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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6800 }	Medical Text: Admission Date: [2135-5-27] Discharge Date: [2135-5-31] Date of Birth: [2074-1-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1943] Chief Complaint: Alcohol withdrawal and possible withdrawal seizure Major Surgical or Invasive Procedure: None History of Present Illness: 61 year-old gentleman with history of alcohol abuse, complicated by alcohol withdrawal with delirium tremens and seizures, presenting from home after a witnessed seizure yesterday and feeling very sick wanting to quit drinking. He was in his prior state of health and was discharged from [Hospital1 18] on [2135-2-27] after being admitted for alcohol withdrawal. He was sober until 2 weeks ago when he started drinking a case of beer daily until 2-3 days ago when he started to feel bad. He noted that his baseline palpitations became much more frequent, he had watery diarrhea 4-5 times per day without any blood, nausea, vomit and body pain. He thought it was secondarely to drinking heavily for 2 weeks, so started to cut back down during the last two days to 4-5 beers per day, but he was not able to keep them down. He denies any fever, chills, rigors, cough, shortness of breath, chest pain, leg swelling. Yesterday morning he was requesting help to a AA friend, when his friend witnessed how he started to have generalized tonic-clonic seizures and stopped spontaneously. Therefore, he came to the emergency room. His last drink was 1-2 days ago. In the ER patient his initial VS were Pain [5-7], T 99.8 F, HR 102 BPM, BP, 161/82 mmHg, RR 22 BPM, SpO2 98% on RA. he was reported in NAD, CTAB, not guaiac, diffuse abdominal pain, positive bowel sounds, tremors, A&O X3. ECG was unchanged from prior. Pt labs showed no WBC, HCT at baseline at 38, PLT of 141, sodium of 126, bicarbonate of 19, glucose 110 with AG of 23, negative CE, AST 533, ALT 427, Lip 78, TB, 1.7, alb 4.5, OH level of 99 and otherwise negative Utox. UA was not done. Patient required 5 mg of IV valium at [2040], [2125], 2230 and 2300 for a total of 20 mg IV. Pt receive 8 mg of IV zofran. He was admited to the medical floor. In the medicine floor his CIWA was betwen 29-36 and received 10 mg of IV valium at 1:00 and 1:50 (total 20 mg) without any response. he received zofran for nausea without any effect. he was considered high risk of seizures with auditory, tactile and visula disturbances. He was placed on NS @ 100 cc/hr. It was considered he was high risk and with high nursing requirements, so he was transfered to the ICU. his VS prior to transfer: BP 129/77 mmHg, HR 98 BPM, RR 18 X', SpO2 97% RA Past Medical History: Alcohol Abuse - Has had multiple admissions for alcohol withdrawal, per records - c/b seizures, DT's - Recurrent patter after short periods of sobriety. Hepatitis C - followed at [Hospital6 ] Depression Scoliosis Social History: Alcohol abuse as above. 40 pack year smoking history, quit 2 years ago. Denies a history of IV drug use. Has one tattoo from age 16 done at home. No blood transfusions. Family History: Father with alcoholism Physical Exam: EXAM ON ADMISSION: VITAL SIGNS - 97.2, 75, 108/57, 22, 97% on RA GENERAL - NAD HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - slight bibasliray crackles, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - mild tremors, WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [6-1] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait 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: [2135-5-27] 07:00PM BLOOD WBC-8.4 RBC-4.22* Hgb-13.4* Hct-38.8* MCV-92 MCH-31.9 MCHC-34.6 RDW-14.1 Plt Ct-141* [2135-5-27] 07:00PM BLOOD Neuts-77.8* Lymphs-16.3* Monos-4.6 Eos-0.8 Baso-0.5 [2135-5-27] 07:00PM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-126* K-4.0 Cl-84* HCO3-19* AnGap-27* [2135-5-27] 07:00PM BLOOD ALT-427* AST-533* CK(CPK)-524* AlkPhos-83 TotBili-1.7* [2135-5-27] 07:00PM BLOOD Lipase-78* [2135-5-27] 07:00PM BLOOD CK-MB-11* MB Indx-2.1 cTropnT-<0.01 [2135-5-27] 07:00PM BLOOD Albumin-4.5 Calcium-8.6 Phos-2.2* Mg-2.3 [2135-5-29] 03:56AM BLOOD calTIBC-211* Ferritn-1662* TRF-162* [2135-5-27] 07:00PM BLOOD ASA-NEG Ethanol-99* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ====================== DISCHARGE LABS: [2135-5-31] 05:55AM BLOOD WBC-5.5 RBC-3.94* Hgb-12.0* Hct-36.4* MCV-92 MCH-30.5 MCHC-33.0 RDW-13.7 Plt Ct-202 [2135-5-31] 05:55AM BLOOD Glucose-103* UreaN-4* Creat-0.7 Na-137 K-3.8 Cl-100 HCO3-25 AnGap-16 [2135-5-30] 05:30AM BLOOD ALT-206* AST-180* [2135-5-31] 05:55AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0 ======================= ECG ([5-27]): Sinus rhythm. Short P-R intervals. Left ventricular hypertrophy. Non-diagnostic small Q waves in inferior leads. Modest septal T wave changes that are non-specific. Compared to the previous tracing of [2134-9-20] there is no significant diagnostic change. Brief Hospital Course: # Alcohol withdrawal: Pt with long history of ETOH abuse who reported visual hallucinations and h/o seizures. He was transferred to the MICU due to high risk of DTs. Pt was monitored in the MICU and was requiring Valium q1-2hrs. He was treated with banana bag. He was then called out to the floor when valium was changed to PO and his CIWA scale decreased to q4h. He was sincerely interested in stop drinking, and wanted to get help. He was seen by SW, who was going to provide outpatient treatment referrals. He decided to leave AMA at 6:22am on [2135-5-31], before everything was set up for him. By the time the night float intern arrived on the floor, he was already in the elevator, and couldn't be persuaded to stay. # Alcoholic hepatitis: Pt with elevated AST and ALT with a ratio of 1.2. Bilirubin is slightly elevated to 1.7 with normal alk phos. LFTs were trending down during this hospital stay. # Hyponatremia - Pt with hypovolemic hyponatremia, which was likely secondary to alcohol binge and dehydration. This resolved with IVF and nutrition. # Anion gap metabolic acidosis - Pt presented with a gap of 23 and a bicarbonate of 19. There was likely an additional component of alkalosis from vomiting. The gap closed with IVF. Medications on Admission: None Discharge Medications: None since patient left AMA without being seen by MD Discharge Disposition: Home with Service Discharge Diagnosis: PRIMARY DIAGNOSES: - Alcohol withdrawal - Alcohol abuse SECONDARY DIAGNOSES: - Alcohol withdrawal seizures and delirium tremens - Hepatitis C - followed at [Hospital6 ] - Depression - Scoliosis Discharge Condition: Alcohol Withdrawal: Minimal anxiety and tremulousness. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [This instruction was prepared ahead of time, but patient did not receive this prior to leaving AMA] You were admitted to [Hospital1 69] because of alcohol withdrawal. Your withdrawal symptoms resolved at the time of discharge. Your liver took a hit from the alcohol, but your liver enzymes were getting better during this hospital stay. You should stop drinking alcohol. Your liver could be permanently damaged if you continue to drink, and you could die from the complications from alcohol. Your medications have been changed: - please take thiamine, folate and multivitamin - you can take imodium as needed for diarrhea Followup Instructions: Please follow up with your primary care doctor, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], within two weeks after discharge. Please call [0-0-] to make an appointment. ICD9 Codes: 2761, 2762, 311, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6801 }	Medical Text: Admission Date: [2124-6-29] Discharge Date: [2124-7-1] Date of Birth: [2064-3-13] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide / Demerol / Ambien Attending:[First Name3 (LF) 1436] Chief Complaint: CC: SOB Major Surgical or Invasive Procedure: Intubation History of Present Illness: . 58 M with CAD s/p CABG, CHF EF 20%, s/p BiV/ICD, OSA, DM2, htn presents with SOB. The pt developed a relatively sudden onset of SOB while sleeping. The family called EMS(arrived 0400 on [6-29]) who found the pt acutely SOB, using accessory muscles, vitals were p 100 bp 220/110 rr 24 83% RA. He was given [Month/Year (2) ] 100 IV and ntg SL x3. Of note, the pt denies any chest pain, no fevers, chills or coughing. On arrival to OSH, remained SOB with sats in 80s on NRB and was intubated nasotracheally since he was a difficult intubation. bp was better controlled to 150/90, he was breifly on nitro gtt which was stopped when he was becoming hypotensive. The pt was then transferred to [Hospital1 18] for further management. . Allergies: demerol, hctz, ambien, aldactone, strawberries. . ECG: regular paced rhythm at 64, QT wnl, no over signs of ischemia . CXR at [Hospital1 18]: 1. Satisfactory endotracheal tube position. 2. Mild cardiac decompensation with small bilateral pleural effusions, but no pulmonary edema. . Past Medical History: PMHx: 1. CAD, s/p recent CABG as above; TTE [3-5] showing dilated LA/LAV, 1+ MR, EF=20-30%, with BiV pacer for ventricular arrhythmias 2. Prostatitis 3. Melanoma s/p excisions 4. DM x 2 years 5. Recurrent PNA 6. GERD 7. gout 8. Sleep apnea 9. s/p hemorrhoidectomy 10. bilateral Iliac artery anneurysm s/p repair 11. Hypertensive cardiomyopathy 12. Hypercholesterolemia 13. Cervical radiculopathy Echo [2123-4-13]: LV EF severely depressed, severely dilated, global HK TR gradient 31, mild RV free wall HK 1+MR, Tr AR . Stress [2123-6-9]: no anginal sx with uninterpretable ECG . Cath [2123-4-12]: 1. Three vessel coronary artery disease. 2. Patent LIMA to LAD. 3. Three patent vein grafts. 4. Marked elevation of right and left heart filling pressures and moderate pulmonary hypertension. Social History: Ex-smoker, with 40 pack-year smoking history. He quit in [2106]. He lives with his wife. [Name (NI) ] history of EtOH consumption. Family History: Father with MI in 50s Physical Exam: p62 bp 144/72 18 96% on CPAP 50% Gen: nasotracheally intubated, though awakem alert, in no resp distress on PSV HEENT: PERRL, OP clear Lungs: crackes at bases, mostly clear CV: RRR, nl s1/s2, no m/r/g Abd: soft, nt/nd, nabs, no masses Extr: trace edema, DP 2+ bilat Pertinent Results: [2124-6-29] WBC-9.7# RBC-5.47# Hgb-14.5# Hct-44.6# Plt Ct-189 [2124-6-29] PT-11.9 PTT-21.2* INR(PT)-1.0 [2124-6-29] Glucose-186* UreaN-30* Creat-2.1* Na-143 K-5.4* Cl-105 HCO3-25 AnGap-18 [2124-6-29] Type-[Last Name (un) ] Rates-/18 PEEP-10 FiO2-50 pO2-70* pCO2-55* pH-7.29* calTCO2-28 Base XS-0 Intubat-INTUBATED Brief Hospital Course: Mr. [Known lastname ] is a 58yo M well known to Dr. [Last Name (STitle) ], with CAD s/p CABG, CHF EF 20%, s/p BiV/ICD, OSA, DM2, obesity and htn presents with acute SOB requiring intubation s/s flash pulmonary edema after missing his [Last Name (STitle) ] dose x 2 days, with subsequent extubation 2 hours later and 2 days of aggressive diuresis. . 1 Resp Distress: Given the history of CHF, acute decomensation of CHF with flash pulmonary edema was the likely etiology. The patient can have sudden onset respiratory decompensation s/s to both high salt meals and/or anxiety and in this case missed his [Last Name (STitle) ] dose for 2 days prior to onset of symptoms. Patient was extubated soon after intubation and with diuresis, had an accelerated resolution of his symptoms. . 2. Cardiac a. pump: on admission, patient was volume overloaded but is now better maintained after diuresis. Patient should be continued on coreg, lisinopril, aldactone, digoxin on pre-admission [Last Name (STitle) 4319] and should not miss [First Name (Titles) ] [Last Name (Titles) 4319]. . b. coronaries: no evidence of active ischemia, though the patient has a history of CAD s/p CABG. mild troponin leak to 0.06 at peak in setting of CHF likely represented demand ischemia. There were no dynamic ECG changes. . c. Rhythm: Mr. [Known lastname ] is s/p BiV/ICD, with stable rhythm. Appears AS-VP on ECG. Continue Amiodorone at pre-admission [Known lastname 4319]. . 3. Dm2: Was maintained on lantus 20 [Hospital1 ] during admission as sugars have been in the 150-200 range. His home dose is 70 [Hospital1 ] and he should return to this regimen upon discharge. . 4. CRI: Mr. [Known lastname ] baseline Creatinine was 1.2-1.5 in [4-5]. He should have his creatinine followed by his PCP and should avoid nephrotoxic medications. . 5. Gout: Allopurinol and colchicine were held during this admission will being diuresed to avoid nephrotoxic medications. Can be restarted on discharge. . Medications on Admission: Coreg 12.5 mg b.i.d. Digoxin 0.125 mg q.o.d., [Month/Day (1) 11573] 40 mg qd Lisinopril 20 mg qd Zetia 10 mg qd Lantus 70U [Hospital1 ] Lipitor 80 mg qd Lexapro 20 mg qd, Folic Acid qd Amiodarone 200 mg qd Protonix 40 mg qd ASA 81 mg qd [Doctor First Name ] 180 mg qd Klonopin 0.5 mg up to b.i.d. Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO QDAY (). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Congestive Heart Failure Discharge Condition: Stable vital signs, afebrile, ambulating. Discharge Instructions: Please note that none of your medications have been changed during this admission. Please return to the hospital if you become short of breath, experience chest pain or severe headache. Please make sure to take all of your medications, including your diuretic, [Doctor First Name 11573]. Please contact your primary care physician if your weight goes up by 3 pounds, or if you notice your legs becoming swollen. Please note that one of your lab values, the Creatinine, which is a measure of your kidney function, was slightly elevated on this admission. Please have your primary care physician recheck this value within 1-2 weeks of discharge from the hospital. Followup Instructions: Please follow up with your cardiologist, Dr. [Last Name (STitle) ], within 1 week of discharge. Please follow up with your primary care physician [Name Initial (PRE) 176] [1-3] weeks of discharge. ICD9 Codes: 4280, 5859, 412, 2749, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6802 }	Medical Text: Admission Date: [2173-9-27] Discharge Date: [2173-10-1] Date of Birth: [2141-5-29] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: S/P MVA Intubated Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname ] was an unrestrained driver in a rollover accident in Pepperall. His GCS was initially 15 then he decompensated at the scene requiring intubation. He was initially sent to St. [Hospital 11042] Hospital in [Location (un) 8117], N.H. then transferred to [Hospital1 43650] for further evaluation and management. He has a C2 fracture, multiple facial fractures and lacerations. Past Medical History: 1. Hepatitis C 2. polysubstance abuse Social History: Single, unemployed + Tobacco + recent heroine use + ETOH Family History: non contributory Physical Exam: Temp 98.9 HR 71 BP 129/71 intubated with spontaneous respirations HEENT Face: ecchymosis and edema around left eye. 2cm lac on left upper eyelid. Swelling on left side of face. Full thickness laceration through left lateral commisure of mouth. Eyes: hyphema on left, pupil dilated, minimally reactive; on right pupil pinpoint and reactive. Negative swinging light test. No [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] pupil. Per ophthalmology exam, no gross nerve entrapment, globe intact, no afferent defect, eye pressure of 45, and hyphema noted. Neck Cervicle collar in place Chest clear with equal breath sounds, no deformities, no crepitus COR RRR Abd Soft, not distended, nl rectal tone, no blood Ext warm, hematoma left ankle, track marks right arm Pertinent Results: [2173-9-27] 12:45PM PT-14.7* PTT-27.5 INR(PT)-1.3* [2173-9-27] 12:45PM PLT COUNT-463* [2173-9-27] 12:45PM WBC-25.6* RBC-4.84 HGB-13.4* HCT-40.4 MCV-83 MCH-27.7 MCHC-33.2 RDW-13.3 [2173-9-27] 12:45PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [2173-9-27] 12:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2173-9-27] 12:45PM LIPASE-24 [2173-9-27] 12:45PM UREA N-11 CREAT-0.9 [2173-9-27] 12:51PM GLUCOSE-151* LACTATE-1.1 NA+-141 K+-3.4* CL--101 TCO2-24 [2173-9-27] C Spine : Type 2 dens fracture without significant displacement. Right C2 transverse process fracture involving the neural foramen. CTA was recommended by Radiology to exclude vertebral artery injury but was thought unlikely to lead to any therapeutic options acutely by the Trauma Team. Left C7 transverse process fracture. [2173-9-27] Head CT : No acute intracranial hemorrhage. Extensive left facial bone fractures which are detailed on the CT facial bones performed subsequently. [2173-9-27] CT Sinus and Mandibles : Multiple left-sided facial bone fractures as detailed above. Crush injury to the left maxillary sinus involves every wall with involvement of the left nasal bone, and nasal septum. [2173-9-27] CT Torso : 1. Tree-in-[Male First Name (un) 239] nodularity in the superior segment of the right lower lobe with pooling of secretions in the lower trachea, concerning for aspiration. Would recommend NG tube to prevent further aspiration. 2. No acute sequelae of trauma. [2173-9-27] Left ankle : No fracture Brief Hospital Course: Mr. [Known lastname ] was admitted to the Trauma ICU, intubated, lightly sedated and his neck was stabilized with a [Location (un) 2848] J collar. His superficial facial lacerations were sutured with absorbable material. His sedation was gradually weaned off and he was able to move all extremities and follow commands. He was easily extubated 24 hours after admission. He was seen by the Opthomology service on multiple occasions. His orbit was intact and there was no entrapment but his intraocular pressure was elevated and he was placed on multiple eye drops. Following transfer to the Trauma floor he was up and ambulating without difficulty, his pain was controlled with Dilaudid and a Clonidine patch and he was able to tolerate a regular diet. His [Location (un) 2848] J collar was in place at all times. Mr. [Initials (NamePattern4) 10867] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ] fractures are non operative and he will require every other week Xrays and physical exams in the [Hospital 28823] Clinic. The Plastic surgery service will repair his orbital fracture next week as [Last Name (un) 84509] as his C spine is stable. he will continue his eye drops and will follow up in 1 week with the Opthomologist. He was discharged on [2173-10-1] with multiple instructions for follow up and he seemed to understand the necessity of keeping up with his eye drops, immobilzing his neck and following up with his appointments. Medications on Admission: none prescribed Discharge Medications: 1. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). Disp:1 bottle Refills:2 2. Atropine 1 % Drops Sig: One (1) Drop Ophthalmic once a day. Disp:1 bottle Refills:2 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). Disp:5 Patch Weekly(s) Refills:2 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). Disp:1 bottle Refills:2 5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). Disp:1 bottle Refills:2 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: S/P MVA with 1.type 2 dens fracture 2. right C2 transverse foramen fracture 3 left C7 transverse foramen fracture 4. left orbital wall fracture 5. left maxillary sinus fracture 6. nasal bone, nasal septum fracture 7. Hepatitis C Discharge Condition: stable Discharge Instructions: * Wear hard cervicle collar for 8-12 weeks. * Continue eye drops ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Call the Opthomology Department at [Telephone/Fax (1) 253] for an appointment [2173-10-5] Call Plastic Surgery Clinic on Tuesday [2173-10-5] at [Telephone/Fax (1) 5343] for a follow up appointment to determine when your surgery will be. Call Dr. [Last Name (STitle) ] for a follow up appointment in 2 weeks at [Telephone/Fax (1) 6429] Call Ortho-spine at [Telephone/Fax (1) 3573] for a follow up appointment in 2 weeks with CT of C spine Completed by:[2173-10-1] ICD9 Codes: 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6803 }	Medical Text: Admission Date: [2125-5-21] Discharge Date: [2125-5-25] Date of Birth: [2069-9-26] Sex: F Service: [Last Name (un) ] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 974] Chief Complaint: fall Major Surgical or Invasive Procedure: 1)endotracheal intubation 2)repair of head laceration with sutures History of Present Illness: 55y/o WF s/p fall while intoxicated. Taken to [Hospital3 3583]. GCS of 15. Tranfered to [Hospital1 18] after head CT revealed a subdural hematoma. AT [Hospital1 18] where GCS found to be 10, however pt was given ativan in route to control agitation. Pt was intubated and sent to the ICU for neurochecks, moitoring, and further workup. Past Medical History: 1)HTN 2)prior subdural hematoma Social History: occasional ETOH, denied IVDA, smoking Family History: unremarkable Physical Exam: Vitals: Tm 100.4 144/76 84 24 99% RA General: A+Ox3, NAD HEENT: PERRLA, CN2-12 intact, 5cm stellate head laceration repaired, surtures removed and covered with steristrips, oral MMM CV: RRR no M/R/G nl S1 S2, no JVD Pulm: CTABL, equal BS BL Ab: s/nt/nd/nm/nhsm +BS Ext: 2+radial/DPP BL, [Last Name (un) 17610] Pertinent Results: [2125-5-21] 08:08PM TYPE-ART PO2-130* PCO2-33* PH-7.42 TOTAL CO2-22 BASE XS--1 [2125-5-21] 10:45AM CALCIUM-7.1* PHOSPHATE-2.2* MAGNESIUM-1.3* [2125-5-21] 10:45AM WBC-13.9* RBC-3.00* HGB-10.1* HCT-27.7* MCV-92 MCH-33.6* MCHC-36.4* RDW-12.7 [2125-5-21] 04:30AM AMYLASE-37 [2125-5-21] 04:30AM ASA-NEG ETHANOL-194* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2125-5-21] 04:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: In the ICU pt's head laceration was repaired successfuly. While intubated in the ICU pt vomited. She was extubated, sent to the floors where she was febrile and found to have an aspiration pneumonia. This was treated with clindamycin and levoflox. Pt's cervical spine was cleared and her collar was taken off. Patient did well on the floors and was discharged in good condition. Medications on Admission: prozac HCTZ Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 3 days. Disp:9 Capsule(s) Refills:0 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:8 Tablet(s) Refills:0 3. Clindamycin HCl 150 mg Capsule Sig: Four (4) Capsule PO Q8H (every 8 hours) for 8 days. Disp:96 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1)Fall 2)chronic left subdural hematoma 3)acute right subdural hematoma 4)head laceration 5)aspiration pneumonia Discharge Condition: Good Discharge Instructions: 1) [Name8 (MD) ] MD [First Name (Titles) ] [Last Name (Titles) 9140] symptoms, headache, change in vision, dizziness, fever, chills, rash, difficulty breathing, diarrhea or any concerning symptoms. 2)Activity as tolerated, but no heavy lifting <10lbs until seen by neurosurgery. 3)You have aspiration pneumonia. Continue to take antibiotics for 9 days after discharge. 4)Continue to take phenytoin for seizure prophylaxis for 3 more days. 5)Bath as normal and let steristrips fall off on their own. 6)Keep repaired head laceration clean. Avoid direct sunlight to scar when possible and apply sunblock when sun exposed. You may also apply vitamin E to scar once a day to help with healing. Followup Instructions: 1) Follow up at Trauma Clinic in 2 weeks ([Telephone/Fax (1) 2359]). You have an appointment for Tuesday [6-12] at 12pm. [First Name8 (NamePattern2) ] [Hospital ] Medical Building Sweet 3A. 2)Follow up with Dr [First Name (STitle) ], Neurosurgery ([Numeric Identifier 11314]). ICD9 Codes: 5070, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6804 }	Medical Text: Admission Date: [2139-5-13] Discharge Date: [2139-5-14] Date of Birth: [2113-4-24] Sex: F Service: MEDICINE Allergies: Latex Attending:[First Name3 (LF) 3984] Chief Complaint: irritated throat, itchy lips Major Surgical or Invasive Procedure: Laryngoscopy History of Present Illness: Ms. [Known lastname 14323] is a 26yo woman with h/o recent intubation at [Hospital1 2177] presenting with itchy throat x 1 day. . The evening before admission, she noticed a "fleshy" feeling when she was clearing her throat. She started developing a sore throat and noted that it hurt when she swallowed her spit. A little later, she developed an itch around her lips, nose, and ears. She denies rash or lip swelling. She did not have the sensation of her throat closing up or having difficulty breathing. She went to her PCP, [Name10 (NameIs) 1023] gave her an Epi injection and sent her to the ED. . Of note, she presented to [Hospital1 2177] 2-3 weeks ago with similar symptoms, which she describes as a "throat ache." She did not have any sensation of itch at the time. She reports that they passed a scope through her nose and told her that her airway was somewhat [Last Name (LF) 15015], [First Name3 (LF) ] the doctors [Name5 (PTitle) 15016] [Name5 (PTitle) ] [Name5 (PTitle) ] 3 days. She recalls that SaO2 was 98% prior to intubation. She did well after extubation and was sent home with an EpiPen. Unfortunately, she did not make her f/u appointment with Allergy. . On review of systems, she c/o a dry cough and an episode of yellow emesis x 1 on the morning of admission. She has had brief headaches that last 1-2 minutes for the last couple of months. In addition, she has been quite [Doctor Last Name 11506] lately and admits to crying for no reason. Finally, she is concerned about a bump that developed on her right thigh 2 days ago. She denies fevers, chills, abdominal pain, diarrhea, or dysuria. Her LMP was one month ago. . Other than eating a fish [Doctor Last Name ] 2 nights ago, she has not had any unusual foods recently. She has not changed detergents or soaps. She has not picked up any new hobbies such as gardening. . In the ED, initial VS were: 97.3 117/73 66 16 100%. She had no signs of respiratory distress. A scope of her upper airway showed that her nasal turbinates and epiglottis were somewhat edematous. Her airway proximal to the vocal cords was described as "full." She was given benadryl 50mg IV, pepcid 20mg IV, solumedrol 125mg IV. . Upon arrival to the ICU, she reported that the itching had resolved. She felt almost back to baseline. Past Medical History: Obesity Giant cell fibroblastoma of left thigh s/p excision [3-26] Depression Fibrocystic breasts s/p abortion s/p appendectomy and unilateral oophorectomy Social History: [11-21] PPD smoker and is interested in quitting (only quit in past when pregnant). Also smokes marijuana daily. Drinks socially once or twice a month. Lives with her aunt and her 5 year old daughter. She recently lost her job at the [Location (un) 86] Globe and is volunteering at a school library. Will be leaving the house with her aunt and moving to a shelter in mid [Month (only) 205]. She is sexually active and uses the Mirena for contraception. Her boyfriend is very supportive. Family History: No h/o problems with throat swelling or angioedema. No cancers in the family. Daughter has eczema and asthma. Physical Exam: No temp 75 112/63 19 100% RA Very pleasant, overweight woman in no distress. PERRL, EOMI, no conjunctival injection or scleral icterus. No swelling of lips or tongue. Mucous membranes moist. Tonsils are generous in size but not erythematous and no sign of exudate. No tenderness on palpation of pharynx externally. No adenopathy or enlargement of thyroid gland. Neck is supple. S1, S2, RRR, no murmur. Lungs clear b/l without crackles or wheeze. No sign of respiratory distress; speaking in full sentences. Abd: +BS, soft, NT, ND. No hepatomegaly. Neuro: Alert and oriented, speech intact. Strength 5/5 in UE and LE b/l. Psych: Appropriate but has moments when she is almost tearful. Ext: No LE edema. DP +2 b/l. Warm, well perfused. Skin: +acanthosis nigricans. +firm papule on medial right thigh without evidence of fluid collection. No urticaria Pertinent Results: Admission labs: [2139-5-13] 04:45PM WBC-13.8* RBC-4.68 HGB-13.8 HCT-40.3 MCV-86 MCH-29.4 MCHC-34.1 RDW-13.8 [2139-5-13] 04:45PM NEUTS-58.3 LYMPHS-34.1 MONOS-5.1 EOS-1.3 BASOS-1.2 [2139-5-13] 04:45PM PLT COUNT-371 [2139-5-13] 04:45PM GLUCOSE-80 UREA N-10 CREAT-0.7 SODIUM-137 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13 Brief Hospital Course: A/P: 26yo woman recently [Month/Day/Year 15016] at [Hospital1 2177] for possible laryngeal edema admitted to the ICU in the setting of perioral itching and minor epiglottis edema. . # Irritated throat / Facial itching: DDx includes allergic reaction/anaphylaxis vs hereditary angioedema vs C1 inhibitor disorder vs. anxiety given social stressors. Patient is unable to identify possible environmental triggers and she has not been started on any new medications. Lack of urticaria would be consistent with C1 inhibitor disorders. Given her age and lack of family history, hereditary angioedema seems unlikely. Acquired C1 inhibitor disorders are usually associated with an underlying condition, such as autoimmune disease or lymphoproliferative disorders. NSAIDs can cause angioedema, but she is clear that she did not have motrin until after her symptoms began. Finally, the mild epiglottis swelling on her scope in the ED may in fact be a normal finding in the setting of her recent intubation. Pt received solmedrol in the ED and was continued on a prednisone taper to be completed at home. She was also treated with famotidine and benadryl while hospitalized. Her symptoms completely resolved within 12 hours. She was also evaluated by ENT who noted widely patent airway and no evidence of compromise. She was strongly advised to follow up with Allergy for further evaluation (C4, C1 inhibitor, and C1q). Pt is advised to schedule f/u with ORL 7-10 days after discharge ([Telephone/Fax (1) 2349] or [Telephone/Fax (1) 41]). . # Leukocytosis: Infectious review of systems is negative and differential is completely normal, so there was no indication for antibiotics. . # Tobacco abuse: Pt was provided smoking cessation counseling. . # Possible depression, social stress: Social worked evaluated the patient and recommended follow-up with SW at [Hospital ] Clinic. Medications on Admission: Took motrin 800mg x 1 after her throat irritation began without any change in symptoms. Mirena IUD Discharge Medications: 1. Prednisone 10 mg Tablet Sig: per below instructions Tablet PO once a day for 4 days: For prednisone taper. You already got 50 mg X 1 today. Start with 40 mg X 1 on day 2, then 30 mg X 1 on day 3, then 20 mg X 1 on day 4, then 10 mg X 1 on day 5. . Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Throat Swelling Discharge Condition: Good. Vital signs stable, no signs of respiratory distress. Discharge Instructions: You were admitted to the hospital with a question of throat swelling and were observed in the ICU overnight with improvement in your symptoms. You will need to take a taper of steroids over the next 5 days. You already took prednisone 50 mg today, then you will take 40 mg tomorrow, then 30 mg the day after, 20 mg the day after that, and 10 mg on the 5th and final day of your taper. Please call your doctor or return to the emergency room if you develop any of the following symptoms: worsening shortness of breath, throat swelling or sensation of it closing, wheezing, inability to control your mouth secretions. Followup Instructions: You will need to follow-up with an allergy specialist. Please call [Telephone/Fax (1) 9316] to make an appointment. Please follow-up with your PCP [Name Initial (PRE) 176] 1 week. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] ICD9 Codes: 311, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6805 }	Medical Text: Admission Date: [2177-6-25] Discharge Date: [2177-6-29] Date of Birth: [2103-3-24] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 48587] is a 74 year-old male with a significant cardiac history who presented for elective cardiac catheterization after having progressive anginal symptoms. He has experienced increasing dyspnea on exertion and left chest pressure at rest and exercise tolerance test with imaging in [2176-12-15] showed a fixed anterior and inferior defect. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [2159] and [2161]. 2. Tachybrady syndrome status post pacer placement. 3. Diabetes mellitus. 4. Status post cerebrovascular accident times two. 5. Atrial fibrillation. 6. Obstructive sleep apnea on CPAP. 7. Peripheral vascular disease. 8. Depression. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Aspirin 325 mg po q.d. 2. Lopressor 50 mg po b.i.d. 3. Lisinopril 10 mg po q.d. 4. Lipitor 20 mg po q.d. 5. Cartia XT 120 mg po q.d. 6. Amiodarone 200 mg po b.i.d. 7. Digoxin 0.125 mg po q day. 8. Lasix 20 mg po q.d. 9. Pletal 100 mg po q.d. 10. Insulin NPH 50 units subq q.a.m., 10 units subq q.p.m. 11. Nitro patch 0.4 micrograms per hour from 8:00 a.m. to 8:00 p.m. 12. Prozac 20 mg po q.d. 13. Alphagan 0.15% two drops OS q.d. 14. ................... 0.1% solution one drop OU b.i.d. PHYSICAL EXAMINATION: The patient had a heart rate of 62, blood pressure 120/70, and oxygen saturation of 97% on room air. General, the is alert and oriented times three. There were no carotid bruits and no elevation in his JVD. Lungs were clear to auscultation bilaterally. Cardiac examination revealed a regular rate and rhythm. Abdomen was benign. Extremities had no edema. LABORATORY STUDIES: CBC showed a white blood cell count of 8.6, hematocrit 41.2, platelets 186. Panel 7 was significant for a BUN of 28 and a creatinine of 1.6. Electrocardiogram showed ventricularly paced rhythm at 60 beats per minute with left axis deviation and left bundle branch block. HOSPITAL COURSE: 1. Coronary artery disease: The patient received intravenous hydration and Mucomyst in preparation for his coronary catheterization. Coronary catheterization revealed a normal left main coronary artery, left anterior descending with a 50% mid and total occlusion of the D1 with left to left collaterals, left circumflex with 70% and 90% obtuse marginal one lesion, and right coronary artery with a total occlusion with left to right collaterals. The 90% obtuse marginal one lesion was intervened on and stented successfully. He was brought to the floor in stable condition and rehydrated with 2 liters of fluid. Over the course of 12 hours the patient had very little urine output and may have missed some of his antihypertensive medications. At midnight the patient awoke from sleep with severe tachypnea and dyspnea. He was noted to be hypertensive with systolic blood pressures in the 200s and hypoxic with oxygen saturations only reaching 80% on a 100% nonrebreather mask. He was tachypneic in the 40s and an arterial blood gas at the time demonstrated a pH of 7.16, PCO2 76 and PO2 of 64. Electrocardiogram showed no acute ischemic changes in the presence of his baseline left bundle branch block. Physical examination demonstrated crackles throughout and he was treated with 16 mg of intravenous Lasix, nitroglycerin drip and morphine with little improvement in his clinical status. Chest x-ray was done and the patient was transferred to the Coronary Care Unit for further care on BIPAP ventilation. Chest x-ray demonstrated pulmonary edema. The patient's nitroglycerin drip was titrated upward for a better blood pressure control. With BIPAP ventilation, the patient's arterial blood gas improved with the following results: pH 7.28, PCO2 58, PO2 130. The patient's antihypertensive medications were restarted, and with better blood pressure control the patient's pulmonary status improved. The etiology of the pulmonary edema was thought to be severe hypertension causing flash pulmonary edema due to diastolic dysfunction. Serial cardiac enzymes were drawn and the patient ruled in for myocardial infarction with a peak CK of 5/74. This was thought to be due to demand and not an acute coronary syndrome. On the day following the acute hypoxic event the patient was weaned off of his BIPAP and maintained good oxygen saturations with face mask. He was quickly weaned to room air and had no further episodes of hypertension or pulmonary edema. An attempt was made to simplify his medication regimen. DISCHARGE CONDITION: Stable to home. DISCHARGE DIAGNOSES: 1. Pulmonary edema. 2. Hypertension. 3. Coronary artery disease. 4. Status post obtuse marginal stenting. 5. Diabetes mellitus. 6. Atrial fibrillation. 7. Obstructive sleep apnea. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q.d. 2. Plavix 75 mg po q.d. times nine months. 3. Lisinopril 10 mg po q.d. 4. Atenolol 75 mg po q.d. 5. Atorvastatin 20 mg po q.d. 6. Digoxin 125 micrograms po q.d. 7. Lasix 20 mg po q.d. 8. Amiodarone 200 mg po q.d. 9. Imdur 30 mg po q.d. 10. Cilostazol 100 mg po q.d. 11. Insulin NPH 50 units subq q.a.m. 10 units subq q.p.m. 12. Fluoxetine 20 mg po q.d. DISCHARGE PLAN: The patient should follow up with his primary cardiologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11493] within one week. He should discuss his medications with his primary physician. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern1) 6916] MEDQUIST36 D: [2177-6-29] 11:17 T: [2177-7-4] 12:19 JOB#: [Job Number 48588] ICD9 Codes: 4280, 9971, 496, 4240, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6806 }	Medical Text: Admission Date: [2179-5-13] Discharge Date: [2179-6-17] Date of Birth: [2108-9-18] Sex: M Service: [Last Name (un) ] CHIEF COMPLAINT: Elevated LFTs and diarrhea. HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old male, status post orthotopic liver transplant in [2178-12-24], complicated by preservation injury requiring admission, now with increased LFTs and diarrhea. Had an ERCP that demonstrated preservation injury. Admitted now with hypotension, systolic BPs in the 70s noted in the transplant office. PAST MEDICAL HISTORY: ETOH cirrhosis, DM type 2, hypertension, CAD, GERD, anemia. PAST SURGICAL HISTORY: Orthotopic liver transplant [2178-12-24], CABG [2162], inguinal hernia repair. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Alcohol abuse in the past, none currently. Tobacco: None in past history. FAMILY HISTORY: Not addressed. MEDS AT HOME: Valcyte 900 mg p.o. once daily, Protonix 40 mg once daily, ursodiol 300 mg t.i.d., Lopressor 37.5 mg b.i.d., Prograf 1.5 mg p.o. b.i.d., CellCept [Pager number ] mg p.o. t.i.d., pentamidine 300 mg inhalation q. month, NPH insulin 30 units SC q. a.m. LABS ON ADMISSION: White count 7, hematocrit 34.5, platelet count 188, coags within normal limits, blood sugar 27, sodium 142, potassium 3.8, chloride 110, CO2 19, BUN 42. PHYSICAL EXAMINATION: On admission, patient was alert and oriented, no acute distress. VITAL SIGNS: Temperature 96.3, heart rate 54, respiratory rate 18, 100% o room air, BP 112/54. Lungs were clear bilaterally. COR: Regular rate, rhythm. Abdomen soft, nontender, nondistended, Roux tube site no erythema. Peripherally 1+ edema bilaterally. Nonfocal neuro exam. HOSPITAL COURSE: Patient was given D50 with elevation of blood sugar. Started on an IV of D5-1/2NS at 60. He was started on vancomycin and Unasyn. Chest x-ray on admission demonstrated heart size within the upper range of normal with a tortuous aorta. There were linear areas of opacity at the left lung base with interval improvement in the area compared to the previous study, with residual small left pleural effusion. The left lower lobe opacities were felt to be related to atelectasis. An EKG demonstrated sinus bradycardia with a rate of 52, with AV conduction delay. Q-waves were noted in leads III and AVF, felt to be possibly related to a prior inferior myocardial infarction. There was concern for cholangitis. Infectious disease was consulted and recommended levofloxacin and Flagyl, changed to Zosyn 4.5 grams IV q. 6, with continuation of vanco. Blood cultures on admission were subsequently found to be negative. Bile culture demonstrated Citrobacter pansensitive, Enterococcus pansensitive and nonfermenter, resistant to Bactrim other pansensitive. Stool cultures were sent off. These were negative for C. diff. A CMV viral load was done. This was not detected. He was placed on Flagyl for concerns for C. diff. C. diffs were negative x3. He continued on Zosyn and vancomycin while awaiting final cultures. He was started on TPN for malnutrition. Patient was noted to be extremely jaundice with an alkaline phosphatase of 154, T- bilirubin of 4.4, and an INR of 1.0. Baseline creatinine was 0.9. Hematocrit was stable. He had generalized edema. His PTCA drained. A CT of his abdomen was done with nonionic contrast. This demonstrated decreased size of the subcapsular hepatic hematomas. There were new intrahepatic biliary dilatations noted predominantly in the left lobe of the liver. Diffuse colon wall thickening was noted consistent with colitis. There was concern for C. diff, and there was increased right pleural effusion and increased ascites. His creatinine started to increase on hospital day 4 to 2.7 from baseline of 2. His Prograf was adjusted. His Prograf level was 11, and IV fluid was decreased. A nephrology consult was obtained, and it was felt that the patient had ATN seen on a urinalysis secondary to hypotension, in addition to IV contrast for the CT, despite prophylaxis with IV bicarbonate and p.o. Mucomyst. He underwent a cholangiogram to assess tube placement. Compared to the cholangiogram performed on [4-15], the tip of the T-tube was lower than the prior location, but still located in the common bile duct. There was no evidence of bile leak or stricture. A renal ultrasound was done to evaluate elevated creatinine. There was no evidence of hydronephrosis in either kidney. A 2-cm cyst in the lower pole of the right kidney was noted, and there was a small amount of ascites noted. The patient underwent central line placement with tip in the correct position. After much consideration, the patient was relisted for retransplantation. He was taken to the OR on [2179-5-21] by Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], and he underwent a liver transplant from a diseased donor liver transplant piggyback, underwent a donor common hepatic artery to recipient proper hepatic artery, portal vein-to-portal-vein anastomosis, a Roux-en-Y hepaticojejunostomy and splenectomy. Assistant surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. Please see operative report. Patient was intubated and transferred to the SICU immediately postop. He received induction immunosuppression intraop with Solu-Medrol 500 mg IV, CellCept 1 gram IV. Postoperatively, he remained in the ICU and gradually was weaned from the vent. His immunosuppression was titrated per protocol. His LFTs started to trend downward. A postop liver duplex was done that demonstrated normal Doppler study, small fluid collection adjacent to the right posterior aspect of the liver. Pathology report from the liver biopsy from the recipient demonstrated extensive large bile duct necrosis with marked bile duct proliferation with associated neutrophils. The hepatic artery was with thrombus. There was negative portal vein. There was marked cholestasis, and trichrome and iron stains were evaluated. Please see path report for further details. Patient required frequent suctioning for thick yellow sputum. O2 sats remained in the 98-100% range. Patient was in first degree AV block. He required packed red blood cells for hematocrits of 26. On [2179-5-28], he was noted to have a right neck swelling and a question of cellulitis. An ultrasound was done. This demonstrated thrombus within the right internal jugular vein. The right subclavian vein appeared patent. On [5-28], he underwent a T-tube cholangiogram that demonstrated no leak, or obstruction, or intrahepatic biliary dilatation. There was free contrast passage into the small bowel loops. Of note, the patient did receive a cardiology consult for AV block. Recommendations included continuation of beta blockers. Gradually, LFTs trended down with an AST of 24, ALT of 32, alkaline phosphatase of 154, and a T-bili of 4.4. Creatinine decreased to 1.1. Hematocrit was stable. He continued on tube feedings, as he failed a swallow eval at bedside. He required Lasix for diuresis for fluid retention. ATN was resolving. His creatinine trended down to 1.4. He required an insulin drip postoperatively for hyperglycemia. He was transferred to the medical surgical unit on postop day 11, on [2179-6-1], and vital signs were stable. Bedside swallow eval was done again. Patient failed the swallow eval. He continued on his postpyloric feeding tube feedings. Physical therapy followed him each day. His Foley catheter was removed, and his feeding tube was capped. His LFTs continued to improve. Sodium increased to 140. He received free water via his postpyloric feeding tube for a free water deficit. Sodium continued to stay elevated around 140-145. His mental status was noted to be confused with inaudible speech at times. Patient was mumbling. His potassium was 5.1. This was treated with insulin, D50 and calcium gluconate per IV with a repeat potassium 4.6. Respiratory status was of concern. Respirations were 22-24 per minute. The patient had upper airway wheezing. Albuterol nebs were given with positive effect. His lung sounds were diminished at the bases. He was assisted to do coughing and deep breathing. He was n.p.o. Mental status started to decline. He became tachycardic and tachypneic. Sepsis was suspected. Blood cultures were sent off on [6-4]. These were positive for Klebsiella sensitive to imipenem and meropenem. He was initially started on vancomycin and Levaquin, and upon finalization of blood cultures, he was switched to meropenem. A UA was positive, and urine culture also demonstrated Klebsiella, sensitive to meropenem and imipenem. He was transferred back to the SICU for close monitoring given concern for aspiration pneumonia. A chest x-ray demonstrated no pneumothorax, small bilateral pleural effusions that were unchanged with retrocardiac linear atelectasis unchanged. His left IJ line was changed over a wire with placement confirmed. He was given IV Lasix, as well as IV fluid, and his sodium trended down. Creatinine continued to be normal at 1.0, hematocrit was stable, and his white blood cell count remained within normal limits. Throughout this, his LFTs continued to improve, with a fluctuation in the alkaline phosphatase with the range between 145 and 188. Total bilirubin trended down to a low of 1.5. He was transferred out of the SICU back to the medical surgical unit after aggressive respiratory hygiene and correction of hypernatremia. [Last Name (un) ] consult was obtained for management of hyperglycemia. His insulin was adjusted. Vancomycin was stopped. Infectious disease recommended continuation of meropenem through the [6-19]. A repeat bedside swallow eval was done with a video swallow on [6-15] which demonstrated mild delay in bolus formation with a single episode of penetration without aspiration. His diet was advanced to ground consistency with thin liquids with supervision. The patient was ordered to alternate every bite and sip. His tube feedings were changed to impact with fiber three-quarter strength with a goal rate of 100-cc. Cardiac echo was done to assess for vegetations given Klebsiella bacteremia. Findings included normal size left atrium, elongated left atrium, mild symmetric left ventricular hypertrophy with an EF greater than 55%. Due to suboptimal technical quality, a focal wall motion abnormality could not be fully excluded. The aortic valve leaflets appeared structurally normal. He had 1+ mitral regurgitation noted. There was moderate pulmonary artery systolic hypertension noted. No pericardial effusions were noted. Patient was cleared for rehab at [Hospital1 ]. Physical therapy recommended continuation of strengthening exercises. Patient was able to perform stand-step, and was able to get out-of- bed to the chair with moderate assist of 2. He continued to require use of the [Doctor Last Name 2598] lift to ensure safety. Occupational therapy evaluated the patient and recommended continuation of occupational therapy at rehab. On physical exam, he was alert and oriented, though forgetful at times with periods of confusion, and patient was noted to moan on and off at times, but unable to state exactly why he was moaning. Respiratory wise, his lungs were decreased throughout in the bases. He continued on his incentive spirometer use. O2 sat was 95% on room air. He denied shortness of breath. Abdomen was soft, nontender, nondistended with hypoactive bowel sounds. He was passing stools. His tube feedings, postpyloric feedings, via Dobbhoff were continued. The Foley catheter was in place draining adequate yellow urine. A central line on the left side, that site was clean and dry. Heart rate was in the 70s with a BP in a range of 110/160 to a systolic in the low- teens. His heart rate was a bit irregular. He was monitored with telemetry without incident. He did not complain of any pain. His abdominal incision was clean and dry with Steri- Strips, and his T-tube was capped. His labs on [6-17] were as follows: White blood cell count 9.6, hematocrit 32.8--this was stable, platelet count 365, sodium 136, potassium 5.4, chloride 100, CO2 27, BUN 40, creatinine 0.5, glucose 119, calcium 8.5, phosphorus 2.5, magnesium 1.8, AST 27, ALT 29, alkaline phosphatase 211--this was noted to gradually increase each day on [6-8] from 109 and each day gradually increasing up to 211. His total bilirubin remained stable at 1.6, with an albumin of 2.4. He continued on his immunosuppression of 10 mg of prednisone per taper. He was due to decrease his prednisone until [6-20], when he would start a decrease in his prednisone taper to 7.5 on [6-21]. CellCept was held. His Prograf dose was 1 mg p.o. b.i.d. with a level of 8.4. PLAN: Discharge to [Hospital ] Rehab with follow-up in outpatient clinic within 1 week. He was scheduled to have twice weekly labs q. Monday and Thursday for CBC, chem-10, LFTs, and trough Prograf level. IV meropenem was to continue for a full course until [6-19]. DISCHARGE DIAGNOSES: Status post liver transplant [2178-12-24] complicated by preservation injury, requiring retransplantation and underwent second liver transplant on [5-21]. Diabetes type 2. Klebsiella urinary tract infection. Klebsiella bacteremia. Malnutrition. Impaired swallowing. Status post coronary artery bypass graft [2162]. DISCHARGE MEDICATIONS: Included vitamin C 500 mg p.o. once daily, ferrous sulfate 300 mg p.o. once daily via Dobbhoff, fluconazole 200 mg p.o. once daily, Lasix 20 mg p.o. once daily, heparin 5000 units SC b.i.d., insulin - Lantus 30 units SC at bedtime with Humalog sliding scale starting at 121-160 - 2 units; 161-200 - 3 units; 201-240 - 5 units of Humalog; 241-280- 7 units of Humalog with Accu-Cheks q.i.d., lansoprazole 30 mg via NG tube once daily, metoprolol 37.5 mg p.o. b.i.d., meropenem 500 mg IV q. 6 h. through [6-19] stopping on the [6-20], nystatin 5 mL p.o. q.i.d. p.r.n., prednisone 10 mg p.o. once daily, Bactrim SS once daily, tacrolimus 1 mg p.o. b.i.d., Valcyte 450 mg p.o. once daily. [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 4841] Dictated By:[Name8 (MD) 4664] MEDQUIST36 D: [2179-6-17] 11:54:32 T: [2179-6-17] 13:30:40 Job#: [Job Number 45773] ICD9 Codes: 5845, 5990, 4280, 2760
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6807 }	Medical Text: Admission Date: [2147-6-13] Discharge Date: [2147-6-15] Date of Birth: [2112-11-14] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil / Hydralazine / cefepime Attending:[First Name3 (LF) 1253] Chief Complaint: DKA, Hypertensive Urgency, Hyperkalemia Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 34 y/o M with PMHx of DM1, ESRD on HD TTR, gastroparesis with frequent hospitalizations for N/V, uncontrolled hypertension and diabetes presented to the ED with N/V and hypoxemic respiratory failure. . Began having abdominal pain, nausea, vomiting today, did not take insulin, progressively worsened, came to ED. No fevers. No shortness of breath, no chest pain. States quality of pain identical to previous episodes of gastroparesis, severity is slightly worse, however. . Prior to this admission, he states symptoms worse than his usual gastroparesis. Afebrile. No sick contacts. [Name (NI) ] recent travel or eating out. Last BM this AM, normal, nonbloody. . In the ED, initial vitals were: 98.0 110 223/119 16 100%. Initial labs were significant for an elevated potassium, creatinine of 11. An EKG demonstrated peaked T waves. He was given insulin 10 units of humulog x 3?, 2mg of calcium gluconate with repeat blood sugar in the 200s. Repeat K+ was 4.8. He was subsequently started on an insulin gtt at 7.5 units/hr in D5. He was given zofran 4mg x1, reglan 10mg, morphine 5mg x 2 and dilaudid 1mg IV for management of his abdominal pain and nausea. For management of his hypertension which was labile and ranged from 165-209/109-113 he was given 20mg IV labetolol. Admission the ICU was requested for management of labile hypertension and insulin gtt. 102 28 165/109 99% on room air. He was comfortable on transfer. . On arrival to the MICU he was comfortable in no apparent distress; his blood pressure was 160, his glucose was 246. Past Medical History: - DM type I since age 19, followed at [Last Name (un) ]. Complicated by nephropathy, neuropathy, gastroparesis, retinopathy. Multiple prior hospitalizations with DKA, nausea/vomiting [2-9] gastroparesis - ESRD on HD T/Th/S via right arm fistula @ [Location (un) ] [Location (un) ], dry weight 73kg - Hypoglycemia - Hyperglycemia/DKA: requiring insulin gtt - Hypertension - Nonischemic cardiomyopathy with EF 30-35% - Anemia: [2-9] iron deficiency and advanced CKD - Depression - Pulmonary hypertension - Migraines Social History: Lives with girlfriend. Mother also local. College degree in marketing, worked at [Company 2475] previously. Tobacco: trying to quit; relapsed and smokes ~1 pack per week EtOH: previously drank heavily (30-40 drinks/week) but has not used alcohol since [2144-11-14] Denies other drugs. Family History: Paternal grandfather had DM2. [Name2 (NI) ] FH DM1. Hypertension in a few family members. [Name (NI) 6419] [Name2 (NI) ] and several siblings alive and healthy, without known medical problems. Physical Exam: Admission Physical: . General: Alert and oriented, pleasant in no apparent distress HEENT: Sclera anicteric, slightly dry oral mucosa, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Tachycardic, Regular rhythm, normal S1 + S2, 3/6 SEM LSB, no rubs, no gallops, 18G R EJ, 22, L 4th digit Lungs: clear to auscultation bilaterally with good air movement and excursion, no wheezing or rhonchi Abdomen: soft, nontender, active bowel sounds, no rebound or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: Admission Labs: . [2147-6-12] 10:50PM BLOOD WBC-11.9# RBC-4.65# Hgb-14.1# Hct-43.7# MCV-94 MCH-30.3 MCHC-32.2 RDW-13.4 Plt Ct-158 [2147-6-12] 10:50PM BLOOD Neuts-94.2 Lymphs-3.2* Monos-2.0 Eos-0.3 Baso-0.3 [2147-6-12] 10:50PM BLOOD PT-10.0 PTT-29.9 INR(PT)-0.9 [2147-6-12] 10:50PM BLOOD Plt Ct-158 [2147-6-12] 10:50PM BLOOD Glucose-501* UreaN-52* Creat-11.3# Na-133 K-6.5 Cl-89* HCO3-16* AnGap-35* [2147-6-12] 10:50PM BLOOD ALT-21 AST-33 AlkPhos-181* TotBili-0.4 [2147-6-12] 10:50PM BLOOD Lipase-78* [2147-6-12] 10:50PM BLOOD Albumin-4.9 [2147-6-12] 11:06PM BLOOD Lactate-3.4* . Imaging: [6-12]: CT Abd/Pelvis: IMPRESSION: 1. No acute process in the abdomen and pelvis. 2. Moderate cardiomegaly and mild pulmonary edema. CXR: IMPRESSION: No focal lung consolidation. Moderate cardiomegaly and mild pulmonary edema, slightly improved from [2147-5-14]. . Brief Hospital Course: 34 y/o M with DM1, gastroparesis, HTN, non-ischemic cardiomyopathy (EF30-35%), admitted to the MICU with diabetic ketoacidosis and abdominal pain c/w gastroparesis, hypertensive urgency. # DKA- DM1 since age 19. History of uncontrolled blood glucose, also with gastroparesis and frequent N/V. Bglc on transfer to MICU 246. Anion gap = 29 on arrival to ED. ICU Course: the patient presented initially with hyperglycemia, but no initial gas to confirm acidosis, this was treated in the ED and blood sugars had normalized and the gap had closed appreciably, he was initially on an insulin drip which was discontinued the next morning when he began taking POs; he had labile blood sugars on HD2 likely due to nausea after his glargine dose and then attempting to correct for the resulting hypoglycemia. He had normalized by the morning of HD3 and was tolerating a regular diet and blood sugars were well controlled. He never needed to go back on the drip. [Last Name (un) ] was consulted and was following the patient. Floor course: Pt had labile sugars while on the floor, ranging from 60-300s. His insulin regimen was titrated. Patient left against medical advice on [6-15]. # Hypertensive urgency- History of labile BP, with multiple admissions for hypertensive urgency/emergency. Unclear etiology of labile BP. On home regimen of lisinopril, amlodipine, patch. Currently hypertension is under control, will resume home medication regimen. ICU Course: the patient received 20mg of IV labetalol in the emergency department which improved his pressures, but subsequently became hypertensive again and a nitroglycerine drip was initiated in the MICU- the patient remained on this drip through most of HD2 has he was still nauseous and would not tolerate his PO antihypertensives. The drip was discontinued on HD3 and the patient took his home medications. He never had any neuro changes, and his renal function was baseline and he was dialyzed regardless. Floor Course: BP remained stable on the floor with home labetalol and [Month/Day (4) 40899] regimen. He left AMA shortly after arriving on the floor to go to a Celtics basetball game. #HyperKalemia - in the setting of ESRD, DKA, he was treated in the ED, downtrended to 4.8. Improved with medical management and hemodialysis. # ESRD: On TuThSa HD. He was given HD for hypertensive emergency/pulmonary edema and hyperkalemia. Received HD on hospital Day 2 and 3. # Gastroparesis: patient with history of gastroparesis, receives relief with zofran, dilaudid, morphine ICU Course: treated with antiemetics and pain medications. #Against medical advice: pt left AMA. He was explained the risks and understood them well. He wanted to attend a basketball game. Medications on Admission: 1. amlodipine 10 mg Tablet daily 2. aspirin 81 mg Tablet, daily 3. [Month/Day (4) 40899] 0.3 mg/24 hr Patch Weekly qMONDAY 4. insulin glargine 14 units qAM 5. insulin lispro 100 unit/mL Solution ISS 6. B complex-vitamin C-folic acid 1 mg Capsule daily 7. lisinopril 40 mg Tablet daily 8. sevelamer carbonate 800 mg Tablet Two (2) Tablet PO TID W/MEALS 9. sertraline 50 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO DAILY (Daily). 10. hydromorphone 2 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO twice a day prn 11. ondansetron HCl 4 mg Tabletq8hrs prn nausea 12. labetalol 200 mg Tablet [Month/Day (4) ]: Three (3) Tablet PO BID 13. labetalol 100 mg Tablet [Month/Day (4) ]: Three (3) Tablet PO at bedtime. Discharge Medications: 1. aspirin 81 mg Tablet, Chewable [Month/Day (4) ]: One (1) Tablet, Chewable PO DAILY (Daily). 2. amlodipine 5 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO DAILY (Daily). 3. [Month/Day (4) 40899] 0.3 mg/24 hr Patch Weekly [Month/Day (4) ]: One (1) Patch Weekly Transdermal QFRI (every Friday). 4. labetalol 200 mg Tablet [Month/Day (4) ]: Three (3) Tablet PO BID (2 times a day). 5. labetalol 100 mg Tablet [Month/Day (4) ]: Three (3) Tablet PO QHS (once a day (at bedtime)). 6. sevelamer carbonate 800 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. B complex-vitamin C-folic acid 1 mg Capsule [Month/Day (4) ]: One (1) Cap PO DAILY (Daily). 8. lisinopril 20 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO DAILY (Daily). 9. sertraline 50 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO DAILY (Daily). 10. lidocaine (PF) 10 mg/mL (1 %) Solution [Month/Day (4) ]: One (1) ML Injection DAILY (Daily) as needed for before dialysis. 11. Dilaudid 4 mg Tablet [Month/Day (4) ]: One (1) Tablet PO twice a day as needed for pain. 12. insulin glargine 100 unit/mL Solution [Month/Day (4) ]: Twelve (12) units Subcutaneous once a day: Breakfast. 13. insulin humalog [Month/Day (4) ]: 0-7 per sliding scale: as directed per sliding scale. Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Hypertensive Urgency Acute on chronic renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital for diabetic ketoacidosis and hypertension. You were admitted to the intensive care unit for close monitoring. Your DKA improved but your sugars and blood pressure remained labile. You decided to leave against medical advice. The risks were explained to you and you understood them. These risks include recurrent DKA, severe hypertension, death, stroke, heartattack, arrythmias. We strongly encourage you to return to the hospital if you feel sick. Weigh yourself every morning, [Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please arrange to followup with your primary care doctor and your diabetes doctors within the next few days. ICD9 Codes: 5849, 4254, 4168, 5856, 3572, 2767, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6808 }	Medical Text: Admission Date: [2111-1-1] Discharge Date: [2111-1-10] Service: TRAUMA [Last Name (un) ] HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is an 88-year-old man status post a mechanical fall who apparently landed on his face with probable loss of consciousness. He was initially transferred to an outside hospital and, by report, had facial fractures with a severe nasal bleed. The patient subsequently asked to be transported to [Hospital1 190] because his primary care doctor is at [Hospital1 1444]. Prior to transport a posterior nasal pack was placed for a significant nose bleed. Upon arrival Mr. [Known lastname ] was hypertensive with a blood pressure systolic of 190-200/palp and a heart rate in the 80's. He was noticeably bleeding from both nares, right greater than left. [Location (un) 2611] Coma Scale was 15. The posterior nasal pack was placed. Upon arrival Anesthesia was called to evaluate Mr. [Known lastname ] because of the high likelihood of needing an airway. A 7.0 endotracheal tube was placed without significant difficulty. After the intubation the Trauma consult team was called to evaluate Mr. [Known lastname ]. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Parkinson's disease. 3. Hypertension. 4. Cerebrovascular accident. 5. Left eye ophthalmoplegia. 6. Echocardiogram in [2110-7-20] revealed an ejection fraction greater than 60%. PAST SURGICAL HISTORY: Coronary artery bypass graft. MEDICATIONS ON ADMISSION: 1. Aggrenox 25/200 p.o. b.i.d. 2. Sinemet 100 mg p.o. with one-half tablet t.i.d. 3. Lipitor 10 mg p.o. q. day. 4. Diltiazem XL 180 mg p.o. q. day. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.0 degrees, heart rate 78, blood pressure 216/88, respiratory rate 18, pulse oximetry 95% on room air. The physical examination was obtained prior to intubation. In general, in no acute distress sitting up in bed speaking in complete sentences. Neck: C-collar. No tracheal deviation. HEENT: Right eye: Pupil round and reactive with full range of motion. Left eye: Deviated laterally. Bilateral orbital ecchymosis. Mid face is stable. No malocclusion. No hemotympanum. Edema and ecchymoses over the entire mid face. Chest notable for a sternotomy scar. No crepitus. Breath sounds bilateral and equal. Cardiac regular rate and rhythm. Normal S1, S2. Abdomen is soft, non-tender and non-distended. Extremities: No deformities, no step-offs. Moves all extremities. Back: No step-offs, non-tender. Rectal: Normal tone, no mass, guaiac negative, normal prostate. Genitourinary: No blood at the meatus, otherwise normal. Neurologic: [Location (un) 2611] Coma Scale 15. Sensory and motor are intact bilaterally in all extremities. LABORATORIES ON ADMISSION: Sodium 139, potassium 4.2, chloride 102, bicarb 26, BUN 34, creatinine 1.3. White blood cell count 15.6, hematocrit 39.8. Platelets 222,000. INR 0.9. PTT 24.0. Lactate 1.3. Fibrinogen 289. Blood gas status post intubation with FiO2 of 100%: 7.46/38/491/28/3. Serum tox screen negative. Urine tox screen negative. Urinalysis negative. RADIOLOGY: Chest x-ray: No fracture, no pneumothorax. Pelvis: No fractures. Cervical spine: Lateral plain films C3, C4 anterolisthesis. Thoracic and lumbar plain films are negative. CT of the head is negative for any intracranial bleeding. CT of the face shows bilateral anterior and medial maxillary sinus fractures, bilateral medial pterygoid fracture. Multiple nasal bone fractures. There are air-fluid levels present within the sphenoid and frontal sinuses and left maxillary sinus. There is suspicion for a right orbital wall fracture but not definitely seen. HOSPITAL COURSE: After being evaluated in the Emergency Department and being intubated by Anesthesia, Mr. [Known lastname ] was subsequently admitted to the Trauma Intensive Care Unit for further management and stabilization. He was started on Kefzol while the nasal packing was in place. The ORL/ENT consult service was asked to see Mr. [Known lastname ] for his multiple nasal fractures and for management assistance with his nasal packing. The ORL team recommended continued nasal packing and followed Mr. [Known lastname ] throughout his hospital stay. The Ophthalmology consult service was also asked to evaluate Mr. [Known lastname ] given his findings on examination as well as his multiple fractures including possible orbit fracture. They continued to follow Mr. [Known lastname ] throughout his hospital stay and there was no ophthalmologic intervention needed during Mr. [Known lastname ] stay except for continuation of his dexamethasone and Cipro ophthalmic drops. They recommended follow up with his ophthalmologist upon discharge. The Plastic Surgery service was also asked to evaluate Mr. [Known lastname ] given his multiple facial fractures. In addition, the Neurosurgery service was asked to evaluate Mr. [Known lastname ] given his findings on his lateral C-spine. The Plastic Surgery service recommended an MRI of his spine which showed multiple severe spondylitic changes of the cervical spine with central canal and neural foraminal stenosis. On the [8-1] Mr. [Known lastname ] was extubated without any problem. [Name (NI) ] was maintained on supplemental oxygen and he did very well. On the [8-2] Mr. [Known lastname ] was transferred to the regular floor where he has been progressing steadily with a decrease in his ecchymosis and edema. The Neurosurgery service signed off on Mr. [Known lastname ] on [1-3] with a final [Location (un) 1131] on the MRI as being unremarkable and without any significant ligamentous injury or spinal cord compression. For Mr. [Known lastname ] multiple facial fractures he was maintained on clindamycin for an antibiotic throughout his hospital stay. Also upon transfer to the floor the physical therapist and occupational therapy team began working with Mr. [Known lastname ] to make sure that he was able to get out of bed and move towards rehabilitation given his multiple fractures and the confirmation of a LeFort type I fracture on a repeat CT scan, he was maintained on a pureed soft diet. He tolerated this well and there was no evidence of aspiration or other problems. On the [2111-1-8] Mr. [Known lastname ] was taken to the Operating Room for an open reduction internal fixation of his LeFort type I fracture with four plates inserted. Dr. [Last Name (STitle) 13797] was the attending plastic surgeon on the case. There was also an excisional biopsy of a left alar lesion performed. Mr. [Known lastname ] was intubated for this procedure and there were no complications associated with the procedure and he tolerated it very well. He was subsequently transferred back to the Post Anesthesia Care Unit and then the regular floor without any problems postoperatively. [Name2 (NI) ] has done remarkably well. He has a nasal packing in place that will be removed prior to discharge by the Plastic Surgery team. He has a nasal splint that will be in place until follow up in the Plastic Surgery Clinic and he will not be able to wear his upper dentures for four weeks and he will be maintained on a pureed diet. He will also be continued on clindamycin for five days per the Plastic Surgery team. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: Acute rehabilitation facility per recommendations of the Physical Therapy team. DIAGNOSES: 1. LeFort type I fracture. 2. Nasal fractures. DISCHARGE MEDICATIONS: 1. Clindamycin 450 mg p.o. t.i.d. times five days. 2. Tylenol with codeine one to two tablets p.o. q. 4-6h. p.r.n. 3. Peridex mouth washes t.i.d. 4. Lipitor 10 mg p.o. q. day. 5. Sinemet 25/100 one-half tab p.o. t.i.d. 6. Dulcolax 10 mg p.o./p.r. q. day p.r.n. 7. Milk of magnesia 30 mL p.o. q. 6h. p.r.n. 8. Colace 100 mg p.o. b.i.d. 9. Diltiazem ER 240 mg p.o. q. day. 10. Dexamethasone ophthalmic solution one drop O.D. b.i.d. 11. Cipro ophthalmic solution one drop O.D. b.i.d. DISCHARGE INSTRUCTIONS: 1. Nasal splint on until seen in the Plastic Surgery Clinic on [2111-1-16], at 2:30 p.m. [Telephone/Fax (1) 274]. 2. No upper dentures for four weeks. 3. Diet is a cardiac diet with pureed. 4. Physical therapy and occupational therapy to work on strength and endurance. 5. Please follow up with Mr. [Known lastname ] primary care doctor, Dr. [First Name8 (NamePattern2) 1312] [Last Name (NamePattern1) 6457], in five to seven days to recheck his physical and psychological condition. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 18153], M.D. [MD Number(1) 18154] Dictated By:[Last Name (NamePattern1) 9126] MEDQUIST36 D: [2111-1-9] 14:20 T: [2111-1-9] 13:29 JOB#: [Job Number 96545] ICD9 Codes: 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6809 }	Medical Text: Admission Date: [2132-11-26] Discharge Date: [2132-12-3] Date of Birth: [2061-11-2] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5552] Chief Complaint: Neck swelling. Major Surgical or Invasive Procedure: [12-1] SVC venogram with initiation of TPA therapy [12-2] PICC line placed in IR [12-2] TPA cath check History of Present Illness: Mr. [Known lastname 1683] is a 71-year-old man with adenocarcinoma of the rectum (diagnosed in [6-/2131]) who underwent neoadjuvant chemoradiation followed by proctosigmoidectomy and a left lower lobe resection for pathologically confirmed lung metastases. Following two cycles of FOLFOX chemotherapy, he underwent resection of a 1.7 cm solitary liver metastasis in [2132-6-29]. He then began further adjuvant therapy with 5FU/LV at 500 mg/m2. Oxaliplatin was eliminated due to neuropathy. He started cycle 2 of 4 planned cycles of 5FU/LV on [11-19] (one week prior to this admission). . He was admitted to OMED for prehydration and CTPA following discovery of non-occlusive thrombus around his port and finding of hypoxia with tachycardia in clinic on day of admission. . He was seen at oncology clinic (day 8 of 5FU/LV) with neck swelling. He had been seen by his primary care physican two days prior and noted to have neck swelling, at which time a CT was done that showed non-occlusive clot around his port. The plan had been to start lovenox with IR clot stripping. However, when at clinic he was noted to be dyspneic with minimal exertion. His O2 sat dropped to 90% and HR up to 110 with ambulation. With rest HR down to 90's and O2 back up to 97%RA. Decision was made to admit to hospital for further monitoring and work-up of pulmonary embolus. . On further review of systems, patient notes that he has been increasingly dyspneic with normal activities (lawn-moving, walking around house, to and from mailbox, etc) at home. He had attributed this to the chemotherapy he is recieving, as he has experienced these symptoms in the past in conjunction with chemotx. He denies symptoms of CHF, including orthopnea, PND, lower extremity swelling. He notes that he has had an MI in the past; also he has significant smoking history, history of hypertension, hyperlipid, and diabetes (diet-controlled?). He denies h/o palps, dizziness, cough, or fever, though does endorse intermittent lightheadedness that is neither exertional nor postional. Past Medical History: 1. Hypertension. 2. Hyperlipidemia. 3. ASCVD, status post MI in [2111] status post PTCA. 4. Status post appendectomy. 5. Diabetes. . Past Oncological History Metastatic adenocarcinoma of the rectum - [6-/2131]: The patient presented with a change in bowel habits and was noted to have an abnormal rectal exam by his primary care physician, [Name10 (NameIs) 39262] [Name Initial (NameIs) ] gastrointestinal evaluation. - [2131-7-23] colonoscopy: Exophytic cancer of the rectum 8-12 cm above the anal margin. Polyp noted at the anorectal junction. Biopsy: Invasive, moderately differentiated adenocarcinoma arising in association with adenoma. Polyp: Adenoma with high-grade dysplasia. - [2131-7-25] rectal ultrasound: T3 posterior midline tumor with luminal narrowing of the rectum. - [2131-8-2] CT scan of the torso: Irregular, polypoid lesion seen within the rectum, with multiple subcentimeter presacral and pericolic lymph nodes identified. Two pulmonary nodules seen in the left lower lobe, the largest measuring 2.9 x 2.2 cm. Multiple low-attenuation lesions seen within the liver, the largest of which may represent cyst, smaller lesions are not fully characterized. Low-attenuation lesions seen within the left kidney, possibly a cyst, although too small to characterize. Per report, a CT PET performed elsewhere demonstrated uptake in the left base of the lung. - [2131-8-14] to [2131-9-25]: Neoadjuvant chemoradiation with continuous 5-FU at 225 mg/m2/day and radiation therapy five days weekly. - [2131-12-10]: Proctosigmoidectomy with stapled coloanal anastomosis and diverting loop ileostomy. Pathology revealed adenocarcinoma of the rectum, low-grade, with invasion into the perirectal adipose tissue and metastasis to 7 of 13 regional lymph nodes (T3N2). The resection margins were uninvolved. - [2132-1-28] PET SCan: Interval progression of disease with an increase in the size of the previously identified lung metastasis. There is a new FDG-avid focus in segment 4A of the liver which most likely represents metastasis. - [2132-2-13]: Ileostomy takedown with simultaneous flexible bronchoscopy and VATS with left lower lobe resection. Pathology from the ileostomy stoma demonstrated findings consistent with ileostomy stoma with no evidence of malignancy. The left lower lobe wedge resection demonstrated an adenocarcinoma, 4.1 cm, consistent with metastasis of rectal origin. The pleural and apparent stapled margins were free of malignancy. - [2132-2-14]: Evaluation by the hepatobiliary surgery consult team due to the finding on his recent PET scan of a likely liver metastasis. It was felt that the lesion was amenable to surgical resection, and it was planned that the patient would undergo two cycles of chemotherapy prior to proceeding with hepatic resection. - [2132-4-9]: FOLFOX chemotherapy initiated. The patient completed two cycles of therapy on [2132-6-3]. - [2132-7-11]: Hepatic resection of a 1.7cm segment 4a metastatic lesion by Dr. [Last Name (STitle) ]. - [2132-10-22]: Cycle 1 Day 1 5FU/LV for further adjuvant chemotherapy. Oxaliplatin eliminated due to neuropathy. - [2132-11-19]: Presented to clinic to begin cycle 2 of 5FU/LV for his resected colon cancer. Social History: The patient is divorced and has three sons in their 40s. He is a construction inspector. He denies alcohol and uses no illicit drugs. He smoked one pack of cigarettes daily for approximately 30 years before quitting in [2111]. Family History: The patient's maternal uncle had an abdominal cancer, details unclear. His father died of an MI. His mother died of [Name (NI) 2481] disease. He has two brothers who are well. Physical Exam: Physical Exam at Admission Vitals: BP 133/63, HR 90, RR 14, sat 95% gen-well appearing man, NAD, appears stated age, ruddy complexion HEENT-nc/at, perrla, EOMI, +plethoric face/ruddy complexion, anicteric, MMM neck-swelling without obvious JVD, no LAD, supple chest-b/l ae no w/c/r heart-s1s2 rrr no m/r/g abd-+well healed abdominal surgical scars, +bs, soft, NT, ND ext-no c/c/e, L.arm-with instrumentation 1+edema, 2+pulses neuro-aaox3, CN2-12 intact, non-focal . Physical Exam at Discharge GEN awake, alert and oriented; NAD; breathing and speaking comfortably in bed HEENT decreased facial swelling/redness from admission LUNGS CTA bilaterally [Last Name (un) ] obese, non-tender NEURO CN II-XII grossly intact, strength 5/5 and symmetric upper and lower extremities Pertinent Results: Labs on Admission [2132-11-26] 11:10AM WBC-7.2 RBC-3.96* HGB-12.5* HCT-34.3* MCV-87 MCH-31.6 MCHC-36.5* RDW-17.9* [2132-11-26] 11:10AM PLT COUNT-226 [2132-11-26] 11:10AM PT-13.2 INR(PT)-1.1 [2132-11-26] 11:10AM GRAN CT-4860 . Labs on Transfer out of ICU [2132-12-2] 04:30AM BLOOD WBC-7.6 RBC-3.54* Hgb-11.2* Hct-31.0* MCV-88 MCH-31.6 MCHC-36.1* RDW-19.6* Plt Ct-134* [2132-12-2] 08:07AM BLOOD PT-14.2* PTT-34.8 INR(PT)-1.2* [2132-12-2] 04:30AM BLOOD Glucose-146* UreaN-21* Creat-1.2 Na-137 K-4.3 Cl-104 HCO3-25 AnGap-12 [2132-12-2] 04:30AM BLOOD ALT-27 AST-31 AlkPhos-121* TotBili-1.1 [2132-12-2] 04:30AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.4 Mg-2.2 . [11-27] CTA Chest: IMPRESSION: 1. No gross pulmonary embolism, subject to suboptimal pulmonary arterial opacification. that if evaluation of PE is needed in the future, it should be evaluated by IVC rather than upper extremity injection. 2. SVC thrombosis with extension in right and left brachiocephalic veins. Left inferior pulmonary vein thrombosis. 3. New and enlarging lung nodules, worrisome for metastasis. 4. Unchanged unevenly distributed subpleural fibrosis, could be drug related. 5. Prior left lower lobe wedge resection and partial liver resection with no signs of local recurrence. 6. Unchanged T4 lesion since [2131] of indeterminate clinical significance. . [11-28] TTE: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of the inferior, inferolateral and basal inferoseptal segments (proximal RCA lesion). The remaining segments contract normally (LVEF = 35-40%). 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. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic regurgitation .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. IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. . [12-1] CT head: Normal non-contrast head CT with no evidence of metastasis. If metastasis is of clinical concern, MR is a more sensitive modality for the evaluation of intracranial metastasis. . [12-2] PTA Venous IMPRESSION: 1. Repeat SVC venogram demonstrated flow improvement in the SVC with no collateral veins across the midline. 2. Venous angioplasty with balloon dilation with further improvement of the flow in the SVC. PLAN: Heparin infusion to further declot the residue clots in the SVC and may switch to Coumadin in the near future to prevent the development of clots in the SVC. Brief Hospital Course: In summary, this is a 71 year-old man with history of metastatic colon cancer s/p multiple surgeries, including proctosigmoidectomy, lung and liver resections, now on cycle 2 of 5 FU/LV presenting from clinic with hypoxia, tachycardia and dyspnea with mild exertion. . DYSPNEA ON EXERTION / HYPOXIA Differential diagnosis at admission included pulmonary embolism, pulmonary infectious process, SVC syndrome, and CHF (given cardiac risk factors). After prehydration, CTPA was done that showed SVC thrombosis with extension into the right and left brachiocephalic veins. There was no pulmonary arterial embolism. Patient was started on heparin drip. Pulmonary service was consulted and agreed that given imaging findings and history of facial swelling and redness, SVC syndrome was a very likely explanation for his symptoms. IR was then consulted and planned for intravenous thrombolysis to break-up clot. Prior to procedure, CT head was done that showed no intracranial metastases. . On [12-1], patient underwent local thrombolytic tx to the SVC clot and was transferred to the ICU for overnight monitoring. He returned to the floor the following day with significant improvement in symptoms. His facial swelling had improved also. He was seen by physical therapy on day prior to discharge and cleared for discharge to home. . He is discharged on Lovenox injections 1 mg/kg [Hospital1 ], which he will likely need to continue for 6 months. He will follow-up with his outpatient oncologists, Dr. [Last Name (STitle) ] and Dr. [First Name (STitle) ]. . LOW PLATELETS Platelets were downtrending at time of discharge. There is concern of HIT given that he was on heparin throughout hospitalization, although his platelet count is still high at 117 (and there were several fluctuations in platelet levels from day to day). We have asked that VNA visit him two days after discharge. His CBC will be faxed to his primary oncologist. If his platelet count continues to fall, he may need readmission and bridging to coumadin with DTI like argatroban. . METASTATIC COLORECTAL ADENOCARCINOMA On cycle 2 of 5FU/LV; further plan for chemotherapy is per Dr. [First Name (STitle) ] and Dr. [Last Name (STitle) ]. . HYPERTENSION We continued his outpatient beta-blocker while hospitalized. ACEI was held for concern of worsening renal failure in setting of multiple contrast loads for CTPA and intravenous thrombolysis. . CHRONIC CONGESTIVE HEART FAILURE Full echocardiogram report is above. Findings are consistent with CAD and sytolic dysfunction. He is on a BB, statin, and ACEI. Aspirin is being held in the setting of receiving chemotherapy. This can be restarted per his oncologist's recs. . HYPERLIPID We continued his outpatient statin. . DIABETES MELLITUS (?DIET-CONTROLLED?) His blood sugars were persistently elevated during hospital course. He required 12 units of glargine HS and was placed on humalog sliding scale. Hemoglobin A1c came back at 7.7. I spoke with him regarding follow-up with his primary physcian and told him there are medications that could help with blood sugar control. He knows to address this issue at his next outpatient visit. . PERIPHERAL NEUROPATHY We continued his outpatient vitamin B6. . He was kept on a cardiac diet. Heparin drip was given for SVC thrombus with switch to Lovenox at discharge. His code status remained full code throughout hospital course. Medications on Admission: # ATORVASTATIN [LIPITOR] - 20 mgTablet - 1 Tablet(s) by mouth daily # LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily # METOPROLOL SUCCINATE [TOPROL XL] - 100 mg SR # VITAMIN B12 50 mg [Hospital1 ] Discharge Medications: 1. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a day. Disp:60 syringes Refills:2 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril Oral 6. Outpatient Lab Work Patient needs CBC on Friday [12-5] and faxed to Dr. [First Name8 (NamePattern2) 636] [Last Name (NamePattern1) ] at [Hospital1 18] ([Telephone/Fax (1) 28907]. Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: PRIMARY DIAGNOSIS Superior vena cava syndrome Non-occlusive thrombus in the superior vena cava . Hypertension Hyperlipidemia Diabetes, diet-controlled Discharge Condition: Vitals signs stable. Satting fine on room air. Discharge Instructions: You were hospitalized for treatment of a blood clot in a vein leading into your heart. You underwent a procedure to help dissolve the clot. We have started you on a medicine called Lovenox to help prevent any clots from forming again. You will likely need to take this medicine for 6 months but should follow-up with your oncologist, Dr. [First Name (STitle) ], to determine exactly how long. You have been instructed on how to administer this medicine by injection. . You will need to have your blood drawn on Friday by the visiting nurses. The results will be faxed to Dr. [First Name (STitle) ], and she will call you with any concerns. . We noticed during this hospitalization that your blood sugars were high. You should discuss this with your primary care physician, [Name10 (NameIs) ] discuss whether there is any need to begin medical treatment for diabetes. . Your follow-up appointments at [Hospital1 18] are below. . Please return to the emergency room or call your doctor if you have any fever, any worsening shortness of breath Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8950], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2132-12-17] 9:00 [First Name4 (NamePattern1) 2747] [Last Name (NamePattern1) 5780], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2132-12-17] 10:00 Completed by:[2132-12-4] ICD9 Codes: 2875, 5859, 412, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6810 }	Medical Text: Admission Date: [2122-5-4] Discharge Date: [2122-5-6] Date of Birth: [2069-1-6] Sex: M Service: MEDICINE Allergies: Flexeril Attending:[First Name3 (LF) 3984] Chief Complaint: liver failure Major Surgical or Invasive Procedure: attempted paracentesis History of Present Illness: 53 yo man with HCV, cirrhosis, distant alcoholism, s/p CABG, h/o AAA repair, CHF, admitted to ICU w/presumed SBP (elev peripheral WBC, abdominal pain, hypothermia) and hepatorenal syndrome. Serum Cr peaked at 4.6 now at 2.5 (baseline pta was around 1). Required vasopressors initially to maintain BP but was not intubated. CT scan [4-20] showed large amt of ascites new since [Month (only) 216]. Did not get paracentesis at that time, was treated empirically with Ceftriaxone. Stabilized and called out to floor. There, after 10 days of ceftriaxone, a paracentesis showed 14 wbc. Hospital course on the medical floor has been marked by ongoing hepatic failure as well as encephalopathy which is said to be relatively new to this patient. He has reportedly been hemodynamically stable. He is being transferred to [Hospital1 18] for further hepatology evaluation. Upon arrival to [Hospital1 18], pt is confused and unable to give additional history. ROS unable to obtain. Past Medical History: Known esophageal varices with h/o GI bleeding from ??????erosive gastritis?????? HCV ?????? unclear whether ever treated Anemia [1-29] GIB and renal failure Colonoscopy with polypectomy GI AV malformation DM II CAD s/p cabg CHF EF 45% Hep C HTN Hyperlipidemia AFib b/l avascular necrosis of hips (new on admission) MRSA Social History: Married, lives w/wife [First Name8 (NamePattern2) ] [Name (NI) 22226] [Telephone/Fax (1) 66908]) who is also seriously ill (? cognitive impairment) [First Name8 (NamePattern2) ] [Known lastname 22226] = brother # [Telephone/Fax (1) 66909]. The patient has three childre. One son lives in [Name (NI) 108]. Family History: Pt. unable to provide due to encephalopathy. Physical Exam: On transfer - Afebrile, Tc 96.6, HR 95 BP 136/60, 95% on RA VITALS on admit:T 96.9 BP 117/51 HR 80 RR 18 93%RA wt 116kg GEN Confused , appears old than stated age, poorly groomed SKIN Yellow, multiple petchia on arms HEENT PERRL, sclera yellow, OP clear NECK JVD, no lad LUNGS CTAB CV RRR no m/r/g ABD distended, non-tender, BS+, shifting dullness EXT 3+edema up to abdomen NEURO Confused, positive asterixis Pertinent Results: labs on admission: [2122-5-4] 07:30PM BLOOD WBC-13.8* RBC-3.74* Hgb-11.3* Hct-33.6* MCV-90 MCH-30.2 MCHC-33.7 RDW-19.2* Plt Ct-63* [2122-5-4] 07:30PM BLOOD Neuts-86.9* Lymphs-8.7* Monos-3.7 Eos-0.6 Baso-0.1 [2122-5-4] 07:30PM BLOOD PT-31.8* PTT-57.7* INR(PT)-3.4* [2122-5-5] 04:34PM BLOOD Fibrino-80* [2122-5-4] 07:30PM BLOOD Glucose-97 UreaN-98* Creat-3.6* Na-133 K-5.4* Cl-98 HCO3-23 AnGap-17 [2122-5-4] 07:30PM BLOOD ALT-123* AST-215* LD(LDH)-257* AlkPhos-75 Amylase-56 TotBili-25.7* [2122-5-5] 04:34PM BLOOD proBNP-3220* [2122-5-4] 07:30PM BLOOD Lipase-100* [2122-5-4] 07:30PM BLOOD Albumin-2.9* Calcium-9.7 Phos-5.3* Mg-2.6 [2122-5-5] 04:34PM BLOOD Cryoglb-NO CRYOGLO [2122-5-6] 12:30PM BLOOD AFP-3.3 [2122-5-4] 07:30PM BLOOD C3-48* C4-5* Labs prior to death: [2122-5-6] 03:18AM BLOOD WBC-9.8 RBC-3.06* Hgb-9.6* Hct-27.6* MCV-90 MCH-31.3 MCHC-34.8 RDW-19.4* Plt Ct-47* [2122-5-6] 12:30PM BLOOD PT-23.3* PTT-44.4* INR(PT)-2.3* [2122-5-6] 03:18AM BLOOD Calcium-9.9 Phos-6.8* Mg-2.8* [2122-5-6] 11:13AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.005 [2122-5-6] 11:13AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2122-5-6] 11:13AM URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [2122-5-6] 11:13AM URINE Hours-RANDOM UreaN-2 Creat-3 Na-121 [2122-5-6] 11:13AM URINE Osmolal-217 HCV viral load: not detected. ABDOMINAL US: 1. Echogenic liver consistent with fatty infiltration. Advanced liver disease, including hepatic cirrhosis/fibrosis cannot be excluded. Marked ascites. The patient was marked for tap. 2. Reversal of the normal portal venous flow. The portal veins, hepatic veins, and hepatic arteries are patent. 3. Gallbladder sludge without evidence of cholecystitis. RENAL US: The right kidney measures 11.4 cm in length, and the left kidney measures 9.4 cm in length. There is no hydronephrosis. The cortical thickness and echogenicity are normal. No shadowing stones are present. The urinary bladder is poorly evaluated secondary to the presence of a large amount of ascites in the pelvis. KUB: Multiple dilated loops of small bowel are identified, the largest measuring approximately 3.6 cm in diameter. There is also prominence of the ascending and transverse colon, the latter measures 6.8 cm in widest diameter. There is no evidence of free intraperitoneal air on these images. The patient is status post median sternotomy as well as aortic bypass graft. There is a hazy appearance to the abdomen consistent with known ascites. CXR: 1. Discoid atelectases. 2. No evidence of congestive heart failure or pulmonary infiltration. ECHO: Technically difficult study. Limited views obtained. 1.The left atrium is mildly dilated. 2.The left ventricular cavity size is normal. Overall left ventricular systolic function is hard to assess given the limited views but the basal portion of the inferior wall appears dyskinetic. 3. Right ventricular systolic function is hard to assess but is probably normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation seen. 5.The mitral valve leaflets are mildly thickened. Very mild (TR- 1+) mitral regurgitation is seen. 6. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. 