams po BID were initiated for hyponatremia. Po intake was
encouraged.
Her floor course was otherwise uneventful.
Now the day of discharge [**2201-7-5**], she is afebrile, vital signs
were stable, and neuro exam stable. She is tolerating a good
oral diet and her pain is well controlled. The patient has had a
bowel movement and is voiding without difficulty. The patient's
serum sodium was 133 and her serum BUN of 23. The patient had a
3 point rise in her serum sodium since the day prior while on
the sodium chloride tablets. The patient will go home on this
medication for 5 days at a lower dose of 1 gram [**Hospital1 **] with follow
up with her primary care this week for follow up of
hyponatremia, elevated BUN, and hypertension.
She is set for discharge home.
Medications on Admission:
None
Discharge Medications:
1. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: do not exceed 4 grams tylenol in 24
hours.
3. bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release
(E.C.) PO DAILY (Daily) as needed for constipation: hold for
loose stools.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for Pain: do not drive while taking this medication,
di not take if lethargic.
Disp:*60 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
Disp:*60 Tablet(s)* Refills:*2*
7. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 5 days: please follow up at your primary
care physicians to follow your sodium level this week.
Disp:*10 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
please draw a chem 10 wednesday [**2201-7-8**] (to monitor BUN-
slightly elevated 23 the day of discharge and serum sodium
trending down currently 133 day of discharge while on sodium
tablet repleation)
9. follow-up with your primary care this week
please make an appointment with your primary care physcian this
week after having your labs drawn on wenesday- to follow up your
slightly elevated BUN and low trending serum sodium. and to
eveluate further need of sodium chloride tablets 1 po every 12
hours and hypertension and initiation of hydralazine for
treatment of high blood pressure during your hospital stay.
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid Hemorrhage
Anterior Comunicating artery Aneurysm (ruptured)
Urinary tract infection
Bradycardia
Hyponatremia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization coiling ofanterior communicating
artery
Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow up with Dr [**First Name (STitle) **] in 4 weeks with a MRI/MRA of the
brain ([**Doctor Last Name **] protocol). Please call [**Telephone/Fax (1) 4296**] to make this
appointment.
Please follow up with you primary care physician this week as
your serum BUN has been slightly elevated and your serum sodium
is has been trending slightly low. You will be given a
prescription to have your lab studies drawn and please follow up
with you primary care by Friday to dicuss. You were also started
on a medication for high blood pressure -hydralazine-please
discuss further management of your hypertension at that time
Completed by:[**2201-7-5**]
ICD9 Codes: 2761, 5990, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6787
} | Medical Text: Admission Date: [**2110-6-25**] Discharge Date: [**2110-6-30**]
Date of Birth: [**2047-5-23**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: This 63 year-old male with a
history of chronic obstructive pulmonary disease, head and
neck cancer, lower extremity deep venous thrombosis and
status post a recent extended hospitalization and intubation
for pneumonia and sepsis and adult respiratory distress
syndrome who returned from [**Hospital3 **] Hospital after a
witnessed aspiration. The patient had previously been
discharged with a PEG tube for tube feedings as he had failed
a swallow study with aspiration of all consistencies of food
or fluid. However, at the rehab facility the patient
developed respiratory distress and suctioning revealed tube
feed material in his lungs. The patient developed an
increased oxygen requirement and a low grade fever and was
transferred to the Emergency Department at [**Hospital1 346**] for further management. In the
Emergency Department the patient was felt to be in
respiratory distress and was hypoxic with an arterial blood
gas of 7.32/70/81. The patient was asked if he would like to
be intubated for his respiratory distress and he responded
yes. The patient was intubated and he was transferred to the
Medical Intensive Care Unit.
PAST MEDICAL HISTORY: Hypertension.
Head and neck cancer.
Tongue cancer status post radiation therapy.
Hypercholesterolemia.
Chronic tobacco use.
Lower extremity deep venous thrombosis.
Recent hospitalization for pneumonia, sepsis and adult
respiratory distress syndrome.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Levoxyl 50 micrograms daily.
2. Colace.
3. Lovenox 60 b.i.d.
4. Albuterol and Atrovent nebs.
5. Protonix 40 mg daily.
6. Coumadin.
7. He had received one dose of Vancomycin and Ceftazidine at
the rehab facility.
SOCIAL HISTORY: The patient was a long time smoker and is a
pool player.
PHYSICAL EXAMINATION: Temperature 101.8. Heart rate 116.
Blood pressure 148/77. Respiratory rate 40. Oxygen
saturation 60 percent on room air, 88 percent on
nonrebreather. General tachypneic, uncomfortable. HEENT on
BiPAP. Pupils are equal, round and reactive to light.
Supple neck. Cardiovascular examination tachycardic,
regular. Lungs diffuse crackles. Decreased breath sounds on
the left and rhonchi on the right. Abdomen soft, nontender,
nondistended. PEG tube in the left upper quadrant.
Extremities no lower extremity edema. Chest x-ray showed
diffuse patchy infiltrates consistent with acute on chronic
aspiration pneumonia.
LABORATORIES ON ADMISSION: White blood cell count 12.6,
hematocrit 32.2, platelets 415, sodium 142, potassium 4.6,
bicarbonate 31, BUN 20, creatinine 0.7, lactate 1.9.
INTENSIVE CARE UNIT COURSE:
1. Respiratory failure: The patient was admitted to the
Intensive Care Unit and remained intubated overnight. The
following morning he was switched to pressure support
ventilation and was weaned off of the vent to face mask
within 48 hours. He was continued on his Albuterol
Atrovent nebulizers. The patient was felt to have had an
aspiration pneumonitis and he was not given any further
doses of antibiotics. He remained afebrile without
systemic signs of infection during his entire Intensive
Care Unit stay. The patient will need to be fed with tube
feeds with the head of the bed elevated to decrease his
risk of recurrent aspiration.
1. Aspiration: The patient has a history of head and neck
cancer, tongue cancer and a long intubation recently for
adult respiratory distress syndrome. After he was
extubated during his previous hospitalization he was
unable to swallow any fluid or liquid without aspiration.
At that time the decision was made to place a PEG tube
with a post pyloric entry point into the gastrointestinal
tract to facilitate nutrition for this patient, however,
this does not decrease his risk of aspiration
significantly and the patient should continue to be fed
with the head of the bed elevated.
1. Deep venous thrombosis: The patient has a known lower
extremity deep venous thrombosis. He was continued on
Lovenox 60 b.i.d. during his Intensive Care Unit stay and
was started on transition to Warfarin.
1. Hypothyroidism: The patient was continued on his
outpatient dose of Levoxyl 50 micrograms daily.
The remainder of this discharge summary will be dictated by
the covering intern.
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], [**MD Number(1) 24326**]
Dictated By:[**Last Name (NamePattern1) 18139**]
MEDQUIST36
D: [**2110-6-30**] 08:27:42
T: [**2110-6-30**] 08:49:01
Job#: [**Job Number 56132**]
ICD9 Codes: 5070, 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6788
} | Medical Text: Admission Date: [**2186-9-17**] Discharge Date: [**2186-9-21**]
Service: [**Last Name (un) **]/MED Please note that the patient was admitted
on the Orthopedic Service and discharged on the Medicine
Service.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 95026**] is a 79 year old
male with a past medical history significant for a non-small
cell lung carcinoma with metastases to the brain status post
two cycles of chemotherapy with Carboplatin/Taxol, who
experienced a fall on [**9-15**] upon exiting his car and
walking five to six steps. He notes no preceding events
prior to the fall, and notes that it was not mechanical in
etiology. The patient was taken to an outside hospital and
was found to have a left hip subtrochanteric fracture without
neurovascular impairment. At the time, he was found to have
a decreased hematocrit and was transfused. He was
subsequently transferred to [**Hospital1 188**] for an open reduction and internal fixation.
In the Operating Room during this procedure, the patient had
two episodes of supraventricular tachycardia associated with
a decrease in blood pressure ameliorated by cardioversion on
each occasion. The patient was started on an Amiodarone
drip, remained normotensive throughout the rest of the case,
and was transferred to the Surgical Intensive Care Unit.
The patient had a third episode of supraventricular
tachycardia while in the Intensive Care Unit which was
treated successfully with adenosine. Mr. [**Known lastname 95026**] experienced
a fourth episode of supraventricular tachycardia while in the
Intensive Care Unit which converted into normal sinus rhythm
with Lopressor. On subsequent episodes of supraventricular
tachycardia with hypotension, the patient was bolused with
normal saline.
The Cardiology Service was consulted and evaluated the
patient in the Intensive Care Unit. The recommendations per
Cardiology were to continue the Amiodarone intravenously and
continue to use Adenosine as needed for symptomatic
supraventricular tachycardia.
The patient was transferred to the Floor and continued on
intravenous Amiodarone and was started on an oral Amiodarone
load. On [**9-19**], the patient was transferred to the
Medical Service.
PAST MEDICAL HISTORY:
1. Metastatic non-small cell lung carcinoma diagnosed in
[**2186-8-6**], metastatic to the brain. The patient was
noted to have three left frontal lobe metastases, who of
which have regressed after systemic chemotherapy. The
patient is status post two cycles of chemotherapy,
Carboplatin/Taxol. During the last admission, Mr. [**Known lastname 95026**]
was evaluated by the Radiation Oncology Service and was to
have a stereotactic radio surgery for removal of the brain
metastases.
2. Malignant pleural effusions status post pleurodesis.
3. Hypertension.
4. History of supraventricular tachycardia during his last
hospitalization.
5. Benign prostatic hypertrophy.
6. Status post meningioma resection in [**2177**].
7. Status post left inguinal hernia repair in [**2182**].
ALLERGIES: Dilantin (liver toxicity, rash).
MEDICATIONS ON TRANSFER:
1. Amiodarone 400 mg p.o. three times a day.
2. Amiodarone intravenous drip.
3. Ativan p.r.n.
4. Morphine p.r.n.
5. Calcium gluconate p.r.n.
6. Potassium chloride p.r.n.
7. Magnesium sulfate p.r.n.
8. Acetaminophen 325 to 650 mg p.o. q. four to six hours
p.r.n.
9. Lovenox 30 mg subcutaneously q. 12 hours.
10. Colace 100 mg p.o. twice a day.
11. Zofran p.r.n.
12. Percocet one to two tablets p.o. q. four to six hours
p.r.n.
13. Metoprolol 12.5 mg p.o. twice a day.
14. Terazosin 5 mg p.o. q. h.s.
SOCIAL HISTORY: The patient has been married to his wife for
the last 54 years. No children. He is a retired Lieutenant
Colonel in the Air Force and has worked as a defense
contractor. He has no known occupational exposures. He
notes a half pack per day usage of tobacco for 30 years. He
also notes one cocktail imbibed each evening.
FAMILY HISTORY: His mother expired at age 75; she had a
history of hypertension. Father deceased at age 87 secondary
to pneumonia. His brother is 74 years old and in good
health. His sister had passed away from breast cancer.
PHYSICAL EXAMINATION: Temperature 98.0 F.; blood pressure
150/80; heart rate 62; respiratory rate 18; oxygen saturation
95 to 96% on room air. In general, the patient appears in no
acute distress sitting up in a chair. HEENT: Sclerae
anicteric. Normocephalic, atraumatic. Mucous membranes were
moist. Oropharynx is clear. Pupils equally round and
reactive to light and accommodation. Extraocular movements
are intact. Neck is supple with no lymphadenopathy and no
carotid bruits. Chest is symmetric excursion, moderate air
movement, no dullness to percussion. Cardiovascular:
Regular rate and rhythm, S1 and S2; II/VI systolic ejection
murmur with no gallops, no rubs. Abdomen is soft, nontender,
nondistended, normoactive bowel sounds. Extremities: Left
leg was bandaged in an ACE. Right leg had one plus edema.
Neurologic: Cranial nerves II through XII intact. Alert and
oriented times three, appropriate responses with mood and
affect full.
LABORATORY ON TRANSFER: White blood cell count 3.6,
hematocrit 28.1, platelets 162. Sodium 137, potassium 4.2,
chloride 104, bicarbonate 24, BUN 16, creatinine 0.6, glucose
102.
STUDIES: ECG on [**2186-9-18**], demonstrated sinus rhythm,
right bundle branch block, QRS morphology, potential left
atrial abnormality, no significant changes from previous
tracing on [**9-17**].
HOSPITAL COURSE:
1. CARDIOVASCULAR: Mr. [**Known lastname 95026**] has a history of
supraventricular tachycardia present during his last
hospitalization treated with beta blockade. He had
experienced a fall without a clear precipitating factor or
mechanical reason which led to this admission. During his
prior admission, the patient was asymptomatic during his
episodes of supraventricular tachycardia on Telemetry. It is
possible that the patient's supraventricular tachycardia led
to his fall prior to admission. Mr. [**Known lastname 95026**] had experienced
episodes of supraventricular tachycardia during the procedure
and peri-procedure and he was initiated on an Amiodarone drip
after two cardioversions.
The Cardiology Service was following and recommended to
continue an Amiodarone load. Mr. [**Known lastname 95026**] will be continued
on Amiodarone 400 mg p.o. twice a day until [**9-30**]. He
will begin a maintenance dose of 200 mg p.o. q. day starting
on [**10-1**].
Mr. [**Known lastname 95026**] has a history of hypertension and has been on
Lopressor and Terazosin as an outpatient. During this
admission, an ACE inhibitor was initiated and he will be
titrated up on this medication as tolerated.
Mr. [**Known lastname 95026**] will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] for his
supraventricular tachycardia on [**10-18**] at 01:00 p.m. in
the [**Hospital Ward Name 23**] Building.
2. ORTHOPEDICS: Mr. [**Known lastname 95026**] was diagnosed with a left
subtrochanteric hip fracture status post fall and transferred
from the outside hospital for open reduction and internal
fixation. This procedure was performed on [**2186-9-17**],
with the complication of supraventricular tachycardia as
described above. The patient remained on the Orthopedic
Service until transfer on [**2186-9-19**]. Physical Therapy
had evaluated the patient and continued to follow while
admitted.
Mr. [**Known lastname 95026**] was changed to a touch-down weight bearing status
to the left lower extremity on postoperative day three.
Recommendations were made to continue daily dressing changes
to the wound sites and the patient was to continue with
thigh-high TEDS stockings to the lower extremities.