7.There is no pericardial effusion. Brief Hospital Course: 1. Liver failure/Decompnesated cirrhosis. The reason for fairly rapid decompensation was not clear. Per history, there was no recent alcohol use. The history regarding patient's previous management of Hep C was not clear. MELD score on presentation was 45. Hepatology service was involved and the possibility of liver transplant was enterntained. The patient was encephalopathic. He was managed with Lactulose 45 ml qid. Rifamaxin 400 mg tid. Repeat HepC viral load came back non-detectable. Abd US showed cirrhosis, marked ascites, GB sludge, and patent vessels. Diagnostic paracentesis was attempted on the floor but was unsuccessful ("dry tap"). The patient was treated empirically with Vancomycin and Zosyn for presumed peritonitis. The patient was transfered to the ICU and the arrangements were made for large volume paracentesis to be done by IR given compromised respiratory status. Per IR request, patient was to receive 4 units of FFP to reverse coagulopathy and to lower INR to <2 prior to the procedure. After two units of FFP the patient developed respiratory distress and required 100% NRB to keep Os sats in high 90%. The family meeting led by Dr. [Last Name (STitle) 497] in the presence of the patients brother, [Name (NI) ], as well as the renal fellow and ICU team was held. Given the patient's poor prognosis and multiple comorbidities, the decision was to change the goals of care from DNR/DNI to comfort measures. The patient was started on Morphine drip and passed away in a few hours. The family consented to autopsy. . Renal failure. Presumed to be secondary to hepatorenal syndrome vs. ATN vs. increased compartment syndrome vs. other. Patient was anuric. Renal US showed no evidence of obstruction. Patient has been treated with midodrine and octreotide for presumed hepatorenal syndrome. . Coagulopathy/thrombocytopenia. Coags, cryoglubulin, fibrinogen were monitored. There was no evidence of DIC. Patient received Vit K. FFP/cryo were administered as needed given tenuous respiratory status. . Abdominal pain. The patient was septic on presentation to the OSH and treated empirically for SBP w/o paracentesis. On admission to the ICU, the patient had positive peritoneal signs on exam. WBC was 13.8 on transfer to [Hospital1 ] and then normalized. The patient was treated empirically with Zosyn and Vancomycin. KUB showed ileus. US showed patent vasculature. NG tube was placed but patient then self-removed the NG tube. Medications on Admission: Home meds lisonpril 5 mg qd pantoprazole 40mg [Hospital1 ] oxazepam 15mg qd percocet 5mg q8h lasix 40 mg po bid amiodarone 200 mg po qd glipizide 10 mg qam 5mg qpm atorvastatin 40 mg qd viagra prn Meds on transfer ceftriaxone x 10 days, now complete Insulin SS NPH 38/24 Protonix Lactulose 45 qid MVI Folate Thiamine Aldactone 50 Lasix 80 daily Flagyl 250 tid (added for encephalopathy) Oxycodone 10 q4 hours for ??????abdominal pain?????? Zofran 8 mg po prn Miconazole cream for ? fungal infection around paracentesis site. Genatmicin for ??????pus?????? around his Foley. Foley was d/c??????ed, U/A and Urine culture negative completed 5 days of vancomycin, for a Rash on abdomen, ? cellulitis ?????? but thought was more fungal, so changed to miconazole cream Discharge Disposition: Expired Discharge Diagnosis: Peritonitis Liver cirrhosis, decompensated Coagulopathy Ileus Discharge Condition: Expired [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2122-5-11] ICD9 Codes: 0389, 5849, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6811 }	Medical Text: Admission Date: [2121-7-3] Discharge Date: [2121-7-6] Date of Birth: [2093-4-20] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Bee Sting Kit Attending:[First Name3 (LF) 1835] Chief Complaint: Malignant Melanoma Major Surgical or Invasive Procedure: Stereotactic Brain biopsy History of Present Illness: His oncological history started in 09/[2118]. He was treated in [State 4260]. He had biopsy of a polypoid 4.5 mm [Doctor Last Name ] level III melanoma from the left eyelid. Had excision of left eyelid with reconstruction. In [3-/2120], lymph node recurrence was in the left jaw and a subsequent biopsy consistent with metastatic melanoma. In [5-/2120], a neck dissection revealed melanoma in four out of 76 nodes, no evidence of any extracapsular extension. Then, he had a repeat recurrence within his eyelid and conjunctivae which were resected with clear margins. He has been treated with interferon. However, on interferon which he was having done in [Location (un) ], he developed a new lung nodule as well as an eyelid recurrence. Lung nodule was surgically biopsied and was found to be consistent with metastatic melanoma. He was then referred to the melanoma clinic here at [Hospital1 69]. As part of the screening he was found to have new single metastasis of 9 x 5 mm in the left frontal lobe. Past Medical History: childhood heart murmur history of peptic ulcer disease Social History: college graduate with a degree in culinary arts and works as a cook. He does smoke about a pack a day and has done do for the past eight to ten years. He drinks occasionally. He is divorced. Family History: Family history is remarkable for an aunt who died of cancer and his mother told him that there is a family history of melanoma. Physical Exam: GENERAL: He is alert, pleasant, cooperative young man in no acute distress. He is well developed, well nourished. He does have multiple tattoos. VITAL SIGNS: Blood pressure is 142/82, pulse of 80, respirations 16, temperature 97. CARDIOVASCULAR: He has regular rate and rhythm. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation bilaterally. EXTREMITIES: No clubbing, cyanosis, or edema. HEENT: Head, he has a well-healed scar in the left lower eyelid. There is no evidence of any melanoma or hyperpigmented area. He does have a partial left lid ptosis laterally because of the reconstructive surgery done there. Eyes, pupils equal, round, reactive to light. Because of the retraction of the lid, he does have some difficulties moving the left eye to the left as well but he has full extraocular movements on the right. Visual fields are full. There is no nystagmus. Mouth examination, tongue is midline, palate elevates symmetrically. Oral mucosa is pink and moist. NECK: Soft and supple. NEUROLOGIC: Cranial nerves II through VI, IX through XII are intact. He does have some diplopia interestingly more on rightward gaze as well as the leftward gaze he states because of the difficulty moving the eyes, although I cannot find any evidence of a CN III on examination. Medial gaze in the left eye appears to be intact as well as on the CN VI on the right eye. This is not complete. He cannot wrinkle the brow and close the eye fairly well and has some decreased excursion of the angle of the mouth. Motor is [4-4] bilaterally, normal tone, no drift. Sensation is intact to light touch, temperature, joint position sense, and vibration throughout. Cerebellar, he has normal appendicular coordination, normal gait, is able to toe tandem and heel walk quite well. Reflexes are [12-2]+ throughout with downgoing toes. Pertinent Results: [2121-7-3] 04:12PM PT-12.0 PTT-25.6 INR(PT)-1.0 [2121-7-3] 04:12PM PLT COUNT-195 [2121-7-3] 04:12PM WBC-12.5* RBC-4.36* HGB-13.0* HCT-35.4* MCV-81* MCH-29.8 MCHC-36.6* RDW-13.9 [2121-7-3] 04:12PM CALCIUM-8.4 PHOSPHATE-2.1# MAGNESIUM-1.9 [2121-7-3] 04:12PM GLUCOSE-120 UREA N-13 CREAT-1.0 SODIUM-135 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-28 ANION GAP-10 Brief Hospital Course: Pt was admitted to the Neurosurgery Service and underwent a stereotatic biopsy without complication. He was monitored overnight in the PACU, a post op CT did not show any sign of hemorrhage. Overnight he complained of significant facial, head and pulmonary pain requiring him to be started on a PCA. Neurologically he was at baseline with Cranial nerves II through VI, IX through XII are intact. He does have some diplopia on rightward gaze and lefward gaze. Motor strenght was intact and no pronator drift. A chronic pain service consult was obtained. They recommended increasing neurontin to 600mg TID, methadone to 10mg po TID, cont oxycodone 25 po q3-4 PRN, d/c iv morphine. He was transferred to the surgical floor on POD#1 tolerating a regular diet, urinating without problems. An MRI of his brain showed: "Status post left frontal craniotomy. Blood products at the surgical site are noted without significant edema or mass effect. Subtle residual enhancement is identified at the inferior aspect of the surgical site in the left frontal lobe. No evidence of hydrocephalus." He will f/u in brain tumor clinic. He should be referred to [First Name4 (NamePattern1) 1193] [Last Name (NamePattern1) 1194] Center if needed to control pain. Medications on Admission: Percocet and Neurotin Discharge Medications: 1. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:90 Capsule(s) Refills:2 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day: take while on decadron. Disp:6 Tablet(s) Refills:0 3. Dexamethasone 1 mg Tablet Sig: take 2 tablets tid on [7-5] and one tablet tid on [7-6] Tablet PO see above for 2 days. Disp:9 Tablet(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: Use while on narcotics. Disp:60 Capsule(s) Refills:2 5. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:180 Capsule(s) Refills:2 7. Oxycodone 5 mg Tablet Sig: Five (5) Tablet PO Q3H (every 3 hours) as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Malignant Melanoma Discharge Condition: Neurologically stable Discharge Instructions: Keep incision clean and dry do not get wet until staples are removed No heavey lifting No driving while on narcotics Watch incision for redness, drainage, swelling, bleeding, fever greater than 101.5 call Dr[Name (NI) 9034] office Followup Instructions: Follow up in Brain tumor clinic Provider: [Name10 (NameIs) 5005] [Last Name (NamePattern4) 5342], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2121-8-11] 11:00 Completed by:[2121-7-6] ICD9 Codes: 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6812 }	Medical Text: Admission Date: [2100-6-24] Discharge Date: [2100-7-3] Date of Birth: [2052-4-4] Sex: F HISTORY OF PRESENT ILLNESS: This is a 48 year old woman with presumptive diagnosis of Crohn's disease presumptively, PUD diagnosed in [2087] which was refractory to medical management requiring two operations, a vagotomy/antrectomy and Billroth obstruction requiring two additional surgeries, a Roux-en-Y and a revision. Despite these aggressive interventions, the patient has been unable to tolerate p.o. feeds without substantial pain. The patient presents with total parenteral nutrition chronically. In [2100-2-21], small intestine biopsy found to be consistent stomach area, subsequently the patient was found to be ANCA negative with gastrointestinal series and computerized axial tomography scan suggestive of Crohn's disease. The patient was then started on Prednisone 60 mg q.d. The patient was in this state of health until four days prior to admission when she began to develop fevers up to 104?????? with nightsweats and increase in baseline nausea, vomiting and diarrhea. One day prior to admission, the patient developed a dry cough, dependent edema and fatigue. The patient presented to the [Hospital6 256] for further evaluation. PAST MEDICAL HISTORY: 1. Multiple stomach operations as listed above 2. Tonsillectomy 3. Appendectomy 4. Previous Hickman line infection in [2098-8-22] with Staphylococcus aureus treated with six weeks of Vancomycin MEDICATIONS: 1. Prednisone 40 mg p.o. q.d. 2. Compazine 25 mg prn 3. Tylenol prn 4. Zantac 5. Duragesic 75 mcg every 72 hours 6. Total parenteral nutrition ALLERGIES: Sulfa drugs-develops a rash FAMILY HISTORY: Father with ulcer disease, mother with cerebrovascular accident. SOCIAL HISTORY: The patient is a state representative and lives with husband and children, denies tobacco or alcohol use. PHYSICAL EXAMINATION: The patient is in general a [Doctor Last Name 11332] woman with round moon facies, pleasant in no apparent distress. Head, eyes, ears, nose and throat examination, pupils are equal, round, and reactive to light and accommodation, extraocular movements intact, mucous membranes moist. Cardiovascular examination: Normal S1 and S2, regular rate and rhythm, no murmurs, rubs or gallops appreciated. Pulmonary examination, rhonchi diffusely in bilateral lung fields, in some segments late inspiratory crackles are audible. Abdominal examination, slightly distended diffusely tender to palpation, positive bowel sounds. Well healed midline scar, no rebound tenderness. Chest examination, Hickman site clean, dry and intact without erythema. Extremity examination with 2+ pitting edema up to the knees. Neurological examination, cranial nerves II through XII grossly intact to motor and sensory examination. Mental status intact. Rectal examination was guaiac positive as per surgery team. LABORATORY DATA: White blood cell count 15.7, hematocrit 28.9, white count differential 70% neutrophils, 13% bands, 9% lymphs, 8% monos, platelet count 300, PT 11.8, PTT 30.0, INR 0.9. Urinalysis, color yellow, specific gravity 1.034, negative for blood, nitrates, glucose, ketones, bilirubin 30 mg/dl of protein, 0-2 red blood cells, [1-25] white blood cells, no bacteria or yeast. +/+ mucous noted. Glucose 93, sodium 138, potassium 3.4, chloride 99, bicarbonate 22, BUN 19, creatinine .2. ALT 49, AST 82, alkaline phosphatase 1101, amylase 18, total bilirubin .6, lipase 19, albumin 2.6, calcium 7.3, phosphate 3.4, magnesium 1.8. Chest x-ray significant for severe bilateral opacities. HOSPITAL COURSE: In the Emergency Department the patient was afebrile, oxygen saturation of 84% on room air, 92% on 4 liters. Examined by the Surgery Team for abdominal symptoms and was found to have a nonacute abdomen. Sputum cultures sent times three for pneumocystis carinii pneumonia as well as blood cultures. The patient was begun on broad coverage to cover pneumocystis carinii pneumonia versus atypical pneumonia. Antibiotics included Levofloxacin, Clindamycin, Primaquine. Right upper quadrant ultrasound was performed for the high liver function tests showing a large amount of layering sludge in the gallbladder with a normal liver. On [6-25], the first of an eventual 4 out of 5 blood cultures returned as positive for yeast. The right subclavian Hickman was pulled and tip sent for culture. The patient was started on Amphotericin B, Pripto, Cytomegalovirus, HSV, legionella studies sent as well as stool studies for fecal leukocytes, ova and parasites. On [6-26], holosystolic murmur located in the lower left sternal border was noted, I/VI and echocardiogram was performed to evaluate for endocarditis, the results of which were negative. On this day the patient's cough became productive, sputums were sent for multiple studies and arterial blood gases was performed for increasing oxygen requirement. The patient was sating 93 to 100% on 70% face mask. Arterial blood gases showed a pH of 7.42, pCO2 of 45, pO2 of 66, total bicarbonate of 30, base 3. The patient was taken for bronchoscopy and [Male First Name (un) ], intubated electively for hypoxia. On bronchoscopic examination no abnormalities were visualized with microcystic and cytocytic studies sent. The patient was extubated the day following the procedure, 97 to 98% on 50% face mask. The patient's pneumocystic carinii pneumonia medications were switched from Clindamycin and Primaquine to Pentamidine by the pulmonary team. On [6-27], the patient had a hematocrit of 24.7, received 1 unit of packed red blood cells with a hematocrit revised to only 25.7. The following day she received two more units of packed red blood cells rising appropriately to 30.1. Echocardiogram results revealed ejection fraction of greater than 55%, mildly thickened mitral valve leaflet, normal aortic valve leaflet, no evidence of endocarditis. On [6-29], the patient's sputum cultures grew out [Female First Name (un) 564] Albicans believed to be a contaminate. Yeast species for the blood cultures described as Parapsilosis. The patient was kept on intravenous Amphotericin as [Female First Name (un) 564] Parapsilosis can be resistant to Fluconazole as suggested by the Infectious Disease Service. On [6-30], the patient's respiratory status began to improve with an oxygen saturation of 93% on 2.5 liters. On this date the patient first began to complain of her severe back pain which was treated initially with prn Morphine. The patient was treated with Dilaudid PCA Zanaflex with prn Morphine discontinued. On [7-1], an magnetic resonance imaging scan of the spine was performed for evaluation of the lower back pain. Results were negative for stenosis foraminal narrowing, nerve/cord impingement, normal alignment was noted. On [7-2], given the negative blood culture results from [6-29], the patient had a repeat PICC line placement under fluoroscopic guidance. The patient's pulmonary status at this time was much improved. She was sating 94% on 2 liters. The patient was at this point evaluated by physical therapy and felt to be safe to return home with supplemental oxygen. The patient was discharged [7-3] in fair condition. DISCHARGE MEDICATIONS: 1. Duragesic patch 100 mcg topically every 3 days 2. Levofloxacin 500 mg p.o. q.d. 3. Clindamycin 450 mg p.o. q.6 hours 4. Primaquin 15 mg p.o. q.d. 5. Prednisone 40 mg p.o. q.d. 6. Protonix 40 mg p.o. q.d. 7. Zanaflex 2 mg p.o. q.h.s. 8. Amphotericin 24.5 mg intravenously q.d. 9. Dilaudid 6 mg p.o. q.i.d. DISPOSITION: Discharged to home. DISCHARGE DIAGNOSIS: 1. Candidemia 2. Pneumonia versus adult respiratory distress syndrome 3. Candidal Line sepsis 4. Pain control FOLLOW UP: 1. Arranged with primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], phone [Telephone/Fax (1) 250], [Company 191] [Location (un) ] [Hospital Ward Name 23], North [Apartment Address(1) 33818] PM, [2100-8-4]. 2. Infectious Disease Clinic within one week of discharge from hospital, phone [Telephone/Fax (1) 457]. 3. Pain Clinic [Telephone/Fax (1) 1091]. 4. Pulmonary office for appointment within two to three weeks following discharge from the hospital, phone [Telephone/Fax (1) 5091]. 5. [Location (un) 511] Health Therapy phone 1-[Telephone/Fax (1) 33819]. DR.[Last Name (STitle) ],[First Name3 (LF) 7853] C. 12-869 Dictated By:[Name8 (MD) 33820] MEDQUIST36 D: [2100-7-15] 19:01 T: [2100-7-15] 20:27 JOB#: [Job Number 33821] ICD9 Codes: 486, 7907
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6813 }	Medical Text: Admission Date: [2155-10-26] Discharge Date: [2155-10-28] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1943] Chief Complaint: "Colostomy bag explosion." Major Surgical or Invasive Procedure: Endoscopy with biopsy History of Present Illness: Mr. [Known lastname 13170] is a very pleasant 87 y/o gentleman with CAD s/p CABG, rheumatoid arthritis on methotrexate, and chronic renal insufficiency who presented to the ED today with a complaint of explosion of his colostomy bag. Of note, he ha sigmoid colectomy with end colostomy for perforated diverticulitis [10-7]. Patient was discharged to rehab on [10-14] and has been doing very well since.He has not had much abdominal pain and has been doing exercises at his rehab. No nausea or vomiting, poor appetite consistent with his appetite over the past year. Today he presented with 1 episode of large volume melena that exploded his colostomy bad. Dark stool, no red blood. He normally walks independently and feels a bit weak. Today he is otherwise feeling fine and has no complaints. Surgery evaluated him, thinking that this is related to his anastamosis - he had a low hartmann - so likely not bleeding from there. GI evaluated patient in ED as well - and asked to admit to ICU. Vitals from ED were BP 126/87, HR 106 ( he's in afib, not new), RR 27, SP02 100%RA, Afebrile. Without complaints. Colostomy bag was just changed and he has minimal dark stool in it, wich was guaiac positive. Pt was lavaged in ED, and that was negative. Patient received 1 units in ED, and one on arrival to the MICU. On the floor, patient was free of complaints, Temp 97.7, HR 102, BP 138/74 O2Sat 100%RA. 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. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits Past Medical History: Rheumatoid arthritis on methotrexate CAD B/L carotid stenosis, s/p CEA and stent on R, 60-70% on L Prostate Ca s/p radiation Microcytic anemia CRI (BL 1.5-1.6) Past Surgical History: CABGx4 15-20 yrs ago @ [Hospital1 ] R CEA [2145] R carotid stent [2151] Back surgery [83] yrs ago Social History: Smoked 1ppd x 20 yrs but quit 20 yrs ago. No EtOH or RDA. Retired, lives with wife. Family History: Noncontributory Physical Exam: MICU ADMISSION PHYSICAL: GEN: alert, awake, oriented x3, not in acute distress. HEENT: PERRLA, MMM. Oropharynx clear. Poor dentition. Neck: No JVD, no lymphadenopathy, supple. Chest: CTAB. No wheezes, no crackles. CABG scar. CVS: S1 and S2 were irregular. Abdomen: ND,NT, soft, good bowel sounds presente. No organomegaly, no ascites. Colostomy bag in place with minimal dark stool. Large midline scar, well healed, with multiple strips of tape. Extremities: No pitting edema. Good pulses peripherally. Skin: dry skin with seborrheic keratotic lesions, no jaundice. Neurologic: Cranial nerves intact grossly. Good strength throughout. Pertinent Results: ADMISSION LABS: [2155-10-26] 09:30AM WBC-4.4# RBC-2.11* HGB-6.4* HCT-20.3* MCV-96 MCH-30.2 MCHC-31.4 RDW-16.5* [2155-10-26] 09:30AM NEUTS-61.6 LYMPHS-32.1 MONOS-5.0 EOS-0.8 BASOS-0.5 [2155-10-26] 09:30AM PLT COUNT-391 [2155-10-26] 09:30AM PT-13.8* PTT-28.9 INR(PT)-1.3* [2155-10-26] 09:30AM GLUCOSE-120* UREA N-30* CREAT-1.1 SODIUM-137 POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-30 ANION GAP-11 [2155-10-26] 09:44AM LACTATE-1.1 [2155-10-26] 03:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2155-10-26] 03:52PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.017 Hematocrit Trend: [2155-10-26] 09:30AM HCT-20.3* [2155-10-26] 11:52PM HCT-23.2* [2155-10-27] 05:00AM Hct-25.1* [2155-10-27] 12:13PM Hct-25.1* [2155-10-27] 09:25PM Hct-23.7* [2155-10-28] 07:51AM Hct-24.8* DISCHARGE LABS: [2155-10-28] 07:51AM BLOOD WBC-6.7 RBC-2.80* Hgb-8.4* Hct-24.8* MCV-89 MCH-30.1 MCHC-33.9 RDW-17.1* Plt Ct-426 [2155-10-28] 07:51AM BLOOD Glucose-108* UreaN-24* Creat-1.0 Na-134 K-4.1 Cl-102 HCO3-27 AnGap-9 Imaging: EGD: [2155-10-27] Normal esophagus. Stomach: Lumen: A medium size hiatal hernia was seen. Excavated Lesions A single linear non-bleeding 1.5 cm ulcer was found in the antrum. The ulcer was clean based without stigmata of recent bleeding. Duodenum: Excavated Lesions Two ulcers were found in the duodenal bulb. The first was 1.5 x 0.5cm with a clean yellow base. No visble vessels or clots were seen. The other ulcer was noted on the opposite duodenal wall and was 0.7cm in diameter. It had a clean white base without visible vessels or clots. No blood was seen. Other procedures: Cold forceps biopsies were performed to assess for H. pylori at the stomach. Impression: Medium hiatal hernia Ulcer in the antrum; Ulcers in the duodenal bulb(biopsy). Otherwise normal EGD to third part of the duodenum Recommendations: Await biopsy results. Treat for H. pylori if positive. Avoid NSAIDs, Prilosec 20mg [Hospital1 ]. The ulcers were the likely cause of the melena. All the ulcers are currently at a low risk for re-bleeding. Given gastric ulceration would recommend repeat EGD in 8 weeks time. F/u with inpatient GI team Gastric biopsy pending Brief Hospital Course: 87 y/o gentleman s/p Hartmann's procedure for perforated sigmoid diveriticulitis in [9-/2155] who was admitted with acute gastrointestinal hemorrhage likely secondary to gastric ulceration. ACTIVE ISSUES: 1. acute gastrointestinal hemorrhage: presented with large volume melena accompanied by acute drop in hematoctit from prior baseline of 26-29 to 20.3. Patient was initially admitted to the ICU on protonix gtt for close monitoring of hemodyanmics and serial hematocrits. He was transfused 2U pRBC with Hct stabilizing at 23-25. Subsequent EGD showed multiple nonbleeding ulcers in the stomach which were felt to be the cause of initial hemorrhage. Etiology of ulcerations were likely multifactorial from recent stress reaction (following colectomy), NSAID use (on high dose aspirin), possible contribution from methotrexate, +/- H pylori (biopsy pending). Patient was placed on PPI [Hospital1 ], [Hospital1 ] reduced to 81mg, and methotrexate was held indefinitely. He will need repeat endoscopy in 8 weeks to ensure resolution of ulcerations. 2. atrial fibrillation: EKG on admission showed asymptomatic atrial fibrillation. Heart rate remained well controlled on metoprolol 25mg [Hospital1 ]. Despite CHADS score of [12-19], patient did not start on anticoagulation given recent GI bleed. He should follow up with primary care physician to further discuss the risks of anticoagulation and to complete diagnostic evaluation with possible ECHO. [Hospital ] MEDICAL PROBLEMS: 3. s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 3379] for perforated diverticulitis: patient healing well with no evident complications. Patient will follow up in [Month (only) 958]-[Month (only) 547] to discuss the possibility of ostomy reversal to regain intestinal continuity. 4. Rheumatoid arthritis: stable with no signs of active joint inflammation. Discontinued methotrexate, given possible contribution to mucosal ulceration. 5. CAD: stable, with no signs of ischemia, Patient continued on metoprolol with aspirin dose reduced to 81mg as above. TRANSITIONS OF CARE: # GI Bleed: - continue [Hospital1 ] PPI - dose reduce [Hospital1 ] to 81mg - hold methotrexate - f/u gastric biopsy - repeat scope in 8 weeks # afib: new onset - continue rate control - PCP follow up regarding longterm management Medications on Admission: Folic acid 1 Heparin 5000 Mtx 15 weekly Metoprolol 25 Oxycodone 5 Tramadol 50 [Hospital1 ] 325 Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: do not exceed 4gms daily. Discharge Disposition: Extended Care Facility: [Location (un) 582] at [Location (un) 620] Discharge Diagnosis: Primary Diagnosis: acute gastrointestinal hemorrhage gastric ulcers atrial fibrillation Secondary Diagnosis: rheumatoid arthritis perforated diverticulitis s/p colectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [Known lastname 13170], You were admitted to the hospital with a gastrointestinal bleed. You had an endoscopy which showed ulcers in your stomach, which were likely the cause of the bleeding. You received 2 units of red blood cells and your blood counts stabilized. You will need to take a acid suppressing medication twice daily and have a repeat endoscopy in 8 weeks to ensure that these ulcerations have resolved. Please make the following changes to your medication regimen: - HOLD methotrexate until your doctor tells you that you can restart - START omeprazole 40mg twice daily - CHANGE your aspirin to 81mg daily It was a pleasure taking care of you during this hospitalization Followup Instructions: Department: ENDO SUITES When: FRIDAY [2155-12-26] at 12:30 PM Department: DIGESTIVE DISEASE CENTER When: FRIDAY [2155-12-26] at 12:30 PM With: [Name6 (MD) 1948] [Last Name (NamePattern4) 1949], MD [Telephone/Fax (1) 463] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3202] Campus: EAST Best Parking: Main Garage ICD9 Codes: 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6814 }	Medical Text: Admission Date: [2125-11-14] Discharge Date: [2125-11-19] Date of Birth: [2043-8-9] Sex: M Service: MEDICINE Allergies: Diltiazem Attending:[First Name3 (LF) 2195] Chief Complaint: Hypotension, rigors Major Surgical or Invasive Procedure: None History of Present Illness: 82 yo M with history of multiple episodes of past syncope, CAD, hypopituitarism. He is not the most clear historian; however, he reports periods of uncontrollable shaking in his rehab facility prior to presenting to the [Hospital6 12112] ED the night of [2125-11-13]. He was assessed in triage there as having a BP of 59/36 with temp of 96 pulse of 53. At [Last Name (un) 4199] ED, he had a WBC count of 8.9, HCT of 32.9, and a lactate of 1.7. A head CT was performed and noted opacified left maxillary sinus, though no acute intracranial pathology. He reports a clear nasal drainage, though denies any facial pain or yellowish nasal drainage. He has had a scant cough, though denies a productive cough. He reports diarrhea in the last week. He was given 1.5 L of fluid, was started on dopamine and avelox and was then transferred to the [Hospital1 18] ED. He notes that he was treated at [Hospital1 2025] (records state that he was hospitalized from [10-30] to [11-6] for syncopal event and UTI) one week ago and was discharged to rehab, where he has remained in the last week. He was reported as ending a 14 day course of Cipro for complicated UTI on [2125-11-13]. His daughter notes that the patient has been admitted to several different hospitals in the area recently for urinary tract infections. Upon presentation to the [Hospital1 18] ED, vitals were: HR 74, BP 85/58, O2Sat 98%. Had a RIJ sepsis line place as well as a 20g IV. Got a total of 3 L NS in ED. Received 1 g Vancomycin and 4.45 g Zosyn. CVP was 6 at time of signout to the ICU. Receiving 0.09 of levophed prior to transfer to the ICU. Urinalysis was performed. Vitals prior to transfer to the unit were: T 97.3, HR 78, BP 115/51, RR 14, O2Sat 99% 3L NC. ROS: (+)ve: shaking chills, diarrhea, sweats, rhinorrhea (-)ve: fever, nausea, vomiting, constipation, visual changes, sore throat, myalgias, dysuria, abdominal pain Past Medical History: 1) Diabetes mellitus 2) Coronary artery disease with missed IMI in [2105] 3) COPD 4) Pituitary adenoma resection [2106] and [2108] with resulting hypopituitarism 5) OSA 6) Hypertension 7) Hyperlipidemia 8) Hypothyroidism 9) CKD baseline Cr in [6-/2125] was 1.4 10) Gout 11) Dementia 12) Syncope, recurrent since [2101] - Tilt table testing negative x 2 - Holter monitor from [7-/2125]: SR 41 to 92, mean 52, APBs with 6 beat run @ 102 - Nuclear exercise stress test [7-/2124]: [Doctor First Name ] 2'[51]", 5 mets, HR 54 to 70, SBP 90 to 130, no CP, no EKG changes, EF 49% with inferior hypokinesis and moderate fixed inferior defect - Cardiac cath [4-/2121]: mild LCA, collateralized 100% RCA, calcified mild R fem stenosis - Interim IMI by EKG in [2105] Social History: He receives his primary care at [Location 1268] VA with Dr. [Last Name (STitle) 29697]. He receives cardiology care with Dr. [Last Name (STitle) 84073] at [Hospital1 2025]. Tobacco: previously smoked for 80 pack-year history, quit 12 years ago (later stated he quit only months ago) EtOH: Denies Illicits: Denies Family History: NC Physical Exam: VS: T 98.3, HR 80, BP 140/61, RR 17, O2Sat 99% 3L NC. GENERAL: NAD, occasional shaking chill HEENT: PERRL, EOMI, oral mucosa slightly dry, NECK: Supple, no [Doctor First Name ], no thyromegaly CARDIAC: RR, nl S1, nl S2, nl M/R/G LUNGS: CTAB anteriorly ABDOMEN: BS+, soft, NT, ND EXTREMITIES: Warm and well-perfused, no edema or calf pain SKIN: No rashes/lesions, ecchymoses. NEURO: Oriented only to self, difficult to understand his speech, BUE strength intact PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission Labs: . [2125-11-14] 02:50AM WBC-8.7 RBC-3.71* HGB-11.2* HCT-34.5* MCV-93 MCH-30.3 MCHC-32.6 RDW-14.7 [2125-11-14] 02:50AM PLT COUNT-257 [2125-11-14] 02:50AM PT-14.1* PTT-31.8 INR(PT)-1.2* [2125-11-14] 02:50AM GLUCOSE-171* UREA N-31* CREAT-1.7* SODIUM-137 POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-17* ANION GAP-15 [2125-11-14] 02:50AM ALT(SGPT)-25 AST(SGOT)-25 ALK PHOS-65 TOT BILI-0.2 [2125-11-14] 02:50AM LIPASE-17 [2125-11-14] 02:50AM ALBUMIN-3.2* [2125-11-14] 02:59AM LACTATE-1.0 . Cortisol stimulation test (last dose prednisone 15 mg on morning of [2125-11-16]) -- [2125-11-18] Cortisol (5:37am) 1.1 --cosyntropin given at 6:17am [2125-11-18] Cortisol (6:36am) 11.8 [2125-11-18] Cortisol (7:38am) 16.4 [2125-11-18] FSH: < 1 [2125-11-18] LH: < 1 [2125-11-18] TSH: 1.1 [2125-11-18] Free T4: 0.30 [2125-11-18] ACTH: pending . MICRO [2125-11-14] Blood cx: Pending [2125-11-17] Blood cx: Pending [2125-11-14] Urine cx: negative [2125-11-17] Catheter tip: negative . IMAGING: . Chest X ray [2125-11-14]: Appropriately positioned central venous line with no pneumothorax. Brief Hospital Course: 82 yo M with history of multiple episodes of past syncope, CAD, and hypopituitarism, who presented with rigors and hypotension. #. Hypotension: He was admitted with hypotension requiring pressor therapy with norepinephrine. He was afebrile without an increased WBC count and was not tachycardic. He was started empirically on antibiotics (cefepime, ciprofloxacin, and vancomycin) for possible sepsis. He was also given an increased dose of prednisone 15 mg daily for three days as stress dose steroids given his chronic steroid use. He was aggressively fluid resuscitated on admission and his blood pressure responded well. It remained stable after his acute presentation. Cultures from outside hospital were as follows: [Last Name (un) 4199] blood cultures positive 2 out of 4 bottles for coagulase negative staph (presumed contaminant), [Location (un) 2251] urine cx from [10-19] had GPC/GNR but no other speciation. Patient's urine, blood, and CVL catheter cultures from this admission yeilded no growth. Based on these results it is unclear that his presenting hypotension was at all related to infection. Patient was persistently orthostatic throughout admission even after significant volume resuscitation. At time of discharge patient's blood pressure continued to drop with standing (< 20 points systolic) but was without orthostatic symptoms. Patient is encouraged to continue increased fluid intake to prevent orthostatic symptoms. Patient's hypopituitarism (adrenal insufficiency, hypothyroidism, and likely testosterone deficiency) was also thought to contribute to his symptoms. . #. Panhypopituitarism: He had a recent decrease in his dose of levothyroxine from 100 mcg daily to 25 mcg daily without explanation. He had a normal TSH during this admission. However, his Free T4 was found to be low at 0.30. Endocrine Team was consulted and patient's dose of levothyroxine was increased back to 100 mcg daily. Additionally, his prednisone was increased from 5mg daily to 15 mg daily for a three day course immediately after presentation. After this stress dose steroid course patient underwent an attempted cortisol stimulation test with cosyntropin on [2125-11-18] that revealed a very low basal cortisol level (1.1). His concurrent undetectable LH and FSH make adrenal insufficiency a likely diagnosis. The Endocrine team also stated that patient likely suffered from testosterone deficiency and that he may benefit from closely monitored testosterone replacement therapy in the future. He should continue his daily prednisone 5 mg po daily. He will likely require stress dose steroids (15 mg po x 3 days) during acute illness. It is very important that patient establish care with an Endocrinologist to monitor these issues. Patient had previously established care with Dr. [Last Name (STitle) 41292] at [Hospital1 2025]. Because he has not been seen there in years he will need to reestablish care. His records will be faxed to the [Hospital 2025] [Hospital 1800] clinic and he will be contact[Name (NI) ] to schedule an appointment. If he does not hear from the [Hospital 1800] Clinic in 2 weeks please contact them at [Telephone/Fax (1) 84074]. #. Diabetes: He had some hyperglycemia after admission, likely related to his underlying diabetes and his increased dose of steroids. He was managed with an insulin sliding scale and finger stick blood glucose measurements qachs. Recommend monitoring HbA1C in outpatient setting. Consider adding Januvia to diabetic regimen if possible in the future. #. COPD: Stable. He was continued on his home advair and tiotropium. . #. CAD / Hypertension / Hyperlipidemia: He was continued on simvastatin and aspirin. His lisinopril and metoprolol were initially held due to hypotension and ultimately restarted at home dose without complications. #. Gout: He was continued on his home allopurinol. #. Dementia: He was continued on donepezil #. Prophylaxis: He was given SC heparin for DVT prophylaxis. #. Access: He had a right IJ central line placed for central venous access on [2125-11-14] which was discontinued [2125-11-17]. #. Communication: With patient and daughter, [Name (NI) ] ([Telephone/Fax (1) 84075]; [Telephone/Fax (1) 84076]) #. Code Status: Full Code, confirmed with patient's daughter . #. Dispo: Rehab while awaiting [Hospital3 ] bed assignment Medications on Admission: 1) Aspirin 81 mg daily 2) Donepezil 10 mg daily 3) Metoprolol succinate 12.5 mg daily 4) Lisinopril 10 mg daily 5) Prednisone 5 mg daily 6) Trazodone 50 mg PO QPM 7) Omeprazole 20 mg daily 8) Allopurinol 100 mg daily 9) Advair 250/50 1 INH [Hospital1 ] 10) Calcium carbonate 1250 mg [Hospital1 ] 11) Wellbutrin SR 200 mg [Hospital1 ] 12) Tiotropium bromide 1 INH daily 13) Levothyroxine 25 mcg daily 14) Metoclopramide 10 mg QACHS 15) Simvastatin 80 mg PO QPM 16) Senna 2 tabs PO daily 17) Cipro 500 mg Q12H (course ended on [2125-11-13]) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Insulin Please continue humalog insulin sliding scale with qachs fsbs. 14. Synthroid 100 mcg Tablet Sig: One (1) Tablet PO once a day. 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Discharge Disposition: Extended Care Facility: [Location (un) 29393] - [Location (un) 2251] Discharge Diagnosis: Hypotension Hypopituitarism Hypothyroidism Diabetes Mellitus type 2 Hypertension Discharge Condition: Patient is hemodynamically stable, afebrile, tolerating po diet, able to ambulate with minimal assistance Discharge Instructions: You presented to the Emergency Department with very low blood pressure. You were treated with IV fluids, antibiotics, and medications to increase your blood pressure. You were admitted to the ICU and monitored overnight. Your symptoms improved and you were transferred to the medicine floor. You underwent several studies to evaluate the cause of your symptoms. The exact cause of your symptoms on presentation was not determined. Your hypopituitarism and dehydration are likely significant contributors these recurrent symptoms of loss of consciousness and low blood pressure. It is very important that you establish care with an Endocrinologist to manage this condition. . The following changes were made to your home medications: 1) INCREASE levothyroxine (Synthroid) to 100 mcg tablet, 1 tablet daily Followup Instructions: Please follow up with your primary care provider within one week of discharge. It is very important that you establish care with an Endocrinologist to manage your hypopituitarism and hypothyroidism. The [Hospital 84077] clinic at [Hospital3 2576] [Hospital3 ] will be contacting you to schedule a follow up appointment. If you do not hear from the [Hospital 84077] Clinic within two weeks please contact [Telephone/Fax (1) 84074]. ICD9 Codes: 5990, 412, 496, 2449, 2749, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6815 }	Medical Text: Admission Date: [2112-9-15] Discharge Date: [2112-10-5] Date of Birth: [2051-5-13] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 12174] Chief Complaint: Right arm pain/swelling. Major Surgical or Invasive Procedure: Left IJ line insertion [2112-9-20] History of Present Illness: 61M with HCC, HCV cirrhosis, CHF, DM, history of CVA with left sided weakness, PVD, asthma, presenting with one week of RUE swelling and pain. He and his VNA first noticed RUE swelling about one week ago, and feels this has been getting gradually worse over the course of the week. It also became painful and feels somewhat tight and stiff to move. There has not been weakness. His VNA may have noted redness. No fevers or chills. There was also potentially concern fo swelling on the right side of the face with some symptoms of eye irritation as well (watery eye, itching, no blurred vision). He had a presentation in [2112-7-6] with swelling that involved the left arm, but he felt this was more limited to the L elbow at that time, however - not involving hand or shoulder. He had ultrasounds, bone scan, ortho evaluation, rheum evaluation, all unrevealing. Possible that this was CRPS, and he was treated with lidocaine patches. He denies headache, chest pain, dyspnea, cough, abdominal pain, N/V/D, change in urination, poor glucose control. He does endorse weight gain of 40# "in fluid weight" in the past 6 months, maybe 20# since last admission which he thinks is due to kidney stress and needs to have him fluids at that time. . In the ED, afebrile with normal HR/BP/O2 sats. UENIs without evidence of proximal/distal clot on R. Received 12 units insulin for glucose >400. Admitted for further workup. Past Medical History: ONC HISTORY: Biopsy-proven HCV cirrhosis since [2101]. Noted [5-/2112] to have a 4.7 x 4.3 cm right hepatic lobe mass displaying imaging characteristics consistent with HCC. Biopsy showed well-to-moderately differentiated HCC. Further imaging studies have been limited due to history of contrast nephropathy requiring hydration (which is further limited by cardiac concerns). Discussions of chemoembolization, RFA-sorafenib, ans sorafenib systemic chemo. . OTHER PMH: - HCV cirrhosis, viral load 10/11/[2111]=9,619,847 IU/mL. EGD normal [5-/2112] - Acute and chronic diastolic CHF, LVEF 50% in [12/2109] and 55% on most recent [5-/2112] admission. Hx fluid overload. - Diabetes mellitus for 36 years, on insulin. - Pontine stroke in [2109] with some residual left arm, left leg weakness. The patient also reports that some emotional dysregulation in that his laughter, anger and sadness responses are sometimes inappropriate. - PVD, status post right BKA. - History of osteomyelitis, s/p left foot debridement, 10/[2111]. - Hypertension. - Chronic back pain, spinal stenosis, takes morphine, baclofen and gabapentin. - GERD. - Asthma. Multiple inhalers. - Hx potassium dysregulation in the setting of diuretics. - Anemia. - Proteinuria and microscopic hematuria. Presumed [3-9] DM. - Cholecystectomy, [2099]. - Right wrist ganglion removal in [2080]. - Left eye laser surgery in [2111] for retinal detachment. - Contrast induced renal insufficiency Social History: Lives in an apartment by himself with 2 PCAs in floors above and below him. H/o 20 PY tob use -quit in [2109-9-6]. He has a remote history of alcohol and drugs, but has been sober for the last 15-20 years. He is on disability, he does not work. Originally from [State ], lived in [Location 86] since [2068]. Family History: DM, HTN. Physical Exam: ADMISSION EXAM: T97.9, 102/64, HR 70, R20, 99% on RA General: obese male with general anasarca, no respiratory distress. HEENT: PERRL, anicteric. No obvious ptosis, conjunctival injection, or periorbital swelling. Mild general sense of increased fullness/lack of symmetry with enlargement of R side of face. Painless. Normal facial muscle strength and sensation. OP clear. Neck: obese. JVD elevation difficult to appreciate. Heart: regular, S1 S2, [3-13] SM best at RUSB. No heave. Chest: Limited by poor bed mobility. Preserved air entry bilaterally without obvious wheezes or crackles, but posterior exam limited. Abdomen: obese, +BS, soft, NT, ND. +pitting abdominal wall and sacral edema. Extrem: R arm grossly larger than left both proximal/distal. Relative increase in both pitting and nonpitting edema. Pitting edema most notable in dependent areas. No obvious erythema except small area on medial upper arm, which has some increased tenderness relative to elsewhere. Tender with excessive touch of skin. No sense of tautness of skin relative to other side. Joint ROM preserved without significant tenderness with passive motion at each joint. LLE also with 1-2+ pitting edema, less painful. Some chronic venous stasis changes. Neuro: alert, oriented. CN II-XII intact. LUE weak with limited active movement at elbow and shoulder with some contracture and muscle atrophy. RUE with 5/5 strength at each site except weak finger abduction. Able to move LLE but with minimal strength. DISCHARGE EXAM: VS - 98.1 136/80 70 18 94% GEN - morbidly obese, no acute distress CV - RRR no m/r/g LUNGS - CTA b/l ABD - soft NT ND EXT - no CCE, right AKA, left [Hospital Ward Name ] cyst SKIN - warm and dry Pertinent Results: ADMISSION LABS: [2112-9-15] 04:00PM WBC-5.7 RBC-2.85* HGB-8.3* HCT-24.8* MCV-87 MCH-29.1 MCHC-33.4 RDW-13.5 NEUTS-61.2 LYMPHS-28.6 MONOS-6.6 EOS-3.1 BASOS-0.5 PLT COUNT-102* PT-14.5* PTT-34.6 INR(PT)-1.3* GLUCOSE-294* UREA N-41* CREAT-1.6* SODIUM-139 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11 ALT(SGPT)-26 AST(SGOT)-38 ALK PHOS-97 TOT BILI-0.2 LIPASE-19 CALCIUM-8.2* PHOSPHATE-4.2 MAGNESIUM-2.4 OSMOLAL-312* LACTATE-1.3 CBC, chems at relative baseline . [2112-9-16] CXR: IMPRESSION: Lungs are fully expanded and clear. There is no apical mass. Pleural surfaces are smooth. No pneumothorax. Heart is top normal size. Interval increase in caliber of the upper mediastinum could be due to differences in patient position or adenopathy, and not necessarily a change. If there is serious concern for vascular patency, then direct imaging of the vein should be performed. . [2112-9-15] RUE DOPPLER U/S: IMPRESSION: No evidence of DVT in the right upper extremity including the right internal jugular vein and visualized portions of the subclavian vein. Extensive soft tissue edema. Evaluation of the left upper extremity was limited given inability to properly position the arm. No evidence of thrombus in the visualized left internal jugular, subclavian, and cephalic veins. . DISCHARGE LABS: [2112-10-4] 05:30AM BLOOD WBC-7.4 RBC-2.95* Hgb-8.4* Hct-25.1* MCV-85 MCH-28.4 MCHC-33.3 RDW-14.0 Plt Ct-201 [2112-9-27] 05:30AM BLOOD Neuts-65.5 Lymphs-24.2 Monos-7.0 Eos-2.9 Baso-0.3 [2112-10-4] 05:30AM BLOOD PT-14.4* PTT-35.8* INR(PT)-1.2* [2112-10-5] 05:00AM BLOOD Glucose-228* UreaN-48* Creat-2.1* Na-137 K-4.0 Cl-103 HCO3-26 AnGap-12 [2112-10-4] 05:30AM BLOOD ALT-18 AST-27 AlkPhos-62 TotBili-0.3 Brief Hospital Course: Primary Reason for Hospitalization: 61yo man with hepatocellular CA, CHF, HTN, DM, hep C cirrhosis, PVD, hx of CVA, admitted for RUE cellulitis. He was started on ampicillin/sulbactam. CXR was negative. You were also started on bacitracin/polymyxin ointment for a right-eye conjunctivitis. Active Diagnoses: # Somnolence: Ddx included hepatic encephelopathy vs. uremia vs. hypercarbia vs. medication effect (was on gabapentin, baclofen, MSContin, oxycodone) vs. hypoventilation/OSA. Less likely etiologies include CVA, more likely hemispheric than brainstem. Patient has some degree of cirrhosis, but normal EGD in [Month (only) 547] [2112], no peripheral stigmata on exam, and synthetic function not terribly depressed (normal coags, though admission albumin 2.5). Renal function steadily deteriorating and BUN climbing so this could likely be a contributing etiology. TSH wnl. Infection also in ddx, though afebrile, WBC not high at this time, UA negative, and has been on abx for cellulitis. We increased the frequency of lactulose to treat potential hepatic encephelopathy, titrating to [4-8] BM/day. He was encouraged to use BIPAP overnight for obesity hypoventilation in case hypercapnia was contributing to his somnolence, but this seems more chronic in nature. He was cultured to rule out toxic/metabolic causes of encephalopathy. Cultures were negative. Cr increased despite octreotide, midodrine and pt became volume overloaded, leading to need for dialysis. Dialysis was initiated and pt's MS improved to baseline indicating uremia was likely contributing to AMS. However around the same time pt was also started on lactulose, so could have had a level of HE. Pt's hypoxic episodes could have been contributory to AMS as well. # Hypoxemia: A-a gradient <10 making hypoxemia is suggestive of hypoventilation, likely secondary to obesity hypoventilation/sleep apnea. Hypercarbia appears to be somewhat chronic in nature given pH of 7.34 and pCO2 of 54 (if acute change, would expect pH of 7.28 or so). Pt denies recent worsening of cough or dyspnea. Has been afebrile. He was encouraged to use BIPAP while asleep for obesity hypoventilation. A CXR was obtained to assess for any acute process. He was admitted to MICU for worsening respiratory distress, given his anasarca pulmonary edema was the focared diagnosis, though aspiration pneumonitis and PNA were also considered. He was treated with Vancomycin/Zosyn empirically and he received bedside hemodialysis to remove excess fluid. In MICU his repiratory status improved with HD, empiric therapy and patient began auto-diuresing. On floor was continued on UF 3x weekly and his sats remained in the high 90s. # Anasarca- Likely secondary to hypoalbuminemia from cirrhotic disease and progressive renal failure (renal protein wasting though not nephrotic range proteinuria). Also, was off of lasix and spironolactone since prior discharge on [8-30] and was just restarted on [9-16] (40 mg IV) and [9-18] (60 mg) w/ poor response. Has become oliguric in response to recent lasix challenges. Per hepatology consult on the day of ICU transfer, patient appears to have hepatorenal syndrome, so he was given albumin 25 q8h and diuresis was held. He received albumin before arriving to MICU and in MICU was started on midodrine/ocreotide for possible hepatorenal syndome. Hepatology and renal followed in MICU and he received bedside HD. Pt was then transitioned to UF as mentioned above. Anasarca resolved and pt's creatine improved to 1.8 on discharge. He will be set up for outpatient UF 3x weekly. # [Last Name (un) ]: History of CKD w/ baseline creatinine around 1.6. Recent history of contrast nephropathy with creatinine as high as 3.7. Currently rising from 1.6 on admission to 2.6 today. Likely secondary to poor forward flow in setting of intravascular depletion with a component of hepatorenal syndrome. Gave albumin and held diuresis in the setting of likely hepatorenal syndrome. As above, he was started on midodrine and octreotide in MICU in addition to, HD line placed by IR and bedside HD initiated. Tunneled line was placed and used for UF as above. # RUE cellulitis: Unclear whether this was a true infection in setting of significant swelling, likely secondary to anasarca. UENI negative for DVT. On exam, arm does not appear erythematous or particularly tender. No CXR findings to suspect SVC syndrome. Started ampicillin/sulbactam for cellulitis in a diabetic on [2112-9-16] and showed significant improvement. Seen by ID, who recommended 7-10 days of abx, switched to vancomycin on [2112-9-19]. Pt was treated until day of discharge with vanco and at this point cellulitis had resolved. # Right-eye bacterial conjunctivitis: Treated with bacitracin/polymixin eye ointment. # Anemia: Unclear etiology. Pt has had recent EGD ([5-16]) w/o evidence of varices. Pt has had a colonscopy x 4 years ago (no report) and will need to d/w PCP. [Name10 (NameIs) ] transfused 1 unit on [9-18] with appropriate bump. Remained stable when on floor. # Pain: Held baclofen, gabapentin, and MSContin in the setting of increased somnolence. As his MS improved he was restarted on baclofen and given po oxycodone PRN for pain. # Hepatocellular CA: Recent CT scan showed stable disease. Given multiple comorbidities, he was not a candidate for therapy. He aslo developed contrast nephropathy last CT scan and will be followed by AFP and U/S. Pt's disease is currently end stage. Palliative care consulted and pt had good understanding of prognosis of disease. He was discharged with transition to hospice care. # Chronic diastolic CHF: Continued carvedilol, hydralazine, amlodipine. # PVD: Continued aspirin and statin. . # LLE ulcer: Wound care consulted. . # DM: Continued outpatient insulin glargine and sliding scale. . # Elevated uric acid: Has had elevated levels in the past. Checked CPK level. Started allopurinol. . # Asthma: Continued fluticasone and tioptropium. . # Hypoalbuminemia: Nutrition consulted. Checked urine protein. Transitional Issues: - transition to hospice care when disease worsens, for now will go for UF 3x weekly. Medications on Admission: 1. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY. 3. albuterol sulfate 2.5mg/3mL (0.083%) Nebulization [2-7] Inh Q4H PRN dyspnea. 4. ammonium lactate 12 % Lotion ASDIR as needed for once daily. 5. clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ]: to arm. 6. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [Hospital1 ]. 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY. 8. fluticasone 50 mcg/Actuation 1 Spray Nasal DAILY. 9. gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times a day. 10. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H. 11. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Insulin insulin glargine [Lantus] 100 unit/mL Solution 26U [Hospital1 ]. 13. Insulin Sliding Scale insulin lispro [Humalog] per home sliding scale [Hospital1 ]. 14. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution 1 neb q6hrs. 15. lactulose 10 gram Packet Sig: One (1) packet PO at bedtime. 16. simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS. 17. omeprazole 20 mg Capsule PO DAILY. 18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID. 19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY. 20. Spiriva with HandiHaler 18 mcg Capsule 1 Inhalation once a day. 21. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO BID. 22. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID PRN constipation. 23. multivitamin Tablet Sig: One (1) Tablet PO DAILY 24. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY. 25. baclofen 10 mg Tablet Sig: One (1) Tablet PO three times a day. 26. MS Contin 15 mg Tablet Extended Release PO 2-3 times per day. 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. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q6H (every 6 hours). 7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [Hospital1 ] (2 times a day). 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. sodium chloride 0.65 % Aerosol, Spray Sig: [2-7] Sprays Nasal [Hospital1 ] (2 times a day) as needed for dry nasal passages. 14. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:20 Tablet(s) Refills:2 15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO twice a day. Disp:120 Tablet, ER Particles/Crystals(s) Refills:0 16. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 17. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q2H (every 2 hours) as needed for constipation. 18. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 20. MS Contin 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO every 6-8 hours as needed for pain: do not drink alcohol or drive with this medication. 21. insulin glargine 100 unit/mL Cartridge Sig: Twenty Eight (28) Units Subcutaneous twice a day. 22. insulin lispro 100 unit/mL Insulin Pen Sig: per sliding scale Subcutaneous per sliding scale: please administer according to sliding scale. Disp:30 pen Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary Diagnosis: [Last Name (un) ] requiring dialysis and ultrafiltration Hypervolemia requiring ultrafiltration Right arm cellulitis (skin infection). Right eye conjunctivitis (infection). Health Care Acquired Pneumonia End stage HCC and liver cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Mr. [Known lastname 4542], It was a pleasure taking care of you during this hospitalization. You were initially admitted to the hospital for right arm swelling and found to have a skin infection of that arm (cellulitis). You were started on antibiotics and slowly responded to this. Doppler ultrasound did not show a blood clot. Your eye was also found to have an infection (conjunctivitis), so you were given an antibiotic eye ointment. During your admission you were also found to have a pneumonia which required a short stay in the ICU. We treated you with IV antibiotics and your pneumonia improved. While you were here, you also had an acute kidney injury. This resulted in volume overload to the point where it became difficult for you to breath. We determined that your kidneys were not able to remove the extra fluid by themselves, so we started you on dialysis. Your kidney function improved after dialysis, so we started you on a different type of dialysis called ultra-filtration. We have arranged for outpatient dialysis for you, which will happen three times a week. We have made the following changes to your home medications: STOP: hydralazine STOP: gabapentin CHANGE: lasix from 40mg daily to 40mg twice daily CHANGE: insulin sliding scale START: Metolozone 2.5 mg daily START: potassium chloride 40meq twice daily Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: LIVER CENTER When: TUESDAY [2112-10-18] at 11:45 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 2424], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital3 249] When: FRIDAY [2112-10-14] at 10:10 AM With: DR [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]/[Company 191] POST [Hospital 894] CLINIC Phone: [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 ICD9 Codes: 486, 5849, 5715, 4280, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6816 }	Medical Text: Admission Date: [2173-12-4] Discharge Date: [2173-12-15] Date of Birth: [2124-12-5] Sex: M Service: Transplant Surgery HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old male who is well known to the Transplant Surgery Service who was diagnosed in [2170] when he presented with acute upper gastrointestinal bleed secondary to esophageal varices which were banded. The patient was diagnosed with hepatitis C and found on liver biopsy to have cirrhosis and underwent URO treatment with PEG-interferon and ribavirin. The patient's evaluation also demonstrated a less than 5 cm lesion in the liver for which he had radiofrequency ablation therapy, and then the patient was listed for transplant. On presentation, the patient denied chest pain or shortness of breath. Denied a history of diabetes, coronary artery disease, pulmonary or renal issues. The patient had a good appetite and approximately a 25-pound weight gain. The patient complained of pruritus, dark urine, and loose stools. PAST MEDICAL HISTORY: 1. Hepatitis C; chronic infection. 2. Cirrhosis. 3. End-stage liver disease. 4. Hepatocellular carcinoma; status post radiofrequency ablation of a right lobe lesion, less than 5 cm. 5. Upper gastrointestinal bleed secondary to varices; status post multiple bandings. 6. CMV/EBB positive. 7. Hepatitis B core antibody positive. 8. Hemorrhoids. 9. [2173-7-2] echocardiogram with an ejection fraction of greater than 55%. 10. Chest computed tomography with a right lower lobe 5-mm nodule consistent with granuloma. 11. Colonoscopy in [2170] where the patient had rule out polyps. PAST SURGICAL HISTORY: Multiple esophagogastroduodenoscopies. ALLERGIES: Possible allergy to CODEINE (that causes fever). MEDICATIONS AT HOME: Nadolol 20 mg by mouth in the evening. SOCIAL HISTORY: History of alcohol use. Tobacco use until the [2149]. Intravenous drug use approximately 30 years ago. PHYSICAL EXAMINATION ON PRESENTATION: Temperature on admission was 98.4, heart rate was 66, blood pressure was 128/84, respiratory rate was 20, and oxygen saturation was 98% on room air. The patient's weight was 88.8 kilograms. The patient was awake, alert, and oriented. In no apparent distress. The patient's lungs revealed clear to auscultation bilaterally. Heart revealed a regular rate and rhythm. Examination of the abdomen revealed a soft and reducible umbilical hernia with positive bowel sounds. The abdomen was nontender and nondistended, no tap tenderness, no rebound. No guarding. Examination of the extremities revealed no edema. The patient had 2+ femoral pulses and dorsalis pedis pulses bilaterally and equal. Rectal examination revealed no prolapse, no hemorrhoids. External examination was done. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 6.6, hematocrit was 37.9, and platelets were 143. Sodium was 140, potassium was 3.4, chloride was 106, bicarbonate was 29, blood urea nitrogen was 13, creatinine was 0.7, and blood glucose was 120. INR was 1.3. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram showed a normal sinus rhythm at 60. A chest x-ray showed no cardiomegaly. No acute cardiopulmonary process. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Transplant Surgery Service. The patient was kept nothing by mouth and was consented for a liver transplant. The patient had the operation on the day after admission. The patient was admitted to the Intensive Care Unit. On postoperative day one, the patient remained afebrile with stable vital signs. The patient received morphine as needed for pain. The patient was continued on Unasyn, Bactrim, fluconazole, and ganciclovir and was put on CellCept and Solu-Medrol for immunosuppression. On postoperative day two, the patient had no acute complaints. The patient was stable. The patient continued to be nothing by mouth with a nasogastric tube in place. The patient had a Foley and was doing well. The patient's right internal jugular cordis was changed over wire to triple lumen catheter without any difficulties, and the patient was extubated. The patient's issues on postoperative day three were bradycardia and the patient was hypertensive, most likely due to the increase in the patient's volume from the surgery. The patient was still intubated and kept nothing by mouth with intravenous fluids. The patient was given Lasix for diuresis. The patient's perioperative antibiotics were discontinued, and he was Heplocked. The patient was transferred to the floor. On postoperative day four, the patient was complaining of some pain at the incision site on the back. The patient remained afebrile and continued to be somewhat hypertensive. The patient was advanced to a regular diet as tolerated. The patient was also on ............ of 1 gram [Hospital1 ] and prednisone, and Neoral for immunosuppression. On postoperative day five, the patient had no complaints. He remained afebrile. He continued to be somewhat hypertensive. The patient was continued on a prednisone taper. The patient's Foley was removed and Heplocked. He was encouraged to be out of bed and ambulate. On postoperative day six, the patient remained afebrile and somewhat hypertensive. With elevated blood sugars we obtained [Initials (NamePattern4) ] [Last Name (NamePattern4) ] consultation to monitor the patient's sugars, and the patient was continued on a prednisone taper, and CellCept, and Neoral. On postoperative day seven, the patient had no complaints. The patient was doing well. The patient continued to be out of bed with ambulation. He was taking good oral intake. On postoperative day eight, the patient was doing well. He remained afebrile with stable vital signs. The [Initials (NamePattern4) 228] [Last Name (NamePattern4) 1661]-[Location (un) 1662] drains were both removed without any difficulties. However, the patient's liver function tests were elevated from the previous day. Obtained a liver biopsy which showed mild to severe rejection, focal acute cholangitis and focal lobular neutrophilic aggregates and mild ............ perfusion injury. The patient was promptly put on Solu-Medrol 500 mg intravenously times three to treat the acute cellular rejection. On postoperative day number nine, the patient had no complaints. He remained afebrile with stable vital signs. He was doing well on the high-dose steroids. The patient's blood sugars were well controlled, [First Name8 (NamePattern2) ] [Last Name (un) ] input. On postoperative day ten, the patient completed his last dose of Solu-Medrol and was put on a by mouth form of steroid taper. The patient's liver function tests had improved on the Solu-Medrol and continued to do well from that aspect. FINAL DISCHARGE DIAGNOSES: 1. Hepatitis C; chronic infection. 2. Status post acute cellular rejection. 3. Cirrhosis. 4. End-stage liver disease. 5. Hepatocellular carcinoma. 6. Status post right radiofrequency ablation. 7. Upper gastrointestinal bleed due to esophageal varices; status post multiple bandings. 8. CMV and EBB positive. 9. Hepatitis B core antibody positive. 10. Hemorrhoids. 11. Status post orthotopic liver transplantation. MEDICATIONS ON DISCHARGE: 1. Fluconazole 400 mg by mouth every day. 2. Bactrim single strength one tablet by mouth once per day. 3. Protonix 40 mg by mouth once per day. 4. Percocet one to two tablets by mouth q.4-6h. as needed (for pain). 5. CellCept [Pager number ] mg by mouth twice per day. 6. ............ 900 mg by mouth once per day. 7. Neoral 200 mg by mouth twice per day. 8. Prednisone taper. 9. Insulin sliding-scale. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]; please call transplant coordinator for a follow-up appointment. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1331] Dictated By:[Last Name (NamePattern1) 3118] MEDQUIST36 D: [2173-12-30] 20:35 T: [2173-12-30] 21:39 JOB#: [Job Number 51683] ICD9 Codes: 5715, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6817 }	Medical Text: Admission Date: [2149-12-16] Discharge Date: [2149-12-19] Date of Birth: [2097-1-25] Sex: M Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 4232] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: left internal jugular central venous line placement hemodialysis History of Present Illness: 52 year old male the past medical history of end-stage renal disease on hemodialysis, hypertension, anemia, IVDU complicated by recurrent epidural and hepatitis C who presented to [Hospital1 18] ED from dialysis with altered mental status. . His mom notes he has had confusion since midnight. He went to dialysis this morning and asked repetitive questions. Per dialysis reports, he was alert and oriented for few minutes and then would not be oriented to nothing. He vomiting once in dialysis with no reports of hypoglycemia though he was hypertensive to 190/132. His ROS is negative for recent fall, focal weakness, diplopia, chest pain, shortness of breath, abdominal pain or dysuria. His mom does report having recent change in his antihypertensives from ... to ... Hypertensive at the facility: 190/132. He was transferred to [Hospital1 18] ED for futher evaluation and management. . In the ED, initial vitals were 97.4 82 188/119 16 100%. He was noted to have waxing and [Doctor Last Name 688] mental status in the ED though no focal neurological deficit. He was noted to have seizure after IV labetalol which was described as three minute tonic clonic with loss of consciousness and 10 minute postictal.. He was given 2 mg IV ativan. LP attempted but because of degenerative changes were not able to obtain CSF. Neurology was consulted who recommended ASA 325mg, MRI brain, 24hr EEG. Ativan prn sz >3 min 2mg. Keppra 1g IV x1 if repeat sz occurs. Consider LP, pls get WBC, UA (if he makes urine), tox screen. He was subsequently transferred to MICU for further evaluation and management. Vitals prior to transfer were 98.9 72 155.74 12 100%2LNC. Past Medical History: 1. End-stage renal disease on dialysis, potentially due to either antibiotic or drug use. 2. Hepatitis C virus. 3. History of multiple soft tissue abscesses as well as spinal abscesses. 4. Hypertension. 5. Scoliosis. 6. Opioid dependence. 7. Status post left upper arm AV graft excision due to bleeding. Social History: He does have one child age 14; both his son and his wife live in [State 8842]. The patient used to work as a carpenter and doing tiles although currently is on SSI. Family History: Brother recently passed away from drinking. No history of kidney disease in the family. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Admission labs: [2149-12-16] 09:55AM [Month/Day/Year 3143] WBC-3.3* RBC-3.32* Hgb-10.6* Hct-31.0* MCV-93 MCH-31.9 MCHC-34.1 RDW-13.7 Plt Ct-46* [2149-12-16] 09:55AM [Month/Day/Year 3143] Neuts-76.7* Lymphs-16.5* Monos-4.1 Eos-2.6 Baso-0.2 [2149-12-16] 07:35AM [Month/Day/Year 3143] Glucose-108* UreaN-67* Creat-9.9* Na-139 K-7.1* Cl-92* HCO3-25 AnGap-29* [2149-12-16] 07:35AM [Month/Day/Year 3143] ALT-22 AST-39 AlkPhos-95 TotBili-0.2 [2149-12-17] 03:20AM [Month/Day/Year 3143] Calcium-9.0 Phos-3.8 Mg-2.3 [2149-12-16] 01:17PM [Month/Day/Year 3143] VitB12-854 [2149-12-16] 07:35AM [Month/Day/Year 3143] ASA-4.4 Ethanol-NEG Acetmnp-6* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2149-12-16] 07:50AM [Month/Day/Year 3143] Glucose-104 Lactate-1.6 K-6.8* . Imaging: . CXR (portable AP) [2149-12-16]: Mild vascular congestion without overt edema. . [2149-12-19] Echo The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric LVH with normal global biventricular systolic function. Mild diastolic LV dysfunction. . Vein Mapping: IMPRESSION: 1. Patent bilateral brachial and radial arteries with triphasic flow. 2. Patent but small caliber of bilateral cephalic and basilic veins with measurements as above. 3. Subclavian veins could not be imaged due to presence of dressings . EEG: [12-17] IMPRESSION: This is an abnormal routine EEG in wakefulness due to continuous left hemispheric slowing maximally seen in the temporal region, attenuation of faster frequencies, and absent alpha rhythm on the left. These findings are indicative of left hemispheric cortical and subcortical dysfunction, maximal in the temporal region. In addition, background activity was slow on the right indicative of a diffuse encephalopathy of non-specific etiology. No electrographic seizures or epileptiform discharges were present. If clinical suspicion for seizures is high, a 24 hour recording is recommended to rule out subclinical left hemispheric and particularly left temporal seizures. . abd US [12-17] IMPRESSION: 1. Enlarged liver without a focal lesion; splenomegaly and patent portal vein. 2. Incidental note of a small gallbladder polyp. 3. Small atrophic kidneys. . [2149-12-16] CT head IMPRESSION: No acute intracranial process. Specifically, no intracranial hemorrhage detected. . Micro: [2149-12-16] 9:48 am [Month/Day/Year 3143] CULTURE FINAL REPORT [2149-12-22] [Year/Month/Day ] Culture, Routine (Final [2149-12-22]): PROPIONIBACTERIUM ACNES. Anaerobic Bottle Gram Stain (Final [2149-12-20]): Reported to and read back by DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] ON [2149-12-20] AT 2245. GRAM POSITIVE ROD(S). [2149-12-16] 9:30 am [Month/Day/Year 3143] CULTURE SET 1. FINAL REPORT [2149-12-22] [Year/Month/Day ] Culture, Routine (Final [2149-12-22]): PROPIONIBACTERIUM ACNES. Anaerobic Bottle Gram Stain (Final [2149-12-21]): GRAM POSITIVE ROD(S). . Discharge labs: [2149-12-19] 06:38AM [Month/Day/Year 3143] WBC-5.4 RBC-3.96* Hgb-12.3* Hct-36.4* MCV-92 MCH-31.2 MCHC-33.9 RDW-13.8 Plt Ct-81* [2149-12-16] 09:55AM [Month/Day/Year 3143] Neuts-76.7* Lymphs-16.5* Monos-4.1 Eos-2.6 Baso-0.2 [2149-12-19] 06:38AM [Month/Day/Year 3143] Plt Ct-81* [2149-12-19] 06:38AM [Month/Day/Year 3143] Glucose-94 UreaN-35* Creat-6.5# Na-140 K-4.8 Cl-99 HCO3-28 AnGap-18 Brief Hospital Course: 52 year old male the past medical history of end-stage renal disease on hemodialysis, hypertension, anemia, IVDU complicated by recurrent epidural and hepatitis C who presented to [Hospital1 18] ED from dialysis with altered mental status. . # Altered mental status: The patient presented with confusion that improved after admission. Non-contrast CT head negative. Initially there was concern for a CNS infection, so LP was attempted. LP was unsuccessful, and the patient received 1 dose of vancomycin and ceftriaxone before antibiotics were d/c'ed. Neurology was consulted, and felt that the Ddx included hypertensive encephalopathy versus benzo withdrawal or seizures. Patient was admitted to the MICU and his mental status improved. On reevaluation by neurology, it was felt that an MRI and LP were no longer needed and they recommedned a 20 minute EEG. This showed diffuse L sided slowing, with no epileptiform features. When called out to the floor he was AAO x 3 and responding to questions appropriately. Pt's mental status remained stable throughout the rest of hospitalization. Given history of benzodiazepine use and abrupt stop, very well could have been benzodiazepine withdrawal seizures. Neurology did not want to start pt on anti-epileptic at this time. He will follow up with neuro in one month to be re-evaluated. . # Hypertensive urgency: The patient had hypertension and severe headache. He was initially treated with labetolol, but this was stopped due to bradycardia. In the MICU, he was transitioned to a nicardipine gtt, with improvement in [Hospital1 ] pressure. On HD day, he was transitioned to captopril 25mg PO tid with bp of 140s/90s. On the floor pt was started on lisinopril 10mg daily and amlodipine 5mg daily, with adequate bp control. . # Headache: The patient complained of a severe headache. This responded best to clonazepam and oxygen. Neurology recommended verapamils for vascular headache. However, his headaches ultimately improved by time of discharge. . # Seizure: The patient was noted to have seizure activity in the emergency department. 20-minute EEG showed diffuse slowing on the left. Patient had no further seizures. See above. . # Pancytopenia: Unclear etiology. Obtained RUQ U/S to evaluation for cirrhosis in setting of known hepatitis C. . # Opioid dependence: The patient attends a methadone clinic as a outpatient, where his methadone dose is 140 mg daily. He was maintained on this dose and discharged with a letter to his methadone clinic. . # ESRD: HD was performed on admission and on HD 2. MS [First Name (Titles) ] [Last Name (Titles) ] pressures improved with HD. Vein mapping was scheduled to be performed on [2149-12-18], so we did it in hospital instead. At the request of the renal team we also checked an echocardiogram to see if heart failure could be contributing to his hypervolemia or if this was purely from ESRD. Echo revealed normal ventricular function without any wall motion abnormalities and an EF > 55% . FC . Transitional: needs follow up for [Date Range ] cultures follow up in neuro clinic one month Medications on Admission: CALCIUM ACETATE 667 mg [1-23] capsules with meals daily CLONAZEPAM 1 mg po qdaily METHADONE 140 mg daily per methadone clinic Trazodone Iron Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for headache. Tablet(s) 2. calcium acetate 667 mg Capsule Sig: [1-23] Capsules PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO qAM for 7 days. Disp:7 Tablet(s)* Refills:0 4. methadone 40 mg Tablet, Soluble Sig: 3.5 Tablet, Solubles PO DAILY (Daily). 5. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:7 Tablet(s) Refills:0 7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:7 Tablet(s) Refills:0 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:7 Tablet(s) Refills:0 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:7 Tablet(s) Refills:0 10. clonazepam 1 mg Tablet Sig: One (1) Tablet PO qPM as needed for anxiety for 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: metabolic encephalopathy new onset seizure Hypertension ESRD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you. You were admitted to the hospital for mental status changes and seizures. Your mental status changes improved after hemodialysis. We believe that your mental status changes were either caused by a post-ictal state (which means confusion after a seizure), or from metabolic encephalopathy which is related to your renal disease. The neurology team evaluated you and think that your seizure could have been caused by withdrawal from clonazepam. At this time, we are not yet starting any anti-epileptic medications. We have arranged for follow up in the neurology clinic here, the information is below. Please do not drive or operate any heavy machinery for six months or until a neurologist or your PCP gives you clearance to drive. . During this hospitalization you also had high [Known lastname ] pressure, which likely contributed to some of your headaches. We are starting several medications for this. Please see the information below. . We have made the following changes to your home medications: START: Lisinopril 10mg tab. One tablet by mouth once daily START: amlodipine 5mg tab. one tablet by mouth once daily CHANGE: Clonazepam from 1mg once daily to 1mg twice daily START: folate and thiamine supplements . Followup Instructions: PCP [Name Initial (PRE) ]:Thursday, [12-25] @ 2:20pm for 40min appointment Name:[First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 91953],MD Location: [Hospital6 5242] CENTER Address: [Location (un) 5243], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 798] Department: NEUROLOGY When: WEDNESDAY [2150-1-21] at 1 PM With: DRS. [Name5 (PTitle) ] & [Doctor Last Name ] [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMODIALYSIS When: SATURDAY [2149-12-20] at 7:30 AM Department: TRANSPLANT CENTER When: FRIDAY [2150-1-9] at 8:00 AM With: [Name6 (MD) 2105] [Name8 (MD) 2106], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: TRANSPLANT SOCIAL WORK When: FRIDAY [2150-1-9] at 9:00 AM [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 4236] ICD9 Codes: 5856, 2875, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6818 }	Medical Text: Admission Date: [2122-7-8] Discharge Date: [2122-7-14] Service: MEDICINE Allergies: Keflex Attending:[First Name3 (LF) 832] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubation History of Present Illness: [Age over 90 ]yo F with h/o CAD, dCHF, symptomatic bradycardia s/p PPM, severe pulmonary hypertension admitted from [Hospital ] rehab with cough, SOB and hypotension today. Per records and signout from [Hospital ] rehab patient initially had ST and cough on [7-5]. Was afebrile and treated with robutussin [7-6]. Then overnight on [7-7] noted to be hypotensive (89/59 ->80/50) with )2sat 70% on RA->88% on 2LNC. Patient was placed on NRB and BP dropped precipitously to 69/30 so she was given 500mL bolus at [Hospital ] rehab but was not responsive (BP 70/37, HR 77 RR 24, [Last Name (un) ] 100% NRB) and was subjectively more SOB so sent to ED. In the ED, initial vs were: T 98.6 85 120/34 28 100 on NRB. Then had fever to 100.8. CXR showed RLL PNA and patient was given vanc and levoquin as well as 1L NS however BP continued to "dwindle" and patient was more and more dyspneic so she was given succinylcoline, etomidate, versed, and fentanyl and then intubated and a CVL was placed in left IJ. EKg was reportedly with inferior STD thought [12-30] demand from increased work of breathing. Started on levophed drip for persistent hypotension and thoguht sepsis vs chf. . Review of systems: unable as intubated/sedated Past Medical History: - Severe pulmonary HTN, severe TR, RV dysfunction and normal LV function - Symptomatic bradycardia s/p pacemaker implantation - HTN - Renal insufficiency - Chronic venous stasis - Recurrent leg cellulitis - Gout - Morbid obesity - s/p TAHBSO - OA Social History: lives at [Hospital ] rehab. demented but reportedly A+OX 3 in ED last night. wheelchair to ambulate. unmarried. denies tobacco or EtOH use. Family History: There is no family history of premature coronary artery disease or sudden death Physical Exam: Vitals: T: 98.7 BP:108/38 P:89 R: 18 O2:100 on TV 400 X 14 FIo2 60 peep 8 General: intubated/sedated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP to earlobe Lungs: crackles bilateral bases CV: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ edema Pertinent Results: Labs on Admission: [2122-7-8] 03:30AM BLOOD WBC-20.4# RBC-3.66 Hgb-10.5* Hct-32.8* MCV-90 MCH-28.8 MCHC-32.2 RDW-17.7* Plt Ct-178# [2122-7-8] 03:30AM BLOOD Neuts-92.5* Lymphs-4.2* Monos-3.0 Eos-0.1 Baso-0.2 [2122-7-8] 03:30AM BLOOD Plt Ct-178# [2122-7-8] 03:30AM BLOOD PT-15.0* PTT-32.1 INR(PT)-1.3* [2122-7-8] 03:30AM BLOOD Glucose-128* UreaN-46* Creat-1.5* Na-143 K-3.6 Cl-101 HCO3-29 AnGap-17 [2122-7-8] 11:42AM BLOOD CK(CPK)-23* [2122-7-8] 03:30AM BLOOD proBNP-4886* [2122-7-8] 03:30AM BLOOD cTropnT-0.06* [2122-7-8] 11:42AM BLOOD CK-MB-4 cTropnT-0.08* [2122-7-9] 03:28AM BLOOD CK-MB-3 cTropnT-0.06* [2122-7-8] 05:59PM BLOOD Calcium-8.1* Phos-3.5 Mg-2.0 [2122-7-8] 03:35AM BLOOD Lactate-3.1* [2122-7-9] 03:45AM BLOOD Lactate-0.9 [2122-7-8] 10:42AM BLOOD freeCa-1.04* [2122-7-11] 10:56AM BLOOD Type-ART Temp-36.6 pO2-62* pCO2-39 pH-7.47* calTCO2-29 Base XS-4 Intubat-NOT INTUBA . Labs on Discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt [2122-7-14] 07:00 10.0 3.76* 10.9* 32.8* 87 28.8 33.0 17.3* 173 Glu UreaN Creat Na K Cl HCO3 AnGap [2122-7-14] 07:00 97 32* 1.2* 144 3.2* 100 34* 13 [2122-7-14] 07:00 ca: 8.4 phos: 3.0 Mg: 1.8 MICROBIOLOGY: [2122-7-14] URINE CULTURE PENDING [2122-7-13]: UA negative [2122-7-8] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STREPTOCOCCUS PNEUMONIAE} INPATIENT [2122-7-8] BLOOD CULTURE Blood Culture NEGATIVE [2122-7-8] URINE Legionella Urinary Antigen -NEGATIVE [2122-7-8] URINE URINE CULTURE-NEGATIVE [2122-7-8] MRSA SCREEN MRSA SCREEN-FINAL {STAPH AUREUS COAG +} INPATIENT [2122-7-8] BLOOD CULTURE Blood Culture, Routine-NEGATIVE ** [2122-7-8] TTE: The left atrium is mildly 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. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. Compared with the prior study (images reviewed) of [2122-2-24], the estimated pulmonary artery pressures are lower. The severity of tricuspid regurgitation is reduced (although image quality on current study is very limited). A very small pericardial effusion is seen. . [2122-7-8] ECG: Sinus rhythm with atrial premature beat. Left atrial abnormality. Modest ST-T wave changes with prolonged QTc interval are non-specific but cannot exclude possible drug/electrolyte/metabolic effect. Clinical correlation is suggested. Since the previous tracing of same date there is no signficant change. . [2122-7-8] CXR: 1. Worsening right pleural effusion with adjacent atelectasis with or without coexisting infection. 2. Improved left pleural effusion. . [2122-7-9] CXR: No evidence of vascular congestion or acute focal pneumonia. . [2122-7-13] CXR: Bilateral pleural effusions, right great than left. Brief Hospital Course: [Age over 90 ] yo F with h/o d CHF, HTN, dementia here with cough/fever/hypoxia requiring intubation and hypotension requiring levophed likely [12-30] sepsis from PNA although may also have component CHF. Admitted to the MICU on [7-8], transferred to the floor on [7-11] and discharged on [7-13] . # Shock: When pt was admitted, hypotension was thought [12-30] sepsis vs. CHF. An ECHO was done which showed improved heart function when compared to an echo from [Month (only) 958]. IVF boluses were used for her hypotension as sepsis was thought to be the likely cause of her hypotension. The pt was originally on levophed, however this was d/c'd soon after her admission (within 12 hrs). An MI was also r/o with cardiac enzymes and serial EKGs. The pt was originally started on vanc/zosyn, however we narrowed to levoquin once further sputum culture speciation showed pneumococcus. She continued her course of IV levofloxacin on the floor and was sent with a prescription to continue it PO as an outpatient for at total of 10 day course. . # Hypoxic Respiratory Failure: Likely multifactorial and includes baseline compromised respiratory function from severe pulmonary hypertension with likely superimposed PNA. Pt was weaned to pressure support and extubated after 2 days on the ICU. The main thought was PNA, so she was treated with abx as above. Pt also had pleural effusion, with the thought to do thoracentesis, however she stablized so this was deferred. Also, pt was continued on home dose (3x a week) of lasix and metolazone. This regimen was continued on the floor and will be continued as an outpatient. On the floor, she was satting well in the mid-high 90s on 2L NC. . #Nutrition: Patient failed her bedside s/sw for concern of an aspiration risk. However, her PO meds were continued mixed in applesauce, and she was able to take her pills. She was sent for video s/s eval on [7-14] and they recommended nectar thickened liquids and soft solid diet. # Hypertension: Pt hypertensive to 180s-190s thought [12-30] anxiety. Returned to normotensive range with ativan in the MICU. Started on prn zydis for anxiety. Once transferred to the floor, she had an episode of hypertension the night of [7-12] up to 189/76. She was given amlodipine 10mg for this and her pressures responded well. She continued to take this daily throughout her admission, and we have discharged her on this as well. . # CRI: Baseline creatinine over last year 1.4-1.9. Ranged from 1.2-1.5 throughout admission. We monitored her creatinine, renally dosed her meds, and avoided nephrotoxins. . # Anemia: Appeared to be at her baseline, we monitored her daily and guaiac'd her stools which were negative. . # Code status: Pt was admitted as a full code, and continues to be a full code at discharge. This was discussed with her niece, who feels that the patient should be making her own decisions, but agreed that code status should be further addressed. We feel that this is something that should be followed up as an outpatient. Medications on Admission: Oxycodone 2.5mg [Hospital1 ] Ativan 0.5mg daily at night and Q6H PRN anxiety APAP 650mg daily Sorbitol 15mL daily Calcium 1300mg daily colace 100mg daily Omeprazole 20mg daily Nitro 0.3mg PRN Aspirin 81mg daily Metolazone 2.5mg 3 x weekly (M/W/F) Allopurinol 100mg QOD Mag hydroxide 30ml daily PRN Lasix 40mg M/W/F Ergocalciferol 5000units Q21days guiafensin PRN Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Tablet(s) 3. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ergocalciferol (Vitamin D2) 400 unit Capsule Sig: One (1) Capsule PO 2 times per week. 11. Sorbitol 70 % Solution Sig: Fifteen (15) ml Miscellaneous once a day. 12. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO twice a day. 13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 14. Calcium Carbonate 650 mg (1,625 mg) Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Primary: Hypotension Respiratory distress Pneumonia Secondary: Renal insufficiency hyptertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], You were admitted to the hosptial from rehab because you had low blood pressures and shortness of breath. At the hospital, you were brought to the ICU and had a breathing tube placed as you were having difficulty breathing on your own. After a couple of days, you improved and the tube was removed. You have been breathing well since. You also had a pneumonia which has been treated with antibiotics. You should continue your antibiotics as listed below. While you were here, we had some trouble controlling your high blood pressure, so we started you on an additional blood pressure medicine called amlodipine. Please continue to take this according to the instructions below. You should also follow up with your cardiology appointments as instructed below. Medication changes: - Take levofloxacin 500 mg by mouth each day until your prescription runs out (until [2122-7-18]) - Take amlodipine 10 mg by mouth each day - Continue all other the medications you were taking prior to your hospitalization Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [2122-8-31] at 10:00 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: THURSDAY [2122-10-1] at 8:30 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: THURSDAY [2122-10-1] at 9:20 AM With: DR. [First Name11 (Name Pattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23**] Garage ICD9 Codes: 5849, 4280, 4168, 2859, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6819 }	Medical Text: Admission Date: [2200-6-14] Discharge Date: [2200-7-16] Date of Birth: [2125-1-23] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7591] Chief Complaint: fatigue, elevated WBC Major Surgical or Invasive Procedure: Central line for Plasmapheresis Skin biopsy History of Present Illness: 75-year-old woman with no significant medical problems presented to her PCP complaining of "not feeling well". Patient reports that on [6-2] she saw her dentist because she had been feeling well for a few weeks. She basically states she was fatigued. Her son who accompanies her surgeries sleeping a lot during the day. She was found to have 3 abscessed teeth which were removed on [6-5]. She was begun on clindamycin 300 mg QID on [6-2] she took until [6-12]. For the last 3 nights she has had a fever with max temperature of 100.8. She denies cough, shortness of breath, abdominal pain, dysuria, frequency, stiff neck, headache. She has noted that her stools are a little bit looser, but has not had profuse diarrhea. She denies shaking chills, night sweats. . In the ED, initial vital signs were 98.3 88 130/69 16 100%. White blood cell count was 257K with 98% other forms, hematocrit 29, platelets 58K. Her LDH was 472. Creatinine was 0.8. BMT was consulted in the ED and recommended smear review and bone marrow biopsy, further recommendations pending. Patient was given allopurinol 300 mg PO x 1. She was planned [Hospital Unit Name 153] admit for pheresis. Vitals upon transfer were pulse 84, RR 18, BP 140/84, O2Sat 96% RA. . On arrival to the MICU, patient reports no problems. There is no dyspnea, headache or confusion. Past Medical History: Osteopenia Elevated blood pressure Social History: She is widowed and remarried. Her two sons are doing well (daughter-in-law [Name (NI) 553] [Name (NI) ]). Has 4 granddaughters. Does not work. She lives in [Location 14663] for the summer. She does not use tobacco, EtOH, drugs. Walks 20 min every morning, and a few times a week walks in the evenings as well. Family History: Mother had pancreatic cancer. Father had a myocardial infarction at age 82 and diabetes. Son w/ [Name2 (NI) ] [Location (un) ] syndrome. Sister with severe itching for 1 year, unexplained despite extensive testing Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 98.4 BP 154/89 HR 90 R 19 Sat 93%RA General: Alert, orientedx3, no acute distress HEENT: Pupils equal round and reactive, extraocular movements intact, oropharynx clear w/o lesions or petechiae, good dentition, mild gingival hyperplasia NECK: JVP flat CV: nl s1s2, regular rate and rhythm, no murmur/rubs/gallops PULM: clear to auscultation bilaterally w/good air movement, no crackles/wheezes ABD: soft, non-tender, non-distended, +Bowel sounds, no hepatosplenomgaly LYMPH: no cervical LAD EXT: warm, well perfused, no cyanosis/clubbing/edema, no open lesions SKIN: no rashes NEURO: AOx3, 5/5 strength in all extremities, DISCHARGE PHYSICAL EXAM: T98.7, BP 140/84, HR 103, RR 18, 98%RA General: Alert, orientedx3, no acute distress HEENT: Pupils equal round and reactive, extraocular movements intact, oropharynx clear w/o lesions or petechiae, good dentition, mild gingival hyperplasia NECK: JVP flat CV: nl s1s2, regular rate and rhythm, no murmur/rubs/gallops PULM: clear to auscultation bilaterally w/good air movement, no crackles/wheezes ABD: soft, non-tender, non-distended, +Bowel sounds, no hepatosplenomgaly LYMPH: no cervical LAD EXT: warm, well perfused, no cyanosis/clubbing/edema, no open lesions SKIN: no rashes NEURO: AOx3, 5/5 strength in all extremities, Pertinent Results: ADMISSION LABS: [2200-6-14] 02:30AM BLOOD WBC-249.5* RBC-2.94* Hgb-8.6* Hct-25.5* MCV-87 MCH-29.2 MCHC-33.6 RDW-17.0* Plt Ct-52* [2200-6-13] 04:20PM BLOOD Neuts-1* Bands-0 Lymphs-1* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-98* NRBC-2* Other-0 [2200-6-14] 02:30AM BLOOD PT-14.3* PTT-27.4 INR(PT)-1.3* [2200-6-13] 04:20PM BLOOD UreaN-14 Creat-0.8 Na-138 K-3.4 Cl-98 HCO3-27 AnGap-16 [2200-6-13] 04:20PM BLOOD ALT-31 AST-28 LD(LDH)-472* AlkPhos-103 TotBili-0.5 [2200-6-13] 04:20PM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0 UricAcd-4.6 Blood smear [6-13]: Numerous large monomorphic cells with very high N:C ratio, minimal cytoplasm, multiple nucleoli, rare granules and no clear auer rods. Rare platelets, normal appearing RBC with occasional nucleated RBC. FLOW CYTOMETRY IMMUNOPHENOTYPING [2200-6-14] INTERPRETATION Acute Myelogeneous Leukemia. Peripheral blood morphological review shows high white counts, blasts with high N:C ratio, irregular nuclear contours, very sparse granules. No Auer rods seen. Given the absence of HLA-DR [Last Name (STitle) ] CD34, while the morphology does not support it, the flow profile does not rule out acute promyelocytic leukemia. Correlation with cytogenetics and FISH is recommended. Cytogenetics Report [2200-6-15] Culture of this specimen yielded no metaphase cells; therefore, chromosome analysis could not be performed FISH analysis with probes to the PML and RARA loci was interpreted as NORMAL. Imaging Echo (pre-chemo) [2200-6-15]: IMPRESSION: Normal left ventricular cavity size and global/regional systolic function. MR HEAD W/O CONTRAST [2200-6-19] IMPRESSION: Evidence of ischemia in the right centrum semiovale following the distribution of the superior division of the sylvian MCA. BILAT LOWER EXT VEINS [2200-6-19] IMPRESSION: No deep venous thrombosis in the right or left lower extremity TTE (Congenital, focused views) [2200-6-20] This focused study demonstrates a patent foramen ovale with small amount of right-to-left interatrial flow at rest. CT CHEST W/CONTRAST CT ABD & PELVIS WITH CONTRAST [2200-6-24] IMPRESSION: 1. Findings most consistent with typhlitis/neutropenic colitis, given patient's history. 