3. HEMATOLOGY/ONCOLOGY: Mr. [**Known lastname 95026**] was recently diagnosed
in [**2186-8-6**] with non-small cell lung cancer and has
received two cycles of Carboplatin/Taxol. He is being
followed by Dr. [**Last Name (STitle) **] for his oncologic care. During his
last admission to [**Hospital1 69**] he was
evaluated by Radiation Oncology for the brain metastases and
stereotactic radio surgery was recommended. Mr. [**Known lastname 95026**] was
scheduled to have this SRS on [**9-19**], however, this
therapy was deferred while he is dealing with the acute issue
of his hip fracture. Further decisions regarding his
oncologic care - SRS and chemotherapy - will be determined by
Dr. [**Last Name (STitle) **] as an outpatient.
Mr. [**Known lastname 95026**] was noted to have a significant hematocrit drop
while admitted. Postoperatively the patient received two
units of packed red blood cells. On the day prior to
discharge, Mr. [**Known lastname 95026**] received another two units of packed
red blood cells. Hematocrit is pending at the time of this
discharge.
Secondary to the patient's chemotherapy, last cycle completed
[**9-14**], his cell counts are expected to nadir on [**9-21**].
Secondary to Mr. [**Known lastname 95027**] brain metastases and issue of
anti-coagulation that was raised at his left hip open
reduction and internal fixation, the decision was to
anti-coagulate Mr. [**Known lastname 95026**] with maintenance doses of Lovenox,
30 mg subcutaneously q. 12 hours, for a total of six weeks.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient is to be discharged to [**Location (un) 2716**]
Point in [**Location (un) 55**] for further rehabilitation.
DISCHARGE DIAGNOSES:
1. Left hip open reduction and internal fixation performed
on [**2186-9-17**].
2. Supraventricular tachycardia.
3. Anemia.
4. Non-small cell lung carcinoma.
5. Metastatic lesions to the left frontal lobe of the brain.
6. Anti-coagulation.
7. Hypertension.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg p.o. twice a day, last dose on [**9-30**] in the evening.
2. Amiodarone 200 mg p.o. q.day to be started on [**10-1**].
3. Lorazepam 0.5 mg p.o./IV four times a day p.r.n. - hold
for excessive sedation ( respiratory rate less than 8; oxygen
saturation less than 92%).
4. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n.
5. Lovenox 30 mg subcutaneously q. 12 hours.
6. Colace 100 mg p.o. twice a day.
7. Percocet one to two tablets p.o. q. four to six hours
p.r.n. pain.
8. Metoprolol 12.5 mg p.o. twice a day - hold for systolic
blood pressure less than 100, heart rate less than 50.
9. Terazosin 7 mg p.o. h.s.
10. Captopril 6.25 mg p.o. three times a day.
DISCHARGE INSTRUCTIONS:
1. Mr. [**Known lastname 95026**] is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on
[**10-18**], at 01:00 p.m., office located on the [**Location (un) **]
of the [**Hospital Ward Name 23**] Building.
2. The patient also has a follow-up appointment with Dr.
[**Last Name (STitle) 284**] in the [**Hospital 5498**] Clinic on the [**Location (un) 1773**] of
the [**Hospital Ward Name 23**] Building, appointment scheduled for [**9-28**] at
12:20 p.m.
3. The patient is to have daily dressing changes to the
wound sites.
4. He is currently on touch-down weight bearing status on
the left lower extremity until further directed by Dr.
[**Last Name (STitle) 284**].
5. Mr. [**Known lastname 95026**] is to have thigh high TEDS stockings in
place.
6. Mr. [**Known lastname 95027**] blood counts and electrolytes should be
monitored three times per week.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 44562**]
MEDQUIST36
D: [**2186-9-20**] 16:05
T: [**2186-9-20**] 19:10
JOB#: [**Job Number **]
ICD9 Codes: 9971, 4271, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6789
} | Medical Text: Admission Date: [**2173-5-23**] Discharge Date: [**2173-6-4**]
Date of Birth: [**2091-3-20**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
Lumbar puncture
intubation
History of Present Illness:
82F with multiple sclerosis, dementia, seizures, renal calculi
s/p recent lithotripsy and recurrent UTI was being moved from
bed to chair by [**Doctor Last Name **] lift and was noted by care taker to have
convulsive motion in all four extremities. Given ativan 2mg by
EMS with completeresolution and transferred to [**Hospital 8125**] Hospital.
There she was seen to have additional convulsive movements,
given ativan again with ultimate resolution of symptoms.
However, during the evalution at the OSH she had a SBP as low as
40s. Central access was attempted at bilateral femoral arteries
without success and therfore peripheral dopamine was initiated
with moderate effect. She was found to be hypothermic at 93.0
with a pH of 7.17. She was given ceftriaxone 2gm imperically. CT
head at OSH was normal. Patient was transferred to [**Hospital1 18**]. Of
note the patient was pn ciprofloxacin s/p lithotripsy presumably
for renal stones.
.
In the ED her vital signs were T 92 rectally, HR 84 BP 105/34
RR13 she was 80mg of hydrocortisone for adrenal insufficiency
and on chronic prednisone recently titrated down to 5mg PO
daily. In addition she was given 600mg of linezolid given her
history of UTIs only responsive to this antibiotic. The patient
was intubated and a right subclavian central line was placed.
7mg of versed was given while the patient was taken to the CT
scanner for a head and torso CT.
.
Seen by Neuro in the ED - suggesting EEG, repeat head CT,
restarting home dose antiepileptics and to treat the UTI/closely
control the temperature today.
Past Medical History:
MS - followed by Dr. [**Last Name (STitle) 10835**] in the past
dementia, with frontal dysfunction
seizure disorder (prior to recent events, last sz was in [**2154**])
HTN
h/o hyponatremia
osteoporosis
s/p R leg fracture
gait disturbance
urinary incontinence
Social History:
Lives with husband and has full-time caregiver x 7 years. The
patient is not independent of her ADLs.
She is reported to follow commands and interact with broken
speech but is generally non-communicative at baseline.
Family History:
Sister and Father had MS, both deceased
Physical Exam:
VS T 95.2 HR85 BP91/47 RR15 Sa02100%
AC TV 500 Rate 14 Peep 5 FiO2 100%
GENERAL:intubate, sedated
HEENT: has bits of blood in her hair. Disheveled. No obvious
trauma. Eyes closed. Anicteric once opened.
NECK: JVP is flat. Neck was very stiff on exam prior to
intubation.
CARDIOVASCULAR: regular rate on telemtry. difficult to
auscultate in the setting of rhonchorus upper airway sounds when
we examined her in the ED.
LUNGS: CTAB no W/W/R
ABDOMEN: soft,NT/ND,positive bowel sounds.
EXTREMITIES: no clubbing cyanosis or edema.
NEURO: Intubated and sedated. Minimally responsive to pain. No
corneal reflex on right but does have a corneal reflex on the
left. Pupils reactive bilaterally.
Pertinent Results:
[**2173-5-22**] 10:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2173-5-22**] 10:00PM URINE RBC-0-2 WBC->50 BACTERIA-FEW YEAST-NONE
EPI-[**3-29**]
[**2173-5-22**] 10:30PM LACTATE-1.3
[**2173-5-23**] 04:00AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* POLYS-9
LYMPHS-55 MONOS-36
.
[**5-22**] cxr:
IMPRESSION: Left retrocardiac opacity is seen, which may
represent an area of consolidation and/or atelectasis. Small
left pleural effusion may also be present.
.
ct chest/abdomen:([**2173-5-23**])
IMPRESSION:
1. Small bilateral pleural effusions and adjacent atelectasis.
2. Bilateral renal calculi, without evidence of hydronephrosis
or hydroureter. The largest stone on the right appears similar
in size, but there are several calcific densities within the
right renal pelvis which may represent small fragments from
reported recent lithotripsy. No perinephric fluid collections
are identified.
3. Small 9 mm enhancing focus within the liver, which was not
seen on the prior study, but this may reflect differences in
contrast timing. This is not completely evaluated on this study,
however, the differentials would include a
hemangioma/FNH/adenoma, though a malignancy cannot be entirely
excluded.
.
ct head [**5-23**]:
CT HEAD WITHOUT IV CONTRAST: No hemorrhage or mass effect is
identified. The ventricles are symmetric, there is no shift of
normally midline structures. The [**Doctor Last Name 352**]-white matter
differentiation is stable. There is marked enlargement of the
ventricles, which is symmetric, and stable in comparison to
prior study. Soft tissue and osseous structures are within
normal limits.
.
IMPRESSION: No mass effect or hemorrhage is identified. No
interval change from the prior exam from [**2173-1-9**].
.
[**5-23**] EEG:
IMPRESSION: This is an abnormal EEG due to the frequent
electrographic
seizures with origin in the left hemisphere, left hemisphere
slowing, a
slow and disorganized background and infrequent suppressed
background
activitiy. The first abnormality suggests frequent
electrographic
seizures with origin in the left hemisphere with secondary
generalization. The left hemisphere slowing suggests
corresponding
subcortical dysfunction. The last two abnormalities suggest a
severe
encephalopathy, which may be seen with infections, toxic
metabolic
abnormalities or medication effect.
.
[**5-24**] EEG:
IMPRESSION: This 24-hour video EEG telemetry demonstrated many
electrographic seizures characterized by rhythmic 1-1.5 Hz
spikes and
sharp waves seen with a widespread distribution bilaterally
although
sometimes with a left hemisphere emphasis. It was not clear
whether
there was any clinical correlate to these electrographic
seizures. At
other times, frequent widespread epileptiform discharges were
seen in a
more isolated or non-rhythmic manner. The background was slow
and
disorganized throughout the recording suggestive of a moderate
encephalopathy.
Brief Hospital Course:
Ms. [**Known lastname **] is an 82 year old woman with advanced multiple
sclerosis, dementia, seizures, renal stones, and recurrent UTI
who presented after two seizure episodes.
.
1) Seizure -
The patient has presented several times in the past with
seizures in the setting of urinary tract infections. In [**11-30**]
the patient presented in non-convulsive status epilepticus that
was felt to be triggered by a UTI. In [**12-30**] the patient again
presented with a seizure and a UTI but this time the seizure was
felt to be triggered by hyponatremia. On admission the patient
was therapeutic on dilantin. Based on neurology consultation
recommendations her lamotrigine was increased by 50mg each weak
to achieve goal of 200mg [**Hospital1 **]. As an outpatient her dilantin can
be decreased by 100 q week. It should be noted that repeat
Dilantin levels should be checked every 3 days, and adjusted
accordingly while the patient is taking ciprofloxacin.
.
2) Hypotension -
Etiology of acute decompensation was likely sepsis in the
setting of elevated mixed venous oxygen saturation, no elevation
of cardiac enzymes, unchanged EKG and recurrent UTI. Required
low dose IV dopamine, than changed to levophed for improved
predictability and greater inotropic effect. Weaned to off. Pt
was placed on high dose steroids on admission given chronic
prednisone of 5mg daily. She was tapered back to prednisone 5mg
daily.
.
3) Infection -
WBC from 7.5 to 13.7 over 5 hours. Grossly positive UA. Patient
had very stiff neck on physical exam in the ED prior to
intubation. However this was unlikely meningitis as lumbar tap
performed in the MICU revealed only 3 WBC and gram stain was
negative
She was given Linezolid for history of VRE UTI and Ceftriaxone
for gram negative coverage. Urine, blood, CSF, and sputum
cultures were all negative. Given negative cultures, she was
changed to linezolid and ciprofloxacin to complete a 14 day
course.
- three days prior to discharge the patient developed a slight
leucocytosis to 13.3 and temp 100.1. Blood cultures, and chest
x-ray were repeated without evidence of infection. UA was
grossly contaminated- Urine cultures did not reveal any growth.
.
4) Respiratory failure:
Patient was intubated for airway protection, and did well with
extubation on [**5-25**].
.
5[**Last Name (STitle) **]istory of Nephrolithiasis-
The patient has history of nephrolithiasis s/p lithotripsy. On
admission the patient was without evidence for obstruction by
CT. She should follow up with her urologist Dr. [**Last Name (STitle) **] as an
outpatient should clinical suspicion dictate further evaluation.
.
5) FEN:
Tube feeds, speech and swallow evaluation x2 revealed failure of
pt to adequately protect her airway while swallowing. She should
remain NPO. Her NG tube needs to be pulled to prevent erosion as
soon as she is re-evaluated by speech and swallow at rehab.
Code status: DNR/DNI
Medications on Admission:
Medications:
1. Lamotrigine 50 mg PO BID
2. Phenytoin Sodium Extended 100 qam and 200 qpm.
3. Sodium Chloride 2 g TID
4. Pyridoxine 50 mg PO DAILY
5. Cyanocobalamin 50 mcg PO once a day
6. Docusate Sodium 100 mg PO BID (Possibly the Liquid)
7. Ascorbic Acid 500 mg PO TID
8. Ferrous Sulfate 325 PO DAILY
.
The following are from a [**2173-2-9**] Hospitalist note.
9.Calcium Carbonate 500 mg PO TID
10.Cholecalciferol (Vitamin D3) 400 unit PO DAILY
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*20 Tablet(s)* Refills:*0*
2. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 3 days.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO QAM (once a
day (in the morning)).
6. Phenytoin 100 mg/4 mL Suspension Sig: Two (2) PO QPM (once a
day (in the evening)).
7. Vitamin B-12 50 mcg Tablet Sig: One (1) Tablet PO once a day.
8. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO once a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
10. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO twice a
day.
11. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily): to be given at least two hours after ciprofloxacin
dose.
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Sepsis- suspected urinary source
Respiratory Failure
Seizure Disorder
Multiple Sclerosis
Discharge Condition:
Fair.
Discharge Instructions:
You were admitted for seizure and low blood pressure. You
required intensive care unit monitoring with mechanical
ventilation and medications to support your blood pressure. You
were treated for a suspected urinary tract infection.