2. 7 x 12 mm left lower lobe pulmonary nodule; given substantial size, follow-up CT is recommended within three months to show resolution. A small nearby nodule can also be reassessed at that time. Infectious etiologies could be considered or the nodule may incidental, though substantial in size; it would be an unlikely presentation of leukemia. Right middle lobe tree-in-[Male First Name (un) 239] process may represent early infection/inflammation. 3. Small hypodensities bilateral renal cortices, too small to characterize fully. CT CHEST W/CONTRAST CT ABD & PELVIS WITH CONTRAST [2200-7-1] IMPRESSION: 1. Persistent cecitis and ascending colitis with persistent and perhaps slightly increased wall thickening and also greater inflammatory fat stranding. The appearance suggests neutropenic colitis given the patient's history. 2. Left lower lobe pulmonary nodule, increased in the short one-week interval since the prior study, worrisome for an ongoing infectious etiology. DISCHARGE LABS: [2200-7-16] 12:00AM BLOOD WBC-30.4* RBC-2.84* Hgb-8.6* Hct-25.6* MCV-90 MCH-30.3 MCHC-33.5 RDW-16.0* Plt Ct-782* [2200-7-16] 12:00AM BLOOD Neuts-33* Bands-2 Lymphs-12* Monos-44* Eos-0 Baso-0 Atyps-4* Metas-4* Myelos-1* [2200-7-16] 12:00AM BLOOD PT-16.7* PTT-32.6 INR(PT)-1.6* [2200-7-16] 12:00AM BLOOD Glucose-159* UreaN-17 Creat-0.4 Na-136 K-4.5 Cl-105 HCO3-23 AnGap-13 [2200-7-16] 12:00AM BLOOD ALT-11 AST-14 LD(LDH)-239 AlkPhos-154* TotBili-0.2 [2200-7-16] 12:00AM BLOOD Albumin-2.6* Calcium-7.7* Phos-3.2 Mg-1.9 Brief Hospital Course: 75 yo F presenting with 2 weeks of increasing fatigue, mild dyspnea, and recent low grade fever and dental abscess. Given lab findings, with elevated WBC count to 257K with 98% blasts, found to have likely acute myelomonocytic leukemia, course of 7+3 chemotherapy complicated by stroke, typhlitis, neutropenic fever, and likely fungal lung infection. # Acute leukemia: Healthy 75F with 2-3 weeks of fatigue and recent possible dental abscess s/p extraction [6-5] who presented with elevated WBC >200K and anemia/thrombocytopenia discovered at her PCP [Name Initial (PRE) ] [6-13]. She was admitted to the ICU for emergent pheresis. In the [Last Name (LF) 153], [First Name3 (LF) ] IJ central line catheter was placed for pheresis given her WBC of 257 and risk for leukostasis. After pheresis, her WBC count dropped to 127. She was also started on hydroxyurea, allopurinol, and emperic cefepime for chemo. After some discussions with the family she agreed to chemotherapy and was transfered to BMT service for further management. She underwent 7+3 cytarabine & idarubicin, course was complicated by ischemic CVA on [6-18] found to have PFO & no obvious source of thrombus, neutropenic colitis ([2198-6-23]), likely fungal lung infection and neutropenic fever as discussed below. After coming out of her nadir, patient had leukocytosis to 20-30k, peripheral smear and flow showed mature monocytes, possibly consistent with myelodysplasia or robust recovery, less likely recurrence of leukemia or infection. Bone marrow biopsy was not done for evidence of remission as patient does not wish to have further chemotherapy, regardless of potential result. -Patient will continue to follow with Dr. [Last Name (STitle) 410] in clinic #Sepsis/Febrile neutropenia: Pt had low grade fevers on [6-30], and fever to 101.7 @430 [7-1], afebrile at the time of transfer [7-2]. Pt on broad spectrum abx coverage with [Last Name (un) 2830]/vanco. CT chest/abd found new nodule in LLL that was increasing in size suggesting infectious process. Sinus CT found possible involvement of the right maxillary sinus. ENT was consulted and swab culture of the sinus was unrevealing. Before being transferred to the ICU for the second time during this admission, she also developed hypotension with SBP in 80s after receving ambisome. She responded to fluid boluses and did not require pressor support. At time, the hypotension was consider to be mult-factorial including side-effect of ambisome as well as underlying infection. Cultures were negative. Pt was continued on broad spectrum abx coverage. A CT chest/abd ([7-1]) found enlarging nodule in LLL, and sinus CT found possible involvement of the right maxillary sinus with oral-antral fistula. ID consult also followed patient during this admission. - Per oral maxillofacial surgery there is no evidence of a current dental abcess or dental infection - All antibiotics except voriconazole were stopped and patient was stable for two days prior to discharge. # Syncope: Syncopal episode [2200-6-23] likely secondary to vasovagal or orthostatic hypotension.Pt had difficult ambulating and required more assistance than normal. Now ambulating better since starting PT. -PT and OT therapy to continue since pt is still functioning below baseline. Pt will continue to benefit from acute PT. # Ischemic CVA - pt w/ new isolated L-sided mouth droop since [6-18], neurology was consulted, MRI showed subtle area of ischemia in centrum stemi ovale, extending into right insula (vascular territory of R MCA), echo w/ bubble showed PFO, doppler of bilateral LEs negative. -Blood pressure control -ASA 162mg daily started prior to discharge #Rash: Patient had new erythematous non-pruritic maculopapular, blanching rash on the back from the nape of neck to the T8-T9 dermatome. Concern was for leukemia cutis or fungal or drug rash. Dermatology was consulted and believed the rash was dependent erythema with early miliaria from recent fevers, biopsy showed likely drug hypersensitivity reaction. Rash resolved with removal of meropenem from regimen. # Typhlitis/Neutropenic colitis: Pt found to have significant bowel wall thickening and edema from cecum to hepatic flexture consistent with typhlitis/ neutropenic colitis on [2200-6-24]. Pt did not have abdominal pain but has reported some loose stools. Broad spectrum coverage with aztreonam and flagyl until [2200-7-14], was stable of antibiotic until discharge, ID followed. C. diff was negative. # Pulmonary nodule: [Month (only) 116] represent infection vs inflammation. - Pt on aztrenonam, flagyl, vanco, ambisome - concern since nodule size has increased in size over 1 week period - pt will need follow up CT in 3 months to f/u on nodule - pt will follow in outpatient [Hospital ] clinic, to determine length of voriconazole treatment Transitional Issues: - pt will need follow up CT in 3 months to f/u on nodule - goals of care: patient does not want more chemotherapy if she has a recurrence Medications on Admission: CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (OTC) - COD LIVER OIL - (OTC) - Dosage uncertain MULTIVITAMIN - (OTC) - by mouth once a day Discharge Medications: 1. Voriconazole 200 mg PO Q12H RX voriconazole 200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #60 Tablet Refills:2 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. Aspirin 162 mg PO DAILY 4. calcium carbonate-vitamin D3 NF* 1 tablet Oral Daily 5. cod liver oil NF 1 tablet Oral Daily 6. Multivitamins 1 TAB PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:2 8. Acyclovir 400 mg PO Q8H RX acyclovir 400 mg 1 tablet(s) by mouth every eight hours Disp #90 Tablet Refills:0 Discharge Disposition: Home With Service Facility: Allcare VNA of greater [Location (un) ] Discharge Diagnosis: AML Neutropenic Colitis Right MCA Stroke Drug Rash Febrile Neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 14664], It was a pleasure caring for you during your recent hospitalization at [Hospital1 18]. You came to the hospital because you were tired, not feeling well and you were found to have a high white blood cell count by your primary care physician. [Name10 (NameIs) ] were found to have acute myelogenous leukemia so you underwent induction chemotherapy with (7+3) [Doctor First Name ] + cytarabine. You tolerated the chemotherapy well and your blood counts dropped as expected. You also experienced a stroke which resulted in a left facial droop and left arm weakness. A work-up for the cause of the stroke revealed that you have a patent foramen ovale, which is a hole between two [Doctor Last Name 1754] of your heart. In addition you also developed neutropenic colitis which means that the wall of your large intestines was inflammed which is a complication of receiving chemotherpy. We put you on appropriate antibiotics to prevent an infection, rested your bowels, and provide you nutrition via an IV line. In addition you also developed a rash which was a side effect of the antibioitics you were taking. Your nutritional status improved as did the infection in your bowels by the time you were discharged. The following changes were made to your medications: START voriconazole for your fungal infection START acyclovir to prevent viral infections START two baby aspirin a day for your stroke START metoprolol for your high blood pressure Please keep your appointments as scheduled below. Followup Instructions: Please follow up with the following appointments which have been scheduled for you: Department: HEMATOLOGY/BMT When: TUESDAY [2200-7-22] at 2:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9574], NP [Telephone/Fax (1) 3237] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/BMT When: TUESDAY [2200-7-22] at 3:00 PM With: [First Name8 (NamePattern2) 539] [Last Name (NamePattern1) 9816], RN [Telephone/Fax (1) 14665] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: BMT CHAIRS & ROOMS When: TUESDAY [2200-7-22] at 3:00 PM Department: INFECTIOUS DISEASE When: FRIDAY [2200-8-1] at 9:00 AM With: [First Name11 (Name Pattern1) 3049] [Last Name (NamePattern4) 14666], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2200-7-18] ICD9 Codes: 2761, 2875, 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6820 }	Medical Text: Admission Date: [2200-3-22] Discharge Date: [2200-3-27] Date of Birth: [2124-1-13] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide / Allopurinol Attending:[First Name3 (LF) 1646] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD and colonoscopy History of Present Illness: Mr. [Known firstname 12056] [Known lastname 174] is a very nice 76 year-old gentleman with PAFib on coumadin, DM2, HTN, severe PVD, anemia, stomach ulcers, duodenitis who comes with shortness of breath and melena. He was in his prior state of health until [2200-2-27] when he came with shortness of breath and melena and was admitted to our hospital with UGIB. He required 3 RBC units and underwent EGD, which showed duodenitis, erythema of the antrum with an ulcer that was injected and clipped. He was treated for H. pylori and was discharged home on [2200-3-1] with an HCT of 26. He was doing well, followed with his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] on [2200-3-11] who rechecked his HCT and found it at 27. He had been taking his [Year (4 digits) ] [Hospital1 ], which was continued as well as his H. pylori treatment (amox/clarithro/omeprazole). . Over the past three days he has noticed melanotic stools, some mild shortness of breath with activity and back pain. . In our ED his initial VS were: T 98.7 F, HR 66 BPM, BP 97/65 mmHg, RR 18 breaths per minute, SpO2 100% on RA. On physical exam he looked comfortable, no abdominal pain and had guaiac positive stools. His NG lavage showed 2 clots, but no bright red blood. He had placed 2 18G. His initial labs showed INR of 4.0 with a HCT of 18 from his last one ~10 days ago of 27. Interestingly, his WBC showed leukocytosis of 11.7 with 1,895 eosinophils. Pt got reversed with 2 FFP, 10 mv of IV vitamin K and got 1 unit of blood. His VS were stable throughout his ER stay (per ED sign out). His most recent vital signs were HR 65 BPM, HR 130/52 mmHg, RR 20 breaths X', RpO2 100 RA. GI was called and is aware, but have not seen him yet. Past Medical History: -PVD: s/p peripheral angiography & angioplasty L peroneal and anterior tibial [1-/2200] -CAD s/p CABG on [9-/2198] -Right LE cellulitis at vein harvest site (admission [Date range (3) 33634]), cx grew Pseudomonas, on cipro and linezolid until [10/2198] -Diabetes Mellitus -Hypertension -Peripheral [Year (4 digits) ] Disease -Chronic Renal Insufficency -Chronic Anemia -Hyperlipidemia -Gangrene of L foot (tips of 4th and 5th digits) -Gout -Osteoarthritis -Cataracts -Carotid stenosis - s/p L CEA [9-10] Social History: Daughter lives with patient in his appt, ~60pkyr history, quit [2182] Family History: Father: stroke, died in his late 70s Mother: pulmonary embolism after hip fracture, died at age 88 Physical Exam: VITAL SIGNS - Temp 96.6 F, BP 114/45 mmHg, HR 66 BPM, RR 11, O2-sat 100% RA GENERAL - well-appearing man in NAD, comfortable, appropriate, jaundiced (skin, mouth, conjuntiva) HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [5-7] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait 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: [2200-3-22] 09:15AM BLOOD WBC-11.7* RBC-1.89# Hgb-5.6# Hct-18.4# MCV-97 MCH-29.5 MCHC-30.4 RDW-18.0* Plt Ct-473# [2200-3-22] 03:11PM BLOOD Hct-18.3 [2200-3-22] 07:40PM BLOOD Hct-17.2* Plt Ct-351 [2200-3-23] 12:55AM BLOOD Hct-22.8# [2200-3-23] 04:02AM BLOOD WBC-9.8 RBC-2.94# Hgb-8.9# Hct-26.6 MCV-91 MCH-30.2 MCHC-33.4 RDW-18.0* Plt Ct-341 [2200-3-23] 08:39AM BLOOD Hct-26.0* [2200-3-22] 09:15AM BLOOD PT-38.2* PTT-38.4* INR(PT)-4.0* [2200-3-22] 03:11PM BLOOD PT-21.6* INR(PT)-2.0* [2200-3-23] 12:55AM BLOOD PT-16.7* INR(PT)-1.5* [2200-3-23] 04:02AM BLOOD PT-16.0* PTT-30.1 INR(PT)-1.4* [2200-3-22] 09:15AM BLOOD Glucose-112* UreaN-120* Creat-5.6* Na-141 K-5.1 Cl-110* HCO3-13* AnGap-23* [2200-3-23] 12:55AM BLOOD Glucose-78 UreaN-106* Creat-4.8* Na-144 K-4.1 Cl-113* HCO3-18* AnGap-17 [2200-3-23] 04:02AM BLOOD Glucose-76 UreaN-102* Creat-4.8* Na-147* K-4.1 Cl-114* HCO3-17* AnGap-20 [2200-3-23] 12:55AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.2 [2200-3-23] 04:02AM BLOOD Calcium-8.7 Phos-4.7* Mg-2.2 EGD had erosions in his stomach that showed no evidence of active or recent bleeding. His c-scope had multiple diverticuli and a moderate sized ulcer that may have been the source of bleeding. Brief Hospital Course: Mr. [Known firstname 12056] [Known lastname 174] is a very nice 76 year-old gentleman with PAFib supratherapeutic on coumadin, DM2, HTN, severe PVD, anemia, stomach ulcers, duodenitis and recent UGIB coming with melena and clots in his NG-lavage. . #. Upper GI Bleed/Anemia. The patient has a recent gastric ulcer which was cauterized and injected on his last admission. Presented again with 10 point Hct drop in setting of supratherapeutic INR. Positive NGL, recent gastric ulcer, and melena suggestive of upper GI bleed. Patient was transfused 3 units of PRBC with an appropriate increase in his hematocrit. Also given vit k and FFP. HCT stabilized. EGD revealed non bleeding erosions in the stomach with the clips still in place from the last procedure. Because no evidence of current or recent bleeding, c-scope with prep revealed diverticuli and an ulcer which was a possible source of the bleed. After much discussion with the patient's outpatient provider and daughter, [Name Initial (PRE) ] elected to discharge the patient on aspirin/plavix and to avoid coumadin for now. This should be readdressed if the patient does well with no further bleeding issues. #. Back pain: The patient's chief complaint on presentation was actually back soreness. We added standing tylenolol and a lidocaine patch. Oxycodone prn. He has experienced success in the past with PT for back pain, so scheduled this for home. # Coagulopathy. On presentation, INR was 4.0. He was given Vitamin K IV and four units of FFP, with a reversal of his anticoagulation to 1.5. His home coumadin. aspirin and plavix were held. Restarted on discharge. . #. Paroxismal Atrial Fibrillation. H/o PAF. Now in sinus rhythm. Rate controlled with metoprolol. . #. Peripheral [Name Initial (PRE) 1106] disease. Patient is s/p peripheral angiography & angioplasty L peroneal and anterior tibial 1/[2200]. Restarted ASA/plavix. . #. Coronary artery disease. Patient is s/p CABG in [9-10]. BB/statin/asa/plavix. . -Chronic Renal Insufficency - with eGFR of 12 ml/min (MDRD) Stage V CKD with target PTH 150-300 (check every 3 mo). Last Cr check 3.9. . -Chronic Anemia - baseline Hct 28-30. . -Carotid stenosis - s/p L CEA [9-10]. Stable. NTD . #. Diabetes mellitus type 2. On glipizide at home. Covered with insulin in hospital. Restarted at discharge. . #. Hyperlipidemia. - continued simvastatin Plan d/w daughter, [Name (NI) ] [Telephone/Fax (1) 33635] Medications on Admission: Amlodipine 10 mg Daily Plavix 75 mg PO Daily EPO [2190] U SQ QMWF Furosemide 20 mg PO Daily Glipizide 2.5 mg PO Daily Metoprolol 50 mg PO BID Simvastatin PO Daily Sucralfate 1 g PO QID Coumadin 2 mg PO Daily Aspirin 325 mg PO Daily Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 3. Epoetin Alfa 2,000 unit/mL Solution Sig: [2190] ([2190]) units Injection MWF. 4. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 10. Percocet 5-325 mg Tablet Sig: 0.5-1 Tablet PO every four (4) hours as needed for pain. Disp:15 Tablet(s) Refills:0 11. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day as needed for back pain: to low back, 12hrs on and 12 off. . Disp:5 2 Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: 578.9 BLEEDING, GASTROINTESTINAL NOS Secondary Diagnosis: 250.00 DIABETES TYPE II, CONTROLLED, W/O COMPLICATIONS Secondary Diagnosis: 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (15-29) Secondary Diagnosis: 414.05 CAD, BYPASS GRAFT Secondary Diagnosis: 427.31 ATRIAL FIBRILLATION Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN Secondary Diagnosis: 285.1 ANEMIA, ACUTE BLOOD LOSS Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: As we discussed, you were admitted with a intestinal bleed. We have resumed your anticoagulation including aspirin and plavix so you will still be a risk for this happening again. Coumadin has been discontinued for now. Please monitor your stools for any sign of black or bloody bowel movements. Followup Instructions: Department: [Hospital1 18] [Location (un) 2352] - ADULT MED When: FRIDAY [2200-3-28] at 10:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1143], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site ICD9 Codes: 5849, 2851, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6821 }	Medical Text: Admission Date: [2109-10-27] Discharge Date: [2109-10-29] Date of Birth: [2043-7-17] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: s/p fall down stairs, found down Major Surgical or Invasive Procedure: none History of Present Illness: 66M unwitnessed fall down 7 steps, found confused. By report, was down for at least one hour before found. Also by report had roughly 4 drinks before fall. GCS reported @ 11 at OSH, intubated for airway concerns/transfer. On Arrival to [Hospital1 18] pt. was intubated and sedated with obvious deformity of the occipital skull. No other trauma was noted. He was mildly hypertensive, and bradycardic. He was stabalized and taken to CT. Neurosurgery was emergently called. Past Medical History: HTN, Hyperchol Social History: Apparently long drinking history Family History: unknown Physical Exam: T: 96.8 rectal BP: 105/70 HR:52 R: 16 100% on CMV Gen: intubated, sedated, lying on bed in c-collar Lungs: CTAB Cardiac: RRR Abd: Soft, NT, BS+ Neuro: Propofol turned off for exam briefly prior to repeat CT pupils equal and reactive 2->1 bilat Not following commands, moving bilat upper extremities spontaneously. No w/d to noxious stimuli bil lower extremities Toes downgoing bilaterally Pertinent Results: [2109-10-27] 03:47AM BLOOD WBC-15.4* RBC-3.55* Hgb-11.5* Hct-33.7* MCV-95 MCH-32.3* MCHC-34.1 RDW-13.3 Plt Ct-262 [2109-10-28] 02:45AM BLOOD WBC-16.7* RBC-3.02* Hgb-9.8* Hct-28.5* MCV-95 MCH-32.4* MCHC-34.3 RDW-13.5 Plt Ct-192 [2109-10-29] 01:33AM BLOOD WBC-14.6* RBC-2.71* Hgb-8.7* Hct-24.9* MCV-92 MCH-32.1* MCHC-34.9 RDW-13.6 Plt Ct-176 [2109-10-27] 03:47AM BLOOD PT-12.4 PTT-28.5 INR(PT)-1.1 [2109-10-29] 01:33AM BLOOD Plt Ct-176 [2109-10-27] 03:47AM BLOOD Fibrino-242 [2109-10-27] 03:47AM BLOOD UreaN-16 Creat-0.9 [2109-10-27] 05:51AM BLOOD Glucose-198* UreaN-14 Creat-0.8 Na-138 K-2.8* Cl-99 HCO3-18* AnGap-24* [2109-10-29] 01:33AM BLOOD Glucose-167* UreaN-23* Creat-0.8 Na-136 K-3.5 Cl-103 HCO3-22 AnGap-15 [2109-10-28] 02:45AM BLOOD ALT-22 AST-46* AlkPhos-45 Amylase-36 TotBili-0.9 [2109-10-27] 05:51AM BLOOD Calcium-7.4* Phos-3.7 Mg-1.6 [2109-10-29] 01:33AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.0 [2109-10-27] 03:47AM BLOOD ASA-NEG Ethanol-219* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2109-10-27] 05:59AM BLOOD Type-ART pO2-419* pCO2-44 pH-7.29* calTCO2-22 Base XS--4 [2109-10-27] 04:42PM BLOOD Type-[Last Name (un) ] pO2-48* pCO2-31* pH-7.45 calTCO2-22 Base XS-0 [2109-10-29] 01:45AM BLOOD Type-ART pO2-197* pCO2-30* pH-7.54* calTCO2-26 Base XS-4 [2109-10-27] 03:50AM BLOOD Glucose-170* Lactate-4.5* Na-142 K-2.7* Cl-100 calHCO3-22 [2109-10-28] 03:02AM BLOOD Lactate-2.4* CT HEAD W/O CONTRAST Reason: ? patholgy [Hospital 93] MEDICAL CONDITION: 66 year old man with ICH, cranial rx, s/p fall down 7 stairs, sent from OSH, vomiting on arrival REASON FOR THIS EXAMINATION: ? patholgy CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL HISTORY: 66-year-old male status post fall down seven flights of stairs sent from outside hospital with intracranial hemorrhage and cranial fracture. COMPARISON: None. NON-CONTRAST HEAD CT: Extensively comminuted fracture of the skull from the vertex involving the bilateral parietal and occipital bones. There is diffuse intracranial hemorrhage with bihemispheric subarachnoid blood, extra-axial hematoma along the occiput and parafalcine. Given such extensive subarachnoid hemorrhage, it is difficult to ascertain with certainty the exact areas of intraparenchymal blood vs. subarachnoid blood. A 6 mm focus of high density is seen in the superoposterior aspect of the left lateral ventricle which likely represents intraparenchymal blood. Blood is also seen within the interpeduncular fossa. The ventricles appear somewhat dilated, and there are prominent extra-axial collections bilaterally. Small air-fluid level is noted within the right maxillary sinus and ethmoid air cell as well as polypoidal mucosal thickening within the left sphenoid sinus and left frontal sinus. The mastoid air cells remain normally aerated. IMPRESSION: 1. Extensive fracture involving bilateral parietal and occipital bones. Extensive intracranial hemorrhage with a combination of subarachnoid, extra- axial and intraparenchymal blood. 2. The ventricles appear dilated and bilateral frontal prominent extra-axial spaces are noted. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Name (STitle) 7410] DR. [First Name (STitle) 3905] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3906] CT HEAD W/O CONTRAST Reason: assess interval change. please do HEAD CT at [2109-10-27] 20:0 [Hospital 93] MEDICAL CONDITION: 66 year old man with SAH s/p fall REASON FOR THIS EXAMINATION: assess interval change. please do HEAD CT at [2109-10-27] 20:00 CONTRAINDICATIONS for IV CONTRAST: None. STUDY: CT of the head without contrast. INDICATION: 66-year-old male status post arachnoid hemorrhage status post fall. Assess interval change. COMPARISONS: [2109-10-27] CT at 9:00 a.m. TECHNIQUE: Non-contrast head CT. FINDINGS: Extensive intraventricular, intraparenchymal, and bihemispheric subarachnoid hemorrhage is relatively unchanged in appearance compared to the examination from 12 hours prior. There is a small right sided subdural versus epidural hematoma over the right frontal lobe as before. There are small SDH along the falx and the tentorium as before. There is a slight increase in the edema within the left cerebral hemisphere with shift of normally midline structures 2 mm to the right. No new foci of hemorrhage are identified. Prominent extra- axial spaces overlying the frontal lobes are unchanged in appearance. Comminuted fracture of the parietal and occipital bones bilaterally is unchanged. The mastoid air cells remain well aerated. The paranasal sinuses are otherwise unchanged in appearance. IMPRESSION: 1. Relatively unchanged distribution of diffuse intracranial hemorrhage including subarachnoid, intraventricular, intraparenchymal, subdural, and possible epidural components. Close interval followup is recommended. 2. Unchanged comminuted fractures involving the parietal and occipital bones bilaterally. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 2618] [Doctor Last Name ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: MON [2109-10-28] 10:03 AM CT HEAD W/O CONTRAST Reason: F/u SAHCTVPlease perform at 10am [Hospital 93] MEDICAL CONDITION: 66 year old man s/p fall with skull fx and SAH REASON FOR THIS EXAMINATION: F/u SAHCTVPlease perform at 10am CONTRAINDICATIONS for IV CONTRAST: None. CT HEAD WITHOUT CONTRAST INDICATION: 66-year-old man status post fall with skull fractures and subarachnoid hemorrhage. COMPARISON: [2109-10-27], 4:10 a.m. FINDINGS: Compared to the study performed five hours earlier, there is significant increase in intraventricular component of the hemorrhage, with no filling defects in the occipital horns of the lateral ventricles bilaterally. Diffuse bihemispheric subarachnoid hemorrhage has increased in extent compared to the examination performed five hours earlier. It is again difficult to exclude an intraparenchymal component of the hemorrhage. The degree of ventricular dilatation appears somewhat increased. Again noted are prominent extra-axial spaces. Again noted extensive comminuted fracture of the parietal and occipital bones. Mastoid air cells are well aerated. There is mucosal thickening in the sphenoid sinus and ethmoid sinus. There is a small air-fluid level in the right maxillary sinus, unchanged. IMPRESSION: Interval increase in the extent of diffuse intracranial hemorrhage with subarachnoid, extra-axial, and probably intraparenchymal blood. Extensive comminuted fracture involving parietal and occipital bones bilaterally. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Name (STitle) ] DR. [First Name (STitle) 3905] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3906] Approved: SUN [2109-10-27] 6:06 PM CT HEAD W/O CONTRAST [2109-10-29] 3:04 AM CT HEAD W/O CONTRAST Reason: TRAUMATIC BRAIN INJURY. ? INTERVAL CHANGE. [Hospital 93] MEDICAL CONDITION: 66 year old man with traumatic brain injury REASON FOR THIS EXAMINATION: interval change? CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 66-year-old man with traumatic brain injury. Evaluate for interval change. COMPARISON: [2109-8-27], 8:30 p.m. TECHNIQUE: Non-contrast CT of the head. FINDINGS: There has been interval decrease in blood within the right lateral ventricle and left sylvian fissure. Otherwise, the extensive intraventricular, intraparenchymal, and bihemispheric subarachnoid hemorrhages are similar in appearance compared to two days prior. There is a similar 2 mm shift of the midline rightward. There are no new areas of hemorrhage. Multiple skull fractures within the parietal and occipital lobes bilaterally are unchanged. The mastoid air cells are clear. The paranasal sinuses are stable. IMPRESSION: 1. Improved subarachnoid and intraventricular hemorrhage with similar appearing intraparenchymal and extraaxial hematomas. 2. No change in mild rightward midline shift. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10270] DR. [First Name8 (NamePattern2) 11136] [Last Name (NamePattern1) 11137] Brief Hospital Course: Pt. was brought to the trauma bay and stabalized as noted in the HPI. Upon the findings noted on the CT, neurosurgery was emergently consulted. The patient was kept with HOB at >30, NS IVF was used, the patient was given Dilaudid and q1hr neuro check were performed. The patient was maintained NPO in case there was need for surgical intervention. Ventilation via ETT was continued. No signs of elevated ICP were detected. Serial CT scans of the head showed interval worsening of the hemmorhage with no resolution of the midline shift. With no further neurosurgical options a family meeting was held and the patient was made first DNR, then CMO. On [10-29] after the patient was made CMO, at 1542, the patient was pronouced dead after examination revealed no pulse, no breath sounds, and no reflexes. Medications on Admission: ? Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Expired secondary to extensive SAH, s/p cranial trauma Discharge Condition: Expired Discharge Instructions: none Followup Instructions: none ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6822 }	Medical Text: Admission Date: [2186-8-30] Discharge Date: [2186-9-8] Date of Birth: [2138-1-7] Sex: M Service: HISTORY OF PRESENT ILLNESS: A 48-year-old male with a history of Crohn's disease admitted on [8-30] with a headache a right hand numbness and weakness. A CT of the head in the Emergency Room showed a left-sided enhancing mass worrisome for a brain abscess. The patient was in his usual state of health until one month prior when he was diagnosed with epididymitis after noticing right urethral discharge. He was treated with ciprofloxacin 500 mg p.o. b.i.d. times one month. Four days prior to admission the patient noted right-sided weakness, fevers to 102, with severe [9-27] frontal headache. No evidence of seizures and denies any falls or urinary incontinence. He was noted to have photophobia and neck stiffness prior to admission. In the Emergency Department he had a lumbar puncture and a head CT performed, and the head CT noted a left-sided enhancing mass worrisome for a brain abscess. He was given morphine, ceftriaxone, Flagyl, vancomycin, and Decadron and admitted to Neurosurgery and then the Neurosurgery Intensive Care Unit. While in the Neurosurgery Intensive Care Unit he was continued on ceftriaxone, Flagyl, vancomycin, and Decadron, as well as Dilantin. On [8-31] he was noted to have a stereotactic CT-guided biopsy of the brain lesion with multiple cultures sent. Cerebrospinal fluid cultures were negative to date, and the biopsy results were Gram stain negative. He was neurologically stable and was transferred to the floor. At the time of evaluation the patient described a [3-28] headache that was described as "best in several days," and felt his sinus rhythm numbness and weakness was "improving." He denied any fever, chills, and night sweats. No photophobia. No shortness of breath or chest pain. No abdominal pain. No nausea, vomiting, or diarrhea. He denied any change in his bowel movements or dysuria or hematuria. PAST MEDICAL HISTORY: (His past medical history is notable for) 1. Crohn's disease, status post colectomy 15 years ago; notable for a history for a history of psoriasis, arthritis, and fistula related to his Crohn's disease. 2. C7-C6 and C6-C7 laminectomy with screws done in [2186-8-19] secondary to herniation of the disk. MEDICATIONS ON DISCHARGE: Medications prior to admission included Vioxx 25 mg p.o. q.d., ciprofloxacin 500 mg p.o. b.i.d. times one month. MEDICATIONS ON TRANSFER: On transfer, he was receiving vancomycin 1 g intravenously q.12h., Flagyl 500 mg intravenously q.8h., ceftriaxone 2 g intravenously q.12h., Decadron 4 mg intravenously q.6h. (tapered by 1 g every two to three days), Zantac 150 mg p.o. b.i.d., Dilantin 100 mg p.o. q.8h., morphine 2 g intravenously q.4h. p.r.n., Tylenol p.r.n., regular insulin sliding-scale, Percocet, as well as morphine sulfate p.r.n. ALLERGIES: No known drug allergies. FAMILY HISTORY: No family history of cancer. Mother passed away at age 67 from chronic obstructive pulmonary disease and diabetes. Father died at age 69 secondary to a myocardial infarction, and he has three siblings that are healthy. SOCIAL HISTORY: Tobacco history revealed he smoked three to four cigarettes per day and smoked heavily for two years in the distant past. Alcohol wise, he denies any alcohol or intravenous drug use. He lives in Rivi??????re, [State 350]. He has one son who is age 18. Married, is a glass maker, and has no other sexual partners. PHYSICAL EXAMINATION ON PRESENTATION: Generally, he alert and oriented times three, in no apparent distress. He was resting comfortably. His speech was noted to be slightly slurred. Vital signs revealed a temperature of 96.7, pulse of 71, blood pressure of 104/70, respiratory rate 20, oxygen saturation 97% on room air. Head, ears, nose, eyes and throat revealed normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Extraocular movements were intact. Mucous membranes were dry. The oropharynx was clear without any lesion. Neck was supple. No lymphadenopathy. No masses. No jugular venous distention and 2+ carotids, without any bruits. Chest was notable for bibasilar rales, right greater than left, with right-sided rales noted to be approximately one-third of the way up. Cardiovascular revealed a regular rate and rhythm, without any murmurs, gallops or rubs. The abdomen was soft, nontender, and nondistended, with normal active bowel sounds. No hepatosplenomegaly. Colostomy was noted in the right lower quadrant with no erythema. Extremities revealed no cyanosis, clubbing or edema with 2+ pulses bilaterally and symmetric. Skin was warm and dry without any rashes. Neurologically, his cranial nerves II through XII were intact. A mild right facial asymmetry was noted on smile. There was normal sensation across his face. His motor examination revealed 5/5 strength on the left, and 4/5 strength in the right upper extremity and right lower extremity, and sensation was diminished in the right upper extremity. Mini-Mental examination was 28/30, on which he lost a point space on serial sevens. Deep tendon reflexes were diminished on the right side compared to the left, and toes were downgoing bilaterally. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories upon transfer revealed white blood cell count of 13.5, hematocrit 36.4, platelets 230. Coagulations were within normal limits. Coagulation studies were within normal limits. Sodium 136, potassium 3.8, chloride 102, bicarbonate 22, blood urea nitrogen 16, creatinine 0.7, glucose of 110. Magnesium of 1.5, calcium 8.1, phosphate 1.3. AST 8, ALT 10, alkaline phosphatase 74, total bilirubin of 0.4, albumin 3. Differential showed 84% neutrophils, 0 bands, and 11.4% lymphocytes. A cerebrospinal fluid from a lumbar puncture performed on [8-30] showed a white blood cell count of 2325, 60 red blood cells, 80% neutrophils in tube 4; and tube 1 was notable for 2125 white blood cells, 90 red blood cells, with 81% neutrophils, total protein was 172, glucose was 37. The biopsy of the brain mass was Gram stain negative with no polymorphonuclear leukocytes. Culture was negative to date with negative acid-fast bacillus, fungal cultures, as well as nocardia were pending at the time of transfer to the floor. In addition, blood cultures from [8-30] were negative to date, and cerebrospinal fluid cultures showed 1+ polymorphonuclear leukocytes with no microorganism, and fungal cultures were pending. His urine culture was negative, and a [8-30] GC and chlamydia culture were also negative. RADIOLOGY/IMAGING: CT of the abdomen showed multifocal pneumonia, a normal prostate, questionable small fluid collection at the inferior tip of the liver. No evidence of an small-bowel obstruction. An magnetic resonance imaging of the head performed on admission showed a 1.8-cm X 1.4-cm moderately enhancing irregular mass lesion in the left posterior frontal white matter; question abscess versus neoplasm, which was described as lymphoma versus fungal versus toxoplasmosis. Electrocardiogram showed normal sinus rhythm at 85 beats per minute, with normal intervals, normal axis. No ST-T wave changes, mild atrial enlargement. An echocardiogram showed normal left atrium, normal right atrium, normal left ventricle with an ejection fraction of greater than 55%, normal right ventricle, normal aortic valve, 1+ mitral regurgitation, trivial tricuspid regurgitation, trivial pulmonary regurgitation, and no effusion or vegetation noted. HOSPITAL COURSE: Mr. [Known lastname 95985] was admitted to the [Hospital1 1444] on [2186-8-30] with a right-sided weakness and numbness and found on CT and magnetic resonance imaging to have a left posterior frontal lesion, thought to be a brain abscess. He was transferred to the floor on [2186-9-2], and his hospital course will be dictated from that time. The patient was continued on his antibiotic regimen including vancomycin, ceftriaxone, and Flagyl. His biopsy results were followed and waiting for their culture and speciation. The etiology of his abscess was uncertain; however, felt secondary possibly to his Crohn's disease as well as his recent epididymitis. His biopsy results were pending, but the Gram stain was negative that was worrisome in this biopsy. A repeat magnetic resonance imaging was performed to assess abscess size, status post the stereotactic drainage. Subsequently, two days later, the magnetic resonance imaging showed a significant amount of vasogenic edema surrounding the lesion. There was no hemorrhage or hydrocephaly noted but a small susceptibility defect which may not be within the center of the ring enhancing lesion. No other new findings were noted compared to the magnetic resonance imaging dated [8-30]. Over the course of this time, the patient was continued on ceftriaxone, vancomycin, and metronidazole. He continued to receive morphine and Percocet p.r.n. for the pain with subsequent trending downward of his headaches by hospital day [2-25]. He reported mild improvement of his right arm numbness and reported improvement of his neurologic function on the right side of his body. His physical examination improved so that his right facial droop as well as motor examination improved on the right side of his body. On [2186-9-4], a repeat lumbar puncture was attempted. Access was attempted using a 20-gauge lumbar puncture needle; however, access was attempted in several locations; however, the spinous processes were not located. Since this lumbar puncture was an elective procedure continued attempts were deferred, and further attempts were discussed with the Infectious Disease and Neurology team. To further work up the etiology of the patient's brain abscess a scrotal ultrasound was performed that showed no neoplasm, hydrocele of approximately 3.5 cm, as well as a transesophageal echocardiogram to look for possible vegetation with endocarditis being a source of septic emboli. On [2186-9-7], the tissue cultures returned with mild growth of Streptococcus milleri. Based on these results, the patient's vancomycin was discontinued. He was continued on intravenous ceftriaxone as well as oral metronidazole. After several discussions regarding his further course of care and plans; since the patient's headache was resolving, and a repeat lumbar puncture showed documented resolving white blood cell count in cerebrospinal fluid, Mr. [Known lastname 95985] was deemed stable for discharge with several followups. At the time of hospital discharge, the patient had markedly improved headache without having received Percocet or morphine. He will continue Tylenol for the headaches p.r.n. His right-sided weakness had markedly improved at the time of discharge as well. DISCHARGE STATUS: The patient was discharged home with [Hospital6 407]. DISCHARGE INSTRUCTIONS: He will continue the Dilantin and Decadron taper. In addition, he will continue ceftriaxone intravenously and Flagyl for up to a 6-week course. DISCHARGE FOLLOWUP: He was to follow up with his primary care provider, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], one week after discharge. In addition he will have an ENT followup on [9-21] for his continued hoarseness for a vocal cord evaluation. In addition, he was to have an echocardiogram on [9-11] at 11 a.m. to evaluate for endocarditis and to rule out septic emboli as a source of his brain abscess. In addition, he was to follow up in the Infectious Disease Clinic in early [Month (only) 359] to adjust antibiotic course at that time. MEDICATIONS ON DISCHARGE: 1. Dilantin 100 mg p.o. q.8h. 2. Decadron 1 mg p.o. q.6h. times two days. 3. Flagyl 500 mg p.o. t.i.d. times six weeks. 4. Ceftriaxone 2 g intravenously q.12h. times six weeks. 5. Percocet 2 tablets p.o. q.6h. p.r.n. DISCHARGE DIAGNOSES: 1. Streptococcus milleri brain abscess. 2. Continued headaches. 3. Hoarseness. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 16316] Dictated By:[Last Name (NamePattern1) 14434] MEDQUIST36 D: [2187-1-15] 17:35 T: [2187-1-16] 18:25 JOB#: [Job Number ] ICD9 Codes: 486, 2765, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6823 }	Medical Text: Admission Date: [2113-5-19] Discharge Date: [2113-5-28] Service: MEDICINE Allergies: Codeine / Morphine / Penicillin G Sodium / Cortisone Attending:[First Name3 (LF) 4421] Chief Complaint: Fevers and rigors of unknown cause. Major Surgical or Invasive Procedure: None History of Present Illness: 87 yo woman with recent diagnosis of stage III, suboptimally debulked ovarian cancer diagnosed in [Month (only) 956], presented with respiratory distress and fever. She tolerated her first cycle of single [Doctor Last Name 360] carboplatin beautifully 12 hours prior, and then developed fever and chills at 3 AM today. In the ED, her T was 102 degrees F PO. CXR was consistent with CHF (BNP [Numeric Identifier 100467] range). Patient denies cough/headahce/photophobia/chest pain/diarrhea/sick contact. She recieved vancomycin and levofloxacin in the ED for a possible infection, although no site of infection was identified. Upon admission, she was febrile to 103 degrees F PO with rigors, and she was found to be in respiratory distress. Code status was discussed at that time, and she did not want intubation/resuscitation. In [Hospital Unit Name 153], her respiratory distress was attributed to a combination of fever and CHF, the latter possible precipitated by atrial fibrillation. Patient was formerly DNR/DNI but reversed her code status to DNR/intubate. She received nebulizer treatments prn. CT chest showed stable thyromegaly. She had left shift, lactate 3.3 on presentation. She did not have other obvious site of infection. Patient was treated with vanco/levo/flagyl (patient has PCN allergy) but continued to spike fevers. Urine culture/blood cultures showed no growth for many days, and the final results are pending (the patient refused further testing with subsequent fevers). For atrial fibrillation, she was rate controlled with metoprolol as needed. Upon admission she was noted to have a mild tramaminitis. Patient is now transferred back to the regular floor and currently states that she "feels great," without chest pain, sob, discomfort, nausea/vomiting, dysuria, diarrhea, constipation. Past Medical History: Past Medical History: - suboptimally debulked, stage IIIC papillary serous ovarian cancer(with involvement of the omentum and upper abdomen) s/p exploratory laparotomy performed by Dr. [Last Name (STitle) 2406] at [Hospital1 18] [3-11] s/p Cytoreductive surgery for ovarian cancer including omentectomy, radical resection of pelvic mass including bilateralsalpingo-oophorectomy - HTN - osteoporosis - hypercholesterolemia - s/p TAH for fibroids at age 30 - s/p thyroid nodule resection - LLL lung resection for "carcinoid tumor" in [2104]. - carpal tunner surgery - bronchitis, hypertension, - bilateral hearing loss for which she has a hearing aid She is allergic to penicillin which causes a rash. Social History: SOCIAL HISTORY: She does not smoke or drink alcohol. She works in a sales company, retired many years ago. She lives half the year in [State 108] starting in [Month (only) 1096]. She lives in [Location 2624] during her [State 350] part of the year. Family History: FAMILY HISTORY: She has no convincing history of breast or ovarian cancer to suggest a genetic predisposition. Mother and father died at older age without cancer. She has four brothers and sisters who do not have colon cancer, breast cancer, ovarian cancer. She is partly of Ashkenazi [Hospital1 ] background. Physical Exam: exam: Temp: 101.3 Tcurrent: 97.9 HR: 89 BP: 104/50 RR: 16 99% on RA GEN: NAD, AEO x3 HEENT: CNII-XII intact, EOMI, PERRLA CV: Irregular rhythym, [3-12] holosytolic murmur heard loudest at LUSB RESP: Right lower lobe cracles, CTA in all other lung fields ABD: soft, nt, nd, nabs EXT: no c,c,e Pertinent Results: Imaging: CXR [5-19]: CHF picture with stable thyroid mass cxr [5-20]: 1. Increased right lower lobe opacity which could represent pneumonia in the right clinical setting. 2. Stable CHF. cxr [5-21]: IMPRESSION: Improving aeration consistent with improving fluid status, although persistent features of CHF remain. No new consolidations CT neck [5-21]: IMPRESSION: Enlarged thyroid gland is again seen, and is stable in appearance. Ct chest [5-22]: 1. Findings consistent with congestive heart failure. The evaluation for underlying interstitial lung disease is not possible due to superimposed CHF. 2. Focal patchy opacities seen in the right lower lobe may represent a focus of atypical atelectasis, or early pneumonic consolidation. Resolution of this lesion should be documented on follow-up scans after treatment given the patient's history of ovarian cancer. 3. Pulmonary hypertension. 4. Enlarged right lobe of the thyroid, which is stable in appearance dating back to [2112-6-13]. Ultrasound [5-22]: 1) Normal hepatic echotexture with no focal liver lesions or biliary ductal dilatation identified. 2) Likely parapelvic cysts within left kidney. Blood cultures and urine cultures have shown no growth to date Echo ([5-23]): The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Mild to moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [2113-5-19] 04:03PM GLUCOSE-107* UREA N-32* CREAT-1.3* SODIUM-135 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-26 ANION GAP-17 [2113-5-19] 04:03PM CK(CPK)-73 [2113-5-19] 04:03PM CK-MB-NotDone cTropnT-0.02* proBNP-[Numeric Identifier ]* [2113-5-19] 04:03PM WBC-5.5 RBC-3.81* HGB-11.4* HCT-34.0* MCV-89 MCH-29.8 MCHC-33.4 RDW-14.6 [2113-5-19] 04:03PM NEUTS-96.2* BANDS-0 LYMPHS-2.6* MONOS-0.9* EOS-0.1 BASOS-0.2 [2113-5-19] 04:03PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2113-5-19] 04:03PM PLT SMR-NORMAL PLT COUNT-135* [2113-5-19] 03:46PM URINE GR HOLD-HOLD [2113-5-19] 03:46PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.006 [2113-5-19] 03:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: Respiratory distress due to CHF: The patient had a BNP of 10,000, and she was diuresed with good response. It was thought that her CHF was precipitated by fever and atrial fibrillation. She was placed on aspirin, and there was decision not to anticoagulate based on an isolated incident of atrial fibrillation and the morbidity of coumadin. Patient was formerly DNR/DNI but has reversed her code status to DNR/intubate. She was maintained on lasix for her CHF. Fever: The etiology of her fevers remained unclear, but there was no convincing source of an infection. Patients blood and urine cultures were unrevealing. She had no evidence for pneumonia by clinical sx or by imaging. In the unit she was originally treated with vanco/levo/flagyl (patient has a pcn allergy) but she continued to spike fevers. It was then felt that an infectious etiology was unlikely, and all abx were therefore stopped. We spoke to heme onc attending as to whether fevers could be related to carboplatin. Dr. [Last Name (STitle) ] felt this would be very unusual for this drug, but still considered it a possibility, especially in view of LFT abnormalities (below) suggestive of possible drug-induced cholestasis (again unusual for carboplatin). Patients fever curve trended down off of antibiotics, and she was afebrile at the time of discharge. Transaminitis and cholestasis: Patient showed evidence of a transaminitis upon admission which stabilized, although her bilirubin continued to trend upwards to the low 6 range. A right upper quadrant ultrasound with dopplers was obtained that did not indicate any liver lesions, biliary duct dilatation, or hepatic [Last Name (un) ] thrombus. After excluding more likely causes, Dr. [Last Name (STitle) ] considered the possibility that carboplatin might explain the fevers and transaminitis/cholestasis in view of the time course, although acknowledged that this would be unusual for this medication. Hepatology was consulted and agreed with him, and felt that this was possibly a drug induced cholestatis. Hepatology also felt that her hepatitis serologies were not consistent with active viral hepatitis. Her statin was held, and the recommendation was made to the patient that this medication not be restarted. Patient's transaminases and bilirubin plateaued and were trending downwards on discharge, with the patient feeling well (total bilirubin plateaued in the low 6 range, mostly direct in nature). Thyroid mass: Patient had a stable appearing enlarged thyroid on chest/neck CT with associated lymphadenopathy from [2113-5-22]. The patient will follow up with her outpatient endocrinologist. Medications on Admission: aspirin albuterol statin Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:1 4. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once a day. Disp:30 packets Refills:2 7. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q3-4H () as needed. 9. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: Commons Residence At Orchard - [Location (un) 2624] (a.k.a. [Location (un) 5481]) Discharge Diagnosis: Drug-induced cholestasis/hepatitis CHF Ovarian cancer Discharge Condition: Stable Discharge Instructions: Please call your doctor or come to ED if you develop nausea, vomiting, fevers/chills, chest pain, increased yellow color of the skin, or shortness of breath. You should NOT take Lipitor or similar medications again. Please call Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 32192]) on Monday to schedule a follow up appointment (already made), along with follow-up blood studies (already scheduled). Followup Instructions: Provider: [Name10 (NameIs) 17515] CHAIR 1B Date/Time:[2113-6-1] 10:30 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], RN Where: [Hospital6 29] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2113-6-1] 10:30 Provider: [Name Initial (NameIs) 4426] 19 Date/Time:[2113-6-8] 2:00 Please make a follow up appointment with your PCP- [Name10 (NameIs) ] [Last Name (STitle) 14069] - within one week of discharge - [Telephone/Fax (1) 37171]. Also, please call Dr. [Last Name (STitle) ] ([0-0-]) on Monday to schedule a follow up appointment. Completed by:[2113-5-29] ICD9 Codes: 4280, 486, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6824 }	Medical Text: Admission Date: [2185-5-18] Discharge Date: [2185-5-20] Date of Birth: [2135-5-17] Sex: M Service: MEDICINE Allergies: Motrin / Compazine / Morphine / Toradol Attending:[First Name3 (LF) 106] Chief Complaint: chest pain and R flank pain Major Surgical or Invasive Procedure: aspirin desensitization cardiac catheterization History of Present Illness: 50 yo M with history of HTN, CAD, CHF with EF of 30%, s/p ICD pacemaker in [2182-1-29] for VT, and biploar, who presents with chest pain and R lower flank pain. Pt was admitted for similar sx's in [3-5]. Pt states on the morning of admission at about 9 a.m. he developed R flank pain. States he had intense pain on urination and noticed that his urine had blood in it. States the pain has been constant since it began and was only partially relieved by IV dilaudid which he received in the ED. States it is sharp in nature and is equally as strong if he lies still vs. moving around. . Pt states around 12:30p.m. on the DOA he also developed chest pain while he was sitting watching t.v. States it was an [9-7] located in the center of his chest and radiated to his L jaw, L neck, and L arm. States he also had SOB, nausea, and diaphoresis. Took 2 SL nitro's and the pain decreased to a [5-8]. He presented to the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and was subsequently transferred to the [Hospital1 ] for cath. However, given his history of allergy to aspirin (states he gets SOB and his whole body swells) he was transferred to the CCU for asa desensitization prior to cath. On ROS pt denies any recent vomiting, diarrhea, BRBPR, melena. No fevers, chills, night sweats or changes in weight. States legs occasionally get swollen but this has not occurred lately. States at baseline he can only walk a short distance before getting SOB. Sleeps on one pillow and denies any PND or orthopnea. . On review of the online records from the [Hospital1 ], [Location (un) 620] and Mt. [Location (un) ], it was found that the patient has had 4 admissions in the past 4 months for these exact same sx's. Each admission makes note of a completely negative workup including negative cardiac enzymes, no ECG changes, and CT scans which show no evidence of nephrolithiasis. His last [Hospital1 ] admission documents malingering in which the patient was found cutting his hand and placing drops of blood in his urine and then denying this act later. All four admissions document his IV dilaudid seeking behavior, and in the most recent admission to [Hospital3 ] on [2185-4-29], he left AMA after he was refused IV dilaudid and offered only po or IM. Past Medical History: PAST MEDICAL HISTORY: 1. CAD. M.I. x 2 ([2182], [2183]). Catherization @ [Hospital1 336] [2185-2-17]. LAD proximal 40% lesion, mid 30% lesion. DIAG1 proximal 50% lesion. mid 40% lesion. LCA CX proximal diffuse 50% lesion. RCA ostial 30% lesion. Conclusion. Moderate non-obstructive cornary disease. ECHO [5-2] at [Hospital1 ]. Enlarged LV with hypokinesia of inferoseptal wall. EF 40% enlarged LA. Trileaflet aortic valve. Enlarged aortic root [3-2] HTN. Stress test [5-2] at [Hospital1 ]. Dipyridamole injection. Normal uptake of radioisotope without perfusion defect. EF 34%. 2. Dyslipidemia. Cholesterol panel [2185-6-11]. trig 312. HCL 37. LDL cal. 18. 3. History of hypertension. 4. Syncope. Hospitalization [5-/2182] @ [Hospital1 18] for an episode of syncope and palpitations. 5. Status post ICD pacemaker implantation for VT in [2182-1-29] @ [Hospital1 336] 6. Nephrolithiasis [2183] 7. Status post cholecystectomy. 8. Chronic back pain due to degenerative disc disease. Seen on CT at L4-5 and S1 [10-2] 9. Bipolar diagnosed [2183]. 10. multiple hospitalizations [2182]-[2185] around the area for chest pain, flank pain, hematuria. 11. PE in [3-5] at [Hospital1 ], treated with coumadin, then pt reports he had a filter placed at [Hospital ] hospital in [4-2] and since has not been taking coumadin. Social History: On admission pt stated he currently lives with his wife their two children, a 17 year-old daughter and a 15 year-old son, with her. However, later he disclosed that his wife left him for another man in [2-2] and took their children with her. States he lives alone and has little social support. He used to work as a commercial fisherman and as licensed auto mechanic, however he stopped working in [2182] s/p his ICD pacemaker placement. Last year he started receiving disability benefits. He is on Mass Health.Patient??????s diet consists primarily of meat and potatoes. He is unable to exercise because of his back pain. He has a 15 pack-year smoking history, but recently stopped 4 months ago. He denies alcohol use but admitted to the social worker that he used to drink heavily and occasionally attends AA meetings. He used pot in high school, but denies any additional recreational drug use. Family History: Family history is significant for heart disease. Father died from an M.I. at 70 years old. [Name (NI) ] brother has heart problems. Aunts on his father??????s side have unstable angina. Mother died at 62 years old from breast CA, which metastasized to the bone. There is no family history of clotting disorders. Physical Exam: 98.4 91 111/73 15 97% 2L NC Gen: repetitively complaining of pain, but easily moves in bed and appears comfortable. HEENT: MMM, OP clear Neck: no stiffness or limited ROM CV: RRR, no m/r/g Lungs: CTAB Abd: s/nt/nd, +bs. Back: + R CVA tenderness. Ext: no c/c/e. DP and PT pulses 2+ bilaterally. Neuro: A&Ox3. Pertinent Results: [2185-5-18] 05:28PM GLUCOSE-101 UREA N-33* CREAT-1.2 SODIUM-143 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-26 ANION GAP-14 [2185-5-18] 05:28PM CK(CPK)-46 [2185-5-18] 05:28PM CK-MB-NotDone cTropnT-<0.01 [2185-5-18] 05:28PM CALCIUM-9.3 PHOSPHATE-4.0 MAGNESIUM-2.1 [2185-5-18] 05:28PM VALPROATE-20* [2185-5-18] 05:28PM WBC-7.5 RBC-4.55* HGB-13.1* HCT-38.1* MCV-84# MCH-28.9 MCHC-34.5 RDW-14.6 [2185-5-18] 05:28PM PLT COUNT-279# [2185-5-18] 05:28PM PT-13.6 PTT-35.2* INR(PT)-1.2 [2185-5-18] 05:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2185-5-18] 05:28PM URINE MUCOUS-OCC [2185-5-18] 05:28PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 CXR: No acute cardiopulmonary process identified. ECG: NSR at 98. LAD. nl intervals. possible small ST depressions in V4-5 compared to prior (although on review of multiple old ECG's this appears to have been present in the past). Stress Test ([2185-5-19]): This 50 yo man (s/p MI and h/o VT with ICD implantation in [2182]; non-obstructive CAD with LVEF ~30% on cardiac catheterization in [2185]) was referred for a CAD evaluation. The patient was administered 0.142 mg/kg/min of IV persantine over 4 minutes. No neck, back, arm or chest discomfort was reported by the patient throughout the procedure. No significant ST segment changes were noted from baseline. The rhythm was sinus with one VPD. The hemodynamic response to infusion was appropriate. Post MIBI injection, the patient was administered 125mg of IV Aminophylline. IMPRESSION: No anginal type symptoms or ischemic EKG changes from baseline. pMIBI ([2185-5-19]): Diffuse global hypokinesis, LVEF 36%. No reversible perfusion defects detected. Mild fixed inferior wall defect. CT abdomen ([2185-5-19]): 1) No evidence of nephrolithiasis or secondary signs to suggest obstruction. 2) Diffuse coronary artery calcification. 3) Infrarenal IVC filter. 4) Status post cholecystectomy. Brief Hospital Course: A/P: 50 yo M with history of HTN, CAD, CHF with EF of 30%, s/p ICD pacemaker in [2182-1-29] for VT, and biploar, who presents with chest pain and R lower flank pain. This is at least the pt's 4th admission for these two symptoms in the past 4 months; all of these admissions have resulted in negative workups and all have been dominated by the pt's IV dilaudid-seeking behavior. . #Cardiac: 1. CAD: The pt's description of chest pain was concerning for ACS, however, since the pt had presented at least 4 times in the past 4 months with this exact same description and on this admission he had negative enzymes with no ECG changes, it was considered unlikely that this pain was cardiac. The 1mm ST depressions seen in V4-5 have been present in the past on some ECG's. Thus, it was determined that a catheterization was not necessary. The pt underwent a pMIBI stress test which showed no reversible perfusion defects. The pt was continued on plavix, BB and was started on an ACEi. He also underwent aspirin desensitization successfully and was started on ASA 325 daily. His atorvastatin was increased to 80mg daily given his CAD and multiple risk factors. . 2. Pump: The pt's BP remained in good range with metoprolol and lisinopril. His blood pressure will be monitored by his new PCP and medication titration can occur as an outpt. . 3. Rhythm: telemetry monitoring showed no events. Has h/o ICD/pacer. . #Pulm: has h/o PE now s/p IVC filter placement. His O2 sats remained good while in house. . #R flank pain with questionable hematuria: pt gives h/o nephrolithiasis, however, has had 4 CT's in the past 4 months which have all been negative. Pt was observed during last admission to have cut his hand and squeezed the blood into his urine cup. His Ua on this admission was negative for blood. He underwent a CT which showed no evidence of nephrolithiasis or secondary signs to suggest obstruction. His Cr on admission was 1.2 and subsequently increased to 1.9, however, the pt appeared dry and his UOP was low. He was hydrated with IVF and repeat Cr was 1.1. Urology signed off and stated there were no GU issues. However, the pt continued to complain of R flank pain and stated that he had been having this pain for several months and the only thing that had ever helped it was IV dilaudid. When he was told that he would not be receiving IV dilaudid he stated that he was ready to go home and insisted on speedy arrangements of transportation. . #Psych/bipolar disorder: Pt was continued on depakote, trazodone, and zoloft. He was seen by social work who provided support given that his wife recently left him, leaving him alone in his apartment. He denied any suicidal ideations and was deemed safe for discharge. He was urged to follow up with his outpatient psychiatrist as soon as possible. . #Pain: pt reported severe pain, but was able to move very easily. He stated he had [9-7] pain in his R flank that was worse with ambulation, however, he was repeatedly seen wandering the halls in search of food in the patient kitchen. He was treated with his outpatient dose of Oxycontin 80mg [Hospital1 ] and was given IM and po dilaudid 1mg q6 hours prn. On discharge he requested vicodin, stating that he was trying to get off of his oxycontin. This medication was declined and the pt was urged to find a PCP who could assist him with getting off of his oxycontin gradually over time after they have arranged a contract verifying that the pt will not pursue other narcotics from other providers. Medications on Admission: Trazodone 100 mg PO qhs Sertraline (Zoloft) 200mg PO daily Toprolol (Metoprolol XL) 200 mg PO daily Verapamil SR 240 mg PO daily Depakote (divalproex sodium) 750 mg PO qpm. 500 mg PO qam oxycontin 80mg PO bid plavix 75mg PO daily SL nitro prn Discharge Medications: 1. Oxycodone HCl 40 mg Tablet Sustained Release 12HR Sig: Two (2) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 2. Trazodone HCl 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Sertraline HCl 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 7. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the evening)). 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. 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 11. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: non-cardiac chest pain Discharge Condition: stable Discharge Instructions: Please make an appointment and find a new PCP as soon as possible. Given the results of your tests, your chest pain is not likely cardiac in nature and so going from hospital to hospital with this complaint is more likely to put you at increased danger due to unnecessary tests. Similarly, there is no evidence of kidney stones so pursuing more imaging tests would not likely be useful. What is most likely to help is to find a PCP and address your concerns with this doctor who will follow you over the long-term. Followup Instructions: Please find a PCP [Name Initial (PRE) 2678]. If you continue to have right flank pain or hematuria, please address this with your PCP and avoid having additional CT scans. If you are unable to find a PCP, [Name10 (NameIs) ] call [Hospital ] at [Telephone/Fax (1) 250] to schedule an appointment first available. ICD9 Codes: 5849
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6825 }	Medical Text: Admission Date: [2128-2-11] Discharge Date: [2128-2-17] Date of Birth: [2055-10-19] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1436] Chief Complaint: substernal chest pain Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 72 y/o M with h/o CAD (known 3VD, declined bypass x5 yrs), CKD (cr 3.5), dCM (EF 25%, declined ICD previously), DM, BRBPR (not yet worked up) p/w 1 week SOB, substernal chest discomfort and left arm pain, also with bloody stools. Pt was admitted to floor where he received 1u pRBC, O2, morphine, lasix and NTG. Pt then went into acute respiratory distress and was admitted to the ICU. Found to be hypotensive, tachycardic and diaphoretic and agitated. given SL NTG then on IV NTG gtt. received total of 6mg IV morphine and was calmer. For his tachycardia he was given IV lopressor. CXR done at that time showed RLL infiltrate that was worsening on followup CXR with "intermittent infiltrate" (not always seen) in left lung. Pt only put out 300ccs of urine to 280 IV lasix (40mg IV bolus followed by gtt). Trop T 0.11 and went up to 0.67. FSG in the 600s, GAP unknown at presentation but down to 13 prior to transfer (glucose in 200s by then). pt placed on insulin gtt with resolution of blood sugars to 200s. Pt hyperkalemic with K 6.4 --> 7.2 --> 6.1, 1 dose kayexelate given. Pt was taken off bipap and nitro gtt but developed acutely worsening SOB, BP down to 70/40 and levophed was started. Pt started on azithro/unasyn out of c/f PNA. Pt had fever last week but was afebrile at OSH. EKG showed LBBB, wide QRS with elevated K. TTE yesterday showed mildly dilated LV, LVEF 30% akinesis of anterior wall, apex, septum, inf/inferolateral wall, moderate MR, mod TR, mild pHTN PAP 40, small effusion. Pt also received steroids. Pt was transferred to [Hospital1 18] for further management. Vitals prior to transfer were HR 91, BP 85.46 SpO2 99%. . On arrival pt was on levophed 20, insulin 6u/hr, protonix drips and bipap. Vital signs were AF T97.4 HR 93 Bp105/50 (63) RR19 100% on nonrebreather (50%FIO2). . ECG showed NSR at 100bpm with no ST changes suggestive of ischemia but with peaked T waves in antero-lateral leads. Labs showed: trop 1.46 CKBM 49, Cr of 4.1 up from b/l 3.5, K of 6.1, bicarb 19, sodium 134, glucose 285. WBC 10, HCT 30. Lactate 0.6. Pt was placed on bipap at 40% for ABG of 7.11/60/318. Was given lasix 200mg IV without much urine output, placed on lasix gtt of 20 and metolazone 5mg given. After 30 minutes ABG showed 7.14/54/93. . Of note, family very conflicted about goals of care, pt has refused multiple interventions in the past and recurrently noncompliant with therapy. Conversations with family through the language line were extensive. Daughter in law speaks English and knows medical terminology and stated that the interpreter??????s accent was difficult to understand. Pt refused to make decision regarding dialysis, code status, and HCP. At first refused anticoagulation and PR medications but bipap was removed to make him more comfortable and have a conversation effectively and he agreed to these measures. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension OTHER PAST MEDICAL HISTORY: - asthma - BPH Social History: pt is egyptian, arabic speaking only. former smoker. Family History: noncontributory Physical Exam: ON ADMISSION: Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 96 (91 - 105) bpm BP: 119/50(69) {90/44(0) - 119/50(69)} mmHg RR: 16 (11 - 21) insp/min SpO2: 99% on nonrebreather Heart rhythm: SR (Sinus Rhythm) Wgt (current): 109 kg (admission): 109.7 kg GENERAL: moderate distress, incr WOB. 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 halfway up the neck CARDIAC: heart sounds difficult to auscultate over lung rhonchi and wheezes. Normal S1, S2 no m/r/g. LUNGS: labored breathing, on NRB. Diffusely wheezy and rhonchorous. ABDOMEN: protuberant. 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+ AT DISCHARGE: Tmax: 37.2 ??????C (99 ??????F) Tcurrent: 36.7 ??????C (98 ??????F) HR: 108 (101 - 122) bpm BP: 108/47(64) {84/35(49) - 121/54(73)} mmHg RR: 22 (16 - 33) insp/min SpO2: 100% Heart rhythm: ST (Sinus Tachycardia) Wgt (current): 97.5 kg (admission): 109.7 kg GENERAL: moderate distress, incr WOB. Not able to orient. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Shallow ~1cm ulcer on nasal bridge [2-19] BiPAP, nonpurulent. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP halfway up the neck CARDIAC: heart sounds difficult to auscultate over lung rhonchi and wheezes. Normal S1, S2 no m/r/g. LUNGS: labored breathing, on shovel mask with humidified O2. Diffusely rhonchorous and coarse. ABDOMEN: protuberant. Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Pulses 2+ SKIN: No stasis dermatitis, scars, or xanthomas. Pertinent Results: - ECHO: [2122] at [Hospital1 18] TTE: EF 25% 1. The left atrium is mildly dilated. The left atrium is elongated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. No masses or thrombi are seen in the left ventricle. Resting regional wall motion abnormalities include akinesis of the lower third of the LV with inferolateral akinesis. 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic root is mildly dilated. The ascending aorta is mildly dilated. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. 6.The mitral valve leaflets are mildly thickened. Mild mitral regurgitation is seen. 7. No pericardial effusion seen. . TTE [2128-2-11] The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 25 %) secondary to severe hypokinesis/akinesis of the inferior and posterior walls, and extensive apical akinesis with focal dyskinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2122-5-8], inferior wall contractile dysfunction is more extensive, with consequent worsening of mitral regurgitaton. . CXR [2128-2-14] Diffuse right lung opacities have minimally improved, differential still include hemorrage, infection, asymmetric edema. Left upper lobe atelectasis is unchanged. Left mid lung atelectasis and aeration of the left lower lung have improved. There is no evident pneumothorax. Right PICC tip is in the lower SVC. cardiomediastinal contours are stable. Brief Hospital Course: # hypercarbic respiratory failure - Pt presented with respiratory acidosis and elevated CO2 on ABG in 60s range. Pt had become acutely dyspneic [2-10], most likely [2-19] cardiogenic edema in setting of MI with MR. CXR showed pulmonary edema and consolidation of right lung fields greater than left, pt had a significant wet cough, reported fevers at home, and out of c/f CAP pt was started on ceftriaxone/azithro.ers at home). Bronchospasm/some component of COPDlikely played a role(pt longtime smoker w/ history of asthma, on albuterol/fluticasone/ipratropium at home). Pt was maintained initially on facetent at 30-50% with 4L NC, but gas showed PCO2 up to 60s and was started on bipap. Pt remained stable with improvement of CO2 to 55 on bipap. Pt was again taken off bipap and CO2 went up to 79 on [2128-2-15]. Xopenex was given along with standing nebs. PT was aggressively diuresed, with eventual succes. Goals of care discussions were murky and ongoing, on [2128-2-15] the family requested that we attempt to wean pressors and DC antibiotics. Pt was given morphine prn for increased WOB with good effect. On [2128-2-17], another goals of care discussion occured and at that point it was decided that Mr. [Known lastname 66855] would be made comfort measures only. At this point, pressors and all non-comfort focused medications were discontinued. Mr. [Known lastname 66855] passed on [2128-2-17]. . #decompensated heart failure - presented with shortness of breath [2-19] pulmonary edema/fluid overload in setting of [Month/Day (2) 7792]. EF of 25% and severe global LV hypokinesis and MR. At OSH diuresis was attempted with total 280mg IV lasix without success. Once transferred, pt was put on a lasix gtt which was run between 20-30 mg per hour for 2 days with success after addition of metolazone. Pt was net negative several liters by [2128-2-15]. Lasix was stopped on [2128-2-17] consistent with his goals of care. . #[Name (NI) 7792] - pt p/w several days of epigastric pain and SOB. Acute decompensation with evidence of fluid overload also with elevated cardiac enzymes MB of 49. Likely inferior infarct associated with mitral regurgitation. Echo [2128-2-11] showed EF of 25% with severe global hypokenesis/akenesis of left ventricle with moderate mitral regurg. In setting of goals of care cath was deferred. Pt was given aspirin and plavix load, started on heparin gtt for 48 hours. #hypotension - pt was unable to maintain BP on his own, off pressors would drop to 70s systolic. Was started on levophed and failed attempts to wean. Hypotension [2-19] decreased cardiac output in setting of LV hypo/akinesis. Levophed was continued until he was made CMO on [2128-2-17], and Mr. [Known lastname 66855] passed on [2128-2-17]. . #anemia - pt with HCT drop on arrival s/p transfusion of 1u PRBCs at OSH. On admission HCT 30 which went down to 25. pt with history of reported melena for 6 months not worked up, but no signs of obvious bleeding. Pt had no stools and therefore no witnessed melena during this hospitalization. No BRBPR. Hct was trended, remained stable s/p 1u pRBCs at [Hospital1 18]. There was some concern that pt was bleeding into lung parenchyma as he began coughing up thick bloody mucous on [2128-2-14]. Initially pt was continued on heparin, plavix, ASA, in setting of [Date Range 7792], but after 48 hours heparin gtt was discontinued. . # hyperkalemia - K up to 7.1 at OSH on presentation. Resolving on transfer s/p kayexelate at OSH but still in 6 range with peaked T waves on ECG. With kayexelate, insulin gtt, bicarb, beta agonist nebs, lasix gtt, K corrected to normal range. [2-19] pt'[Initials (NamePattern4) ] [Last Name (NamePattern4) ] on CKD, see below. . # ESRD - [Last Name (un) ] on CKD, most likely cardiac in origin in setting of poor perfusion to kidneys. On transfer pt was found to be hyperkalemic, acidotic (respiratory acidosis with metabolic component). Nephrology was consulted for concern that pt would need dialysis. Dialysis was not initiated as patient was made CMO. . #metabolic acidosis - Pt presented with metabolic component of acidosis with AG of 17. Likely in setting of renal failure [2-19] decreased perfusion, FSG was monitored and remained in the 200 range, then controlled with insulin gtt, and pt was transitioned to SQ regimen without issues. . #goals of care - family discussions were held in depth every day of hospitalization. on [2128-2-15] they were informed we had tried everything we could do, and agreed to wean pressors and DC antibiotics. Mr. [Known lastname 66855] was made CMO on [2128-2-17], and Mr. [Known lastname 66855] passed on [2128-2-17]. . # DM - poorly controlled, p/w FSG of 600 to OSH but no AG. BS down to high 100s on insulin gtt, stabilized and pt transitioned to subcu insulin. This was stopped on [2128-2-17] as patient was made CMO. . #Nutrition - pt initially kept NPO c/f aspiration (audible gurgling/choking noises). Family fed the pt chicken and respiratory status worsened, felt that he developed aspiration pneumonitis. Goals of care were clarified and family wanted to feed the pt which was fine as we were not escalating care. . #communication - pt is arabic speaking only. . #contact: [Name (NI) ] [Telephone/Fax (1) 66856] ([Name2 (NI) ]er in law) [Name (NI) ]: [Telephone/Fax (1) 66857] (son) Medications on Admission: proair fluticasone-propionate (flovent) 2 puffs by mouth [Hospital1 ] lasix 60po daily lisinopril 20mg daily simvastatin 20 mg po daily glyburide 5mg daily metoprolol succinate 50 mg daily vitamin D 5000u 1x per wk doxazosin 2mg qhs allopurinol 100mg tab daily atrovent 2 puffs 4times daily aspirin 81mg Discharge Medications: None, patient deceased Discharge Disposition: Expired Discharge Diagnosis: Non-ST Segment Elevation Myocardial Infarction Decompensated Systolic Heart Failure End Stage Renal Disease Diabetes Mellitus Type II Hypoxemic and Hypercarbic Respiratory Failure Discharge Condition: Deceased Discharge Instructions: Dear Mr. [Known lastname 66855], It was a pleasure taking care of you at [Hospital1 18]. You were admitted with a heart attack and decompensated systolic congestive heart failure with resultant respiratory distress and renal failure. We initially treated your heart attack with blood thinners and your heart failure with diuretics. Unfortunately however, your condition was too severe to be treated with medical management alone. With your healthcare proxies, we decided to focus on comfort focused care, and arranged for you to be sent home with hospice care. The following medication changes were made: STOP all medications except: sublingual morphine 2-8mg as needed for comfort liquid atropine drops as needed for secretions All other pre-hospital medications should be discontinued as we are focusing on comfort measures. Followup Instructions: None ICD9 Codes: 486, 5856, 5070, 5849, 4254, 4280, 2767, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6826 }	Medical Text: Admission Date: [2188-9-7] Discharge Date: [2188-9-9] Service: MEDICINE Allergies: Penicillins / Codeine Attending:[First Name3 (LF) 1253] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] yo male with a pmh of a-fib on coumadin, and dCHF who began having crampy abdominal pain last night and BRBPR starting at 11pm. He described the pain as diffuse, crampy abdominal pain, not worse in any particular area, and bright red blood mixed with brown stool last night. He denies any fevers, chills, CP, cough, dysuria, myalgias, or shortness of breath. He is a little tired and feels "chilled" this AM. Otherwise negative review of systems. . In the ED: No active bleeding was noted, his HCT dropped from 31->24 since [2188-9-3]. Labs also notable for INR of 3.6. His BPs were initially 88 systolic, he got 1L NS, 2units FFP (2nd running at transfer), no red cells, and BPs responded to around 100 systolic. EKG showed Twave flattening, he had a trop of 0.08 (baseline 0.07). GI rec'd CTA which showed diverticulosis, no active extravasation, streak artifact from hip. There was late phase filling in the spleen which was not thought to be a site of active bleeding. He received vitamin K 10mg, and Protonix 40 IV. While receiving the first unit of FFP he had itching and hives, for which he got 50mg of Benadryl which caused AMS, now resolved. Continued FFP. 18 and 16 PIV. Transfer vitals 81 106/60 19 100% 4L. small blood around meatus. . On the floor, he was comfortable sitting up in bed, in no acute distress. He is answering questions appropriately with his son at the bedside. His only complaint is of crampy adbominal pain. . Review of systems: Per HPI. All else negative Past Medical History: diastolic Heart Failure Memory impairment Right femoral neck fracture s/p hemiarthroplasty [2185-9-8] AFib on coumadin Diverticulosis BPH basal cell carcinoma seborrheic keratosis s/p inguinal hernia repair s/p R cataract surgery s/p L 3rd/4th finger surgery - [2176] Social History: Lives [Location 6409] originally from [Location (un) ]. He worked in a chocolate factory. His sons take turns staying the night with him. He lost his wife in [2188-3-25]. Occasional ETOH. Was drafted in WW2, and on account of his pigeon breeding hobby, he was asked to lead the pigeon corps. - Tobacco: previous history - Alcohol: occassional - Illicits: denies Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: VS: 81 106/60 19 100% 4L General: Alert, oriented, no acute distress, pale, very thin HEENT: Sclera anicteric, mildly dry MM, oropharynx clear, multiple fillings, all his own teeth Neck: supple, JVP ~8cm, no LAD Lungs: Clear to auscultation bilaterally with decreased breath sounds at right base CV: irregularly irregular with a normal rate, soft II/VI SEM at USB Abdomen: soft, mildly tender diffusely, thin, scaphoid, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, doplerable pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: VS: 98.6 110/80 84 18 94%RA General: Very thin elderly man lying in bed in NAD HEENT: Sclera anicteric, mildly dry MM, oropharynx clear Neck: supple, JVP ~6cm Lungs: CTAB w no wheezes, rales or rhonchi CV: irregularly irregular with a normal rate, soft II/VI SEM at USB Abdomen: soft, BS+, thin, non-distended, non-tender, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused Rectal: dark brown/black stool, guaiac positive Pertinent Results: LABS: Admission Labs: [2188-9-7] 06:00AM BLOOD WBC-6.8 RBC-3.29* Hgb-7.2* Hct-24.0* MCV-73* MCH-21.8* MCHC-29.9* RDW-19.2* Plt Ct-201 [2188-9-7] 06:00AM BLOOD PT-35.4* PTT-32.0 INR(PT)-3.6* [2188-9-7] 06:00AM BLOOD Glucose-121* UreaN-45* Creat-1.2 Na-136 K-4.3 Cl-101 HCO3-27 AnGap-12 Cardiac biomarkers: [2188-9-7] 06:00AM BLOOD cTropnT-0.08* Hct trend: [2188-9-8] 08:49 28.6* [2188-9-8] 02:53 25.6* [2188-9-7] 15:29 29.9* [2188-9-7] 06:00 24.0* [2188-9-3] 09:46 31.6* Discharge labs: [2188-9-9] 06:25AM BLOOD WBC-6.7 RBC-3.68* Hgb-9.1* Hct-27.9* MCV-76* MCH-24.9* MCHC-32.8 RDW-19.4* Plt Ct-135* [2188-9-9] 06:25AM BLOOD UreaN-36* Creat-1.2 Na-136 K-4.0 Cl-103 HCO3-29 AnGap-8 IMAGING: CTA ABD W&W/O C & RECONS Study Date of [2188-9-7] 7:04 AM IMPRESSION: 1. Extensive sigmoid diverticulosis without signs of acute diverticulitis. No CTA signs of active bleeding within the small or large bowel lumen, though limited evaluation in the bowel loops in the pelvis due to streak artifact from adjacent right hip total arthroplasty. 2. Stable bilateral pleural effusions, large on the right and moderate on the left. 3. Focal enhancement in the posterior spleen on delayed phase images, possible hemangioma or AV malformation. Brief Hospital Course: [Age over 90 ] year old male with a pmh of a-fib and dCHF on coumadin and aspirin who presented with a lower GI bleed in the setting of a supratherapeutic INR. ACTIVE ISSUES: GI bleed: Likely due to known severe diverticulosis, exacerbated by supratherapeutic INR from coumadin, as well as being on aspirin. Source is most likely lower given BRBPR mixed with stool. However, his BUN/Cr ratio was elevated, though this relationship has been present in historical blood draws. He was given FFP and 10 mg Vitamin K in the ED and subsequently sent to the MICU. He had a maroon bowel movement x1 in the MICU and received 2 units PRBCs with an appropriate increase. CTA showed diverticulosis with no signs of active bleeding. His vitals and hematocrit remained stable, no further episodes of bloody bowel movements. The patient was offered colonoscopy, however upon discussion with his son, he decided that he would rather not undergo the procedure. Given that he was medically stable and his bleed was likely due to diverticulosis in the setting of supratherapeutic INR, this seemed a perfectly reasonable choice. He was warned, however, that the CTA could not adequately rule out other sources of bleeding such as AVM or new malignancy that has evolved since last colonoscopy in [2178] (though this is unlikely). He should follow up with his PCP as an outpatient to have hematocrit checked and ensure that he is no longer having blood in his BMs. Atrial fibrillation: Has a history of a-fib, and has been on coumadin since [2185] (CHADS2 score is 2). Mildly supratherapeutic INR to 3.6 in ED. In setting of LGIB, INR was reversed with vitamin K and FFP. Coumadin held while inpatient, continued rate control w metoprolol. The patient was instructed to not restart the coumadin until his follow up with PCP, [Name10 (NameIs) 3] he will need to discuss with him the risks/benefits of continuing coumadin in the the setting of GI bleed. INACTIVE ISSUES: Diastolic CHF, chronic: Appeared euvolemic with a stable right sided pleural effusion. Given GI bleed, lasix, lisinopril (recently DC'd) and metoprolol were initially held. Metoprolol restarted at half dose, lasix and lisinopril were not restarted on discharge. Defer decision on restarting to PCP. TRANSFER OF CARE ISSUES: - GI bleed: recheck hgb/hct as outpatient, consider outpatient colonoscopy if patient continues to have blood w his BMs - Coumadin: assess risks and benefits prior to restarting. Because his INR was reversed and coumadin stopped, he will need heparin bridging if he is to restart therapy. Medications on Admission: furosemide 20 mg Tablet; 0.5 tabs PO daily lisinopril 2.5 mg Tablet; 1 tab PO daily (on hold this week for hypotension) metoprolol succinate 25 mg Tab; 1 tab PO daily warfarin 1 mg tab; 1 to 2 tabs PO daily as directed by md ascorbic acid 500 mg tab; 1 tab PO daily aspirin 81 mg tab; 1 tab PO daily calcium carbonate [Tums] 3 tabs daily cholecalciferol (vitamin D3); 1,000 unit capsule; 1 cap PO daily docusate sodium 100 mg Capsule; 1 Capsule PO BID vitamin A-vitamin C-vit E-min; 1 Tablet PO twice a day Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. vitamin A-vitamin C-vit E-min Tablet Sig: One (1) Tablet PO once a day. 4. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Tums 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary - Gastrointestinal Bleed - Supratherapeutic INR Secondary - Atrial Fibrillation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Last Name (Titles) 101773], You were admitted to the [Hospital1 18] because of bleeding with your stool. You required transfusions of blood and blood products. You had a high INR - or coumadin level. We believe that this INR contributed to the bleeding but the [Last Name ] problem was likely in the colon, possibly diverticulosis. We discussed the risks and benefits of a colonoscopy and ultimately you decided to discuss this with your regular doctors. Moving forward, we ask you to do the following: 1. STOP Coumadin 2. STOP Lisinopril 3. REDUCE the dose of your Metoprolol to a HALF pill twice daily (12.5 mg) 4. STOP Lasix (at least until your primary care appointment) Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: [State ]When: FRIDAY [2188-9-12] at 10:00 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 This is a follow up appointment of your hospitalization. You will be reconnected with your primary care physician after this visit. Department: CARDIAC SERVICES When: MONDAY [2188-10-6] at 9:00 AM 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: 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6827 }	Medical Text: Admission Date: [2151-7-12] Discharge Date: [2151-7-15] Date of Birth: [2100-9-14] Sex: M Service: CARDIOTHORACIC Allergies: Pollen/Hayfever Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: [2151-7-12] Mitral Valve Repair(#32 [Doctor Last Name 405] Annuloplasty band) History of Present Illness: 50 y/o male with known MVP since [6-9] when murmur was detected. Serial Echo's have shown 4+ MR with a LVEF of 50%. Now presents for surgical repair. Past Medical History: MVP, Depression, Asthma, Laser eye [Doctor First Name ], Colonoscopy/polyp removal, removal plantar warts Social History: Denies Tobacco. Admits to 1 ETOH beverage/day. Family History: Mother and sibling with MVP. Denies premature CAD. Physical Exam: VS: 70 132/75 72" 235# Gen: WD/WN male in NAD HEENT: PERRL, EOMI, NC/AT, OP benign Neck: Supple, FROM, -JVD, Murmur radiated to bilat. carotids Chest: CTAB -w/r/r Heart: RRR 4/6 Syst murmur Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [2151-7-12] Echo: PRE-BYPASS: 1. The left atrium is dilated. A small secundum ASD is present. A left-to-right shunt across the interatrial septum is seen at rest. 2. Left ventricular wall thicknessess is normall. The left ventricle is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%) but in the setting of severe mitral regurgitation there may be intrinsic dysfunction. 3. Right ventricular chamber size and free wall motion are normal. 4. There are focal calcifications in the aortic arch. 5. There are three aortic valve leaflets which are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened and myxomatous. There is partial mitral leaflet flail of the P2 scallop and prolapse of most of the posterior leaflet. The anterior leaflet is slightly restricted. An eccentric jet of Severe (4+) mitral regurgitation is seen directed anteriorly. 7. There is a physiologic pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. An annuloplasty ring is seen well seated in the mitral position. Trivial MR is seen. The mean gradient across the mitral valve is 4 mmof Hg and the maximum about 8 mm Hg. 2. LV function is moderately depressed globally, with slight improvement after starting an infusion of epinephrine. RV systolic function is preserved. 3. Descending Aorta is intact post decannulation 4. Other findings are unchanged and the secundum ASD is still seen. [2151-7-12] 02:43PM BLOOD WBC-11.3# RBC-3.51 Hgb-11.4# Hct-33.1 MCV-94 MCH-32.5* MCHC-34.5 RDW-13.6 Plt Ct-141* [2151-7-12] 02:43PM BLOOD PT-15.0* PTT-40.7* INR(PT)-1.3* [2151-7-12] 04:01PM BLOOD UreaN-14 Creat-0.9 Cl-111* HCO3-24 Brief Hospital Course: Mr. [Known lastname 73350] was a same day admit after undergoing all pre-operative work-up as an outpatient. On the day of admission he was brought to the operating room where he underwent a minimally invasive mitral valve repair. Please see operative report for details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Later on postoperative day one, he was weaned from sedation, awoke neurologically intact and extubated. Beta blockade and aspirin were resumed. On postoperative day one, he was transferred to the step down unit for further recovery. Mr. [Known lastname 73350] was gently diuresed towards his preoperative weight. He had a short run of atrial fibrillation which converted to normal sinus rhythm with and increase in his beta blockade. The physical therapy service worked with him daily for assistance with his postoperative strength and mobility. Mr. [Known lastname 73350] continued to make steady progress and was discharged home on postoperative day three. He will follow-up with Dr. [Last Name (STitle) 1290], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Celexa 20mg qd, MVI, Flonase prn, Lasix 20mg [Hospital1 ], Evoclin topical qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:4 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day for 7 days. Disp:7 Packet(s) Refills:0 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 weeks. Disp:60 Tablet(s) Refills:0 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months: Take while using narcotics. Disp:30 Capsule(s) Refills:1 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day for 1 months. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Mitral Regurgitation s/p Min. Inv. Mitral Valve Repair PMH: MVP, Depression, Asthma, Laser eye [Doctor First Name ], Colonoscopy/polyp removal, removal plantar warts Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. If you have any issues with you wound, please contact Dr. [Last Name (STitle) 1290] 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) Please shower daily. No swimming for 2 weeks. No lotions, creams or powders to wounds until they have healed. After your wounds have healed, please use sunblock on scar when in sun. 5) Take lasix 40mg once daily and potassium 20mEq once daily for 7 days then stop. Monitor your weight daily. 6) Take Ibuprofen 600mg three times daily for three weeks and then stop. 7) Take ranatadine (Zantac) for one month and then stop. Take colace while taking percocet or as needed for constipation. You may resume you at home multivitamins. 8) Continue to use antibiotic prophylaxis (Amoxicillin) with procedures (Dental/Surgical). You may resume yor at home allergy and rosacea medications. 9) Please call with any questions or concerns. Followup Instructions: [Hospital 409] clinic on [Hospital Ward Name 121] 2 in 2 weeks. Dr. [Name (NI) ] in 1 month. ([Telephone/Fax (1) 1504] Follow-up with Dr. [First Name (STitle) ] (Cardiologist) in 2 weeks. Dr. [Last Name (STitle) 38259] in [3-7] weeks. ([Telephone/Fax (1) 73351] Please call all providers for appointments. Completed by:[2151-7-15] ICD9 Codes: 4240, 4280, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6828 }	Medical Text: Admission Date: [2154-1-4] Discharge Date: [2154-1-9] Date of Birth: [2081-7-17] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 72 year old female status post emergent coronary artery bypass graft times two secondary to catheterization complicated by asystole and hypotension, who was transferred recently from rehabilitation for management of a pericardial effusion. The patient was admitted in [2153-11-20] for an elective catheterization at which time the procedure was complicated by a perforation with subsequent ST elevations, asystole, and placement of an intra-aortic balloon pump and emergent coronary artery bypass graft times two. The patient was managed at [Hospital1 69] and then discharged to [Hospital6 310] on [2153-12-19]. At rehabilitation, the patient has progressed very poorly with persistent fatigue, dyspnea on exertion, tachypnea, as well as persistent pleural effusion. As part of her work-up, an echocardiogram was obtained on [1-3], which revealed a significant pericardial effusion as well as a reported right atrial compression and the patient was subsequently transferred to [Hospital1 69] for further management. Upon admission to the hospital, the patient was taken immediately to catheterization. Tamponade was suggested by equalization of the RA, right ventricular end diastolic pressure, and wedge pressures of approximately 15; 400 cc of serosanguinous fluid was drained from the pericardial space with resolution of normal pressures. Following the procedure, the patient was admitted to the Cardiac Care Unit, for observation. On arrival to the Cardiac Care Unit, the patient was without any complaints of shortness of breath and did not report any significant chest discomfort. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Emergent coronary artery bypass graft times two in [11/2153], secondary to catheterization complicated by perforation after diagnosis of 99% left anterior descending, normal circumflex, non-critical right coronary artery. Course was complicated by ST elevations and subsequent asystole during the catheterization, placement of an intra-aortic balloon pump and subsequent emergent coronary artery bypass graft times two (SVG to the left anterior descending and obtuse marginal). ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Lopressor 50 mg p.o. twice a day. 2. Aspirin 325 mg p.o. q. day. 3. Plavix 75 mg p.o. q. day. 4. Protonix 40 mg p.o. q. day. 5. Lasix 60 mg p.o. q. day. 6. Lisinopril 2.5 mg p.o. q. day. 7. Fentanyl patch 25 micrograms applied to skin and change q. 72 hours. 8. Percocet, one tablet p.o. q. four to six hours p.r.n. break through pain. SOCIAL HISTORY: The patient is a Cantonese speaking female with a very involved family who lives locally. She denies any past history of smoking or alcohol use. She was transferred from [Hospital ] Rehabilitation. PHYSICAL EXAMINATION: Vital signs were temperature 99.5 F.; heart rate 102; blood pressure 108/56; respiratory rate 20; saturating 94% on room air. Weight 46.9 kilograms. In general, awake, in no acute distress. HEENT: Pupils equally round and reactive to light. Moist mucous membranes. Neck: Jugular venous pressure at 10 cm. Cardiovascular: Regular rate and rhythm; no murmurs, rubs or gallops. Chest wall: Thoracotomy scar clean, dry and intact. Pigtail catheter intact without erythema. Pulmonary: Clear to auscultation bilaterally with scant crackles and decreased breath sounds at bilateral bases, left greater than right. Abdomen: Positive bowel sounds, soft, nontender, nondistended. Extremities: One plus pitting edema bilaterally. LABORATORY: White blood cell count 6.8, hematocrit 32.5, platelets 327. Sodium 135, potassium 3.9, chloride 97, bicarb 30, BUN 15, creatinine 1.3. PT 12.8, PTT 26.2, INR 1.1. Arterial blood gases: 7.44/40/60. Chest x-ray: Left pleural effusion, pneumopericardium, no obvious infiltrates. Mild congestive heart failure. HOSPITAL COURSE: The patient is a 72 year old female status post coronary artery bypass graft times two in [2153-11-20], who was admitted for pericardial effusion with evidence of cardiac tamponade on catheterization status post drainage of the effusion and placement of a pigtail catheter. 1. Cardiovascular: The patient recently underwent a coronary artery bypass graft times two approximately two and a half weeks prior to the time of admission. She was continued on her aspirin therapy, however, her Plavix was held given the serosanguinous fluid that was removed from the pericardial space. In addition, her beta blocker and ACE inhibitor were also held as the patient was mildly hypotensive at the time of admission, and these were titrated back as tolerated. The patient had no complaints of chest pain and no suggestion of anginal symptoms over the course of the hospital stay. The patient had her pericardial sac effectively drained during the catheterization and secondary to placement of pigtail catheter. Over the first two hospital days, the drainage from the catheter slowly decreased in quantity. An echocardiogram was obtained on Hospital day number four, which demonstrated near complete resolution of the pericardial effusion with fibrin formation, suggestive of early consolidation. Since the drain put out less than 50 cc in the 24 hours prior to this time, the pigtail catheter was removed without difficulty and the patient subsequently felt subjectively less short of breath and complained of less pain. The patient's blood pressure remained stable over the remainder of the hospital stay. Her beta blocker and ACE inhibitor were added back to her medication regimen and titrated up as tolerated. An echocardiogram was obtained on [2154-1-7], for evaluation of the pericardial effusion which, in addition, demonstrated a normal left atrium and left ventricle, small remnant of a pericardial effusion and ejection fraction of 70%. The patient's Lasix and Aldactone were held at time of admission secondary to feeling that the patient was likely on the dry side. Her fluid status was monitored closely over the hospital stay. As the patient begins to take more p.o. input, she will likely need titration of her Lasix back to her usual outpatient dose. In addition, the patient was maintained in Telemetry and demonstrated normal sinus rhythm with only occasional PCV's on Telemetry throughout the hospital stay. 2. Pulmonary: The patient was noted to have persistent pleural effusions, which are likely secondary to her coronary artery bypass graft performed approximately two weeks prior to the time of admission. Consideration was given to a thoracentesis, however, the patient maintained excellent oxygen saturations, a normal arterial blood gas and had no complaints of shortness of breath or respiratory discomfort once the pigtail catheter was removed. Since the fluid surrounding the lung space is likely similar to the fluid surrounding the pericardial space, it was not felt warranted to perform a thoracentesis for diagnostic purposes since Chemistry and Culture data were to be obtained from the pericardial fluid. Therefore, since the patient was asymmetric with her pleural effusions, it was felt that to monitor them closely and to hold off on aggressive therapeutic measures at this time. 3. Renal: The patient had a normal creatinine at time of admission which was followed closely over the hospital stay. She maintained excellent urine output and her creatinine remained within normal limits. 4. Infectious Disease: The patient had a normal white blood cell count and was afebrile at the time of admission. She did not demonstrate any signs or symptoms of infection throughout the course of the hospital stay. 5. Hematological: The patient's hematocrit was watched closely status post catheterization and pericardial drainage, however, her hematocrit remained stable and she had no bleeding issues during the hospital stay. 6. Musculoskeletal: The patient complained of significant arthritic back pain which she reported being chronic in nature. She was provided with a Fentanyl patch as well as Percocet p.r.n. breakthrough pain. These medications appeared to adequately control the patient's discomfort and she had no further complaints of pain. CONDITION AT DISCHARGE: The patient was discharged to home in stable condition. DISCHARGE INSTRUCTIONS: 1. She is to follow-up with Dr. [Last Name (STitle) ] in Clinic at the end of [Month (only) 956]. DISPOSITION: The patient will be discharged to rehabilitation for further Physical Therapy and rehabilitation status post coronary artery bypass graft. MEDICATIONS AT TIME OF DISCHARGE: 1. Aspirin 325 mg p.o. q. day. 2. Lopressor 25 mg p.o. twice a day. 3. Heparin 5000 units subcutaneously twice a day. 4. Colace 100 mg p.o. twice a day. 5. Fentanyl patch 25 micrograms per hour to be changed q. 72 hours. 6. Zestril 2.5 mg p.o. q. day. 7. Percocet 1 tablet p.o. q. six hours p.r.n. breakthrough pain. 8. Tylenol 650 mg p.o. q. four hours p.r.n. fever or pain. 9. Dulcolax suppositories one tablet p.r. q. day p.r.n. [Name6 (MD) ] [Name8 (MD) ], MD [MD Number(1) 21980] Dictated By:[Name8 (MD) 8860] MEDQUIST36 D: [2154-1-8] 14:15 T: [2154-1-8] 14:19 JOB#: [Job Number 38594] ICD9 Codes: 9971, 5119, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6829 }	Medical Text: Admission Date: [2110-6-17] Discharge Date: [2110-6-25] Date of Birth: [2066-10-31] Sex: F Service: NEUROLOGY Allergies: Penicillins / Ceftazidime / Carbamazepine / Cephalosporins / cefepime Attending:[First Name3 (LF) 5167] Chief Complaint: Chief Complaint: Increased seizures Major Surgical or Invasive Procedure: Left PICC line placed by IR History of Present Illness: Ms. [Known lastname ] is a 43F with a past medical history of [Doctor Last Name ] encephalitis, epilepsy, right hemiparesis, global aphasia, tracehal stenosis, tracheobronchomalacia, chronic tracheostomy, and recent ICU admissions for pneumonia and UTI in [Month (only) ] for with urosepsis and seizures. She was recently discharged on [6-11] from the neurology service for increased seizures and Burkholderia bacteremia. Patient presents today after being found at her group home with increased seizure frequency and febrile to 103. CXR there showed R infiltrate, and she was started on vancomycin. Patient was initially tachycardic and hypotensive but this reportedly resolved with tylenol and IVF. . In the ER, initial vitals were 101, 89, 102/55, 27, 100% on 35% humidified trach mask. She was seen by neurology who recommended admission to MICU with plans for transition to neurology service once hemodynamically stable. Per neuro recs, she received additional keppra 500mg IV and ativan 1mg IV. She also received 1.5L NS and IV levaquin (despite taking PO levaquin since d/c) and had SBP in the 90s. No pressors were required. EKG showed sinus tachycardia and CXR here was poor quality with questionable R infiltrate. She was admitted to MICU for monitoring given SBP in 90s. Vitals on transfer were 99/54, 87, 25, 100% 15L track mask. She was admitted to the MICU around and was started on linezolid, tobramycin and aztreonam because of her multiple drug allergies. . She had a PICC line placed on [2110-6-18], but her course has also been complicated by frequent seizures. Her seizures are her usual semiology of R facial twitching. Her zonisamide was increased to 500mg QHS and her pheyntoin was increased to 100mg TID. She was then transferred to the neurology floor service for further management of her seizures. Past Medical History: 1. [Doctor Last Name ] encephalitis 2. Epilepsy 3. Partial left hemispherectomy at age 19 complicated by right hemiparesis and partial aphasia 4. Mental retardation 5. Left thoracolumbar scoliosis 6. Vagal nerve stimulator implanted [12-7], needs battery change 7. h/o Aspiration pneumonias, now on scopolamine patch 8. S/p PEG placement using T tube 9. S/p tracheostomy 10. MRSA line infection in the past 11. Hx multiple UTIs, Urosepsis (enterococcus, other) 12. Difficult venous access requiring femoral sticks 13. Constipation 14. Mood disorder, on SSRI; also Zyprexa - dense global aphasia w/ right hemiparesis - right spastic hemiplegia - tracheal stenosis and tracheobroncomalacia (trach dependent) - recent h/o Pseudomonas aspiration PNA requiring hospitalization - major depression Social History: No history of tobacco, alcohol, illicit drug use. Lives in a group home. Family History: No family history of seizures or [Doctor Last Name ]. Physical Exam: On ADMISSION: General: Non-verbal but following commands HEENT: NC/AT, EOMI in L eye, R eye with disconjugate eye movements, sclera anicteric, MMM, oropharynx clear Neck: supple, trach in place Lungs: Clear to auscultation bilaterally anteriorly with coarse breath sounds, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, GI tube in place, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, trace BLE edema, no clubbing or cyanosis ON DISCHARGE: VITALS: T97,5 (ax), BP 87/33, HR 51, RR 18, 100% on 35% trach mask GEN: somnolent, opened eyes to voice, able to follow simple commands HEENT: MM mildly dry, OP clear, trach in place NECK: No nuchal rigidity PULM: Diffuse rhonchourous breath sounds bilaterally CARDS: RRR no m/r/g ABD: soft, NT, ND, no guarding or rebound EXT: trace non-pitting edema to knees bilateraly, bilateral contractures at fingers, on R has wrist contracture SKIN: no rashes, scar on R chest for VNS . NEUROLOGICAL EXAM: Mental Status: somnolent, but arousable to sternal rub, but was not able to follow commands except for "lift this arm" while touching her L arm. She is non-verbal. . Cranial Nerves: I: Olfaction not tested II: PERRL 4->2mm and brisk III, IV, VI: patient has R eye exotropia, so eye movements are disconjugate. V: pt unable to cooperate/respond to testing VII: mild L sided facial droop VIII: pt unable to cooperate/respond to testing IX, X: not visualized [Doctor First Name 81]: pt unable to cooperate/respond to testing XII: tongue protrudes in midline . Motor: normal bulk, tone increased in [Name Prefix (Prefixes) ] [Last Name (Prefixes) 6816] and RUE. Able to lift her L arm fully off the bed, but only able to move distal RUE up off bed. Unable to move either LEs, but does withdraw bilaterally on LE's to pain. Fingers flexed and contracted bilaterally. . Sensory: pt was unable to cooperate with the sensory exam . Reflexes: [Hospital1 ] Tri [Last Name (un) 1035] Pat Ach R 0 0 0 0 0 L 0 0 0 0 0 . Coordination and Gait: patient bedbound, unable to test Pertinent Results: ADMISSION LABS: [2110-6-17] 08:14PM LACTATE-0.7 [2110-6-17] 07:09AM URINE RBC-1 WBC-90* BACTERIA-FEW YEAST-NONE EPI-<1 [2110-6-17] 06:31AM GLUCOSE-104* UREA N-11 CREAT-0.7 SODIUM-131* POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-23 ANION GAP-13 [2110-6-17] 06:31AM PHENOBARB-28.0 PHENYTOIN-7.1* [2110-6-17] 06:31AM WBC-10.6 RBC-2.35* HGB-7.3* HCT-22.6* MCV-96 MCH-31.3 MCHC-32.5 RDW-15.9* [2110-6-17] 01:18AM WBC-14.9# RBC-2.76 HGB-8.7* HCT-25.4* MCV-92 MCH-31.6 MCHC-34.3 RDW-15.9* [2110-6-18] 04:00 6.4 2.39* 7.4* 23.4* 98 31.0 31.6 15.8* 265 [2110-6-18]: Feces negative for C.difficile toxin A & B by EIA. DISCHARGE LABS: [2110-6-25] 03:26AM BLOOD WBC-2.3* RBC-2.52* Hgb-7.6* Hct-23.5* MCV-93 MCH-30.1 MCHC-32.3 RDW-15.9* Plt Ct-218 [2110-6-25] 03:26AM BLOOD Neuts-26* Bands-0 Lymphs-61* Monos-7 Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-0 [2110-6-25] 03:26AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [2110-6-25] 03:26AM BLOOD Glucose-101* UreaN-17 Creat-0.7 Na-140 K-4.2 Cl-105 HCO3-28 AnGap-11 [2110-6-25] 03:26AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.2 [2110-6-25] 03:26AM BLOOD Phenoba-27.2 Phenyto-10.0 IMAGING: CXR [2110-6-17]: IMPRESSION: No evidence of pneumonia. Low lung volumes with resultant bronchovascular crowding ECHO [2110-6-20]: IMPRESSION: normal study; no vegetations seen Brief Hospital Course: Ms. [Known lastname ] is a 43F with a past medical history of [Doctor Last Name ] encephalitis, epilepsy, right hemiparesis, global aphasia, tracehal stenosis, tracheobronchomalacia, chronic tracheostomy, and recent admission for bacteremia and pneumonia, who presented with MRSA bacteremia. # Sepsis: She was reportedly febrile to 103 at her group home with tachycardia and hypotension that responded to IV fluids. Had a Postivie UA, elevated white count, with blood cultures positive for MRSA from an OSH, but no lactate. Given her history of VRE UTI last month, MRSA and prior resistant Pseudomonas in sputum in [Month (only) ], treated broadly with linezolid, aztreonam, tobramycin and added levofloxacin for coverage of BURKHOLDERIA (PSEUDOMONAS) CEPACIA. Narrowed to linezolid only on [6-17]. Completed course of levo for pseudomonas on [6-19]. Tunneled catheter pulled and new PICC line placed by IR. We planned to continue linezolid + vancomycin until Vanc level was therepeutic, but pt developed neutropenia on linezoolid (see below), and this was D/C'd early. Patient was continued on vancomycin for a 2 week course from her first negative blood culture, for a course that finishes on [7-4]. She was sent back to her group home with VNA to complete the course. # Hem/Onc: pt developed neutropenia on linezolid on [6-20]. Her linezolid was then stopped and her neutropenia improved, and she was no longer neutropenic on [6-23]. # Recent hypotension: Patient was reportedly hypotensive at OSH/group home and responded to IVF. She was admitted to the MICU for hemodynamic monitoring given SBP in the 90s in the ED. Upon review of prior notes, her SBP seemed to range from the 90s-120s on previous admission. EKG was without signs of acute concern and prior normal TTE in [4-16] was reassuring against cardiac cause as well. Patient recived fluid bolusus as needed. Lactates have been WNL, and her blood pressures remained relatively stable throughout her admission despite some fluctuations into the mid-80's. # Seizures: Patient has very difficult to control seizures and was just discharged from the neurology service for this on [6-11]. Had intermittent seizure activity with rapid eye movements and facial twitching felt to be above her baseline. Neurology was consulted recommended increasing zonisamide to 500QHS, dilantin to 100 TID after 300bolus, and if breathing stably to give phenobarb bolus 5mg/kg. After this, patient was transferred to the neurology service, where her dilantin was further changed to 100/150/100 TID. Her seizures improved on this regimen but they also likely improved as her bacteremia was treated. Medications on Admission: 1. phenobarbital 20 mg/5 mL Elixir Sig: Thirty (30) mg PO HS (at bedtime). 2. phenobarbital 20 mg/5 mL Elixir Sig: Sixty (60) mg PO BID (2 times a day). 3. levetiracetam 100 mg/mL Solution Sig: 1500 (1500) mg PO BID (2 times a day). 4. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO NOON (At Noon). 5. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 6. phenytoin 50 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO TID (3 times a day). 7. fluoxetine 20 mg/5 mL Solution Sig: Five (5) cc PO DAILY (Daily). 8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 9. montelukast 5 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 10. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every four (4) hours. 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours. 13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 14. scopolamine base 1.5 mg Patch 72 hr Sig: 1.5 Patch 72 hrs Transdermal Q72H (every 72 hours). 15. senna 8.8 mg/5 mL Syrup Sig: Two (2) Tablet PO DAILY (Daily). 16. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 17. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 9 days: Last day = [6-19]. Disp:9 Tablet(s) Refills:0 Discharge Medications: 1. phenobarbital 20 mg/5 mL Elixir Sig: Thirty (30) mg PO HS (at bedtime). 2. phenobarbital 20 mg/5 mL Elixir Sig: Sixty (60) mg PO BID (2 times a day). 3. levetiracetam 100 mg/mL Solution Sig: 1500 (1500) mg PO BID (2 times a day). 4. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO NOON (At Noon). 5. zonisamide 100 mg Capsule Sig: Five Hundred (500) mg PO DAILY (Daily). 6. fluoxetine 20 mg/5 mL Solution Sig: Twenty (20) mg PO DAILY (Daily). 7. phenytoin 50 mg Tablet, Chewable Sig: One Hundred (100) mg PO BID (2 times a day): Dose is 100/150/100 at TID dosing. 8. phenytoin 50 mg Tablet, Chewable Sig: One [Age over 90 1230]y (150) mg PO QDAY (): Dose is 100/150/100 at TID dosing. 9. olanzapine 10 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO DAILY (Daily). 10. montelukast 5 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every four (4) hours. 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H. 14. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. vancomycin in 0.9% sodium Cl 1.25 gram/150 mL Solution Sig: 1.25 grams Intravenous every twenty-four(24) hours: Last dose is [2110-7-4]. Disp:9 doses Refills:0 16. senna 8.8 mg/5 mL Syrup Sig: Two (2) tabs PO once a day. 17. miconazole nitrate 2 % Powder Sig: One (1) application Topical four times a day as needed for rash. Discharge Disposition: Home With Service Facility: Infusion Resource Discharge Diagnosis: Primary: MRSA bacteremia Secondary: Epilepsy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. NEURO EXAM: Somnolent, but arousable, can follow simple commands, will move UE's spontaneously, and withdraw LE's minimally to painful stimuli Discharge Instructions: Dear Ms. [Known lastname ], You were seen in the hospital for an infection of your blood. You were treated with intravenous antibiotics and repeat blood tests showed that your infection was clearing. You will need to complete a 14 day course of vancomycin, to finish on [2110-7-4]. We made the following changes to your medications: 1) We INCREASED your PHENYTOIN to 100mg, 150mg, 100mg three times a day. 2) We INCREASED your ZONISAMIDE to 500mg once a day 3) We STARTED you on VANCOMYCIN 1250mg every 24 hours with last dose on [2110-7-4]. 4) We STOPPED your SCOPALAMINE PATCH, however, your doctors [First Name (Titles) ] [Name5 (PTitle) 40837] [Name5 (PTitle) ] decide to restart this, depending on your secretions. Please continue to take your other medications as previously presbribed. If you experience any of the below listed Danger Signs, please call your doctor or go to the nearest Emergency Room, or have one of the aides at your group home assist you with getting medical attention. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Department: NEUROLOGY When: MONDAY [2110-8-4] at 10:30 AM With: [First Name11 (Name Pattern1) 1216] [Last Name (NamePattern4) 1217], MD [Telephone/Fax (1) 2928] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: NEUROLOGY When: MONDAY [2110-8-4] at 11:15 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN [Telephone/Fax (1) 857] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6830 }	Medical Text: Admission Date: [2167-3-31] Discharge Date: [2167-4-7] Date of Birth: [2096-8-27] Sex: M Service: VASCULAR SURGERY CHIEF COMPLAINT: Nonhealing right foot ulcer with Methicillin resistant Staphylococcus aureus infection x3 months HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 29275] is a 70-year-old white male with a past medical history significant for type II diabetes mellitus that is currently noninsulin dependent as well as nicotine abuse and coronary artery disease who presents with a non-healing ulceration of his right lateral foot that has been present for approximately three to four months. The patient saw Dr. [Last Name (STitle) ] in his clinic and was evaluated for elective surgical revascularization. He had a preoperative cardiac evaluation and underwent a cardiac catheterization that revealed three vessel disease. In [2167-1-13], the patient underwent a coronary artery bypass grafting x3 with left internal mammary artery to the left anterior descending coronary artery as well as aorto-saphenous vein graft to the first diagonal branch and aorto-saphenous vein graft to the posterior tibial descending coronary artery. He was subsequently discharged from the hospital at that time and then represented to the vascular surgery service in [Month (only) 958] for revascularization of his right leg. At this time, he denied any symptoms of coronary disease such as increasing shortness of breath, chest pain, diaphoresis or nausea or vomiting. PAST MEDICAL HISTORY significant for the above coronary artery disease, as well as type II noninsulin dependent diabetes mellitus x7 years with associated neuropathy, hyperlipidemia, postoperative atrial fibrillation after coronary artery bypass grafting that subsequently resolved with amiodarone, Methicillin resistant Staphylococcus aureus from the wound in his right foot as well as depression and morbid obesity. His ejection fraction was noted to be 34% in [2166-11-13]. PAST SURGICAL HISTORY: 1. Bilateral hallux amputations 2. Coronary artery bypass grafting SOCIAL HISTORY: Significant for living alone as well as a 50 pack year history of nicotine abuse that he says stopped in [2167]. He denies to alcohol abuse, but states he has not had anything to drink in over 10 years. ADMISSION MEDICATIONS: 1. Nicoderm patch 14 mg qd 2. Cipro 250 mg po tid x10 days 3. OxyContin 20 mg po bid 4. Senokot 2 tablets at bedtime 5. Risperdal 1 mg po at 5 p.m. 6. Combivent metered dose inhaler 2 puffs q6h 7. Amiodarone 400 mg po qd 8. Lopressor 25 mg po bid 9. Lasix 20 mg po bid 10. Ecotrin 11. Aspirin 325 mg po qd 12. Vancomycin 1 gm intravenous q 12 hours x30 days 13. Prevacid 30 mg po qd 14. Glucophage 1000 mg po bid 15. Glyburide 10 mg po q 10 a.m. and 5 mg po q p.m. 16. Lipitor 10 mg po qd 17. Folic acid 1 mg po qd 18. Neurontin 300 mg po bid 19. Neurontin 100 mg po at 5 p.m. 20. Niferex 150 mg po bid 21. Colace 100 mg po bid 22. Lactulose 20 mg po bid HOSPITAL COURSE: The patient was admitted to [Hospital6 1760] where he underwent a right above knee popliteal to posterior tibial artery bypass graft using non reverse saphenous vein. Details of this procedure are dictated in a separate operative note. The patient tolerated the procedure well and was extubated in the post anesthesia care unit. He was subsequently transferred to the Vascular Intensive Care Unit where he was monitored with a central venous pressure line. He did have some mental status changes on postoperative day #1 in which she became severely combative, confused and agitated. He had a slight temporary decrease in his O2 saturation that was subsequently evaluated with a blood gas which revealed a pO2 of 67. The patient was then placed on a nonrebreather and a repeat gas revealed a pO2 of 139. Despite this, the patient still has severe mental status changes and remained combative. He had to get a copious amount of Haldol to control him and had to be placed on 1 to 1 monitoring. He remained confused and overnight had a decreased urine output that responded quite well with Lasix. He improved slightly on postoperative day #2, but still required large amounts of Haldol. All of his narcotics were subsequently discontinued. A psychiatry consult was then obtained. They felt that this was postoperative delirium secondary to anesthesia and pain medication. It has been noted that the patient had similar episodes coming out of anesthesia before. He greatly improved on postoperative day #3 and had no further issues. He was scheduled for a split thickness skin graft to his right foot ulcer, however this was canceled to avoid placing patient under anesthesia again. An Apligraf synthetic skin substitute was placed on postoperative day #4 at the bedside with no pain medication given. The patient tolerated this procedure quite well and Adaptic and dry sterile dressing were placed over the wound and will remain there for one week. At this time, the patient is doing quite well. He is awake, alert and oriented in no apparent distress. Vital signs are stable. He has been afebrile. Of note, he had a small urinary tract infection that grew out over 100,000 colonies of Enterobacter that are sensitive to Bactrim. He was started on Bactrim on [2167-4-6] 1 double strength tablet twice daily to continue for five days and to end on [2167-4-11]. Also, of note, he had multiple cultures from his foot all of which grew out Methicillin resistant Staphylococcus aureus. For this, he has been placed on vancomycin throughout his hospitalization 1 gm intravenous q 12 hours with peak and trough levels done periodically. His creatinine has remained stable at 0.8. He will be screened and discharged to rehabilitation today. For his dressings, a dry sterile dressing and Ace wrap are to be placed from his toe up to his thigh. His dressing over his right foot wound is not to be removed. This is where the skin graft is placed and should only be evaluated by the surgery team. For this, he will follow up with Dr. [Last Name (STitle) ]. He will, however, need to have an Ace wrap placed up to his thigh daily. PHYSICAL EXAMINATION: GENERAL: Obese male who is in no apparent distress and is awake and alert. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Obese with positive bowel sounds, nontender, nondistended. EXTREMITIES: Right lower extremity incisions. Steri-Strips were placed on the upper portion of the right medial thigh and the area clean, dry and intact without evidence of dehiscence or drainage. Staples are placed from the knee down and are also clean, dry and intact without dehiscence, drainage or erythema. He has a palpable graft pulse. There is an incision at the distal right leg over the posterior tibial artery which is palpable and clean, dry and intact. There is a 2 x 1 cm right lateral foot ulcer with nice granulation tissue present for which an Apligraf has been placed. FOLLOW UP: He is to follow up with Dr. [Last Name (STitle) ] in one week to evaluate the Apligraf, otherwise that dressing is not to be removed except by the vascular surgery team. DISCHARGE MEDICATIONS: 1. Senokot 2 tablets po q hs 2. Colace 100 mg po bid 3. Iron sulfate 150 mg po bid 4. Neurontin 100 mg po at 5 p.m. 5. Neurontin 300 mg po bid 6. Atorvastatin 10 mg po qd 7. Folic acid 1 mg po qd 8. Protonix 4 mg po qd 9. Lopressor 25 mg po bid 10. Paroxetine 20 mg po qd 11. Albuterol nebulizer solution q4h prn 12. Miconazole powder 2% applied to the groins bilaterally 13. Lactulose 30 mg po bid 14. Heparin 5000 units subcutaneous q8h 15. Risperidone 1 mg po qd 16. Amiodarone 400 mg po qd 17. Aspirin 325 mg po qd 18. Vancomycin 1 gm intravenous q 12 hours for three more weeks from this date 19. Bactrim 1 double strength tablet po bid for 5 more days and to end [2167-4-11] DISCHARGE DIAGNOSES: 1. Non-healing ulceration of the right lateral foot currently managed with a right above the knee to posterior tibial bypass as well as Apligraf. 2. Postoperative delirium secondary to anesthesia and pain medication currently resolved at this time. 3. Coronary artery disease which remains asymptomatic at this time. 4. Diabetes mellitus currently controlled on oral medication. 5. Hypertension currently controlled. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3409] Dictated By:[First Name3 (LF) 29276] MEDQUIST36 D: [2167-4-7] 08:17 T: [2167-4-7] 08:52 JOB#: [Job Number 29277] ICD9 Codes: 4280, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6831 }	Medical Text: Admission Date: [2164-8-25] Discharge Date: [2164-8-28] Date of Birth: [2085-5-29] Sex: M Service: MEDICINE Allergies: Lopressor / Lisinopril Attending:[First Name3 (LF) 689] Chief Complaint: facial swelling/laryngeal edema Major Surgical or Invasive Procedure: Endotrachial Intubation History of Present Illness: See MICU [Location (un) ] note from [8-26] for full details. Briefly this is a 79yo patient with PMH significant for HTN, CAD, s/p CABG being transferred from the ICU for probable angioedema after taking lisinopril. . Patient had been giving script for lisinopril a while back but only started taking it on Friday [8-24] AM. He started to feel his lips, tongue and face swelling and it progressivly worsened to include his throat. He was admitted to the ICU and was intubated and sedated. ENT saw patient and recommended keeping tube in place. However, patient self-extubated overnight and actually remained stable. His condition improved and he was transferred to the floor for further care. . On arrival to the medical floor, patient was stable. Vital signs- T 96.5, HR 74, BP 125/64, R 14, satting 100% on 4L. No complaints except for some facial swelling but reduced from admission. Denied any shortness of breath, chest pain, headaches, dizziness. Doing well, comfortable. Past Medical History: -HTN -Psoriasis -Hypercholesterolemia -CKD, baseline Cr 2.6 -CAD s/p MI([2135]) s/p Cardiac Stress Test([5-20]: Mild Reversible Ischemic Changes), s/p Cath([2-21]: 1 vessel disease, No stenting required), Chronic Stable Angina -Cardiomyopathy, EF 50% 2/09 -Mild Dementia (short term memory impairment) -Gout -BPH -Eczema -s/p L hip fx s/p hemiarthroscopy [3-/2164] Social History: NA Family History: NA Physical Exam: General: Intubated, sedated HEENT:Conjunctiva injected. Pupils symmetric, constrict equally to light. Lip swelling. Intubated, OGT in place. Neck: supple. No bruit. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Bradycardic rate, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes, hives. Pertinent Results: [2164-8-26] 03:03AM BLOOD WBC-15.8# RBC-3.50 Hgb-10.6* Hct-31.2* MCV-89 MCH-30.4 MCHC-34.0 RDW-13.3 Plt Ct-336 [2164-8-25] 09:00AM BLOOD WBC-8.1 RBC-3.68* Hgb-11.2* Hct-33.4* MCV-91 MCH-30.3 MCHC-33.4 RDW-13.1 Plt Ct-313 [2164-8-25] 09:00AM BLOOD Neuts-91.2* Lymphs-7.7* Monos-0.9* Eos-0.2 Baso-0.1 [2164-8-26] 03:03AM BLOOD PT-12.0 PTT-23.5 INR(PT)-1.0 [2164-8-26] 03:03AM BLOOD Glucose-168* UreaN-65* Creat-2.8* Na-143 K-4.9 Cl-115* HCO3-18* AnGap-15 [2164-8-26] 03:03AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.3 Brief Hospital Course: 79yo male admitted to ICU for probable angioedema due to lisinopril injestion. 1. Angioedema Pt was admitted to the ICU and was intubated and sedated. He was also started on IV steroids, H2 blockers, and benadryl. ENT saw patient and recommended keeping 6 mm tube in place. However, patient self-extubated overnight and actually remained stable. His condition improved and he was transferred to the floor for further care on [2164-8-26]. He was initially on 4L NC and satting in high 90s and this was quickly weaned. He experienced some soreness of the throat and had a difficult time swallowing pills at first. ENT saw him and thought this was due to trauma from the ET tube and not lingering angioedema. As his angioedema improved he was able to tollerate first thick liquids, then a regular diet. He was switched to PO steroids with a 7 day taper starting on [8-27]. 2. Acute on chronic kidney injury - baseline 2.6. creatinine was 3.2 on admission but this trended back down to 2.4 by D/C. Allopurinol was held in the ICU given Cr bump. 3. HTN- Antihypertensives were held in ICU but amlodipine was restarted once stable on the medicine floor. 4. CHF. Known EF [3-26] 50% with mild reduced systolic function. Appeared euvolemic on exam. 5. CAD -held ASA as above -continued simvastatin Medications on Admission: Amlodipine 2.5mg PO daily Aspirin 325mg PO daily Furosemide 20mg daily Lisinopril 40mg daily Oxybutinin 5mg daily Simvastatin 80mg daily Allopur. inol 100mg daily eucerin cream Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Angioedema Secondary Diagnosis: Hypertension Chronic Kidney Disease Discharge Condition: Good. Vital Signs stable Discharge Instructions: You were admitted to the hospital for swelling in your face and throat after you took lisinopril. You were taken to the ICU because the swelling in your neck gave you difficulty breathing. After one night in the ICU you actually pulled out your breathing tube but did well without it. You remained stable the next day and was transferred to the regular medicine floor on [8-26], where you remained stable. You initially had trouble swallowing pills and food but this has gotten better and you are now able to swallow food. Your facial swelling has also decreased. We have scheduled follow up appointments with your primary care doctor and the allergy Dr. [Last Name (STitle) 357] go to your scheduled appointments. You were also prescribed prednisone, famotidine, and fexofenadine to decrease residual swelling. Please take the prednisone as follows: 6 tablets on day one, 5 tablets on day two, 4 tablets on day three, 3 tablets on day four, 2 tablets on day five, 1 tablet on day six, and 1 tablet on day seven. Please return to the hospital or call your doctor if you have worsening throat/facial swelling, hives or skin rash, or any other symptoms that concern you. Followup Instructions: Please make a follow-up appointment with your primary care doctor, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], within the next two weeks. His office phone number is: ([Telephone/Fax (1) 12871] Allergist [Last Name (LF) ],[Name8 (MD) ] MD ([Telephone/Fax (1) 14583] Tuesday [10-2], 9 am 1 [Location (un) ] pl [Apartment Address(1) 20447] ICD9 Codes: 5849, 4254, 4280, 5859, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6832 }	Medical Text: Admission Date: [2131-8-21] Discharge Date: [2131-8-22] Service: MICU HISTORY OF PRESENT ILLNESS: This is an 88 year old Portuguese speaking female found in respiratory distress at her nursing home. EMS was called and vital signs at that time were a heart rate of 112, blood pressure of 140/80; respiratory rate of 40 and she was 71% on room air. Rales were noted bilaterally. This patient is normally on two liters of home oxygen. She was given Nitroglycerin, 80 mg of Lasix and morphine and nebulizers during transport; the patient was unresponsive. The patient, in the Emergency Department, BiPAP ventilation was started. The patient's systolic blood pressure dropped to the 70s. Dopamine was started and titrated up to 7.5. Blood pressure was stabilized at systolic blood pressure of 110 and Dopamine was weaned off later during the day. The patient was also given Levofloxacin 500 mg times one for possible pneumonia, and Ceftriaxone 1 gram. Per report at nursing home, at 04:30 p.m. the previous day, the patient had an episode of chest pain and was given Ativan, Nitroglycerin and percocet. On oxygen at 01:00 p.m., her O2 saturations were fine. She was without any complaints. At 03:00 a.m., she desaturated to the 70s. No chest pain at that time. The patient was communicating when she left the nursing home. At the time of evaluation, this was unresponsive. She grimaced only to pain. The family was unavailable and a message was left for them. Urine output was 400 cc in the Emergency Room. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease on home O2 of two liters. 2. Diabetes mellitus type 2, insulin dependent. 3. Hypertension. 4. Chronic renal failure with a baseline creatinine of 1.0. 5. Peptic ulcer disease. 6. Coronary artery disease status post coronary artery bypass graft and myocardial infarction in [2121]. 7. Left bundle branch block. 8. Atrial fibrillation. 9. History of pulmonary embolism in [2128], on Coumadin. 10. Positive PPD. 11. Costochondritis. 12. History of supraventricular tachycardia. 13. Congestive heart failure, ejection fraction subnormal, two plus mitral regurgitation. 14. Transient ischemic attack. 15. Hyperlipidemia. 16. "DO NOT RESUSCITATE" and "DO NOT INTUBATE" code status. 17. History of falls. 18. Right wrist fracture in [2131-6-12]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Enteric coated aspirin 325 mg q. day. 2. Diltiazem 120 q. day. 3. Isosorbide MN 120 q. day. 4. [First Name5 (NamePattern1) 233] [Last Name (NamePattern1) 1002] 20 q. day. 5. Paxil 10 mg q. day. 6. Protonix 40 mg q. day. 7. Lisinopril 40 mg q. day. 8. Atenolol 100 mg q. day. 9. Colace 100 mg twice a day. 10. Flovent 110 micrograms, two puffs q. four to six hours p.r.n. 11. Lasix 40 mg twice a day. 12. Atrovent MDI two puffs four times a day. 13. Senna one tablet q. h.s. 14. Lipitor 10 mg q. day. 15. Ativan 0.5 mg three times a day p.r.n. 16. Klonopin 0.5 mg q. h.s. p.r.n. 17. NPH 8 units q. a.m. 18. Coumadin 5.5 mg q. day. 19. Insulin sliding scale. 20. Ground, two grams of sodium. SOCIAL HISTORY: Nursing home resident. No history of tobacco, no history of alcohol. PHYSICAL EXAMINATION: Temperature was 100.8 F.; heart rate was 75; blood pressure 99/47; respiratory rate of 19 and 99% on pressure support, Bi-PAP mask [9-16], FIO2 0.6, total volume around 350. In general, unmasked, ventilation grimaces to pain, right wrist in cast, moderately obese. HEENT: pupils equally round and reactive to light bilaterally. Mucous membranes were moist. Unable to assess jugular venous pressure. Chest with diffuse expiratory wheezes. Minimal crackles at bases bilaterally. Cardiovascular is regular rate and rhythm, grade I/VI systolic ejection murmur heard best at the left lower sternal border. Abdomen with positive bowel sounds, nontender, plus hepatomegaly. No splenomegaly. Extremities warm, no dorsalis pedis bilaterally. No edema. Right wrist in cast. Neurologic: Moves all limbs, grimaces to pain. LABORATORY: On admission, arterial blood gas 7.14, CO2 128; O2 127 on Bi-PAP. White blood cell count of 7.7, hematocrit 30.7, platelets 225. Chemistries were sodium of 145, potassium 4.0, chloride 105, bicarbonate 35, BUN 26, creatinine 1.3, glucose 176. CK is 16. MB not done. Troponin less than 0.01. PT 26.1, [Month/Day (1) 263] 4.5, PTT 39.0. Chest x-ray with pleural thickening in the left, no change from previous examination. Small bilateral effusions, right heart border scarred. EKG with sinus rate, 112, left bundle branch block, old. SUMMARY OF HOSPITAL COURSE: This is an 88 year old woman with chronic obstructive pulmonary disease, congestive heart failure and coronary artery disease status post myocardial infarction and coronary artery bypass graft who had episodes of chest pain [8-20], at 04:30 p.m. which resolved with sublingual Nitroglycerin, percocet and ativan. The patient was stable until 3 a.m. the morning of [8-21], when she developed shortness of breath and desaturated to 70% on room air. Initially, she was in congestive heart failure and diuresed and dropped blood pressure transiently and required dopamine in the Emergency Room. Now, on admission to the Medical Intensive Care Unit she had diffuse wheezes, question of pneumonia on chest x-ray. There was a left shift and a low grade temperature. Concern at the time of the admission to the Medical Intensive Care Unit for an infectious process causing respiratory failure in the setting of a patient with chronic obstructive pulmonary disease. Given chest pain yesterday and reported congestive heart failure earlier, she also ruled out for myocardial infarction. HOSPITAL COURSE BY PROBLEM: 1. RESPIRATORY FAILURE: Most likely secondary to pneumonia, but chronic obstructive pulmonary disease and congestive heart failure likely contributing. The patient was started on Levofloxacin, Ceftriaxone and Flagyl to treat for nursing home acquired pneumonia and possible aspiration. Blood cultures, sputum cultures were sent. Arterial blood gas was repeated and it was 7.21 pH, pCO2 of 108 and a pO2 of 91. She was continued on Bi-PAP and weaned to nasal cannula during the course of her hospital stay and within the first 12 hours, desaturated on nasal cannula 4 liters to the low 80s, and was switched to a Venturi Mask at 40%. The family was [Month (only) 653] regarding the aggressiveness of care. The family re-iterated to the staff that the patient is a "DO NOT RESUSCITATE" and "DO NOT INTUBATE" and the family wished not to have any shock electrocardioversion, or pressors used. We continued nebs for chronic obstructive pulmonary disease component. 2. CARDIOVASCULAR SYSTEM: The patient has known coronary artery disease with episode of chest pain one day prior to admission and was reported to be in congestive heart failure overnight. One set of cardiac enzymes were drawn before the family was [Name (NI) 653]. They wished not to have any labs drawn on the patient. Her first set of cardiac enzymes were unremarkable with a troponin less than 0.01. We continued her aspirin p.r. The patient was unable to take p.o. medications and so the Lipitor was held as well as the beta blocker and ACE inhibitor. 3. DIABETES MELLITUS TYPE 2: The patient was continued on her regular regimen of NPH and insulin sliding scale, however, she took no p.o. during her course of stay here, so she did not require her NPH. 4. HEMATOLOGIC: The patient has a history of pulmonary embolism on Coumadin. [Name (NI) 263] at the time of admission was super therapeutic. Coumadin was held, however, subsequent labs to check hematocrit and [Name (NI) 263] were not drawn. 6. GASTROINTESTINAL/HEPATOMEGALY: Possibly related to congestive heart failure episode. The patient was monitored during the course of her stay. 7. CHRONIC RENAL FAILURE: The creatinine has slightly risen from baseline. Her Levofloxacin was dosed renally and will continue, however, labs were not drawn during the course of her stay, so her creatinine was not followed. 8. NEUROLOGIC: The patient was admitted unresponsive and grimacing only to pain. Had intermittent periods of time where she would ask for ice chips or water, but for the most part was unresponsive. 9. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was NPO during the course of her stay here, unable to take p.o. medications. A family meeting was held twice with the patient's daughters as well as her granddaughter who is her health care proxy. It was re-iterated several times to the medical team that the family did not want extraordinary measures for their mother which included no resuscitation, no intubation, no pressors, no cardioversion, or defibrillation. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: Poor. DISCHARGE DIAGNOSES: 1. Nursing home acquired pneumonia. DISCHARGE MEDICATIONS: 1. Aspirin 300 p.r. 2. Atrovent nebulizer treatments. 3. Albuterol nebulizer treatments. 4. Levofloxacin 500 mg q. day. 5. Ceftriaxone one gram q. day. 6. Flagyl 500 mg twice a day. 7. Ativan 0.5 mg three times a day p.r.n. 8. Insulin sliding scale. DISCHARGE INSTRUCTIONS: 1. The patient does not require Medical Intensive Care Unit level of care at this time and the family does not want additional intervention to be done, so she will be transferred either to the floor for further care or back to her nursing home facility where she can receive antibiotics to treat her pneumonia. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Last Name (NamePattern1) 2706] MEDQUIST36 D: [2131-8-22] 13:19 T: [2131-8-22] 15:44 JOB#: [Job Number 11681] ICD9 Codes: 486, 4280, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6833 }	Medical Text: Admission Date: [2126-5-4] Discharge Date: [2126-5-16] Date of Birth: [2058-2-3] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old female with a history of diabetes, known gallstone disease, transferred from an outside hospital for workup of presumed cholecystitis. The patient had been feeling ill for two weeks prior to her admission to the outside hospital. She was diagnosed with an upper respiratory infection by her primary care physician and given ciprofloxacin. On the day of admission to the outside hospital, she collapsed out of dizziness. At the outside hospital, she had a course significant for a pancreatitis with a lipase of [2123], a presumed cholecystitis with right upper quadrant ultrasound consistent with cholecystitis without biliary dilatation, as well as a left upper lobe pneumonia. She received cefuroxime for antibiotics, and a CT scan which showed significant only for pancreatic atrophy. She continued to have respiratory distress and gastrointestinal pain, and was transferred to [Hospital1 188] for further workup. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. HOSPITAL COURSE BY SYSTEM: 1. Neurological: Patient with a normal mental status on her admission. She was sedated for her intubation. She was weaned periodically, and her mental status was noted to be responsive. 2. Cardiovascular: Ischemia: Patient with known coronary artery disease. She was continued on her PR aspirin. Her beta blocker was held secondary to her hypotension. Pump: The patient with a known low ejection fraction of anywhere from 20-40%. She was slightly volume overloaded on her admission, and received dialysis as she was aneuric throughout her admission at [Hospital1 ]. Afterload reduction was held since she was hypotensive. Rhythm: Patient with known V-tach in the past and AICD placed in [2125-7-2] for V-tach on the setting of a myocardial infarction. She had multiple episodes of V-tach while in-house. She was managed on lidocaine and amiodarone drips, and was seen by EP Service. Did receive multiple shocks throughout her admission. Hypotension: Patient was hypotensive likely secondary to sepsis from pneumonia. Was initially placed on phenylephrine to avoid beta action on the heart, and which was eventually changed to norepinephrine. 3. Pulmonary: Patient was admitted with a left upper lobe pneumonia thought to be community acquired. She was continued on levofloxacin for her community acquired pneumonia. She then developed bilateral infiltrates thought to be failure versus ARDS. She was intubated on the third day of her admission for respiratory distress and hypoxia. She did receive invasive PA catheter monitoring which is significant for a wedge of 20, and after three days, a Swan was discontinued. 4. Gastrointestinal: Patient with a transaminitis and pancreatitis by enzymes while she was here. She received multiple right upper quadrant ultrasounds which was not significant for any cholecystitis, but did have gallstones. She received an ERCP with sphincterotomy which revealed gallbladder sludge. However, her right upper quadrant enzymes never totally resolved, and continued to have a pancreatitis. However, she is felt not to have an active cholecystitis throughout this admission. 5. Heme: The patient did have 1 unit of blood transfusion while she was here, but was guaiac negative, had no clear bleeding source. Thrombocytopenia: Unclear origin. She had a negative HIT antibody. 6. Endocrine: Patient on insulin drip while in-house for her diabetes. 7. Infectious Disease: The patient was maintained on Vancomycin, levo, and Flagyl throughout most of her admission to cover right upper quadrant bugs as well as her pneumonia. She initially received two days of meropenem, and this coverage was changed. She was never febrile throughout this admission. Additional MICU course: The patient was considered septic throughout her time. Was continued on antibiotics and pressor support. However, her admission was complicated by multiple episodes of ventricular tachycardia. She eventually had a sustained V-tach which was pulseless. The patient was coded unsuccessfully, and received multiple shocks, and we are unable to get a pulse back. Family was notified, and no postmortem examination was requested. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. Dictated By:[Last Name (NamePattern1) 6834] MEDQUIST36 D: [2126-5-22] 21:16 T: [2126-5-27] 08:32 JOB#: [Job Number 47759] ICD9 Codes: 486, 4271, 0389, 2875, 5845, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6834 }	Medical Text: Admission Date: [2196-10-26] Discharge Date: [2196-11-30] Date of Birth: [2118-7-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3043] Chief Complaint: Cellulitis/DVT Major Surgical or Invasive Procedure: Thoracentesis (x2) Placement of Chest Tube Pleurodesis Abdominal paracentesis (x4) PICC line placement History of Present Illness: This is a 78 year old man with history notable for extensive pulmonary asbestosis, atrial fibrillation, and RP fibrosis s/p ureterolysis and omental wrap who presented to an outside hospital on [2196-10-26] for elective hernia repair. The patient has long been awaiting repair of a large inguinal hernia and ventral hernia and had stopped taking his coumadin 10 days prior to presentation (he is on this for atrial fibrillation) in order to get these procedures completed. Over the week prior to presentation he had also noted worsening left lower extremity edema and increasing abdominal girth with worsening of his preexisting vental hernia. Other review of systems notable for some nonproductive cough as well as general fatigue and decreased mobility for the past month, which he largely attributed to his impressive hydrocele. He denied any fevers,chest pain, orthopnea, or PND. At the outside hospital initial evaluation revealed abdominal wall erythema concerning for cellulitis as well as a swollen left lower extremity. Ultrasound showed left common femoral vein DVT. He was transferred to [Hospital1 18] for further management. On arrival he complained of fatigue and discomfort from his large hernias. No other issues. Past Medical History: -asbestosis -atrial fibrillation -ureterolysis -RP fibrosis (presumed idiopathic) -omental wrap Social History: The patient worked as a steam engineer for over 40 years. He reports significant asbestos exposure over a period of several years. He lives with his wife of 58 years. He denies TOB or drug use and says he drinks alcohol only very occasionally. Family History: Father died of complications of pernicious anemia, mother died at age 66 of ??????heart problems??????. [Name2 (NI) ] brother died of an MI at age 53, both younger brothers died of CVD in their 40??????s. One sister died of complications of alcoholism at 66, another sister died at age 68 of cerebral hemorrhage. His one remaining sibling, a sister, is 77 and well. Physical Exam: On Presentation: T=94.7 HR 60 BP 153/56 RR30 93% NRB PHYSICAL EXAM GENERAL: Pleasant, speaking in full sentences HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA. dry mmm. OP clear. Neck Supple, No LAD. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. no elevation of JVD LUNGS: decreased breath sounds in lower [2-9] of right lung and poor air movement with crackles in the rest of the lung. ABDOMEN: large ventral hernia, multiple large other hernias. NT, ND. +bs EXTREMITIES: +2 edema to the sacrum. 1+ dorsalis pedis pulses bilaterally GU: very large scrotal hernia and scrotal edema SKIN: macular rash on abdomen and back NEURO: A&Ox3. Appropriate. CN 2-12 intact. UE and LE strength [5-10]. PSYCH: Listens and responds to questions appropriately, pleasant, tangential speech. Pertinent Results: ===================== LABORATORY RESULTS ===================== BLOOD ------ On Presentation: WBC-11.5* RBC-4.20* Hgb-11.4* Hct-34.5* MCV-82 RDW-15.3 Plt Ct-452* ---Neuts-84.8* Lymphs-5.1* Monos-8.7 Eos-1.0 Baso-0.4 PT-14.2* PTT-25.5 INR(PT)-1.2* Glucose-105 UreaN-37* Creat-2.0* Na-140 K-5.5* Cl-107 HCO3-24 Calcium-8.7 Phos-4.1 Mg-1.8 Last Full Labs: WBC-16.1* RBC-3.82* Hgb-10.4* Hct-32.0* MCV-84 RDW-15.9* Plt Ct-649* ---Neuts-86.8* Lymphs-3.4* Monos-8.6 Eos-0.8 Baso-0.4 PT-15.2* PTT-37.0* INR(PT)-1.3* Glucose-121* UreaN-102* Creat-2.0* Na-136 K-4.2 Cl-104 HCO3-21* Other Important Labs: [2196-11-4] 07:50AM BLOOD ALT-10 AST-20 AlkPhos-60 TotBili-0.2 [2196-11-5] 07:15AM BLOOD Triglyc-135 HDL-29 CHOL/HD-4.2 LDLcalc-67 [2196-11-18] 03:50AM BLOOD TSH-4.1 [2196-11-18] 03:50AM BLOOD Cortsol-15.9 [2196-11-8] 12:52PM BLOOD PSA-0.8 [2196-11-9] 07:25AM BLOOD PEP-NO SPECIFIC PEAK ID's Protein/Albumins: [2196-11-4] 07:50AM Albumin-2.7* [2196-11-5] 07:15AM TotProt-6.4 Albumin-3.5 [2196-11-9] 07:25AM TotProt-6.2* [2196-11-11] 05:00AM TotProt-5.9* Albumin-3.2* [2196-11-12] 05:37AM Albumin-3.3* [2196-11-18] 03:50AM Albumin-2.5* [2196-11-22] 05:56AM TotProt-4.3* Albumin-2.2* Urine ------ [2196-11-25]: Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.017 Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-1 TransE-<1 CastGr-18* Pleural Fluid --------------- [2196-11-13] WBC-190* RBC-5875* Polys-11* Lymphs-59* Monos-18* Eos-1* Meso-11* TotProt-3.6 Glucose-129 LD(LDH)-116 Cholest-75 Triglyc-1120 [2196-11-15] WBC-1000* RBC-9333* Polys-19* Lymphs-55* Monos-15* Eos-1* Meso-10* TotProt-3.5 LD(LDH)-116 Amylase-28 Albumin-2.0 Peritoneal Fluid ----------------- [2196-11-5] WBC-1875* RBC-[Numeric Identifier ]* Polys-22* Bands-1* Lymphs-40* Monos-0 Macroph-37* LD(LDH)-120 Albumin-2.0 Triglyc-1304 Adenosine Deaminase: 6.4 (Normal) [2196-11-10] WBC-740* RBC-3150* Polys-8* Lymphs-57* Monos-33* Mesothe-2* TotPro-3.6 LD(LDH)-114 Albumin-2.1 Triglyc-815 [2196-1-24] WBC-570* RBC-720* Polys-58* Lymphs-27* Monos-0 Eos-1* Plasma-2* Mesothe-1* Macroph-11* TotPro-2.4 Glucose-133 LD(LDH)-139 Amylase-16 Albumin-1.4 =============== MICROBIOLOGY =============== Blood Cultures 6: No growth Urine Cultures 4: No Growth Stool for C diff: Negative Peritoneal Fluid Culture 4: No growth Pleural Fluid Culture3: No Growth =========== PATHOLOGY =========== Pleural Fluid Cytology from [11-10], [11-13], and [11-15]: Negative for Malignant Cells Peritoneal Fluid Cytology from [11-5] and [11-13]: Negative for malignant cells Pleural Fluid Immunophenotyping: NTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. Correlation with clinical findings and morphology (see C09-[Numeric Identifier ]) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. =============== OTHER STUDIES =============== ECG [2196-10-26]: Sinus bradycardia. Otherwise, tracing is within normal limits CT Abdomen and Pelvis W/O Contrast [2196-10-26]: IMPRESSION AND PLAN: 1. Abnormal soft tissue encasing the retroperitoneal structures, surrounding the aorta and IVC, extending inferiorly along the presacral space. These findings are incompletely characterized without intravenous contrast. Findings could reflect retroperitoneal fibrosis, though correlation with prior history or any prior imaging would be helpful. The attenuation of this material is not compatible with hemorrhage 2. Complex ventral abdominal wall hernia containing fat, fluid and small bowel, without evidence of obstruction. 3. Large left inguinal hernia, with herniation of fluid and sigmoid colon to the left scrotal sac. 4. Large amount of ascites. 5. Left external iliac, common femoral, and superficial femoral venous thrombosis. Chest Radiograph [2196-11-1]: IMPRESSION: Marked cardiac enlargement predominantly involving the left heart. Extensive bilateral pleural changes including calcifications consistent with previous asbestos exposure. Pulmonary vasculature demonstrates upper zone re-distribution pattern but no conclusive evidence for acute infiltrates. Bilateral Lower Extremity Ultrasounds [2196-11-3]: IMPRESSION: 1. Occlusive deep venous thrombosis in the common femoral vein extending into the greater saphenous and deep femoral veins. Of note, the proximal extent of thrombus is not defined. 2. No right lower extremity deep venous thrombosis. Spirometry [2196-11-4]: Impression: Marked restrictive ventilatory defect with a marked gas exchange defect. The reduced DLCO suggests an interstitial process. There are no prior studies available for comparison. TTE [2196-11-4]: Conclusions The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no VSD seen. 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) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Abdominal Ultrasound w/Dopplers [2196-11-4]: IMPRESSION: 1. Normal portal venous, hepatic venous, and hepatic arterial flow to the liver. 2. Large amount of ascites CT Chest W/O Contrast [2196-11-7]: IMPRESSION: The constellation of findings including an increasing right pleural effusion which is moderately large, massive hiatal hernia, diffuse ground-glass opacities throughout the lungs probably infective or inflammatory, extensive calcification in multiple pleural plaques with extensive intra- abdominal ascites all contribute to the worsening respiratory status. The presence of an increasing pleural effusion with calcified and noncalcified pleural plaques in the setting of asbestos-related disease raises the remote possibility of mesothelioma. TTE [2196-11-8]: IMPRESSION: Mild concentric hypertrophy with normal biventricular regional and global systolic function. Moderate diastolic dysfunction with elevated PCWP. Mild aortic regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [2196-11-4], the findings are similar. A paramembranous VSD is not seen on either study (mentioned in initial report). The velocity across the aortic valve is now lower CT Chest [2196-11-12]: IMPRESSION: 1. Large right-sided pleural effusion which has increased in size since the study performed five days prior. Associated compressive atelectasis of the right lung base. Also compressive atelectasis of the left lung base due to large hiatal hernia which is unchanged. 2. Scattered ground-glass opacities throughout both lungs, stable, likely infectious or inflammatory in nature. No focal consolidations. No other significant changes since the prior study. Renal Ultrasound [2196-11-12]: IMPRESSION: No hydronephrosis. Non-diagnostic Doppler evaluation due to patient's inability to hold breath. CT Chest w/o Contast [2196-11-14]: FINDINGS: There has been a slight decrease in size of the large right pleural effusion since the previous CT on [11-12] with no pneumothorax. The right lower lobe compressive atelectasis remains similar and the large intrathoracic hiatal hernia now contains peripheral fluid tracking up from the extensive ascites. Otherwise, no change since the CT torso on [2196-11-12], and reference to the previous CT report is recommended for complete description of findings. KUB [2196-11-25]: FINDINGS: In the left anterior mid abdomen in the expected location of the patients known ventral abdominal hernia, multiple air-filled and dilated bowel loops are seen, likely involving both small and large bowel. Air is visualized in the rectum. CT is recommended to rule out large or small bowel obstruction. Chest Radiograph [2196-11-26]: FINDINGS: Portable AP upright chest radiograph is compared with [11-22] and [2196-11-25]. There is a large hiatal hernia. There is increase in the right mid lung opacification, which may be atelectasis or pneumonia. There is left basal atelectasis with increasing pleural effusion. Within the left upper lung there is increased opacification, which may be secondary to infection. The right pigtail catheter is unchanged in position. There is atherosclerotic disease of the thoracic aorta. Brief Hospital Course: This is a 78 year old male with history of paradoxical atrial fibrillation, pulmonary asbestosis, and idiopathic RP fibrosis presenting with cellulitis and increased abdominal distension found to have DVT and with progressive chylous ascites. 1)Chylous Ascites: The patient was noted to have a distended abdomen on presentation and imaging revealed a large amount of ascites. As the patient had not had a previous history of ascites this was worked up with liver ultrasound that revealed no parenchymal or vascular dysfunction. Diagnostic paracentesis was obtained on [2196-11-5] that showed chylous ascites. This paracentesis also revealed >250 neutrophils so the patient was empirically started on a five day course of ceftriaxone though he remained afebrile and had no abdominal pain. After the chylous ascites was discovered primary concern was for a malignancy given the lack of liver disease. Multiple imaging studies failed to show a mass, however, multiple fluid cytologies were negative, and the patient's LDH was within normal limits making lymphoma quite unlikely. Therefore, most likely etiology of the development of chylous ascites was thought to be progressive lymphatic obstruction from RP fibrosis leading to increased hydrostatic pressure and leak into the peritoneal cavity. The patient had three therapeutic paracentesis on [11-14], and [11-29] respectively removing 900 cc, 3L and 1 L of chylous fluid respectively. The second of these revealed a neutrophil count of 280 so led to a second course of five days of antibiotics with ciprofloxacin (as the patient was on cefepime/vanc when the paracentesis occured) which completed on [2196-11-29]. All cultures remained negative. Unfortunately, the patient developed secondary chylothorax from fluid tracking up into the pleural space causing respiratory distress. Attempts were made to slow accumulation of fluid with medical therapies including octreotide and low fat diet then low fat TPN but these were unsuccessful. General surgery was consulted twice and both times said that surgery to attempt to improve lymph drainage would be unsuccessful as structures are very small and diffuse and post-surgical scarring would likely be as damaging as initial insult. Case was discussed with thoracic surgery who thought that without clear damage to thoracic duct there was no indication for procedural management. Finally, the possibility of lymphangiogram was discussed extensively with a possible intervention and balloon dilation of cisterna chyli. Unfortunately, planning MRI would have been required and given patient's progressively poor respiratory status this would have required intubation. As lymphangiogram and balloon dilation are extremely uncommon procedures, odds of success were not considered high and risk of intubation and likely difficulty extubation was discussed with the family and patient and they elected to pursue comfort focused care. The possibility of disease modifying therapy for RP fibrosis was discussed with rheumatology, but they said there would be no role for the agents used (almost all of which are immune suppressants) in this acutely sick individual and these things would be unlikely to lead to quick turn-around. 2) Chylothorax/Hypoxic Respiratory Failure: The patient was initially noted to be hypoxic soon after admission with desats to the low 90's on room air. He was seen by pulmonary who attributed this to ascites and his large abdomen causing restrictive pathology in the setting of his underlying pulmonary asbestosis and plaques. This was supported by his initial PFT's that showed a restrictive pattern. The patient then became progressively more hypoxic in the setting of an expanding right sided pleural effusion and a large amount of compressive atelectasis. He was desatting to the low 90's on 4L O2 by nasal cannula when he had his first thoracentesis on [2196-11-10] with considerable improvement after the procedure. By [11-12], however, he had reaccumulated almost completely and by [11-13] was desaturating again so that an ABG showed of O2 of around 53. Therefore, he was transferred to the unit while he awaited a second thoracentesis. As he reaccumulated quickly again after that thoracentesis decision was made to place a pigtail catheter, which was placed on [2196-11-15]. Over the ensuing days the patient continued to put out greater than one liter of chylous fluid per 24 hour period despite the various interventions meant to reduce chylous ascites mentioned (low fat diets, octreotide, etc...). On [2196-11-29] a pleurodesis was attempted in hopes of allowing eventual removal of the chest tube though interventional pulmonology thought this had a very low probability of being successful. After the second thoracentesis the patient remained dependent on at least 4L of oxygen by nasal cannula to keep sats> 90%. On [11-26] he desaturated to the 80's on 6L in the context of worsening infiltrates bilaterally but this seemed to improve with holding TPN and was ultimately thought most likely due to volume overload. However, on the day of expected discharge ([11-30]), his respiratory status worsened (oxygen saturation of 90-92% on non-rebreather) and he did not wish to use the mask. Given that comfort was the goal, he was transitioned back to nasal cannula, and oxygen saturations were no longer followed. 3) Nutrition/Protein Loss: Initially the patient was allowed to eat a regular diet but in attempts at medical management he was converted to a low fat, high protein diet and then made NPO with TPN. Despite TPN his protein and albumin continued to fall presumably due to losses in the chest tube. After he became quite volume overloaded on [2196-11-27] and given the minimal reduction in fluid output seen even with the TPN modifications TPN was stopped as of [11-27] and he was allowed to eat for comfort. He and his family understand he will ultimately continue to become malnourished and weaker but given poor toleration of TPN and comfort focused care this was considered acceptable by them. 4) Health Care Associated Pneumonia: The patient was noted to have intermittently elevated white counts and on [2196-11-19] had a right upper lobe infiltrate on chest radiograph and had purulent sputum. Therefore, he received 9 days of cefepime/vancomycin with some improvement in his sputum production and stable chest radiograph findings. White count failed to trend reliably. He was never febrile. 5) LLE DVT: He was initially on heparin gtt then transitioned to be therapeutic on coumadin. He was transferred back to heparin gtt once on the medical service and continued on this throughout his course there to make procedures feasible without needing a long warfarin wash-out. Anticoagulation with medications other than unfractionated heparin (enoxaparin, warfarin) was not optimal given his renal failure and poor nutritional status. 6)Cellulitis: The patient initially received a dose of penicillin then a few days of cefazolin with minimal improvement in his abdominal rash. He then received 10 days of vancomycin as well as steroid cream after dermatology thought the abdominal rash could be a contact dermatitis. This led to resolution of his abdominal rash. 7) Likely drug rash: Later in his hospitalization (around [11-19]-15th) he developed a morbilliform eruption on his trunk in the context of receiving a dose of piperacillin-tazobactam in the ICU. This medication was stopped an his rash resolved. 8) Hypotension: The patient developed relative hypotension in the hospital. Multiple blood cultures were negative and this seemed stable without mental status changes or end organ dysfunction (except some worsening of his CKD). This was thought likely due to poor cardiac return due to massive third spacing from his protein losses and perhaps external compression of the IVC by his abdomen. 9) Acute Kidney Injury: The patient's baseline Cr is unclear. At presentation Cr was 2 then trended down to 1.5 before trending up again in the setting of worsening ascites and his general deterioration. Renal was consulted twice and ultimately concluded this was likely due to poor preload and forward flow from the heart in the context of his third spacing and massive abdominal distension. He never became oliguric or anuric. 10) Atrial fibrillation: The patient developed atrial fibrillation with rapid ventricular response while his nodal agents were being held. This broke with diltiazem and he was restarted on this medication with good rate control. 11) Goals of Care: After extensive discussion with the family and patient about the lack of options for reversing the patient's chylous ascites accumulation and subsequent respiratory compromise and progressive protein wasting they elected to pursue comfort focused care. Reasonably benign interventions (i.e. antibiotics, pleurodesis through a preexisting chest tube) were pursued but other aggressive cares were not. Similarly oral feeds were pursued even in the face of a possible SBO for the patient's comfort and happiness. His major goal was comfort and the family and patient understood his poor prognosis. When his respiratory status deteriorated on [11-30] (as above), further diagnostics and interventions were not pursued, and he was given morphine. He passed away in the evening of [11-30], and his family was notified. Autopsy was requested and will be performed at [Hospital1 18]. Medications on Admission: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses ================== Chylous Ascites Presumed Secondary to Retroperitoneal Fibrosis Secondary Chylothorax Hypoxic respiratory distress due to external compression Hospital Acquired Pneumonia Spontaneous Bacterial Peritonitis Acute Kidney Injury Cellulitis Left Lower Extremity DVT Secondary Diagnoses ===================== Paroxysmal Atrial Fibrillation Pulmonary Asbestosis Large inguinal and ventral hernias Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired ICD9 Codes: 486, 5849, 5180, 2851, 5119, 4589, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6835 }	Medical Text: Admission Date: [2157-9-22] Discharge Date: [2157-9-24] Date of Birth: [2082-10-25] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[Last Name (NamePattern4) 290] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Cervical lymph node biopsy in OR History of Present Illness: . Mr [Known lastname 66103] is a 74yo morbidly obese male with hx significant for HTN, stroke, cor pulmonale [3-17] COPD, DM, and stroke, transfered from OSH with LLE DVT, PE, and lympadenopathy on CT. . Course at OSH: In brief, patient was admitted to [Hospital3 18201] on [2157-9-12], with productive cough, SOB, increased O2 requirement(2->4L) and treated for a COPD flare with levaquin, solumedrol IV, and advair. He showed improvement in his leukocytosis and respiratory status. After a few days, however, there was a gradual rise in WBC up to 19, and he began to deteriorate again. His CXR was negative for new infiltrates and his Ucx was clear, but his blood grew MRSA and he was placed on IV vancomycin. He showed an elevated d-dimer, and was subsequently found to have R popliteal DVT on LE Dopplers. His respiratory status continued to worsen, but his VQ scan showed low probability for pulmonary embolism. Given patient's obesity and immobility, he was placed on lovenox and warfarin. His Chest CT at the time demonstrated extensive LAD in his cervical and supraclavicular nodes bilaterally with extension down into the anterior mediastium and to the level of the AP window. Previous CT on [2157-6-27], had in fact commented on chest mass/infiltrate. Significant LAD was not noted in the abdomen, and the liver and spleen to be uninvolved. Because of the rapid progression of the LAD, patient was transferred to [Hospital1 ] for further evaluation, tissue biopsy, and treatment. . On presentation to the Medicine Service at [Hospital1 ], patient complains of having pain and discomfort in his shoulder and neck for many months. He describes feeling so weak at one point that he was unable to remain standing long enough to take a shower. He believes that his respiratory status has declined and that he has had trouble breathing for the last few weeks. It became worse around the time he was diagnosed with a DVT at the OSH hospital. He denies chest pain with inspiration or pain in his legs. . He denies any recent travel, chills, or sick contacts. [Name (NI) ] denies CP and palpitations. Patient admits to SOB on lying down. He admits to abdomenal discomfort, bloating and diarrhea for the last few weeks, perhaps for months. Denies blood per rectum or melena. No dysuria, hematuria. He also denies denies pain in his leg. He admits to sweats and weight loss >10lbs in last 6 mo but no fevers. Past exposures include [Doctor Last Name 360] [Location (un) 2452] when he was stationed in [Country 10181]. His brother died of an aucte leukemea at age 74. . Past Medical History: COPD-requires supplemental O2: Pulmonologist Dr. [Last Name (STitle) 28583]. Sleep apnea? Stroke-lacunar infarct Meniere's disease: Right ear deafness. +Vertigo GERD Sick sinus syndrome s/p Permanent pacemaker Diabetes Hypertension Morbid Obesity Chronic renal insufficiency with baseline creatinine of 1.6-1.8 Cor pulmonale: EF50%, per cardiologist Social History: No history of smoking Family History: Brother died at age 74 of leukemia Physical Exam: . T96.9 BP140/72 HR72 RR28 O2sat94%on2L Gen: obese male. NAD, uncomfortable. Unable to finish full sentences. HEENT:PERRL, EOMI, tongue/buccal mucosa/pharyx with ulcers. Neck: bilateral supracalvicular and cervical LAD- nontender, mobile Pulm: distant breath sounds, inspiratory wheeze, no crackles Cor: Regular, nls1s2 no gallops, no murmurs appreciated abdomen: +BS, distended, mildly tender diffusely, most tender in epigastric area, Skin: Large ecchymoses on left thigh (~20cmx8cm), lower back(~15cmx6cm). Nontender, nonpulsating. Ext: Mild tenderness to palpation of popliteal fossa. No edema in extremity. Assymetry in LE not notable Neuro: AxOx3, CNII-XII intact. Sensation intact in UE to light touch. Pertinent Results: OSH: CXR [2157-9-16]: no acute infilatrates or effusions. No cardiomegaly. . CT [2157-6-27]: Infiltrate/mass on chest CT, recommended follow-up . U/S [2157-9-16]: DVT R LE . VQ: Low probablity for PE . UA:yellow, clear, Glucose negative, bili negative, ketone negative, SG1.015, blood moderat, pH 5.0, proetin, negative, urobili neg, nitrite neg, leuko esterase neg. . Bld cx [2157-9-13]: MRSA . Stool [9-16]: neg for C-diff stool Toxin A, WBC, salmonella, shigella, campylobacter and ecoli 0157:H7. . 141 106 77 / 92 AGap=13 3.5 26 1.9 \ Ca: 8.3 Mg: 3.0 P: 4.4 ALT: 51 AP: 100 Tbili: 0.6 Alb: 3.4 AST: 44 LDH: 644 Dbili: TProt: [Doctor First Name ]: Lip: UricA:12.5 . 85 15.9 \ 12.3 / 159 / 35.3 \ N:90 Band:2 L:2 M:3 E:1 Bas:0 Metas: 2 Anisocy: 1+ Microcy: 1+ Plt-Est: Normal . PT: 30.0 PTT: 31.1 INR: 3.2 Brief Hospital Course: Assessment and Plan: . Mr [Known lastname 66103] is a 74yo morbidly obese male with hx significant for HTN, stroke, cor pulmonale [3-17] COPD, CRI, DM, and stroke, transfered from OSH with LLE DVT, PE, and lympadenopathy on CT. . #Enlarged lymph nodes on CT: Patients clinical presentation was most concerning for lymphoma, especially given his family history of leukemia and exposure to [Doctor Last Name 360] [Location (un) 2452]. The nontender superficial, LAD located in the cervical, supraclavicular, and mediastinal areas is typical of Hodgkin's disease. This orderly, anatomic spread to adjacent nodes, is most c/w the contigous spread of HD. However, sensation of abdominal fullness and bone pain, reported as pain in his back and neck, may be indicative of the nontender diffuse LAD of NHL. Patient has remained febrile, even during infection with MRSA per records; however, he has had the other constitutional or B symptoms of weight loss and sweats. The rapid progression of his LAD may suggest an aggressive lymphoma such as mantle cell. However, it appears a past CT in [6-18] commented on the mediastinal infiltrate/mass, which could be referring to the earlier stage of this condition. If this is HD lymphoma, this patient clearly has greater than a single LN region affected, making this [Hospital1 69333] stage II or higher. We need abdomenal and pelvic imaging for further staging. HD Limited disease has 80% long-term survival, whereas advanced disease has a considerably less survial time. If this is HD, it is most beneficial to treat it early. Patient's recent respiratory decline may be [3-17] mediastinal mass obstructing the airway. SVC syndrome is another complication. It is also important to rule out infectious causes of enlarged lymph nodes: CMV, EBV, TB. -surgery was consulted to identify best surgical procedure for excisional lymph node biopsy . CRI: Patient has a history of chronic renal insufficiency. He currently has a BUN77 and Cr1.9, which is in the range he has remained in the last week. It is important to realize that renal involvement with lymphoma is seen in 2 to 14 percent of all patients, and an elevated serum creatinine is reported in 26 to 56 percent. Patient is euvolemic on exam. -determine baseline bun/creatinine levels from PCP [Name10 (NameIs) 15282] to hold lasix -no contrast during imaging . cor pulmonale/COPD: -supplemental oxygen -nebs -advair -spiriva -continue steroid taper . GERD: denies any current symptoms -protonix . HTN: appears to be well-controlled -Beta blocker . CAD: -cont plavix, aspirin -d/c nitropatch . Diabetes -insulin sliding scale . MICU Course: -Patient was transferred to the MICU for desaturations. He was fiberoptically intubated and stabilized on pressors. Biopsy was performed in the OR after INR correction with FFP. Preliminary pathology results showed poorly-differentiated large cell carcinoma with focal glandular and focal clear cell features. After diagnosis was made, it was discussed with the family the few options for therapy and the generally poor prognosis. He was made comfort measures only and expired subsequently after extubation. Medications on Admission: Zopinex and Atrovent, 1.25/0.5 nebulizers every 6 hours while awake Glyburide 2.5 mg po qday Vyvox 600mg po q12h Guaifenisin 1200mg po bid Vitamin B complex, t tablet qday Toprol XL 25mg po qday Protonix 40mg po qday Nitropatch 0.2mg po qday Diltiazem XT 120mg po qdaily Aspirin 325mg po qday Advair 250/50 one puff [Hospital1 ] Spiriva 18micrograms, one puff daily Plavix 75mg po daily MVI one tablet po qday Prednisone 20mg po daily for 2 days, then prednisone 10mg po qday for 2 days, then d/c Requip one tablet po daily Accu-cheks with regular insulin coverage as per sliding scale Coumadin ALLERGY: PENICILLIN Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 4280, 4254, 7907
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6836 }	Medical Text: Admission Date: [2162-1-8] Discharge Date: [2162-1-13] Date of Birth: [2106-7-20] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Chest burning, mild SOB Major Surgical or Invasive Procedure: [2162-1-8] Three Vessel Coronary Artery Bypass Grafting utilizing left internal mammary artery to left anterior descending; saphenous vein grafts to obtuse marginal and posterior descending artery. History of Present Illness: This is a pleasant 55 year-old man who reported a vague "burning" feeling in his chest that began in [Month (only) 205] of this year. He also reports an associated mild SOB. This burning sensation has occurred with activity such as walking up a steep incline or even on a flat surface, occasionally depending on what he had just eaten. Mr. [Known lastname 6264] also notes the burning sensation has occurred at rest, but can be postural - depending on if he is sitting vs. laying down. The patient often associates most of these symptoms with his GERD. Finally, the patient also reports a tightness in the area of his heart that was also tender to touch. This has occurred with and without activity, with stress and could last up to one day. On [2161-12-15], the patient underwent an ETT for CP evaluation. The patient for 5.25 minutes of a modified [Doctor First Name ] protocol to an APHR of 65% and was stopped for fatigue. At peak exercise, EKG showed 1-1.5mm of horizontal ST segment depression in II and lateral leads. These changes turned to downsloping by 3 minutes post-exercise, and returned to baseline by 7 minutes of recovery. The rhythm was sinus without ectopy. Gated images revealed a large, reversible, moderate intensity perfusion defect involving the PDA territory. Small, reversible, severe perfusion defect involving the LAD territory. Transient cavity dilation c/w severe multi-vessel disease. Moderate LV systolic dysfunction (EF 34%), with apical and inferior hypokinesis, c/w post-stress running. On [2161-12-24], patient underwent cardiac catheterization which showed severe three vessel disease and depressed left ventricular function at 35%. Coronary angiography showed a right dominant system with 90% stenosis of the LAD and total occlusions of the second obtuse marginal and mid right coronary artery. PCI of the RCA was attempted but unsuccessful. He was therefore referred for cardiac surgical intervention. Past Medical History: CAD DM2 - dx'd about 7 years ago HTN Hyperlipidemia GERD Social History: He lives with his spouse and has no children. He works as an antique dealer. He denies tobacco. Family History: Negative for premature CAD Physical Exam: Vitals: BP 118/56, HR 66, RR 14, SAT 100% on room air General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [2162-1-13] 07:30AM BLOOD Hct-23.4* [2162-1-11] 01:00PM BLOOD WBC-9.4 RBC-3.13* Hgb-9.5* Hct-25.8* MCV-83 MCH-30.4 MCHC-36.8* RDW-13.6 Plt Ct-157 [2162-1-8] 10:55AM BLOOD WBC-12.3# RBC-3.09# Hgb-9.3* Hct-25.5* MCV-83 MCH-30.2 MCHC-36.6* RDW-13.6 Plt Ct-179 [2162-1-13] 07:30AM BLOOD K-4.3 [2162-1-11] 01:00PM BLOOD Glucose-148* UreaN-15 Creat-0.9 Na-136 K-4.0 Cl-95* HCO3-28 AnGap-17 Brief Hospital Course: On admission, Mr. [Known lastname 6264] was brought to the operating room and underwent three vessel coronary artery bypass grafting by Dr. [First Name (STitle) ] [Name (STitle) ]. The operation was uneventful. Following the procedure, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He maintained stable hemodynamics as he weaned from inotropic support. His CSRU course was otherwise uncomplicated and he transferred to the SDU on postoperative day three. He continued to require diuresis. Over the next several days, medical therapy was optimized. Beta blockade was resumed with most of his other preoperative medications. He remained in a normal sinus rhythm. By discharge, he was near his preoperative weight with room air oxygen saturations of 97%. His discharge chest x-ray was notable for only a resolving left pleural effusion. At time of discharge his blood pressure was 127/69 with a heart rate of 85 in sinus. All surgical wounds were clean, dry and intact. He will need to remain on supplemental Iron as an outpatient for his anemia. Medications on Admission: Metformin 850mg tid Avandia 4mg [Hospital1 ] HCTZ 50mg daily Protonix 40mg daily Lisinopril 40mg daily Atenolol 25mg daily Lipitor 10mg daily ASA 81mg daily - instructed to take 4 tablets the day prior and AM of cath Glucosamine chondroitin 1 tablet [Hospital1 ] Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:60 Capsule, Sustained Release(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills: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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary artery disease - s/p CABG Hypertension Non insulin dependent diabetes mellitus Peptic ulcer disease Hypercholesterolemia Anemia Discharge Condition: Good. Discharge Instructions: You may shower. Wash incision with soap and water and pat dry. Do not apply lotions creams or powders to incisions. Call with fever, redness or drainage from incisions or weight gain more than 2 pounds in one day or five in one week. No heavy lifting, no driving. Followup Instructions: Dr. [First Name (STitle) ] [Name (STitle) ] [Telephone/Fax (1) 170] Follow-up appointment should be in 1 month Dr. [Last Name (STitle) 2392] (PCP) 2 weeks Dr. [Last Name (STitle) ] (Cardiologist) 2 weeks - Please see cardiologist regarding restarting HCTZ after lasix is completed. Completed by:[2162-1-13] ICD9 Codes: 2851, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6837 }	Medical Text: Admission Date: [2113-3-17] Discharge Date: [2113-3-30] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: SOB Major Surgical or Invasive Procedure: s/p AVR(#21StJude porcine)CABGx2(SVG-PDA,SVG-OM)[3-24] History of Present Illness: 83 yo female with known severe AS, CAD presents with acute on chronic diastolic heart failure. Past Medical History: PAST MEDICAL HISTORY: # Deaf, communicates well & reads lips well # HTN # H/O TIA # COPD (emphysema) - on albuterol # Hysterectomy # Appendectomy Social History: Cardiac Risk Factors: Hypertension, tobacco Family History: NC Physical Exam: VS:Hr:73, 126/83,RR-20, 96% on 2Lpm General:AxOx3 Lungs: (B) basilar crackles CVS: SEM III/VI, RRR ABD:benign EXT: o C/C/E No varicosities/No carotid bruits Pertinent Results: [2113-3-28] 05:15AM BLOOD WBC-7.7 RBC-3.07* Hgb-8.0* Hct-25.3* MCV-82 MCH-26.1* MCHC-31.7 RDW-16.0* Plt Ct-297 [2113-3-25] 03:18AM BLOOD PT-13.1 PTT-36.8* INR(PT)-1.1 [2113-3-28] 05:15AM BLOOD Glucose-114* UreaN-8 Creat-0.4 Na-137 K-3.7 Cl-103 HCO3-30 AnGap-8 RADIOLOGY Final Report CHEST (PORTABLE AP) [2113-3-27] 4:19 PM CHEST (PORTABLE AP) Reason: ? ptx s/p chest tube removal [Hospital 93] MEDICAL CONDITION: 83 year old woman with s/p cabg REASON FOR THIS EXAMINATION: ? ptx s/p chest tube removal HISTORY: Chest tube removal. Pneumothorax. A single portable radiograph of the chest demonstrates interval removal of the support lines seen on [2113-3-24]. There are bilateral pleural effusions, worse on the left than the right. Bibasilar atelectasis is present as well. Patient is status post CABG. The aorta is calcified and tortuous. IMPRESSION: Interval removal of support lines. No pneumothorax. Persistent left-sided pleural effusion and bibasilar atelectasis. DR. [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 77924] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 77925] (Complete) Done [2113-3-24] at 2:44:54 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] Division of Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2029-5-27] Age (years): 83 F Hgt (in): 64 BP (mm Hg): 123/57 Wgt (lb): 125 HR (bpm): 82 BSA (m2): 1.60 m2 Indication: Intra-op TEE for AVR, CABG, ? MVR ICD-9 Codes: 786.05, 440.0, 424.1, 424.0 Test Information Date/Time: [2113-3-24] at 14:44 Interpret MD: [Name6 (MD) 928] [Name8 (MD) 929], MD, MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 929], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.1 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.3 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.7 cm Left Ventricle - Fractional Shortening: 0.26 >= 0.29 Left Ventricle - Ejection Fraction: 50% >= 55% Left Ventricle - Stroke Volume: 79 ml/beat Left Ventricle - Cardiac Output: 6.44 L/min Left Ventricle - Cardiac Index: 4.03 >= 2.0 L/min/M2 Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 2.6 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aorta - Arch: 2.3 cm <= 3.0 cm Aorta - Descending Thoracic: 2.6 cm <= 2.5 cm Aortic Valve - Peak Velocity: 5.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 98 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 67 mm Hg Aortic Valve - LVOT pk vel: 0.68 m/sec Aortic Valve - LVOT VTI: 25 Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: 0.5 cm2 >= 3.0 cm2 Mitral Valve - Peak Velocity: 1.5 m/sec Mitral Valve - Mean Gradient: 4 mm Hg Mitral Valve - Pressure Half Time: 94 ms Mitral Valve - MVA (P [12-7] T): 2.3 cm2 Findings LEFT ATRIUM: Mild LA enlargement. Moderate to severe spontaneous echo contrast in the LAA. Depressed LAA emptying velocity (<0.2m/s) RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular calcification. Calcified tips of papillary muscles. Cannot exclude MS. [Name13 (STitle) 15110] to co-existing AR, the pressure half-time estimate of mitral valve area may be an OVERestimation of true area. Mild to moderate ([12-7]+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: 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. No TEE related complications. The patient appears to be in sinus rhythm. 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. The left atrium is mildly dilated. Moderate spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 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. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. The study is inadequate to exclude significant mitral valve stenosis. Due to co-existing aortic regurgitation, the pressure half-time estimate of mitral valve area may be an OVERestimation of true mitral valve area. Mild to moderate ([12-7]+) mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being AV paced. 1. A bioprosthesis is well seated in the aortic position. Leaflets open well. Mean gradient across the valve is 16 mm of Hg. No AI jets are seen. 2. MR is trace to mild. 3. Aorta is intact post decannulation 4. [Hospital1 ]-ventricular function is preserved Brief Hospital Course: on [2113-3-17] Mrs.[Known lastname ] was admitted to MWMC with acute exacerbation of CHF.She was stabilized and transferred to [Hospital1 18] for further cardiac workup. She has known severe AS ([Location (un) 109] 0.8 cm'2), CAD, recent UGIB with duodenal ulcer and AVMs associated with SOB. GI was consulted for her recent history of GI bleed and guiac positive stools. Serial hematocrits were followed and on [2113-3-20] EGD was performed which showed previous treated AVM now resolved. GI cleared her for the OR. Preoperative workup revealed a UTI in which Ciprofloxacin was started. She was taken to the OR on [2113-3-24] where she underwent AVR/CABG x2. Please refer to operative note for further details.Mrs. [Known lastname ] was transferred from the OR to the ICU in stable condition. Postoperatively she was extubated without incident. POD#2 her rhythm was Rapid Atrial Fibrillation 120s, treated with Beta blockade.In attempts to rate controll her AFib, given Beta blocker, she blocked down to a junctional rhythm in the 70s and her Beta blocker was subsequently discontinued.POD#3 she was transferred to the floor. [2113-3-28] Beta blocker was reinstituted with rate and rhythm recovery. She had a large pleural effusion for which she was diuresed with improvement in the effusion. She was started on fluconazole for a yeast UTI, and keflex for her vein harvest incision. She was ready for discharge to home on [3-30]. Medications on Admission: simvastatin 10', metoprolol 37.5'', asa 81', ferrous sulf 325', alb prn, prevacid 40'. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days: For LLE vein harvest site erythema. Disp:20 Capsule(s) Refills:0 9. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: s/p AVR(#21StJude porcine)CABGx2(SVG-PDA,SVG-OM)[3-24] CAD (LM 30%, LCx 30%, RCA 60%), htn, COPD, prior TIA, deafness, appy, hys. Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [First Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [First Name (STitle) ] in 1 week ([Telephone/Fax (1) ]) please call for appointment Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2113-3-30] ICD9 Codes: 5990, 4241, 4280, 4019, 5119, 9971