.
take all of your medications as prescribed
.
call your doctor or 911 of any fevers, furhter seizure activity,
shortness of breath or chest pains, or any other concerning
symptoms
Followup Instructions:
Please keep the following appointment:
[**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2173-6-11**] 9:00
ICD9 Codes: 0389, 5990, 5185, 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6790
} | Medical Text: Admission Date: [**2133-3-12**] Discharge Date: [**2133-3-20**]
Date of Birth: [**2084-2-22**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Latex / Sulfa (Sulfonamides) / Erythromycin Stearate /
Morphine / Vistaril / Benadryl / Nifedipine / Ventolin Hfa /
Penicillins
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
Upper endoscopy
UGI
Gastric emptying study
History of Present Illness:
Ms. [**Known lastname 36038**] is a 49F with PMH of GERD s/p Nissen fundoplication x
2 ([**2118**]), Factor V Leiden, HTN, depression, and chronic
abdominal pain (since [**2118**]) presenting with recurrence of her
abdominal pain, nausea and vomiting and inability to tolerate
PO's. These symptoms had been well controlled over the last two
years but recurred in late [**2132-12-23**]. She says that she is
nauseous all day and vomits about 2-3 times/week. She localizes
her pain to her epigastrium and says that it radiates throughout
her entire abdomen. She says that it worsens slightly with
eating, but identifies no other precipitating or palliating
factors. She states that she has been regurgitating all her
food, and that it comes up undigested.
For these symptoms, she went to her GI doctor Dr. [**Last Name (STitle) 77510**] on
[**2133-1-27**], and UGI series and manometry were normal at that time,
making mechanical obstruction unlikely. She was thought to have
functional bowel disease. In the middle of [**Month (only) 404**], she had to
be hospitalized at [**Hospital 1774**] Hospital for dehydration, and EGD at
that time was normal. She had her Protonix increased to 40mg
[**Hospital1 **], and was started on Buspirone and Pepcid. Her symptoms did
not improve, and she continued to vomit with any PO intake. On
[**3-12**], she called Dr. [**Last Name (STitle) **] and was told to present to the
emergency room.
In the emergency room the patient's vitals were T 97.8 HR 88 BP
136/75 RR 18 O2 sat 100. Labs in the ED were WBC 8.7/HCT
39.8/Plt 341. Lytes were WNL. She received Zofran 4mg and
Dilaudid 0.5 mg with no relief. She was admitted for workup of
her abdominal pain, as well as pre-treatment for known contrast
allergy before her scheduled inpatient CT scan. Given her
possible iodine allergy, she was pre-medicated with Prednisone
40mg PO 16, 8, and 2 hours prior to her exam. In addition,
Cimetidine 300mg and Benadryl 50mg were given 1 hour prior to
exam.
Following her CT scan, the patient developed diffuse urticaria
(over arms, chest, back, face), cough, and subjective SOB. She
remained hemodynamically stable, afebrile, and non hypoxic. She
was given IV solumedrol and famotidine and was transferred to
the ICU. In the ICU, she was treated with IV solumedrol q6h and
H2 blocker for her contrast allergy. She was also given ISS
while on steroids. For her abdominal pain, she was treated
symptomatically with zofran, dilaudid, and miralax. In addition,
her PPI, pepcid, and buspirone were continued. During her ICU
course, her vitals were 96.2 to 97.3, 76-109, 95-143/47-78,
[**11-11**], and 93% on RA. Labs in the ICU were WBC 10.9/RBC 33.2/Plt
311. Lytes were WNL except for glucose (181). LFTs and
amylase/lipase were WNL.+
Past Medical History:
PMH:
- GERD s/p Nissen fundoplication x 2
- Chronic abdominal pain
- Factor V Leiden: h/o UE clot, unclear if deep or superficial;
(patient reports she received Lovenox and Coumadin as an
inpatient but only continued Coumadin for a few weeks)
- Depression
- Hypertension
- Colonic inertia
- Insomnia
- Asthma
Social History:
- Smoking: denies
- EtOH: Denies
- IVDU: Denies
- Lives at home with her husband and three sons (26yo, 23yo,
21yo).
- Homemaker
- Practicing Catholic
Family History:
- Mother with [**Name2 (NI) 499**] cancer in her 60's
- Maternal aunt with breast cancer
- Sister with diabetes
- No FH of clots.
Physical Exam:
VS: 92/43 89 14-16 99
Gen: Awake, alert, NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, no m/r/g
Pulm: CTA B, no wheezes or crackles
Abd: Soft, ND, tender in RLQ, no rebound, no guarding
Ext: no LE edema, DP/PT 2+
Pertinent Results:
[**2133-3-12**] 06:30PM BLOOD WBC-8.7 RBC-4.76 Hgb-13.8 Hct-39.8 MCV-84
MCH-29.1 MCHC-34.8 RDW-13.6 Plt Ct-341
[**2133-3-13**] 07:10AM BLOOD WBC-5.9 RBC-4.21 Hgb-12.5 Hct-36.2 MCV-86
MCH-29.7 MCHC-34.5 RDW-13.1 Plt Ct-323
[**2133-3-14**] 04:01AM BLOOD WBC-10.9# RBC-3.85* Hgb-11.4* Hct-33.2*
MCV-86 MCH-29.5 MCHC-34.2 RDW-13.3 Plt Ct-311
[**2133-3-12**] 06:30PM BLOOD Glucose-96 UreaN-10 Creat-0.7 Na-142
K-4.4 Cl-106 HCO3-27 AnGap-13
[**2133-3-13**] 07:10AM BLOOD Glucose-166* UreaN-10 Creat-0.7 Na-139
K-5.2* Cl-105 HCO3-24 AnGap-15
[**2133-3-14**] 04:01AM BLOOD Glucose-181* UreaN-7 Creat-0.6 Na-142
K-3.5 Cl-108 HCO3-23 AnGap-15
[**2133-3-12**] 06:30PM BLOOD ALT-19 AST-19 AlkPhos-120* TotBili-0.5
[**2133-3-14**] 04:01AM BLOOD ALT-16 AST-13 CK(CPK)-53 AlkPhos-91
TotBili-0.4
CT abdomen/pelvis ([**2133-3-13**]):
IMPRESSION:
1. No evidence of acute intra-abdominal pathology.
2. Post-surgical changes related to fundoplication.
Brief Hospital Course:
This is a 49 year old woman who presented with chronic symptoms
(since [**2132-12-23**]) of epigastric abdominal pain,
persistent nausea, food regurgitation immediately after eating,
and weight loss. She has history of severe constipation
following her Nissen fundoplication that was attributed to
colonic inertia. The differential diagnosis for her upper GI
symptoms were esophageal obstruction, esophageal motility
disorder, Zenker's diverticulum, a disease process related to
her fundoplication (nerve damage or compression), gastroparesis,
rumination syndrome, and psychiatric causes. She has had
extensive workup in the past by GI for her symptoms, and thus
far, all studies have been negative including EGD, UGI series,
manometry,and CT abdomen. During this hospitalization, she had a
repeat UGI series, which was normal, and EGD which was also
normal. She had a gastric emptying study that showed delayed
gastric emptying. She, however, was receiving Dilaudid before
and during the study, which may have affected the results. Her
symptoms of immediate vomiting after eating and nausea despite
being NPO for a weak were inconsistent with gastroparesis.
However, we treated her with IV and then PO Reglan as she may
have significant GI motility disorder with severe constipation
and the above mentioned upper GI symptoms. For her severe
constipation, she was continued on a bowel regimen with Colace,
Senna, MiraLax, and Dulcolax with no problems. Rumination
syndrome seemed unlikely as she had 2 inconsistent features:
persistent nausea and abdominal pain. However, she exhibited
depressive syndrome and indifference to her GI illness. A
psychiatric component may potentially aggravate her symptoms.
She was discharged with GI follow up with Dr.[**First Name (STitle) **]. Total
discharge time 35 minutes.
Of note she had allergic reaction with hives and subjective SOB
after IV contrast administration for the CT abdomen on [**2133-3-13**].
She was treated with IV Solu-Medrol in ED/ICU and then oral
steroids with complete recovery.
Medications on Admission:
Home meds:
Protonix 40 mg PO BID
Pepcid 20 mg PO qHS
BuSpar 15mg PO qHS
Ambien 5mg PO qHS
Prozac 20mg PO qAM
Trileptal 150mg PO qHS
Miralax 6 capfuls qHS
Diovan 160mg PO Daily
Advair 500/50 qAM
Singulair qAM
Atrovent PRN SOB
Meds on transfer:
Heparin 5000U TID
Zolpidem Tartrate 5 mg PO qhs
Fluoxetine 20 mg po daily
Oxcarbazepine 150 mg po qhs
PEG 17 g po daily
Valsartan 160 mg po daily
Pantoprazole 40 mg po bid
Famotidine 20 mg [**Hospital1 **]
Advair Diskus 1 inh [**Hospital1 **]
Montelukast sodium 10 mg po daily
Buspirone 15 mg po qhs
IV solumedrol 125 mg IV q6h
Sarna Lotion 1 ppl tp qid
Ipratropium nebs 1 nb q6h
Insulin SC per ISS
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary Diagnosis:
Primary GI motility syndrome:
Gastroparesis
Constipation from colonic inertia
.
Secondary Diagnoses:
Factor V Leiden deficiency
Hypertension
Gastroesophageal reflux disease
Asthma
Depression
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted to [**Hospital1 18**] with abdominal pain, nausea, and
vomiting. You had a CT scan in the emergency department and
developed an allergic reaction to IV contrast. You were
hospitalized in the ICU for monitoring and received IV steroids.
You were given anti-emetics for your nausea and pain
medications for your abdominal pain. You were also found to be
constipated and were started on a bowel regimen. You had a
normal endoscopy and barium study. A gastric emptying study
showed slow stomach. However, you were taking Dilaudid which may
interfere with the study results. Please take Reglan 30 minutes
before each meal to help your slow stomach. Keep laxatives. We
found you to have depression. Please see your psychiatric doctor
as depression may worsen or significantly contributes to your
symptoms of nausea and vomiting. Please follow up with Dr.
[**Last Name (STitle) **].
Followup Instructions:
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2133-4-7**] 2:40
ICD9 Codes: 4019, 2768, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6791
} | Medical Text: The patient admitted to her PCP that she ingested several
Seroquel tablets given to her by a neighbor prior to admission.
This may have contributed to her hypotension and altred mental
status.
tName: [**Known lastname 108672**], [**Known firstname **] Unit No: [**Numeric Identifier 108673**]
Admission Date: [**2116-9-28**] Discharge Date: [**2116-10-2**]
Date of Birth: [**2070-7-25**] Sex: F
Service: Medicine
CHIEF COMPLAINT:
Hypotension.
Change in mental status.
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old
female with a history of HIV and polysubstance abuse who
pneumonia, who is readmitted with hypotension and change in
mental status.
The patient was at home and took three Klonopin. The patient
states that she felt like she had taken many Klonopin and
felt lethargic and sedated. The patient then called her
infectious disease attending, who referred her to the
Emergency Room. The patient called emergency medical
services and was brought to the Emergency Room by ambulance.
Upon admission, the patient denied any chest pain or
shortness of breath. She did have a slight cough, which was
unchanged from discharge three days ago. She denied any
abdominal pain, nausea, vomiting, diarrhea, dysuria, rashes,
fevers or chills. She admitted to mild neck pain and
lethargy. She was also thirsty.
In the Emergency Room, the patient's picture was concerning
for meningitis. A lumbar puncture was done, which was
negative. The patient's blood pressure remained low, with a
systolic blood pressure in the 70s despite five liters of
intravenous fluids. She was transferred to the Medical
Intensive Care Unit for blood pressure monitoring and
evaluation of her mental status. She had been given a dose
of ceftriaxone and vancomycin in the Emergency Room prior to
the lumbar puncture. She was also given Narcan times four,
with no change in her mental status. The patient denied
suicidal ideation or overdose.
PAST MEDICAL HISTORY: 1. HIV/AIDS, diagnosed in [**2108**], last
CD-4 count 238 on [**2116-9-22**]; patient has been on HAART
therapy in the past but this was discontinued as she was
poorly compliant with her regimen. 2. Polysubstance abuse
with a history of intravenous heroin use and benzodiazepine
abuse. 3. Endocarditis. 4. Hepatitis C. 5. Abnormal PAP
smears. 6. History of Pneumocystis carinii pneumonia,
status post intubation. 7. History of cerebrovascular
accident without residual deficits. 8. Bilateral lower
extremity neuropathy. 9. Status post cesarean section. 10.
History of seizures, status post alcohol and benzodiazepine
withdrawal. 10. Status post vein stripping in left arm.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Paxil 20 mg p.o.q.d., Bactrim DS
one p.o.q.d., Neurontin 1,200 mg p.o.t.i.d., diazepam 10 mg
p.o.q.6h., methadone 120 mg p.o.q.d.
SOCIAL HISTORY: The patient is the fourth of five children,
born to two working parents. She is still in contact with
her three brothers, one sister and her parents. She
completed high school and worked as a waitress, but has been
on unemployment for the last seven years. She has been
arrested multiple times for drug related and prostitution
charges. She has a history of domestic abuse with a
boyfriend who stabbed her in the back. She is no longer in
this relationship. The patient was married in [**2087**] but has
been divorced since [**2091**]. She has an adult daughter who
works as a mutual funds broker. The patient was married
again in [**2108**]. Her second husband died in [**2110**] at the age of
45 from AIDS. The patient currently lives in a subsidized
studio apartment in [**Location (un) 1468**] but has been homeless in the
past. The patient has a history of intravenous drug abuse
with heroin and alcohol abuse. She currently smokes a few
cigarettes per day. She has been on methadone since [**Month (only) 216**]
but had been on it intermittently over the past nine years.
PHYSICAL EXAMINATION: On physical examination, the patient's
vital signs were 82, 88, 80/50, 18, 95% in room air.
General: Mildly distracted middle-aged woman with poor focus
but answered questions appropriately. Head, eyes, ears, nose
and throat: Normocephalic, atraumatic, pupils equal, round,
and reactive to light and accommodation, extraocular
movements intact, oropharynx stained with charcoal, dry
mucous membranes, no neck stiffness. Cardiovascular:
Regular rate and rhythm, no murmur, rub or gallop. Lungs:
Clear to auscultation bilaterally except for a few rhonchi.
Abdomen: Soft, nontender, nondistended, positive bowel
sounds, guaiac negative in Emergency Room. Extremities: No
edema, 2+ pedal pulses. Neurologic examination: Alert and
oriented times three, oriented to hospital and year,
appropriate only slowly.
LABORATORY DATA: White blood cell count was 6.2, hematocrit
35.1, BUN 69, creatinine 2.1 and creatinine clearance 32.3.
Urinalysis: Negative. Toxicology screen: Positive for
benzodiazepines and opiates. Chest x-ray: Negative.
Cerebrospinal fluid: No white blood cells, no red blood
cells, Gram stain with 1+ polycytes, protein 22, glucose 71.