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6838 }	Medical Text: Admission Date: [2127-12-20] Discharge Date: [2127-12-27] Date of Birth: [2046-4-15] Sex: F Service: SURGERY Allergies: Bacitracin / Codeine / Morphine / Benadryl Attending:[First Name3 (LF) 3223] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP with biliary stent placement History of Present Illness: This is a 81 yo female transferred from [Hospital ] hospital in NH. Presented to OSH with abd pain, sharp, mid epigastric, radiating to back, CT wet read showed cholelithiasis, choledocholithiasis with 8mm stone in distal CBD, with dilation of extra and intrahepatic biliary tree. Liver enzymes, bili elevated, wbc 15. also ? LLL infiltrate. Started on abx and transferred to [Hospital1 18]. Here in the ER Patient became hypotensive, resuscitated with IVF. US here in the ER did not show a CBD stone or dilation but could not see distal CBD. Patient febrile here, Bili up from 1.2 to 2.0 Past Medical History: CAD, h/o MI, HTN, hyperlipid, severe COPD ( req 2L NC at home 24/7) Aortic aneurysm . Social History: Lives with husband and has supportive son and daughter-in-law. Physical Exam: T 101, P 106, BP 85/65, RR 26 HEENT: mild icterus Lungs: crackles on the left base CVS: regular Abd: soft, +mild tenderness RUQ, no guarding, no rigidity, BS+ Ext: no edema Pertinent Results: [2127-12-20] 08:05AM BLOOD WBC-25.1* RBC-3.80* Hgb-12.1 Hct-36.8 MCV-97 MCH-31.9 MCHC-33.0 RDW-12.2 Plt Ct-520* [2127-12-22] 02:36AM BLOOD WBC-19.8* RBC-3.77* Hgb-11.8* Hct-36.8 MCV-98 MCH-31.4 MCHC-32.1 RDW-12.3 Plt Ct-528* [2127-12-24] 04:55AM BLOOD WBC-8.9 RBC-3.65* Hgb-11.5* Hct-34.6* MCV-95 MCH-31.4 MCHC-33.1 RDW-12.2 Plt Ct-436 [2127-12-20] 08:05AM BLOOD Glucose-137* UreaN-19 Creat-0.8 Na-134 K-4.6 Cl-93* HCO3-30 AnGap-16 [2127-12-24] 04:55AM BLOOD Glucose-98 UreaN-8 Creat-0.4 Na-139 K-4.3 Cl-97 HCO3-38* AnGap-8 [2127-12-20] 08:05AM BLOOD ALT-525* AST-1034* AlkPhos-571* Amylase-47 TotBili-2.0* [2127-12-22] 02:36AM BLOOD ALT-259* AST-174* AlkPhos-419* Amylase-144* TotBili-0.5 [2127-12-24] 04:55AM BLOOD ALT-120* AST-63* CK(CPK)-16* AlkPhos-408* Amylase-37 TotBili-0.4 [2127-12-21] 03:05AM BLOOD Lipase-1224* [2127-12-22] 02:36AM BLOOD Lipase-42 [2127-12-24] 04:55AM BLOOD CK-MB-NotDone cTropnT-0.04* [2127-12-24] 10:50AM BLOOD cTropnT-0.04* [2127-12-24] 04:55AM BLOOD Albumin-2.7* Calcium-8.1* Phos-2.4* Mg-2.0 [2127-12-21] 03:05AM BLOOD CEA-4.0 . ERCP BILIARY&PANCREAS BY GI UNIT [2127-12-20] 2:24 PM FINDINGS: Twelve fluoroscopic spot images were obtained during ERCP procedure by gastroenterology without a radiologist present. Scout image demonstrate degenerative changes involving the thoracolumbar spine. A cholangiogram shows dilated CBD with atleast two filling defects consistent with stones. A plastic biliary stent was placed across the stones. Numerous filling defects are seen within the gallbladder consistent with stones. Cystic duct is normal. . LIVER OR GALLBLADDER US (SINGLE ORGAN) [2127-12-20] 8:58 AM IMPRESSION: Cholelithiasis without definite evidence of other concerning findings particularly the ones seen at the outside institution per report. . CHEST (PORTABLE AP) [2127-12-21] 7:13 AM IMPRESSION: Bilateral pleural effusions and pulmonary edema. Findings are typical for congestive heart failure. Pneumonia is not excluded. . CHEST (PORTABLE AP) [2127-12-23] 4:30 AM IMPRESSION: As compared to [2127-12-22], no relevant changes. Cardiomegaly and signs of predominantly interstitial lung edema of moderate severity, bilateral pleural effusions. . Cardiology Report ECG Study Date of [2127-12-24] 4:33:24 AM Atrial fibrillation with rapid ventricular response Late R wave progression - probable normal variant Lateral T wave changes are nonspecific Since previous tracing of [2127-12-22], atrial fibrillation new Clinical correlation is suggested Read by: [Last Name (LF) ],[First Name3 (LF) 900] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 139 0 80 288/426 0 60 38 Brief Hospital Course: This is a 81 year old female with Abd pain, biliary dilation, 8 mm stone in CBD, fever, elevated WBC and hypotension. She was transferred here for further treatment for cholangitis/ choledocholithiasis. She was on ASA and Plavix. In the ED she was hypotensive and tachycardic. She went to the ICU for aggressive IVF resuscitation for hypovolemia. She received Lopressor for her tachycardia. Tachycardia: She continued to have intermittent A-fib/tachycardia once on the floor. She was triggered for A-fib on [2127-12-24]. All of her home meds were restarted and she received additional Lopressor as needed. Her cardiologist in NH was contact[Name (NI) ] and she will follow-up with him next week. Our cardiologist were consulted and they recommended a ECHO which will be done in NH. COPD: She continued on her inhalers and pursed lip breathing. Her O2 by nasal cannula continued as she is home dependent. CHF: CXR revealed bilateral pleural effusions and pulmonary edema. Findings are typical for congestive heart failure. She received Lasix with good effect and diuresis for fluid overload. Rectal exam: On rectal exam, a rectal/cervical mass was noted. After further investigation, she was found to have a pessary, and not a rectal mass. It was recommended that she follow-up with her PCP for [Name Initial (PRE) ] colonoscopy. Choledocholithiasis: She went for ERCP on [2127-12-20] and a cholangiogram shows dilated CBD with at least two filling defects consistent with stones. A plastic biliary stent was placed across the stones. Numerous filling defects are seen within the gallbladder consistent with stones. Cystic duct is normal. Her LFT's, Tbili recovered and trended down to normal levels. Her diet was slowly advanced as she was able to tolerate a regular diet by time of discharge. Her abdominal pain resolved and abdomen was soft and nondistended. She will need ERCP and stent removal in the future. ABX: Levofloxacin started [12-20] (received 1 dose Zosyn at [Location (un) 8641]), received 4d of Flagyl. She will complete 10 day course of antibiotics. Imaging: [12-20] CXR: emphysema, poss sm L pleural effusion/atelect, L 2.5cm perihilar nodule, RUQ U/S: Cholelithiasis, no evid intra/extra biliary duct dilation, no filling defect MICRO: [12-20] [Location (un) 8641] BCx: GNR=Aeromonas hydrophilia group; R to Amp/Unasyn [12-20] BCx Neg [12-20] Ucx: Neg [12-20] CXR: persistent B lung edema, mod pleural effusion, cardiomegaly Medications on Admission: plavix 75', Nifedical XL 60', [Last Name (un) ] 24 200', Nitro 0.3sl, Lopressor 25', Atacand 4', Lipitor 20', Protonix 40', Spiriva, Advair 250/50'', ProAir, Fosamax Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 5 days. Disp:10 Tablet(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Atacand 4 mg Tablet Sig: One (1) Tablet PO once a day. 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Nifedical XL 60 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 10. [Last Name (un) ]-24 200 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO twice a day. 11. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Vitamin C 500 mg Tablet Sig: Two (2) Tablet PO once a day. 14. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)). Disp:30 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 8300] VNA & Hospice Discharge Diagnosis: Cholangitis / choledocholithiasis Atrial fibrillation Emphysema, Left pleural effusion/atelectasis Hypotension Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. Followup Instructions: Please follow-up with your PCP [Last Name (NamePattern4) ] 1 week. Call to schedule an appointment. Please follow-up with Dr. [Last Name (STitle) 519] in 2 weeks. Call [Telephone/Fax (1) 6554] to schedule an appointment. [Doctor Last Name ] on [2128-1-16] at 9:00. Report to [Hospital Ward Name 1950] [Location (un) 453] for ERCP and stent removal. Please call [Telephone/Fax (1) 21304] with question or concerns. You will need to stop your Aspirin and Plavix for 1 week prior to your ERCP and stent removal. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2127-12-30] ICD9 Codes: 5119, 4280, 496, 412, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6839 }	Medical Text: Admission Date: [2115-9-13] Discharge Date: [2115-9-17] Service: UROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 6736] Chief Complaint: right abdominal pain and fever of 102.8 Major Surgical or Invasive Procedure: Percutaneous nephrostomy tube placement History of Present Illness: The patient is a 88 year old female who was transferred from an outside hospital on [2115-9-12] with a cheif complaint of right abdominal pain for one day and a fever of 102.8. The patient was transferred here because a CT scan demonstrated massive right hydronephrosis, 11.5 by 10.8 centimeters at largest diameter, consuming most of the right side of her abdomen. There was cortical thinning, however there was some cortex still present. The CT scan was reviewed with the radiologist on staff and this was determined to be an acute on chronic problem. The right kidney was still making urine, as evidenced by the CT scan. A urinalysis was positive for leukocyte esterase and white blood cells. There was no obvious cause of obstruction (no stones, no strictures). The patient denied any dysuria, hematuria or change in urination. She is incontinent at baseline. She has no significant urologic history and has never seen a urologist. At rest, her pain was mild. Past Medical History: Dementia, pacemaker, CHF, asthma, hypothyroid, gout, s/p TAH for uterine cancer (s/p brachytherapy and radiation therapy) Social History: none Family History: none Physical Exam: General: no apparent distress, thin old woman HEENT: pupils equal, round and reactive to light, exreaoccular muscles in tact Neck: supple Lungs: bibasilar crackles Cardiac: regular rate and rhythum, normal S1S2, no murmurs Gastrointestinal: bowel sounds +, soft, nondistended, + diffuse tenderness, worse on the right Extremities: no clubbing, cyanosis or edema, full range of motion Neurologic: demented, AxOx1 Pertinent Results: [2115-9-12] 08:14PM BLOOD WBC-13.3* RBC-3.74* Hgb-10.6* Hct-33.6* MCV-90 MCH-28.4 MCHC-31.6 RDW-14.6 Plt Ct-225 [2115-9-13] 05:55AM BLOOD WBC-15.2* RBC-3.55* Hgb-10.0* Hct-31.6* MCV-89 MCH-28.2 MCHC-31.7 RDW-14.5 Plt Ct-190 [2115-9-13] 08:30PM BLOOD WBC-16.5* RBC-3.26* Hgb-9.3* Hct-29.8* MCV-91 MCH-28.4 MCHC-31.1 RDW-14.4 Plt Ct-172 [2115-9-14] 03:41AM BLOOD WBC-11.6* RBC-2.51* Hgb-6.9# Hct-22.3# MCV-89 MCH-27.4 MCHC-30.8* RDW-14.6 Plt Ct-143* [2115-9-12] 08:14PM BLOOD Neuts-92* Bands-3 Lymphs-2* Monos-1* Eos-0 Baso-1 Atyps-0 Metas-1* Myelos-0 [2115-9-13] 08:30PM BLOOD Neuts-96.4* Bands-0 Lymphs-1.3* Monos-1.6* Eos-0.1 Baso-0.6 [2115-9-12] 08:14PM BLOOD PT-14.7* PTT-33.1 INR(PT)-1.5 [2115-9-14] 03:41AM BLOOD PT-13.6* PTT-36.7* INR(PT)-1.2 [2115-9-12] 08:14PM BLOOD Glucose-160* UreaN-38* Creat-2.0* Na-137 K-3.8 Cl-95* HCO3-28 AnGap-18 [2115-9-13] 05:55AM BLOOD Glucose-161* UreaN-41* Creat-1.9* Na-138 K-3.6 Cl-93* HCO3-34* AnGap-15 [2115-9-14] 03:41AM BLOOD Glucose-127* UreaN-35* Creat-1.6* Na-139 K-3.4 Cl-104 HCO3-27 AnGap-11 [2115-9-12] 08:14PM BLOOD Calcium-9.0 Phos-4.6* Mg-2.1 [2115-9-14] 03:41AM BLOOD Calcium-7.2* Phos-3.2 Mg-1.7 [2115-9-13] 09:52PM BLOOD Type-ART Temp-37.2 pO2-137* pCO2-54* pH-7.34* calHCO3-30 Base XS-2 Intubat-NOT INTUBA Brief Hospital Course: The patient was admitted to [Hospital1 18] on [2115-9-13] for abdominal pain and severe right hydronephrosis on a CT scan. She was started on Ciprofloxacin and kept NPO for percutaneous nephrostomy tube placement later that day by interventional radiology. The procedure went well with no problems. [Name (NI) ] that night, the patient became tachycardic and hypotensive and had to be transferred to the intensive care unit. Of not, blood cultures from an outside hospital were positive for E. coli. She was adequately resuscitated with approximately three liters of intravenous fluid. She responded well in the ICU and she was afebrile overnight. She was started on Aztreonam and cipro. Ultimately her urine grew pan sensitive ecoli; so the aztreonam was stopped and cipro continued. On hospital day two, she was transferred out of the ICU to the floor. She recieved 2 units of red blood cells for a hematocrit of 22.9 (from 29.8). She was started on a regular diet. She had brief episodes of paroxysmal atrial fibrillation which she was treated with lopressor IV and PO; her pacemaker corrected her rapid rate on several occasions. 1 set of cardiac enzymes were neg. and serial ecgs showed no evidence of ischemia. Her electrolytes were aggressively replaced. Medications on Admission: allopurinol 100', levoxyl 0.075', lasix 40', K-dur 10'', ASA, magnesium, albuterol neb, iron, timolol drops, xalatan, trisapt drops Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 2. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 4. Fluticasone-Salmeterol 100-50 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 5. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). Disp:qs Cap(s) Refills:2 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:qs Refills:0 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). Disp:qs Refills:2 9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:qs Refills:2 10. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). Disp:qs Refills:2 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:qs Tablet(s) Refills:0 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:10 Tablet(s) Refills:0 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital 11851] Healthcare - [Location (un) 620] Discharge Diagnosis: Urosepsis Discharge Condition: stable Discharge Instructions: Nephrostomy instructions: please flush with 5 cc sterile water once a day; change drain sponge as needed. Measure nephrotomy output. Followup Instructions: [2115-9-25] for antegrade nephrostogram and stent placement call [Numeric Identifier 107969] to finalize scheduling follow up with Dr. [Last Name (STitle) ] [Last Name (STitle) ] the same day after nephrostogram or shortly after; call [Location (un) ] at [Numeric Identifier 107970] for appointment ICD9 Codes: 4280, 7907, 4589, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6840 }	Medical Text: Admission Date: [2101-6-21] Discharge Date: [2101-7-22] Date of Birth: [2101-6-21] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: [Known lastname ] [Known lastname ], last name after discharge, [Last Name (un) 67680], is the former 1.805 kg product of a 33- [1-15] week gestation pregnancy born to a 19-year-old, G1, P0, now 1 Hispanic female. PRENATAL SCREENS: Blood type O+, antibody negative, RPR nonreactive, rubella nonimmune, hepatitis B surface antigen negative, group beta strep status unknown. The pregnancy was uncomplicated until the mother presented with premature labor. On the day of delivery, she received 1 dose of betamethasone and was treated with magnesium sulfate. The labor progressed despite tocolysis, terminating in a spontaneous vaginal delivery. There was a nuchal cord noted and cut before delivery of the infant's body. The infant was vigorous at delivery, required blow-by oxygen, Apgars were 8 at 1 minute and 8 at 5 minutes. He was admitted to the neonatal intensive care unit for treatment of prematurity. PHYSICAL EXAM UPON ADMISSION TO NEONATAL INTENSIVE CARE UNIT: Weight 1.805 kg, length 43-cm, head circumference 31.5-cm-- all appropriate for gestational age. GENERAL: Nondysmorphic preterm male infant, pink and comfortable in room air with an oxygen saturation of 100%. HEAD, EARS, EYES, NOSE AND THROAT: Anterior fontanel soft and flat. Nondysmorphic facies. Intact palate. Normal red reflex both eyes. CHEST: Clear breath sounds, minimal work of breathing. CARDIOVASCULAR: Regular rate and rhythm, no murmur, pulses +2. Abdomen soft, nontender, nondistended, no hepatosplenomegaly. GU: Normal male. Testes descended into scrotum. MUSCULOSKELETAL: No hip clicks. SKIN: Mongolian spot over back. No sacral dimple. NEURO: Active, moving all extremities, normal tone and reflexes. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. RESPIRATORY: [Known lastname ] has been in room air for his entire neonatal intensive care unit admission. He had significant apnea of prematurity that was treated with caffeine citrate through day of life #14. He continued to have intermittent spells. At the time of discharge, he has not had any episodes of spontaneous apnea or bradycardia for the 5 days prior to discharge. His baseline respiratory rate is 30-50 breaths per minute. 1. CARDIOVASCULAR: A murmur was noted on day of life #3 and persisted. An electrocardiogram was within normal limits. Four-limb blood pressures were also within normal limits, as was the chest x-ray. A cardiology consult was obtained from [Hospital3 1810], and an echocardiogram was performed on [2101-7-14] showing a trivial right pulmonary artery stenosis with no gradient. He was evaluated by the cardiology service from [Hospital1 62374] and is recommended to have cardiology follow-up 4 months of age with Dr. [Last Name (STitle) ], or through the [Hospital1 62374] satellite clinic in [Location (un) ], [State 350]. 1. FLUIDS, ELECTROLYTES AND NUTRITION: [Known lastname ] was initially n.p.o. and started on intravenous fluids. Feedings were introduced late on the first day of life and gradually advanced to full volume. At the time of discharge, he is breast feeding or taking in breast milk or Similac formula. Weight on the day of discharge is 2.67 kg which is 5 pounds 14 ounces, with a corresponding head circumference of 33-cm and a length of 45.5-cm. 1. INFECTIOUS DISEASE: Due to the unknown etiology of the preterm labor, [Known lastname ] was evaluated for sepsis. At the time of admission to the neonatal intensive care unit, a complete blood count was within normal limits. A blood culture was obtained prior to starting intravenous ampicillin and gentamicin. Blood culture was no growth at 48 hours, and the antibiotics were discontinued. 1. HEMATOLOGICAL: Hematocrit at birth was 43.9%. [Known lastname ] did not receive any transfusions of blood products. Most recent hematocrit was on [2101-7-21] at 27.3% with a reticulocyte count of 1.9%. He is being discharged home on supplemental iron. 1. GASTROINTESTINAL: Peak serum bilirubin occurred on day of life 4, a total of 8.1 mg/dl/0.3 mg/dl. He did not require treatment with phototherapy. 1. NEUROLOGICAL: [Known lastname ] has maintained a normal neurological exam during admission, and there are no neurological concerns at the time of discharge. 1. SENSORY/AUDIOLOGY: Hearing screening was performed with automated auditory brain stem responses. [Known lastname ] passed in both ears. 1. PSYCHOSOCIAL: Parent's primary language is Spanish. They speak very little English. They have been very involved in [Known lastname 67681] care during his neonatal intensive care unit admission. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5263], [Hospital3 33953] Community Health Center, [Street Address(2) ], [Last Name (un) 813], [Numeric Identifier 4544], phone number [Telephone/Fax (1) 17826] FAX ([Telephone/Fax (1) 67682]. CARE AND RECOMMENDATIONS AT DISCHARGE: 1. Ad lib breastfeeding or feeding expressed mother's milk. 2. Medications: Ferrous sulfate 0.3 mL p.o. once daily 25/ml dilution, Goldline baby vitamins 1 mL p.o. once daily. 3. Car seat position screening was performed. [Known lastname ] was observed in his car seat for 90 minutes without any episodes of bradycardia or oxygen desaturation. 4. State newborn screens were sent on [6-24] and [2101-7-5]. No notification of abnormal results has been received to date. 5. Immunizations administered: Hepatitis B vaccine was administered on [2101-7-8]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: 1) Born at less than 32 weeks; 2) Born between 32 and 35 weeks with 2 of the following: daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-aged siblings; or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. 7. Follow-up appointments: 1) Appointment with Dr. [Last Name (STitle) 5263] within 5 days of discharge; 2) Pediatric cardiology at 4 months of age. DISCHARGE DIAGNOSES: 1. Prematurity at 33-1/7 week gestation. 2. Suspicion for sepsis ruled out. 3. Apnea of prematurity. 4. Trivial right pulmonary artery stenosis. 5. Status post circumcision [2101-7-16]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2101-7-21] 22:48:35 T: [2101-7-21] 23:41:23 Job#: [Job Number 67683] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6841 }	Medical Text: Admission Date: [2104-10-27] Discharge Date: [2104-11-3] Service: MEDICINE Allergies: Sulfonamides / Penicillins Attending:[First Name3 (LF) 2704] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 83 yo female with a history of HTN, hyperlipidemia, diastolic CHF, ESRD on HD, h/o CVA, and Alzheimers dementia presents from dialysis with a wide complex tachycardia. Patient denies any chest pain, shortness of breath, or other complaints. On the day of admission, she presented for her routine dialysis appointment. During the visit she was noted to look unwell and not herself. On arrival of EMS, BP 77/50, HR 121, RR 16, O2 95%. Patient was brought to [Hospital1 18] ED for eval. . On arrival, HR 135, BP 90/60, RR 16 O2 90%. On exam, irregular rhythym, no JVD, guaiac negative. ECG revealed a wide complex tachycardia at rate of 140bpm. Patient was given Amio and Calcium gluconate. Then spontaneously converted to NSR at [Street Address(2) 14412] elevations inferiorly in II, III, aVF (III > II) also with reciprocal depression in I, aVL, V6, V5. Labs with CK 379, MB 43, MBI 11.3, TnT 13.4. The patient was given Aspirin, heparin, intergrillin (couldn't swallow plavix) and taken to the cath lab. . Left Heart Cardiac Catheterization demonstrated; 1. CTO of RCA 2. LMCA: Distal taper with moderate calcification 3. LAD: Proximal 50% w/ heavy calcification, D1 80% lesion. 4. LCx: Non-dominant w/ distal flow from l-r collaterals 5. Unable to cross CTO of RCA though unlikely acute. . Patient was then transferred to the CCU for management. . On review of symptoms, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CRI secondary to HTN. 2. HTN 3. CVA of posterolateral medulla in [2095]. Pt previously on coumadin, but recently held by PCP due to concern about falls. 4. Hypercholesterolemia 5. Polio at age 18 with residual left lower extremity weakness 6. Aortic insufficiency 7. TR/MR [First Name (Titles) ] [Last Name (Titles) ] 12'[95] 8. s/p bilateral cataracts surgery 9. s/p TAH secondary to uterine fibroids 10. CHF - Diastolic Dysfunction 11. cognitive impairment Social History: The patient lives alone in the [Location (un) ] of [Location (un) 86]. She is completely independent in her ADL and IADLS - she cooks, cleans, washes, dresses, herself. She is a retired nursing assistant. She has no children and family is not involved, however pt has friends who are involved in her life and care.Pt quit drinking alcohol 50 years ago. Pt admits to smoking 0.3 pack/day for 3 years but also quit 50 years ago. Pt denies ever using illicit drugs use. Family History: Noncontributory Physical Exam: VS: T 94.1, BP 148/89 , HR 73, RR 25 , O2 100 % on 4L NC Gen: Elderly woman in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 1+ without bruit; 1+ palpable DP on R, dopplerable PT. Left: Carotid 2+ without bruit; Femoral 1+ without bruit; Dopplerable on Right but extremely faint. Neuro: AOx3, "[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]" is president, US "not" at war and "Red Sox" won world series. Pertinent Results: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed 2 vessel coronary artery disease. The LMCA tapered distally and was noted to have moderate calcification. The LAD had a proximal 50% stenosis with heavy calcification. The D1 had an 80% stenosis at the origin. The LCx was a non-dominant vessel without critical lesions. The RCA had a total occlusion with distal flow from left-to-right collaterals. 2. Resting hemodynamics revealed moderate-severe systemic arterial systolic hypertension with an SBP of 172 mmHg. 3. Supravalvular aortography revealed no evidence of AI and a normal ascending aortic diameter. The aortogram confirmed the total occlusion of the RCA. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Moderate to severe systemic arterial systolic hypertension. 3. Acute inferior myocardial infarction, managed by medical therapy with failed PTCA of complete total occlusion of RCA. Cardiac Echo: The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. There is mild regional left ventricular systolic dysfunction with inferior hypokinesis. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral annular calcification. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. [2104-10-27] 12:25PM WBC-14.5# RBC-3.21 HGB-9.8* HCT-31.2* MCV-97 MCH-30.6 MCHC-31.5 RDW-16.8* [2104-10-27] 12:25PM CALCIUM-9.5 PHOSPHATE-6.4# MAGNESIUM-2.3 [2104-10-27] 12:25PM CK-MB-43 MB INDX-11.3* cTropnT-13.4* [2104-10-27] 12:25PM CK(CPK)-379* [2104-10-27] 12:32PM GLUCOSE-116* NA+-138 K+-5.7* CL--95* TCO2-23 Abdominal USD: IMPRESSION: 1. No gallstones or intra- or extra-hepatic biliary ductal dilatation. 2. Focal mild dilation of infrarenal aorta with nonocclusive mural thrombus, not meeting size criteria for aneurysm. 3. Small kidneys consistent with end-stage renal disease. 4. Possible small cyst at the head of the pancreas; reevaluation for stability is recommended in one year's time. Brief Hospital Course: Brief Hospital Course: . #CAD: Patient was admitted to the CCU post-cath for management. Was continued on ASA 325mg, Plavix 75mg daily (with anticipated duration of one month). Metoprolol was started and titrated to a dose of 37.5mg [Hospital1 ]. Patient was started on captopril at low dose (to be held pre-dialysis). Additionally, lipitor 80mg qd was initiated. Patient was transfered to the floor post-cath day 1 without event. Echo demonstrated LV diastolic dysfunction with preserved EF, RV dilated with depressed systolic function. Echo demonstrated mild aortic stenosis. Recommend outpatient evaluation. . #V.Tach: Patient was monitored on telemetry in the CCU and later on the floor. During that time she had no significant runs of NSVT and no recurrence of her VTach. It was felt that her initial presenting VT was likely due to the metabolic derrangements (hyperkalemia) on presentation and decision was made not to pursue an EP study at this time. . #ESRD: Patient was dialyzed on presentation. Was mildly hypotensive post-dialysis and BP meds were held. Patient was then returned to her usual M/W/F dialysis regimen. No further events. . #Dementia/Social Work: Impression on admission was for mild baseline dementia. Attempts to discuss patient's care revealed that she did not clearly have capacity. After discussion with the patient, social work, and administration it was decided that patient's friend [Name (NI) ] [Name (NI) 3401] ([Telephone/Fax (1) 14413] would serve as healthcare proxy in the future. Social work arranged designation prior to discharge. . #Abd pain: patient complained of intermittent abdominal during her hospitalization. Abdominal exam was non-revealing with intermittent RUQ tenderness. LFT's were normal for post-MI setting and patient was followed clinically. RUQ USD demonstrated no significant biliary pathology. A small cyst in the head of the pancreas was noted which was recommended to be reevaluated in 1-year's time. . #PT/OT: Rec'd--> discharge to rehab. . #Nutrition: Poor PO intake during her hospital stay thought to be contributing to hypotension post-dialysis. Nutrition recommending renal diet, with encouraging PO intake when possible. . #Follow-Up Plan: As per discharge plans. . Remainder of her hospitalization was uneventful. Medications on Admission: Pantoprazole 40 mg daily Toprol XL 25 mg daily Atorvastatin 5 mg daily Aspirin 325 mg daily Donepezil 5 mg qhs BComplex-Vitamin C-Folic Acid 1mg PO daily nephrocaps Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Epoetin Alfa Injection 5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] Inc. Discharge Diagnosis: New diagnoses: STEMI - inferior Mild Aortic Stenosis (diagnosed by echo on recent admit) . End Stage Renal Disease, Dementia, Hypertension Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for evaluation for low blood pressure. On arrival, it was found that you had an abnormal heart rhythm and a previous heart attack. You were taken to the cardiac catheterization lab or an evaulation of the blood vessels that supply your heart. It was found that you have coronary artery disease. You were then admitted to the ICU for observation and management. . Please continue to take all medications as directed upon leaving the hospital. The following medications have been added to your medical regimen: 1. Plavix 75mg daily - please continue to take for at least one month. 2. Lisinopril 2.5mg daily - please do not take on mornings of dialysis. 3. Atorvastatin 40mg daily 4. Toprol 37.5mg [Hospital1 ] . Please call your doctor or return to the emergency department should you experience any sudden chest pain or shortness of breath. Followup Instructions: Dr. [First Name8 (NamePattern2) 401] [Last Name (NamePattern1) ], [Telephone/Fax (1) 250], please call for an appointment in the next one month. [First Name8 (NamePattern2) 1409] [Last Name (NamePattern1) ], [MD Number(3) 1240]:[Telephone/Fax (1) 250] Date/Time:[2104-11-19] 10:30 Dr. [Last Name (STitle) ], Cardiology, [Hospital Ward Name 23] Building of [Hospital3 ] [Hospital Ward Name 5074], [Location (un) 436], ([Telephone/Fax (1) 11176], Tuesday [11-11] at 1:40pm. . Repeat evaluation of pancreatic cyst in one-year's time for interval change. ICD9 Codes: 5856, 4271, 4280, 2767, 4241, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6842 }	Medical Text: Admission Date: [2190-6-16] Discharge Date: [2190-6-18] Date of Birth: [2119-8-11] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Aspirin / Augmentin Attending:[First Name3 (LF) 689] Chief Complaint: Cough Major Surgical or Invasive Procedure: None History of Present Illness: [Known lastname 93777] is a 70 year old female with a history of DM 2, HTN, breast CA, hypothyroid with a productive cough found to have a left lower lobe pneumonia. The patient reports 2 days of productive cough with associated headache, myalgias, and dizziness. She has severe left shoulder pain for two days to the point where she felt like she might be having an MI. The pain radiated to her ears. Felt fine on Monday did water aerobics on in the afternoon and then had a deep tissue massage. She was very fatigued and had body aches worse in the shoulder region. She finally came to the ED as she was not getting better. . Of note patient seen in clinic two to three weeks ago for a persistent cold. She was given 10 days of azithromycin. . In the [Hospital1 18] ED, VS 99.6 127 134/70 16 98%RA. The patient had a CXR notable for a left base conslidation. She received levofloxacin 750 mg, had 1 set of blood cultures drawn, and was admitted to Medicine for further management. On transfer her vitals were: HR 106, 22, 98% RA . Currently, the patient is having some mild body ahces and just generally feels unwell. Past Medical History: Past Medical History: - Breast CA - diagnosed [2169] s/p left mastectomy - Thyroid CA - diagnosed [2185] s/p thyroidectomy and I-125. - DM 2 - Hypothyroid - Migraines - Hyperlipidemia - HTN - Chronic Pain - 60%-69% stenosis of the internal carotid Social History: Social History: No tob (quit 40yrs ago) No EtOH Family History: Non-Contributory Physical Exam: Physical Exam: VS: 98, 156/74, 107, 22, 97% RA Gen: Uncomfortable, NAD HEENT: MMM, OP clear CV: s1+, s2+, RRR, No M/R/G Pulm: Rhales on left side Abd: Soft, NT, ND, +BS Ext: No edema Neuro:CN II-XII intact Pertinent Results: [2190-6-16] 06:30PM BLOOD WBC-12.8# RBC-4.34 Hgb-10.0 Hct-32.1* MCV-74* MCH-23.1* MCHC-31.2 RDW-14.9 Plt Ct-218 [2190-6-17] 06:20AM BLOOD WBC-7.6 RBC-3.90* Hgb-8.6* Hct-29.4* MCV-75* MCH-22.0* MCHC-29.3* RDW-14.9 Plt Ct-182 [2190-6-18] 06:10AM BLOOD WBC-6.1 RBC-3.55* Hgb-7.9* Hct-26.9* MCV-76* MCH-22.4* MCHC-29.5* RDW-15.0 Plt Ct-200 [2190-6-18] 12:30PM BLOOD Hct-27.5* [2190-6-16] 06:30PM BLOOD Neuts-90.0* Lymphs-6.2* Monos-3.6 Eos-0.1 Baso-0.1 [2190-6-18] 06:10AM BLOOD Neuts-80.6* Lymphs-12.4* Monos-5.2 Eos-1.5 Baso-0.3 [2190-6-16] 06:30PM BLOOD Glucose-148* UreaN-12 Creat-0.6 Na-137 K-3.8 Cl-100 HCO3-25 AnGap-16 [2190-6-17] 06:20AM BLOOD Glucose-83 UreaN-11 Creat-0.5 Na-144 K-4.0 Cl-114* HCO3-21* AnGap-13 [2190-6-17] 06:20AM BLOOD ALT-17 AST-15 AlkPhos-65 TotBili-0.4 [2190-6-16] 09:13PM BLOOD Lactate-1.9 CXR: Left-sided pneumonia Brief Hospital Course: Assessment and Plan: [Known lastname 93777] is a 70 year old female with a history of DM 2, HTN, breast CA, hypothyroid with a productive cough found to have a left lower lobe pneumonia with recent therapy for URI. . # CAP: Patient with evidence of LLL pneumonia. Patient with antibiotic course (azithromycin) 2 weeks ago. No further risk factors for HAP. However, given recent azithromycin therapy broadened antibiotic coverage given potential for resistence. On HD# 3, blood cultures were negative x 24 hours, patient remained afebrile with improvement in symptoms and leukocytosis resolved. Given this, the decision was made to narrow her antibiotics to Levofloxacin. Of, note Legionella negative. . # Anemia: Slow decline in Hematocrit. No obvious source. Pt denies any source of bleeding. HD stable and guaiac negative. Hct stable at time of discharge. Iron studies sent for further evaluation of anemia and can be followed up as an outpatient. - Would consider repeating Colonoscopy as outpatient. . # DM 2: FS and ISS while inpatient. Restarted home meds upon discharge. . # HTN: Continue Diltiazem and simvastatin. . # Carotid Stenosis: Patient with known 60-70% carotid stenosis. On plavix and statin. Will continue. . # Hypothyroid: Cont thyroid replacement . # Anxiety: Continue Valium . # Chronic pain: Continue Gabapentin, Paroxetine, Percocet. . # FEN: Encouraged PO hydration, IV hydration PRN, replete electrolytes PRN, regular diet. . PPx: Heparin SQ, bowel regimen, On Omeprazole at home and continued Medications on Admission: Plavix 75 mg daily Valium 5 mg daily Diltiazem XT 240 mg daily Gabapentin 300 mg po bid Glipizide ER 2.5mg daily Hydrocodone-homatropine 5mg-1.5mg/5mL syrup - 1 tsp Q4H Ibandronate 150 mg QMonthly Levothyroxine 112 mcg daily Metformin 500 mg QAM and 1500mg QPM Paroxetine 30mg daily Maxalt 10 mg prn Simvastatin 40 mg qhs Vitamin D OM3FA Omeprazole 40 mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety. 3. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:4 Tablet(s) Refills:0 12. Metformin 500 mg Tablet Sig: One (1) Tablet PO QAM. 13. Metformin 500 mg Tablet Sig: Three (3) Tablet PO QPM. 14. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 15. Outpatient Lab Work Recheck CBC on [2190-6-22] Discharge Disposition: Home Discharge Diagnosis: Pneumonia Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You presented to the hospital with a cough and muscle aches. You were found to have a pneumonia. You were started on an antibiotic. You should complete the entire course of the medication. Also, you were found to have anemia, but no evidence of bleeding. We sent some blood work that Dr. [Last Name (STitle) ] will follow-up on. We will have you repeat blood work prior to your appointment with Dr. [Last Name (STitle) ]. You should call your doctor if you feel lightheaded, dizziness, chest pain, shortness of breath, wheezing, abdominal pain, vaginal bleeding or rectal bleeding. Followup Instructions: Appointment: Primary Care When: THURSDAY, [2190-6-24], 2:15PM With: [Last Name (LF) ], [First Name7 (NamePattern1) 2048] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 ] HEALTHCARE - [Hospital ] MEDICAL GROUP Address: [Street Address(2) 2687],8TH FL, [Location (un) ],[Numeric Identifier 822] Phone: [Telephone/Fax (1) 133] Completed by:[2190-6-18] ICD9 Codes: 2762, 4019, 2859, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6843 }	Medical Text: Admission Date: [2166-6-3] Discharge Date: [2166-6-11] Date of Birth: [2105-6-4] Sex: F Service: MEDICINE Allergies: Haldol / Darvon / Keppra Attending:[First Name3 (LF) 53626] Chief Complaint: rectal bleeding Major Surgical or Invasive Procedure: EUA, rigid sigmoidoscopy, ligation of bleeding hemorrhoids History of Present Illness: 60F w/ history of MGUS, COPD, HCV cirrhosis, iron deficiency anemia and previous admissions for GI bleed now being admitted to [Hospital Unit Name 153] for presumed lower gi bleed. Somewhat of vague historian but pt reports 4-5 episodes of bright red per rectum x 2 days. Denies melena. Also reports persistent nausea and non-bilious, non-bloody emesis. Reports metallic taste. Subjective fevers and chills. Has history of hemorrhoids and constipation that has been treated successfully with magnesium oxide. Not clear that she has experienced more constipation over the last several days preceding her bleeding from rectum. She has experienced some rectal pain which she attributes to hemorrhoids - this has now resolved. Good appetite but decreased po's for unclear reasons. Denies chest pain but reports dyspnea on exertion over the last several days. No cough. Reports light headed when standing. Of note, pt was hospitalized on 2 occasions in [2166-2-12] for bright red blood per rectum. Work-up included EGD which demonstrated duodenal angioectasias, Schatski's ring and duodenitis and portal gastropathy. A colonoscopy had been performed which was significant for large internal hemorrhoids without stigmata of recent bleedng. She did have a colonoscopy in [1-16] which demonstrated sigmoid diverticulosis. She required red cell transfusions on both admissions. It was felt that her bleeding was most likely related to hemorrhoidal bleeding and she had been advised to follow up with surgery. In ed, noted to be afebrile and hemodymically stable. She was found to be orthostatic however and crit was 23 and then 19 on recheck. She was guiac positive on rectal exam. NG lavage was negative. She received 1 unit prbc, Protonix 40, and benadryl Past Medical History: 1) iron deficiency anemia 2) GI bleed - presumed secondary to hemorrhoids 3) Sigmoid diverticulosis 4) Schatzki's ring 5) Duoenal polyps and duodenitis 6) MGUS 7) ?etoh/ HCV cirrhosis followed by Dr. [Last Name (STitle) 497] (vl 9k in [5-15]) 8) psychotic disorder 9) remote polysubstance abuse - etoh, cocaine, marijuana 10) COPD 11) compex partial seizures Social History: Lives alone in [Location (un) ], has home physical therapy and a homemaker. She reports that she has quit tobacco ~ 1 month ago. She denies recent EtOH, howevert reported to have heavy drinking 6 months ago. She denies recent marijuana, cocaine use. Contacts: daughter ([Doctor First Name ] [Telephone/Fax (1) 99373])' son (mark [Doctor Last Name ]) [Telephone/Fax (1) 99374] Family History: M-asthma, GM-CAD, HTN, denies any h/o liver disease or bleeding disorders; great aunt with epilepsy; Physical Exam: Physical exam on admission (to [Hospital Unit Name 153]) PE: 118/70 89 16 100ra gen: cachexic african american female, lying in bed, looking uncomfortable secondary to pruritus, o/w pleasant heent: dry mm, anicteric sclera, flat jvp cv: s1, s2 regular w/ soft 2/6 sem throughout pulm: ctab abd: nabs, soft, ntnd, no cvat, guiac positive per ed extr: decreased skin turgor, no edema Pertinent Results: Laboratory studies on admission: [2166-6-3] 03:04PM WBC-11.5 RBC-2.73 HGB-7.5 HCT-23.4 MCV-86 RDW-22.8 PLT COUNT-325 NEUTS-87 BANDS-4 LYMPHS-2 MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 GLUCOSE-90 UREA N-6 CREAT-1.0 SODIUM-128* POTASSIUM-4.7 CHLORIDE-90 TOTAL CO2-22 URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2166-6-3] 08:10PM HGB-6.2 HCT-19.6 EKG [6-3]: NSR @ 85 bpm, nl axis, nl intervals, qI, avL, isolated O.[Street Address(2) 1755] elevation V2, TWF avL, V2, V3 TTE [6-5]: LVEF>55%, 1+ AR, 1+ MR, mild pulmonary artery systolic hypertension. Trivial/physiologic pericardial effusion. . CXR [2166-6-6] IMPRESSION: Mild congestive heart failure with new small right pleural effusion and bibasilar atelectasis. . CT [6-6] IMPRESSION: 1. No evidence of free intraperitoneal air, drainable fluid collections, or regions of inflammation in the abdomen or pelvis. 2. Small amount of ascites, small amount of free fluid in the pelvis, bilateral pleural effusions, and subcutaneous edema are consistent with aggressive volume resuscitation. 3. Consolidation at both lung bases, likely related to compressive atelectasis. 4. Diffusely low attenuation liver is consistent with fatty infiltration. . [6-10] CXR IMPRESSION: Decreasing right lung base atelectasis and smaller right pleural effusion Brief Hospital Course: In the [Hospital Unit Name 153], the patient received an additional 1unit FFP, and 2 units PRBC (last [6-4] at 2 p.m.) with HCT 22,8 -> 24.6. She had a 16 beat run of NSVT, asymptomatic. She was evaluated by gastroenterology, who noted 2 large lacerated external hemorrhoids oozing on rectal exam. Surgery was consulted, and she underwent an EUA, rigid sigmoidoscopy, and ligation of bleeding internal hemorrhoids on [2166-6-4]. Following the procedure, she was observed overnight in the [Hospital Unit Name 153]. This morning, she had a large BM (brown with scan amount of blood) in which the surgical packing was expelled. . Floor course: # Lower GI bleed: This was most likely related to hemorrhoids, for which the patient underwentligation [2166-6-4]. She does have multiple other possible sources of UGI bleeding (portal gastropathy, duodenitis, and duodenal ectasias), however, these are unlikely contributors to current presentation, given (-) NG lavage in ED. She was transfused 1 unit PRBC on [6-5] with good response in hematocrit to 30. She was continued on PPI [Hospital1 ] given portal gastropathy and continued on low dose propranolol (started in the ICU for portal hypertension). The patient was followed by the GI service throughout her hospital stay, who recommended high fiber diet, stool softners, and [Last Name (un) ] baths [2-14] times daily as needed. Her hematocrit will need to be monitored closely as an outpatient to ensure stability. . # Blood loss anemia: The patients hematocrit, which was 19 on admission, was due to GI bleeding superimposed on chronic iron deficiency (baseline HCT high 20s). She was continued on iron therapy and, as mentioned above, received a total of 3 units PRBC (last [2166-6-5]) with stabilization of hematocrit. . # LLQ/RLQ abdominal tenderness: Following transfer to the general medical floor, the patient developed deep LLQ and RLQ tenderness with voluntary guarding on [6-6]. Given concern for possible perforation (recent hemorrhoidal ligation), inflammatory process/abscess, or biliary obstruction (as Tbili was 2.1, elevated from baseline), a CT abd/pelvis was obtained [6-6] which showed.... Surgery was consulted, who felt that surgical complication/perforation was unlikely. She was initially kept NPO with IVF, but her diet was then advanced. At time of discharge, she is tolerating a regular, high fiber diet. . # Bacteremia - Course was complicated by E.coli bacteremia, treated initially with levofloxacin. However, the patient became delerious one evening and a code purple was called. All narcotics were stopped and levofloxacin was changed to ceftriaxone as the former can cause mental status changes in patients. She was discharged on cefpodoxime, with a total course of 14 days from positive blood cultures. . # Fever - On the day prior to discharge, the patient had a low grade fever. Workup included CXR and UA/Urine culture, all of which were negative. Fever resolved and the patient was discharged on a total of 14 days of antibiotics starting from day of positive blood cultures for E.coli bacteremia. . # Altered mental status - Occurred 2 nights prior to discharge, and acutely resolved with removal of sedating meds and changing levofloxacin to ceftriaxone. The patient required and sitter transiently but the was stopped one day prior to discharge. No infectious etiology of delerium other than bacteremia. . # Alcohol abuse: On admission, the patient denied ongoing alcohol abuse, she was initially maintained on prn ativan for CIWA >10, which was discontinued as patient displayed no symptoms consistent with alcohol withdrawal. She was continued on multivitamin, thiamine, and folate. # NSVT: As mentioned above, the patient had one 16 beat run of NSVT [6-4] while in the ICU a transthoracic echocardiogram [6-5] showed LVEF >55%, 1+ AR, 1+ MR, 1+ TR, mild PA sys HTN, trivial physiologic pericardial effusion. Given that her EF was not suppressed, she is not currently a candidate for ICD. An outpatient holter may be pursued at the discretion of her primary care physician. [Name10 (NameIs) ] function tests were obtained, which showed a high normal TSH and a mildly elevated free T4 at 1.8 (normal 0.9-1.7). These should be repeated in 6 weeks as an outpatient. # Hypoxia: On transfer to the floor, the patient was noted to be 96% 2L NC (had been 100% RA on admission to [Hospital Unit Name 153]). The patient has a reported history of COPD and reported an unchanged chronic non-productive cough. There was no evidence on clinical exam of fluid overload. A CXR PA was obtained [6-6] which showed mild CHF and new right pleural effusion with associated atelectasis. The patient was started on albuterol/atrovent nebs standing/prn. Her oxygen was titrated down and, at discharge, ambulatory sats were stable. # Partial complex seizure: The patient remained stable off anti-seizure medications. # Full Code Medications on Admission: protonix 40 qd senna colace hydrocortisone 2.5% [Hospital1 ] ferrous sulfate 325 qd camphor-menthol prn 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Albuterol 90 mcg/Actuation Aerosol Sig: [1-13] puff Inhalation four times a day as needed for shortness of breath or wheezing. Disp:1 MDI Refills:2 11. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. [Last Name (un) ] bath 2-3 times a day as needed 13. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 9 days. Disp:19 Tablet(s) Refills:0 14. Hydrocortisone 2.5 % Lotion Sig: QS Topical twice a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: Hemorrhoidal bleeding Secondary: Hepatitis C, blood loss anemia, diverticulosis, MGUS, cirrhosis, chronic obstructive pulmonary disease, complex partial seizures. Discharge Condition: Stable Discharge Instructions: Please follow-up as indicated below. Please take all medications as prescribed. You have been prescribed stool softeners to avoid irritation of your hemorrhoids with bowel movements. You have also been prescribed propranolol, which will decrease portal hypertension. You are encouraged to stop smoking. Please follow-up with your primary care physician or come to the emergency room if you develop rectal bleeding, abdominal pain, nausea, vomiting, fevers, chills, or other symptoms that concern you. Please adhere to a high fiber diet. Followup Instructions: 1) Primary Care: Please follow up with your PCP on [6-17] at 3:45 with your primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10743] ([0-0-]). 2) Liver Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2166-6-27] 2:40 [Initials (NamePattern5) ] [Last Name (NamePattern5) ] Medical Building [Location (un) ] 3) Surgery Dr. [Last Name (STitle) 5182] ([Telephone/Fax (1) 5189]) [2166-6-24] 9:30 [Initials (NamePattern5) ] [Last Name (NamePattern5) 23] building, [Location (un) 470] 4) Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2166-8-6] 4:30 5) Please call Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 410], your hematologist, at [Telephone/Fax (1) 3760], to have your MGUS evaluated and followed. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 53627] ICD9 Codes: 496, 5715, 4271, 2851, 2762, 7907, 5119, 5180
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6844 }	Medical Text: Admission Date: [2136-1-11] Discharge Date: [2136-1-13] Date of Birth: [2071-6-12] Sex: M Service: OTOLARYNGOLOGY Allergies: Naprosyn Attending:[First Name3 (LF) 12657] Chief Complaint: acoustic neuroma Major Surgical or Invasive Procedure: translabyrinthine acoustic neuroma excision with abdominal fat graft History of Present Illness: 64yo M h/o acoustic neuroma, symptomatic for the past 3 months s/p prednisone in [10-25]. Past Medical History: OSA, COPD, DM2, melanoma, bad HTN Physical Exam: AVSS Incision C/D/I Mastoid dressing in place. No strikethrough CN3-12 intact Moving all extremities with intact 5/5 strength No cerebellar dysfunction Steady gait Brief Hospital Course: The patient was admitted to the otolaryngology service on [2136-1-11] with attending Dr. [Last Name (STitle) 3878] after undergoing translabrynthine resection of acoustic neuroma. The patient tolerated the procedure without intra-operative complications. Please refer to the operative note for full operative detail. The patient was extubated in the OR and transferred to the ICU in stable condition. He underwent q1hr neuro checks over the evening of POD0 with no problems. After an uneventful night in the in ICU, he was transferred to the general floor. His pain was well controlled on parental narcotics. His diet was slowly advanced on POD 0 and on day of discharge he was tolerating a regular diet. Exam upon d/c was unremarkable. The remainder of the hospital course was relatively unremarkable, and pt was discharged in stable condition, ambulating and voiding independently, and with adequate pain control. Pt was given explicit instructions to follow-up in clinic with Dr. [Last Name (STitle) 3878] and PCP [Last Name (NamePattern4) ] 1 week. Pt was given detailed discharge instruction outlining wound care, actvitiy, diet, f/u and the appropriate medication scripts. Brief hospital course by systems below: * N: The patient's pain was well controlled on PO pain medications without complications. He has been neurologically intact throughout his admission. * CV: stable without issues throughout admission on his home meds * P: The patient was weaned to RA postoperatively. At time of discharge he was ambulating independently without supplement oxygen. * GI: The patient was initially NPO. His diet was advanced as tolerated on POD0. At time of discharge he was tolerating a regular house diet without nausea or vomiting, passing flatus, and having BMs. * GU: The patient initially had a foley catheter. This was removed on POD#1 and he subsequently voided without complications. * HEME: The patient was offered SCH and pneumoboots throughout admission for DVT prophylaxis. * ID: The patient received perioperative antibiotics and ancef while in house. He is discharged on 1 week of keflex. Medications on Admission: 1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 2. diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 3. fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. glyburide 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 7. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety, vertigo. Disp:20 Tablet(s) Refills:0 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lovastatin 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: 1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 4. fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. glyburide 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety, vertigo. Disp:20 Tablet(s) Refills:0 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. lovastatin 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Discharge Disposition: Home Discharge Diagnosis: Acoustic neuroma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please call or go to emergency room if fever greater than 101.5, if increased redness or discharge from wound or around drain site, if numbness/weakness, if short of breath, if you notice leg swelling, if increased pain uncontrolled by pain medications, or for any other concerning symptoms. -Keep mastoid dressing in place until your follow up appointment with Dr. [Last Name (STitle) 3878]. He will remove it at that point. -Please do not drive or consume alcohol while taking narcotics. -Please follow up with your primary care provider concerning hospitalization. -Please resume all home medications unless instructed otherwise. Followup Instructions: F/u with Dr. [Last Name (STitle) 3878] in 1 week Completed by:[2136-1-13] ICD9 Codes: 4019, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6845 }	Medical Text: Admission Date: [2199-2-26] Discharge Date: [2199-3-8] Date of Birth: [2123-1-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 458] Chief Complaint: VT storm, unable to extubate after VT ablation Major Surgical or Invasive Procedure: VT ablation History of Present Illness: The patient is a 76-year-old man with coronary artery disease status post single vessel CABG with previous critical aortic stenosis status post-aortic valve repair in [2196], status post AICD, history of PEA arrest, history of VT, who presented to [Hospital1 ] with VT storm [2-25] with 40 ICD shocks and was transferred to [Hospital1 18] for VT ablation. Pt. with VT initially post CABG/AVR, and was started on amiodarone and mexelitine which he did not tolerate. . The patient reports sitting at home watching TV, then went to the bathroom and felt ICD fire. The patient denies prior palpitations, chest pain, shortness of breath or dizziness. ICD fired several times. . At [Hospital3 ], pt. continued ot have VT in the ED, and the patient was was started on lidocaine and amiodarone drips and admitted to the Intensive Care Unit. He was started on p.o. Amiodarone load and lidocaine drip was discontinued without any further episodes of VT. The patient had a cardiac cath which is unchanged from [3-10]. He has LAD 40% ostial lesion, left circumflex, 70% ostial lesion, RCA 40% mid lesion with patent left circ. He also had an TTE demonstrating reduced EF (30-35%) compared to 1 year ago (40%). . Transferred here for VT ablation. In EP lab, intubated and found to have 2 separate foci near mitral valve annulus. [12-5] VT foci were able to be ablated. In addition, had pacer adjusted such that when VT was induced burst pacing extinguished 2nd site of VT. He was initially extubated, but was somewhat somnolent, and given a h/o hypoxia-induced PEA arrest s/p extubation from inguinal repair last year, pt. was re-intubated easily and transferred to PACU for further monitoring. Of note, pt. was positive 1L during procedure. . In PACU, had CXR demonstrating likely reflecting left pleural effusion and fluid overload. Currently, pt. is intubated, sedated on propofol, L arterial sheath pulled at 7PM. . Review of symptoms unable to be obtained [1-5] sedation. Review of PMH shows recent MCA stroke, with need for walker at baseline. No report of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Per [Hospital1 ] notes, he denied recent fevers, chills or rigors. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CAD status post 1v CABG (SVG-->OM). 2. AS status post AVR in [2196] which is a tissue valve. 3. Status post AICD in [2196]. 4. Diabetes. 5. Hypertension. 6. Hypercholesterolemia. 7. Spinal stenosis. 8. PEA arrest in [2197] s/p hernia repair with prolonged intubation. 9. History of VT. 10. Pulmonary hypertension. 11. Diverticulosis. 12. Thalassemia. 13. Right MCA infarct [12/2198] 14. Left internal carotid artery stenosis. ([12/2198]) 15. Lumbar stenosis 16. sternal nonunion after CABG [07]. Systolic and diastolic dysfunction presumed to be secondary to hypertensive diabetic and valvular heart disease. 18. Charcot joints. 19. Chronic renal failure, BL 1.2-1.3 Social History: The patient currently lives in [Location 4288] with his wife. [Name (NI) ] is a retired owner of a printing center franchise. He quit work approximately 8-9 years ago. He does not smoke. He does not use illicit drugs and he very infrequently drinks alcohol. Family History: NC Physical Exam: VS: T afebrile, BP 107/35, HR 61, RR 12, O2 100% on AC 50%/Tv 500/RR 12/PEEP 5 Gen: obese man, intubated, sedated. Per EP fellow, Oriented x3, but sleepy prior to procedure. HEENT: NCAT. Sclera anicteric. PERRL, EOMI with doll's. Neck: very large with excess tissue, JVP not assessed as pt. flat post-procedure. no carotid bruits CV: RR, normal S1, soft s2, loud harsh early systolic murmur best heard at LUSB Chest: Large anterior chest wall deformity with unstable sternum, large incision from CABG/valve repair well-healed. Decreased BS on left anteriorly. No crackles, wheeze, rhonchi noted Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. L scar medial to arterial puncture site, sl. indurated, well healed Skin: + mild stasis dermatitis, R shin ulcers 1.5mm X 2 mm, oval marked, with no crepitus, mild erythema. 1+ pitting edema to knees Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; dopplerable DP and PTs Left: Carotid 2+ without bruit; Femoral 2+ without bruit; dopplerable DP and PTs Pertinent Results: CXR on admission: Lung volumes are low with opacification of the left lower lobe, likely reflecting left pleural effusion and atelectasis. Consolidation can't be excluded. Vascular redistribution in the right upper lobe suggests fluid overload. . CXR at [Hospital3 ] ([2-25]): The diaphragms are markedly elevated with low lung volumes. This makes evaluation of the lung bases impossible. There is suggestion of increasing interstitial opacities of the upper lung zones which could be a function of the high diaphragms or some superimposed edema. . 2D-ECHOCARDIOGRAM performed on [2199-2-25] demonstrated (per [Hospital1 ] ECHO report): Technically difficult study. LV dimensions mildly dilated. Global LV systolic function is moderately to severely reduced with an estimated EF of 30-35%. There is global hypokinesis with abnormal septal motion. RV is mildly dilated with moderate hypokinesis. There is moderate biatrial enlargement. Aortic valve bioprosthesis appears to be well seated with appropriate gradients for this valve. Trace AR. Mitral leaflets are mildly thickened with mild MR. [First Name (Titles) ] [Last Name (Titles) ] with moderate PHTN. Estimated PASP is 43 mmHg + CVP. A minimal pericardial effusion is seen. Pacer wire is noted in right heart [Doctor Last Name 1754]. Compared to prior study dated [2198-6-30], LV systolic function appears somewhat lower on the current study. . ETT performed on [11-8] demonstrated: A Dobutamine stress echo was carried out during which time peak HR of 127bpm was obtained (86% of maximum predicted HR). At rest, LVEF estimated 25%. Evidence of LVH as well as LAE. Global LV systolic dysfunction. Aortic valve moderately calcified with 40mmHg peak gradient and 20mmHg mean valve gradient. This represents no significant change from prior study of [2196-11-8]. With Dobutamine, LVEF increased to 35-40%. Again, global hypokinesis was seen. Peak gradient increased to 65mmHg with mean gradient of 26 mmHg. Unfortunately, LVOT velocity could not be obtained either at rest or at peak dose Dobutamine, therefore aortic valve area could not be calculated. These findings however appear to be most consistent with a cardiomyopathy with moderate AS rather than hemodynamic insignificant AS. Suggest clinical correlation. . CARDIAC CATH performed on [2199-2-25] demonstrated: The patient had a cardiac cath which is unchanged from [3-10]. He is LAV 40% ostial lesion, left circumflex, 70% ostial lesion, RCA 40% mid lesion and he describes to us left circumflex is patent. LABORATORY DATA: notable for BL Cr 1.2, 1.5 on admission to [Hospital1 ] with hct 34 on admission and 30 upon transfer. Discharge labs: [2199-3-8] 07:10AM BLOOD WBC-7.2 RBC-4.05* Hgb-8.2* Hct-27.6* MCV-68* MCH-20.4* MCHC-29.9* RDW-16.6* Plt Ct-268 [2199-3-8] 07:10AM BLOOD Plt Ct-268 [2199-3-8] 07:10AM BLOOD PT-14.3* PTT-30.6 INR(PT)-1.2* [2199-3-8] 07:10AM BLOOD Glucose-60* UreaN-19 Creat-1.4* Na-140 K-5.0 Cl-101 HCO3-31 AnGap-13 [2199-3-8] 07:10AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.1 Brief Hospital Course: 76yo with h/o VT, CABG, PEA arrest s/p extubation and h/o difficulty weaning, who underwent VT ablation procedure for VT storm, and who had difficult weaning of endotracheal tube after VT ablation procedure and was started on antiarrythmics for control of VT. Rhythm: He found to have 2 automatic foci which were the cause of his VT storm on presentation. He was reduced to 200 mg Amiodarone sometime prior to admission for unclear reasons. His TSH and LFTs are wnl. On the day of presentation, he underwent successful ablation of 1 of the 2 VT foci with other focus easily controlled in lab with burst pacing after pacer adjustment. He continued to have periods of ventricular rhythms which were paced out, though s/p VT on [3-1] which was too slow to burst pace per pacer settings, likely because of amio. On morning of [3-2], patient triggered for VT at 116-126 bpm SBP 90-110s. No benefit with vagal maneuver, carotid massage so IV lidocaine was given, amiodarone and mexiletine were discontinued and patient was switched to quinidine. Patient had his lower pacing rate increased to 75bpm and subsequently, patient had no more episodes of VT. His mexiletine was titrated up to 648mg TID with QT of 560 which was corrected for wide QRS to 480ms which was minimally changed from his pre-quinidine QT. However, he developed diarreah on the quinidine so he was switched back to amiodarone and mexiletine. His pacer was also adjusted to have a lowered VT detection zone from 130 down to 115bpm. He had no episodes of VT on this regimen and was discharged on telemetry monitoring with paced HR ranging in 70s. He will also need Q6month CBC, TFTs, LFTs on discharge. CAD/Ischemia: Cath showed unchanged disease from previous. CP free prior to cath. Patient continued on statin, zetia, receiving aspirin via aggrenox. LDL 117 at OSH. Atorvastatin was increased to 80mg daily. He was also continued on his beta blocker and ACEi. Pump: Depressed EF to 30-35% compared to ECHO last year, with CXR e/o pleural effusion and pulmonary edema. On 80 mg po lasix qdaily at home. Pt. with limited BL activity [1-5] previous stroke, so unsure if class II or III NYHA CHF, though some evidence for benefit in both. Initially lasix and lisinopril were held in setting of ARF, but patient continued to improved and by discharge, patient was restarted on lisinopril and titrated up to his home dosage. He was also started on low dose lasix of 40mg PO daily. Respiratory failure: Given patient's history of difficult course post-extubation from prior procedure, he was watched closely after extubation from his EP procedure. He did well post-extubation with incentive spirometry, oxygen, and was discharged with sats of 94% on RA. Microcytic anemia: Decreased Hct likely due to Fe deficiency + known thalassemia trait. Hct 34->30 at [Hospital3 ] and then ->25, now improved to 28.4. Patient's Hct remained stable throughout his hospital course with no indication of acute bleeding. Acute on chronic renal failure: CR 1.3 at baseline, hyperphosphatemic initially so added phos-binder which improved this. Creatinine peaked at 2.0, and on discharge was 1.2-1.3. Cr bump likely pre-renal given significant diuresis and dry appearance on exam vs. contrast nephropathy from recent cath at [Hospital3 ]. Restarted low dose lisinopril and lasix - titrated as Cr and BP allow. Urinary obstruction: Patient was unable to void after foley removed on [3-3] and had residuals above 300cc. Started on tamsulosin on [3-2]. Patient was discharged to rehab with foley in, and to continue on tamsulosin for 1 week. Plan to remove foley on [2199-3-9] with trial void. Valves: bioprosthetic Aortic valve, no longer anticoagulated HTN: beta blocker was increased to metoprolol 75mg PO TID. ACEi as above. BP well controlled on this DM: restarted home NPH with sliding scale. He was discharged back on home metformin and NPH dosing. He can restart his home regimen of regular insulin 4 units before dinner at rehab as needed. Chronic pain: continue neurontin s/p stroke: continue aggrenox. No changes in neuroexam post procedure. FEN: regular diabetic cardiac diet Prophylaxis: hep SC, home PPI Code: FULL CODE Medications on Admission: 1. Prilosec 20 mg p.o. daily. 2. Aggrenox 1 capsule p.o. b.i.d. 3. Colace 200 mg p.o. daily. 4. Amiodarone 200 mg p.o. daily. 5. Trazodone 50 mg p.o. q.h.s. 6. Iron 325 mg p.o. daily. 7. Lasix 80 mg p.o. daily. 8. Lopressor 50 mg p.o. b.i.d. 9. Lipitor 40 mg p.o. daily 10. Multivitamin 1 tablet p.o. daily. 11. Neurontin 300 mg p.o. t.i.d. 12. Lisinopril 20 mg p.o. b.i.d. 13. Senna p.r.n. 14. Zetia 10 mg p.o. daily. 15. Ativan 0.5 mg p.r.n. 16. Insulin NPH 25 units before breakfast and insulin NPH 25 units q.h.s. 17. Regular insulin 4 units before dinner. 18. Glucophage 1000 mg p.o. b.i.d. 19. Lactulose p.r.n. Discharge Medications: 1. Outpatient Lab Work Lab draws of LFTs, TFTs, CBC every 6 months. Please have results faxed in to PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] at (F) [Telephone/Fax (1) 77387] 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QIDACHS (4 times a day (before meals and at bedtime)). 14. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 15. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 17. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 20. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 22. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty Five (25) units subcutaneous Subcutaneous QAM before breakfast. 23. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty Five (25) units subcutaneous Subcutaneous at bedtime. 24. Insulin Aspart 100 unit/mL Solution Sig: Give per insulin sliding scale Subcutaneous four times a day. 25. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Final diagnosis Recurrent ventricular tachycardia Secondary diagnosis Coronary artery disease Systolic congestive heart failure Acute on chronic renal fialure Hypertension Urinary retention Discharge Condition: Stable Discharge Instructions: You were admitted for a procedure to deactivate areas of your heart which were firing irregularly. You had two areas of irregular activity and one of the two areas were deactivated. Your pacemaker was also adjusted to better control the rate of your heart. You were observed after the breathing tube was removed after the procedure. You were also started on a medication called mexiletine in addition to your amiodarone which will help control your heart rhythm. You will need to take 200mg every 8 hours of mexiletine daily. Other medication changes are as follows: - your lipitor was increased to 80mg daily - your lasix was decreased to 40mg daily - your metoprolol was increased to 75mg 3 times a day Followup Instructions: Your follow up appointment with the electrophysiology team is as follows: Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], [First Name3 (LF) 3947]. Phone:[Telephone/Fax (1) 62] Date/Time:[2199-3-18] 9:40am on the [Location (un) 436] of [Hospital Ward Name 23] Building, [Hospital1 18]. You also have an appointment with your cardiologist, Dr. [Last Name (STitle) 10220] at [Hospital3 2568] ([Telephone/Fax (1) 77388]. Your appointment is on Tuesday [3-19] at 1:45pm. You have an appointment with your primary care provider, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [Location (un) ]. T ([Telephone/Fax (1) 77389]. Your appointment is on [Last Name (LF) 2974], [3-15] at 1pm. You will also need lab draws to check your CBC, LFTs every 6 months. ICD9 Codes: 4271, 5849, 5119, 5859, 4280, 4168, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6846 }	Medical Text: Admission Date: [2191-5-27] Discharge Date: [2191-6-6] Service: MEDICINE Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / rofecoxib / Vioxx Attending:[Last Name (un) 7835] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: Endotracheal Intubation (presented intubated) Central Venous Line placement (Right IJ) Arterial Line Placement History of Present Illness: [Age over 90 ]-year-old female with afib not on anticoagulation, CAD, DM, HTN, CHF, CKD presenting from OSH with cardiac arrest. She was recently admitted to OSH in [Month (only) 956] for GI bleed and discharged to rehab and recently discharged back home where she had been doing well for a month. On day prior to admission at OSH, she was noted to have altered mental status with slurred speech. CT head was reportedly negative. In the ED she was noted to have long pauses greater than >25sec at its worst with associated syncope. She was evaluated by cardiology; metoprolol and digoxin were stopped and pacemaker was placed for sick sinus syndrome. Infectious work-up revealed enterococcal UTI that was sensitive to vancomycin. She was initially on levofloxacin and later on vanc/zosyn prior to transfer. One blood culture also grew GPCs in clusters for which ID was consulted. Given that she was afebrile and without leukocytosis, ID felt that this may be contaminant and recommended that vancomycin be discontinued until speciation of the GPCs. This was ultimately speciated to coag neg staph. Hospital course was further complicated by acute on chronic renal failure, waxing and [Doctor Last Name 688] mental status, urinary retention (for which bethanechol and tamsulosin were started) and hypoglycemia (sugars 50s). . Pt was being evaluated by PT for transfer to rehab when she was found nonresponsive and pulseless on night prior to transfer. She was not on telemetry at that time. She had VT/Vfib and defibrillated 4 times, given epinephrine, intubated, and placed on ventilator. She was transferred to CCU and started on vasopressors, levophed and dopamine. She was broadly cultured and placed on vanc/zosyn and right IJ was placed. She was weaned off levophed with IVFs but still on dopamine at transfer. A CXR showed left sided consolidation. She was given 150mg amiodarone and placed on amiodarone drip. Cooling protocol was not initiated due to fact she was opening her eyes and moving all extremities. TTE was performed; results still pending by time of discharge. Last TTE from [2191-2-28] had shown EF 55-60%, mild concentric LVH, and mild pulm art HTN. Past Medical History: chronic afib repair of right quadriceps tendon rupture CAD CHF HTN DM chronic renal failure osteoarthritis anxiety history of upper GI bleed cholecystectomy carpal tunnel repair Social History: She is a widow, lives with her youngest son. She has 3 sons in all. She does not smoke, does not drink alcohol Family History: Unable to obtain Physical Exam: General: intubated, sedated, opens eyes to verbal stimuli [Month/Day/Year 4459]: pupils not reactive to light, does not track; ET tube with minimal bloody secretions Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: bibasilar crackles, no wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley draining clear yellow urine with some small blood clots Ext: 2+ pitting edema b/l, cyanosis of fingers/toes b/l Neuro: does not withdraw to pain, opens eyes to voice, does not follow commands, very minimal movement of extremities Discharge Exam: 98.1 97.4 138/87 61 22 96%RA General: Pleasantly demented, oriented to person and city but waxes and wanes throughout the day. Often cries out for her mother or her father. [Name (NI) 4459]/Neck: NCAT, no [Doctor First Name ], carotid upstrokes brisk and symmetric CV: Regular rate and rhythm, S1 + S2 clear and of good quality,2-3/6 early systolic murmur over RUSB, no rubs or gallops appreciated Lungs: Clear to auscultation bilaterally, moving air well and symmetrically, no wheezes, rales or rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: 1+ [Location (un) ], mainly pedal, RLE in knee brace Neuro: Moving all extremities spontaneously, not very cooperative with examination, demented, confused, inattentive, not oriented to person, place or time. Pertinent Results: ADMISSION LABORATORY DATA [2191-5-27] 07:24PM BLOOD WBC-8.2 RBC-3.75* Hgb-10.5* Hct-34.6* MCV-92 MCH-28.0 MCHC-30.3* RDW-16.4* Plt Ct-114* [2191-5-27] 07:24PM BLOOD PT-13.4* PTT-36.0 INR(PT)-1.2* [2191-5-27] 07:24PM BLOOD Glucose-142* UreaN-35* Creat-2.1* Na-135 K-3.2* Cl-100 HCO3-24 AnGap-14 [2191-5-27] 07:24PM BLOOD Glucose-142* UreaN-35* Creat-2.1* Na-135 K-3.2* Cl-100 HCO3-24 AnGap-14 [2191-5-27] 07:24PM BLOOD ALT-18 AST-33 CK(CPK)-139 AlkPhos-93 TotBili-0.4 [2191-5-27] 07:24PM BLOOD CK-MB-23* MB Indx-16.5* cTropnT-0.33* [2191-5-27] 07:24PM BLOOD Albumin-2.8* Calcium-7.4* Phos-3.3 Mg-1.7 [2191-5-28] 05:47AM BLOOD Vanco-16.9 [2191-5-27] 07:57PM BLOOD Type-ART Temp-32.2 Tidal V-500 PEEP-5 FiO2-50 pO2-123* pCO2-29* pH-7.44 calTCO2-20* Base XS--2 -ASSIST/CON Intubat-INTUBATED [2191-5-27] 07:57PM BLOOD Lactate-2.4* [2191-5-27] 07:57PM BLOOD O2 Sat-98 [2191-5-27] 07:57PM BLOOD freeCa-1.07* Discharge Labs: [2191-6-3] 06:13AM BLOOD WBC-4.9 RBC-3.39* Hgb-9.5* Hct-31.3* MCV-92 MCH-27.9 MCHC-30.3* RDW-17.3* Plt Ct-159 [2191-6-3] 06:13AM BLOOD PT-11.3 INR(PT)-1.0 [2191-6-3] 06:13AM BLOOD Glucose-89 UreaN-18 Creat-1.2* Na-146* K-3.7 Cl-110* HCO3-28 AnGap-12 [2191-6-3] 06:13AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.4 Microbiology: BCx x2 negative UCx [2191-6-2] (dirty UA) negative UCx [2191-5-28] negative RADIOLOGY CXR [2191-5-27] FINDINGS: The ET tube tip is 2.5 cm above the carina. Right IJ line tip is in the mid SVC. Cardiac pacemaker with single lead is visualized. Orogastric tube tip is off the film, at least in the stomach. There are bilateral pleural effusions, bilateral lower lobe volume loss, pulmonary vascular redistribution and mild cardiomegaly. TTE [2191-5-28] Results Measurements Normal Range Left Atrium - Long Axis Dimension: 6.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: 6.2 cm <= 5.2 cm Right Atrium - Four Chamber Length: 5.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 2.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 1.7 cm Left Ventricle - Fractional Shortening: 0.41 >= 0.29 Left Ventricle - Ejection Fraction: 75% >= 55% Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.05 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 15 < 15 Aorta - Sinus Level: 2.7 cm <= 3.6 cm Aortic Valve - Peak Velocity: 2.4 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 24 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 14 mm Hg Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.57 Mitral Valve - E Wave deceleration time: 127 ms 140-250 ms TR Gradient (+ RA = PASP): 61 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Moderate LA enlargement. LEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Hyperdynamic LVEF >75%. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. AORTIC VALVE: Mild AS (area 1.2-1.9cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Trivial MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Mild to moderate [[1-24]+] TR. Severe PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF 75%). The anterolateral papillary muscle is anteriorly displaced. Right ventricular chamber size and free wall motion are normal. There is mild aortic valve stenosis (however, a component of subvalvular obstruction cannot be excluded with certainty). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: small, hyperdynamic left ventricle Brief Hospital Course: Patient is a [Age over 90 ]-year-old female with history of afib not anticoagulated, CAD, IDDM, HTN, dCHF, CKD who was initially admitted to [Hospital3 ] on [2191-5-2] for a AMS/slurred speech and pan-sensitive enterococcal UTI infection, s/p pacemaker implantation of symptomatic bradycardia and sinus pause, s/p PEA arrest at OSH transferred to [Hospital1 18] now with improved hemodynamics after short term intubation and pressor support in MICU. # Cardiac Arrest: Per code notes from [Hospital6 302], pt was found to have PEA arrest and went into VT/Vfib after several doses of epinephrine. Etiology of cardiac arrest yet unknown. Anesthesia notes speculate that this was precipitiated by an aspiration event. However, per CCU attending, this is unknown. Unfortunately, pt was not monitored on telemetry at that time and rhythm that precipitated this is unknown. Other possible causes of cardiac arrest include PE (less likely as pt was not noted to be hypoxic) or infectious causes (possible as pt had UTI and one positive blood culture-CONS). Patient was transferred from [Hospital3 ] to [Hospital1 18] intubated and on pressors. She was initially treated with broad antibiotic coverage with vanc/zosyn/levo until cultures returned negative. Patient self-extubated herself and her hemodynamics continued to improve. Pressors were discontinued on [2191-5-31] and she had no further episodes of hypotension or events on telemetry. Bedside TTE showed hyperdynamic LVEF and normal overall function. After improvement in hemodynamics she was transferred to the floor for further management # dCHF: Patient does not carry diagnosis of CHF per history though TTE in MICU with hyperdynamic LVEF (75%) and symmetric LVH in this elderly patient with long-standing hypertension indicates dCHF likely contributing. S/p PEA arrest at OSH and cardiogenic shock while in CCU/MICU. Patient appeared hypovolumic and remained normotensive during admission. Treated with Metoprolol (see below A.Fib problem) for rate control and dCHF. Cardiology was consulted in MICU for cardiac arrest. She was taken off digoxin (normal LVEF and bradycardia), isosorbide (hypotension), lasix (hypotension). Her PO intake was poor and she was hypovolumic so volume control in this dCHF patient was not an issue. # Atrial Fibrillation: Not anticoagulated given age and profound dementia though definately qualifies by CHADS2 criteria. Rate controlled as an outpatient with Metoprolol 75mg PO BID. Patient was bradycardic requiring pacemaker at [Hospital3 ] so metoprolol discontinued. While on pressor support in [Hospital1 18] MICU she became tachycardic, a.fib with RVR, was restarted on Metoprolol but became hypotensive. As she was weaned off pressors Metoprolol was re-initiated at low doses first 12.5mg PO BID then to TID. On TID dosing she had episodes of A.Fib with RVR overnight so she was changed to Metoprolol Succinate 50mg Daily for longer action and a slightly higher dose. While on 50mg Succ her HRs were much better controlled and she had no further episodes of hypotension. Discontinued Digoxin as she has normal cardiac function and was rate controlled with Metoprolol. # Sick sinus syndrome: Patient has long-standing history of atrial fibrillation, often sick sinus syndrome occurs in setting of A.Fib. S/p pacemaker implantation at [Hospital3 ] for symptomatic bradycardia and sinus pause of 25 seconds. Pacemaker overrides at HRs<60. See Atrial Fibrillation problem for Metoprolol changes # Respiratory failure: Pt intubated on arrival to [Hospital1 18] though appeared to be oxygenating well. CXR with b/l pleural effusions. Patient self-extubated on [2191-5-30] and did well with high flor mask, was weaned to nasal cannula and then maintained on RA for duratino of admission # Chronic kidney disease: Unclear baseline, admitted in ARF with creatinine of 2.0. Cr likely related to hypotension from cardiac arrest. Creatinine improved to 1.2 on discharge # Urinary retention: Had been started on flomax and bethanechol at OSH. Discontinued flomax as not necessary, was maintained with foley catheter though discontinued morning of discharge and patient voided without issue. # Insulin Dependent Diabetes Mellitus: Unclear control of blood sugars since receives her care at an OSH. While inpatient her BS were well controlled and she did not require insulin doses # Dirty UA: Urinalysis completed [2191-6-2] early morning for delirium, worsening confusion and screaming. UA dirty though patient with foley in place. Recent history of treated Enterococcal UTI at [Hospital2 ] [Hospital3 6783]. Did not treat initially since could not tell if patient symptomatic and foley was in place, additionally, patient incontinent at baseline and has poor hygiene in demented state so contamination likely as well. Culture returned negative (2 negative UCx during this admission) and she was not treated with antibiotics. TRANSITIONAL ISSUES: # HCP [Name (NI) ] [Name (NI) 14429] (son) [Telephone/Fax (1) 110232], [Telephone/Fax (1) 110233] # Code: Full (confirmed with HCP) # Would continue to readdress code status and goals of care with HCP # Patient was having some loose stools. Ordered C.Diff but patient did not have bowel movement day of discharge. No leukocytosis or fevers and patient eating pureed diet so C.Diff unlikely but would monitor her stool output and consider C.Diff if concerned. Medications on Admission: Home Meds (Have not been confirmed as patient demented, per OSH DC summary in [2191-2-23]) - Digoxin 0.125mg daily - Iron sulfate 325mg [Hospital1 ] - Lasix 40mg daily - Insulin sliding scale - Isosorbide 60mg daily - Metoprolol 75mg [Hospital1 ] - MVI - Protonix 40mg [Hospital1 ] - Miralax - Potassium 20meq daily - Crestor 5mg daily - Tylenol - Alamag - Nitroglycern prn . Hospital Meds (on transfer from OSH): - Amiodarone gtt - Bethanechol 25mg TID - Digoxin 0.125mg daily - IV dopamine gtt - Heparin SC 5000units [Hospital1 ] - Insulin lispro sliding scale - Ipratropium/albuterol nebs 8 puffs QID - Norepinephrine 250mg IV daily - Nystatin powder [Hospital1 ] - Pantoprazole 40mg IV BID - Zosyn 2.25mg q8h - Miralax 17mg qod - Crestor 5mg daily - MVI - Vancomycin 1g daily (last dose 9:30AM [5-27]) - Flomax 0.4mg --> discontinued . Transfer from MICU to Medicine Medications: - Acetaminophen [Telephone/Fax (1) 1999] mg PO/NG Q6H:PRN pain - Docusate Sodium (Liquid) 100 mg PO/NG [Hospital1 ] - Heparin 5000 UNIT SC TID - Insulin SC (per Insulin Flowsheet) - Morphine Sulfate 2-4 mg IV Q4H:PRN pain - Metoprolol Tartrate 12.5 mg PO/NG [Hospital1 ] - Senna 1 TAB PO/NG [Hospital1 ]:PRN constipation Discharge Medications: 1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 2. Miralax 17 gram Powder in Packet Sig: One (1) PO DAILY. 3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: Not to exceed 4 grams per day. 4. insulin lispro 100 unit/mL Solution Sig: One (1) dose Subcutaneous ASDIR (AS DIRECTED): per sliding scale. 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Last Name (un) 5502]Nursing & Rehabilitation Center - [Location (un) 5503] Discharge Diagnosis: Active: - s/p cardiac arrest - sick sinus syndome s/p pacemaker - bradycardia - dCHF - Urinary Retention (foley in place) Inactive: - Atrial Fibrillation (not-anticoagulated) - Chronic Kidney Disease - Insulin Dependent Diabetes Mellitus Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [Known lastname 14429], It was a pleasure treating you during this hospitalization. You were transferred to the intensive care unit at [Hospital1 18] from [Hospital ] Cardiac Care Unit for management of shock after a cardiac arrest. You were intubated and on medications to keep your blood pressure elevated when you arrived to the hospital. As you improved the endotracheal tube was removed and you were taken off medications which were increasing your blood pressure. We are still not clear why a cardiac arrest occurred since it happened at St.[Doctor Last Name 6783] though it is possible an aspiration event occurred. While at [Hospital1 18] your clinical status continued to improve and you had no episodes of low blood pressure, slow heart rate or aspiration events after transfer from our MICU. You continued to improve and we felt you were safe from a medical stand point to be discharged to a rehabilitation center. The following changes to your medications were made: - STOP Digoxin: Slow heart rate and normal heart function indicates this medication is not necessary - STOP Rosuvostatin: There is no need to continue this medication at [Age over 90 ] years old and in interest of limiting polypharmacy it is safe to discontinue this medicaiton - STOP Iron supplementation (limiting polypharmacy) - STOP Multivitamin (limiting polypharmacy) - REDUCE Lasix to 40mg daily. Should hold [Hospital1 ] dosing until instructed to increase by your outpatient Cardiologist. This was changed since your blood pressures were low and Lasix is a diuretic which can lower it further. - HOLD Isosorbide as patient asymptomatic during admission and had episodes of hypotension. Would not hesitate to restart if she begins having symptoms - CHANGE Metoprolol to Metoprolol Succinate 50mg PO Daily. This was reduced because of bradycardia on Metoprolol and sick sinus syndrome s/p pacemaker at [Hospital2 ] [Hospital3 6783] - No other changes were made, please continue taking home medications as prevoiusly prescribed Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [2191-6-29] at 9:40 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4450], M.D. [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: 4275, 5070, 5849, 2760, 5859, 4280, 2724, 4271, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6847 }	Medical Text: Admission Date: [2171-8-29] Discharge Date: [2171-9-13] Date of Birth: [2125-1-16] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 949] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Left internal jugular central vein line placement History of Present Illness: Mr. [Known lastname 1024] is a 46 year old gentleman with a PMH EtOH cirrhosis c/b multiple prior UGIBs and past possible HRS, continued alcohol abuse c/b seizures, CKD (had been on HD until [Month (only) ] [2169]), now being transferred from [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for management of hypovolemic shock secondary to GI bleed, and possible TIPS procedure. History obtained from OMR and OSH records, as well as conversation with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ICU nurse, as patient is intubated and sedated. [Name (NI) ] girlfriend reported to OSH that patient had filled four "buckets" of bloody emesis at home, and was then convinced to go to the ED at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2171-8-27]. On arrival, patient was only able to speak in short sentences, but was making little sense. VS on arrival were BP 91/37 HR 160 RR 20 (temperature and SaO2 not recorded). He became obtunded, and was intubated shortly thereafter, with Fentanyl boluses, followed by propofol drip. Labs were notable for: H/H 2.8/8.2, Plts 64, Cr 3.9, INR 2.6, urine tox positive for oxycodone, EtOH level 238, and UCx with 100,000 Coag negative staph. OG tube was placed, and this prouced another container full of bloody emesis. Massive transfusion protocol was initiated in the ED, and patient was given 4 units FFP, 2 units of PRBC and 4 Liters of NS. EGD that evening showed erosive esophagitis, Barrett's esophagus, coffee grounds in stomach, and a suggestion of duodenal varices. Gastroenterologists at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] hypothesized that the patient may have been chronically bleeding from his esophagitis/varices, as they could find little evidence of active bleeding. During his admission at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], he received a total of 10 units PRBCs, 7 units FFP, and two 6-packs of platelets. He was kept on octreotide drip (began [8-27]) and pantoprazole 40 mg IV BID ([8-27]). He was also treated with Zosyn for possible aspiration pneumonia (starting on [2171-8-27]). For sedation, he was kept on propofol for sedation with lorazepam IV boluses as needed. Prior to transfer to [Hospital1 18] labs H/H [7-11], and plt 25 @ 1200 today. For access, he had a right triple lumen CVL and a left a-line. He also had an OG tube, and fully matured RUE AV fistula (not used since [69]/[2169]). He was transferred to [Hospital1 18] for further management, including possible capsule endoscopy, balloon enteroscopy and/or TIPS. On arrival to the MICU, patient was intubated and sedated, but appeared comfortable. Past Medical History: 1. Multiple admissions to [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 83800] for upper and lower GI bleeds. Most recently at [Hospital1 18] UGIB, admitted [Date range (3) 83801]: transfused 9U PRBC, 8U FFP and 10U plts. No noted varices on EGD [2171-4-2]. Thought to be secondary to erosive esophagitis. 