HOSPITAL COURSE: 1. Neurologic: The patient was admitted
with a change in mental status. The patient was sedated and
there was concern over ingestion. Toxicology screen did not
reveal any ingestion, however, she does take benzodiazepines
and opiates on a regular basis.
Psychiatry was consulted, who did not feel that the patient
had suicidal ideation or had a suicide attempt.
Neuropsychiatric consultation demonstrated diffuse deficits
with lack of attention. An electroencephalogram was
performed, which demonstrated diffuse slowing consistent with
mild encephalopathy.
The patient's mental status improved slightly over the next
few days and she became less lethargic. She continued to
deny any ingestion. After consultation with infectious
disease, psychiatry, neuropsychiatry and the medical team,
the patient was felt safe for discharge and near her
baseline. The patient is to follow up immediately after
discharge with the psychiatric social worker at the methadone
clinic..
2. Hypotension: The patient was initially brought to the
Medical Intensive Care Unit and given a total of nine liters
of normal saline. The patient's blood pressure responded
adequately and normalized. She was transferred to the floor
on hospital day number one and her blood pressure remained
stable throughout her hospital course. It is unclear why her
blood pressure dropped initially. This may have been
secondary to ingestion or volume depletion.
3. Pulmonary: The patient's oxygen saturation remained
normal in room air. She completed her azithromycin course
from her last hospitalization for community acquired
pneumonia. She continued to have a mild cough but was
afebrile on discharge.
4. Renal: The patient was admitted with a creatinine of
2.1. Following the fluid challenge, her creatinine improved
to her baseline. This likely due to a pre-renal state from
volume depletion.
5. Hematology: The patient's hematocrit was slightly lower
than her baseline. However, the patient was guaiac negative
and did not demonstrate signs of bleeding. The patient was
menstruating and this was felt to contribute to her anemia.
Her hematocrit remained stable and she was safe for
discharge.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged with direct
follow-up with the psychiatric social worker at the [**Hospital 2514**]
Clinic. She was then discharged to home. Of note,
occupational therapy was also consulted, who felt that the
patient was safe to live at home.
DISCHARGE DIAGNOSES:
1. Hypotension, likely secondary to volume depletion.
2. Change in mental status, may be secondary to volume
depletion or toxic ingestion.
3. Anemia.
4. Acute renal failure, secondary to volume depletion.
5. Community acquired pneumonia.
6. Methadone maintenance for heroin addiction.
7. HIV.
DISCHARGE MEDICATIONS:
Paxil 20 mg p.o.q.h.s.
Bactrim one p.o.q.d.
Neurontin 400 mg p.o.t.i.d.
Methadone 120 mg p.o.q.d.
HAART therapy on hold.
Diazepam on hold, no signs of withdrawal on discharge.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15731**], M.D. [**MD Number(1) 15732**]
Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36
D: [**2116-10-4**] 16:48
T: [**2116-10-5**] 10:11
JOB#: [**Job Number 41928**]
ICD9 Codes: 2765, 5849, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6792
} | Medical Text: Admission Date: [**2193-1-7**] Discharge Date: [**2193-1-18**]
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: This patient was transferred from an
outside hospital for cardiac catheterization, where his chief
complaint had been shortness of breath.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 17702**] is an 81-year-old
white male with a past medical history significant for
hypertension, benign prostatic hypertrophy, and a remote
tobacco history, who was in generally good health with no
known coronary artery disease, and presented to an outside
hospital with acute shortness of breath the night prior to
admission while sitting and watching television. He stated
that his shortness of breath worsened with ambulation and
other activity. He denied having any associated chest pain,
nausea, vomiting, palpitations, or diaphoresis. He was taken
to the Emergency Department of the outside hospital, where an
EKG done showed poor R wave progression in leads V1 through
V3. Cardiac enzymes were cycled and showed a troponin of
39.21, and a CK of 246. At this time he was transferred to
the coronary care unit at the outside hospital, where a chest
x-ray was found to be consistent with congestive heart
failure. The patient received a 40 mg intravenous dose of
Lasix, and responded with a 1,200 cc diuresis. He was
started on heparin, aspirin, a beta blocker and an ACE
inhibitor. The heparin was however discontinued secondary to
some mild hematuria. He continued to remain symptom free,
and was transferred to the [**Hospital1 188**] for cardiac catheterization.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Gout. 3.
Hypercholesterolemia. 4. Remote history of kidney stones.
5. Benign prostatic hypertrophy with normal biopsy.
MEDICATIONS ON ADMISSION: 1. Univasc 15 mg p.o. q.d. 2.
Allopurinol 300 mg p.o. q.d. 3. Atenolol 100 mg p.o. q.d.
4. Hydrochlorothiazide.
ALLERGIES: The patient has no known drug allergies..
SOCIAL HISTORY: Mr. [**Known lastname 17702**] has a 20-pack-year smoking
history, but quit smoking approximately 20 years before. He
denies any alcohol or other illicit drug use. He lives with
his son in [**Name (NI) 5110**] and is a retired employee of [**Company 86**]
[**Male First Name (un) 17703**] Company.
FAMILY HISTORY: His mother and sister both passed away in
their 70s secondary to coronary artery disease.
PHYSICAL EXAMINATION: On admission Mr. [**Known lastname 17702**] was a pleasant
elderly man in no acute distress. He was found to have a
temperature of 98.1 degrees, heart rate of 78 and sinus
rhythm, blood pressure 178/90, respiratory rate 18 and an
oxygen saturation on room air of 95%. His pupils were
equally reactive to light and accommodation and his
extraocular movements were intact. His neck was supple with
jugular venous distension at approximately 8 cm, 2+ palpable
carotid pulses with no bruits. His cardiac examination
revealed a regular rate and rhythm with normal S1 and S2, as
well as a 2/6 systolic ejection murmur. He did not have any
S3, S4 or rubs. His lungs were clear to auscultation
bilaterally. His abdomen was soft, nontender, nondistended
with no hepatosplenomegaly or other palpable masses. His
extremities were warm and dry, with minimal bilateral pedal
edema. He had 2+ palpable pedal pulses. Neurologically he
was alert and oriented to person, place and time, with 5/5
strength and sensation in both upper and lower extremities.
LABORATORY DATA: On admission his complete blood count was
significant for a white blood cell count of 9.9, hematocrit
44 and a platelet count of 188. Chem-7 showed a sodium of
136, potassium 3.9, chloride 99 and a bicarbonate of 29, BUN
and creatinine of 46 and 1.8, and a blood glucose of 154.
His prostate specific antigen at the time of admission was
18. At the outside hospital he was found to have successive
troponins of 39.2 and 47.1 as well as a CK of 246. His
initial PT and PTT were 12.2 and 31.8, and at the time that
his heparin was stopped due to hematuria his PTT was 91.5.
HOSPITAL COURSE: Mr. [**Known lastname 17702**] was accepted as a transfer from
[**Hospital3 **], and admitted to the cardiac catheterization
laboratory. While there, he was found to have a left
ventricular ejection fraction estimated to be 20-25%. He was
also found to have distal 40% occlusion of his left main
coronary artery, subtotal occlusion of the left anterior
descending artery, proximal 70% focal disease as well as
distal occlusion of the left circumflex artery, and a
proximal 70% occlusion of the obtuse marginal artery. The
patient tolerated his catheterization well, and was
subsequently transferred to the floor in stable condition.
On hospital day two, through various discussions with his
family and the cardiac surgery service, the patient decided
to proceed with coronary artery bypass grafting surgery.
On hospital day two the patient was restarted on heparin at
which time he redeveloped hematuria. The urology service was
subsequently consulted to further evaluate this issue. He
underwent flexible cystoscopy which revealed a likely
prostatic source to his gross hematuria. The heparin drip
was restarted and a three-way Foley catheter was placed so
that he could have continuous bladder irrigation to keep his
urine clear. Follow up was arranged with the urology service
as an outpatient in the future once his cardiac issues have
been resolved.
Mr. [**Known lastname 17702**] was taken to the operating room on [**2193-1-11**] where he underwent coronary artery bypass grafting x 3.
Please refer to the dictated operative note for full details
of his procedure. The patient tolerated the procedure well,
and was transferred in stable condition to the cardiac
surgery recovery unit. At the time of transfer, he was found
to have a mean arterial pressure of 72, being A-paced at 80
beats per minute. He was on a milrinone drip at 0.25 mcg per
kg per minute as well as a propofol drip at 10 mcg per kg per
minute. Following arrival in the CSRU, the patient
subsequently required a small dose of Levophed to maintain a
mean arterial pressure in the 60s. He also received two
units of packed red blood cells for an hematocrit of 24.6,
and was found to have a post transfusion hematocrit of 25.6.
On postoperative day one the patient was reversed, weaned
from the ventilator, and successfully extubated. He was
weaned off of his milrinone and Levophed drips, continuing
only on an insulin drip at approximately two units per hour.
He continued at this time to have continuous bladder
irrigation through his three-way Foley catheter.
In the days following extubation, the patient did require
intermittent milrinone to maintain his cardiac index. At
this time diuresis was also started with Lasix with excellent
response. Levofloxacin was also started for treatment of a
urinary tract infection.
On postoperative day four, the patient was weaned off
milrinone altogether, received one unit of blood for an
hematocrit of 27%, and captopril was slowly titrated up. At
this time, he was deemed stable and ready for transfer to the
floor. Continuous bladder irrigation had been stopped, and
urine draining into the Foley catheter was tea colored.
On transfer to the floor, the patient initially had a large
oxygen requirement, requiring six liters of nasal cannula
oxygen to maintain oxygen saturations above 95%. This was
slowly weaned, as he improved, and diuresis continued. He
continued to improve as well in terms of functional mobility
in his therapy sessions with the physical therapy service.
His Foley catheter was discontinued on [**1-17**] which was
postoperative day six, and the patient was initially able to
void, though in small amounts. By lateral that night, the
patient became uncomfortable and was subsequently unable to
void. A three-way Foley catheter was replaced, and 800 cc of
clear yellow urine as well as one large blood clot drained
into the Foley catheter.
On postoperative day seven, it was felt that the patient was
stable and ready for discharge from a cardiopulmonary
standpoint. It was felt at this time that he would benefit
from a short stay at an extended care rehabilitation
facility. It was also deemed necessary at this time that the
Foley catheter, which was placed on the night prior to
discharge remain in place for approximately 1-2 weeks with
outpatient urology follow up.
Physical examination on discharge: Mr. [**Known lastname 17702**] was found to
have a temperature of 99.1 degrees with a heart rate of 78 in
sinus rhythm and a blood pressure of 120/56. He had an
oxygen saturation on room air of approximately 92%, but
continued to require some nasal cannula oxygen for activity.
He continued to diurese well at this time. His neck was
supple with no abnormalities. On cardiac examination he had
a regular rate and rhythm with normal S1 and S2 and a grade
2/6 systolic ejection murmur. His lungs were clear to
auscultation bilaterally. His sternal incision was healing
nicely with no erythema or drainage, and his sternum was
stable. His abdomen was soft, nontender, nondistended, with
no organomegaly or other probable masses. He had a three-way
Foley catheter in place with a small amount of fresh blood
around the penile meatus. His extremities were warm and well
perfused with minimal lower extremity edema.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 325 mg p.o. q.d.
2. Lasix 20 mg p.o. b.i.d. x 7 days.
3. Potassium chloride 20 mEq p.o. b.i.d. x 7 days.
4. Captopril 12.5 mg p.o. t.i.d.
5. Lopressor 12.5 mg p.o. b.i.d.
6. Zantac 150 mg p.o. q. day.
7. Trazodone 100 mg p.o. q.h.s. for sleep.
8. Tylenol 650 mg p.o. q. 4 hours as needed for pain or
discomfort.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting x 3.
2. Hypertension.
3. Gout.
4. Hypercholesterolemia.
5. Benign prostatic hypertrophy with hematuria, and failure
to void following surgery.
The patient is being discharged with a three-way Foley
catheter in place. His activity should be as tolerated,
though he requires continued sessions with physical therapy
to increase strength, mobility and endurance. During this
time he should slowly be weaned from his nasal cannula oxygen
requirement with activity. His diet should be a cardiac
heart healthy diet.
FOLLOW UP: He will follow up with his cardiologist in
approximately one to two weeks, with the wound clinic in
approximately two weeks. He should also follow up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in approximately four weeks' time. Follow up
should also be with Dr. [**Last Name (STitle) 986**] of the Urology Department at
[**Hospital1 69**] in approximately one to
two weeks' time, phone #[**Telephone/Fax (1) 990**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 17704**]
MEDQUIST36
D: [**2193-1-18**] 09:24
T: [**2193-1-18**] 09:33
JOB#: [**Job Number 17705**]
ICD9 Codes: 4280, 4271, 5990, 4589, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6793
} | Medical Text: Admission Date: [**2159-1-15**] Discharge Date: [**2159-1-23**]
Date of Birth: [**2093-8-8**] Sex: M
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Three-vessel disease.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old male with
a [**5-12**] month history of exertional dyspnea and shortness of
breath. The patient had an ETT in [**2158-7-31**] which was
positive and was treated medically at that time, but the
exertional angina persisted, and the patient had a cardiac
catheterization that showed three-vessel disease with a
normal ejection fraction.
PAST MEDICAL HISTORY: Status post right knee surgery.
Hypercholesterolemia. Coronary artery disease.
SOCIAL HISTORY: He is retired and lives alone. He denied
tobacco. Occasional alcohol, approximately [**5-7**] drinks per
week.
FAMILY HISTORY: Uncle had a history of myocardial infarction
in his 60s. Brother died in his 50s from diabetes.
ALLERGIES: PERCOCET.
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o. q.d., Lipitor
10 mg p.o. q.d., Atenolol 25 mg p.o. q.d., Lorazepam 0.5 mg
q.h.s. p.r.n., Nitroglycerin p.r.n.
CATHETERIZATION RESULTS: Left anterior descending with
subostial occlusion, left circumflex proximal 30%, 70% in
obtuse marginal 2, and 70% in obtuse marginal 3. Right
coronary artery with high-rising posterior descending artery
80% ostial, 70% proximal posterior lateral.
ETT showed 70% maximal PHR. Electrocardiogram showed [**Street Address(2) 4793**]
depression inferior in V4-6, resolved at rest. Anterior
septal and apical ischemia. Ejection fraction of 60%.
REVIEW OF SYSTEMS: The patient denied diabetes,
cerebrovascular accident, transient ischemic attack,
seizures, and hypertension. He denied asthma, chronic
obstructive pulmonary disease, upper respiratory infection,
cough, orthopnea. The patient did complain of dyspnea on
exertion. He denied peptic ulcer disease, hematochezia,
melena, blood in stool. He denied claudication, edema,
peripheral vascular disease, vein stripping. He denied
nausea, vomiting, diarrhea, or constipation. He denied
voiding difficulties, benign prostatic hypertrophy, or
hematuria.
LABORATORY DATA: On [**1-9**] white count was 6.1,
hematocrit 42.7, platelet count 170; sodium 140, potassium
5.1, chloride 103, bicarb 28, BUN 14, creatinine 0.7; INR
1.0, PT 12.5.
Electrocardiogram showed sinus rhythm at 72, there were
T-waves in III, Q-waves in AVF and III.
Chest x-ray showed no pulmonary congestion, infiltrates, or
nodules, no effusions.
PHYSICAL EXAMINATION: Vital signs: Heart rate 78 in sinus
rhythm, blood pressure 122/72, respirations 18, oxygen
saturation 96% on room air. General: The patient was
resting in bed in no apparent distress. He was alert and
oriented times three. The patient followed commands.
Neurological: Grossly intact. HEENT: Pupils equal, round
and reactive to light. Extraocular movements intact.
Anicteric. Noninjected eyes. Moist mucous membranes.
Normal mucosa. Nasopharynx: Supple. No lymphadenopathy.
No bruits. Lungs: Clear to auscultation bilaterally.
Heart: Regular, rate and rhythm. Normal S1 and S2. No
murmurs, rubs, or gallops. Abdomen: Soft, nontender,
nondistended. No masses. Extremities: Warm and well
perfused extremities. No clubbing, cyanosis, or edema. No
varicosities. Pulses: Carotid 2+ bilaterally, dorsalis
pedis and posterior tibial were 2+ bilaterally.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Surgery Service and underwent coronary artery bypass grafting
times four with LIMA to left anterior descending, saphenous
vein graft to obtuse marginal 2 and obtuse marginal 3, and
saphenous vein graft to posterior descending artery.
The patient had a mean arterial pressure of 68, CVP of 8, and
atrial paced at 88 on Propofol drip and Neo-Synephrine at 0.5
pressure support.
The patient was transferred to the CSRU on postoperative day
#1. The patient had a dose of Lasix for a low urine output,
and the patient was extubated. The patient was continued on
Neo-Synephrine drip at 0.5 for pressure support and was on
prophylactic antibiotics.
The patient's T-max was 101.8??????. He had good blood pressure
and good pulse. He was in normal sinus rhythm. He was
positive at 1.6 L. White count was 15.3, hematocrit was
31.5, creatinine 0.8. He otherwise was doing well.
The patient was started on Lasix b.i.d., and the patient's
medial chest tube was removed.
On postoperative day #2, the patient was on the floor. The
patient remained afebrile with a heart rate of 104 in sinus
rhythm. Blood pressure was 140s/80s. The patient otherwise
had good p.o. intake and making good urine.
The patient's chest tube was removed, and JP was removed. He
was placed on Lopressor 25 b.i.d. to control his blood
pressure.
On postoperative day #3, the patient was paranoid in the
hospital and became confused. The patient locked himself in
the bathroom and refused all services. Psychiatry was
[**Name (NI) 653**], and the patient was given Haldol which relieved
the symptoms.
The patient remained afebrile with a pulse of 106, white
count 23.3. The patient was pancultured, and ABG and chest
x-ray was obtained, as well as contacting [**Name (NI) **] for elevated
blood sugar.
Psychiatry stated that the patient had an acute episode of
confusion and paranoia and was consistent with delirium, and
they recommended to minimize narcotics, which were
subsequently stopped, and to obtain a head CT, which was
obtained. Head CT showed no acute infarction, hemorrhage, or
masses.
The Haldol was started on a standing dose at night and p.r.n.
dose and to monitor the patient for alcohol withdraw
symptoms.
On postoperative day #4, the patient had a temperature of
101.4??????. He otherwise was doing well. White count came down
to 15.5. The patient's paranoia had slightly improved, and
the patient was more cooperative with the staff and was less
confused.
On postoperative day #5, the patient had continued to
improve. The patient's T-max was 100.9??????. He was in sinus
rhythm and tachycardiac up to 140-150s. Lopressor was
increased to control blood pressure and the heart rate.
The patient's white count went down to 10.8. Psychiatry
recommended adding Trazodone p.r.n. and at night for sleep,
and the patient was also placed on Metformin for blood
glucose control and to stop the Insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **].
On postoperative day #6, the patient had a temperature of
102.4??????. He otherwise was doing well.
The patient complained of increased breathing. The patient's
ABG was 7.48, 35, 70, 27, and 2, in room air. The patient
was taking good p.o. and making good urine. The patient
continued to have a white count of 10.6. No other cultures
came back positive. The patient continued to improve.
On postoperative day #7, the patient had a low-grade
temperature of 100.4??????, but otherwise was taking good p.o.,
making good urine, and the patient's white count continued to
stay low at 10.4
On postoperative day #7, Psychiatry recommended that the
patient obtain an Occupational Therapy consult for safety at
home. They also recommended to stop the Haldol.
On postoperative day #8, the patient continued to improve.
The patient had a white count of 11.9, which had been stable.
Occupational Therapy cleared the patient to go home, and
Psychiatry felt that the patient was safe to go home.
CONDITION ON DISCHARGE: Good.
DISPOSITION: Home with VNA.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Delirium.
3. Hypercholesterolemia.
4. Status post right knee surgery.
5. Status post coronary artery bypass grafting times four.
FOLLOW-UP: Please follow-up with Dr. [**Last Name (STitle) 70**] in six weeks;
please call for a follow-up appointment. Follow-up with Dr.
.................. in [**12-1**] weeks. Follow-up with
endocrinologist in [**12-1**] weeks. Follow-up with cardiolgoist in
[**12-1**] weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3118**]
MEDQUIST36
D: [**2159-1-23**] 11:48
T: [**2159-1-23**] 12:22
JOB#: [**Job Number 35334**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6794
} | Medical Text: Admission Date: [**2199-2-1**] Discharge Date: [**2199-2-9**]
Date of Birth: [**2146-4-2**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
S/P Laparoscopic appendectomy presents with LLQ pain and
abdominal distension.
Major Surgical or Invasive Procedure:
Sigmoid colectomy and sigmoid colostomy and Hartmann's
procedure, drainage of retroperitoneal and peritoneal abscesses.
History of Present Illness:
Patient is a 52 yo male s/p laparoscopic appencedtomy [**2199-1-25**].
Patient with abdominal pain in the left lower quadrant and
abdominal distension. He was transferred to [**Hospital1 18**] one week post
op for further evaluation and treatment. CT scan reveals
perforated sigmoid colon and retroperitoneal intraperitoneal
abscess.
Past Medical History:
PMH:
Prostate CA
Hyperlipidemia
CAD s/p cath
HTN
GERD
Social History:
No tobacco, daily ETOH, married, lives with family
Family History:
non contributory
Physical Exam:
Temp 98.5 HR 84 BP 121/76 RR 20 O2 sat 98% RA
Exam:
Gen: NAD, Awake, alert Ox3
CVS: RRR S1& S2
Lungs: CTA BL
Abd: Soft, greatly distended, hypertympanic, Tender LLQ,no
guarding or rebound
Ext: No edema
Pertinent Results:
[**2199-2-1**] 09:45PM WBC-14.8* RBC-3.99* HGB-12.2* HCT-34.0*
MCV-85 MCH-30.6 MCHC-35.9* RDW-12.9
[**2199-2-1**] 09:45PM NEUTS-81.8* LYMPHS-10.6* MONOS-4.6 EOS-2.2
BASOS-0.8
[**2199-2-1**] 09:45PM PLT COUNT-386
[**2199-2-1**] 09:45PM PT-13.4 PTT-34.4 INR(PT)-1.1
[**2199-2-1**] 09:45PM CALCIUM-7.8* PHOSPHATE-4.3 MAGNESIUM-2.5
[**2199-2-1**] 09:45PM GLUCOSE-115* UREA N-23* CREAT-0.8 SODIUM-136
POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-27 ANION GAP-16
[**2199-2-2**] 7:20 pm SWAB PERITONEAL FLUID CULTURE.
**FINAL REPORT [**2199-2-6**]**
GRAM STAIN (Final [**2199-2-2**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN SHORT CHAINS.
WOUND CULTURE (Final [**2199-2-6**]):
A swab is not the optimal specimen collection to evaluate
body
fluids.
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
ESCHERICHIA COLI. SPARSE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S =>32 R
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S
PENICILLIN G---------- =>64 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2199-2-6**]): NO ANAEROBES ISOLATED.
[**2199-2-2**] CT Abdomen/pelvis :
Findings compatible with perforated viscus with likely source at
the sigmoid colon/descending colon junction. At this junction, a
fluid
collection measuring up to 6.6 cm, containing air, enteric
contrast and fluid is demonstrated. This collection tracks and
involves to the retroperitoneum anterior to the psoas muscle
where another discrete collection is demonstrated measuring up
to 6.7 cm in its greatest dimension (SI). A third discrete
collection is demonstrated within the lateral intraperitoneal
cavity (series
2, image 48) measuring up to 4.9 cm in its greatest dimension
(AP). Extensive associated pneumoretroperitoneum tracking to
dissecting to involve the mediastinum. There is also a moderate
amount of pneumoperitoneum.
Brief Hospital Course:
Patient is a 52 yo male s/p laparoscopic appendectomy at an OSH
on [**2199-1-25**]. Patient's post operative course was complicated by
SOB, abdominal distension, and LLQ pain. Patient with pain in
his LLQ that is constant and worsens with movement. Patient was
kept in the hospital and placed on TPN and IV ABX. Patient with
no nausea or vomiting. No fevers or chills. Patient having
bowel movements and passing flatus. He was transferred to [**Hospital1 18**]
for further evaluation and management.
Patient with repeat CT scan showing perforated sigmoid colon and
retroperitoneal intraperitoneal abscess. He underwent a sigmoid
colectomy and sigmoid colostomy and
Hartmann's procedure, drainage of retroperitoneal and peritoneal
abscesses on [**2199-2-2**]. Post operatively patient sent to the ICU
intubated. He had a PCA for pain. He was extubated on [**2-3**]. He
remained NPO/LR with an NGT to low continuous wall suction.
Foley is in place with adequate urine output. He stayed on
Cipro/Flagyl x 10 days for peritonitis and intra/RP abscesses.
He was transferred to a regular nursing floor on [**2198-2-4**].
Culture grew VRE, and in consultation with ID, he was started on
linezolid.
Following transfer to the Surgical floor he continued to make
good progress. As his bowel function returned his nasogastric
tube was removed and he began a liquid diet which was gradually
advanced to regular and tolerated well.
He was seen on a regular basis by the ostomy nurse for general
care and teaching and was slowly understanding the necessary
treatments although he did wax and wane in his ability to care
for the ostomy. Prior to discharge, he did demonstrate adequate
understanding and ability to care for the ostomy.
Medications on Admission:
Amlodipine Besylate 10 mg QD
Metoprolol Succinate ER 75 mg QD
Hydrochlorothiazide 25 mg QD
Quinapril 40 mg QD
Aspirin 81 mg QD
Citalopram HBR 10 mg QHS
Simvastatin 40 mg QHS
Alprazolam 0.5 mg PRN
Claritan 10 mg PRN
Famotidine 20 mg PRN
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)): STOP taking this medication and do not restart
until 2 weeks after finishing linezolid.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): thru [**2199-2-12**].
Disp:*11 Tablet(s)* Refills:*0*
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): thru/[**2199-2-12**].
Disp:*7 Tablet(s)* Refills:*0*
11. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Perforated sigmoid colon
retroperitoneal intraperitoneal abscess.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with abdominal pain from a
hole in your sigmoid colon. Surgery was done which entailed a
temporary colostomy. Hopefully when the inflammation resolves
and you have lost some weight (30-40 pounds), you can have the
colostomy reversed, probably not for 3-4 months. It is very
important that you start a weight loss program after you have
recovered from this operation.
* Your incision is healing from the inside out therefore you
will need to have dressing changes daily while it heals. You
will also need to continue to learn how to care for your
colostomy. The VNA will be able to help you with that.
Please take the three antibiotics as prescribed. The linezolid
has been pre-approved by your insurance company. If there are
any issues, the approval number is #[**Numeric Identifier 52931**]. The linezolid can
interact with citalopram (Celexa), so STOP taking citalopram,
and do not restart it until 2 weeks after finishing the
linezolid.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-30**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
* Continue packing wound daily with saline damp gauze followed
by a dressing on top.
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
* Continue all of your instructions from the Ostomy nurse.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 2 weeks.
Call Dr. [**Last Name (STitle) **] for an appointment in [**2-22**] weeks to help with
a safe weight loss program.
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6795
} | Medical Text: Admission Date: [**2163-7-17**] Discharge Date: [**2163-7-20**]
Date of Birth: [**2087-9-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Dizziness/Lightheadedness
Major Surgical or Invasive Procedure:
Temporary Pacemaker Wire Placement
Permanent Pacemaker Placement
History of Present Illness:
Patient is a 75 yo male with hx of CAD, HTN,
Hypercholesterolemia who presented to [**Hospital1 18**]-[**Location (un) 620**] this am
after developing dizzuness and lightheadedness at home this am.
The pt reports he was getting coffee this AM when he felt
lightheaded, and dizzy but no overt chest pain, palpitations,
shortness of breath, syncope. He subsequently sat down and
finished his coffee but appeared pale to his wife who checked
his pulse and noted it to be irregular and bradycardic with a
heart rate of 26. The pt was BIBA to [**Hospital1 18**] [**Location (un) 620**] where an EKG
demonstrated complete heart block with junctional escape in the
20s to 30s. Otherwise his ECG was significant for LBBB with
LAD. He was afebrile with HR of 30 and BP of 160/82, with RR of
10 and SaO2 of 100%. He was never hypotensive during his OSH
stay. He received atropine in the [**Location (un) 620**] ED and his rhythm
converted to sinus bradycardia. He was subsequently transferred
to [**Hospital1 18**] for further evaluation and management.
.
ROS: The pt denies any chest pain, palpitations, sob, abd pain,
n/v/d, URI, sick contact, insect bites - specifically tick
bites, arthritis symptoms, black stools, melana, back pain.