2. EtOH cirrhosis: acute EtOH hepatitis in [8-27] (was not started on corticosteroids due to GI bleed, UTI and [Last Name (un) ]); was started on pentoxyphyline to prevent HRS with a planned 4 week course from [2168-9-26] (last day [2168-10-24]); negative hepatitis A, B and C serologies. Complicated by GI bleeds as above in the past (but no varices), and possible history of HRS. 3. CKD: Cr baseline around 3.0. Was HD-dependent via RUE fistula until [2170-9-18]. Diagnosis was multifactorial from ATN +/- NSAIDs +/- HRS 4. MRSA bacteremia [2171-10-23] treated with vancomycin 5. EtOH abuse with h/o seizures in the setting of heavy alcohol consumption 6. Gastroesophageal Reflux Disease 7. MVA [3-/2153]: Right femur fracture with [Male First Name (un) ] placement, pelvic fracture 8. Asthma Social History: Has never smoked. Drank [11-22] Vodka daily until recently, but denies drinking in the past 4 months (last drink first week of [Month (only) 359]). Never has used IV drugs. Lives with girlfriend, [Name (NI) 5627] [Name (NI) 83758] [Telephone/Fax (1) 83759]. Has 2 children, daughter 17, son, 16 who live with their mother who the patient is still very close to. Pt formerly worked at Mass Electric. Family History: Mother - Deceased [12-20] alcoholic liver disease Father - Deceased [12-20] [Name2 (NI) 499] cancer, diagnosed in his 40s. No other family history of [Name2 (NI) 499] cancer. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 97.8 nBP: 100/56 aBP: 136/66 P: 74 R: 18 SaO2: 100% on AC TV 500 RR 12 FiO2 50% PEEP 5 General: Intubated/sedated, appears comfortable HEENT: Scleral icterus, PERRL, no head trauma. Neck: Unable to assess JVP due to habitus. Right IJ in place without surrounding hematoma or erythema. CV: Regular rate and rhythm, normal S1/S2, II/VI systolic murmur loudest at the LLSB. Lungs: Upper airway sounds of ventilation transmitted throughout. Breath sounds throughout anterior lungfields. Abdomen: Distended with tense subcutaneous edema worse on flanks bilaterally. Unclear whether distention is primarily from anasarca vs. underlying ascites. Unable to assess for hepatosplenomegaly due to distention. Slight erythema on lower abdomen. Minimal scrotal edema and erythema. GU: + Foley Ext: Onchonychia. 2+ distal pulses. 2+ pitting edema in UE bilaterally. RUE with prominent fistula, +thrill. Lower extremities with 4+ pitting edema to halfway up thighs. Neuro: Opens eyes to voice. Opens and closes eyes on command, but does not squeeze hands. Withdraws to pain. DISCHARGE EXAM VS: 99.8 98.8 89 130/60 20 92% RA GENERAL: NAD. HEENT: NCAT. Icteric sclera. MMM. CARDS: RRR no MRG PULM: CTAB. Decreased breath sounds right base. ABD: NABS. Soft NT/ND. EXT: 2+ edema BL to knees Pertinent Results: ADMISSION LABS [2171-8-29] 07:49PM BLOOD WBC-5.4# RBC-2.90* Hgb-9.1* Hct-27.1* MCV-93 MCH-31.4 MCHC-33.7 RDW-16.7* Plt Ct-36* [2171-8-29] 07:49PM BLOOD Neuts-87.6* Lymphs-6.9* Monos-5.4 Eos-0.1 Baso-0 [2171-8-29] 07:49PM BLOOD PT-14.8* PTT-30.9 INR(PT)-1.4* [2171-9-1] 03:11AM BLOOD Fibrino-173* [2171-8-29] 07:49PM BLOOD Glucose-184* UreaN-93* Creat-4.2* Na-139 K-4.3 Cl-107 HCO3-21* AnGap-15 [2171-8-29] 07:49PM BLOOD ALT-60* AST-97* LD(LDH)-171 CK(CPK)-159 AlkPhos-90 Amylase-207* TotBili-6.2* [2171-8-29] 07:49PM BLOOD CK-MB-4 cTropnT-0.15* [2171-8-30] 02:15AM BLOOD CK-MB-4 cTropnT-0.14* [2171-8-29] 07:49PM BLOOD Albumin-3.1* Calcium-7.9* Phos-5.8# Mg-2.1 UricAcd-12.6 Cholest-94 [2171-8-29] 07:49PM BLOOD Triglyc-134 HDL-31 CHOL/HD-3.0 LDLcalc-36 LDLmeas-<50 [2171-8-29] 07:49PM BLOOD Osmolal-330* [2171-8-29] 07:49PM BLOOD TSH-0.76 [2171-8-29] 08:09PM BLOOD Type-ART Temp-36.7 Tidal V-500 PEEP-5 FiO2-50 pO2-104 pCO2-38 pH-7.36 calTCO2-22 Base XS--3 -ASSIST/CON Intubat-INTUBATED [2171-8-29] 08:09PM BLOOD Lactate-1.1 IMAGES AND PROCEDURES: CXR [8-29] FINDINGS: Portable semi-upright chest radiograph was obtained. Endotracheal tube terminates at the level of the carina and should be withdrawn 2-3 cm. Orogastric tube courses into the stomach and out of view. Right IJ catheter likely terminates in the right atrium and can be withdrawn 4 cm for more optimal positioning. Consider repeat radiograph after repositioning. Bilateral pleural effusions and dense retrocardiac opacity are noted, with low lung volumes and possible mild pulmonary edema. Moderate cardiomegaly noted. CXR [9-10] FINDINGS: In comparison with study of [8-31], the degree of pulmonary vascular congestion has somewhat decreased, though part of this may be due to the upright position. Substantial enlargement of the cardiac silhouette persists with large right pleural effusion with atelectasis involving the right middle and lower lobes. Blunting of the left costophrenic angle is seen but the left chest is otherwise clear. ECHO [8-31] The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is an abnormal systolic flow contour at rest, but no left ventricular outflow obstruction. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with near hyperdynamic left ventricular systolic function. Dilated and hypokinetic right ventricle with mild tricuspid regurgitation and mild to moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [2170-1-3], the right ventricle appears dilated and hypokinetic with elevated pulmonary pressures. Colonoscopy [8-30] Normal colonic mucosa from rectum up to the cecum. No signs of active bleeding. One small diverticula seen in the ascending [Month/Year (2) 499]. Retroflexed view revealed small internal hemorrhoids Otherwise normal colonoscopy to cecum EGD [8-30] Severe esophagitis in lower esophagus with what appeared 2 tongues of salmon colored mucosa left undisturbed.Moderate to severe diffuse portal gastropathy without signs of active bleeding. Normal duodenum bulb, second portion and normal small bowel mucosa up to proximal jejunum Otherwise normal EGD to second part of the duodenum CXR [8-31] A radiograph centered at the thoracoabdominal junction was obtained to assess for placement of an orogastric tube, which terminates within the stomach. Within the chest, endotracheal tube and central venous catheter are unchanged in position, and there remains marked enlargement of the cardiac silhouette, now accompanied by mild pulmonary vascular congestion. Worsening homogeneous opacity in the right mid and lower lung region likely represents a combination of a large right pleural effusion and atelectasis involving the right middle and right lower lobes. Portable CXR [9-10] Small left pleural effusion has minimally increased. Moderate right pleural effusion is probably unchanged allowing the difference in positioning of the patient, decreased though from [8-31]. There is no evident pneumothorax. Cardiomegaly is obscured by the pleural effusions. Right lower lobe and right middle lobe atelectases have improved. There are increasing atelectases in the left lower lobe. PA and Lateral CXR [9-11] FINDINGS: PA and lateral views of the chest are obtained. Since the prior study, there is interval improvement of right pleural effusion. There is also evidence of right middle lobe atelectasis with associated volume loss. The previously seen left lower lobe atelectasis is improved since the prior study. There is no pneumothorax. Cardiac size is unchanged. CONCLUSION: Improved right pleural effusion and left lower lobe atelectasis with persistent right middle lobe atelectasis and volume loss. No pneumothorax. KEY LAB STUDIES: Pleural fluid ([9-11]) ANALYSIS WBC RBC Polys Lymphs Monos Meso Macro Other [2171-9-11] 17:51 1000* [Numeric Identifier 22065]* 2* 48* 0 1* 491 02 PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Albumin Cholest [2171-9-11] 17:51 1.5 89 172 < 1.0 24 GRAM STAIN (Final [2171-9-11]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. Urine Cultures Negative Blood Cultures Negative DISCHARGE LABS: [2171-9-12] 06:15AM BLOOD WBC-2.9 RBC-2.87* Hgb-9.2* Hct-27.0* MCV-94 MCH-31.9 MCHC-33.9 RDW-17.1* Plt Ct-85* [2171-9-12] 06:15AM BLOOD PT-14.3* PTT-38.5* INR(PT)-1.3* [2171-9-12] 06:15AM BLOOD Glucose-86 UreaN-22* Creat-4.2# Na-134 K-3.6 Cl-97 HCO3-34 AnGap-7* [2171-9-12] 06:15AM BLOOD ALT-14 AST-27 LD(LDH)-165 AlkPhos-122 TotBili-3.2* [2171-9-12] 06:15AM BLOOD TotProt-5.3* Albumin-2.9* Globuln-2.4 Calcium-8.1* Phos-2.5* Mg-1.9 Brief Hospital Course: Mr. [Known lastname 1024] is a 46 year old gentleman with a PMH EtOH cirrhosis c/b multiple GI bleeds, CKD with baseline and ongoing alcohol abuse, transferred to [Hospital1 18] for further evaluation of GI bleed. # GI bleed: Unclear source, as EGD revealed no prominent active bleed; most likely sources include erosive esophagitis and duodenal varices, although these may not account for the amount of blood loss evidenced by blood counts at OSH. Hematemesis, melena, brisk tempo of bleeds and precipitous in counts would also be more consistent with upper GI source. He was transferred for further exploration with possible EGD/[Last Name (un) ] vs. capsule study, with consideration of TIPS, based on findings. Patient was hemodynamically stable (normal HR and BP) on admission to MICU, with H/H increased to [8-15] after massive blood product repletion at OSH. On [2171-8-30] EGD showed no sign of active bleeding, severe esophagitis, moderate gastropaty and colonoscopy was unremarkable. This raised the possibility of a portal gastropathy. His CVL from OSH was removed and new line placed in LIJ. Octreotide and pantoprazole now since [2171-8-27], octreotide discontinued on [2171-9-2]. He was started on Zosyn for the possibility of an aspiration PNA (see below) which also doubled as SBP prophylaxis and he completed a 7 day course on [2171-9-3]. Capsule endoscopy on floor did not function properly, perhaps secondary to body habitus. Patient thereafter monitored, with stable hematocrit for nearly 2 weeks thereafter as patient awaited placement in rehab. Ultimately, his blood losses were thought to be secondary to gastropathy. # Cirrhosis: MELD 27 on discharge(mortality over 3 months = 20%). Secondary to alcholic liver diseases, with prior decompensations from GI bleeds and possible HRS. No known hepatic encephalopathy, ascites or variceal bleeds. Patient was removed from transplant list in [2169] for failure to keep appointments and relapse with alcohol use. Octreotide, pantoprazole and Zosyn were continued as above. After completion of his EGD/colonoscopy and following his extubation on [2171-9-1], he was started on lactulose and rifaximin for prevention of hepatic encephalopathy. These medications were continued on discharge. # Pleural effusion: Patient found to have pleural effusion on CXR. Per prior reports and notes, has been longstanding and likely [12-20] volume overload and was previously characterized as hepatic hydrothorax following pleural effusion analysis several months prior to admission. Patient offered thoracentesis, but was initially very against the idea and declined, preferring instead to allow dialysis to take off fluid. Patient ultimately agreed to the procedure, and it was performed on [2171-9-11]. Extended light's criteria suggested transudative effusion. Post-procedure portable XR raised concern of trapped lung, but repeat PA and lateral XR was unremarkable. He may require periodic thoracentesis if fluid reaccumulates and he develops dyspnea or coughing. # Acute on chronic kidney disease: Creatinine elevated on admission to 4.2 from baseline in the low 3 range, with urine electrolytes consistent with prerenal azotemia. There was concern for developing HRS, especially in setting of GI bleed, but the patient was still making urine so it was considered less likely. Clincially, he was total body volume overloaded with extensive peripheral edema. Patient was briefly trialed on furosemide drip, but experienced worsening creatinine and after discussion with renal it was decided to move forward with ultrafiltration in order to remove his excess fluid (5L off on [8-31]). Thereafter, patient was initiated on hemodialysis and will continue a MWF course via his RUE AVF. A small pseudoaneurysm was appreciated- he was evaluated by transplant surgery who will follow him as an outpatient. # Urinary tract infection: On [9-12], patient developed low grade fevers. Continued to cough, but cough was slightly improved s/p thoracentesis mentioned above. Patient also with chills, some sweats. UA suggestive of urinary tract infection, so patient was started on levaquin with dosing to also cover a potential pulmonary source as well. Will complete roughly 5d of treatment. # Aspiration Pneumonia: Based on retrocardiac opacity on CXR, as well as concern for aspiration reported from OSH. Treated with Zosyn as mentioned previously, remained afebrile without leukocytosis while in ICU. # Alcohol abuse: Continued through current admission, with EtOH level 238 on admission. Initially patient was on midazolam drip as well. Because of history of seizures during alcohol intoxication, and patient was closely monitored. Patient did well and did not show evidence of withdrawal. Received counseling and SW consultation with a focus on rela # UTI: Noted at OSH, treated with total 7 days of Zosyn. Was coag negative staph. Repeat cultures were negative. # Supraventricular Tachycardia: he developed a narrow-complex tachycardia during dialysis session on [9-6] with pulse instantaneously rising to 130 from 80. Was asymptomatic. EKG appeared consistent with AVNRT. Failed vagal maneuvers. Broke with IV metoprolol and he maintained sinus rhythm for the remainder of the hospitalization after we re-initiated his home-dose metoprolol tartrate [Hospital1 ]. TRANSITIONAL ISSUES: - patient to continue levaquin with a dose of 500 mg on [9-15] and [9-17] (500 mg q48hr) to complete ~5 day course for UTI - patient to continue hemodialysis once discharged from hospital - patient may need repeat thoracentesis for hepatic hydrothorax. Please evaluate with CXR if he has increased coughing or shortness of breath. - followup/workup of microhematuria seen repeatedly on UA - watch phos level (decreased sevelamer from 1600TID to 800TID b/c phos on low side) - watch potassium level (patient has required replacement) - f/u in liver clinic FOLLOW UP: - patient will need PCP followup after [Name Initial (PRE) ]/c from rehab - outpatient nephrology f/u - transplant surgery f/u for AVF pseudoaneurysm - aggressive social work support for alcohol relapse prevention PENDING STUDIES: - Pleural fluid culture (NGTD) - Pleural fluid cytology - Urine culture (NGTD) - Blood culture (NGTD) MEDICATION REGIMEN: - CONTINUE metoprolol as previously - START NEW MEDS lactulose, rifaximin, pantoprazole, sucralfate, nephrocaps, sevelamer, miconazole powder, multivitamins, thiamine, folic acid - DISCONTINUE spironolactone Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 25 mg PO BID 2. Spironolactone 25 mg PO DAILY Discharge Medications: 1. Metoprolol Tartrate 25 mg PO BID RX metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:2 2. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth DAILY Disp #30 Tablet Refills:3 3. Multivitamins 1 TAB PO DAILY RX multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 4. Thiamine 100 mg PO DAILY RX thiamine HCl [Vitamin B-1] 100 mg 1 tablet(s) by mouth DAILY Disp #30 Tablet Refills:2 5. Lactulose 30 mL PO TID please titrate to [1-20] bowel movements a day RX lactulose 10 gram/15 mL 30 cc by mouth three times a day Disp #3 Liter Refills:1 6. Miconazole Powder 2% 1 Appl TP TID RX miconazole nitrate [Lotrimin AF Powder] 2 % rash [Hospital1 ]:PRN Disp #1 Container Refills:3 7. Nephrocaps 1 CAP PO DAILY RX B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth DAILY Disp #30 Capsule Refills:2 8. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:2 9. Rifaximin 550 mg PO BID RX rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:2 10. sevelamer CARBONATE 1600 mg PO TID W/MEALS RX sevelamer carbonate [Renvela] 800 mg 2 tablet(s) by mouth three times a day Disp #180 Tablet Refills:2 11. Sucralfate 1 gm PO QID RX sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp #120 Tablet Refills:2 12. Levofloxacin 500 mg PO 2X Duration: 1 Doses dose on [9-15] and [9-17] after dialysis Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: GI Bleed Alcholic cirrhosis Aspiration pneumonia Acute Tubular Necrosis secondary to hypovolemic shock Volume overload Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 1024], It was a pleasure being involved in your care. You were admitted first to the ICU at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Hospital for for concern of severe bleeding into your GI tract and then transferred here. It was reported that you had vomited several buckets of blood. When your blood counts were done, they were found to be EXTREMELY low. The bloody vomit is certainly related to alcohol abuse. An endoscopy and a colonoscopy were done to look for a site of bleeding. When we did not find one, we did a capsule endoscopy (you swallowed a pill with a camera) to look for bleeding in your small intestine. This was also unrevealing. The bleed likely originated from gastric (stomach) inflammation which was seen on the scope study. During this episode you were noted to be very confused. This can happen with severe liver disease. We gave you lactulose and rifaximin to make you have bowel movements. Your mental status eventually cleared on these medicines. There was a high suspicion that you had inhaled stomach contents while you were confused because you were not clearing your airway properly. We treated you with an 8 day course of the powerful IV antibiotic Zosyn. Also since you had low blood pressures, the ICU had to give you many liters of fluid to keep your blood pressure high enough. Unfortunately, this caused your tissues to swell up. After your episodes of low blood pressure resolved, the nephrologists (kidney doctors) took 10 liters of fluid out of your body with ultrafiltration and then gave you dialysis on [9-4] to support your kidney function, which remains extremely poor. You will be continuing hemodialysis on an outpatient basis. Prior to discharge, on [9-12], you were found to have a low grade fever. We looked at your urine, which suggested a urinary tract infection. We are treating you with antibiotics. It is important that you take the medicines we prescribe after discharge EXACTLY AS PRESCRIBED. Please see them attached. Briefly: - please CONTINUE metoprolol as previously - please START NEW MEDS levofloxacin, lactulose, rifaximin, pantoprazole, sucralfate, nephrocaps, sevelamer, miconazole powder, multivitamins, thiamine, folic acid - please DISCONTINUE spironolactone Followup Instructions: Please follow up with your PCP after discharge from rehab: Name: [Last Name (LF) ],[First Name3 (LF) ] P. Location: [Hospital 46644] MEDICAL ASSOCIATES Address: [Location (un) 32946], [Location (un) ],[Numeric Identifier 32948] Phone: [Telephone/Fax (1) 32949] Fax: [Telephone/Fax (1) 64198] Department: LIVER CENTER When: THURSDAY [2171-9-19] at 9:20 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Name: [Last Name (LF) 7674], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital 46644] MEDICAL ASSOCIATES Address: [Location (un) 32946], [Location (un) ],[Numeric Identifier 12023] Phone: [Telephone/Fax (1) 32949] Appointment Thursday [2171-9-26] 3:10pm Department: TRANSPLANT CENTER When: MONDAY [2171-9-30] at 10:45 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 14955], MD [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2171-9-13*] ICD9 Codes: 5789, 5070, 5845, 2851, 5990, 2762, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6848 }	Medical Text: Admission Date: [2111-2-5] Discharge Date: [2111-2-6] Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 5880] Chief Complaint: failure to thrive Major Surgical or Invasive Procedure: Placement of open gastrojejunal feeding tube. History of Present Illness: The patient is an 81-year-old lady, status post a sigmoid colectomy. Postoperatively the patient developed respiratory failure requiring an open tracheostomy tube and the patient also had a history of CVA and not able to tolerate a regular diet. For the past several months, the patient had been fed via nasal jejunal feeding tube and the patient was taken to the operating room on an elective basis for an open gastrojejunal feeding tube placement. Past Medical History: PMH: Hypothyroidism; Temporal arteritis 2 years ago, with residual left eye blindness; HTN; h/o dizziness/vertigo; Polymyalgia rheumatica; h/o laryngeal CA [25] yrs, s/p XRTx41. PSH: Hysterectomy at age 25 for fibroids, per pt; Appendectomy [2054]; Breast lump excision, benign per pt; Right knee arthroscopy Social History: Pt is married and has 2 children. 35 pack year smoker, quit 20 years ago. Family History: Father died of lung CA, sister and brother died of MI. Other brother had a stroke in his 80s, now 84. Physical Exam: Afebrile VSS NAD CTA B/L RRR +BS, NT, ND, soft Pertinent Results: [2111-2-5] 06:27PM BLOOD Glucose-121* K-4.6 [2111-2-5] 06:27PM BLOOD Calcium-8.8 Phos-5.5# Mg-1.6 Brief Hospital Course: The patient was taken to the operating room on [2111-2-5] for placement of open gastrojejunal feeding tube. There were no complications and the patient was transfered to the floor from the PACU. On POD 1 tube feeds were started (promode [1-19] strangth @ 30ml/hr) and tracheostomy was decanulated. The patient was tolerating TF & breathing well on her own. She was subsequently discharged back to [Hospital3 7]. Medications on Admission: 1. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): via G tube. 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily): via G tube. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): via G tube. 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): via G tube. 5. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): via G tube. 7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) 30 mg PO DAILY (Daily): via G tube. 8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO once a day. 9. Calcium Carbonate 1,250 mg Capsule Sig: One (1) Capsule PO twice a day: via G tube. 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO four times a day: via G tube. 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day: via G tube. 12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO twice a day: via G tube. 13. Loperamide 1 mg/5 mL Liquid Sig: Two (2) mg PO QID PRN: via G tube. 14. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day: via G tube. 15. Potassium Chloride 10 % Liquid Sig: Forty (40) meq PO once a day: via G tube. 16. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg PO once a day: via G tube. 17. Dalteparin (porcine) 5,000 anti-Xa u/0.2mL Syringe Sig: One (1) Subcutaneous twice a day. 18. Acetaminophen 500 mg/5 mL Liquid Sig: Five (5) mL PO q4-6 hr prn: via G tube. Discharge Medications: 1. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): via G tube. 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily): via G tube. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): via G tube. 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): via G tube. 5. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): via G tube. 7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) 30 mg PO DAILY (Daily): via G tube. 8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO once a day. 9. Calcium Carbonate 1,250 mg Capsule Sig: One (1) Capsule PO twice a day: via G tube. 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO four times a day: via G tube. 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day: via G tube. 12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO twice a day: via G tube. 13. Loperamide 1 mg/5 mL Liquid Sig: Two (2) mg PO QID PRN: via G tube. 14. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day: via G tube. 15. Potassium Chloride 10 % Liquid Sig: Forty (40) meq PO once a day: via G tube. 16. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg PO once a day: via G tube. 17. Dalteparin (porcine) 5,000 anti-Xa u/0.2mL Syringe Sig: One (1) Subcutaneous twice a day. 18. Acetaminophen 500 mg/5 mL Liquid Sig: Five (5) mL PO q4-6 hr prn: via G tube. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: failure to thrive Discharge Condition: good Discharge Instructions: Restart you home medications as usual. You may resume activity as tolerated. You may shower, then pat-dry incision. Do not rub incision. No tub baths or swimming for 3-4 weeks. You may leave the incision uncovered or use a light dressing for comfort. Keep the white strips until they fall off. Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Inability to pass gas or stool * Other symptoms concerning to you Followup Instructions: 1. Call Dr.[Name (NI) 6433] office for a follow-up appointment ([Telephone/Fax (1) 9946] Completed by:[2111-2-6] ICD9 Codes: 4280, 4019, 2449, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6849 }	Medical Text: Admission Date: [2150-6-19] Discharge Date: [2150-6-24] Date of Birth: [2080-8-12] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 16330] Chief Complaint: found down, xferred to OSH, then to [Hospital1 18] Major Surgical or Invasive Procedure: Central venous line placement Intubation/extubation with invasive ventilation History of Present Illness: Mr. [Known lastname 16490] is a 69 yo with IDDM, PVD, CVA [2138] (no residual deficits), ESRD [1-9] ([3-12]) DM, not on HD, with a h/o of multiple episodes of hypoglycemia taken emergently to OSH after this wife found him unresponsive in bed, surrounded by empty coke cans. Blood glucose was 6. [Name (NI) 1094] wife states that the patient has not been feeling well for the last couple of days prior to event, having increased [Last Name (LF) ], [First Name3 (LF) 1658] colored, foul smelling diarrhea. Pt denieed fevers, chills, abdominal pain, but has not been eating well. Wife reports more incontinence. Patient has had DM for decades and is on NPH and regular insulin followed by [Last Name (un) ]. Worsening renal fx reportely over the past year, with multiple discussions with his nephrologist, Dr. [First Name (STitle) 805] about initiation of HD. Yesterday AM, the patient was more confused, reportedly, then was found unresponsive by his wife. with a BG of 6. Pt was given 1 amp of dextrose in the field. The patient reportedly did not fall, and did not complain of any CP, SOB, dizziness, lightheadedness or diaphoresis. He does not remember feeling shaky before the episode. . Pt was taken to OSH emergently, was intubated in the field. Prior to intubation, the patient apparently vomited and aspirated a large amount of particulate matter (witnessed by paramedics). Particulate matter was aspirated from his ETT. When brought to the ED, the patient was not responding to any commands. Head CT was done at OSH was reportedly negative, showing an old infarct, but no acute process. Blood sugar was reportedly in the 20s. Laboratory studies revealed an non-AG metabolic acidosis, renal insufficiency but normal lactate levels. Per OSH records, the patient had a transient episode of hypotension of unkown etioology, but rebounded back quickly with 500ccs bolus. Per the patient's wife, the patient did administer his NPH this AM. Patient with h/o DM and found unresponsive with significant hypoglycemia. Intubated for airway protection but not waking up (Etomidate, Ativan given). Exam shows brainstem function (gag) but not much else. Paitent HD stable, on vent. To come TO [Hospital1 18] tonight to MICU green as patient is usually cared for at [Hospital1 18] for DM and renal failure. . Prior to xfer from OSH, received a call from [Name8 (MD) 16491] MD reporting that the patient was becoming more awake, following commands. Pt unlikely able to protect airway, so kept intubated and xferred to [Hospital1 18]. In the MICU, he became more awake, but continued to have problems with aspiration. CXR noted bilateral effusions and infiltrates c/w aspiration PNA. Past Medical History: 1. Ischemic colitis [2-8], s/p ex lap and rigid sigmoidoscopy without evidence of ischemic bowel. 2. PVD: s/p right popliteal to dorsalis pedis bypass and left femoral-popliteal and popliteal-anterior tibial bypass, R CEA, and right SFA stent. 3. Type I Diabetes mellitus - brittle diabetic; episodes of severe hypoglycemia and DKA 4. Status post CVA >10 yrs ago. 5. History of CHF with preserved EF 6. COPD- no PFTs in system 7. Hypertension 8. Glaucoma 9. CKD-baseline cr 2.1-2.4 (Cr clearance of 25-30, stage 4)is preparing for PD with Dr. [First Name (STitle) 805] at [Last Name (un) ] 10. h/o Duodenal ulcer but on EGD above not seen 11. Anemia of chronic disease. 12. Esophageal dysmotility. 13. h/o VRE UTI 14. Rectal CA-dx [2148] no surgery due to comorbidities; s/p palliative XRT 15. Secondary hyperparathyroidism Social History: Lives with his wife. [Name (NI) ] smoked for >50yrs at most 2ppd. Now smokes 1ppd. Remote heavy EtOH use in past (3+ drinks per day), quit 2-3 years ago. No recreational drug use. Used to work in greenhouse supply business, then sold real estate now disabled. Sleeps up to 22 hours per day per wife's report. Does not allow visitors to house. Admits to lack of motivation. . Wife, [Name (NI) 4115] [Telephone/Fax (1) 16487] (H), [Telephone/Fax (1) 16488] (C) Family History: Mother colon cancer. Father with throat cancer. Brother died of colon cancer at age 62. Physical Exam: Vitals: Tmin 95.7; Tc95.7, HR 50-61; BP 123-182/49-57; RR 16 on AC 550x16; FIO2 of 0.5; PEEP 5. Gen: chronically ill appearing, somnolent elderly male, intubated, sedated. HEENT: pupils irregular, assymetric and non-reactive; EOMI, b/l periorbital edema, MM dry Neck: supple, no LAD, no JVP elevation, +linear well-healed scar over Right cartoid Cardio: PMI inferiorly displaced and diffuse, RRR, nl S1/S2, no murmurs or rubs appreciated Resp: CTAB, no exp wheezes Abd: + BS, soft/NT/ND, no HSM, no masses Ext: no c/c/e; b/l LE w/ significant atrophy. multiple scars. dopplerable pulses bilat. Neuro: intubated, sedated on boluses, but responding to commands when waking up Pertinent Results: [2150-6-23] EKG: Sinus tachycardia. Right bundle-branch block. Left axis deviation. Left anterior fascicular block. Compared to previous tracing of [2150-4-2] heart rate is increased. Otherwise, multiple abnormalities as previously noted persist without major change. . [2150-6-22] CXRAY: Right internal jugular vascular catheter terminates in the proximal superior vena cava. Cardiac contour and vascular pedicle width have slightly increased and are accompanied by worsening vascular engorgement, diffuse perihilar haziness and interstitial opacities, likely due to increased volume status and fluid overload. Superimposed secondary process such as aspiration is difficult to exclude in the setting of diffuse edema. Bilateral layering pleural effusions are noted. Brief Hospital Course: A/P 69M,ESRD, CAD, PVD, brittle type I DM with very labile sugars taken emergently to OSH after being found unresponsive by his wife with a blood glucose of 6. . 1) Hypoglycemia: This was likely the effect of NPH, lantus with decreased clearance (worsening renal fx, decrease PO intake and increased diarrhea). Pt has had very labile blood sugars in the past, with multiple episodes of hypoglycemia. Patient taking NPH/regular [9-10] at home in AM. [First Name8 (NamePattern2) ] [Last Name (un) ] notes, the patient takes lantus as well. Patient was initially maintained on an insulin drip whiel in the ICU, but later transitioned to Lantus 4 units with RISS coverage at meal time. . 2) Respiratory failure: Patient was intubated for airway protection in the field, with visible aspiration and suctioning back of particular matter. He was extubated following transfer to [Hospital1 18]. He was started on levofloxacin and flagyl as empiric therapy for aspiration pneumonia. . 3) PVD: Patient has known severe peripheral vascular disease, s/p multiple bypass surgeries and vein harvesting. Patient is due back fro R SFA angioplasty some time soon to save the patient's right leg. There has to be a discussion between renal and vascular surgery about risk of contrast dye and the risk of starting the pt on HD. He was continued on Aspirin, and Dr. [Last Name (STitle) ] made aware of admission. . 4) Diabetes mellitus, type I: Patient has exocrine and endocrine pancreatic insufficiency given type I DM, presenting with [Male First Name (un) 1658]-colored stools. He was continued on pancreatic replacement enzymes. [Last Name (un) ] was consulted and patinet was maintained on a regimen of Lantus 4 units + RISS. . 5) Renal Insufficiency: Mild acute on chronic at time of presentation, likely prerenal in the setting of poor PO intake. Creatinine returned to baseline of ~4 with hydration. Planning is in progress for eventual hemodialysis. Renal function is likely declining due to progression of disease. Patient has a non-gap metabolic acidosis, and was started on Sodium citrate prior to discharge. He was continued on a regimen of epo, calcitriol, lanthanum, and calcium acetate. . 6) Nutrition: Patient underwent a speech & swallow evaluation with report of ongoing aspiration with thin liquids with coughing after drinking. He also appeared to have residue in his throat of which he is unaware given that he coughed up [Location (un) 2452] juice and eggs from earlier this morning when he aspirated. Therefore, he was recommended to be put on a diet of ground solids & nectar thick liquids if he alternates between bites and sips and if he ends his meal w/several sips of nectar to clear residue from his pharynx. The following recommendations were made: -Diet of nectar thick liquids & ground consistency solids using the following: a) slow rate of intake b) small bites and sips c) Alternate between bites and sips d) End meal w/several sips of nectar thick liquid to clear residue from his throat e) PO medications crushed with purees Patient refused thick liquids for duration of hospitalization and subsequently had very poor PO intake of liquids. . 7) Depression: Social work consult was obtained, and patient was started on Lexapro 5 mg daily (renally dosed). . 8) Code status: full code, confirmed with patient repeatedly during this hospitalization. Medications on Admission: Norvasc 2.5 mg as directed 1 tab QD Fosrenol 1000 Mg chew one with each meal. Lasix 40mg 1 per day Glucagon Emergency Kit 1mg Phoslo 667mg three times a day 2 tablets Hectorol 0.5mcg twice a day Hydralazine Hcl 50mg twice a day Neurontin 100mg two at bedtime. Procrit 4000 U/ml as directed twice a week. Ferrous Sulfate 325mg 1 time per day Folic Acid 1mg 1 time per day Lantus ? dose Humulin ? dose Lipram 20-4.5-25 four times a day 2 tabs Metoprolol Tartrate 100mg twice a day () Losec 20mg 1 time per day Foltx 1-2.5-25mg 1 time per day ASA 325 qd Discharge Medications: 1. Aspirin 325 mg Tablet [Location (un) ]: One (1) Tablet PO DAILY (Daily). 2. Calcium Acetate 667 mg Capsule [Location (un) ]: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Heparin (Porcine) 5,000 unit/mL Solution [Location (un) ]: One (1) injection Injection TID (3 times a day). 4. Lanthanum 500 mg Tablet, Chewable [Location (un) ]: One (1) Tablet, Chewable PO TID (3 times a day): Please give with meals. 5. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) [Location (un) ]: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Calcitriol 0.25 mcg Capsule [Location (un) ]: One (1) Capsule PO DAILY (Daily). 7. Escitalopram 10 mg Tablet [Location (un) ]: 0.5 Tablet PO DAILY (Daily). 8. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution [Location (un) ]: Fifteen (15) ML PO BID (2 times a day). 9. Epoetin Alfa 4,000 unit/mL Solution [Location (un) ]: One (1) mL Injection QMOWEFR (Monday -Wednesday-Friday). 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 11. Lantus 100 unit/mL Solution [Last Name (STitle) ]: Four (4) units Subcutaneous at bedtime. 12. Levofloxacin 250 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q48H (every 48 hours) for 2 days. 13. Metronidazole 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day) for 2 days. 14. Folic Acid 1 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 15. Norvasc 2.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 16. Insulin Regular Human 300 unit/3 mL Insulin Pen [Last Name (STitle) ]: Per sliding scale Subcutaneous QACHS. 17. Metoprolol Tartrate 100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day. 18. Hydralazine 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO four times a day: Uptitrate dose as needed . Discharge Disposition: Extended Care Facility: [Location (un) 16492] [Doctor Last Name ] Discharge Diagnosis: Hypoglycemia Aspiration pneumonia Respiratory failure Depression Diabetes mellitus, type I Acute renal failure End-stage renal disease Secondary hyperparathyroidism Pancreatic insufficiency Discharge Condition: Stable glucose levels and vital signs. Discharge Instructions: You were admitted to the hospital with hypoglycemia. It is important that you adhere to a diabetic diet with frequent oral intake to prevent high/low blood glucose levels. . You have been treated for an aspiration pneumonia which occurred due to respiratory failure when your blood glucose level was low at home. You have a 9-day course of antibiotics remaining. . You have been started on a medication called Lexapro for symptoms of depression. . You should return the hospital if you are experiencing chest pain, shortness of breath, fevers, or uncontrolled blood glucose levels. Followup Instructions: You should follow-up with your nephrologist Dr. [First Name (STitle) 805] at the [Hospital ] clinic next week, as previously scheduled. . Provider [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 722], DPM Phone:[Telephone/Fax (1) 8645] Date/Time:[2150-7-29] 12:45 . Provider VASCULAR LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2150-11-12] 10:30 . Provider [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2150-11-12] 11:15 ICD9 Codes: 5070, 4280, 496, 2762, 4439, 5849
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6850 }	Medical Text: Admission Date: [2165-1-7] Discharge Date: [2165-1-12] Date of Birth: [2106-2-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 20224] Chief Complaint: found down Major Surgical or Invasive Procedure: none History of Present Illness: 58 yo male with history of tracheostomy for respiratory failure in [9-16], recent C5 spinous process fracture, atrial fibrillation, PEs, anticoagulation stopped [2164-12-24], and endocarditis presents after being found down. The patient was found in his apartment on the floor. The patient was found to be intoxicated, but no complaints on arrival to the ED. In the ED, his initial vital signs were HR 100 BP 140/100 RR 24 O2 100% on an unclear amount of O2. The patient was initially combative and agitated. He received haldol and lorazepam. He became somnolent after these medications and was placed on a non-rebreather. A chest x-ray showed no significant infiltrate. A CTA was performed which showed no evidence pulmonary embolism, however possible RML infiltrate, RLL and LLL atelectasis. He had a head and neck CT which did not show significant change from previous. His labs were significant for hyperkalemia, but was moderately hemolyzed. A repeat K was 5.6, with no EKG changes. His tox screen was significant for ETOH level of 488. He received a total of 2 L of NS. He then had an episode of RVR which was treated with 15mg, then 25mg of IV diltiazem. His rate was not well controlled, so he was started on a diltiazem drip. He also received ceftriaxone 1gm, levofloxacin 500mg, and valium 10mg IV prior to transfer. On transfer to the [Hospital Unit Name 153], his vital signs were HR 120 BP 136/82 O2 100% on NRB RR 25. Unable to obtain review of systems secondary to somnolence. Past Medical History: Prolonged hospitalization for respiratory failure requiring tracheostomy Pulmonary Embolism [9-16] requiring tPA, off coumadin, s/p IVC filter placement in [10-17] Atrial Fibrillation, not on anticoagulation Tricuspid valve endocarditis Cardiomyopathy, likely non-ischemic History of C diff Hepatitis C Depression Polysubstance abuse (heroin, cocaine, ETOH). Detoxed following admission to an inpatient facility about 3 years ago. Currently in [Hospital1 ] suboxone program. Social History: Lives in [Location ] alone. Had been homeless previously. Was previously a pharmacist. Drinks 2 pints of Whiskey per day. Distant heroin/cocaine abuse. Does use tobacco. Family History: Father died of lung cancer in mid 70s, alcohol abuse, hypertension. Mother died of lung cancer in mid 70s. Three siblings; two brothers, one sister, all in good health. Physical Exam: GENERAL: Somnolent, intoxicated in NAD, able to follow simple commands HEENT: ecchymoses over left eye, normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Tachycardic irregular rhythm. Normal S1, S2. Possible 2/6 systolic murmur at RUSB, however difficult to appreciate secondary to tachycardia. No rubs or [Last Name (un) 549]. JVP flat LUNGS: Crackles anteriorly on right, left clear, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: unable to participate, has resting coarse tremor. Pertinent Results: admission labs: 7.1>14.1/42.2<178 WBC increased to 12.6 on [1-8] and then decreased steadily. Hct decreased to 38.5 and remained stable through ICU admission. Plateletys decreased to 116 on [1-9] and then rose to baseline diff: N33, L59, M5, E2, B1; patient developed 10 bands on [1-8] and neurtophils increased to 79 and lymphs decreased to 15. INR 1.1, PT 12.7, PTT 27.1; PTT increased while on heparing gtt and then decreased 144/5.8/104/27/10/0.6<114 Cr remained stable, K decreased to within normal and was 3.3 on day of d/c from ICU ALT 149, decreased then increased again and was 130 as of [1-11] AST 388, decreased to 255 on [1-11] LD 575, decreased then increased to 518 on [1-11] CK 257 to 82 to 34 Alk Phos 127, decreased to 103 TB 0.4 increased to max of 2.3 then 1.6 on [1-11], Direct was elevated to 1.3 on [1-10] ca 8.1/mg1.3/phos2.2 8.7/2.1/3.1 on [1-11] HBV serology [1-10] pending [1-7] asa neg, ethanol 488, acet, benzo barb and TCA neg HCV Ab [1-10] pending UA [1-7]- neg, and neg tox ABG [1-7] 7.45/38/185 blood ctx [1-9], [1-8], [1-7] pending cdiff [1-9] neg [1-8] urine ctx neg CTA: No PE, no dissection. RML lateral segmental bronchus and RLL basilar segmental bronchi not well seen, may be occluded due to secretions/mucus plug. RLL atelectasis/collaps spares superior segment. L basilar atelectasis. RML ill defined opacity - atelectasis vs consolidation. Has azygous right lobe noted. CXR: Possible RML opacification, otherwise unremarkable CT C spine: Limited evaluation due to extensive motion artifact. Evaluation of new fracture is limited. Grossly unchanged appearance of C5 fracture. CT Head: No acute bleed EKG: on arrival in sinus rhythm at a rate of 107bpm, av conduction delay, artifact, no ST changes Liver/gallbladder u/s [1-9] 1. Limited study due to motion as the patient was unable to hold his breath. 2. Echogenic liver compatible with fatty infiltration. 3. No intra- or extra-hepatic ductal dilation. 4. Normal gallbladder. Brief Hospital Course: 58 yo male with history of recent C5 spinous process fracture, atrial fibrillation, PEs, and tricuspid valve endocarditis admitted for alcohol [Month/Day (2) ], atrial fib with RVR and respiratory distress. 1. Respiratory Distress: Given the patient was afebrile, felt was likely aspiration pneumonitis, and patient was started on Levofloxacin/Flagyl on [1-8] for aspiration pneumonia. The Flagyl was stopped on [1-10]. He completed a 5 day course of levofloxacin for pneumonia empirically and improved. 2. Atrial Fibrillation: Most likely was in rapid ventricular response secondary to increased catecholamine surge from [Month/Day (4) ]. He was treated with diltiazem drip initially. As [Month/Day (4) ] improved HR was controlled with resumption of his home medications. 3. ETOH intoxication/Polysubstance abuse: Patient was maintained on CIWA during admission, and given MVI/thiamine. His [Month/Day (4) ] was complicated by hallucinations. He requested to leave [1-11] but was thought too intoxicated, likely due to benzos used to treat his [Last Name (LF) ], [First Name3 (LF) ] psychiatry was consulted and agreed he was not competent to leave. He was improved on [1-12] and again wanting to leave. He was again evaluated by psychiatry and felt able to be discharged safely. He was also evaluated by physical therapy and cleared to be discharged safely from their perspective. Social work was consulted to assist with transportation. 4. Hepatitis: He was noted to have a transaminitis on admission thought secondary to alcohol given AST to ALT ratio in addition to Hep C. He had relatively preserved synthetic function and lft's improved to normal during his course.. 5. Depression: He was continued citalopram. Quetiapine was held out of concern for worsening sedation with this medication. Medications on Admission: Suboxone 8mg/2mg TID Citalopram 60mg QD Gabapentin - unknown dose Quetiapine 25 mg PO BID Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q4H PRN Omeprazole 20 mg PO QD Diltiazem HCl 60 mg PO QID Metoprolol Tartrate 12.5 mg PO BID Tamsulosin 0.4mg QD Ambien 10mg QHS Calcium with D Discharge Medications: 1. Diltiazem HCl 60 mg Tablet [Month/Day (1) ]: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:0 2. Metoprolol Tartrate 25 mg Tablet [Month/Day (1) ]: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 3. Citalopram 20 mg Tablet [Month/Day (1) ]: Three (3) Tablet PO DAILY (Daily). 4. Multivitamin Tablet [Month/Day (1) ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [Month/Day (1) ]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Seroquel Oral 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [Month/Day (1) ]: One (1) Capsule, Sust. Release 24 hr PO once a day. 8. Calcium Carbonate-Vitamin D3 600-400 mg-unit Tablet [Month/Day (1) ]: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Alcohol withdrawal Secondary diagnoses: Pneumonia Hepatitis Atrial fibrillation Alcohol abuse Discharge Condition: Alert and oriented, able to hold conversation about risks and benefits of staying in the hospital, afebrile. Able to walk without assistance. Discharge Instructions: You were admitted with alcohol withdrawal and alcoholic hepatitis. We treated you in the intensive care unit with medications to prevent seizures or DTs. We also treated you with the antibiotic levofloxacin for pneumonia while you were here. We did not make any medication changes while you were here. You were given a prescription for a daily multivitamin. We encourage you to stop drinking alcohol. Please continue to work with your primary doctor to work on your addiction as it is a [Last Name 40904] problem for you. Your primary care doctor saw you just before your discharge. Please continue to work with him in the future. Followup Instructions: You have an appointment with your primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4427], for Tuesday, [2165-1-15] at 2:10pm. His number is [Telephone/Fax (1) 250]. Please keep your previously scheduled appointments: Provider: [Name10 (NameIs) ] [Last Name (STitle) ]/DR [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2165-1-23] 2:30 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2165-1-23] 2:30 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2165-1-23] 2:10 ICD9 Codes: 486, 4254
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6851 }	Medical Text: Admission Date: [2193-1-30] Discharge Date: [2193-2-21] Date of Birth: [2106-8-7] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2297] Chief Complaint: somnolence Major Surgical or Invasive Procedure: [2193-2-5] Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 363], surgeon 1. T8 to L1 fusion. 2. Laminectomy of T11. 3. Multiple thoracic laminotomies. 4. Instrumentation T8 to L1. 5. Autograft and allograft. 6. Vertebroplasty L1 [2193-1-30] Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 363], surgeon: 1. Partial vertebrectomy of T11 and T12. 2. Fusion, T10 to T12. 3. Instrumentation, T10 to T12. 4. Cage placement. 5. Vertebroplasties T10 and T12. 6. Autograft. a line Right internal jugular central line placement intubation and extubation History of Present Illness: 86 yo man with diet controlled DM2, recently diagnosed benign pharyngeal mass associated with aspiration, spinal stenosis, s/p a fall in late [Month (only) 1096], admission [Date range (1) 94858]/12, readmitted on [2193-1-29] for LE weakness and s/p spinal fusion surgeries on [1-30] and [2-5] for T11 fracture, with VAP post-op and now with increasing hypercarbia and somnolence. Pt initially presented 3 days after a fall; on his first admission no evidence of fracture was found, although he had new onset atrial fibrillation and discovery of a L pharyngeal mass and associated aspiration during that visit. The atrial fibrillation self-resolved after pt received a calcium channel blocker, and pathology from the pharyngeal mass was benign. He was discharged to rehab on [2193-1-18] with a Dobhoff tube in place. Repeat swallow eval on this admission recommended he continue NPO. He was readmitted on [1-29] after another fall (?) and found to have a T11 fracture with a significant lower extremity paraparesis and was admitted to ortho spine. On [1-30] he had a partial vertebrectomy of T11 and T12 with T10 to T12 fusion. He was extubated a day after surgery; at that time he had CXR evidence of VAP and he was started on vanc/Zosyn and reintubated. Sputum grew MSSA and pt was switched to nafcillin on [2-6]; he finished his course of nafcillin on [2-10]. He returned to the OR on [2-5] for a planned T8-L1 fusion and was extubated on [2-6]. Pt developed afib with RVR in the TSICU; he was cardioverted and started on an amiodarone drip which was then stopped for prolonged QTc. Pt devoloped rapid afib again but spontaneously converted. He was rate controlled on metoprolol. He triggered on [2-11] for afib with RVR that was difficult to control with IV metoprolol and diltiazem; pt received a dilt gtt overnight and had increasing O2 requirements from 2-4L NC to facemask with oxygen. Per pt's daughter, pt was last at his baseline mental status prior to his second operation, but was conversant and articulating thoughts clearly on the night of [2-11]. On [2-12], pt became increasingly somnolent with blood gas 7.26/72/85 and was transferred to the MICU. Past Medical History: ANEMIA, chronic, unknown baseline BENIGN PROSTATIC HYPERTROPHY, hx turp, hx incontinence CONSTIPATION DEPRESSION DIABETES TYPE II - diet controlled GAIT DISORDER, falls d/t spinal stenosis MELANOMA leg [2187] no records SPINAL STENOSIS S/P HIP REPLACEMENT, KNEE REPLACEMENT Social History: Admitted from rehab in [Location (un) ] where he has been since discharge. Prior to admission [1-13], was living in [Hospital 4382] at [Doctor Last Name ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 410] where he has been living for the past one year, active in many activities, walks with walker. He is retired from sales, whole-selling men's clothes about 20 years ago. He is a widower for one year after over 50 years of marriage. Has two daughters. Family History: No premature CAD, no diabetes. The patient has personal history of diet-controlled diabetes. Physical Exam: (on MICU TRANSFER) HR 56, BP 100/70, temp 99, O2 92% on NRB, RR 16 Gen: Caucasian male, non-responsive to sternal rub, not withdrawing to pain Cardiac: Nl s1/s2 irregular rhythm Pulm: crackles at bases bilaterally Abd: soft, NT, ND normoactive bowel sounds Ext: 1+ LE edema present bilaterally Pertinent Results: ADMISSION LABS [2193-1-29] 07:00PM BLOOD WBC-10.3 RBC-4.17* Hgb-12.6* Hct-36.3* MCV-87 MCH-30.2 MCHC-34.7 RDW-14.3 Plt Ct-224 [2193-1-29] 07:00PM BLOOD Neuts-88.8* Lymphs-6.7* Monos-3.4 Eos-0.8 Baso-0.3 [2193-1-29] 07:00PM BLOOD PT-11.6 PTT-28.7 INR(PT)-1.1 [2193-1-29] 07:00PM BLOOD ESR-15 [2193-1-29] 07:00PM BLOOD Glucose-128* UreaN-26* Creat-0.6 Na-137 K-4.0 Cl-99 HCO3-28 AnGap-14 [2193-1-29] 07:00PM BLOOD ALT-22 AST-16 AlkPhos-172* [2193-1-29] 07:00PM BLOOD Lipase-10 [2193-1-30] 09:04PM BLOOD Calcium-7.1* Phos-3.7 Mg-1.5* [2193-1-29] 07:00PM BLOOD CRP-39.5* [2193-2-2] 06:15PM BLOOD Vanco-13.1 [2193-1-30] 05:13PM BLOOD Type-ART pO2-155* pCO2-43 pH-7.43 calTCO2-29 Base XS-4 Intubat-INTUBATED [2193-1-30] 05:13PM BLOOD Glucose-110* Lactate-1.1 Na-135 K-3.6 Cl-102 [2193-1-30] 05:13PM BLOOD Hgb-11.9* calcHCT-36 O2 Sat-98 [2193-1-30] 05:13PM BLOOD freeCa-1.12 Brief Hospital Course: 86 yo man with diet controlled DM2, recently diagnosed benign pharyngeal mass associated with aspiration, spinal stenosis, s/p a fall in late [Month (only) 1096], admission [Date range (1) 94858]/12, readmitted on [2193-1-29] for LE weakness and s/p spinal fusion surgeries on [1-30] and [2-5] for T11 fracture, with VAP post-op and now with increasing hypercarbia and somnolence. Pt initially presented 3 days after a fall; on his first admission no evidence of fracture was found, although he had new onset atrial fibrillation and discovery of a L pharyngeal mass and associated aspiration during that visit. The atrial fibrillation self-resolved after pt received a calcium channel blocker, and pathology from the pharyngeal mass was benign. He was discharged to rehab on [2193-1-18] with a Dobhoff tube in place. Repeat swallow eval on this admission recommended he continue NPO. He was readmitted on [1-29] after another fall (?) and found to have a T11 fracture with a significant lower extremity paraparesis and was admitted to ortho spine. On [1-30] he had a partial vertebrectomy of T11 and T12 with T10 to T12 fusion. He was extubated a day after surgery; at that time he had CXR evidence of VAP and he was started on vanc/Zosyn and reintubated. Sputum grew MSSA and pt was switched to nafcillin on [2-6]; he finished his course of nafcillin on [2-10]. He returned to the OR on [2-5] for a planned T8-L1 fusion and was extubated on [2-6]. Pt developed afib with RVR in the TSICU; he was cardioverted and started on an amiodarone drip which was then stopped for prolonged QTc. Pt devoloped rapid afib again but spontaneously converted. He was rate controlled on metoprolol. He triggered on [2-11] for afib with RVR that was difficult to control with IV metoprolol and diltiazem; pt received a dilt gtt overnight and had increasing O2 requirements from 2-4L NC to facemask with oxygen. Per pt's daughter, pt was last at his baseline mental status prior to his second operation, but was conversant and articulating thoughts clearly on the night of [2-11]. On [2-12], pt became increasingly somnolent with blood gas 7.26/72/85 and was transferred to the MICU. In the MICU, the patient was intubated. His hypercarbic respiratory failure was felt to be secondary to post-op deconditioning and weakness, possible aspiration pneumonia. CTA chest did not show PE but did show pneumonia. He was initially hypothermic with T 94 and bairhugger was placed. He had bradycardia to the 40s. He underwent bronchoscopy, and BAL grew pan-sensitive klebsiella and staph aureus, resistant to erythromycin and clindamycin. The patient did have hypotension requiring neosynephrine, which was weaned off the day after admission to the MICU. He was treated with vancomycin and zosyn. In speaking to the family, the patient was going to need to be transitioned to trach, which the family did not want. The patient actually bit his ETT and required extubation, and the family opted to not re-intubate, as he would need a trach the following day. The patient did maintain his saturations, however, his mental status did not improve. Throughout his MICU admission, he has been minimially responsive to pain, opening his eyes but not verbalizing or following commands. The vertebroplasty was likely limiting his respiratory effort, and in this setting, we were holding warfarin, although treating with aspirin. The patient's acidosis worsened and his family opted to transition to [Month/Day (4) 3225]. The patient did have afib and required diltiazem drip prior to admission to the MICU; he had no further episodes of afib. The patient has a pharyngeal mass, which is benign, but does increase risk for aspriation. He does have T2DM, which was controlled with insulin sliding scale. He had acute kidney injury, with creatinine elevated to 2.7, from baseline of 0.7 prior to his MICU admission. This was thought to be related to ATN related to initial hypotension episode. The patient's code status was changed multiple times throughout his admission, according to the wishes of his HCP, his daughter, talk to [Name (NI) 94859] ([Telephone/Fax (1) 94860], cell [Telephone/Fax (1) 94861]. Finally, in discussion with his HCP, he was transitioned to [Name (NI) 3225]. The patient was started on a dilaudid drip for comfort and expired on [2193-2-21]. His daughter, [Name (NI) 94859], was at the bedside and declined autopsy. Medications on Admission: Discharge meds [1-18]: ASA 81, citalopram 20 daily, enablex 15 mg, collace, bisacodyl, lidocaine patch, lansoprazole 30 mg [Hospital1 ], psyllium . Meds on transfer: Senna 1 TAB PO/NG [Hospital1 ]:PRN constipation Ondansetron 4 mg IV Q4H:PRN nausea/vomiting Milk of Magnesia 30 mL PO/NG Q6H:PRN constipation Insulin SC (per Insulin Flowsheet) Heparin 5000 UNIT SC BID Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol FoLIC Acid 1 mg PO/NG DAILY Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Docusate Sodium (Liquid) 100 mg PO/NG [Hospital1 ] Calcium Carbonate 500 mg PO/NG QID:PRN osteopenia Bisacodyl 10 mg PR HS:PRN constipation CefePIME 2 g IV Q8H Vancomycin 1000 mg IV Q 12H Discharge Disposition: Expired Discharge Diagnosis: Patient expired on [2193-2-21] at 1505. Discharge Condition: expired Completed by:[2193-2-21] ICD9 Codes: 5845, 9971, 2851, 2760
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6852 }	Medical Text: Admission Date: [2195-5-14] Discharge Date: [2195-5-16] Service: MEDICINE Allergies: Amoxicillin / Sulfonamides / Penicillins Attending:[First Name3 (LF) 710] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: 88 y.o woman with metastatic [First Name3 (LF) 499] cancer to the liver, possible primary pancreatic cancer, recent dx of UTI on cipro, who presented to the hospital after developing acute shortness of breath at home. The patient was at home at her [Hospital3 ] when her aide noticed her to be in acute respiratory distress. The aid called her son in law, who is a physician, [Name10 (NameIs) ] because the hospice agency was unable to come to evaluate, he decided to bring her to the hospital. . Of note, the patient had recently been admitted to the hospital on [4-7] for tachycardia, cough, found to have a bandemia and was treated for pneumonia. During that admission, after extensive consultations with palliative care and given the patient's underlying oncologic disease, she was discharged with PO antibiotics and was placed in hospice care the day after. According to his chart in OMR, the family has been actively involved in the decision to place her in hospice as the patient herself has not wanted to know anything about her diagnosis. . In the ED, initial vs were: T 97.9 P 113 BP 170/90 R 23 O2 sat 99% on NRB. Patient was given Vancomycin 1 gram IV x1 and Ativan 2 mg IV x1. Zosyn was ordered but not given in the ED. She was also given 40mg IV lasix enroute by EMS. The patient was hypoxic, and was placed on Bipap 40%, [9-15], drawing a tidal volume of 400cc with minute ventilation of 16. Vitals on transfer were HR 110, BP 135/87, RR 40 O2 sat of 100%. Past Medical History: - Biopsy proven [Month/Day (1) 499] ca, possible pancreatic cancer, and possible liver mets (not Bx proven). The family knows, however, the patient does not and apparently the PCP has been in discussion with the family, and the patient has told the PCP she does not want to know her diagnosis. They feel she will be anxious and depressed and do not want her to know. -HTN -glaucoma -OA -?Rheum dx -LBP -gait disorder -stage I pressure ulcer on kyphotic area of spine, noted [2-18] -GERD -Depression -Extensive bilateral DVT's seen on u/s [2-18] with IVC filter in place -pulmonary artery hypertension Social History: "The patient lives in [Hospital3 ] with a home health aide to whom she is dearly attatched. She has two daughters, one lives in [Name (NI) 531] and one in [Location (un) 86]. The patient went to teachers college and worked in an engineering office. Her social supports include her family. She does do physical therapy, but she says that she does not do much of the activities because she gets tired. Denies alcohol, smoking. Says that she sometimes eats 50% of the meals; she tries to drink Boost in between. She has been doing physical therapy, which is continuing, and apparently, she has made progress. In terms of sleep, she says that some nights are good and some nights are not, but she denies any pain while sleeping or that wakes her up from sleep. She feels otherwise safe at home." Family History: No history of [Location (un) 499] cancer, IBD, breast cancer, CAD, diabetes, rheumatic diseases, asthma. Physical Exam: Vitals: T: 98.5 BP: 102/47 P: 100 R: 22 O2: 97% on Bipap General: responsive to voice, in moderate distress HEENT: BiPAP mask on Neck: supple, JVP not elevated, no LAD Lungs: Bilateral crackles and rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, palpable cords, 2+ bilateral LE edema Skin: diffuse ecchymoses Pertinent Results: CXR: IMPRESSION: Extensive opacification in the right middle lobe with air bronchograms. Although the significant rotation severely limits evaluation of this region, there is a likely underlying infiltrate. Brief Hospital Course: Patient admitted to the MICU service with respiratory distress. Thought to most likely be secondary to her known pneumonia. She received vancomycin in the ED and was started on cefepime and ciprofloxacin IV as empiric coverage for HAP. She was placed on BiPAP overnight and then a facemask in the morning. She seemed comfortable. Family meeting held on [5-15] regarding goals of care. At this point, family preferred CMO with morphine gtt. Patient called out to floor on [2195-5-15] and expired [2195-5-16]. Medications on Admission: Acetaminophen 500 mg Tablet Two (2) Tablet by mouth three times a day. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray One (1) spray Nasal DAILY (Daily). Calcium Carbonate 500 mg Tablet, Chewable One (1) Tablet, Chewable by mouth four times a day. Ciprofloxacin 500mg [Hospital1 ] Cholecalciferol (Vitamin D3)400 unit Tablet Two (2) Tablet by mouth DAILY (Daily). Docusate Sodium 100 mg Capsule One (1) Capsule by mouth twice a day Duloxetine 20 mg Capsule, Delayed Release(E.C.) Two (2) Capsule, Delayed Release(E.C.) by mouth DAILY (Daily). Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [12-14] Adhesive Patch, Medicateds Topical DAILY (Daily) as needed for pain. Lorazepam 0.5 mg Tablet One (1) Tablet by mouth every four (4) hours as needed for anxiety. Magnesium Hydroxide 400 mg/5 mL Suspension Thirty (30) ML by mouth every six (6) hours as needed for constipation. Metoprolol XL 50 mg Tablet One (1) Tablet by mouth once a day. Mirtazapine 30 mg Tablet One (1) Tablet by mouth HS (at bedtime). Oxycodone 10 mg Tablet Sustained Release 12 hr One (1) Tablet Sustained Release 12 hr by mouth every twelve (12) hours. Oxycodone 5 mg Tablet One (1) Tablet by mouth every four (4) hours as needed for pain. Polysaccharide Iron Complex 150 mg Capsule One (1) Capsule by mouth DAILY (Daily). Prednisone 5 mg Tablet One (1) Tablet by mouth DAILY (Daily). Sennosides [Senna] 8.6 mg Tablet Two (2) Tablet by mouth HS (at bedtime). Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[2195-5-18] ICD9 Codes: 486, 4019, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6853 }	Medical Text: Admission Date: [2133-7-19] Discharge Date: [2133-8-6] Date of Birth: [2067-3-29] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6075] Chief Complaint: s/p seizure Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname ] is a 66 y/o man with hx of HTN, hemorrhagic CVA with seizure disorder secondary to that, which have left him dependent in all ADL's with cognitive impairment. He was admitted on [7-19] with respiratory failure, fever. and increased lactate (9) likely secondary to a seizure with subsequent aspiration pneumonia. He was at home watching TV with his wife, clapping and singing, when he began to "shake all over" with his eyes rolling back into his head. He was not incontinent of feces or urine at the time. He was unresponsive during the episode. After about 10 minutes, he awoke and noted to be wheezy, c/o shortness of breath, and somnolent. He was transferred to the ED by ambulance. In terms of his seizure history, he is followed by neurology at the VA. In [12-29], he had an EEG with showed left frontal > temporal dysfunction and interictal discharges suggestive of an irritative focus. This was a change from his EEG in [1-23], and he was started on Tegretol. His last refill was [2133-3-30]. According to his family and per the note from his PCP, [Name10 (NameIs) ] ran out of Tegretol at that time. His PCP was holding the Tegretol until he had a chance to see neurology. An EEG while in house also showed epileptiform waves in bilateral frontal lobes and diffuse slowing suggesting encephalopathy. Past Medical History: - HTN - CVA (hemorrhagic) times two (bilateral frontal lobes) - Seizure disorder secondary to stroke - Hyperlipidemia - Cognitive deficit secondary to stroke Social History: Lives with wife on Mission [Doctor Last Name ], smoking hx., but no ETOH Family History: NC Physical Exam: PE: GEN: Laying in bed with eyes closed, laughing occasionally VS: T 97 HR 83 BP 139/78 RR 17 Sats 94 on 4L NC HEENT: NCAT, PERRL, face grossly symmetric COR: distant heart sounds, RRR, no MRG PULM: Distant breath sounds, occ expiratory wheezes, no rhonchi or crackles anteriorly ABD: obese, soft, nt, nd EXT: 2+ pulses, No c/c/e, does not move lt. side as much as right, but moves all 4 NEURO: Alert, oriented to person only. Unable to follow commands to comply with full examination. Pertinent Results: [2133-7-19] 10:45AM WBC-17.7* RBC-5.49 HGB-15.5 HCT-48.2 MCV-88 MCH-28.3 MCHC-32.2 RDW-13.5 [2133-7-19] 10:45AM NEUTS-66.5 LYMPHS-26.9 MONOS-3.9 EOS-1.1 BASOS-1.6 [2133-7-19] 10:45AM PLT COUNT-350 [2133-7-19] 10:45AM PT-11.9 PTT-25.9 INR(PT)-1.0 [2133-7-19] 10:45AM D-DIMER-8385* [2133-7-19] 10:45AM GLUCOSE-143* UREA N-17 CREAT-1.3* SODIUM-143 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-21* ANION GAP-23* [2133-7-19] 10:45AM ALT(SGPT)-27 AST(SGOT)-27 CK(CPK)-56 ALK PHOS-130* AMYLASE-85 TOT BILI-0.5 [2133-7-19] 10:45AM CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-2.4 [2133-7-19] 10:59AM LACTATE-9.2* [2133-7-19] 11:48AM PO2-280* PCO2-38 PH-7.33* TOTAL CO2-21 BASE XS--5 . CXR ([7-22]) Lung volumes remain quite low. Consolidation at the base of the right lung has worsened since [7-21], probably atelectasis. Pulmonary vascular congestion is present but there is no edema and the heart is normal size. No pneumothorax or appreciable pleural effusion. Right jugular line tip projects over the upper right atrium. . EEG: ([7-20]) IMPRESSION: This was abnormal EEG due to the presence of sharp wave epileptiform discharges seen in the Delta frequency slowing in the frontal region bilaterally suggest a abnormality in the subcortical or midline structures. Generalized theta frequency slowing of the background indicates a moderate encephalopathy. . CT head: ([7-19]) IMPRESSION: No hemorrhage or mass effect identified. . CT abdomen: IV contrast only ([7-19]) IMPRESSION: 1. No intra-abdominal infectious source identified. 2. L1 compression fracture, age indeterminate. 3. Small bilateral pleural effusion/atelectasis. 4. Left renal cyst and many other tiny left renal hypodensities, likely simple cysts, but too small to characterize. 5. Colonic diverticuli without evidence of diverticulitis. 6. Cholelithiasis without evidence of cholecystitis. 7. Enlarged prostate. Brief Hospital Course: 66 y/o man with hx of HTN, hemorrhagic CVA with seizure disorder, cognitive impairment admitted with respiratory failure and fever likely secondary to seizure with subsequent aspiration pneumonia . He required CPAP to maintain his sats on the day of admission. His O2 requirements were weaned over the next few days and he is now on 4L NC with sats in the mid 90s. On admission, he was febrile to 102.7, and in the interval after admission has developed a RLL consolidation vs atelectasis. His blood and urine cultures have been negative. There was question of a PE with an elevated D-Dimer and hypoxia, but the family was unwilling to proceed with CTA. He was initially on Vanc/Levo/Flagyl on admission, but Vanc was d/c on [7-22]. . # Hypoxia: Pt was admitted to the MICU due to very low O2 sats and was initially on CPAP to maintain sats. His oxygen was weaned down during his MICU stay and he was transferred to the floor on HD# 5 on 4L NC. He was quickly weaned down to 2L NC, but it was difficult to maintain his sats above 90 on RA while he was so lethargic. ABG showed good oxygenation and ventilation. He was found to be very wheezy on exam and was started on xopenex nebs along with atrovent. Due to continued wheezing, Advair was added. This improved during his hospital course, and eventually he was taken off all nebulizers and only required albuterol prn. . # Fever: Likely secondary to aspiration pneumonia in combination with atelectasis. Blood and urine cx remained negative throughout hospital course. He was treated for aspiration pneumonia with levo/flagyl x 10 days. However, he spiked a fever to 102 overnight and was restarted on Levo/Clinda due to concern that metronidazole was interacting with carbamazepine to contribute to his continued somnolence. CXR revealed worsening atelectasis, likely in part due to lethargy and poor inspiratory effort. It was difficult to get the patient to use incentive spirometer due to patient lethargy and cognitive function impairing him from following commands. . # Seizures: Head CT did not show any evidence of hemorrhage or mass effect. Per VA notes, pt has no documented hx of seizures but was started on Tegretol for an EEG that was strongly suggestive of seizures. Tegretol was stopped 2 months prior to admission. Neurology was consulted and recommended restarting the tegretol. Tegretol level was within normal limits at 9. However, the patient remained very lethargic during his hospital stay, and was transitioned from Tegretol to Keppra in an attempt to improve his mental status. . # Lethargy: Concerning for underlying infection, esp given spiking temperatures. Possibly continued unrecognized seizure activity with post-ictal states. Will repeat EEG today and adjust AEDs as needed. Changing carbamazepine to Keppra in an attempt to decrease sedation. . # hx of hemorrhagic stroke: Pt has hx of hemorrhagic strokes in bilateral frontal lobes. Due to this pt has cognitive deficits documented with multiple neuropsych testing at the VA. Per his family, pt is not at his baseline and is more lethargic and more deconditioned. Due to his deconditioning, he will be transferred to rehab. . # HTN: Pt was continued on home meds. He required an increase in his metoprolol dose for occasional BP in the 170s. . # Aspiration: He had two video speech and swallow evaluations during his hospital stay due to concern that he was reaspirating and thus continuing to spike fevers. . # FEN: Given his aspiration pneumonia, he needed a video swallow which he passed. He was cleared for thin liquids. . # Code: full . # Communication: Wife: [Name (NI) 501] [Name (NI) ] [Telephone/Fax (1) 103691]; Dtr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 103692] [Telephone/Fax (1) 103693] (home) Cell: [Telephone/Fax (1) 103694]. The patient had been intermittantly lethargic upon transfer out of the ICU to the floor. On hospital day 13, he developed a new right frontal hemorrhage. He was briefly transferred to the MICU for close monitoring then back out to the neuro step-down unit. While on the floor, he remains on tube-feeds via NG tube. He is intermittantly responsive. He will open his eyes to loud voice and answer simple yes or no questions. He will not follow commands. His pupils are equally round and reactive to light, eyes moving all directions, face symmetric, he has marked increased tone in all 4 extremities and notable paratonia. His reflexes are brisk, toes upgoing b/l. He withdraws to pain x4. He remains very inattentive but has achieved a new lowered baseline and is now stable for transfer to a care facility. Medications on Admission: Medications on Admission: - Donepezil 10 daily - Lisinopril 10 daily - Simvastatin 40 daily - Omeprazole 20 po daily - Felodipine 10 daily - Olanzapine 2.5 [Hospital1 ] - Metoprolol 25 [Hospital1 ] - Carbemazepine 200 [Hospital1 ] (Discontinued after last refill on [2133-4-30], Discharge Medications: 1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for wheezing. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)) as needed for seizures. 10. Carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 15. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary Diagnosis: 1. Seizure 2. Aspiration Pneumonia 3. Cognitive decline [12-25] hemorrhagic stroke Secondary Diagnoses: 1. Hypertension 2. High cholesterol Discharge Condition: Stable to be discharged to extended care facility Discharge Instructions: You had a seizure which led to a pneumonia. You have been restarted on tegretol for the seizure disorder and you should not stop taking this unless directed by your neurologist. We started you on advair and combivent inhalers for your wheezing. You should have a pulmonary function test to check your lung function. Please call your PCP or go to the ER if you experience any of the following symptoms: chest pain, fevers, chills, further seizure activity, abdominal pain, shortness of breath or increasing wheezing. Followup Instructions: Follow-up with your PCP in the next 2 weeks. Call [Telephone/Fax (1) 41354] to make this appointment. Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2133-9-18] 2:30 Completed by:[2133-8-5] ICD9 Codes: 0389, 5070, 5180, 431, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6854 }	Medical Text: Admission Date: [2157-10-10] Discharge Date: [2157-10-14] Service: MEDICINE Allergies: Sulfonamides / A.C.E Inhibitors / Protonix Attending:[First Name3 (LF) 4365] Chief Complaint: Respiratory distress, CHF exacerbation Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] yo M w CHF (EF 40%), CAD s/p CABG, CKD, DM2, CHB with pacemaker who presents from his [Hospital3 ] with increased shortness of breath. His torsemide dose had recently been increased from 10mg to 20mg daily over the weekend given weight gain, poor urinary output and rales on exam per visiting nursing. On [10-9] this dose was increased to 40mg daily, however, without substantial benefit and pt was referred to ED today for respiratory distress. According to his son, prior to this time he had been doing well on the torsemide, however still had very poor exercise tolerance and even the smallest task (such as weighing himself) causes him to become dyspnea. . He has had multiple recents admissions for hypoxia and respiratory distress secondary to CHF: [Date range (1) 35209], [Date range (1) ] (MICU stay), [Date range (1) 35210] (MICU stay/BiPAP). On discussions with the patient and his family the decision was made to change his code status to DNR/ but ok to intubate (for short time). . In ED, VS were T 97.1 HR 70 (paces ) 115/59, RR 32, O2 sat low 80s on 100% NRB. He was acutely SOB with increased work of breathing and placed on BiPAP 10/5 (FiO2 100% - 40%). He had some symptomatic improvement with this. His CXR was consistent with pulmonary edema and given concern for possible underlying pneumonia, he was treated with CTX and azithromycin in addition to 100mg IV Lasix. . ROS: as above. Negative for fever, chills. +weight gain. +R hand weakness (unchanged). + LE edema. No abdominal pain, nausea, vomiting, diarrhea or constipation Past Medical History: Type II diabetes mellitus CAD s/p CABG in [2127] Single chamber PPM for CHB EF 40%, [12-22]+ MR/TR Moderate pulmonary HTN BPH s/p TURP CKD baseline Cr 2-2.2 Gout Partial Hip replacement last year after fall Macular Degeneration on R eye B/L vision loss Hearing loss Social History: Used to work in a confectionary store in [State 760]. Now lives in [Hospital3 ] facility with his wife. [Name (NI) ] two sons, one in [Name (NI) 86], both involved in care. 30 pack year smoking history of cigars and pipes. Rarely drinks EtOH. Denies illicits. Family History: Mother with CAD in her 50s died from myocardial infarction. Physical Exam: Tmax: 36.4 ??????C (97.5 ??????F) Tcurrent: 35.8 ??????C (96.5 ??????F) HR: 70 (67 - 70) bpm BP: 108/59(73) {89/17(42) - 112/66(98)} mmHg RR: 18 (11 - 23) insp/min SpO2: 95% Heart rhythm: V Paced Gen: NAD, pleasant, conversive, alert HEENT: NC/AT, EOMI, L pupil surgical, R reactive, dry lips/MM Neck: supple, JVD to jaw, no carotid bruits, no LAD Heart: Pacemaker in place, distant RRR, nl S1/2, no S3/4, no murmurs or rubs Lungs: Slightly tachypneic with very little use of accessory muscles, crackles at bases b/l, no wheezes Abd: +BS, soft, tympanic throughout, NT/ND Ext: 1+ edema L leg, [12-22]+ R leg, 1+DP and PT pulses B/L Neuro: AAOx3, moves all 4 extremities, weakness of RUE compared to L Skin: no ulcers, rash or lesion, no decubitus ulcer Psych: mood/affect appropriate Pertinent Results: Labs on admission: [2157-10-11] 05:10AM BLOOD WBC-5.8 RBC-2.79* Hgb-8.4* Hct-24.8* MCV-89 MCH-30.2 MCHC-33.9 RDW-18.5* Plt Ct-102* [2157-10-10] 02:00PM BLOOD Neuts-80.6* Lymphs-10.0* Monos-7.1 Eos-2.0 Baso-0.3 [2157-10-10] 08:51PM BLOOD PT-18.3* PTT-39.9* INR(PT)-1.7* [2157-10-11] 05:10AM BLOOD Glucose-51* UreaN-100* Creat-3.3* Na-137 K-4.0 Cl-101 HCO3-25 AnGap-15 [2157-10-10] 08:48PM BLOOD CK(CPK)-99 [2157-10-10] 08:48PM BLOOD CK-MB-4 cTropnT-0.01 [2157-10-10] 02:00PM BLOOD cTropnT-0.03* [2157-10-10] 02:00PM BLOOD CK-MB-NotDone proBNP-3989* [2157-10-10] 02:32PM BLOOD Type-ART pO2-552* pCO2-36 pH-7.43 calTCO2-25 Base XS-0 . Labs on discharge: [2157-10-14] 07:40AM BLOOD WBC-5.7 RBC-2.90* Hgb-8.7* Hct-26.0* MCV-90 MCH-30.1 MCHC-33.6 RDW-18.4* Plt Ct-133* [2157-10-14] 07:40AM BLOOD Glucose-82 UreaN-111* Creat-4.2* Na-133 K-4.4 Cl-96 HCO3-24 AnGap-17 [2157-10-14] 07:40AM BLOOD Calcium-8.5 Phos-5.9* Mg-2.9* Iron-49 . Microbiology: Urine Cx: [10-10] negative . Imaging: CXR: [10-11] FINDINGS: As compared to the previous radiograph, there is unchanged moderate pulmonary edema accompanied by bilateral pleural effusions. Also unchanged is the amount of interstitial fluid accumulation and the size of the cardiac silhouette. No evidence of newly appeared parenchymal opacities. Unchanged right-sided pacemaker. . Right upper extremity ultrasound [2157-10-13]: IMPRESSION: No evidence of DVT in the right upper extremity. Brief Hospital Course: Patient is a [Age over 90 ] year old man with history of diastolic and systolic CHF, CAD status post CABG, CKD, DM2 who presents with respiratory distress likely secondary to CHF flare and pulmonary edema initiated on BiPAP in the ED. . Plan: # SOB/Dyspnea/Acute on chronic diastolic and systolic heart failure: The patient presented with acute respiratory distress, initially requiring bipap and ICU monitering. He was initially placed on a lasix drip, which was then converted to torsemide 30mg [Hospital1 ], with stabilization of his respiratory status and transfer to the regular medical floor. On the medical floor, his torsemide was weaned down to 20mg [Hospital1 ], then to 20mg daily on discharge to help with his rising kidney function, particularly because his respiratory status remained stable. He was also started on valsartan 40mg daily to assist with afterload reduction. On discharge, he was breathing comfortabley on his baseline 2 liters oxygen via nasal cannula, and will follow up with Dr. [Last Name (STitle) 5717] in clinic. . # Acute on chronic renal failure: The patient's creatinine has been rising over past 6-8 months, which is attributed to his poor forward flow from his congestive heart failure and recurrent diuretic use with exacerbations. His new baseline on admission was 2.8-3.4, and patient had acute renal failure with rise in his creatnine to 4.2 at time of discharge. Renal consult was obtained and his acute renal failure was attributed to his diuretic use and addition of valsartan, although no change in management was made as he required these medications for his congestive heart failure. He was started on sevelamer TID with meals, and was discharged to start taking procrit 10,000 units every other week and iron supplements for his kidney-disease related anemia. It is unclear if he will tolerate the procrit with his congestive heart failure. Although his creatnine was still rising at time of discharge, per discussion with the patient's primary care physician and the nephrologists, we felt comfortable discharging him on a lower dose of torsemide, 20mg daily, to be increased to [Hospital1 ] as needed for volume overload. His electrolytes and creatnine will be monitered by home nursing on discharge, and he will follow up with Dr. [Last Name (STitle) 5717] and Dr. [Last Name (STitle) 4090] (from nephrology) in clinic. . # CAD status post remote CABG: The patient was maintained on his outpatient aspirin, beta blocker. . # Anemia: The patient's recent baseline Hct has been approx 25. His anemia is attributed to his renal failure and he was discharged on iron supplements, and procrit if tolerated. . # BPH: Continued Flomax . # Diabetes mellitus type II: Held glipizide and treatd with humalog ISS, restarted glipizide on discharge. Medications on Admission: Aspirin 81 mg po daily Senna 8.6 mg po bid Tamsulosin 0.4 mg po qhs Glipizide 10 mg po daily Torsemide 10 mg po daily Carvedilol 6.25 mg po bid Albuterol INH prn Home oxygen at 2L/min continuous Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day: Can increase to 2 times per day if needed. Disp:30 Tablet(s) Refills:2 7. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet(s) Refills:2 10. Procrit 10,000 unit/mL Solution Sig: One (1) injection Injection every other week. Disp:10 injections Refills:2 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 12. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Acute on chronic systolic and diastolic congestive heart failure Acute on chronic renal failure Discharge Condition: Improved respiratory status, worsening renal function. Discharge Instructions: You were admitted to the hospital with exacerbation of your congestive heart failure. -Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. -Adhere to 2 gm sodium diet -Fluid Restriction: please restrict fluid intake to no more than 1000 to 1500mL per day -Please take medications as directed. Medication changes include: --> torsemide 20mg daily --> addition of ferrous sulfate 325mg daily --> addition of procrit injection 10,000 units every other week --> addition of sevelamer to be taken with meals --> addition of valsartan - Please follow up with appointments as directed - Please contact physician if develop shortness of breath, chest pain/pressure, any other questions or concerns Followup Instructions: Please follow up with renal doctors, Dr. [Last Name (STitle) 4090] ([Telephone/Fax (1) 773] on Thursday [10-31] at 1:00pm, located on [Location (un) 436] of [Hospital Ward Name 23] building. Please follow up with following appointments: -Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 13171], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2157-10-20] 8:30 -Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2157-10-25] 10:00 -Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10477], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2157-10-25] 10:30 ICD9 Codes: 5849, 4280, 4168, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6855 }	Medical Text: Admission Date: [2106-9-28] Discharge Date: [2106-10-7] Date of Birth: [2039-2-13] Sex: F Service: MEDICINE Allergies: Morphine / Dilaudid (PF) Attending:[First Name3 (LF) 1253] Chief Complaint: hypotension, confusion Major Surgical or Invasive Procedure: right internal jugular central venous catheter placement History of Present Illness: 67F with hx of CRI (bl cr 1.4), Crohn's, pancreatic insufficiency and multiple UTIs presents from rehab with complaints of fever and hypotension. Per the pt, she has been in rehabs since her discharge on [2106-9-8]. She was in her USOH until two days ago when she developed increased frequency of bowel movements, up to 6x/day from a baseline of 2x/day. She noted that the bowel movements were "liquidy" unlike her usual formed stools and denied abdominal pain, hematochezia or melena. She also noted chills but denied subjective fever. She stated she had not had cough, sob, cp, or dysuria. However she did note that during previous episodes of UTI she had always been without symptoms. She also noted that she uses pampers diapers because she sometimes has difficulty making it to the toilet, this has especially been the case in the last couple of days when she has been having bowel frequency. . Per the Rehab facility, two days ago the pt was confused and so she was sent for stat labs. Today the pt was complaining of weakness, and found to have T 100.4, pulse 107 bp 98/58 rr 18 92%RA, fsg 132. The labs returned showing WBC 14.3, Cr 2.5, and a u/a that was cloudy, 1+ LE, 6 wbc. UCx showed 10k-30k Gram Positive species. Given this picture, the decision was made to send the pt to the ED. . In the ED the pt was found to be 99.5 82 73/45 24 100% Non-Rebreather. She had a CBC showing WBC 14.8, Cr 2.6 from baseline 1.2, u/a with trace leuks and few bacteria, CXR without acute process. Trop 0.07. CT abd without evidence of colitis. A RIJ was placed, the pt was given 3L NS with improvement in BP to 100s/70s, and vanc, zosyn and flagyl. Systolics returned to the 80s so the pt was started on levophed 0.03 and transferred to the ICU. . On the floor, the pt was 96 108/54 (on levo) 75 100%2Lnc. She denied any pain but did endorse some confusion. She states that she had some diarrhea for the preceding few days and chills. The pt had a bm which was very loose and had 4 red capsules were found in it. She had repeat labs which showed wbc 12.9, hct 25.9, cr 2.0. . Review of systems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Coronary artery disease s/p RCA w/ bare metal stent on [2102-2-2](single vessel disease) 2. Diastolic CHF (Recent ECHO [2105-10-15], EF~55%) 3. Crohn's Disease: h/o pancolitis w/o small bowel involvement; colonoscopy [10-14] showed no active disease, was on 5-[Month/Year (2) ] 4. Chronic Renal Failure (Cr~1.4 at baseline) 5. DM Type II on insulin 6. Hypertension 7. h/o idiopathic dilated CMP, now resolved 8. Peptic ulcer disease 9. Alcoholic cirrhosis 10. GERD 11. Rheumatoid arthritis 12. Pulmonary embolus in [2098] 13. Total right knee replacement with subsequent chronic pain 14. [Doctor Last Name ] mal seizure in childhood 15. Cervical disc disease 16. L5/S1 radiculopathy with anterolisthesis of L4 on L5 on X-Ray with EMG consistent with mild radiculopathy 17. History of GI bleed of unclear etiology ([2-/2103]), questionable hemorrhoids 18. h/o MRSA right knee wound infection s/p knee replacement 19. Anemia 20. H/o CDiff colitis ([5-/2102]) 21. Osteopenia 22. Chronic pancreatitis 23. Cervical spndylysis 24. h/o Candidal esophagitis Social History: Patient lives with a disabled son in [Name (NI) 669]. Recently discharged to rehab. She was married but divorced a long time ago. 4 pack year smoking history, quit 15 years ago. Drank ~1 pint alcohol/day x 10 years, quit 15 years ago. Denies illicit drug use. Ambulates with a walker at baseline. Family History: M: [Name (NI) ] Ca F: DM with Bilateral [Name (NI) 6024] Sister: Cervical cancer & RA Son: Stroke Physical Exam: Vitals: 96 108/54 (on levo) 75 100%2Lnc General: obese female in nad, oriented x3 but somewhat confused, decreased alertness HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender to deep palpation in the RLQ, LLQ, and suprapubic regions, mild discomfort on palpation of the upper abdomen. neg [Doctor Last Name ] sign. no rebound/guarding. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+pedal edema. Neuro: A&Ox3. 5/5 strength. CN intact. Neuro exam non-focal. Pertinent Results: Admission Labs: [2106-9-28] 10:35AM [Month/Day/Year 3143] WBC-14.8# RBC-3.29 Hgb-9.9* Hct-29.1* MCV-88 MCH-30.1 MCHC-34.1 RDW-15.9* Plt Ct-274 [2106-9-28] 10:35AM [Month/Day/Year 3143] Neuts-77.6* Lymphs-16.0* Monos-5.6 Eos-0.6 Baso-0.1 [2106-9-28] 10:35AM [Month/Day/Year 3143] PT-14.1* PTT-27.1 INR(PT)-1.2* [2106-9-28] 10:35AM [Month/Day/Year 3143] Glucose-177* UreaN-41* Creat-2.6# Na-133 K-4.2 Cl-98 HCO3-20 AnGap-19 [2106-9-28] 10:35AM [Month/Day/Year 3143] ALT-13 AST-20 AlkPhos-150* TotBili-0.5 [2106-9-28] 09:32PM [Month/Day/Year 3143] Calcium-8.0* Phos-4.0 Mg-1.3* . Discharge labs: [2106-10-7] 05:11AM [Month/Day/Year 3143] WBC-8.4 RBC-3.29* Hgb-9.9* Hct-31.4* MCV-95 MCH-30.0 MCHC-31.5 RDW-16.8* Plt Ct-379 [2106-10-7] 05:11AM [Month/Day/Year 3143] Glucose-82 UreaN-19 Creat-1.2* Na-140 K-4.8 Cl-108 HCO3-21* AnGap-16 [2106-10-7] 05:11AM [Month/Day/Year 3143] Calcium-9.4 Phos-4.9* Mg-2.4 . Microbiology: [Month/Day/Year ] cultures [2106-9-28] (x2), [2106-9-29] (x1), and [2106-10-1]: No growth Urine culture [2106-9-28]: <10,000 organisms/ml Urine culture [2106-9-29]: No growth C. diff toxin [2106-9-28] and [2106-10-6]: Negative Stool cultures [2106-10-6]: pending C. diff PCR [2106-10-2]: negative . Imaging: . EKG [2106-9-28]: Sinus rhythm with a ventricular premature beat. Possible inferior myocardial infarction of indeterminate age. Poor R wave progression. Non-specific ST-T wave changes. Compared to the previous tracing of [2106-9-4] ventricular premature beat is new. . CXR [2106-9-28]: Appropriately positioned right IJ central venous catheter. No evidence of complication. . CT abdomen/pelvis (non-contrast) [2106-9-28]: 1. Findings consistent with acute epiploic appendagitis along the mid descending [Month/Day/Year 499]. Within the limitations of a non-contrast study, no evidence of colitis. 