Past Medical History:
1. CAD: NSTEMI in '[**53**] when he presented with chest pain
(positive top but neg CK) s/p cardiac catheterization with POBA
of LCx. The pt had a neg Thallium stress test in '[**60**].
2. Hypertension
3. Hypercholesterolemia
4. Increased intraocular pressure
Social History:
The pt is a retired realtor who lives in [**State **] with his wife.
[**Name (NI) **] is visiting his daughter who lives in MA. He has intact ADL
and IADLs at home.
Tob: quit; former smoked 4-5cig/day for 40 years but quit
20+years ago
EtOH: occasional
Family History:
Father: CAD, COPD, tob+
Mother: None
[**Name (NI) 18806**] and [**Name (NI) 68213**]: none
Physical Exam:
Vitals: T: 96.9, HR: 56, BP: 147/52, RR: 10, SaO2: 100% RA
GEN: Well appearing middle aged man who appears younger than
stated age. Conversing fluently in full sentences. NAD
HEENT: EOMI, anicteric, op clear, mmm
NECK: No JVD, no [**Doctor Last Name **] a waves.
CHEST: CTA bilaterally anteriorly
CV: RRR, S1, S2.
ABD: soft, NT, ND, BS+
GROIN: Right groin line in place without obvious echymosis,
hematoma, bruits.
EXT: wwp, no c/c/e
NEURO: A+O x3, appropriate.
.
.
Pertinent Results:
[**2163-7-17**] 12:50PM WBC-10.3 RBC-4.88 HGB-15.6 HCT-43.6 MCV-89
MCH-32.0 MCHC-35.9* RDW-13.3
[**2163-7-17**] 12:50PM PLT COUNT-194
[**2163-7-17**] 12:50PM NEUTS-73.9* BANDS-0 LYMPHS-21.0 MONOS-2.9
EOS-1.4 BASOS-0.9
[**2163-7-17**] 12:50PM PT-12.0 PTT-25.0 INR(PT)-1.0
[**2163-7-17**] 12:50PM GLUCOSE-150* UREA N-11 CREAT-1.1 SODIUM-132*
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-26 ANION GAP-14
[**2163-7-17**] 12:50PM CK(CPK)-62
[**2163-7-17**] 12:50PM cTropnT-<0.01
..................
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2163-7-17**] 10:10 PM
COMPARISON: [**2163-7-17**].
AP CHEST RADIOGRAPH:
There has been interval placement of a pacing lead that appears
to be entering via the IVC. Tip is seen overlying the right
ventricle. Otherwise no significant change is seen from prior
study with stable cardiac and mediastinal contours. No focal
consolidations or pleural effusions identified.
...................
TTE [**7-19**]:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
mild-moderate pulmonary artery systolic hypertension. There is a
partially echo filled space anterior to the distal right
ventricular free wall which most likely represents a fat pad.
IMPRESSION: Preserved global and regional biventricular systolic
function. No definite pericardial effusion identified.
Mild-moderate pulmonary artery systolic hypertension.
......................
EXERCISE MIBI [**2163-7-20**]
Reason: CAD S/P PCI, ? ISCHEMIA
RADIOPHARMECEUTICAL DATA:
3.2 mCi Tl-201 Thallous Chloride;
22.0 mCi Tc-[**Age over 90 **]m Sestamibi;
HISTORY: Chest pain. History of heart block and pacer placement.
SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB:
Exercise protocol: Modified [**Doctor First Name **]
Resting heart rate: 60
Resting blood pressure: 170/90
Exercise duration: 7.5 min.
Peak heart rate: 77
Percent max predicted HR: 53%
Peak blood pressure: 176/90
Symptoms during exercise: none
Reason exercise terminated: stopped at patient request
ECG findings: uninterpretable due to left bundle branch block
INTERPRETATION:
Imaging Protocol: Gated SPECT
Resting perfusion images were obtained with Tl-201.
Tracer was injected 15 minutes prior to obtaining the resting
images. Exercise
images were obtained with Tc-[**Age over 90 **]m sestamibi.
This study was interpreted using the 17-segment myocardial
perfusion model.
The image quality is good. Uptake is seen in the left axilla and
arm, likely venous in etiology.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 63%.
No prior studies.
IMPRESSION: Normal myocardial perfusion study at the level of
exercise achieved. Normal ejection fraction.
Brief Hospital Course:
A/P: 75 yo male with history of HTN, CAD, inc chol, who
presented earlier today with symptoms of dizziness and
lightheadedness. Found to be in heart block, received atropine
in the ED.
.
1. CV:
A. Bradycardia: The pt is currently in NSR, however was found
to be in high degree AV block thought to be paroxysmal AV block
secondary to diseased intrinsic conduction system. The pt has a
history of MI in the past with LCx disease which may partially
explain the conduction disease (but not well). Other etiologies
of CHB include Lyme disease, viruses, med, toxins, rheumatoid
disorders, however these all seem unlikely. Cardiac enzymes were
negative. Precise etiology of AV block remains unclear.
Temporary pacing wires were placed by EP fellow via fluoro and
patient underwent placement of a permanent pacemaker on [**2163-7-17**].
Patient tolerated the procedure well. He will follow-up in the
device clinic on [**2163-7-18**].
.
B. CAD: The pt has a history of CAD with PTCA in the past but
had normal stress test in '[**60**]. Given symptomatic bradycardia as
above, we did not aggressively treat his blood pressure or heart
rate given risk for further bradycardia or hypotension.
He was continued on ASA 325 mg qd and Zocor 10mg qd. On [**2163-7-19**]
he had an episode of chest pain which was sub-sternal, difficult
to characterize, then moved to R side. Responded to SL NG x 2
and morphine. No associated SOB, N/V. EKG unrevealing. CE sent.
Pulsus was 2. HD stable with SBP 130s, HR 70s. He underwent a
PMIBI which showed a normal myocardial perfusion study at the
level of exercise achieved.
Normal ejection fraction. He was able to exercise for 7.5 mins.
He did not have any anginal symptoms. No further episodes of
chest pain while in-patient. Prior to discharge was restarted on
atenolol and lisinopril after placement of pacer.
.
2. Hypertension: Beta blocker and thiazide diuretics that
patient takes as an out-patient were initially held given his
bradycardia. After pacer placement these were restarted.
Patient was also started on lisinopril for better blood pressure
control. He will follow-up with his PCP [**Last Name (NamePattern4) **] [**1-31**] weeks for further
titration of his anti-hypertensives and will have his
electrolytes checked at that time.
.
3. Hyperglycemia on admission labs: The pt does not carry a
history of DM, and this could reflect a stress response. Fasting
AM sugars was within normal limits at time of discharge,
however, patient was advised to follow-up with his PCP regarding
his blood sugar. He should be monitored for fasting and post
prandial hyperglycemia and should have an HgA1C checked.
.
Medications on Admission:
ALLERGIES: NKDA
.
MEDICATIONS:
1. Metoprolol XL 50mg once daily
2. Indapamide (Thiazide Diuretic) 2.5mg once daily
3. Zocor 10mg once daily
4. ASA 325mg once daily
5. Eye drops - Cosopts for right eye and ?Xelotan for both eyes
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Indapamide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Cosopt 2-0.5 % Drops Sig: One (1) gtt Ophthalmic twice a
day: Right eye.
5. Xalatan 0.005 % Drops Sig: One (1) gtt Ophthalmic at
bedtime.
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Complete heart block
..
Secondary diagnoses
hypertension
CAD
hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted for heart block and had a pacemaker placed.
You should follow up in device clinic as arranged. You should
return to the ED with increasing pain at the pacer site, fevers,
chills, palpitations, fainting, chest pain, shortness of breath,
or for any other problems that concern you.
Followup Instructions:
You have an appointment at the device clinic on [**2163-7-28**] at
10 am in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**].
.
You should follow up with your PCP and your primary cardiologist
when you return to [**State **]. You will need to see a cardiologist
that specializes in pacer makers. You should have your blood
pressure checked by your PCP as you may need to have your blood
pressure medications adjusted. You should also have your PCP
check your blood sugar as it was intermittently elevated while
you were in the hospital.
ICD9 Codes: 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6796
} | Medical Text: Admission Date: [**2143-4-11**] Discharge Date: [**2143-4-12**]
Date of Birth: [**2071-2-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Elective Pulmonary Vein Isolation for Atrial Fibrillation -
Post-PVI monitoring
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation
History of Present Illness:
Since Dr [**Last Name (STitle) **] last saw him in [**Month (only) 359**], Mr. [**Known lastname 37217**] had an
overall increase in his burden of AF, with fairly frequent
episodes with progressively increasing fatigue over the last few
months despite being on amiodarone. This led to him having a
repeat echocardiogram that was done earlier this month, which
exhibited a left ventricular ejection fraction of 40% as well as
mild AR, mild-to-moderate MR, and borderline pulmonary
hypertension, which was unchanged from his previous study. He
continues to take amiodarone 200 mg a day as well as warfarin
for thromboembolic prophylaxis. His ventricular response to AF
fibrillation that day was about 110 beats per minute. He had
previously been on Toprol and then was switched to Bystolic and
he believes that his heart rate has been faster in AF since
switching to Bystolic.
.
In terms of his ongoing management, he wished to be aggressive
in restoring consistent sinus rhythm. He requested to undergo
pulmonary vein isolation. He did a cardiac MRI prior to this
procedure as ordered post-consult (see below).
.
He went for a pulmonary vein isolation today ([**2143-4-11**]). Ablation
started at 9:37am; at 1228 noted to go into heart block with
RFA, external pacing without effect at 200ma, CPR started and
sustained for 2minutes. BP stable and saturation did not drop
throughout episode. Patient reverted to flutter. At 1243 pt in
flutter with SBP in 80s, external DCCV with 100J with reversion
to sinus briefly. Patient received totals of 4L NS/LR with UOP:
16500cc. Decision made to transfer patient to the CCU for
post-isolation monitoring.
In the CCU VSS, telemetry with intermittent sinus tachy with
flips to sinus brady. His only complaint is some soreness at the
back of his throat which he attributes to "putting a breathing
tube" during the procedure, but it does not bother him
otherwise.
He currently denies any chest discomfort, SOB, palpitations,
dizziness, lightheadedness, fatigue.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
(Patient denies this as per pre-procedure interview dated
[**2143-4-9**] but in old notes)
2. CARDIAC HISTORY:
- Paroxysmal atrial fibrillation, on Amiodarone, Coumadin and
Toprol s/p cardioversion x2 ([**2141-3-31**])
- Coronary Artery Disease
- PERCUTANEOUS CORONARY INTERVENTIONS: Initial stenting done in
[**2131**], clean cath in [**2139**], repeat cardiac catheterization in [**Month (only) **]
[**2141**] for chest discomfort in the setting of AFib, which
demonstrated mild in-stent restenosis to 30% in the LAD stent.
- PACING/ICD: None
- CABG: None
3. OTHER PAST MEDICAL HISTORY:
- GERD
- Left hernia repair, excision of inclusion cyst from chest wall
([**8-/2142**])
- Ptosis surgery
- Bilateral cataract surgery
Social History:
Married with 3 children and stays with wife. ADL independent.
Works as a lawyer.
- Tobacco history: Remote.
- ETOH: One drink 5x/week.
- Illicit drugs: None.
Family History:
Father (51), uncle (51) and grandfather (51) all had MIs at ages
provided. Sister with DM, valve disease and heart failure at age
50.
Otherwise, no family history of arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
VS: T=96.4 BP=124/83 HR=119 RR=20 O2 sat=96% on 3L delivered
through nasal prongs
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NEURO: PERRL, EOMI. Facial asymmetry on inspection with
decreased nasolabial fold and facial drooping on left. Able to
raise eyebrows, but R>L.Power Grade [**4-4**] in all extremities
throughout. Biceps, triceps, knee, ankle reflexes 2+ throughout.
Downgoing plantars bilaterally. In-the-ear hearing aids present
ears bilaterally. Facial sensation intact throughout. No uvulal
deviation. Able to swallow water without choking. No tongue
fasiculations or deviation. Full power in shrugging shoulders
and on lateral rotation of head.
NECK: Supple with JVP of 3 cm.
CARDIAC: PMI located in 6th intercostal space, 1cm lateral to
the midclavicular line, thrusting in nature. Regular rhythm (but
varies from bradycardia of 50s to tachycardia of 120s throughout
examination), normal S1, S2. Grade [**1-6**] pansystolic murmur heard
at the apex radiating to the axilla. No rubs / gallops. No
thrills, lifts. No S3 or S4. No midline sternotomy scar.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
was unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2143-4-11**] 07:10AM WBC-5.7 RBC-3.92* HGB-13.3* HCT-38.0* MCV-97
MCH-33.8* MCHC-34.9 RDW-13.6
[**2143-4-11**] 07:10AM PLT COUNT-221
[**2143-4-11**] 07:10AM PT-28.0* PTT-49.0* INR(PT)-2.7*
[**2143-4-11**] 07:10AM GLUCOSE-214* UREA N-20 CREAT-1.0 SODIUM-141
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
[**2143-4-11**] 08:51PM SODIUM-138 POTASSIUM-3.8 CHLORIDE-102
[**2143-4-11**] 08:51PM MAGNESIUM-1.6
[**2143-4-12**] 04:56AM BLOOD WBC-9.2# RBC-3.43* Hgb-11.8* Hct-33.7*
MCV-98 MCH-34.4* MCHC-35.0 RDW-14.0 Plt Ct-170
[**2143-4-12**] 04:56AM BLOOD PT-24.8* PTT-46.3* INR(PT)-2.3*
[**2143-4-12**] 04:56AM BLOOD Glucose-148* UreaN-18 Creat-0.9 Na-136
K-4.0 Cl-102 HCO3-28 AnGap-10
.
EKG:
[**2143-4-11**] 0723h
Atrial fibrillation with ventricular response rate 66-120.
.
[**2143-4-11**] 0835h Pre-Procedure / Baseline
Atrial fibrillation with ventricular response rate 75-100. QT
440ms.
.
[**2143-4-11**] 1232h Post-Procedure
Sinus bradycardia 50 beats per minute.
.
DISCHARGE LABS:
[**2143-4-12**] 04:56AM BLOOD WBC-9.2# RBC-3.43* Hgb-11.8* Hct-33.7*
MCV-98 MCH-34.4* MCHC-35.0 RDW-14.0 Plt Ct-170
[**2143-4-12**] 04:56AM BLOOD Glucose-148* UreaN-18 Creat-0.9 Na-136
K-4.0 Cl-102 HCO3-28 AnGap-10
[**2143-4-12**] 04:56AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.4
Brief Hospital Course:
Mr [**Known lastname 37217**] is a 72 year old man with history of paroxysmal
atrial fibrillation s/p pulmonary vein isolation with procedure
complicated by complete heart block transferred to the CCU for
monitoring.
.
# Complete Heart Block/Arrthymias. Complete heart block
transient in the setting of PVI. Question of vagal event
precipitating event. In the CCU patient oscillated from sinus
bradycardia to sinus tachycardia. Blood pressures remained
stable and patient largely asymptomatic. On evening of transfer
patient given 400mg PO QD. Decision made to uptitrate amio to
200mg PO TID for one week followed by 200mg PO BID x 3-4weeks.
Patient also discharged with [**Doctor Last Name **] of Hearts Monitor for planned
3 week monitoring.
OUTPATIENT ISSUES:
-- Rhythm control with Amio: 600QD x1 week, followed by 200mg PO
BID
-- Discharged with [**Doctor Last Name **] of Hearts
-- Continued on home metoprolol 25mg XL QD.
.
# Paroxysmal Atrial Fibrillation s/p PVI. Unfortunately
procedure terminated prior to complete ablation. Post-procedure
patient was monitored for general procedure-related
complications: groin site pain / erythema / swelling / bleeding,
Retroperitoneal bleeding. Patient reverted back into aflutter
intermittently.
1. Rhythm/Rate. Amio uptitrated and beta-blocker contined.
2. Anticoagulation continued with home Coumadin; INR therapeutic
in house
.
# Coronary Artery Disease s/p stent placement in [**2131**]
(Successful PTCA and stenting of the mid LAD) Currently without
cardiac complaints, ECG without changes concerning for ischemia.
Patient continued on Aspirin 325mg PO daily, metoprolol,
lisinopril.
.
# HTN: Normotensive in house. Held metoprolol, lisinopril, lasix
on evening on admission in acute post-procedure setting.
Pressures remained stable throughout stay. Patient restarted on
home regimen prior to discharge.
.
# DM: Continued on home Metformin, Pioglitazone and Glucophage
with Insulin SC sliding scale for additional coverage. Finger
sticks controlled in house
OUTPATIENT ISSUE
- f/u pendng HbA1c
.
# DYSLIPIDEMIA. Continued on home Rosuvastatin
.
# GERD: Continued on home Omeprazole
.
Patient was full code during this admission
Medications on Admission:
- Amiodarone 200mg tab qpm
- Furosemide 20mg tab qam
- Lisinopril 10mg tab at bedtime
- Lorazepam 2mg tab qhs
- Metformin 1000mg tab [**Hospital1 **]
- Metoprolol succinate 25mg tab extended release tab qhs
- Omeprazole 20mg capsule delayed release EC [**Hospital1 **]
- Pioglitazone (Actos) 30mg po od
- Rosuvastatin (Crestor) 10mg tab qam
- Sildenafil (Viagra) - 50mg tab prn
- Warfarin 5mg tab 1-1.5 tab qhs as directed by PCP
OTC
[**Name Initial (PRE) **] Aspirin 81mg 2 tab qpm
Pre-procedural
- Coumadin 2.5mg on [**2143-4-9**]
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): Take 200mg three times a day x1 week; decrease to 200mg
twice daily .
Disp:*90 Tablet(s)* Refills:*0*
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO HS (at bedtime).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. rosuvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
9. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. warfarin 5 mg Tablet Sig: 1.5 Tablets PO 1X/WEEK ([**Doctor First Name **]): as
directed by PCP and coumadin clinic.
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO 6X/WEEK
(MO,TU,WE,TH,FR,SA).
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Atrial Fibrillation
Sinus Bradycardia
Complete heart block
.
Secondary:
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 37217**] it was a pleasure taking care of you.
.
You presented to [**Hospital1 18**] for elective pulmonary vein isolation for
treatment of your atrial fibrillation. Unfortunately the
procedure was terminated early when you developed what is known
as complete heart block, which indicates an electrical
dysychronization between atria and ventricles. You were
monitored closely in the CCU without event.
.
CHANGES TO YOUR MEDICATIONS:
INCREASE Amiodorane. Please take one 200mg tablet 3 times daily
for one week (total of 600 daily); after that decrease dosing to
twice daily (total of 400mg daily).
.
No other changes were made to your medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
Appointment: Friday [**4-19**] at 1PM
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within 1-2 weeks. You will be called at home with the
appointment. If you have not heard from the office by Wednesday
[**4-17**] or have any questions, please call the number above.
Completed by:[**2143-4-13**]
ICD9 Codes: 9971, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6797
} | Medical Text: Admission Date: [**2165-5-24**] Discharge Date: [**2165-5-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
84 yo M w/ PMH of CHF, afib, LGIB, gastric ulcer s/p clipping,
gallstone pancreatitis and cholecystitis p/w abd pain, elevated
amylase/lipase and GNR bacteremia for ERCP from OSH in NH. Pt.
was initially admitted in early [**Month (only) **] to the OSH with
abdominal pain and diagnosed with cholecystitis and gallstone
pancreatitis. He reportedly had an NSTEMI during this episode
and so was only treated with antibiotics as surgery was too
risky. He was also admitted in [**Month (only) **] w/ GIB and had gastric
ulcer clipped. Most recently, he was watching a red sox game on
[**5-21**] when he began having abdominal pain then nausea and
vomitting. He had some blood in his emesis but at OSH his Hct
remained stable and his vomiting resolved. His amylase and
lipase were elevated in the 1000 range and his LFTs and Tbili/AP
were elevated as well. He was tachycardic and moderately
hypotense to 96/67. He was planned for MRCP but this was not
done given recent ulcer clipping w/ metal clip and he was
transfered to [**Hospital1 18**] for ERCP and close monitoring from the ICU
at St. [**Hospital 11042**] Hospital in [**Location (un) 8117**], NH.
.
On presentation to the ICU, he continued to complain of
abdominal pain which he says was only improved with dilaudid but
returns to the same baseline pain in between doses. He was
immediately taken for ERCP where stone fragments with frank pus
were drained.
Past Medical History:
Atrial fibrillation off coumadin [**3-18**] GIB
CHF
AAA s/p remote repair
COPD emphysema on Home O2 2L
Bladder CA s/p surgery and BCG
PVD s/p fem-[**Doctor Last Name **]
Cholecystitis
Gallstone pancreatitis
CAD
Duodenal AVM s/p large bleed
Spinal stenosis
Prinzmetal angina
Sleep apnea
Urosepsis
Social History:
Lives at home w/ wife and oldest daughter. Quit smoking in [**2152**]
but had smoked 52yrs x 2.5PPD. Previous heavy ETOH, but only
occasional now.
Family History:
Father died of CAD at age 47
Mother had breast CA
Physical Exam:
VS - Temp 96.6F, BP 104/81, HR 117, R 20, O2-sat 94% 4l
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - sclerae anicteric, MM dry
NECK - JVD to Ear lobe
LUNGS - Decreased breath sounds diffusely. Crackles half way up
the back.
HEART - Irregular rhythm, II/VI systolic murmur
ABDOMEN - BS+, soft, moderately tender in LUQ and LLQ but not in
RUQ. Midline well healed laparotomy scar.
EXTREMITIES - DP and PT pulses not palpable, warm/WP, 1+ pedal
edema
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, appropriately conversant
Pertinent Results:
[**2165-5-24**] ERCP
Normal major papilla
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique
Contrast medium was injected resulting in complete opacification
of the biliary tree. There were few filling defects that
appeared like sludge at the lower third of the common bile duct.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire
Sludge, few small stone fragments, and purulent bile in small
amount were extracted successfully using a 8.5 mm balloon.
Successful placement of a 10Fr 9cm biliary stent.
Otherwise, the caliber and course of the the common bile duct,
common hepatic duct, right and left hepatic ducts, and
intrahepatic bile ducts were normal.
Normal limited pancreatogram
[**2165-5-24**] AP CXR:
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Lungs are clear, heart top normal size, and pulmonary
mediastinal vasculature engorged. Pleural effusion is minimal if
any. No pneumothorax.
[**2165-5-24**] 05:52PM GLUCOSE-72 UREA N-21* CREAT-1.3* SODIUM-139
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12
ALT(SGPT)-132* AST(SGOT)-81* LD(LDH)-163 ALK PHOS-247*
AMYLASE-447* TOT BILI-2.0* LIPASE-773* ALBUMIN-3.0*
CALCIUM-7.7* PHOSPHATE-3.0 MAGNESIUM-2.2 NEUTS-84.6*
LYMPHS-7.8* MONOS-2.5 EOS-5.0* BASOS-0.1PLT COUNT-226 PT-17.4*
PTT-37.2* INR(PT)-1.6*
Brief Hospital Course:
84 yo M w/ CHF, Afib not anticoagulated, known cholelithiasis,
presents from OSH with gallstone pancreatitis and pansensitive
E.coli bactermia for ERCP.
#. E.coli bacteremia: Patient remained hemodynamically stable
throughout hospital course with good urine output. Given history
of known CHF he was carefully given IV fluid support and his
home lasix dose was initially held. OSH cultures from blood grew
E.coli pan sensative and he was switched from Zosyn to
ciprofloxacin on hospital day #2. He will finish a 14-day course
(last day [**6-5**]). Surveillance blood cultures were negative as of
day of discharge. He will follow up with ERCP in 6 weeks for
stent removal. The recommendation of the ERCP team that he be
considered for early cholecystectomy was discussed with the PCP
by both the [**Hospital Unit Name 153**] team and hospitalist, and the PCP prefers to
hold off for now given his significant cardiovascular and
pulmonary comorbidities.
#Gallstone pancreatitis s/p ERCP: Pus drained from bile ducts
with sphincterotomy and stent placement. Patient improved
clinically and was advanced to regular diet without difficulty.
He will follow up with the ERCP team in 6 weeks for stent
removal.
#. Hx of GIB: Hct stable on admission but then began to trend
downward after recieving fluids, did not have any s/s of GIB and
his Hct eventually trended back towards the value at admission.
#. CHF/CAD: Appeared mildly volume overloaded on admission, but
given borderline BP in setting known bacteremia home lasix was
held and IVF given prn. As he recovered, spironolactone, then
lasix were resumed. Given brisk diuresis on home lasix and
increased dose of metoprolol, Lasix was decreased to 20mg daily
to allow blood pressure room. Continued on BB, imdur, statin,
not on aspirin at home [**3-18**] GI bleed; restarting coumadin as
below but would observe on this before adding ASA (can be done
as outpatient).
.
#. Afib: Afib: Presented from OSH in RVR. Controlled with one
dose of IV metoprolol 5mg. He was continued on PO metoprolol for
rate control and increased on hospital day #3 due to persistent
heart rate in the 130s, likely related to increased activity on
transfer to the medical floor (now walking independently, out of
bed). His metoprolol was titrated up to 75mg [**Hospital1 **] with good
effect. He remained asymptomatic throughout all tachycardic
episodes. His PCP has been holding coumadin given recent GI
bleed but had planned to restart this on [**5-27**], so he was started
on 2mg warfarin daily, to be followed by his PCP (discussed with
PCP)
Medications on Admission:
Home
ocuvite 2tabs daily
Omeprazole 20mg daily
isosorbide dinitrate 20mg [**Hospital1 **]
Simvastatin 40mg daily
doxazosin 2mg QHS
Metoprolol tartrate 25mg [**Hospital1 **]
Furosemide 40mg daily
spironolactone 25mg Daily
nitroquick 0.4mg PRN
.
On transfer
Pip/tazo 2.25g Q6hours day 1=[**5-23**]
Pantoprazole 40mg IV daily
ondansetron 4mg Q6 PRN
Hydromorphone 0.5-1mg Q4PRN
Metoprolol 2.5mg IV Q8hours
Metronidazole 500mg Q12 hours
Heparin SC Q12
Discharge Medications:
1. Outpatient Lab Work
INR check on [**2165-5-29**], please fax results to Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) **]
office (phone # [**Telephone/Fax (1) 82541**]) per standing order.
2. Ocuvite 1,000-60-2 unit-unit-mg Tablet Sig: Two (2) Tablet PO
once a day.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5min up to three times.
11. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 8117**] Home Health and Hospice
Discharge Diagnosis:
Primary: gallstone pancreatitis, atrial fibrillation
Secondary: coronary artery disease, chronic systolic heart
failure
Discharge Condition:
good, stable, ambulating independently
Discharge Instructions:
You were transferred for an ERCP for gallstone pancreatitis and
your abdominal pain improved. You should continue to take
antibiotics as directed. You had a very fast heart rate
afterwards that may have been partially due to the infection,
and your metoprolol dose was increased.
If you have lightheadedness, chest pain, shortness of breath,
episodes of loss of consciousness, fevers, chills, abdominal
pain, or any other concerning symptoms, call your doctor or seek
medical attention immediately.
Followup Instructions:
Dr.[**Name (NI) 2798**] office will call you to schedule a follow up ERCP
for stent removal in [**5-20**] weeks. If you do not hear from them,
you can call them at ([**Telephone/Fax (1) 10532**].
You should follow up with your primary care physician [**Name Initial (PRE) 176**] 1
week; call Dr.[**Name (NI) 82542**] office at [**Telephone/Fax (1) 82541**] to make an
appointment.
You should have your INR checked tomorrow. Have your labs drawn
as per your prior routine and Dr.[**Name (NI) 82542**] office will call you
with any changes to your coumadin dose.
ICD9 Codes: 7907, 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6798
} | Medical Text: Admission Date: [**2152-6-7**] Discharge Date: [**2152-6-23**]
Date of Birth: [**2077-8-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2152-6-7**] Cardiac Catheterization
[**2152-6-14**] Mitral Valve Repair(28mm Csgrove Annuloplasty Band) and
Four Vessel Coronary Artery Bypass Grafting(Left internal
mammary artery to left anterior descending, saphenous vein
grafts to diagonal, ramus, and posterior descending artery).
History of Present Illness:
This is a 74 year old male with a six month history of worsening
dyspnea on exertion. Several weeks prior to admission, he
admitted to rapid decrease in exercise capacity. For several
years, he had used two pillows for sleep. He has no history of
chest pain or PND. On [**6-6**], he presented to his
cardiologist with the above complaints. Office echocardiogram
showed an LVEF of 15-20%. He was subsequently admitted to [**Hospital 6451**] with congestive heart failure. BNP on admission was
1400. He was diuresed with IV Lasix with improvement in his
shortness of breath. He was stabilized on medical therapy and
transferred to the [**Hospital1 18**] for further evaluation and treatment.
Past Medical History:
Congestive Heart Failure, Hypertension, Hyperlipidemia, Type II
Diabetes Mellitus, Pulmonary Hypertension, Chronic Renal
Insufficiency, History of Atrial Fibrillation, GERD, History of
Urinary Sludge, Prior Tonsillectomy, Hidradenitis Suppurative
s/p Surgery
Social History:
15 pack year history of tobacco. Quit smoking over 25 years ago.
Admits to 3 ETOH drinks per month. Married, lives with spouse.
Family History:
Denies premature coronary disease.
Physical Exam:
PREOP EXAM - Vitals: 137/64, 79, 18, 95% RA
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, soft systolic
murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2152-6-7**] 10:20AM BLOOD WBC-6.8 RBC-3.99* Hgb-12.5* Hct-36.9*
MCV-93 MCH-31.5 MCHC-34.0 RDW-14.6 Plt Ct-264
[**2152-6-7**] 10:20AM BLOOD PT-13.9* PTT-28.4 INR(PT)-1.2*
[**2152-6-7**] 10:20AM BLOOD Glucose-147* UreaN-20 Creat-1.3* Na-140
K-3.6 Cl-105 HCO3-23 AnGap-16
[**2152-6-7**] 10:20AM BLOOD ALT-18 AST-19 AlkPhos-84 TotBili-0.9
[**2152-6-7**] 10:20AM BLOOD Albumin-4.3 Cholest-133
[**2152-6-7**] 10:20AM BLOOD %HbA1c-6.2*
[**2152-6-7**] 10:20AM BLOOD Triglyc-115 HDL-31 CHOL/HD-4.3 LDLcalc-79
[**2152-6-7**] Cardiac Catheterization
1. Coronary angiography in this right-dominant system revealed
three-vessel disease:
--the LMCA had no angiographically apparent disease.
--the LAD had diffuse 80% stenosis in its mid-portion. D1 was a
very
large vessel wrapping around the lateral wall, with an ostial
80%
stenosis.
--the LCX had an 80% proximal stenosis
--the RCA was occluded in its mid-portion and fills by
right-to-right
and left-to-right collaterals.
2. Resting hemodynamics revealed elevated right- and left-sided
filling
pressures with RVEDP 10 mmHg and LVEDP 26 mmHg. There was
moderate
pulmonary arterial hypertension with PASP 59 mmHg. The cardiac
output
was low-normal with CI 2.1 L/min/m2. The PCWP was elevated at
26 mmHg.
There was mild systemic arterial systolic hypertension with SBP
145
mmHg. There was no gradient across the aortic valve upon
pullback of
the angled pigtail catheter from LV to ascending aorta.
[**2152-6-8**] Carotid Ultrasound: Bilateral less than 40% carotid
stenosis.
[**2152-6-8**] Echocardiogram: Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe regional left ventricular systolic dysfunction with
near-akinesis of the inferior/inferolateral walls. There is
moderate-to-severe hypokinesis of the remaining segments (LVEF =
20%). No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted under cardiology and [**Known lastname 1834**] cardiac
catheterization which revealed severe three vessel coronary
artery disease with moderate to severe pulmonary
hypertension(see result section). Cardiac surgery was consulted
and further evaluation was performed. Carotid ultrasound found
no significant disease of the internal carotid arteries. Repeat
echocardiogram was notable for an LVEF of 20% with mild mitral
regurgitation(see result section). Post catheterization, he had
a slight decline in renal function and his ACE inhibitor was
discontinued. His preoperative creatinine peaked to 1.7.
Creatinine just prior to surgery was 1.5. Preoperative course
was also notable for bouts of paroxysmal atrial
fibrillation/flutter for which he was maintained on intravenous
Heparin.
On [**6-14**], Mr. [**Known lastname **] [**Last Name (Titles) 1834**] coronary artery bypass
grafting and a mitral valve repair by Dr. [**Last Name (STitle) **]. For surgical
details, please see separate dictated operative note. Following
the operation, he was brought to the CVICU for invasive
monitoring. On postoperative day one, sedation was weaned and he
was extubated. However, due to severe agitation and confusion
associated with atrial fibrillation and low mixed venous
saturations, he was electively reintubated. While intubated and
sedated, cardioversion was performed but unsuccessful. He was
also given several units of PRBCs. On postoperative day three,
he self-extubated. He did not required reintubation but was
initially maintained on 100% shovel mask. Despite medical
therapy and multiple cardioversions, he continued to experience
atrial fibrillation. Given atrial fibrillation, he was
eventually started on Amiodarone and Warfarin. He temporarily
required a Heparin bridge. Postoperative renal function remained
relatively stable. His confusion and agitation gradually
improved with use of haldol. On [**2152-6-20**], Mr. [**Known lastname **] was
transferred to the step down unit for further recovery. He
continued to be gently diuresed towards his preoperative weight.
The physical therapy service worked with him daily to increase
his strength and mobility. Keflex was started for mild
incisional erythema. An ace inhibitor was started given his low
preoperative ejection fraction. Mr. [**Known lastname **] continued to make
steady progress and was discharged to Baypoint of [**Hospital1 1474**]. Dr. [**Name (NI) 38327**] coumadin clinic will assume management of his coumadin
dosing after discharge from rehabilitation. His goal INR is
2.0-2.5. He will also follow-up with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (un) **]. Amiodarone will be tapered to 200mg once daily.
Medications on Admission:
Aspirin 325 qd, Zestril 20 qd, Toprol XL 50 qd, Lasix, KCL,
Nexium 40 qd, Plavix Load of 600mg
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days.
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Warfarin 1 mg Tablet Sig: Adjust for goal INR 2.0-2.5 Tablets
PO DAILY (Daily): Adjust dose for goal INR of 2.0-2.5.
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day for 10 days:
Take with lasix and stop when/if lasix stopped.
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take amiodarone 400mg twice daily for 2 more days.
Starting [**2152-6-26**], take 400mg once daily for 7 days and then
decrease to 200mg once daily therafter until seen by Dr.
[**Last Name (STitle) 7047**]. .
13. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for constipation.
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
Primary: Coronary Artery Disease, Mitral Regurgitation, Acute on
Chronic Systolic Heart Failure - s/p CABG and MV Repair
Secondary: Postoperative Atrial Fibrillation, Postoperative
Agitation, Hypertension, Hyperlipidemia, Type II Diabetes
Mellitus, Pulmonary Hypertension, Chronic Renal Insufficiency
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) You are taking coumadin (a blood thinner) for atrial
fibrillation. You goal INR is 2.0-2.5. You coumadin dosing will
be managed by Dr. [**Last Name (STitle) 7047**] and you will need an appointment for
blood draw (PT/INR) when discharged from rhab for coumadin
management. [**Telephone/Fax (1) 8725**]
8) Take amiodarone 400mg twice daily for 2 more days. Starting
[**2152-6-26**], take 400mg once daily for 7 days and then (Starting
[**7-3**])decrease to 200mg once daily therafter until seen by Dr.
[**Last Name (STitle) 7047**].
9) Take lasix and potassium once daily for 10 days. Monitor
electrolytes and replete as needed. Monitor daily weights. Preop
weight 150lbs. You may need continued treatment with lasix but
will be determined per cardiologist or rehab physician.
10) Take Keflex for 5 days for sternal wound erythema.
11) Monitor renal function (BUN/CREAT)given history of chronic
renal insufficieny and currently on Ace and lasix. Preop Creat
1.3. [**6-23**] Creat 1.4.
12) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**5-13**] weeks, call [**Telephone/Fax (1) 170**] for appt
Dr. [**Last Name (STitle) 7047**] in [**3-12**] weeks, call [**Telephone/Fax (1) 8725**] for appt
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 15369**] in [**3-12**] weeks, call [**Telephone/Fax (1) 6699**] for appt
****Coumadin management with Dr. [**Last Name (STitle) 7047**] via his coumadin
clinic. They are aware of patient (contact[**Name (NI) **] [**2152-6-23**]). Please
contact his office when discharged from rehab to schedule PT/INR
draw and appointment for coumadin management.****
Completed by:[**2152-6-23**]
ICD9 Codes: 4240, 2930, 4271, 5849, 4280, 4168, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 6799
} | Medical Text: Admission Date: [**2110-1-13**] Discharge Date: [**2110-1-24**]
Date of Birth: [**2056-3-11**] Sex: F
Service: OME
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 63364**] is a 53-year-old
female with history of stage IIIA and IB melanoma with new
retroperitoneal, pelvic and inguinal lymphadenopathy. She
underwent excisional biopsy of a 2.1-mm thick melanoma from
her right ankle in the spring of [**2105**]. She underwent wide
local excision, skin flap and right inguinal sentinel lymph
node biopsy without residual melanoma at the primary site.
Two sentinel lymph nodes showed evidence of microscopic
involvement with melanoma. Her postoperative course was
complicated by failure of the flap to take. Dr. [**Last Name (STitle) **]
performed a right superficial inguinal femoral
lymphadenectomy with right sartorius rotation flap on [**2106-7-16**] with pathology showing microscopic melanoma in [**12-22**]
residual lymph nodes. She began adjuvant interferon in
[**2106-10-12**], undergoing 2 dose reductions due to peripheral
neuropathy and persistent back pain. She completed 39 weeks
of interferon. She underwent skin biopsy of a left posterior
thigh lesion in [**2107-1-12**] revealing a 0.62-mm thick
superficial spreading melanoma, [**Doctor Last Name 10834**] level IV without
ulceration for which she underwent re-excision on [**2107-2-2**] without residual melanoma noted. She developed
worsening right lower extremity edema in late [**2109-10-12**]
with abdominal pelvic CT revealing retroperitoneal and pelvic
lymphadenopathy. She underwent CT-guided biopsy of a pelvic
node revealing metastatic melanoma. She was screened for high-
dose IL-2 therapy and underwent prescreening testing. She now
is admitted to begin cycle 1 week on high-dose IL-2 therapy.
PAST MEDICAL HISTORY: Cervical dysplasia treated with
colonoscopy, cervical neck disk disease treated with surgery,
lumbar spine disk herniation, a history of depression.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives with significant other, smokes,
currently on disability, no EtOH.
MEDICATIONS ON ADMISSION: Wellbutrin SR 200 mg daily,
Klonopin 0.5 mg at bedtime, 0.25 mg t.i.d. p.r.n., Premarin
0.625 mg cream, Lexapro 20 mg daily, Nexium 40 mg p.o. daily,
lorazepam 1 mg t.i.d. p.r.n., Percocet 1-2 tablets every 4
hours p.r.n. pain, calcium 500 mg daily, multivitamin 1
tablet daily.
PHYSICAL EXAMINATION: GENERAL: Well-appearing female in no
acute distress. Vital signs: Stable. HEENT: Clear. Heart:
Regular rate and rhythm. Chest: Clear bilaterally. Abdomen:
Palpable lower abdominal masses. Extremities: 3+ right lower
extremity edema.
LABS ON ADMISSION: WBC 11.2, hemoglobin 10.9, hematocrit
31.6, platelet count 496,000, BUN 17, creatinine 0.8, sodium
137, potassium 3.9, chloride 99, CO2 30, glucose 86 INR 1.1,
ALT 10, AST 16, albumin 3.8.
HOSPITAL COURSE: Ms. [**Known lastname 63364**] was admitted and underwent
central line placement to begin therapy. Her admission weight
was 68 kg and she received interleukin II 600,000
international units per kilo equaling 40.8 million units IV
every 8 hours times 14 potential doses. During this week she
received [**11-24**] doses with 2 doses held related to shortness
of breath on treatment day #5. She stabilized on treatment
day #6 but that evening developed increasing shortness of
breath associated with hypoxia requiring 100% non-rebreather
with O2 sats in the mid 90s consistent with acute pulmonary
edema. Chest x-ray was consistent with that and she was
treated with Lasix with good urine output. That night on
treatment day #7 she desatted to 80% on a non-rebreather and
was transferred to the ICU where continued diuresis was
carried out. ____________ edema. She was tried on CPAP which
she did not tolerate well and was placed back on 100% non-
rebreather. She did not require intubation. She slowly
improved with diuresis and was transferred back to 7 [**Hospital Ward Name 1950**]
on [**1-22**] where she continued to improve with eventual
discharge on [**2110-1-24**].
Other side effects during IL-2 therapy included rigors
improved with Demerol; development of an erythematous
pruritic skin rash; mild nausea improved with antiemetic
therapy; and diarrhea improved with Lomotil therapy. During
this week she had no acute renal failure noted. She developed
transaminitis with a peak ALT of 87 and peak AST of 99, both
improved at the time of discharge. She developed
hyperbilirubinemia with peak bilirubin of 4 improved to 1 at
the time of discharge. She was anemic without need for packed
red blood cell transfusion. She developed thrombocytopenia
with a platelet count low of 11,000, improved to 111,000 at
the time of discharge. She had no coagulopathy or myocarditis
noted. By [**2110-1-24**] she had recovered from side
effects to allow for discharge to home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with her significant other.
DISCHARGE DIAGNOSES: Metastatic melanoma status post cycle 1
week on high-dose IL-2 therapy complicated by acute pulmonary
edema.
DISCHARGE MEDICATIONS: Wellbutrin 200 mg p.o. daily, Nexium
40 mg p.o. daily, Lexapro 20 mg p.o. daily, Percocet 1-2
tablets every 4 hours p.r.n. pain, Ativan 1 mg every 6 hours
p.r.n. anxiety. Outpatient physical therapy.
FOLLOW-UP PLANS: Ms. [**Known lastname 63364**] will recover from her
complicated first week of high-dose IL-2 therapy. Week 2 of
therapy will not be administered at this time but we will
plan to follow up with CT scans at week 7 to assess disease
response to determine whether treatment again would be
warranted.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 19077**]
Dictated By:[**Last Name (NamePattern1) 18853**]
MEDQUIST36
D: [**2110-4-4**] 11:12:09
T: [**2110-4-4**] 14:08:25
Job#: [**Job Number 63365**]
cc:[**Location (un) 63366**]
ICD9 Codes: 2768 |
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