2. Multiple healed rib fractures of the visualized right lower ribs which are new since the since the [2105-8-18] study. However, no acute fractures identified. . Left foot (3 views) [2106-10-5]: No fracture or dislocation detected. Brief Hospital Course: 67F with CAD, DM2, CKD, Crohn's, pancreatic insufficiency, and muliple urinary tract infections presents from rehab with complaints of fever and hypotension. . # Septic shock: The patient presented from rehab with fever, altered mental status and hypotension. She was found to have SBPs in the 70s refractory to 3L IVF boluses and requiring levophed gtt to maintain MAPs >60. Fever was documented at up to 103. Wbc was 14 on presentation, with creatinine 2.6 (up from baseline 1.4). . The source of infection was unclear. [Name2 (NI) ] cultures were negative. Urine culture from rehab grew 10-30K GPCs (never speciated). CXR was unremarkable. CT abdomen/pelvis showed only epiploic appendigitis. C. diff toxin and PCR were negative. Nonetheless, the patient was presumed to have a GI or GU source of infection, and was treated with broad spectrum antibiotics (vancomycin, meropenem, and metronidazole). Antibiotics were subsequently narrowed to ceftriaxone and metronidazole. The patient was discharged on cefpodoxime and metronidazole, with a plan to complete a 14-day course of antibiotics on [2106-10-11]. The patient was instructed to resume taking her prophylactic dose of cipro (which she takes twice daily for Crohn's) when her course of cefpodoxime and metronidazole is complete. . For the patient's hypotension, diuretics were held, and the patient was treated with IV fluids and norepinephrine. As her condition improved, she was weaned off of pressors, and called out of the ICU. On the medical floor, her [Date Range ] pressure remained stable, and torsemide was restarted but then stopped in the setting of ongoing diarrhea. The patient was discharged off of torsemide. She was instructed to monitor her weight and discuss the medication change with her PCP. . # Acute on chronic kidney injury: The pt presented with Cr 2.6 up from 1.4. Her increased Cr likely represented a prerenal state in the setting of diarrhea, diuresis, and septic shock. The patient's creatinine improved with fluid resuscitation and treatment of her sepsis, and was 1.2 at the time of discharge. . # Altered mental status: The patient was confused on admission due to hypotension and infection. Her mental status returned to [Location 213] with normalization of her hemodynamics and treatment of her sepsis. . # Diarrhea: The patient had persistent watery, guaiac-negative diarrhea. The differential diagnosis included antibiotic induced diarrhea, infectious diarrhea, C. diff, Crohn's, and pancreatic insuffiency. CT abdomen pelvis showed only epiploic appendigitis. The patient received pancreatic enzyme supplementation without any effect on her diarrhea. C. diff toxin was repeatly negative, as was C. diff PCR. Once the C. diff PCR came back negative, the patient was started on loperamide, with marked improvement in her diarrhea. . # Chronic Anemia: The patient presented with hematocrit 29.1. Her hematocrit remained stable throughout her admission. Her diarrhea was guaiac-negative. . # Coronary artery disease: The patient has known single-vessel disease and is s/p RCA w/ bare metal stent on [2102-2-2]. [Date Range ] 325mg daily was continued. The patient had a single episode of atypical chest pain on the evening of [2106-10-5], without any EKG changes or enzyme elevations. This episode was thought to be gastrointestinal rather than cardiac in etiology. . # Chronic systolic and diastolic heart failure (Recent ECHO [8-19], EF 45-50%): The patient was felt to be hypovolemic on admission, so diuretics and carvedilol were initially held. Carvedilol and torsemide were restarted, but then torsemide was stopped in the setting of persistent diarrhea. The patient was discharged off of torsemide, with the instruction to follow up with her PCP [Last Name (NamePattern4) ] [2106-10-11], at which time restarting torsemide should be considered. . # Crohn's Disease: The patient has a history of pancolitis w/o small bowel involvement. CT of the abdomen and pelvis were notable only for epiploic appendigitis. The patient's diarrhea was thought to be unrelated to Crohn's. Mesalamine was continued. . # Diabetes mellitus, type II, on insulin: The patient was treated with Lantus and a Humalog insulin sliding scale, with good glycemic control. She was discharged on her pre-admission regimen of Lantus 40 units at bedtime. . # GERD: Continued [Hospital1 ] omeprazole. The patient had a single episode of chest discomfort on the evening of [10-5] which was likely related to GERD. . # Chronic pain: The patient was discharged on oxycontin 20mg [Hospital1 ], gabapentin 600 mg [Hospital1 ], and lidoderm patch. She requested a prescription for oxycontin at the time of discharge. The inpatient team spoke with the patient's PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 1022] [Last Name (NamePattern1) ], who confirmed it was okay to give the patient enough oxycontin to last until her follow-up appointment. The patient was warned not to drive or participate in other hazardous activities while on oxycontin. . # Chronic pancreatitis: The patient continued pancreatic enzyme supplementation. . # Toe pain: The patient stubbed her left toe. This was evaluated with x-rays which were negative for fracture. . # Code status: Full code . # Transitional issues: 1. A stool culture was pending at the time of discharge. 2. The patient was discharged off of torsemide. Consideration should be given to restarting this. 3. The patient will complete her course of cefpodoxime and metronidazole on [2106-10-11], at which time she should resume cipro, which she takes for Crohn's disease. Medications on Admission: oxycontin 20mg PO BID Lantus 40u qhs torsemide 30mg daily cipro 250mg PO BID Carvedilol 12.5mg [Hospital1 ] MVI wtih mineral Neurontin 200mg PO q2pm Neurontin 300mg qam and qpm Lidocaine patch daily to L knee acetaminophen 325mg 2tabs q4h prn pain Aspirin 325mg daily Vit D 2tabs daily Mesalamine 1600mg TID Omega 2 fatty acids daily omeprazole 20mg [Hospital1 ] Zocor 20mg daily Heparin sc Ferrous sulfate 325mg daily Ipratroprium bromide 17mcg aerosol inhaler 2puffs q6h prn Albuterol sulface mdi 1-2puffs q6h prn neurontin 300mg [Hospital1 ] zenpep 20k-68k-9k 4 caps before meals zenpep 2 caps before shakes Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours): Do not drive or participate in hazardous activities while on oxycontin. Disp:10 Tablet Extended Release 12 hr(s) Refills:0 3. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty (40) units Subcutaneous at bedtime. 4. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day. 5. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for left knee pain: 12 hours on, 12 hours off. 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. Disp:90 Tablet(s) Refills:0 10. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 11. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 13. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 16. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for sob/wheezing. 17. Zenpep 20,000-68,000 -109,000 unit Capsule, Delayed Release(E.C.) Sig: as directed Capsule, Delayed Release(E.C.) PO as directed: Take 4 tablets before each meal and 2 tablets before each snack. 18. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:30 Capsule(s) Refills:0 19. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:8 Tablet(s) Refills:0 20. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 4 days. Disp:12 Tablet(s) Refills:0 21. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day: Resume ciprofloxacin on [2106-10-12]. 22. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: 1. septic shock, source unclear 2. hypotension 3. diarrhea 4. acute on chronic kidney injury . Secondary: 1. Crohn's disease 2. Chronic pancreatitis 3. Coronary artery disease 4. Chronic systolic and diastolic congestive heart failure 5. Diabetes melllitus 6. GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with fever and low [Location (un) ] pressure. You were admitted to the intensive care unit, where you briefly required a pressor medication for [Location (un) ] pressure support. You were treated with antibiotics. As you condition improved, you [Location (un) ] pressure stabilized, and you were able to leave the intensive care unit. . You had persistent diarrhea. Multiple tests for a bowel infection called C. difficile were negative. A CT of your abdomen showed epiploic appendigitis, which is a benign, self-limited condition that is likely unrelated to your diarrhea. You were given loperamide (Immodium), with improvement in your diarrhea. Some stool studies were pending at the time of discharge and will need to be followed by your primary care doctor. . At the time of discharge, you had 4 days of antibiotics left. Your antibiotics are called cefpodoxime and metronidazole. When you have completed your 4 days of cefpodoxime and metronidazole, you should restart the ciprofloxacin that you take for Crohn's disease. . There are some changes to your medications: STOP torsemide for now and discuss with your primary care doctor whether you should restart this medication at the time of follow-up. START loperamide (Immodium) as needed for diarrhea START metronidazole and cefpodoxime (antibiotics) for another 4 days. Restart ciprofloxacin 250 mg twice daily when you have finished metronidazole and cefpodoxime. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. . Follow up as indicated below. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY With: [Name6 (MD) ] [Last Name (NamePattern4) 2163], MD [Telephone/Fax (1) 463] Building: [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage *The office is working on a follow up appt for you in the next few weeks and will call you at home with an appt. IF you dont hear from the office by [Location (un) 2974], please call them directly to book. Department: [Hospital ] HEALTH CENTER When: MONDAY [2106-10-11] at 1:40 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 5808] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST [Hospital 2002] CLINIC When: THURSDAY [2107-1-20] at 2:30 PM With: DR. [First Name (STitle) ] [Name (STitle) ] [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: DIV. OF GASTROENTEROLOGY When: MONDAY [2107-3-21] at 11:30 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 2163], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) **] Campus: EAST Best Parking: Main Garage ICD9 Codes: 0389, 5849, 4280, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6856 }	Medical Text: Admission Date: [2100-10-20] Discharge Date: [2100-10-23] Date of Birth: [2020-6-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 509] Chief Complaint: Dizziness and Diaphoresis Major Surgical or Invasive Procedure: None History of Present Illness: 80 yo M with a h/o nephrolithiasis, chronic renal insufficiency, hypertension, angina, and BPH p/w diaphoresis and chest pain. . Recently admitted from [Date range (1) 91606] with dysuria presumed [12-22] to EColi UTI and acute kidney injury secondary to nephrolithiasis and complicated by renal tubular acidosis. He presented with a creatinine of 5.2 from an unknown baseline (last Cr in the online medical record was 1.6). In addition to the stones and UTI, he also had decreased PO intake. Renal ultrasound showed unchanged obstructing nephrolithiasis on L at UPJ and non-obstructing R ureteral nephrolithiasis unchanged form previous imaging in [2099-11-20]. Urology was consulted and recommended IR placement of L percutaneous nephrostomy tube, which was performed by IR on the night of admission without complications. Given the stones, he was kept on po cefpodoxime for 2 weeks or until the stones ar removed. SPEP and UPEP were sent showed no evidence of multiple myeloma. With placement of percutaneous nephrostomy tube and IV fluids, the patient's creatinine improved to 3.0 on discharge. Nephrology was consulted for his RTA and recommended bicarb therapy which improved the patient's bicarb to 19 prior to discharge. . The patient had various other issues including a fleeting transaminitis that was evaluated by ultrasound, normocytic anemia with a hematocrit of 33. He was guaiac negative. The patient's baseline was unclear, though in [2098-10-20] he had a HCT of 40. Iron studies were deemed consistent with anemia of chronic inflammation. Finally the patient complaine of Angina consistent with his history of CAD. Hedid not have chest pain while inpatient. He was continued on his home medications. He was not restarted on an ACEi. . He presented today to Dr.[Name (NI) 8156] office for a follow-up after his inpatient stay with a new complaint of dizziness with position change. Since discharge he had no fever/chills, dysuria, or hematuria. He awoke this morning with some left flank pain and dizziness upon rising from bed, which he described as the sensation of the room spinning. He continued to experience transient dizziness with position changes. He began to feel "sweaty" approximately 30 minutes prior to presentation to Dr.[Name (NI) 8156]. He also began to complain of nausea, along with some blurriness of vision. At approximately 11:10 AM, he complained of a constant, minute-long, non-radiating substernal chest pain but was unable to specify quality or severity. . One 81 mg chewable aspirin was given. His pulse was 40-48, his BP was 115/55. EKG showed Sinus bradycardia with increased 1st degree AV delay compared with prior EKG . EMS thought that he had STE in inferior leads. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] thought it was A Mobitz II and later slow afib. After word of a K of 6.3-6.8. Cardiology said it was Hyperkalemia. Nephrology thought it was sinus brady with apcs. Ultimately, the patient received 2 g CaGlu, 10 u regular insulin x 2, 30 g of kayexalate x 2 and 40mg of Lasix IV with 1L NS. A renal ultrasound showed improved hydro. . In the ICU, he is without complaint. Of note, he tells me he's lost 40 pounds in 2 years. Past Medical History: 1. Hypertension 2. THR [1-/2098], bilateral total hip replacements, the right in [2071] or [2072] at [Hospital1 18], the left in [2080] at [Hospital1 18]. 3. DVT after his right primary THR in the early [2069] 4. Three brain aneurysm procedures, presumably [Doctor Last Name ] aneurysms(clippings performed, one in [2065] and two in [2078].) 5. Renal insufficiency - unsure of the baseline is ?was 2.0 on dc- if the cause was obstructive uropathy- would have progressed further 6. Hypothyroidism 7. BPH 8. Cataracts (blind in L eye) 9. Hyperlipidemia Social History: He is retired, former truck driver, lives with wife in [Name (NI) 3494], and independent in ADLs. Still smokes cigarettes, a half pack a day for 50 years. He does not drink alcohol. Denies recreational drug use. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: GENERAL - frail elderly man, NAD HEENT - bitemporal wasting, R pupil reactive, L eye with dense cataract, EOMI, sclerae anicteric, MM dry, OP clear NECK - supple, no JVD/LAD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, distant heart sounds, no m/r/g ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. Nephrostostomy tube c/d/i. EXTREMITIES - WWP, no c/c/e SKIN - no rashes or jaundice NEURO - awake, A&Ox3, CNs II-XII grossly intact with exception of [Name (NI) 86478] ptosis and nasolabial flattening. Pertinent Results: Admission labs [2100-10-20] 11:50AM BLOOD WBC-5.6 RBC-3.62* Hgb-10.9* Hct-32.8* MCV-91 MCH-30.2 MCHC-33.3 RDW-15.4 Plt Ct-250 [2100-10-20] 11:50AM BLOOD Neuts-77.4* Lymphs-16.2* Monos-3.4 Eos-2.4 Baso-0.6 [2100-10-20] 11:50AM BLOOD PT-15.2* PTT-29.6 INR(PT)-1.3* [2100-10-20] 11:50AM BLOOD Glucose-133* UreaN-44* Creat-3.3* Na-136 K-6.8* Cl-106 HCO3-21* AnGap-16 [2100-10-20] 06:52PM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0 [2100-10-20] 03:29PM BLOOD K-6.5* [2100-10-20] 06:57PM BLOOD K-4.5 . Other labs [2100-10-20] 06:52PM BLOOD TSH-1.1 [2100-10-21] 03:11AM BLOOD PTH-119* . CEs . [2100-10-20] 11:50AM BLOOD cTropnT-<0.01 [2100-10-20] 06:52PM BLOOD CK-MB-3 cTropnT-<0.01 [2100-10-21] 03:11AM BLOOD CK-MB-2 cTropnT-<0.01 [2100-10-21] 03:11AM BLOOD CK(CPK)-34* [2100-10-20] 06:52PM BLOOD CK(CPK)-46* . Discharge labs [2100-10-22] 06:20AM BLOOD WBC-5.9 RBC-3.56* Hgb-10.8* Hct-32.8* MCV-92 MCH-30.2 MCHC-32.7 RDW-15.5 Plt Ct-226 [2100-10-22] 06:20AM BLOOD Glucose-94 UreaN-40* Creat-2.7* Na-141 K-4.0 Cl-103 HCO3-30 AnGap-12 [2100-10-22] 06:20AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.7 . . Urine . [2100-10-20] 02:05PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 [2100-10-20] 02:05PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM [2100-10-20] 02:05PM URINE RBC-0-2 WBC-[1-22] Bacteri-OCC Yeast-NONE Epi-0-2 [2100-10-20] 02:05PM URINE Hours-RANDOM UreaN-281 Creat-36 Na-107 K-35 Cl-118 . . UCx [10-20] no growth . MRSA screen [10-20] and [10-21] pending . . Cardiology . ECG Study Date of [2100-10-20] 11:32:08 AM ECG interpreted by ordering physician. [Name10 (NameIs) 357] see corresponding office note for interpretation. Intervals Axes RatePR QRS QT/QTc P QRS T 48 276 96 428/407 12 70 57 . ECG Study Date of [2100-10-20] 6:40:06 PM Sinus bradycardia with atrial premature beats. Compared to tracing #2 no diagnostic interval change. TRACING #3 Read by: [Last Name (LF) ],[First Name3 (LF) 125] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 56 0 98 420/413 0 83 50 . ECG Study Date of [2100-10-20] 3:05:06 PM Sinus bradycardia with atrial premature beats. Compared to tracing #1 no diagnostic interval change. TRACING #2 Read by: [Last Name (LF) ],[First Name3 (LF) 125] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 50 0 96 [Telephone/Fax (2) 102529]4 . ECG Study Date of [2100-10-20] 11:39:44 AM Sinus bradycardia with atrial premature beats. Prolonged A-V conduction. No other diagnostic abnormality. Compared to the previous tracing of [2099-12-8], except for the change in rate and atrial premature beats, no diagnostic interval change. TRACING #1 Read by: [Last Name (LF) ],[First Name3 (LF) 125] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 49 0 98 446/426 0 72 61 . ECG Study Date of [2100-10-21] 9:48:50 AM Sinus bradycardia with atrial premature beats. Compared to tracing #3 no diagnostic interval change, except for the rhythm and the atrial premature beats. This tracing is within normal limits. TRACING #4 Read by: [Last Name (LF) ],[First Name3 (LF) 125] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 58 0 98 428/424 0 86 51 . ECG Study Date of [2100-10-23] 8:14:58 AM Sinus bradycardia with marked A-V conduction delay and occasional atrial premature beats in a bigeminal pattern. Compared to tracing #2 no diagnostic change. TRACING #3 Read by: [Last Name (LF) ],[First Name8 (NamePattern2) 2206] [Doctor Last Name ] Intervals Axes Rate PR QRS QT/QTc P QRS T 54 240 98 [Telephone/Fax (2) 102530] 54 . . Radiology . RENAL U.S. Study Date of [2100-10-20] 4:21 PM The right kidney measures 10.8 cm, and the left kidney measures 8.1 cm. There has been interval placement of a left-sided nephrostomy tube. Previously-noted left hydronephrosis has improved, with now only pelvicaliectasis seen on the left side. Previously noted left ureteropelvic junction stone is not well visualized on the current exam. Within the right kidney, two cysts are again identified, without change. At least two right non-obstructing renal calculi are seen in the lower pole measuring 5 and 3 mm. No right-sided hydronephrosis is present. The urinary bladder is decompressed about a Foley catheter. IMPRESSION: 1. Interval placement of a left-sided nephrostomy tube with interval improvement in previously noted hydronephrosis. Currently, there is pelvicaliectasis on the left side. 2. Nonobstructing renal calculi and renal cysts in the right kidney are unchanged from prior. Brief Hospital Course: 80 yo M with a h/o nephrolithiasis, chronic renal insufficiency, hypertension, angina, and BPH p/w diaphoresis nausea and chest pain. Found to have a bradycardia and hyperkalemia initially refractory to standard maneuvers.He also noted vertigo on position changes whch was felt likely secondary to bradycardia. Hyperkalemia was successfully treated with Ca gluconate, Insulin/dextrose, Kayexalate and furosemide and he had no further episodes of this and potassium remained in the normal range to discharge. Bradycardia was felt to be secondary to atenolol toxicity and atenolol was held and his bradycardia improved to the 60s by discharge. He was advised to make an appointment to see his PCP [Name Initial (PRE) 176] 1 week. . # Hyperkalemia: Initial hyperkalemia to 6.8 in ED in the setting of worsening renal function(creatinine 3.3 on admission) and was treated in the ED with 2 g CaGlu, 10 u regular insulin x 2, 30 g of kayexalate x 2 and 40mg of furosemide IV with 1L NS. By arrival in the ICU, this had resolved to 4.4. THis continued to be stable and was thought to have been a result of the combination of atenolol toxicity and renal failure. On stopping the atenolol, his potassium remained stably within the normal range and improved as his renal function improved to 4.2 on discharge. ECG showed sinus bradycardia and this was felt to be atenolol toxicity and not due to hyperkalemia. He was advised to make an appointment to see his PCP [Name Initial (PRE) 176] 1 week. . # Bradycardia: Mr [Known lastname ] initially presented with vertigo, diaphoresis and chest pain in the context of bradycardia to 40-48 and was admitted to the MICU for management of hyperkalemia (which improved after treatment) and bradycardia which improved following stopping atenolol. His initial ECGs showed appearances which appeared to alternate between what was thought to be a slow AF to what resembled a Mobitz 2 with 2:1 block and was latterly seen to be Sinus rhythm with bigeminal PACs and first degree AV block, PR interval= 230 ms. [Name13 (STitle) ] had a negative MI workup with negative cardiac enzymes x3. He was observed with telemetry. Electrophysiology were consulted for further evaluation of persistent bradycardia to the 50s after discontinuation of atenolol. Atenolol is a renally cleared beta blocker which was felt likely to have accumulated to high levels given the patient's poor renal clearance of the drug in the setting of acute kidney injury. In addition, it was felt that the patient also likely had baseline sinus node dysfunction making him more sensitive to the effect of the beta blockade. On reviewing previous results, he has had longstanding AV node delay and bradycardia as evidenced on a Holter recording from [6-27]. Barring any further progression of his underlying nodal dysfunction, it is likely that the patient will return to his baseline once the atenolol effect has fully cleared and indeed by the day of discharge, his heart rate was increasing to the 60s. The plan was therefore to continue to hold all beta blockers for now and use non renally excreted beta blockers in the future such as metoprolol if clinically indicated. There was no need for a pacemaker but if his nodal disease worsens, this can be addressed as an out-patient. He was advised to make an appointment to see his PCP [Name Initial (PRE) 176] 1 week. . # Renal Insufficiency: The patient has nephrolithiasis and is s/p left nephrostomy for hydronephrosis. From a baseline of 1.6 in [2099-11-20], the patient had a recent admission for [Last Name (un) ] with possible new baseline of 3.0. Creatinien was 3.3 on anmission and had hyperkalemia as described above with a K 6.8. A renal ultrasound was performed on [10-20] showed interval improvement in left sided hydronephrosis and nonobstructing renal calculi and renal cysts in the right kidney were unchanged from prior studies. FeNa was 7.2% and uninformative. His medications were renally dosed and his creatinine improved following treatment of teh hyperkalemis and stoping atenolol. His creatinine on discharge was 2.3. He should follow-up with renal in the community. He was advised to make an appointment to see his PCP [Name Initial (PRE) 176] 1 week. . # Vertigo: The patinet noted vertiginous symptoms on sitting forward with no change on head-turing. Initial considerations included BPPV although abrupt head turning demonstrated no nystagmus and did not bring on symptoms. Latterly this was felt to be the result of his bradycardia and was recovering as his heart rate increased. . # Weight loss: Patient claimed he had lost 40 pounds in ~ 2 years. He had evidence of temporal wasting and denied depression. Albumin was 2.6 on admission and improved to 3.4. He was advised to make an appointment to see his PCP [Name Initial (PRE) 176] 1 week. . # Dyslipidemia: We continued simvastatin. . # Coronary artery disease: Mr [Known lastname ] had episodes of chest pain on admission which was felt to be likely due to his bradycardia and he was ruled out for MI with negative cardiac enzymes x3. His isosorbide mononitrate was held due to low BP and should be restarted in the community by his PCP. [Name10 (NameIs) ] was advised to make an appointment to see his PCP [Name Initial (PRE) 176] 1 week. . # Hypothyroidism: Was hypothermic at 95.6F and rapidly became normothermic. TSH was 1.1. We continued home levothyroxine. Medications on Admission: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:28 Tablet(s) Refills:0 7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual q5min as needed for chest pain: Please take one tablet every five minutes as needed for chest pain for up to three tablets, if still having pain call your doctor or 911. 8. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 10. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 12 days. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for CP. 7. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Bradycardia likely due to atenolol toxicity Hyperkalemia Acute on chronic renal failure . Secondary diagnoses: Hypertension Bilateral Total Hip Replacement s/p DVT following right primary Total Hip Replacement s/p clipping procedures to ? cerebral aneurysms Nephrolithiasis causing hydronephrosis s/p left nephrostomy tube insertion Hypothyroidism Benign Prostatic Hyperplasia Cataracts (blind in L eye) Hyperlipidemia 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: It was a pleasure taking care of you during your stay at the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ]. You presented following an episode of dizziness followed by chest pain in your PCP's office. You were noted to have a very slow pulse. You were taken to the emergency department and you were found to have worsening of your renal failure and a high potassium level. You received treatment which successfully lowered your potassium level. You continued to have a low pulse and you were admitted overnight for observation in the Intensive Care Unit. You had an ultrasound of your kidneys which showed improved distension of your left kidney. It was felt that your symptoms could be accounted for by toxic levels of your atenolol and this was stopped. It will be reviewed by your PCP regarding [Name Initial (PRE) ] similar drug which is not processed through the kidneys. There was no evidence of a heart attack on blood tests. BY [10-22] your heart rate had improved and you were reviewed by cardiology regarding you low pulse and they felt that this was due to your atenolol. Your dizziness improved and this was felt likely due to your low pulse. You felt better and you were discharged home on [10-23]. You should make an appointment to see your PCP [Name Initial (PRE) 176] 1 week. . Changes to mediations: We stopped your atenolol permanently We held your isosorbide mononitrate and this should b restarted by your PCP . . Instructions to patient: If you have further worsening symptom or further chest pain, you should seek medical attention. Followup Instructions: You should make an appointment to see our PCP [Name Initial (PRE) 176] 1 week ICD9 Codes: 5849, 2767, 2449, 5859, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6857 }	Medical Text: Admission Date: [2154-1-31] Discharge Date: [2154-2-3] Date of Birth: [2104-12-12] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2901] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization with DESx2 to LCx History of Present Illness: Ms. [Known lastname 34191] is a 49 year old woman with a PMHx s/f DM2, HTN, and HLD who presented this morning with 1 hour of chest pain radiating to the left hand, back, jaw accompanied by shortness of breath. She presnted to the emergency room with initial vitals of 98.1 81 141/107 24 100%. EKG demonstrated STE if II,III, AVF with 1mm STD in AVL. Aspirin 324, plavix 600mg, and a heparin drip were administered in the ED. . A code STEMI was called and Ms. [Known lastname 34191] was taken to the cath lab. 2 DES were placed in the proximal/mid LCx. A tight proximal OM lesion was also visualized which was not intervened upon. Ms. [Known lastname 34191] had some recurence of her chest pain which resolved with nicardipine. Total contrast load was 220. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of current chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes + (A1C 12.5 in [2153-10-9]), Dyslipidemia + , Hypertension + 2. OTHER PAST MEDICAL HISTORY: - Depression Social History: - Tobacco history: Trivial remote smoking history - ETOH: occasional, social - Illicit drugs: none - Works as a cook. Emigrated from [Country 7192] 16 years ago. Family History: Mother with first MI at age of 55 who died several years ago from the complications of CAD. Grandmother who died at 70 from MI. Mother and grandmother with DM, HTN, and HLD. Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: NAD. Spanish Speaking Only. 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 without JVD at level of clavicle at 90 degrees. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. R cath site intact with band in place SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, CNII-XII intact, 2+ reflexes biceps/brachioradialis/patellar/ ankle PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . PHYSICAL EXAM ON DISCHARGE: Vitals: Tm/Tc: 98.8/98.4 118-137/59-73 66-87 18 99(RA) FS: 298-266-298-222 GENERAL: obese spanish speaking only woman in no acute distress HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, JVD 2cm above clavicle CHEST: CTABL no wheezes, no rales, no rhonchi CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive. no rebound/guarding, neg HSM. neg [Doctor Last Name 515] sign. EXT: wwp, no edema. DPs, PTs 2+. Pertinent Results: ADMISSION LABS: WBC-11.6* RBC-5.24 Hgb-15.8 Hct-43.4 MCV-83 MCH-30.2 MCHC-36.4* RDW-12.2 Plt Ct-332 Neuts-61.8 Lymphs-33.1 Monos-3.2 Eos-1.0 Baso-1.0 PT-11.6 PTT-28.1 INR(PT)-1.1 Glucose-295* UreaN-13 Creat-0.5 Na-133 K-4.4 Cl-92* HCO3-24 AnGap-21* cTropnT-<0.01 %HbA1c-12.0* eAG-298* BLOOD ALT-63* AST-102* CK(CPK)-675* AlkPhos-83 TotBili-0.8 . CARDIAC ENZYMES: [2154-1-31] 11:20AM BLOOD cTropnT-<0.01 [2154-1-31] 06:01PM BLOOD CK-MB-180* [2154-2-1] 05:32AM BLOOD CK-MB-66* MB Indx-9.8* cTropnT-1.74* . CARDIAC CATHETERIZATION REPORT ([2154-1-31]): 1. Selective coronary angiography of this right dominant system demonstrated single-vessel coronary artery disease with branch vessel disease in the LAD. The LMCA was free of angiographically significant disease. The LAD proper was free of angiographically significant disease, but did give rise to a small D2 with a 90% stenosis. The LCx gave rise to an OM1 with a 90% stenosis at its origin and the circumflex was occluded in the mid vessel. There was a 40% stenosis in the mid-RCA. 2. Limited resting hemodynamics revealed moderate central aortic hypertension (169/88mmHg with a mean of 122mmHg). 3. Successful PTCA and stenting of mid Lcx with 2.5x23 and 2.5x15 (distal to proximal overlapping) Promus drug eluting stents postdilated with 2.75mm NC balloon. 4. Successful hemostasis of right radial arteriotomy with TR band. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. STEMI involving the mid-LCx. 3. Residual disease in OM1. 4. Successful PCI of mLCx with DESx2. 5. Consider PCI of OM ostial lesion in one month as oupatient. 6. Successful RRA TR band. . ECHO ([2154-2-1]): The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. There is mild regional left ventricular systolic dysfunction with severe hypokinesis to akinesis of the inferior, inferolateral, and lateral walls. The remaining segments contract normally. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The mitral valve shows characteristic rheumatic deformity with mild valvular mitral stenosis (area 1.9 cm2 by planimetry). Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate symmetric left ventricular hypertrophy with normal cavity size. Severe hypokinesis to akinesis of the inferior, inferolateral, and lateral walls. Rheumatic deformity of mitral valve leaflets with mild mitral stenosis and mild mitral regurgitation. Labs on Discharge: [2154-2-2] 05:45AM BLOOD WBC-10.9 RBC-4.66 Hgb-13.7 Hct-38.4 MCV-83 MCH-29.3 MCHC-35.5* RDW-12.3 Plt Ct-268 [2154-2-3] 06:40AM BLOOD Glucose-205* UreaN-15 Creat-0.5 Na-137 K-4.2 Cl-100 HCO3-28 AnGap-13 [2154-2-3] 06:40AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.0 Brief Hospital Course: Primary Reason for Hospitalization: Ms. [Known lastname 34191] is a 49 year old with a PMHx significant for poorly controlled DM, HTN, and HLD who presented with an inferior STEMI. During this hospitalization, she received 2 DES to the LCx. Active Diagnoses: # STEMI: Patient received 2 DES to proximal/mid LCx, culprit lesion mid-LCx with 100% occlusion. She received a plavix load, aspirin 325, and heparin drip in the ED. She is chest pain free with resolved STE after stenting. Echo showed LVH and hypokinesis/akinesis of inferolateral/lateral walls, rheumatic deformity of MV leaflets, mild MS, mild MR. She was discharged on Atorvastatin 80mg daily, ASA 325mg daily, Lisinopril 20mg daily, Plavix 75mg daily (will need for 1 year), metoprolol succinate 25mg PO daily. She is scheduled to follow-up with Dr. [Last Name (STitle) ] in 1 month for repeat cath to evaluate and intervene on OM lesion. . # HTN: Patient's antihypertensive regimen was modified to maintain SBP 100s-130s. She was discharged on lisinopril 20mg daily and metoprolol succinate 25mg PO daily. Home HCTZ was discontinued. . # DMII: Patient's DM is poorly-controlled with last HgbA1c of 12 in [2153-10-9]. Hyperglycemic on admission to 300s, improved to 100s on insulin drip. She was discharged on home levemir 40U [Hospital1 ] and novolog 24U before every meal. She is scheduled to follow-up at [Last Name (un) ]. # HLD: Discontinued home pravastatin, and started atorvastatin 80mg daily in light of recent MI. Chronic Diagnoses: # Depression: She was continued on home sertraline. ======================= TRANSITION OF CARE: 1. Patient will need to return for repeat cardiac cath with Dr. [Last Name (STitle) ] to evaluate and intervene on OM1 lesion (appointment scheduled). 2. Patient will need to follow-up with [Last Name (un) ] Diabetes Center regarding DM management. 3. Patient was educated on the importance of taking plavix and glycemic control with a Spanish interpreter present. Medications on Admission: Sertraline 50mg daily Lisinopril 20mg daily Pravastatin 80mg daily Novolog Insulin Sliding scale (22 units before meals) Levemir Sliding scale 45 units [Hospital1 ] HCTZ 25mg Metformin 1000 [Hospital1 ] ASA 81mg (has not been renewed in several months) 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. 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. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 7. Levemir 100 unit/mL Solution Sig: Forty Five (45) Units Subcutaneous twice a day. Discharge Disposition: Home Discharge Diagnosis: STEMI (heart attack) Poorly-controlled diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 34191], It was a pleasure participating in your care at [Hospital1 771]. You were admitted to the hospital with a heart attack. You had a cardiac catheterization where a stent was placed to open up a blocked artery in your heart. Please attend the outpatient appointments listed below to follow up for care after your heart attack. We made the following changes to your medications: 1. START metoprolol succinate 25mg by mouth daily 2. START clopidogrel (Plavix) 75mg by mouth daily - will need to take this for ONE YEAR 3. START atorvastatin 80mg by mouth daily 4. INCREASE aspirin to 325mg by mouth daily 5. STOP pravastatin 6. STOP hydrochlorothiazide 7. CHANGE your pre-meal insulin to 24 units novolog before meals Followup Instructions: Name: NP [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 34192] Location: [Hospital6 28009] Address: [Street Address(2) 34193] [Hospital1 ], [Numeric Identifier 26327] Phone: [Telephone/Fax (1) 34194] Appointment: Thursday [2154-2-7] 10:45am Department: [Last Name (un) ] Diabetes Center When: Saturday, [2154-2-16] With: Please call ([Telephone/Fax (1) 3258] to confirm what time and what provider will see you. Department: CARDIAC SERVICES When: WEDNESDAY [2154-2-27] at 9:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909] Completed by:[2154-2-4] ICD9 Codes: 4019, 2724, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6858 }	Medical Text: Admission Date: [2119-8-25] Discharge Date: [2119-9-1] Date of Birth: [2058-1-29] Sex: F Service: MED Allergies: Codeine / Cephalosporins Attending:[First Name3 (LF) 2474] Chief Complaint: fever, malaise, weakness Major Surgical or Invasive Procedure: PICC line placement by Interventional [First Name3 (LF) ] History of Present Illness: 61 year old woman with history cervical cancer and multiple line infections. Patient has previously undergone radiation therapy for cervical cancer, which led to radiation enteritis requiring bowel resection and subsequent shortgut syndrome. Since development of shortgut syndrome, patient has required chronic total parenteral nutrition leading to frequent line infections. Patient has a history of two years of pain and paresthesias down her left thigh and and into her leg. She was evaluated by her neurologist and had an EMG/NCS which suggested lumbosacral plexopathy bilaterally. This was attributed to radiation. She has noticed in the last two days that she has had more neck pain than usual which can sometimes happen with her migraine headaches but also some pain between the shoulder blades, more on the right. She also noted that two days ago she started having the shooting pain and paresthesias running down her right leg. Yesterday or today she tried to get up and walk and she noted that she totally buckled and could not support her weight. She thinks her weakness is worse on the left versus the right. She has chronic diarrhea from the radiation and has an ileostomy. She also self-catheterizes because she has bladder dysfunction from radiation as well. She has a fever and is developing malaise that for her is always suggestive of a line infection. She was referred to the ED for further evaluation. Past Medical History: 1. Cervical cancer status post radiotherapy, radiation enteritis resulting in bowel resection and need for TPN, also with ileostomy 2. History of candidemia. 3. Deep venous thrombosis secondary to multiple central lines. 4. Chronic abdominal pain secondary to adhesions, incisions, and radiation, on stable doses of pain regimen. 5. chronic incontinence which she attributes to radiation 6. osteoarthritis and osteoporosis 7. cholecystectomy 8. migraines/tension headaches 9. L3-4 herniated disc 10. left upper extremity thrombosis secondary to PICC line 11. iron deficiency anemia 12. ureteral stenosis 13. depression Social History: married, nonsmoker, no drugs, no history of iv drug use Family History: non contributory Physical Exam: T98.6 P91 BP128/68 RR18 O299% RA Gen: No acute distress HEENT: NCAT, PERRL, EOMI, oral mucus membranes moist Neck: Supple, no cervical lymphadenopathy Lungs: Clear, no wheezes, rales or rhonchi Heart: nl S1, S2, RRR, no MRG Abd: Soft, NT, ND, no rebound or guarding Ext: No clubbing cyanosis or edema Pertinent Results: MR [Name13 (STitle) ] W& W/O CONTRAST; MR [Name13 (STitle) 6452] W & W/O CONTRAST 1. No evidence of discitis, osteomyelitis, or epidural abscess. 2. Mild degenerative changes. 3. Free fluid in the pelvis. ------- [2119-8-25] 10:03PM PT-13.4* PTT-31.8 INR(PT)-1.2 [2119-8-25] 08:00PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.011 [2119-8-25] 08:00PM URINE BLOOD-LG NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-4* PH-7.0 LEUK-MOD [2119-8-25] 08:00PM URINE RBC-[12-9]* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-[3-24] [2119-8-25] 08:00PM URINE AMORPH-MOD [2119-8-25] 07:23PM COMMENTS-GREEN TOP [2119-8-25] 07:23PM LACTATE-2.2* [2119-8-25] 07:23PM HGB-10.9* calcHCT-33 [2119-8-25] 07:05PM GLUCOSE-112* UREA N-26* CREAT-1.5* SODIUM-132* POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-24 ANION GAP-16 [2119-8-25] 07:05PM ALT(SGPT)-42* AST(SGOT)-43* ALK PHOS-183* AMYLASE-79 TOT BILI-0.8 [2119-8-25] 07:05PM CALCIUM-8.4 PHOSPHATE-2.1# MAGNESIUM-1.5 [2119-8-25] 07:05PM OSMOLAL-280 [2119-8-25] 07:05PM WBC-11.8* RBC-3.66# HGB-10.7# HCT-30.1# MCV-82 MCH-29.2 MCHC-35.4 RDW-13.9 [2119-8-25] 07:05PM NEUTS-95.3* BANDS-0 LYMPHS-3.4* MONOS-1.1* EOS-0.1 BASOS-0.2 [2119-8-25] 07:05PM PLT SMR-NORMAL PLT COUNT-181 [2119-8-25] 07:05PM PT-13.1 PTT-29.1 INR(PT)-1.1 [2119-8-25] 06:01PM COMMENTS-GREEN TOP [2119-8-25] 06:01PM LACTATE-3.1* [2119-8-25] 05:40PM GLUCOSE-77 UREA N-27* CREAT-1.5* SODIUM-130* POTASSIUM-3.6 CHLORIDE-92* TOTAL CO2-23 ANION GAP-19 [2119-8-25] 05:40PM WBC-18.2# RBC-1.63# HGB-4.8# HCT-13.3# MCV-82# MCH-29.4 MCHC-36.0* RDW-14.2 [2119-8-25] 05:40PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [2119-8-25] 05:40PM PLT SMR-NORMAL PLT COUNT-304 Brief Hospital Course: 61F with history of cervical cancer, shortgut syndrome requiring chronic total parenteral nutrition complicated by frequent line sepsis. Upon initial evaluation, given patient's symptoms of fever and back pain, neurology and neurosurgery consults were obtained for concern of epidural abscess. However, MRI revealed no epidural abscess and as patient became hemodynamically unstable (systolic blood pressure to 60s), patient was initiated on dopamine for pressor support. Patient was transferred to the medical intensive care unit, where working diagnosis was considered to be gram negative sepsis secondary to either line infection or urinary tract infection (patient self-catheterizes due to bladder dysfunction from radiation therapy). Peripheral intravenous central catheter was removed on hospital day two due to high suspicion of line infection. Urine cultures revealed an enterococcus infection, and blood cultures revealed a gram negative rod that ultimately speciated as Klebsiella. Patient was treated initially with aztreonam, gentamicin, and fluconazole, and later changed to vancomycin, gentamicin, and levofloxacin given enterococcus in urine. By hospital day 4, patient was afebrile and hemodynamically stable following weaning off pressors and was transferred to floor. Following transfer, patient's antibiotic regimen was changed to ampicillin sulbactam given the fact that at this point both enterococcus and Klebsiella cultures were found to be sensitive to that regimen. Surveillance blood cultures continued to be negative following removal of PICC, and patient was felt to be stable for placement of a new PICC on hospital day eight, required for continued TPN. At the time of discharge, patient had been afebrile for greater than 48 hours, was hemodynamically stable, and had negative surveillance blood cultures. Patient was discharged home with services and was to continue additional antibiotic therapy for eight days following discharge. Patient was instructed to follow up with her primary care physician [Name Initial (PRE) 176] 10 days following discharge. Medications on Admission: 1. prozac 20mg twice daily 2. fiorinal 100mg once to four times daily 3. coumadin 0.5mg once daily 4. xanax 0.5mg once daily 5. ativan 1mg as needed 6. oxycontin 20mg every 12 hours 7. methadone 5mg three times daily 8. B12 once monthly 9. salagem 5mg three times daily (for dry mouth) 10. mobic 7.5mg once daily 11. pyridium 100mg twice daily 12. vivelle dot hormone patch 0.03 once weekly 13. vitamin d 5000mg once weekly Discharge Medications: 1. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety. 4. Acetaminophen-Caff-Butalbital [Medical Record Number 3668] mg Tablet Sig: [1-20] Tablets PO Q4-6H (every 4 to 6 hours) as needed for Headache. 5. Ropinirole Hydrochloride 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Phenazopyridine HCl 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for Bladder pain for 3 days. 8. Ampicillin-Sulbactam Sodium [2-19] g Recon Soln Sig: 4.5 grams Injection three times a day for 8 days. Disp:24 doses Refills:0 9. Normal Saline Flush 0.9 % Syringe Sig: Five (5) cc Injection SASH as needed for PICC Flush for 1 months. Disp:1 month supply Refills:5 10. Heparin Flush (Porcine) in NS 100 unit/mL Kit Sig: Five (5) cc Intravenous SASH as needed for PICC Flush for 1 months. Disp:1 month supply Refills:5 11. IV Infusion Pump Infusion Set Sig: One (1) Unit Miscell. continuous. Disp:1 infusion set Refills:0 12. TPN TPN: 50g amino acids 100g Dextrose no Lipids Disp: 30 day supply Refills: 5 Discharge Disposition: Home With Service Facility: TLC Staff Builders Discharge Diagnosis: Sepsis Urinary tract infection Shortgut syndrome Radiation myelopathy/radiculopathy Discharge Condition: Good Discharge Instructions: 1) Continue TPN daily. Make sure to dedicate and mark one lumen of your PICC line for TPN ONLY. Do not use that lumen for any other medications. TPN orders: - 10 hour cycle - 100 grams Dextrose - 50 grams amino acids - 1000cc total Electrolytes: NaCl 150meQ, NaPO4 10meQ, KCl 40meQ, KPO4 15meQ, MgSO4 10meQ, CaGluc 10meQ 2) Continue Unasyn 4 grams, three times a day for 8 more days. Use only the non-TPN lumen for Unasyn, and use that same lumen for all other IV medications. 3) Call your primary care physician or come to the emergency room if you have fever, chills, sweats, or other signs of infection or bladder infection. 4) Continue taking your outpatient medications as directed. Followup Instructions: Please make an appointment to see your primary care physician 7-10 days after discharge. Provider: [Name10 (NameIs) 706] MRI Where: [Hospital6 29] [Hospital6 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2119-9-7] 10:45 Provider: [Name10 (NameIs) ] [Name8 (MD) 9406], MD Where: LM [Hospital Unit Name 4337] DISEASE Phone:[Telephone/Fax (1) 457] Date/Time:[2119-9-11] 11:30 Provider: [Name10 (NameIs) ] DENSITY TESTING Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 4586] Date/Time:[2119-10-9] 12:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477] MD, [MD Number(3) 2478] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6859 }	Medical Text: Admission Date: [2124-1-1] Discharge Date: [2124-1-8] Date of Birth: [2047-12-1] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 76 year old lady who only speaks Russian. She is status post small bowel resection for incarcerated ventral hernia repair about three years ago and now returned to the Emergency Room for symptoms of nausea, vomiting and abdominal pain for approximately 12 hours of duration. She denied fevers, chills. She had a bowel movement the day before. She described pain as colicky and located at the left abdominal lower quadrant and radiates sometimes in the middle. She also reported chest pain on exertion, requiring sublingual nitroglycerin. PAST MEDICAL HISTORY: Significant for coronary artery disease, hypertension and chronic obstructive pulmonary disease. PAST SURGICAL HISTORY: As aforementioned, ventral hernia repair, and status post mastectomy, as well as knee surgery. She denied history of allergic reaction to medications. HOME MEDICATIONS: Lipitor 20 q. day. Atenolol 50 mg twice a day. Baby aspirin. Sublingual nitroglycerin as needed. Cozaar 50 mg q. day. PHYSICAL EXAMINATION: Elderly woman in no acute distress. She is afebrile with temperature of 98.3; heart rate of 68; blood pressure 183/87; she is breathing on room air, 16 times per minute. Oxygen saturation is 96%. She is alert and oriented with family. Chest is clear bilaterally to auscultation. Heart has a regular rate and rhythm. The abdomen is obese, nondistended but tender, especially on the left side, greater than the right side. There is no hernia. There is no peritoneal sign. Rectal examination showed normal tone and guaiac negative by Emergency Room examination. LABORATORY DATA: White blood cell count of 11.8; hematocrit of 37.1 and platelets of 246. Sodium 137; potassium 4.7; chloride 99; bicarbonate 29; BUN 25; creatinine of 1.0 and blood sugar level of 163. A CAT scan of the abdomen showed high grade small bowel obstruction with transition in prior surgical area. By report, there is an echocardiogram done on [2122-1-7] which showed an ejection fraction of greater than 80% and left ventricular hypertrophy and no mitral regurgitation or aortic stenosis. HOSPITAL COURSE: The patient was diagnosed with a small bowel obstruction, requiring emergency surgery. A preoperative cardiology consult was obtained, given high and multiple risks factors of coronary artery disease. It was suggested that perioperative treatment with betablocker be initiated and a postoperative electrocardiogram with cardiac enzymes is also recommended. The patient was brought to the operating room for emergency laparotomy, exploratory laparotomy. Intraoperatively, it was found that the small bowel obstruction occurred at the previous anastomosis site which is subsequently resected. There is minimal amount of blood loss. The patient received 2,700 cc of Crystalloid during the operation. She was transferred to the Post Anesthesia Care Unit in fair condition. Postoperatively, the patient had cardiac enzyme work-up with CK of 150 to 282; CK MB of 8; the second set is 9 and treponon is less than 0.3. The patient was treated with betablocker perioperatively as suggested by the cardiology service; however, she displayed episodes of agitation and wide complex tachycardia, dyspnea with question of pulmonary edema and hypertension with decreased oxygen saturation. Because of the requirement of closed monitoring, she was transferred to the Surgical Intensive Care Unit postoperatively for closer monitor and for fluid management and for respiratory care. She received Kefzol and Flagyl empirically for prophylaxis which was subsequently discontinued on postoperative day number two. She is also requiring aggressive pain control regimen. Essentially, her Intensive Care Unit course was uneventful. She was able to wean off high requirement of oxygen and subsequently was transferred to the regular floor on [2123-1-5] where she remained comfortable and receiving respiratory care in terms of PT and instructions of coughing with incentive spirometry. Her pain is well controlled, although because of her poor functionality, it was slow in terms of her recovery. Therefore, although she was taking good amount of pain control pills, she was thought to be needed to be discharged to a rehabilitation facility for a short period of rehabilitation before going home. DISCHARGE DIAGNOSES: Small bowel obstruction, status post exploratory laparotomy. DISCHARGE STATUS: To rehabilitation facility. DISCHARGE INSTRUCTIONS: She will take all her prior home medications with Percocet for pain control. DISCHARGE CONDITION: Stable. [Name6 (MD) 843] [Name8 (MD) 844], M.D. [MD Number(1) 845] Dictated By:[Dictator Info ] MEDQUIST36 D: [2124-1-7] 03:41 T: [2124-1-7] 17:28 JOB#: [Job Number 25578] ICD9 Codes: 5185, 9971, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6860 }	Medical Text: Admission Date: [2174-7-25] Discharge Date: [2174-8-23] Date of Birth: [2111-3-22] Sex: M Service: . HISTORY OF PRESENT ILLNESS: This is a 63 year old male who complained of substernal chest pain and epigastric pain for approximately three minutes for two days. He had exertional chest pain for one to two years, but had increasing frequency of the chest pain for the last couple of months. He noticed it while lifting weights when the pain started and it usually resolved with rest, however, because of its increasing nature, he decided to come in for evaluation. He denied any nausea, diaphoresis, radiation or chest pain, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, or pedal edema. He did have a history of gastroesophageal reflux disease which he was noted to have an increasing epigastric pain when he was sitting up; however, there was no correlation between the two symptoms. The patient presented to the Emergency Department but did not have chest pain or EKG changes at that time. PAST MEDICAL HISTORY: 1. High cholesterol. 2. Depression. 3. Chronic obstructive pulmonary disease. 4. Emphysema. 5. Borderline hypertension. SOCIAL HISTORY: He has a positive history for smoking as well as a positive history for alcohol abuse. MEDICATIONS ON ADMISSION: 1. Albuterol nebulizers. 2. Serevent. 3. Aspirin. 4. Flovent. 5. Lipitor. 6. [Doctor First Name ]. 7. Sublingual Nitroglycerin. 8. Claritin. 9. Wellbutrin. 10. Beclomethasone. PHYSICAL EXAMINATION: On vital signs he was afebrile; his vital signs were otherwise stable. He was 95% on room air. He is in no apparent distress. Pupils are equal, round and reactive to light. His neck with no jugular venous distention; it was supple. His heart was regular rate and rhythm with no murmurs, rubs or gallops. His pulmonary examination was clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended, and bowel sounds are present. Extremities are two plus dorsalis pedis with no cyanosis, clubbing or edema. LABORATORY: On admission, his sodium was 141, potassium 4.3, chloride 107, bicarbonate of 21, BUN of 19, creatinine 1.0, blood sugar 170. His white count was 5.7, hematocrit of 43.3, platelet count of 232 and his cardiac enzymes were normal with a CK of 82, MB of zero, troponin of less than 0.3. The patient was admitted to the hospital for a cardiac evaluation. A cardiac stress test was done at that time and it was positive. HOSPITAL COURSE: The patient was then taken to cardiac catheterization where it was found that his cardiac catheterization was positive for multi-vessel disease. At that time, Cardiothoracic Surgery was consulted. During cardiac catheterization, the patient required IABP for pressor support and cardiac surgery was consulted. The patient was transferred to the Coronary Care Unit at that time. On [2174-7-29], the patient was taken to the Operating Room for a coronary artery bypass graft times four, left internal mammary artery to left anterior descending; saphenous vein graft to patent ductus arteriosus; saphenous vein graft to diagonal and saphenous vein graft to obtuse marginal 1 and obtuse marginal 2. The patient was transferred to the CSRU postoperatively. The patient was doing well in the postoperative period. He was slowly weaned from his ventilator, however, he had high chest tube outputs and his IABP was slowly weaned prior to any attempts at extubation. His IABP was slowly weaned and on 1:3 it was able to be removed. The patient had a run of rapid atrial fibrillation also postoperatively, which was rate controlled at that time. On postoperative day number three, the patient had a right pleural effusion which required chest tube placement for drainage and he was begun on diuresis. He was also started on Levofloxacin for positive sputum with Gram positive rods, four plus, after a temperature spiked. Due to his prolonged ventilatory support, tube feeds were started. The patient was slowly weaned, however, the patient required significant Ativan and it was believed to be that the patient was suffering withdrawal symptoms underneath the sedation. Attempts to wean the patient were unsuccessful at that time, however, the patient was able to stay supported on C-PAP ventilation. The patient was extubated on postoperative day number 11, however, the patient was unable to protect his airway and needed to be reintubated postoperatively on postoperative day number 12 due to low saturations. Cultures during that time continued to grow. He had profuse sputum which grew out Serratia which was multi-drug resistant. The patient was started on cefepime. The patient continued to have high secretions which required a great deal of suctioning and also Pulmonary was consulted for a bronchoscopy. Infectious Disease was also contact[Name (NI) ] for assistance with antibiotic selection for the multi-drug resistant Serratia. On postoperative day number 20, the patient was successfully weaned from his ventilator and was extubated. The patient was then started on Cefepime for his Serratia which continued to improve. It was planned for a PICC line for long-term intravenous antibiotics, however this could not be placed at the bedside so Interventional Radiation placed PICC was planned. The patient was transferred to the Floor on postoperative day number 27. While on the Floor, he continued to receive aggressive pulmonary toilet, chest Physical Therapy and ambulation. The patient was on one-to-one sitters, however, that was stopped on [2174-8-21], postoperative number 23. The patient continued to improve. On [2174-8-22], the patient will be taken for Interventional Radiology who placed a PICC line for intravenous Cefepime and the patient is at that point in time, stable for discharge to rehabilitation. CONDITION ON DISCHARGE: The patient is discharged to rehabilitation in stable condition. DISCHARGE MEDICATIONS: 1. Albuterol one to two puffs inhaler q. four hours p.r.n. 2. Insulin sliding scale. 3. NPH 10 units q. a.m. and q. p.m. 4. Lipitor 40 mg p.o. q. day. 5. Bupropion 75 mg p.o. q. day. 6. Haldol 2 mg p.o. twice a day. 7. Albuterol two puffs q. six hours. 8. Solu-Medrol 2 puffs twice a day. 9 Flovent two puffs twice a day. 10. Protonix 40 mg p.o. q. day. 11. Ipratropium two puffs twice a day. 12. Cefepime 2 grams intravenous q. 12 hours. 13. Enteric-coated aspirin 325 p.o. q. day. 14. Percocet one to two tablets p.o. q. four hours p.r.n. 15. Colace 100 mg p.o. twice a day. 16. Lopressor 75 mg p.o. twice a day. DISPOSITION: The patient is discharged to rehabilitation in stable condition. DISCHARGE DIAGNOSES: 1. High cholesterol. 2. Coronary artery disease status post coronary artery bypass graft times four. 3. Depression. 4. Alcohol withdrawal, delirium tremens. 5. Pneumonia status post Cefepime treatment. DI[Last Name (STitle) 408]E INSTRUCTIONS: 1. He is instructed to follow-up with Dr. [Last Name (Prefixes) ] in four weeks. 2. He is instructed to follow-up with his primary care physician in one to two weeks. 3. To follow-up with his Cardiologist in two to four weeks. Please see addendum for exact discharge date as well as any change in the medications. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[First Name (STitle) ] MEDQUIST36 D: [2174-8-21] 20:03 T: [2174-8-21] 23:01 JOB#: [Job Number 103503] ICD9 Codes: 5185, 4111, 7907
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6861 }	Medical Text: Admission Date: [2165-2-3] Discharge Date: [2165-3-17] Date of Birth: [2087-4-25] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[First Name3 (LF) 5880] Chief Complaint: s/p fall from standing Major Surgical or Invasive Procedure: PEG/Trach Ex lap and liver repair for liver laceration placement A line/central line/swan ganz History of Present Illness: Pt is a 77 y/o man w/ hx of CHF and hypertension who presents from [Hospital 1474] hospital after falling from standing. Pt reports that he hit his head, his rt elbow and the right side of his abdomen. He says he was getting up out of bed when he fell. He does not remember anything else about the fall. At the OSH, pt denied LOC. He complained of mid back pain ([4-8]). His vitals on presentation to OSH were 97.7 152/74 100 18 97%RA. Pt was pale, alert and oriented. Hct was found to be low at 35.8, with MCV of 90.7 and RDW of 19.5. Platelets were low at 65. WBC was normal at 7.5. Found to have SDH, transported to [Hospital1 18] for further managment. During transport, pt was slow to respond to questions. Pt had sinus tachcardia and complained of [4-8] HA. He began to require O2 and was 100% on 4L. In the [Name (NI) ], pt received Thiamine HCl 100mg/mL-2mL, Multivitamin IV 10mL Vial, Folic Acid 1mg/0.2mL Syringe, Morphine Sulfate 2mg Syringe, Furosemide 40mg/4mL Vial. Pt is able to ambulate at baseline, but he reports that he does not ambulate very frequently. He sometimes uses a wheelchair. Pt reports that he has had palpitations in the past. He does not recall getting dizzy when he stood up, however, pt's son reports that he often does complain of dizziness when he stands up. Per son, pt has never blacked out before. He has never had an MI. At baseline pt reports that he has some swelling in his legs. Pt reports that the swelling he has now is worse than usual but is unable to say when it got worse. [Name (NI) 1094] son reports that the swelling has been coming and going for years. Pt reports that he has a cough which is new. His cough is not productive. He denies fevers or chills. At home, never has required O2 but now has new O2 requirement. [Name (NI) 1094] son reports that he has been more tired than usual this past week. Pt has a history of recurrent PNA. Pt complains of headache, and low back pain. Back pain is not new for him, but it is worse after his fall. In the [Name (NI) ] pt was complaining of neck pain when c-spine collar was removed. Pt denies SOB, chest pain, N or V. Past Medical History: - CHF - first diagnosed in '[55], Echo in [2158] w/ EF of 45-50%, Echo in [10-3] w/EF of 60%, no WMA - COPD - FEV1 of 0.6 L, never intubated per outside records - Recurrent PNA - last in [11-3] - Htn - GERD - Chronic low back pain - for many years, ?osteoarthritis - Cancer? - ?infected gallbladder - s/p percutaneous drainage in [2164-10-9], cx grew klebsiella - Gout - Rheumatic fever - Echo in [10-3] shows nl Aortic, mitral and tricuspid valves, trace MR, moderate TR - Renal insufficiency with ACE inhibitor in [10-3], now resolved . Social History: Pt lives on his own. Reports that he cares for himself, but has 3 sons who live near by. Tob - smokes for 61 years, ? ppd, ?stopped in [2-3] EtoH - denies, outside records indicate EtoH use in [10-3] Family History: 5 brothers, one died, 3 healthy, not in contact with last brother, denies heart disease and DM, 3 sons healthy . Physical Exam: Vitals - T99.2 BP 156/60 HR 84 RR 16 SaO2 98% on 3L General - pale, thin, man, lying flat on a stretcher with neck in c-spine collar, NAD HEENT Eyes - conjunctiva erythematous R>L, pupils 2mm, sluggish response, but equal, unable to test for EOM but no gross abnormalities noted Ears - decreased hearing especially in left ear, TMs obscurred due to wax Throat - red, slightly swollen tongue, dry MM, lips cracked Neck - Unable to assess due to c-collar Chest - speaks in full sentences, no use of accessory muscles, anertior lung exam w/ decreased breath sounds at apices bilaterally, otherwise good air movement, few crackles at both bases, no wheezes CV - RRR, nl S1 and S2 with III/VI systolic murmur best heard at the LLSB Abd - +BS, soft, non-distended, moderately tender to palpation in RUQ and rt flank, no rebound or guarding, negative [Doctor Last Name 515] Rectal - per ED, guiaic neg, nl tone Extrem - rt elbow with lac and swollen, able to move normally, 2+ pitting edema bilat up to high calf, cool feet, poor distal pulses, tender to palpation Neuro CN II - unable to assess CN III, IV, VI - poor cooperation with tests of EOM, but pt moves eyes in all directions when not instructed to CN V - reports normal facial sensation bilat CN VII - moves face normally CN VIII - decreased hearing in both ears L>R CN IX, X - gag not assessed CN XII - tongue midline Strength - pt reports that he "can't" lift legs off of bed, but reports that he usualluy walks a bit at home Sensation - reports nl sensation to light touch and vibration in LE bilat Reflexes - 2+ in biceps, brachioradialis, patellar reflexes bilat, Babinski equivical Skin - dry and flaky thoughout, worst on feet, nails extremely long and thinkened, erosions on shins bilat Mental status - AAOx3, pt able to answer questions when can hear questions and wants to answer, non-cooperative with history and physical exam Pertinent Results: [2165-2-3] 08:55AM WBC-6.9 RBC-3.21* HGB-9.1* HCT-29.5* MCV-92 MCH-28.3 MCHC-30.8* RDW-19.5* [2165-2-3] 08:55AM NEUTS-69 BANDS-0 LYMPHS-14* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-5* NUC RBCS-1* [2165-2-3] 08:55AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [2165-2-3] 08:55AM PLT SMR-LOW PLT COUNT-89* [2165-2-3] 08:55AM PT-13.6* PTT-25.7 INR(PT)-1.2* [2165-2-3] 08:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2165-2-3] 08:55AM HAPTOGLOB-323* [2165-2-3] 08:55AM ALBUMIN-2.8* [2165-2-3] 08:55AM CK-MB-5 proBNP-5930* [2165-2-3] 08:55AM cTropnT-0.03* [2165-2-3] 08:55AM LIPASE-13 [2165-2-3] 08:55AM GLUCOSE-99 UREA N-22* CREAT-1.0 SODIUM-139 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19 [2165-2-3] 05:33PM calTIBC-174* VIT B12-GREATER TH FOLATE-11.0 FERRITIN-1428* TRF-134* [2165-2-3] 05:33PM IRON-19* [2165-2-3] 05:33PM CK-MB-5 cTropnT-0.02* [2165-2-3] 05:33PM LD(LDH)-322* CK(CPK)-183* Brief Hospital Course: A/P 77 y/o M w/ hx of CHF and htn, who presented to OSH after fall from standing. Unclear if fall due to trip and fall or other cause, as pt has no recollection of event. At OSH pt was found to have subdural hematoma and was transferred to the [Hospital1 ] for further management. On admission pt was sent to the MICU. Neurosurgery and spine consults were obtained for recommendations regarding the patients subdural hematoma and L1/L5 compression fractures. The patient remained in a ccollar and on logroll precautions until such time that spine service cleared the cspine and provided a TLSO brace for getting out of bed. Neurosurgery followed until the subdural was proven stable. The medical service also worked the patient up for possible causes of syncope, none which were proven. Not long into the patient's stay he aspirated chicken and rice subsequently developing pneumonia requiring intubation. His respiratory condition worsened to ARDS. He was empirically treated with vanc, zosyn, levoflox although no clear microorganism grew from his sputum even with good sputum samples obtained with bronchoscopy. Pt also developed septic shock requiring pressors to maintain blood pressure. Meanwhile, it was noted that the patient had a R elbow laceration with leaking bursa. The ortho service noted that the wound was not infected and could be adequately managed with wet to dry dressings. Also, while on the MICU service the patient suffered from anemia and thrombocytopenia as well as mild adrenal insufficiency. Pt was given steroids. A HIT panel was sent and returned negative. To maintain nutritional support the pt was placed on tube feeds. The patient also required other typical ICU interventions for CHF, hypernatremia, hypokalemia, hypomagnesemia. Pt was maintained on pneumoboots and heparin SQ for DVT prophylaxis as well as protonix for GI prophylaxis. On the [2-20] the patient underwent PEG and trach placement. This unfortunately was complicated by a liver laceration causing acute blood loss anemia and requiring exploratory laparotomy and liver repair. The PEG was exchanged for a GJ tube. Post operatively the patient was transferred to the surgical trauma service. The patient required extensive volume and blood resussitation but did recover better than expected from this acute event. Subsequently on the surgical trauma service, the patient again developed septic shock from a pseudomonas, enterobacter, and staph pneumonia with difficult sensitivity spectrums. This continues to be treated with Vanc/Cefepime/Zosyn/Flagyl. The patient did finally wean off pressors successfully. The patient was also worked up for CDiff which was negative, all line tips have been negative, and urine has been free of bacteria. The patient did again develop thrombocytopenia. HIT panel was now positive. All heparin products were d/c'd, and the patient was changed to fondaparinux for dvt prophylaxis. The patient was given cardioprotective lopressor when tolerated. Vent weaning has been particularly slow and diuresis particularly difficult. The patient has had mild renal failure associated with over diuresis. Tube feeds have been restarted and are tolerated well. The J port is used, and the G port is clamped. Podiatry has seen the patient for foot care. The patient has also developed a R forearm thrombophlebitis which is improving. Due to assymmetric swelling a dvt study was performed to r/o RUE dvt. Pt did develop atrial fibrillation/flutter which required cardioversion. By the time of d/c the patient has cleared mentally only enough to track/aknowledge our presence at times, moves 4 ext minimally, and rarely follows commands. Interval summary completion: Before being able to be discharged to rehab, Mr [Known lastname 22933] developed another episode of sepsis. He was pancultured, with a persistent psuedomonal pneumonia. He also developed a large sacral decubitis ulcer, which showed significant epidermal sloughing given his markedly edematous subcutaneous tissues. Because of constant stooling, this ulcer became secondarily infected. He developed a septic shock recalcitrant to broad spectrum antibiotics, pressors, bicarbonate and steroids. He was made DNR by his health care proxy on [3-16], and ultimately succumbed to his disease on [3-17]. Medications on Admission: - Hydrocodone - Lasix 20mg - Protonix 40mg - Lopressor 25mg - Temozepam - ?Nebulizer - has received Advair, Tiotropium, Duoneb, albuterol in the past Discharge Medications: n/a Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Subdural hemorrhage L1/5 compression fractures CHF ARDS Liver laceration Pseudomonas and Enterobacter and Staph aureus pneumonias HIT+ Thrombophlebitis R olecranon bursa rupture/ulcer Blood loss anemia Metabolic alkylosis Septic shock Hyperglycemia Hypokalemia Hypomagnesemia Atrial fibrillation/flutter Hypernatremia Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a ICD9 Codes: 5185, 5070, 2760, 2851, 0389, 5990, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6862 }	Medical Text: Admission Date: [2171-12-4] Discharge Date: [2171-12-18] Date of Birth: [2171-12-4] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: [Known lastname 3979] [Known lastname 28221] is the former 2.625 kilogram product of a 33-6/7 weeks gestation born to a 41-year-old G4, P3 now 4 woman. Blood type AB-positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group B Strep status unknown. The pregnancy was remarkable for a placenta previa with recurring vaginal bleeding. The mother was admitted to the [Hospital1 346] on [2171-11-8]. She received betamethasone at that time. Decision was made to deliver on the day of delivery due to significant recurrent bleeding. Cesarean section performed under spinal anesthesia. Infant emerged vigorous. Had Apgars of 8 at 1 minute and 8 at 5 minutes. Required blow-by oxygen for recurrent cyanosis. He was admitted to the neonatal intensive care unit for further treatment. PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 2.625 kilograms, greater than 90th percentile. Length 49 cm, 90th percentile. Head circumference 31.5 cm, 50th percentile. General: Near term infant in mild-to- moderate respiratory distress. Color: Pink, plethoric. Head, eyes, ears, nose, and throat: Normal facies, intact palate. Nondysmorphic facial features. Chest: Mild-to-moderate retractions, fair air entry, intermittent grunting. Cardiovascular: No murmur, present femoral pulses. Abdomen: Flat, soft, nontender, no masses, or hepatosplenomegaly. Hips: Stable. GU: Normal phallus. Testes in scrotum. Neuro: Normal tone and activity. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory: [Known lastname 3979] was placed on continuous positive airway pressure shortly after admission to the neonatal intensive care unit. Chest x-ray was consistent with surfactant deficiency. He was electively intubated and received 2 doses of surfactant. He was extubated to CPAP on day of life #2. On day of life #3, he transitioned to nasal cannula and by day of life 4, he was on room air. He remained in room air for the rest of his neonatal intensive care unit admission. [Known lastname 3979] did not have any episodes of spontaneous apnea and bradycardia. At the time of discharge, he is breathing comfortably with a respiratory rate of 40-60 breaths per minute. 2. Cardiovascular: [Known lastname 3979] has maintained normal heart rates and blood pressures. No murmurs have been noted. Baseline heart rate is 130-140 beats per minute with a recent blood pressure of 78/36 with a mean of 53. 3. Fluid, electrolytes, and nutrition: [Known lastname 3979] was initially NPO and treated with intravenous fluids. Enteral feeds were started on day of life #2 and gradually advanced to full volume. He has been breast feeding or taking expressed breast milk p.o. There is a family history of the mother and siblings who have cow's milk protein intolerance. [Known lastname 3979] has received Prosobee if any formula was required. At the time of discharge, he has been all p.o. feedings without gavage feedings for 48 hours. Weight on the day of discharge is 2.67 kilograms with a length of 50 cm and a head circumference of 31.5 cm. Serum electrolytes were checked in the 1st week of life and were within normal limits. 4. Infectious disease: Due to the unknown etiology of the respiratory distress, [Known lastname 3979] was evaluated for sepsis at the time of birth. A white blood cell count and differential were within normal limits. A blood culture was obtained prior to starting intravenous ampicillin and gentamicin. The blood culture was no growth at 48 hours, and the antibiotics were discontinued. 5. Hematological: Hematocrit at birth was 57%. [Known lastname 3979] did not receive any transfusions of blood products during admission. 6. Gastrointestinal: [Known lastname 3979] required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life 3, total of 14.7/0.3 mg per deciliter direct. Most recent bilirubin was on day of life 11, [2171-12-15], a total of 10.6/0.3 mg per deciliter direct. This is consistent with breastmilk jaundice. 7. Neurological: [Known lastname 3979] has maintained a normal neurological exam during admission. There are no neurological concerns at the time of discharge. 8. Sensory: Audiology: Hearing screening was performed with automated auditory brainstem responses. [Known lastname 3979] passed in both ears. Condition at discharge is good. Discharge disposition is home with the parents. Primary pediatrician is Dr. [First Name8 (NamePattern2) 66270] [Name (STitle) 47710], [Apartment Address(1) 63502], [Location (un) 55], [Numeric Identifier 38804], phone #[Telephone/Fax (1) 66271]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Ad-lib breast feeding or p.o. feeding expressed mother's milk. If formula is required parenteral choice is Prosobee. 2. Medications: Ferrous sulfate 25 mg per mL dilution 0.25 mL p.o. once daily. Infant multivitamin drops 1 mL p.o. once daily. 3. Car seat position screening was performed. [Known lastname 3979] was observed in his car seat for 90 minutes without any episodes of oxygen desaturation or bradycardia. 4. State newborn screen was sent on [2171-12-7]. There was a report of an elevated 17OHP level. A repeat was sent on [2171-12-12] with no notification of abnormal results. Likely the initial elevation was spurious and due to prematurity. Results should be followed. 5. Immunizations administered: Hepatitis B vaccine was administered on [2171-12-9]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: 1. Born at less than 32 weeks; 2. Born between 32 and 35 weeks with 2 of the following: Daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or 3. With chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW-UP APPOINTMENTS RECOMMENDED: Dr. [First Name8 (NamePattern2) 66270] [Name (STitle) 47710] within 3 days of discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 33-6/7 weeks gestation. 2. Respiratory distress syndrome secondary to surfactant deficiency. 3. Suspicion for sepsis ruled out. 4. Unconjugated hyperbilirubinemia. 5. Status post circumcision. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 54936] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2171-12-18] 03:03:13 T: [2171-12-18] 05:05:45 Job#: [Job Number 66272] ICD9 Codes: 769, 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6863 }	Medical Text: Admission Date: [2105-1-13] Discharge Date: [2105-1-26] Date of Birth: [2030-12-12] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: worsening dyspnea Major Surgical or Invasive Procedure: re-do sternotomy for aortic valve replacement (#23 [First Name8 (NamePattern2) ] [Male First Name (un) 923] tissue) [2105-1-19] History of Present Illness: Mr. [Known lastname 732] has known CAD, s/p CABG [2085] at CMC with cardiac cath in [2099] which showed patent graft to RCA w/90% stenosis at insertion, TO SVG to OM, patent LIMA-LAD. He has had recent increase in his DOE/orthopnea and echo [11-26] showed severe AS, [Location (un) 109] 0.75cm2, peak aortic gradient 69, 2+MR, EF42%. He was admitted last week with increased SOB, had mildly elevated BNP, underwent cardiac cath [1-12] which revealed native LAD and RCA TO, SVG->OM occluded, SVG->PDA patent, PDA prox 90%. He was transferred to [Hospital1 18] for consideration of cardiac surgery. Past Medical History: coronary artery disease aortic stenosis PMH: s/p inferior wall myocardial infarction -s/p CABG '[85] congestive heart failure-acute on chronic diastolic hypertension hypercholesterolemia atrial flutter-s/p 2 failed cardioversions, on coumadin previously intollerant of amiodarone d/t bradycardia s/p deep vein thromboses '[82] and '[85] s/p pulmonary emboli '[93] and [2097] recurrent LLE cellulitis-usually requiring IV abx-none recently obesity ?h/o cerebrovascular accident-diagnosed by opthamologist w/o CT scan, major complaint was headache-no residual onychomycosis of toes ?h/o sleep apnea Social History: Race:white Last Dental Exam:1 month ago for caps Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 85862] in [Hospital1 3597] NH Lives with:wife Occupation:retired draftsman for ATT Tobacco:quit [2075] 40-60 pky ETOH:4-5 drinks/week-less lately Family History: non-contributory Physical Exam: Pulse:56 Resp:18 O2 sat: 95% on 4L NC B/P Right: 116/70 Left: Height: Weight: General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur3-4/6 SEM radiating to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [] EdemaLLE-chronic venous stasis chnages, 2+edema, no evidence of cellulitis, RLE chronic venous stasis changes, Tr edema Varicosities: None [x] Neuro: Grossly intact[x] Pulses: Femoral Right: 2+/cath site w/o hematoma/bruit Left:2+ DP Right:1+ Left:1+ PT [Name (NI) 167]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right:transmitted murmur Left:transmitted murmur Pertinent Results: [2105-1-26] 05:20AM BLOOD WBC-7.7 RBC-3.47* Hgb-9.9* Hct-30.4* MCV-88 MCH-28.4 MCHC-32.4 RDW-14.8 Plt Ct-258 [2105-1-26] 05:20AM BLOOD PT-15.0* INR(PT)-1.3* [2105-1-25] 01:00PM BLOOD PT-14.0* INR(PT)-1.2* [2105-1-24] 07:30AM BLOOD PT-14.4* INR(PT)-1.2* [2105-1-26] 05:20AM BLOOD Glucose-112* UreaN-32* Creat-1.1 Na-135 K-4.1 Cl-93* HCO3-34* AnGap-12 [2105-1-24] 07:30AM BLOOD Glucose-99 UreaN-22* Creat-0.9 Na-137 K-3.7 Cl-96 HCO3-31 AnGap-14 PRE-BYPASS: The left atrium is normal in size. The left atrium is dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size is moderately dilated and there is mild global hypokinesis. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results on [Known firstname ] [Known lastname 732]. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including epinephrine infusions 0.02 mcg/kg/min, phenylephrine 1.0 mcg/kg/min Intact thoracic aorta. Moderate mitral regurgitation. Mild tricusid regurgitation. There is a bioprosthesis in the native aortic position, stable and functioning well with no residual regurgitation. The mean gradient is 15mm post replacement. Mild global RV hypokinesis. LV systolic function is mildly improved with LVEF 45%. Mild mitral regurgitation. Mild . Brief Hospital Course: The patient was admitted [2105-1-13] for further preop workup. Carotid scan revealed <40% stenosis bilaterally. Dental clearance was obtained. Heparin was initiated for atrial fibrillation. Echo revealed critical aortic stenosis with aortic valve area <0.8cm2, 2+ mitral regurgitation and ejection fraction 50-55%. Sleep medicine was consulted for a question of obstructive sleep apnea. CPAP was recommended and this was initiated. The patient was brought to the operating room on [2105-1-19] for redo sternotomy, aortic valve replacement with St. [Male First Name (un) 923] tissue valve. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU on Neo, epinephrine and propofol for further observation and invasive monitoring. The epinephrine drip was weaned off, and the patient acutely decompensated, becoming hemodynamically unstable with a metabolic acidosis. He was volume resuscitated with colloid and 4 units packed red blood cells. He was further treated with levophed, epinephrine, calcium and bicarbonate. TEE was performed. Atrial fibrillation ensued and he was cardioverted and subsequently paced. Right femoral line was placed. The patient stabilized. He was extubated on POD 1, hemodynamics stabilized and he awoke neurologically intact. Chest tubes and pacing wires were discontinued without complication. Coumadin was initiated for atrial fibrillation. He progressed and was transferred to the step down floor for further recovery. He was gently diuresed toward his preoperative weight. Low dose beta blockade was initiated in light of bradycardia. He was evaluated by physical therapy. By POD 7 he was cleared by Dr. [Last Name (STitle) ] for discharge to rehab. Medications on Admission: Medications on transfer: lovenox 130mg SC twice daily norvasc 10mg by mouth daily lipitor 80mg by mouth daily aspirin 81mg my mouth daily questran 1 packet dailydaily colace 100mg twice daily lasix 80mg by mouth daily zestril 40mg by mouth daily multivitamin 1 by mouth daily potassium chloride 20mEq by mouth twice daily nitroglycerine 0.3 mg SL as needed Plavix - last dose:[1-10] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours). 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 12. Metolazone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Furosemide 40 mg IV Q12H 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). 16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose to change daily for goal INR 2-2.5 (atrial fibrillation). 17. Outpatient Lab Work follow Chem 7, CBC, INR 1st INR draw [2105-1-27] 18. CPAP CPAP, Autoset while sleeping 19. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: coronary artery disease aortic stenosis PMH: s/p inferior wall myocardial infarction -s/p CABG '[85] congestive heart failure-acute on chronic diastolic hypertension hypercholesterolemia atrial flutter-s/p 2 failed cardioversions, on coumadin previously intollerant of amiodarone d/t bradycardia s/p deep vein thromboses '[82] and '[85] s/p pulmonary emboli '[93] and [2097] recurrent LLE cellulitis-usually requiring IV abx-none recently obesity ?h/o cerebrovascular accident-diagnosed by opthamologist w/o CT scan, major complaint was headache-no residual onychomycosis of toes Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Ultram prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule appointments Surgeon Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Primary care/Cardiologist Dr. [Last Name (STitle) 29070] in [12-20] weeks Dr. [Last Name (STitle) ] (pulmonary sleep medicine) ([Telephone/Fax (1) 9525] following discharge from rehab (arrange for sleep study prior to appointment) Completed by:[2105-1-26] ICD9 Codes: 4241, 2762, 4280, 4019, 2720, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6864 }	Medical Text: Admission Date: [2195-7-8] Discharge Date: [2195-7-30] Service: SURGERY HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a [Age over 90 ]-year-old man with a history of coronary artery disease, congestive heart failure, hypertension, chronic obstructive pulmonary disease, who was transferred from [Hospital3 4527] Hospital. He was admitted to the outside hospital on [2195-7-7] with complaints of right upper quadrant pain and fevers to 102. He also had complaints of nausea and vomiting. A CT scan at the outside hospital showed the presence of gallstones with a moderately dilated gallbladder and evidence of pericholecystic fluid. The patient was subsequently transferred to [Hospital1 346] for evaluation and possible surgical intervention. At the outside hospital, the patient was started on intravenous antibiotics for broad spectrum coverage for cholecystitis. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction 2. Congestive heart failure 3. Hypertension 4. Gout 5. Chronic obstructive pulmonary disease 6. Benign prostatic hypertrophy 7. Cholelithiasis PAST SURGICAL HISTORY: 1. Bilateral total hip arthroplasties 2. Right elbow surgery 3. Transurethral resection of prostate 4. Right carotid endarterectomy ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Peri-Colace, Serax 10 mg by mouth daily at bedtime, protein powder, potassium chloride 10 mEq by mouth twice a day, Isordil 10 mg by mouth twice a day, Tums, aspirin, multivitamin, Thiazide 37.5 mg by mouth once daily, Prevacid, allopurinol 300 mg by mouth once daily, lasix 40 mg by mouth once daily. SOCIAL HISTORY: The patient lives in a nursing home. He has a 50 pack her smoking history. He denies any alcohol use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On presentation, temperature 98.4, heart rate 83, blood pressure 94/51, respiratory rate 16, oxygen saturation 96% on 12 liters. General: Elderly male, able to follow commands. Head, eyes, ears, nose and throat: Notable for icteric sclerae. Neck: No jugular venous distention. Respiratory: Crackles at bilateral bases. Cardiovascular: Regular rate and rhythm, II/VI systolic murmur. Abdomen: Positive bowel sounds, no evidence of surgical scars, nontender, nondistended, no rebound or guarding. Extremities: 2+ pitting edema. Rectal: Guaiac negative. LABORATORY DATA: White blood cells 21.0, hematocrit 32.1, platelets 118. Sodium 142, potassium 3.8, chloride 105, bicarbonate 29, BUN 35, creatinine 1.0, glucose 80. PT 14.3, PTT 35.1, INR 1.4. Calcium 8.8, magnesium 2.1, phosphate 3.9, albumin 2.7. ALT 148, AST 208, alkaline phosphatase 222, total bilirubin 4.9, amylase 59, lipase 21. HOSPITAL COURSE: The patient was initially admitted to the Surgical Intensive Care Unit for further evaluation and management of his cholecystitis. He was made nothing by mouth and continued on intravenous Unasyn. A nasogastric tube was also placed. While in the Surgical Intensive Care Unit, a central venous line was placed to monitor the patient's fluid status, given his history of congestive heart failure. The patient was also evaluated by the endoscopic retrograde cholangiopancreatography team given his symptoms and elevated bilirubin and white blood cell count. The decision was made to proceed with an endoscopic retrograde cholangiopancreatography rather than surgical intervention with a cholecystectomy, given the patient's multiple medical problems. On [2195-7-9], the patient underwent an endoscopic retrograde cholangiopancreatography with general anesthesia. Moderate diffuse dilation was seen at the biliary tree, with the common bile duct measuring 10 mm. The gallbladder was noted to be edematous and very abnormal appearing. Multiple stones were also seen in the gallbladder. The intrahepatic ducts were normal. A sphincterotomy was also performed with drainage of purulent bile. Recommendations were made to perform a percutaneous cholecystostomy tube placement under CT guidance. On that same day, an 8 French pigtail catheter was inserted into the gallbladder under CT guidance. Approximately 100 cc of dark bile was retrieved and sent for culture. The culture eventually grew out Klebsiella organisms which were sensitive to both Unasyn and levofloxacin. Following the placement of the cholecystostomy tube, the patient symptomatically improved. He complained of less abdominal pain and nausea and vomiting. On hospital day number three, the patient was noted to convert his cardiac rhythm from normal sinus rhythm to a rapid atrial fibrillation. His blood pressures were initially stable, and an esmolol infusion was started. Thirty minutes following the initiation of the esmolol infusion, the patient was found profoundly hypotensive, with systolic blood pressures in the 60s, and also decreasing oxygen saturation to 88%. He was started on Neo-Synephrine infusion to maintain his blood pressures. His cardiac rhythm did convert back to normal sinus rhythm. He also received fluid boluses and his requirement for pressors was eventually obviated. The patient was ruled out for myocardial infarction with serial cardiac enzymes. On hospital day number five, the patient was also noted to have a low hematocrit. He was transfused with two units of packed red blood cells, with an appropriate rise in his hematocrit. Given his nothing by mouth status, the patient was also started on total parenteral nutrition for nutrition. The likely etiology of the patient's decreased hematocrit was a post-sphincterotomy bleed. His hematocrit eventually stabilized, and the patient required no additional blood transfusions. On hospital day number seven, the patient was transferred from the Surgical Intensive Care Unit to the floor. The patient was also found to have elevated amylase and lipase levels. His lipase eventually reached a level in the 500s. He was thought to have post-endoscopic retrograde cholangiopancreatography pancreatitis. The patient was therefore kept nothing by mouth, and administered total parenteral nutrition, since he had biochemical evidence of pancreatitis. On hospital day number nine, the patient was switched from intravenous Unasyn to levofloxacin for antibiotic coverage. His diet was also advanced to a full liquid diet, given his clinical improvement. The patient, however, continued to complain of abdominal pain in his epigastric area. He was also noted to have increasing alkaline phosphatase and total bilirubin levels. This was concerning for possible obstruction of his bile ducts. On [2195-7-20], the patient underwent a cholangiogram through his existing cholecystostomy tube. He was found to have a single large and multiple small stones, as well as a patent cystic and common bile duct. These findings were consistent with a nonobstructing distal common bile duct stone. These new cholangiogram findings prompted further discussion of a possible cholecystectomy vs. a repeat endoscopic retrograde cholangiopancreatography for stone removal. Given the patient's multiple medical problems, a risk factor assessment was initiated. He underwent a surface echocardiogram on [2195-7-21] to assess his ejection fraction. He was noted to have mildly dilated left atrium and mild symmetric left ventricular hypertrophy. The overall left ventricular systolic function was mildly depressed. The aortic valve leaflets were moderately thickened. Moderate tricuspid regurgitation was seen. His estimated ejection fraction was 50 to 55% on echocardiogram. On [2195-7-22], the patient also underwent a stress MIBI. During this examination, he had no anginal symptoms. His electrocardiogram was uninterpretable since he had an existing left bundle branch block on electrocardiogram. He was found to have a mild reversible defect of the basilar portion of the lateral wall and normal wall motion with an ejection fraction of 46%. With the patient's worsening alkaline phosphatase and bilirubin levels, he was switched back to Unasyn for antibiotic therapy. A Cardiology consult was also obtained for risk assessment for non-cardiac surgery. The patient was deemed to get only limited benefit from revascularization and, in addition, in light of his other medical illnesses, only medical management was recommended. An endoscopic retrograde cholangiopancreatography was repeated on [2195-7-23]. A filling defect consistent with a calculus in the distal common bile duct was noted. This stone was extracted and successful placement of a double-pigtail biliary stent was performed. After discussion with the patient and his family, the decision was made to proceed with a laparoscopic cholecystectomy with the possibility of an open cholecystectomy. On [2195-7-28], the patient was taken to the operating room for a laparoscopic cholecystectomy. The patient tolerated the procedure well, and there were no perioperative complications. Postoperatively, the patient has not had any more symptoms of abdominal pain. He is slowly being advanced to a regular diet. He did require some diuresis with lasix following his operation. On postoperative day number two, the patient's total parenteral nutrition was decreased to half volume in attempts to stimulate the patient's appetite. He has been making progress with physical therapy, and was able to get out of bed to a chair. Case Management has been involved, and planning for possible discharge to an acute level rehabilitation facility. At the time of this dictation, the patient is currently being screened and will likely be discharged on [2195-7-30] or [2195-7-31]. DISCHARGE DIAGNOSIS: 1. Cholelithiasis and choledocholithiasis status post endoscopic retrograde cholangiopancreatography x 2 and laparoscopic cholecystectomy 2. Status post cholecystostomy placement and removal 3. Cholangitis treated with intravenous antibiotics 4. Coronary artery disease 5. Chronic obstructive pulmonary disease 6. Congestive heart failure 7. Hypertension DISCHARGE MEDICATIONS: The patient's discharge medications will be included on his page one summary and on his discharge addendum. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient will be discharged to an acute level rehabilitation facility. FOLLOW-UP INSTRUCTIONS: The patient will follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. [Name6 (MD) 843] [Name8 (MD) 844], M.D. [MD Number(1) 845] Dictated By:[Doctor Last Name 43796] MEDQUIST36 D: [2195-7-29] 22:15 T: [2195-7-30] 00:19 JOB#: [Job Number 43797] ICD9 Codes: 4280, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6865 }	Medical Text: Admission Date: [2137-8-8] Discharge Date: [2137-8-16] HISTORY OF PRESENT ILLNESS: The patient is a 79 year old female with a past medical history of atrial fibrillation, supraventricular tachycardia, bradycardia and an episode of ventricular tachycardia in [2119], who presented to her primary exertion. The patient had been previously managed on beta blockers and calcium channel blockers, but her symptoms were worsening. She was given a Holter Monitor and returned to her primary care physician's office where she was complaining of increased palpitations. At her primary care physician's office, her blood pressure was found to be somewhat low and a subsequently EKG revealed ventricular tachycardia. She was work-up. At [Last Name (un) 1724], she was stable in monomorphic ventricular tachycardia and essentially asymptomatic. Attempted cardioversion with amiodarone was unsuccessful and her ventricular tachycardia persisted with some increased shortness of breath. She was therefore DC cardioverted and transferred to [Hospital1 346] for an Electrophysiology study and potential ventricular tachycardia ablation. At [Hospital1 69], she was taken to the Electrophysiology Laboratory for attempted ventricular tachycardia ablation. The procedure was complicated by decreased blood pressures to the 80s systolic. Subsequent cardiac echocardiogram revealed a 1.5 cm hemodynamically significant pericardial effusion with right atrial pressures of around 25 by pulmonary artery catheterization. She also had recurrent ventricular tachycardia in the Electrophysiology Laboratory and was given a Lidocaine drip. Pericardiocentesis was performed in which we drained approximately 250 cc of blood with subsequent normalization of blood pressures. The patient was therefore transferred to the Cardiac Care Unit where again she experienced a decrease in blood pressures. An additional amount of fluid was drained. Her blood pressures subsequently normalized. In addition, the patient had an elevated CPK, MB and troponin. Lidocaine was eventually discontinued and she was switched to amiodarone plus Mexitil and aggressively diuresed secondary to congestive heart failure. She was eventually cardioverted on [2137-8-13] from atrial fibrillation back to normal sinus rhythm. Today, she was transferred to the [Hospital Unit Name 196] Service for further evaluation. PAST MEDICAL HISTORY: 1. Hypertension. 2. History of atrial fibrillation. 3. History of supraventricular tachycardia. 4. History of paroxysmal ventricular tachycardia. 5. Hypercholesterolemia. 6. Bradycardia status post permanent pacemaker. 7. Chronic lower extremity edema. 8. Degenerative joint disease. 9. Increased urinary frequency. 10. Fibrocystic breast disease. ALLERGIES: Bactrim. MEDICATIONS ON TRANSFER FROM CARDIAC CARE UNIT: [Unit Number ]. Aspirin 325 mg p.o. q. daily. 2. Lasix 20 mg p.o. q. daily. 3. Lipitor 10 mg p.o. q. daily. 4. Amiodarone 400 mg p.o. three times a day. 5. Protonix 40 mg p.o. q. daily. 6. Colace 100 mg twice a day. 7. Mexiletine 150 mg three times a day. 8. Captopril 75 mg p.o. three times a day. 9. Metoprolol 100 mg p.o. twice a day. 10. Norvasc 10 mg p.o. q. daily. 11. Carvedilol 25 mg twice a day. PHYSICAL EXAMINATION: Vital signs revealed 97.4 F. Temperature; blood pressure 193/90; heart rate paced sinus rhythm at 74; respiratory rate of 18. She is [Age over 90 ]% on two liters nasal cannula. In general, she is pleasant, lying in bed and in no acute distress. HEENT examination revealed neck supple; sclerae anicteric. Increased jugular venous distention to the ear at 45 degrees. Cardiovascular examination revealed an S1 and an S2; regular rate and rhythm. I/VI systolic ejection murmur heard mostly at the left upper sternal border; occasional premature ventricular contractions. Distal pulses and radial pulses two plus and regular. Lungs with decreased breath sounds at the bases; otherwise clear to auscultation bilaterally. Abdomen soft, nontender, and present bowel sounds. Extremities: Markedly swollen bilaterally. One to two plus pitting lower extremity edema; one to two plus pulses bilaterally. Warm and well perfused. LABORATORY: On transfer, white blood cell count was 8.0, hematocrit 31.8, platelets 241. Sodium 139, potassium 3.8, chloride 101, bicarbonate 28, BUN 14, creatinine 0.8 with blood glucose of 93. While in the Cardiac Care Unit, her CK peaked at 336 on [8-9], with a peak MB of 54 and a peak troponin of 40, both on [8-8]. Her current cardiac enzymes are overall down trending with her last CPK of 53 and her last troponin of 10.7 on [8-10]. A previous echocardiogram performed on [2137-8-9], showed an ejection fraction of 40% with mild left atrial enlargement and right atrial enlargement. Symmetric mild left ventricular hypertrophy. One plus mitral regurgitation and a trivial pericardial effusion. HOSPITAL COURSE: The patient was brought into the [Hospital Unit Name 196] Service for further evaluation. Because of her elevated cardiac enzymes, it was decided to perform stress imaging to determine if the patient had any significant cardiac ischemia. A Persantine Sestamibi stress test was performed on [2137-8-14], which was significant for an appropriate heart rate and blood pressure response, no angina, uninterpretable EKG; the MIBI portion was significant for no perfusion defects, no wall motion abnormalities and an ejection fraction of 60%. Given the results of the negative stress test, it was therefore only necessary to better control the patient's blood pressure. She was discontinued from her Carvedilol and her Norvasc was increased from 5 mg p.o. q. daily to 10 mg p.o. q. daily. Her blood pressure the next day subsequently stabilized into the 110s over 70s, and she was overall doing quite well, ambulating well without any difficulty. A Physical Therapy consultation was obtained and felt that she was safe to return home with some occasional Physical Therapy services. She will slowly decrease her amiodarone with a new dose on [2137-8-16], of 400 mg p.o. daily. She will take this for a total of three weeks and then switch to 200 mg p.o. daily of amiodarone. She will also be discharged on [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts Monitor and follow-up with Dr. [Last Name (STitle) 284] in Electrophysiology Service Clinic in approximately four weeks. She will also follow-up with her primary care physician in approximately one week for any adjustment of her blood pressure medications. CONDITION AT DISCHARGE: The patient is ambulating well and overall is doing quite well. She was felt to be safe for discharge. DISCHARGE STATUS: To home with Physical Therapy services. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with Dr. [Last Name (STitle) 4949], her primary care physician, [Name10 (NameIs) ] [8-23], at 10:45 a.m. 2. She will also follow-up with Dr. [Last Name (STitle) 284] in approximately four weeks on the results of her [Doctor Last Name ] of Hearts Monitor which she will be discharged home on today. 3. In addition she will follow up with Dr. [Last Name (STitle) 44150] of cardiology at [Last Name (un) 1724]. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. q. daily. 2. Lisinopril 40 mg p.o. q. daily. 3. Lipitor 10 mg p.o. q. daily. 4. Ranitidine 150 mg p.o. q. daily. 5. Aspirin 325 mg p.o. q. daily. 6. Metoprolol 100 mg p.o. three times a day. 7. Amiodarone 400 mg p.o. q. daily for three weeks; then 200 mg p.o. q. daily starting on [2137-9-6]. 8. Mexiletine 150 mg p.o. three times a day. 9. Norvasc 10 mg p.o. q. daily. DISCHARGE DIAGNOSES: 1. Recurrent paroxysmal ventricular tachycardia status post unsuccessful ventricular tachycardia ablation. 2. Paroxysmal atrial fibrillation. 3. Hypertension. 4. Hypercholesterolemia. 5. Bradycardia status post permanent pacemaker. 6. Chronic lower extremity edema. 7. Degenerative joint disease. 8. Pericardial tamponade complicating EPS, treated with pericardiocentesis. [First Name4 (NamePattern1) 610] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3812] Dictated By:[Name8 (MD) 44151] MEDQUIST36 D: [2137-8-20] 20:55 T: [2137-8-26] 15:05 JOB#: [Job Number 44152] ICD9 Codes: 4271, 4280, 9971, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6866 }	Medical Text: Admission Date: [2160-11-20] Discharge Date: [2160-11-23] Date of Birth: [2121-2-8] Sex: M Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: Patient is a 39-year-old right-handed gentleman, who presented on transfer from [Hospital3 418] Hospital after having a seizure. Patient was found by his wife to be flailing his arms and legs and foaming at the mouth while asleep. Patient has no recollection of this. Was taken to [Hospital3 417] Hospital, stabilized, and transferred to [Hospital1 69]. PAST MEDICAL HISTORY: 1. Asthma. 2. Obsessive-compulsive disorder. 3. Hypercholesterolemia. MEDICATIONS: 1. Dilantin, loaded on Dilantin on transfer. 2. Occasional baby aspirin. 3. Ibuprofen occasional. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: On physical exam, he was afebrile at 97.9 temperature, blood pressure 128/67, heart rate 74, respiratory rate 16, and sats is 96%. He was alert, awake, oriented, conversant, fluent speech. Face was symmetric. Smile was equal. Tongue was midline. Neck was supple. Lungs were clear. Cardiac: Regular, rate, and rhythm. Abdomen: Positive bowel sounds, nontender, and nondistended. Spine: Nondistended and nontender. Pupils are equal, round, and reactive to light. His reflexes are 1+ throughout. His toes were downgoing. Head CT scan at the outside hospital showed a 2 cm high attenuation lesion in the medial right temporal lobe without significant edema or mass effect. Ventricles and sulci within normal limits. Patient had a MRI scan which also showed a 2 cm hemorrhage in the right medial temporal lobe with posteromedial to the temporal gyrus, hyperintense on both T1 and T2 sequences. Minimal mass effect or edema. Patient is admitted to the Neuro Intensive Care Unit for close monitoring. Was seen by Dr. [Last Name (STitle) 1132] and on [2161-1-21] underwent an arteriogram which showed no evidence of high flow shunting. Postprocedure he was awake, alert, and oriented times three. His groin site was clean, dry, and intact. His pedal pulses were positive. He was transferred to the regular floor on postprocedure day #1, and discharged to home on postprocedure day #2 on Dilantin 100 mg po tid. Will follow up for surgery for removal of cavernous malformation at a later date. He will follow up with Dr. [Last Name (STitle) 1132] in [1-16] weeks. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2161-8-10] 10:55 T: [2161-8-20] 11:24 JOB#: [Job Number 45427] ICD9 Codes: 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6867 }	Medical Text: Admission Date: [2130-3-24] Discharge Date: [2130-4-4] Date of Birth: [2067-10-22] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 603] Chief Complaint: auditory hallucinations Major Surgical or Invasive Procedure: none History of Present Illness: 62 yo female with history of PUD, memory deficits, history of auditory hallucinations who presents after hearing voices telling her to kill herself. Per report, patient has had AH intermittently in since [2124] and had previously been on medications which patient states helped her. Hallucinations are described as a woman's voice telling her to fall down her stairs. Patient also states that she believes snakes are inside of her and that she sees snakes. The snakes tell her to hurt herself. Per report, the patient has long-standing memory difficulties (leaves gas stove on). The patient went to [Hospital1 112] yesterday for auditory hallucinations where she was found to have a negative head CT. Infectious workup for delerium revealed a UTI and the patient was started on a course of macrobid. . Patient currently complains of epigastric pain, which worsens with spicy food and is improved with maalox. She also complains of left flank pain. She denies currently hearing voices, but states that she hears them frequently. Past Medical History: -- History of Auditory Hallucinations since [2124] after the birth of her son. Was treated with seroquel and zoloft at that time per the records with good response. -- Depression -- Peptic Ulcer Disease -- Diverticulosis -- Tension Headache -- Memory Deficits Social History: Lives with son [Name (NI) ]. Not currently working. Prior history of smoking, no tobacco now. No drugs or alcohol. Family History: Older sister with memory deficits. Mother with [Name2 (NI) ] (died at 81). No psychiatric family history. Physical Exam: Admission physical exam: VS - Temp 98.3, BP 125/73, HR 82, R 18, O2-sat 98 % RA GENERAL - well-appearing in NAD, comfortable, well groomed HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, mildly enlarged thyroid with tenderness on palpation, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, mild epigastric tenderness on palpation, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - scars from burns on the thighs bilaterally NEURO - awake, A&Ox3, attention good with days of the week backwards (mixed up monday and tuesday), CNs II-XII intact, muscle strength 5/5 deltoids/triceps/biceps, illiopsoas, sensation grossly intact throughout, cerebellar exam intact, steady gait . Discharge physical exam: VS - 98.6 122/84 92 18, 96% RA GENERAL - pleasant woman laying comfortably in bed NECK - supple, mildly enlarged thyroid with tenderness on palpation, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/non-tender/non-distended, no masses or HSM, no rebound/guarding BACK - area of lumbar puncture non-erythematous EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - scars from burns on the thighs bilaterally; no lesions on hands or feet NEURO: CN II-XII intact; pupils equal, round and reactive to light; strength 5/5; romberg negative PSYCH: endorses pleasant voices telling her to walk around, denies SI/HI Pertinent Results: Admission labs: [2130-3-24] 05:50PM BLOOD WBC-8.1 RBC-4.68 Hgb-12.9 Hct-39.5 MCV-84 MCH-27.5 MCHC-32.7 RDW-12.5 Plt Ct-294 [2130-3-24] 05:50PM BLOOD Glucose-122* UreaN-16 Creat-0.8 Na-142 K-4.0 Cl-105 HCO3-27 AnGap-14 [2130-3-24] 05:50PM BLOOD ALT-14 AST-19 AlkPhos-82 TotBili-0.1 [2130-3-24] 05:50PM BLOOD Lipase-74* [2130-3-24] 05:50PM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2 [2130-3-24] 05:50PM BLOOD VitB12-877 Folate-11.1 [2130-3-24] 05:50PM BLOOD TSH-3.6 [2130-3-24] 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . CSF analysis: [2130-3-28] 12:33PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0 Lymphs-67 Monos-33 [2130-3-28] 12:33PM CEREBROSPINAL FLUID (CSF) TotProt-55* Glucose-72 [2130-3-28] 12:33PM Syphilis (VDRL) (CSF) Non-Reactive (-) [2130-3-28] 12:33PM Herpes Simplex Virus PCR (CSF) Negative . Discharge labs: [2130-3-31] 07:03AM BLOOD WBC-6.4 RBC-4.70 Hgb-13.2 Hct-40.1 MCV-85 MCH-28.0 MCHC-32.8 RDW-12.8 Plt Ct-294 [2130-3-31] 07:03AM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-136 K-5.3* Cl-101 HCO3-27 AnGap-13 [2130-3-31] 07:03AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.3 [2130-3-31] 07:03AM BLOOD HIV Ab-NEGATIVE . CXR [2130-3-24]: Frontal and lateral views of the chest were obtained. In the left upper to mid lung, there is a 0.5 cm calcified nodule most likely representing a calcified granuloma. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. No overt pulmonary edema is seen. Brief Hospital Course: 62 year old woman with history of PUD, dementia of unclear etiology, and auditory hallucinations who presents after hearing voices telling her to harm herself. #. Hallucinations/SI: The patient has a history of auditory hallucinations and subacute memory decline since [2124]. The patient was seen by psychiatry for hallucinations, who recommended Risperdal [Hospital1 ] for symptoms. RPR, TSH, HIV, and B12 were negative on admission. However, the patient was noted to have positive RPR and anti-treponemal antibody at an OSH in [2128], untreated per records and discussion with PCP. [Name10 (NameIs) 92169] antibody had been repeated at the OSH just prior to the patient's admission to [Hospital1 18], and again returned positive during her hospital stay. Positive anti-treponemal antibody with subacute memory decline and vivid visual and auditory hallucinations concerning for neuro-syphilis as source of symptoms. The patient underwent lumbar puncture that showed 1 WBC and elevated protein to 55 that may be consistent with late neuro-syphilis. CSF-VDRL and HSV PCR negative, anti-treponemal antibody pending. As the patient was noted to have a penicillin allergy, she was transferred to the ICU for penicillin desensitization. She then was started on a 10 day course of penicillin G to be completed night of [2130-4-7]. Given the patient underwent desensitization, she may not miss a dose of medication, as it may result in serious side effects. The patient should follow up with her PCP on discharge regarding her symptoms, and for referral to cognitive neurology. She should undergo neuropsychiatric testing as an outpatient. Under the guidance of psychiatry, she was started on risperidone. She had marked improvement in her hallucinations on this medication. #. Abdominal pain: On admission, the patient complained of mild abdominal pain that by history was consistent with GERD. She was also found to have a mildly elevated lipase to 74. Abdominal pain may also be a manifestation of the hallucinations i.e. snakes in stomach. She was started on ranitidine and Maalox for symptoms. With improvement in her symptoms, she was transitioned to pantoprazole. She should follow up with her PCP if symptoms recur. #. Vulvovaginitis: Patient reported whitish vaginal discharge and pruritis after starting penicillin. Pelvic exam revealed erythema, and the patient was given fluconazole 150mg PO x1. # CODE: FULL CODE # CONTACT: HCP: [Name (NI) ] (son)-[Telephone/Fax (1) 92170] =============================================================== TRANSITIONAL ISSUES # Patient should complete 10-day penicillin course night of [4-7]. She may not miss a dose, as she has a PCN allergy and is s/p desensitization. # Patient needs follow up with cognitive neurology. Must make appointment through PCP for insurance purposes. Medications on Admission: Nitrofurantoin 100mg [Hospital1 ] x 5 days (started [2130-3-23]) Ranitidine 150mg [Hospital1 ] Meclizine unknown dose Discharge Medications: 1. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for GERD. 2. risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. penicillin G potassium 20 million unit Recon Soln Sig: 4 million units Injection Q4H (every 4 hours) for 4 days: Patient may not miss dose due to hypersensitivity, last dose 2/24 PM. Discharge Disposition: Extended Care Facility: [Hospital 745] Health Care Center Discharge Diagnosis: PRIMARY DIAGNOSIS: Auditory hallucinations, depression, syphilis SECONDARY DIAGNOSIS: urinary tract infection, GERD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], You were admitted to the hospital for hearing voices that were telling you to hurt yourself. Prior to your admission, you were also discovered to have a urinary tract infection. You were continued on 3 days of ciprofloxacin for your urinary tract infection. For the voices you were hearing, you were evaluated by psychiatry, who recommended medication to help resolve the voices. You were also noted to have tests indicative of a chronic syphilis infection that we think may be causing the voices. The voices improved over the course of your hospitalization. Because you have had a penicillin allergy in the past, you were transferred to the ICU during your admission to start you on a course of penicillin. You had a special IV placed, and will complete a 10 day course of penicillin for your syphilis. It is important that you do not miss a dose of penicillin. On discharge, please follow up with your primary care physician for [Name Initial (PRE) ] referral to a cognitive neurologist. . Medications changed this admission: START risperidol 1 mg every morning and 2 mg every evening START Penicillin G Potassium 4 Million Units IV Q4H (LAST DAY [2130-4-8]) START Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO/NG 4 times daily as needed for heartburn START pantoprazole 40 mg daily. Discuss stopping this medication with your primary care physician on discharge. STOP nitrofurantoin STOP ranitidine Followup Instructions: Please call your primary care physician for [Name Initial (PRE) ] follow up appointment on discharge: Name: [First Name8 (NamePattern2) 2411] [Last Name (NamePattern1) 38279], NP Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3530] You should follow up with cognitive neurology. Your primary care physician will set up this appointment for you on follow-up. ICD9 Codes: 5990, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6868 }	Medical Text: Admission Date: [2131-2-15] Discharge Date: [2131-2-20] Date of Birth: [2078-12-5] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin Attending:[First Name3 (LF) 1055] Chief Complaint: Polyuria/Polydypsia Major Surgical or Invasive Procedure: R femoral line placement History of Present Illness: Briefly, patient is a 52 yo lady with DM1, Graves' disease, HTN, chronic migraines, Hep C, asthma, [Hospital ] transfered from the MICU with DKA in setting of medication non compliance. Patient self d/ced all her meds over a week ago due to polyuria and fatigue, stating she just "didn't feel like taking them" and wanted to lie still. Patient had been having a typical URTI with cough, rhinorrhea, also with N/V/D x 3-4 days prior to admission. Patient then developed shortness of breath which prompted her to come to the hospital. In the ED, FS was critically high, AG of 37-->admitted to MICU for DKA, given 10 U regular insulin IV and started on insulin drip. She was hydrated with 3L NS in the ED. . In the MICU, gap closed with NPH/Humalog SS, continued NS->D51/2NS x 1L, now taking POs, [Last Name (un) ] consult placed. . On the floor, patient has multiple complaints, ROS positive for chronic headaches, +migraine history, a "pulling" sensation in her chest x several months, localized to the left, diffuse in nature, radiates to her neck, left arm with tingling/numbness on occasion with these episodes, also radiating down her left leg. She says that these episodes occur mostly with exertion when she is cleaning the house or walking. Patient also c/o crampy abdominal pain periumbilical and pelvic in location, similar to when she had her babies, these are no associated with menses. She says that she always has this pain but that it is currently worse. She also c/o burning and sharp pains in ther legs b/l which is also chronic in nature. Patient is taking POs but often gets nauseous and vomits. Patient also says that she has intermittent fresh blood in her stools, on the toilet paper and in the bowel which she thinks is associated with straining, also with occasional dark black stools x several months. Past Medical History: 1. Type 1 diabetes mellitus diagnosed in [2125]. 2. Hypertension. 3. [Doctor Last Name 933] disease. 4. Asthma. 5. Hepatitis C. 6. GERD. 7. Obesity. 8. Rheumatoid arthritis. 9. Recent bilateral knee arthroscopy in [2129-5-26]. 10. Migraines. 11. Status post TAH and pelvic floor surgery with bladder lift. Social History: The patient denies tobacco or alcohol use. Lives with a 22-year-old daughter. Currently has home VNA. Family History: Non contributory Physical Exam: VS: 98.4 BP 126/74 HR 84 R 18 O2 sat 100% RA FS 86 194 lbs Gen: middle aged lady, NAD, talkative HEENT: moist, edentulous, anicteric, EOM full Neck: supple, JVP flat Chest: CTA b/l, no wheezing or rales CVS: nl S1 S2, split S2, no m/r/g appreciated Abd: soft, mildly tender diffusely, no rebound or guarding, BS present but trace, no HSM Ext: warm, dry, 1+ dp pulses b/l, no chronic skin changes/rashes, R fem line in place, clean/dry/intact, no swelling, non tender, full range of motion of LE b/l; deformity of fingers b/l, slightly contracted/curled inward Neuro: A&O Pertinent Results: [2131-2-15] 11:00PM TYPE-[Last Name (un) ] PO2-73* PCO2-20* PH-7.10* TOTAL CO2-7* BASE XS--21 [2131-2-15] 11:00PM GLUCOSE-528* [2131-2-15] 10:30PM GLUCOSE-535* UREA N-25* CREAT-1.3* SODIUM-130* POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-6* ANION GAP-33* [2131-2-15] 07:50PM GLUCOSE-817* UREA N-30* CREAT-1.6* SODIUM-127* POTASSIUM-6.4* CHLORIDE-85* TOTAL CO2-<5 VERIFIE [2131-2-15] 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2131-2-15] 07:50PM URINE HOURS-RANDOM [2131-2-15] 07:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2131-2-15] 07:50PM WBC-15.4# RBC-5.11# HGB-15.3# HCT-46.9# MCV-92# MCH-29.9 MCHC-32.6 RDW-12.2 [2131-2-15] 07:50PM NEUTS-86.2 LYMPHS-10.5* MONOS-3.1 EOS-0.1 BASOS-0.1 [2131-2-15] 07:50PM HYPOCHROM-1+ [2131-2-15] 07:50PM PLT COUNT-359 [2131-2-15] 07:50PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.025 [2131-2-15] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2131-2-15] 07:30PM URINE HOURS-RANDOM [2131-2-15] 07:30PM URINE GR HOLD-HOLD [2131-2-15] 06:41PM GLUCOSE-767* . CHEST SINGLE PORTABLE: Comparison is made to [2130-12-3]. Heart size is normal. The mediastinal and hilar contours are unremarkable. The lungs are clear. There are no pleural effusions or pneumothorax. Visualized osseous structures are unremarkable. . IMPRESSION: No evidence of acute cardiopulmonary process Brief Hospital Course: Ms. [Known lastname 18741] is a 52 yr old female with type 1 DM, HTN, Asthma, chronic migraines, RA, HTN admitted with DKA in setting of med non compliance. # DKA: Patient reports not taking her meds [2-22] depression, recent illness and simply not wanting to continue taking medication. No clear source of infection, neg UA, clear CXR. ? abd source given localized abd pain radiation to back. Other possible exacerbating factors include CAD, hyperthyroidism. Cardiac enzymes were negative x 3 however patient with evidence of lateral ischemia with TWI on EKG associated with tachycardia, noted in lateral leads I, avL, V5-6. Patient also with vague complaints of ?angina, chest discomfort with exertion. Patient likely needs an outpatient stress test in the near future for further work up. Patient was initially managed in the MICU with insulin gtt, FS q 1 hr and aggressive IVF hydration with closure of the anion gap. After one night in the unit, patient was transfered to the floor with good control. Patient followed by [Last Name (un) ] who managed the patient with NPH insulin and Humanlog sliding scale. At the time of discharge, she was achieving decent sugar control on her consistent carbohydrate diet. She will follow up with [Last Name (un) ] as an outpatient. At the time of discharge, the patient voiced understanding that she really needed to maintain good sugar control to prevent another occurrence of the events leading to this hospitalization. . # Chest Pain - Patient with new EKG changes, TWI in lateral leads I, aVL, V5-6, ?demand ischemia in setting of tachycardia vs. new ischemic event precipitating DKA. CE negative x 1 on admission. Patient relays symptoms somewhat suggestive of angina, chest tightness on exertion with sob, diaphoresis, radiation to arm. ?difficult to interpret in setting of DM, as well as the patient's inconsistent reports. Repeat enzymes remained flat. The patient will need to follow up as an outpatient for stress testing and coronary risk stratification. . # Abd Pain: Ongoing complaints x many months, crampy pain, periumbilical and pelvic, likely fibroids vs. pancreatitis vs. PUD. Lipase elevated on admission to 245, trending down to normal likely in setting of DKA, tolerating POs but with relatively poor intake. Continued on PPI. Her intake improved somewhat leading up to discharge. She expressed awareness that she needed to keep her PO intake consistent to prevent problems with her glucose management. She was instructed to follow up her abdominal pain as an outpatient with EGD/colonoscopy, and possible pelvic ultrasound. Patient experienced some improvement with Reglan during her stay. . # Neuropathic pain/Neuropathy - patient c/p burning/tingling/numbness in legs, also ?gastroparesis given history of vomiting. Continued on Tramadol, started Neurontin [Hospital1 ]. This medication will likely take time to work, and effectiveness of this regimen can be evaluated and titrated as an outpatient. . #. Graves' Disease: Patient taking methimazole as outpatient, although there is concern regarding her medication compliance. This could account for her elevated free T4 on screening in house. Will continue current methimazole dose for now, will need to recheck as outpatient. . #. GERD: Will continue PPI for now. This may help her abdominal pain as well. Giving NSAIDS (tramadol) currently. . #. Asthma: Continuing with current outpatient regimen. No evidence for asthma exacerbation at this time. . #. HTN: Patient on antihypertensives as an outpatient. Have been holding these since admission for her DKA. Currently BP has been running wnl, so will continue to hold. With resumption of outpatient dietary habits may creep back up. Will need to follow up as outpatient. . #. Seronegative polyarthritis: Continue sulfasalazine, NSAID prn for now. Patient has been followed by Dr. [Last Name (STitle) ] in [Hospital 2225] clinic for this problem. . #. Hepatitis C: Patient is not taking any antiviral therapy. Seen by Dr. [Last Name (STitle) ] in Hepatology. Genotype is 1A, biopsy revealed Grade I inflammmation. Decision was made not to pursue antiviral therapy. . #. Migraine headaches: The patient experienced several headaches that fit her usual migraine pattern during her stay. These headaches were responsive to sumatriptan in house, along with oxycodone. Her headaches had improved by the time of discharge. She was sent home with a small amount of sumatriptan for any additional headaches prior to her next outpatient visit. Medications on Admission: * Methimazole 10 mg tid * Cyclobenzaprine 10 mg [Hospital1 ] * Pantoprazole 40 mg qd * Diazepam 5 mg [Hospital1 ] * Montelukast 10 mg qd * Salmeterol q12 * Fluticasone 110 mcg, 2 puffs [Hospital1 ] * Hyoscyamine Sulfate 0.375 mg [Hospital1 ] * Albuterol 1-2 puffs q6hrs prn * Losartan 100mg qd * Hydrochlorothiazide 25 mg qd * Aspirin 81 mg qd * Sulfasalazine 1500 mg [Hospital1 ] * 70-30 unit/mL 80U qam * 70-30 unit/mL 90U qhs Discharge Medications: 1. Methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 2. 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 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 inhaler Refills:2 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:50 Tablet(s) Refills:0 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:50 Tablet(s) Refills:0 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:2 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:1 inhaler Refills:2 10. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 11. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). Disp:1 small bottle Refills:2 12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:2 15. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID PRN as needed for nausea. Disp:10 Tablet(s) Refills:0 16. Imitrex 100 mg Tablet Sig: One (1) Tablet PO once a day as needed for migraine. Disp:10 Tablet(s) Refills:0 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty Six (36) units Subcutaneous qAM with breakfast. Disp:qs qs Refills:2 18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Six (26) units Subcutaneous qPM with dinner. Disp:qs qs Refills:2 19. Humalog 100 unit/mL Solution Sig: Per sliding scale units Subcutaneous four times a day. Disp:qs qs Refills:2 20. Lancets Misc Sig: One (1) lancet Miscell. four times a day. Disp:qs qs Refills:2 21. test strips Sig: One (1) glucometer test strip four times a day. Disp:qs qs Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] [Hospital 2256] Discharge Diagnosis: Diabetic ketoacidosis Type 1 diabetes mellitus . Secondary: Hypertension Hepatitis C virus infection Chronic arthritis Migraine headaches Chronic abdominal pain Discharge Condition: stable, tolerating PO and ambulating without assistance. Discharge Instructions: Please continue to take all medications as prescribed. It is extremely important that you continue to take your diabetes medications and check your blood sugars with every meal and before bedtime. You should call Dr. [Last Name (STitle) ] at [Last Name (un) ] if your blood sugars are above 300 at any time. If you experience new chest pain, shortness of breath, fevers, chills, nausea, vomiting, or any other concerning symptoms, contact your physician or return to the emergency room. Followup Instructions: Provider: [First Name11 (Name Pattern1) 20] [Last Name (NamePattern4) 7176], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2131-3-12] 4:00 (Rheumatology) . Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 2422] Date/Time:[2131-5-2] 9:40 (Liver doctor) . Please call your primary care doctor to make an appointment within the next 2-4 weeks. You need to schedule an outpatient exercise MIBI stress test for your heart. Your physician will make this appointment for you. . If you would like outpatient psychiatric follow up, you can call Dr. [Last Name (STitle) 10166], who you have seen before, at ([Telephone/Fax (1) 32356] to set up an appointment. . You should contact Dr. [Last Name (STitle) ] at ([Telephone/Fax (1) 16687] to arrange an outpatient colonoscopy and discuss a possible outpatient upper endoscopy. . You have an appointment at [Last Name (un) ] with Dr. [Last Name (STitle) ] on [3-1], at 9:00 AM to discuss your diabetes management. Please make every effort to keep this appointment. Completed by:[2131-3-12] ICD9 Codes: 5849, 3572, 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6869 }	Medical Text: Admission Date: [2168-1-15] Discharge Date: [2168-1-21] Date of Birth: [2099-2-25] Sex: M Service: UROLOGY Allergies: Percodan / Demerol / Shellfish Attending:[First Name3 (LF) 11304] Chief Complaint: bladder cancer Major Surgical or Invasive Procedure: laparoscopic cystectomy, ileal conduit History of Present Illness: bladder cancer Past Medical History: pmh: turbt [2165] gim/cis preop, htn, DM, copd Brief Hospital Course: Patient was admitted to the Urology service after undergoing radical cystectomy and ileal conduct. No concerning intraoperative events occurred; please see dictated operative note for details. Patient received perioperative antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin. With the passage of flatus, patient's diet was advanced. The patient was ambulating and pain was controlled on oral medications by this time. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. The ostomy was perfused and patent. Patient is scheduled to follow up in one weeks time with in clinic for wound check and in 3 weeks time for stent removal. Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: use while taking narcotics, over the counter. Disp:60 Capsule(s) Refills:0 4. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days: Start the day before stents are scheduled to be removed. Disp:6 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: bladder cancer Discharge Condition: stable Discharge Instructions: -Please resume all home meds -Do not drive while taking oxycodone. -You may shower, but do not immerse incision, no tub baths/swimming. -Small white steri-strips bandages will fall off in [4-28] days, you may remove at that time if irritating. -Call if incision becomes markedly more red, swollen, or begins to drain purulent fluid, or for fever more than 101.5. -Please refer to visiting nurses (VNA) for management of the ileal conduct. -Take ciprofloxacin for 3 days, starting the day before your stents are to be removed in the clinic Followup Instructions: 1 week for staple removal 3 weeks for stent removal Completed by:[2168-1-21] ICD9 Codes: 9971, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6870 }	Medical Text: Admission Date: [2107-1-28] Discharge Date: [2107-2-4] Date of Birth: [2024-4-25] Sex: F Service: SURGERY Allergies: Iodine/Potassium Iodide / Amoxicillin / Codeine / Tetracycline / Simvastatin / Atorvastatin Attending:[First Name3 (LF) 301] Chief Complaint: Nausea and Vomiting Major Surgical or Invasive Procedure: [2107-1-29] - ERCP [2107-1-31] - 1. Laparoscopic cholecystectomy. 2. Adhesiolysis over 60 minutes History of Present Illness: 82F with MVP, HTN, h/o SBO s/p rsxn [1-9] and VHR [2103], who developed n/v x many starting last PM after custard pie and coke. Thought was [2-7] lactate insufficiency but diffuse abd pain this AM and persistent nausea with light-headedness prompted ED visit today. Was seen in clinic yesterday for palpitations (EKG APCs, echo and holter studies ordered). EKG here NSR. No f/c, no sob/cp. CT a/p obtained which showed gallstones, sig GB wall thickening, + PCF, CBD 8mm, no obvious CBD stones but internal echoes w/n GB suggestive of sludge vs gangrenous cholecystitis. Given cipro/flagyl in ED. Past Medical History: Cervical Stenosis Hypertension Mitral valve prolapse anxiety Hyupercholesterolemia Osteoporosis hemorrhoids B12 Deficciency s/p TAH '50s s/p bilateral femoral hernia repair ('[73], '[80]) SBO s/p resection [1-9] Dr. [Last Name (STitle) ], VHR [2103] Social History: Lives in apartment by herself, sister lives upstairs. Denies tobacco, EtOH, or IVDU. Family History: Noncontributory Physical Exam: Upon Discharge: VS:97.7, 76, 90/56, 18, 93% RA GEN: NAD, AAOx3 HEENT: NCAT CV: RRR, S1S2 LUNGS: CTAB ABD: Soft, NTND, old drain site in LUQ is C/D/I EXT: no cyanosis, erythema, or edema are present. Pertinent Results: [2107-1-27] 04:25PM BLOOD WBC-7.4 RBC-4.31 Hgb-12.7 Hct-37.3 MCV-87 MCH-29.5 MCHC-34.1 RDW-13.5 Plt Ct-242 [2107-1-28] 11:40AM BLOOD WBC-14.9# RBC-4.19 Hgb-12.4 Hct-34.0* MCV-81* MCH-29.6 MCHC-36.4* RDW-13.7 Plt Ct-212 [2107-1-29] 06:05AM BLOOD WBC-7.8 RBC-3.46* Hgb-10.1* Hct-29.0* MCV-84 MCH-29.3 MCHC-34.9 RDW-13.8 Plt Ct-174 [2107-1-30] 02:29AM BLOOD WBC-7.6 RBC-3.32* Hgb-10.0* Hct-28.1* MCV-85 MCH-30.0 MCHC-35.4* RDW-14.0 Plt Ct-173 [2107-1-31] 01:49AM BLOOD WBC-4.4 RBC-3.26* Hgb-9.8* Hct-27.6* MCV-85 MCH-30.0 MCHC-35.4* RDW-13.9 Plt Ct-155 [2107-2-1] 03:09AM BLOOD WBC-7.8# RBC-3.72* Hgb-10.8* Hct-31.3* MCV-84 MCH-29.1 MCHC-34.6 RDW-13.9 Plt Ct-247# [2107-2-2] 06:10AM BLOOD WBC-7.6 RBC-3.93* Hgb-11.6* Hct-32.6* MCV-83 MCH-29.6 MCHC-35.6* RDW-13.8 Plt Ct-265 [2107-1-28] 11:40AM BLOOD Neuts-93.4* Lymphs-3.2* Monos-2.9 Eos-0.4 Baso-0.1 [2107-1-28] 04:54PM BLOOD PT-13.4 PTT-30.3 INR(PT)-1.1 [2107-1-30] 02:29AM BLOOD PT-16.7* PTT-49.9* INR(PT)-1.5* [2107-1-27] 04:25PM BLOOD UreaN-10 Creat-0.6 Na-140 K-3.6 Cl-101 HCO3-29 AnGap-14 [2107-1-28] 11:40AM BLOOD Glucose-138* UreaN-7 Creat-0.5 Na-133 K-2.7* Cl-95* HCO3-26 AnGap-15 [2107-1-29] 06:05AM BLOOD Glucose-216* UreaN-5* Creat-0.5 Na-141 K-8.8* Cl-116* HCO3-21* AnGap-13 [2107-1-29] 08:29AM BLOOD Glucose-105 UreaN-5* Creat-0.6 Na-142 K-4.0 Cl-110* HCO3-24 AnGap-12 [2107-1-29] 10:22PM BLOOD Glucose-112* UreaN-6 Creat-0.5 Na-138 K-3.4 Cl-108 HCO3-24 AnGap-9 [2107-1-30] 02:29AM BLOOD Glucose-86 UreaN-6 Creat-0.5 Na-138 K-3.5 Cl-108 HCO3-24 AnGap-10 [2107-1-31] 01:49AM BLOOD Glucose-76 UreaN-10 Creat-0.4 Na-139 K-3.9 Cl-109* HCO3-23 AnGap-11 [2107-2-1] 03:09AM BLOOD Glucose-102 UreaN-4* Creat-0.5 Na-137 K-3.5 Cl-103 HCO3-29 AnGap-9 [2107-2-2] 06:10AM BLOOD Glucose-147* UreaN-2* Creat-0.5 Na-138 K-3.6 Cl-99 HCO3-29 AnGap-14 [2107-2-3] 06:00AM BLOOD Glucose-107* UreaN-7 Creat-0.6 Na-137 K-3.7 Cl-102 HCO3-29 AnGap-10 [2107-1-27] 04:25PM BLOOD CK(CPK)-119 [2107-1-28] 11:40AM BLOOD ALT-22 AST-34 AlkPhos-73 TotBili-3.1* [2107-1-29] 06:05AM BLOOD ALT-276* AST-384* AlkPhos-198* Amylase-15 TotBili-5.0* DirBili-2.2* IndBili-2.8 [2107-1-29] 10:22PM BLOOD CK(CPK)-121 [2107-1-30] 02:29AM BLOOD ALT-191* AST-159* AlkPhos-193* TotBili-4.4* [2107-1-30] 06:03AM BLOOD CK(CPK)-96 [2107-1-31] 01:49AM BLOOD ALT-130* AST-67* LD(LDH)-140 AlkPhos-154* Amylase-150* TotBili-1.6* [2107-2-1] 03:09AM BLOOD ALT-116* AST-95* LD(LDH)-222 AlkPhos-148* Amylase-57 TotBili-0.9 DirBili-0.4* IndBili-0.5 [2107-2-3] 06:00AM BLOOD ALT-64* AST-34 AlkPhos-117 Amylase-80 TotBili-0.8 [2107-1-28] 11:40AM BLOOD Lipase-23 [2107-1-29] 06:05AM BLOOD Lipase-17 [2107-1-31] 01:49AM BLOOD Lipase-389* [2107-2-1] 03:09AM BLOOD Lipase-119* [2107-2-3] 06:00AM BLOOD Lipase-200* [2107-1-29] 10:22PM BLOOD CK-MB-3 cTropnT-<0.01 [2107-1-30] 06:03AM BLOOD CK-MB-NotDone cTropnT-0.03* [2107-1-27] 04:25PM BLOOD Phos-3.2 Mg-2.3 [2107-1-28] 11:40AM BLOOD Albumin-3.9 [2107-1-29] 06:05AM BLOOD Calcium-7.3* Phos-1.6# [2107-1-29] 10:22PM BLOOD Calcium-7.8 Phos-1.7* Mg-1.7 [2107-1-30] 02:29AM BLOOD Calcium-8.1* Phos-1.6* Mg-1.8 [2107-1-31] 01:49AM BLOOD Calcium-7.7* Phos-1.7* Mg-2.2 [2107-2-1] 03:09AM BLOOD Albumin-3.1* Calcium-7.7* Phos-2.5* Mg-1.9 [2107-2-2] 06:10AM BLOOD Calcium-7.8* Phos-2.1* Mg-2.2 [2107-2-3] 06:00AM BLOOD Calcium-8.2* Phos-2.2* Mg-2.1 [2107-1-28] 11:46AM BLOOD Lactate-1.1 [2107-1-30] CHEST (PORTABLE AP) Lungs now demonstrate pulmonary vascular congestion but no definite edema. Small left pleural effusion suggests relative cardiac decompensation, as does interval increase in heart size, still within normal limits. No pneumothorax. [2107-1-29] ERCP BILIARY&PANCREAS FINDINGS: 14 fluoroscopic images were performed by the GI service during ERCP and are submitted for review. There is dilation of the common bile duct to 14 mm however there is smooth tapering at the distal margin on distal aspect of the CBD. No luminal filling defects are seen within the biliary system. A plastic stent catheter was placed at the end of the procedure. For full details please refer to the GI ERCP note. [2107-1-28] CT ABDOMEN W/CONTRAST CONCLUSION: 1. Inflamed enhancing thick-walled gallbladder with pericholecystic fluid suggestive of acute cholecystitis. There are internal hyperdensities within the gallbladder, which may represent sludge versus sloughing of the gallbladder mucosa which could represent early gangrenous cholecystitis. 2. Dilated CBD and intrahepatic ducts with the CBD measuring approximately 8 mm without evidence of a definite calculus in the CBD. 3. Stable compression deformity of L1 vertebral body with approximately 50% loss of vertebral body height. [2107-1-28] CHEST (PA & LAT) No acute cardiopulmonary process. Stable compression fracture. Brief Hospital Course: Ms.[Known lastname ] was admitted to the surgical service on [2107-1-28] with a chief complaint of nausea and vomiting. A CT scan showed gallbaldder wall thickening, a dialted CBD and multiple gallstones. The pt was started on Ciprofloxacin and Flagyl. On [1-29] the pt underwent an ERCP with sphincterotomy and a stent was placed. On the evening of [1-29] during routine vital sign checks the pt was noted to have a heart rate in the 130's though she was asymptomatic. Her systolic blood pressures were low in the high 80's to 90's where she had previously been in the 120-130s range. A 12 lead EKG was done whcih revealed atrial fibrilation with a rapid ventricular response. The pt was placed on telemetry and given 10mg of Diltiazem IV for rate control, however she remained in RAF in the 110-120 range with persistently low pressures despite being asymptomatic. At that time the decision was made to transfer her to the ICU for managment of her a-fib. The pt was placed on phenelelhrine in the ICU for her hypotension. By the morning of [1-30] she was back in sinus rhythm, off pressors and once again normotensive. She was monitored thoughout the day and cardiology was consulted. Her abdominal pain, however, persisted. On [1-21] the pt was taken to the operating room for a lararoscopic cholecystectomy. The pt did experience some episodes of atrial fibrilation intra-operatively but remained hemodynamically stable. The pt was transferred to the ICU post-operatively, but did not require any inotropic support. On the morning on POD1 [2-1] she was transferred back to the regular surgical floor in sinus rhythm and under beta blockade. She was started on diet and advanced as tolerated. The pt was discharged to a rehab facility on [2-3], tolerating a regular diet, ambulating without assistance, and pain well conrolled with oral pain medications. Patient will be discharged to home with VNA services. She will follow up with Dr. [Last Name (STitle) ] in 2 weeks and with her primary care provider. Medications on Admission: HCTZ 25, ativan 0.5 qhs, zocor 10, cyanoalbumin 1gm qday Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. Cholangitis. 2. Cholelithiasis. 3. Chronic cholecystitis. 4. Atrial Fibrillation Discharge Condition: Stable 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. * 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. Other: Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: You have the following appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 304], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2107-2-18] 3:15 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7323], M.D. Date/Time:[2107-3-1] 8:50 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7323], M.D. Date/Time:[2107-11-8] 11:30 Completed by:[2107-2-3] ICD9 Codes: 4589, 4240, 2768, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6871 }	Medical Text: Admission Date: [2106-6-28] Discharge Date: [2106-7-4] Date of Birth: [2047-6-23] Sex: F Service: CCU, FAR 3. HISTORY OF THE PRESENT ILLNESS: This is a 59-year-old female with a history of coronary artery disease status post cardiac catheterization at [Hospital1 69] in [2091]; hypertension; and anxiety. The patient presented to an outside hospital with four days of chest pain and right arm pain. EKG showed nonsignificant ST changes in lead V4 through V6. The first set of enzymes with CK of 62, MB 1.5 index, 2.4 troponin less than 0.1. The patient was transferred to the [Hospital1 69] for cardiac catheterization, which showed left main coronary artery 30 to 40 distal stenosis, LAD mild irregularities, left circumflex small [Last Name (LF) 12425], [First Name3 (LF) ] mild diffuse disease, RCA large [First Name3 (LF) 12425] with 95% mid stenosis. PCI stent was placed in the RCA. Post cardiac catheterization, the patient was found to be hypotensive with systolic blood pressures in the 60s to 70s. She had nausea and vomiting. She complained of right lower quadrant pain and tenderness. The hematocrit was 31 from 39 precatheterization. CT showed large right retroperitoneal bleed with compression of bladder. IV protamine was given, and the patient was transferred to the Coronary Care Unit Team with Vascular Surgery notified. SOCIAL HISTORY: The patient is a smoker of one half of a pack per day for 40 years. She has a history of hypertension, high cholesterol, with total cholesterol of 191 and LDL of 108, and positive family history, father with [Name (NI) 110991] with less than 55. PAST MEDICAL HISTORY: 1. Coronary artery disease. In [2101-12-25], cardiac catheterization showed a proximal left circumflex 60% stenosis, EF 86% and no interventions were done. 2. The patient had an ETT MIBI in [2101-2-22], which was negative. 3. The patient also has a history of hypertension, anxiety, on Zoloft, but the patient denies depression. SOCIAL HISTORY: The patient lives at home [Initials (NamePattern4) ] [Last Name (NamePattern4) 3146] with her husband and son. She is a smoker. REVIEW OF SYSTEMS: Noncontributory. FAMILY HISTORY: History is as above. PHYSICAL EXAMINATION: Examination revealed the following: VITAL SIGNS: Heart rate 75, blood pressure 108/63, respiratory rate 26, 93% on two liters nasal cannula. GENERAL: The patient is anxious and in no acute distress. HEENT: Mucous membranes were moist. NECK: Could not assess secondary to body habitus. LUNGS: Lungs revealed decreased breath sounds at the bases, otherwise, clear. COR: Normal, S1 and S2, no murmurs appreciated. ABDOMEN: Obese. Positive tenderness in the right lower quadrant; firm, normoactive bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema; 2+ PT/DP pulses bilaterally. LABORATORY DATA: Laboratory data revealed the following: CBC, WBC 26.2, hematocrit 37.7, status post transfusion of two units RBCs. Platelet count 145,000. CT of the abdomen: Please see history of present illness. HOSPITAL COURSE: #1. CAD, status post RCA stent. She she was started on Plavix, aspirin, and Integrilin was discontinued secondary to the bleed. The Plavix and aspirin were held and restarted on [2106-6-30]. Vascular Surgery was consulted for the retroperitoneal bleed and recommended continuing to monitor. The hematocrit was drawn serially q.6h. and remained stable after serial blood transfusions. She received a total of seven units throughout the hospital course. She was also started on Pravastatin 20 mg PO q.d. Rate and rhythm stable. #2. PULMONARY: Stable. #3. RENAL: Stable. #4. GI/FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was tolerating clear liquids. The patient was started on Pantoprazole. Electrolytes were checked and repleted as normal. Code was full. #5. PROPHYLAXIS; Pneumoboots, Pantoprazole. #6. GENITOURINARY: The patient complained of urinary discomfort. The Urinalysis was significant for positive nitrites. She was started on Bactrim double strength, one tablet PO b.i.d. times five days. She was discharged to home for follow up to Dr. [Last Name (STitle) 1147] and the primary care physician. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg PO q.d. 2. Plavix 75 mg PO q.d. times 30 days, last dose [7-28]. 3. Ativan 0.5 mg PO q.8h. p.r.n. times ten days. 4. Ranitidine 150 mg PO b.i.d. 5. Sublingual nitroglycerin one tablet sublingual q.5 minutes times three doses p.r.n. 6. Aspirin 325 mg q.d. 7. Vitamin E 400 mg q.d. 8. Zoloft 75 mg PO q.d. 9. Metoprolol XL 100 mg PO q.d. 10. Bactrim double strength one tablet PO b.i.d. times five days. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Discharge to home. FINAL DIAGNOSIS: Diagnosis revealed acute coronary syndrome with retroperitoneal bleed. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 12175], M.D. [MD Number(1) 37596] Dictated By:[Last Name (NamePattern1) 41557] MEDQUIST36 D: [2106-7-4] 13:06 T: [2106-7-4] 13:14 JOB#: [Job Number 110992] ICD9 Codes: 496, 4111, 4019, 2720, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6872 }	Medical Text: Admission Date: [2167-7-7] Discharge Date: [2167-7-15] Date of Birth: [2093-3-2] Sex: M Service: CARDIOTHORACIC Allergies: Ampicillin / Golytely Attending:[First Name3 (LF) 2969] Chief Complaint: Esophageal cancer Major Surgical or Invasive Procedure: Esophagoscopy, Transhiatal esophagectomy and feeding tube jejunostomy. History of Present Illness: Pt is a 74 y/o male who presents with T1/2 NO Mx Esophageal cancer needing treatment. This was discovered after a GIB presumably from the esophagus as a result of aspirin usage. He required 7 units of blood for this bleed. At that time the patient had an EGD which showed a concerning GE junction lesion. Once the patient improved from his acute event, EGD/EUS was re-performed with path showing adenocarcinoma Past Medical History: Emphysema, Cardiomyopathy, "Extra beats",Pre op for left fem-[Doctor Last Name ], Bilateral lower extremity stents, Claudication - can't go more that [Age over 90 ] yards, No rest pain, Cataracts, HTN, Reportedly passed stress last yr, Carotid doppler reportedly ok couple yrs ago, Horseshoe kidney, Basal Cell CA, Bladder Stricture, Hepatitis in [Country 26231] - unknown type Social History: Cigarettes: [x] current Pack-yrs:_80 ETOH: [x] No Exposure: [x] No Marital Status: [x] Married Lives: [x] w/ family Family History: Non-ontribitory Pertinent Results: [2167-7-14] 06:55AM BLOOD WBC-11.4* RBC-3.76* Hgb-10.3* Hct-33.3* MCV-89 MCH-27.4 MCHC-31.0 RDW-14.8 Plt Ct-299 [2167-7-12] 07:30AM BLOOD WBC-10.8 RBC-3.96* Hgb-11.3* Hct-35.6* MCV-90 MCH-28.6 MCHC-31.8 RDW-14.4 Plt Ct-223 [2167-7-10] 02:38AM BLOOD WBC-10.0 RBC-3.57* Hgb-10.3* Hct-31.1* MCV-87 MCH-28.9 MCHC-33.2 RDW-14.2 Plt Ct-151 [2167-7-8] 03:03AM BLOOD WBC-11.4* RBC-4.03* Hgb-11.9* Hct-33.7* MCV-84 MCH-29.6 MCHC-35.3* RDW-14.6 Plt Ct-144* [2167-7-7] 02:24PM BLOOD WBC-8.7 RBC-4.11* Hgb-11.9* Hct-34.9* MCV-85 MCH-29.0 MCHC-34.1 RDW-13.8 Plt Ct-177 [2167-7-9] 04:22AM BLOOD PT-15.2* PTT-46.3* INR(PT)-1.3* [2167-7-14] 06:55AM BLOOD Glucose-124* UreaN-27* Creat-0.7 Na-145 K-3.8 Cl-112* HCO3-27 AnGap-10 [2167-7-12] 07:30AM BLOOD Glucose-111* UreaN-22* Creat-0.8 Na-145 K-3.8 Cl-108 HCO3-28 AnGap-13 [2167-7-9] 04:22AM BLOOD Glucose-93 UreaN-28* Creat-0.9 Na-138 K-4.6 Cl-108 HCO3-24 AnGap-11 [2167-7-8] 03:03AM BLOOD Glucose-111* UreaN-25* Creat-1.3* Na-138 K-4.5 Cl-107 HCO3-21* AnGap-15 [2167-7-7] 02:24PM BLOOD Glucose-116* UreaN-19 Creat-1.1 Na-141 K-4.2 Cl-109* HCO3-24 AnGap-12 [2167-7-9] 04:22AM BLOOD Calcium-7.4* Phos-2.8 Mg-2.2 [2167-7-7] 02:24PM BLOOD Calcium-7.1* Phos-3.3 Mg-1.6 [2167-7-9] 12:59AM BLOOD Type-ART pO2-86 pCO2-47* pH-7.34* calTCO2-26 Base [2167-7-14] chest x/ray: The mediastinal contours are stable. There is no evidence of pneumothorax or pneumomediastinum. The post-surgical drain in the upper mediastinum is unchanged in location. There is interval minimal change in bilateral small pleural effusion. There is improvement of the atelectasis of the right middle lobe. There is no evidence of new consolidations and there is no evidence of failure. [2167-7-11] Head CT: IMPRESSION: 1. No hemorrhage, edema, or evidence of other acute intracranial abnormalities. Please note that MRI would be more sensitive for metastatic disease, infection, or acute infarction. 2. Mild parenchymal involutional change and mild chronic small vessel ischemic disease. [2167-7-8] 03:12AM BLOOD Type-ART pO2-102 pCO2-38 pH-7.40 calTCO2-24 Base XS-0 Intubat-INTUBATED [2167-7-7] 12:47PM BLOOD Type-ART Tidal V-700 PEEP-3 FiO2-55 pO2-153* pCO2-45 pH-7.36 calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2167-7-7] 09:47AM BLOOD Type-ART pO2-146* pCO2-46* pH-7.34* calTCO2-26 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [2167-7-7] 12:47PM BLOOD Glucose-135* Lactate-1.3 Na-135 K-4.3 Cl-104 [2167-7-8] 03:12AM BLOOD freeCa-1.13 [2167-7-7] 09:47AM BLOOD freeCa-1.07* Brief Hospital Course: Pt is a 74 y/o male who presents with T1/2 NO Mx Esophageal cancer needing treatment. This was discovered after a GIB presumably from the esophagus as a result of aspirin usage. He required 7 units of blood for this bleed. At that time the patient had an EGD which showed a concerning GE junction lesion. Once the patient improved from his acute event, EGD/EUS was re-performed with path showing enocarcinoma. On [2167-7-7] was taken to the operating room for Esophagoscopy, Transhiatal esophagectomy and feeding tube jejunostomy. Patient remained intubated over night and extubated thed next morning Tx to the ICU follow air-way. Patient remained NPO, cervical JP to bulb suction. Did well in the ICU on [2167-7-11] transfered to F9 med [Doctor First Name ] floor. [2167-7-12] Placement of right pigtail catheter now with bilateral pleural effusions, right greater than left. the eve of [2167-7-12] night patient developed delirum patient pulled his own pig tail catheter out. Geriatric consult placed reccomended: Check UA and culture, Risperidone 0.25mg QPM (Do not discharge patient on this medication, Repeat ECG in am to monitor QT, and Recommendations for non-pharmacologic delirium prevention: a) Remove all lines and catheters as soon as possible, esp Foley b) Avoid sedatives, especially antihistamines and benzodiazepines c) Encourage family to be at bedside, with familiar home objects d) Explore and encourage baseline religious/spiritual coping mechanisms for illness. e) Preserve sleep wake cycle by minimizing overnight interruptions and allowing for stimulation and activity during the day ie cancelling midnight vitals unless medically indicated f) OOB for meals if/when eating TID g) Reorient frequently h) Ensure BM at least once every other day, if not daily. i) Providing hearing aids as needed glasses and dentures to trazadone at night. resiradol with good effect by [2167-7-14] A+O. Interventional pulmonolgy felt pig-tail drained enough of effussion on insertion (600cc). [2167-7-14]; Patient remains A+O x3 all day, neck staples removed and stay-sutures placed. Neck drain bulb removed from catheter and sponged attached. Every other staple from abd removed and replaced with stay-suture. Grape Juice test performmed and no leakaged noted patients diet advanced to clear liquids. Medications on Admission: Advair 250/50'', Carvedilol 12.5'', Digoxin 0.25', Lisinopril 10', Lipitor 10', Spironolactone 12.5', Timolol', Prednisolone eye gtts' Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 3. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours). 4. Oxycodone 5 mg/5 mL Solution Sig: [12-19] PO Q3H (every 3 hours) as needed for PAIN. 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 6. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 7. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Insulin sliding scale Insulin SC Sliding Scale - Accept or Override Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-50 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice 51-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 301-350 mg/dL 8 Units 8 Units 8 Units 8 Units 351-400 mg/dL 10 Units 10 Units 10 Units 10 Units 13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) 5165] Discharge Diagnosis: esophageal cancer Discharge Condition: good Discharge Instructions: Please call Dr. [Last Name (STitle) ] office with any questions or concerns [Telephone/Fax (1) 4741]. Call with fevers greater than 101.5 Call with increased shortness of breath, chest pain and or secretions Call with increased drainage, redness or swelling from incisions Followup Instructions: You have a follow up appointment first you are to report to the [Hospital Ward Name ] on [7-24] at 10 am to radiology in the RABS building 3 rd floor for your esophagram which you need to be NPO after midnight. After your test you need to go to the [Hospital Ward Name 517] [Location (un) 453] chest disease center for your follow up appointment with Dr [Last Name (STitle) ] at 11:30 am or right after your test. Completed by:[2167-7-15] ICD9 Codes: 5119, 4254, 2930, 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6873 }	Medical Text: Admission Date: [2134-9-12] Discharge Date: [2134-9-15] Date of Birth: [2053-7-4] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 6075] Chief Complaint: Left-sided weakness Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 36756] is an 81 year-old right-handed cigarette smoker with a longstanding history of HTN, HL and CKD III-IV, who presents with acute-onset Left-sided weakness while using the toilet this morning around 7:45am. He said while on the toilet, he had nausea and dry heaves, which he has been experiencing every morning for several weeks now (his son thinks this is secondary to a recent increase in the dose of one of his medications, but not sure which one). He "slid" off the toilet before he could wipe, and called his son to help him back up because he realized "everything wasn't workin" meaning that his left arm and leg were paralyzed. After finishing his business on the toilet, he asked his son to call EMS, who took him to the [Hospital1 18] ED. No HA at any time. No sensory changes or paresthesias. No dysarthria or altered level of arousal at any time. No fever/sweats/chills. No diarrhea. No CP or SOB. ROS +for nausea and vomiting, as noted above. He arrived via ambulance and a code stroke was called at 8:37am. We rapidly assessed the patient and he was found to have left arm and shoulder weakness (trap/delt/[Hospital1 ]/tri) with preserved grip strength as well as left leg weakness with complete paralysis of all LLE muscles except hamstrings, which were 2-3/5. There was no sensory loss on my exam at the CT scanner. Past Medical History: 1. HTN on [Last Name (un) ], CCB, BB, loop diuretic 2. CKD III-IV 3. Cigarette smoker 4. Dementia NOS, on AChE-antagonist 5. Hyperlipidemia 6. Mood disorder NOS on bupropion 7. BPH, untreated for several years (formerly on medication that per OMR "did not agree with" pt.) 8. h/o benign polyps on colonoscopy 9. h/o Cervical Fusion 10. h/o Testicular Cyst Removal # Says + PMH of strokes, but describes an episode from decades ago with tingling in both feet ascending up his entire body that does not make much sense and son cannot corroborate. Social History: Tobacco: >20pk-yr h/o cigarette smoking. EtOH: less than one drink per week Recreational Drugs: never Work: retired; formerly in construction Family History: Mother (deceased, 87) Hypertension, CAD/MI Father (deceased, 52) Hypertension, stroke All brothers: hypertension; one brother: leukemia No known family history of DM2, kidney disease, other cancers Physical Exam: Mental Status exam: Awake and alert spontaneously. Oriented to person, year, month, date, day of week, season, city, location, reason for treatment. Able to relate history without difficulty. Attentive. Speech sounded dysarthric vs. raspy from smoking Hx (patient and son insist this is how he normally sounds). Repetition was intact. Language is fluent with intact repetition and comprehension, normal prosody, and normal affect. There were no paraphasic errors. Able to read and write without difficulty. Naming is intact to low and medium frequency objects, impaired to high-frequency objects. Memory - registers 3 objects and recalls [1-20] at 5 minutes. There was no evidence of apraxia or neglect or ideomotor apraxia; the patient was able to reproduce and recognize hammering a nail and brushing teeth with both hands. There was no evidence of left-right confusion as the patient was able to accurrately follow the instruction to tough left ear with right hand. Calculation was intact (answers seven quarters in $1.75). -Cranial Nerves: I: Olfaction not tested. II: PERRL, 3 to 2mm and brisk. Visual fields are full. III, IV, VI: EOMs full. No nystagmus. No saccadic intrusion during smooth pursuits. Normal saccades. V: Facial sensation intact and subjectively symmetric to light touch V1-V2-V3. VII: Slight flattening of the left nasolabial fold. No ptosis. Brow elevation is symmetric. Eye closure is strong and symmetric. Mild left NLF depresion with smile, otherwise symmetric facial elevation. VIII: Hearing intact and subjectively equal to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 0/5 LEFT trapezius (right is full). XII: Tongue protrusion is midline. -Motor: Flaccid right arm. No tremor or faciculations were observed. No asterixis. Normal muscle bulk. Flaccid LUE/LLE except for Left hand. No hypertonicity or spasticity. Delt Bic Tri WrE FFl FE IO \|\| IP Quad Ham TA [Last Name (un) 938] Gastroc L 4 5 5- 4 5- 4 4- 4 4 4+ 0 0 0 R 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception in either distal lower extremity. Eyes-closed Finger-to-[Last Name (un) ] testing revealed no proprioceptive deficit (did not miss [Last Name (Titles) ]) on right. No extinction to DSS. No agraphesthesia on either side. -Reflex examination: [Hospital1 ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. No frontal release signs, including normal (absent) rooting, <only +/- glabellar>, grasp, or palmar-mental reflexes. -Coordination: Finger-[Last Name (un) ]-finger testing with no dysmetria or intention tremor on the right. Heel-knee-shin testing with no dysmetria on the right. -Gait: not tested due to hemiparesis Pertinent Results: WBC-9.5 RBC-4.28* Hgb-11.2* Hct-34.1* MCV-80* MCH-26.2* MCHC-32.9 RDW-16.3* Plt Ct-247 Glucose-110* UreaN-35* Creat-2.0* Na-142 K-4.0 Cl-104 HCO3-25 AnGap-17 [2134-9-12] 08:40AM BLOOD CK-MB-3 cTropnT-0.03* [2134-9-12] 06:30PM BLOOD cTropnT-0.02* [2134-9-13] 03:07AM BLOOD CK-MB-3 cTropnT-0.04* [2134-9-14] 09:14AM BLOOD cTropnT-0.03* Cholest-114 Triglyc-93 HDL-38 CHOL/HD-3.0 LDLcalc-57 %HbA1c-6.0* eAG-126* VitB12-848 Folate-17.3 TSH-3.9 NCHCT [2134-9-12] IMPRESSION: 1. No acute intracranial hemorrhage or major vascular territorial infarction detected. If there is continued clinical concern, an MRI with diffusion-weighted imaging can be performed. 2. Moderate-to-severe chronic microangiopathic ischemic disease. MRI/MRA BRAIN 1. Acute/subacute infarction involving the right precentral gyrus and paramedian right frontal gyrus without significant surrounding edema or mass effect. 2. Periventricular and subcortical white matter disease likely representing the sequela of chronic small vessel ischemic disease. There is also cortical and central atrophy. Encephalomalacia involving the bilateral occipital lobes is likely present, possibly representing sequela of previous infarction. 3. A midline superior posterior scalp lipoma is present. 4. The MRA of the head and neck is significantly limited due to motion and technical factors. No gross flow-limiting stenoses identified. ECHO The left atrium is moderately dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). A mild mid-cavity gradient is identified. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened, and display somewhat reduced systolic excursion, but frank aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. CAROTID ULTRASOUND: [Street Address(1) 72681] <40% stenosis bilaterally Brief Hospital Course: Pt [Name (NI) 36756] was admitted for sudden onset left sided hemiplegia. He was brought in by ambulance within the appropriate time window for t-PA. He was evaluated in the ED by our neurology resident and the stroke fellow and felt it was appropriate to give tPA. Head CT was done which showed no infarct or hemorrhage, but CTA/perfusion was not done at that time. He was given tPA and strength improved within 3 hours. He monitored in the ICU post tPA. He had a CT scan of the head which did not demonstrate blood and he was placed on Plavix. He had residual left sided weakness post tPA, but was significantly improved. He had an MRI of the head which demonstrated a new infarct in the right precentral gyrus along the ACA,MCA territory. A TTE was negative for any etiology of stroke. Vessel imaging of the head and neck revealed no significant stenosis or aneurysms to explain the infarct. Carotid duplex U/S revealed <40% stenosis bilaterally. In conclusion, no etiology for stroke was identified and patient was treated with stroke prevention with Plavix and statin. Home antihypertensives were initially held and allowed to autoregulate. He was started on home meds prior to discharge. Home lasix had been held as well, and patient had no evidence of volume overload (clear lungs, no edema, good 02 sat on room air). He will restart 20 mg Lasix at discharge and was instructed to follow up with his PCP [Name Initial (PRE) 176] 2-3 days about restarting the full 40 mg dose. He will follow up with Dr. [First Name (STitle) ] in stroke clinic. Medications on Admission: 1. Aspirin 81mg daily 2. amlodipine 5mg daily 3. valsartan 160mg daily 4. furosemide 40mg daily 5. simvastatin 20mg qhs 6. bupropion 100mg [Hospital1 ] 7. glanatmine 16mg daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hyperlipidemia, stroke/MI prevention. Disp:30 Tablet(s) Refills:2 2. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Galantamine 16 mg Cap,24 hr Sust Release Pellets Sig: One (1) Cap,24 hr Sust Release Pellets PO once a day as needed for alzheimers. 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: take half tab once daily and follow up with your PCP in the next 3 days. Discharge Disposition: Home With Service Facility: Care Network Discharge Diagnosis: Primary - Stroke Secondary - Pulmonary artery Hypertension (est: 68-70 mmHg) - Hypertension - CKD III-IV Cr now 2.0 (GFR mid-30s), c/w his baseline GFR. - Cigarette smoker - Dementia NOS, on AChE-antagonist - dyslipidemia - Mood disorder NOS on bupropion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Neurologic status: no deficits Discharge Instructions: You were admitted for a stroke. You were unable to move the left side of your body. You were given a drug for this acute stroke and you were admitted to the ICU. The strength on your left side improved. You were started on plavix to help prevent future strokes. You were also started o Lisinopril to help control your blood pressure and restarted on your norvasc. You had an echo performed which demonstrated pulmonary artery hypertension. You were started on new medications to help prevent stroke. You should quit smoking, since it increases your risk of stroke. Your Lasix was held in the hospital. You should take only a half tab daily for now, and follow up with your PCP [Name Initial (PRE) 176] 3 days. Followup Instructions: [Hospital 4038] Clinic; Dr [First Name (STitle) ], S. Time/Date: Monday [10-18] at 3 pm. Phone # ([Telephone/Fax (1) 7394]. Please call to confirm and to obtain directions. ICD9 Codes: 2720, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6874 }	Medical Text: Admission Date: [2160-4-19] Discharge Date: [2160-4-22] Date of Birth: [2108-10-11] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 5301] Chief Complaint: melena Major Surgical or Invasive Procedure: EGD History of Present Illness: HPI: 51F with h/o upper GI bleed from duodenal ulcer 5y ago presented to OSH with 3d of melena (4-6x/d) and coffee ground emesis. She states she has had lower abdominal pain and epigastric pain since the melena started. Yesterday morning, she developed lightheadedness and presyncope (no LOC, no head trauma). She denies associated chest pain, palpitations. Her prior UGIB was in the setting of NSAID use, and she has continued to use ibuprofen 3x/wk + recent Naproxen use for back pain s/p mechanical fall. She reports occasional low grade fever over the past couple of days with Tmax 99.8. She denies sick contacts and recent travel. Reports social EtOH use, no known h/o liver disease. VS on presentation to OSH ED included HR 98 and BP 89/51. Hct at OSH was 37, troponinI elevated at 0.59 but CK flat, and WBC 35.0. NG lavage was performed with coffee grounds, no bright red blood that did not clear with 250cc; guaiac positive stool on DRE. She received morphine 4mg IV, Pepcid 20mg IV, Protonix 40mg IV, and 2L NS. She was transferred to the [Hospital1 18] ED for further management. . In the ED, VS were T 99.2, HR 106, BP 101/44, RR 20, O2sat 100%RA. She was given morphine 4mg IV, ceftriaxone 1g IV, and 1L NS. GI was consulted. She was transferred to the MICU for management of UGIB. . Currently, she states she feels a little better. She c/o thirst and lower abdominal pain. Her lightheadedness has resolved and her nausea has improved. Last BM was yesterday evening. Past Medical History: 1. Depression/adjustment d/o- surrounding daughter's death in [2158] 2. Asthma 3. HTN 4. UGIB- 5y ago in FL, [3-14] duodenal ulcer assoc. w/NSAID use, per pt EGD without apparent source--> ex lap, duodenal source found and repaired with "fatty tissue", c/b SBO. 5. Goiter s/p thyroidectomy Social History: Lives in [Location 3146], Mass. with boyfriend and 26yo daughter. [Name (NI) 1403] as nurse [First Name (Titles) ] [Last Name (Titles) ] NH. + tobacco, 1/2ppd x 40y. + occ. EtOH ([3-15] drinks, 1x/wk). Denies IVDU. Family History: Father with h/o liver disease presumed [3-14] EtOH and upper GI bleed. Brother with h/o liver disease presumed [3-14] EtOH. Physical Exam: Vitals- T 96.9, HR 106, BP 115/59, RR 14, O2sat 100% 2LNC General- somnolent but easily arousable, lying flat in bed with NAD HEENT- NCAT, sclerae anicteric, dry mucous membranes, NGT draining scant amounts pink-tinged fluid Neck- supple, no JVD Pulm- CTAB, good air movement CV- RRR, nl S1/S2, no m/r/g Abd- +BS throughout, nondistended, soft, no epigastric TTP, + RLQ/LLQ tenderness to moderate palpation with no rebound/guarding, no palpable hepatosplenomegaly Extrem- no LE edema, DP pulses 2+ b/l Skin- no jaundice or scleral icterus, no spider angiomata, no caput medusae, ?palmar erythema Pertinent Results: [2160-4-19] 09:10AM ALT(SGPT)-12 AST(SGOT)-21 LD(LDH)-244 CK(CPK)-34 ALK PHOS-73 TOT BILI-0.2 [2160-4-19] 09:10AM CK-MB-NotDone cTropnT-0.15* [2160-4-19] 09:37PM CK(CPK)-36 [2160-4-19] 09:37PM CK-MB-NotDone cTropnT-0.15* [2160-4-19] 09:37PM HCT-30.8* [2160-4-19] 12:51PM HCT-35.2* [2160-4-19] 09:10AM ALBUMIN-2.9* [2160-4-19] 09:10AM WBC-28.6* RBC-3.93* HGB-10.9* HCT-31.7* MCV-81* MCH-27.6 MCHC-34.3 RDW-16.8* [2160-4-19] 09:10AM PLT COUNT-344 [2160-4-19] 05:35AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.019 [2160-4-19] 05:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2160-4-19] 03:59AM URINE HOURS-RANDOM [2160-4-19] 03:59AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.008 [2160-4-19] 03:59AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2160-4-19] 01:51AM HGB-12.2 calcHCT-37 [2160-4-19] 01:00AM GLUCOSE-137* UREA N-26* CREAT-0.8 SODIUM-136 POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-24 ANION GAP-17 [2160-4-19] 01:00AM estGFR-Using this [2160-4-19] 01:00AM CK(CPK)-31 [2160-4-19] 01:00AM cTropnT-0.13* [2160-4-19] 01:00AM CK-MB-NotDone [2160-4-19] 01:00AM WBC-32.2* RBC-4.24 HGB-11.6* HCT-34.4* MCV-81* MCH-27.3 MCHC-33.6 RDW-16.8* [2160-4-19] 01:00AM NEUTS-88* BANDS-5 LYMPHS-4* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2160-4-19] 01:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [2160-4-19] 01:00AM PT-11.5 PTT-20.9* INR(PT)-1.0 CXR: IMPRESSION: 1. No evidence of aspiration or pneumonia. 2. Probable healing right rib fractures. TTE: Conclusions: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly to moderately depressed (40-50%) with basal inferior, lateral and apical hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. EGD: Esophagus: Mucosa: Diffuse continuous erythema and ulcerations of the mucosa with no bleeding were noted in the lower third of the esophagus and middle third of the esophagus. These findings are compatible with esophagitis. Localized erythema and erosions of the mucosa with no bleeding were noted in the gastroesophageal junction. These findings are compatible with NGT trauma. Stomach: Contents: Food was found in the stomach body. Mucosa: Localized erythema and erosion with multiple ulcerations of the mucosa with no bleeding were noted in the pylorus. Normal mucosa was noted in the antrum. Cold forceps biopsies were performed for histology at the stomach antrum. Duodenum: Normal duodenum. Other findings: The anatomy of the pylorus was distorted secondary to hypertrophic gastric folds and multiple ulcerations. Impression: Erythema and ulcerations in the lower third of the esophagus and middle third of the esophagus compatible with esophagitis Food in the stomach body Erythema and erosion and multiple ulcerations in the pylorus The anatomy of the pylorus was distorted secondary to hypertrophic gastric folds and multiple ulcerations. Normal mucosa in the antrum (biopsy) Erythema and erosions in the gastroesophageal junction compatible with NGT trauma Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 71980],[Known firstname ] [2108-10-11] 51 Female [Numeric Identifier 71981] [Numeric Identifier 71982] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) 2093] Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] GOODELL/mtd SPECIMEN SUBMITTED: Gastric Biopsy Procedure date Tissue received Report Date Diagnosed by [2160-4-19] [2160-4-19] [2160-4-23] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/nbh DIAGNOSIS: Stomach, antrum, mucosal biopsy: Antral mucosa with no diagnostic abnormalities recognized. [2160-4-22] 05:25AM BLOOD WBC-14.1* RBC-3.68* Hgb-10.0* Hct-30.1* MCV-82 MCH-27.1 MCHC-33.2 RDW-16.6* Plt Ct-338 [2160-4-22] 05:25AM BLOOD Plt Ct-338 [2160-4-22] 05:25AM BLOOD Glucose-99 UreaN-5* Creat-0.6 Na-141 K-3.5 Cl-106 HCO3-24 AnGap-15 [2160-4-20] 03:07AM BLOOD CK(CPK)-36 [2160-4-20] 03:07AM BLOOD CK-MB-NotDone cTropnT-0.14* [2160-4-19] 09:37PM BLOOD CK-MB-NotDone cTropnT-0.15* [2160-4-19] 09:10AM BLOOD CK-MB-NotDone cTropnT-0.15* [2160-4-19] 01:00AM BLOOD cTropnT-0.13* [2160-4-22] 05:25AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0 Cholest-117 [2160-4-22] 05:25AM BLOOD Triglyc-93 HDL-58 CHOL/HD-2.0 LDLcalc-40 Brief Hospital Course: In the ED, VS were T 99.2, HR 106, BP 101/44, RR 20, O2sat 100%RA. Her hct was 34 on admit. She was given morphine 4mg IV, ceftriaxone 1g IV, and 1L NS, and admitted to MICU for management of UGIB. She had EGD which showed multiple mucosal ulcerations and erosions throughout esophagus, pylorus. They recommended ppi [Hospital1 ] and carafate, repeat EGD in 3 weeks with Dr. [Last Name (STitle) 9746]. Hct was stable o/n, so pt. was transferred to floor. # UGIB: likely NSAID-induced gastritis/duodenitis. large, severe ulcerations bring up possibility of obstructive picture. Diet was advanced without difficulty and hct remained stable with clearing of blood in stools at discharge. Discharged on 1 month of ppi [Hospital1 ] and carafate until f/u EGD with Dr. [Last Name (STitle) 9746] in three weeks. She was also given strict orders to not use NSAIDs or alcohol. Given severe ulceration and high risk for rebleeding, pt. had cardiac catheterization postponed as below. . # Leukocytosis: WBC count markedly elevated to 32 on admit, trended down slowly to 14 upon discharge. She should have CBC done as outpt. to confirm resolution. Otherwise, she may need workup for myeloproliferative diseases. . # Elevated troponin: No symptoms suggestive of ischemia. Troponin I elevated at OSH at 0.59 (upper limit 0.5) with flat CK. Troponin T mildly elevated here at 0.13. no elevation of CKs. No e/o renal dz. Cards consulted and believe she had NSTEMI given ECHO with moderately depressed EF. Started baby aspirin and [Name (NI) 71983], with plans to start ACE-I as outpatient as BP can tolerate. Given recent bleed and likelyihood of needing to place stents requiring anticoagulation, decision was made not to proceed with catheterizaiton. Pt. was discharged with plans for outpt. cath evaluatino as outpt. after follow EGD performed in 3 weeks. Until that time, pt. was told to take off work and to limit activity severely so as [Last Name (un) ] to stress heart. She will follow up with Drs. [Last Name (STitle) 10302] and [Name5 (PTitle) 171] as outpt. . Medications on Admission: Prozac 20mg/40mg qod Vasotec 20mg qd Vicodin ES 7.5-750mg q6h prn Ativan 1mg tid prn anxiety MVI Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:0 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q DAY () as needed for pain. Disp:30 Adhesive Patch, Medicated(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: not to exceed 4g tylenol in one 24 hour period. Disp:45 Tablet(s) Refills:0 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual as directed: take 1 tab sublingually should you develop[ chest pain. If chest pain does not resolve, can take another tab each 5 minutes for a total of 3 tabs total. Disp:30 0 Refills:0 Discharge Disposition: Home Discharge Diagnosis: NSTEMI Upper GI bleed Blood Loss Anemia Gastritis Esophagitis HTN _____________ Depression Asthma Discharge Condition: good, tolerating foods, satting well on room air, chest pain free, Discharge Instructions: You have had a GI bleed and heart attack. You were evaluated by GI and cardiology and are at high risk for having another heart attack, however given your GI bleed, we are holding off on coronary catheterization. Given your high risk of bleeding and heart attack, you should take all medications as prescribed, follow up as below and adhere to the following discharge instructions. Please seek medical attention immediately should you develop chest pain, shortness of breath, dizziness, nausea, palpitations. Also, seek medical attention should you develop any symptoms of GI bleeding such as dizziness, lightheadedness, black stools, bright red blood with stools, or palpitations. You should avoid even moderate exertion and limit lifting to 5 pounds or less. You should limit your walking to 1 block at a time for now, and take off work until cleared by your PCP or cardiologist. Take all medications exactly as prescribed. You should adhere to a low salt, low cholesterol diet with a maximum of 2g sodium a day. Weigh yourself every day and call your PCP should you gain more than 3 pounds. You should attend your follow-up apointments as outlined below. Followup Instructions: You should follow up [Last Name (un) 5767] Dr. [Name (NI) ] at the following appointment: Provider: [Last Name (LF) 5302],[First Name8 (NamePattern2) 2352] [Last Name (NamePattern1) 2352] - ADULT MEDICINE (SB) Date/Time:[2160-4-29] 12:00 You have a GI appt. for EGD with Drs. [Last Name (STitle) 6880] and [Name5 (PTitle) 9746] which you must attend. Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5085], MD Phone:[Telephone/Fax (1) 1983] Date/Time:[2160-5-6] 8:00 Provider: [Name10 (NameIs) ] WEST,ROOM TWO GI ROOMS Date/Time:[2160-5-6] 8:00 You have a cardiology appointment with Drs. [Last Name (STitle) 171] and [Name5 (PTitle) 10302] on [5-21] at 3PM. Call ([Telephone/Fax (1) 1987] to get directions and location or appointment or to reschedule. You also have the following appointment which you should attend: Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 9045] Date/Time:[2160-5-21] 9:00 ICD9 Codes: 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6875 }	Medical Text: Admission Date: [2131-6-5] Discharge Date: [2131-8-27] Date of Birth: [2093-10-20] Sex: F Service: MICU-ORANG THE PATIENT WAS TRANSFERRED FROM THE [Hospital1 ]-[Hospital1 ] FACILITY ON [6-5] FOR A WEANING FROM HER VENTILATOR UNDER THE SUPERVISION OF HER PRIMARY CARE DOCTOR, DR. [Last Name (STitle) ]. HISTORY OF PRESENT ILLNESS: This is a 37 year old white female with a long history of pulmonary issues, well known at [Hospital1 69] and to Dr. [Last Name (STitle) 217], now here for weaning of her ventilator. Her vent on admit was C-PAP 40% FIO2, PEEP of 5, PS30, respiratory firing at 28 to 32. She was admitted to [Hospital3 33538] on [2131-4-17] from [Hospital1 188] status post a Medical Intensive Care Unit admission for pneumonia. At [Hospital3 105], she had no success with two weaning trials. Her last arterial blood gas on [2131-6-17] was 7.40/87/53/97% saturation on 40% FIO2. Her [Hospital1 ] course was as follows: Pulmonary: The patient was unable to tolerate weaning from a pressure support of 30 with attempts to decrease by 2 cm q. three to four days. The patient was diuresed to 110 pounds. Her weaning was complicated by her anxiety and tachypnea with this anxiety. Cardiovascularly, she was stable with her baseline sinus tachycardia 110 to 120. Her systolic blood pressures ranged from the 90s to the 100s. Her EKG showed no changes. Renally, she has a chronic hyponatremia. She also has hypokalemia with her diuresis and was on Spironolactone. Endocrine: She had a TSH of 11.58 on [2131-6-3]. GI: She had constipation with many laxatives prescribed. Hematologic: She had a persistent leukocytosis with a normal B12 and folate. For rehabilitation she was able to walk 140 feet per day times two. Psychiatric: She had anxiety and depression on Olanzapine; the patient did confirm this history. She did not complain of any SI, shortness of breath, chest pain, cough or headache on admission. She had no bowel movement in three days on admission. She did complain of increased fatigue. She also complained of night sweats times two days and mild stomach pains since she was started on her tube feeds prior to admission to the [Hospital1 190]. PAST MEDICAL HISTORY: 1. She had a junctional rhythm in [2131-2-16]. 2. Biventricular congestive heart failure with cor pulmonale for her right heart failure and a question of tachycardia induced left heart failure. 3. History of a Pseudomonas pneumonia in the Spring. 4. Status post tracheostomy. 5. Hodgkin's lymphoma in [2125] status post CHOP and x-ray therapy. This was complicated by Histoplasmosis, adult respiratory distress syndrome, pulmonary fibrosis, bronchiectasis. 6. Status post left pneumectomy secondary to Aspergillosis of her left lung. 7. Tuberculosis in [2121]. 8. Status post splenectomy. 9. History of anxiety and depression. 10. Cardiomyopathy which has left her with an ejection fraction of 20%. 11. History of syncope in [2131-2-16], that was questionable vasovagal. 12. Baseline carbon dioxide is 50 to 55. 13. History of supraventricular tachycardia in the 150s when she is hyperkalemic and junctional bradycardia in the 50s when she is hypokalemic. 14. Status post J-tube placement. 16. Hyponatremia secondary to congestive heart failure and diuresis. MEDICATIONS: 1. Serevent two puffs twice a day. 2. Combivent four puffs four times a day. 3. Pulmocare 45 cc an hour. 4. Tube feeds. 5. Lasix 40 three times a day. 6. Percocet one q. four hours p.r.n. 7. Olanzapine 2.5 q. day. 8. Lorazepam 1 mg p.o. q. six hours p.r.n. 9. Spironolactone 100 q. day. 10. Buspirone 5 three times a day. 11. Lorazepam 0.5 q. four to six hours p.r.n. 12. Metolazone 5 mg q. day. 13. Protein supplements. 14. Amitriptyline 10 mg q. h.s. 15. Digoxin 0.125 q. day. 16. Zinc sulfate 220 q. day. 17. Reglan 10 q. day. 18. Colace 100 q. eight hours. 19. Senna, one q. day. 20. Iron sulfate 325 q. day. 21. Protonix 40 q. day. 22. Vitamin C. 23. Subcutaneous heparin 5000 units twice a day. 24. Subcutaneous Simethicone 80 q. eight hours p.r.n. ALLERGIES: She had allergies to sulfa, Oxacillin and Verapamil. From Verapamil she got a red face. Unknown what her reaction to sulfa and oxacillin was. SOCIAL HISTORY: She smoked tobacco for five years in college. She resides at the [Hospital1 ]-[Hospital1 5042] facility. She also lived with her mother. PHYSICAL EXAMINATION: She is 67 inches tall, 113 pounds on admission. Negative 500 cc on the day of admission. She was in no acute distress. Pupils equal, round and reactive. Extraocular movements are intact. She had rhonchi and coarse rales in the right lower lung field. Left lung fields had transmitted breath sounds status post pneumonectomy. Regular rate and rhythm, tachycardic. Abdomen soft, nontender. No cyanosis, clubbing or edema. On examination she was awake, alert and pleasant. LABORATORY: On admission, white blood cell count 17.1, hematocrit 38.6, 453 platelets, differential of the white count showed 87% polys, no bands, 6 lymphocytes. Sodium 126, potassium 4.8, 71 chloride, 35 bicarbonate, 41 BUN, 0.5 creatinine, 94 glucose. On [5-29], she had a cortisol that was 13.4 at 07:00 a.m., 40.9 at 10:00 a.m. Her EKG showed normal sinus rhythm at 118 with a left axis. She had T wave inversions in V1, V2, half mm ST depression in V2 through V4. HOSPITAL COURSE: This is a 37 year old woman with multiple pulmonary problems including a history of a left pneumonectomy, cardiomyopathy with an ejection fraction of 20%; chronic hypercapnia, who was admitted for a wean from her ventilator. 1. PULMONARY: [Known firstname 1356] had a long history of severe lung disease. She had a history of Hodgkin's disease status post CHOP and x-ray therapy which was complicated by Histoplasmosis, adult respiratory distress syndrome, status post left pneumectomy for Aspergillus and had a recent admission this past Spring for a pneumonia. She had been on pressure support, 30/5 40% FIO2 on admission. She had failed to wean from this with barriers that were thought to be her volume status secondary to her cardiomyopathy. Also, her anxiety for which she is on multiple medications and finally her increased dead space in which her VD/VT is likely 80%. She needs to have a permissive hypercapnia for her to be able to ventilate sufficiently. Her baseline PA CO2 is in the 80s and her renal compensation for this brings her bicarbonate from 40 to 50. She has tolerated this well and was able to wean from her vent during the day. [Known firstname 1356] was kept on a T-tube during the day while she received her pressure support via her tracheostomy at night. She has been weaned down to 15/5 with FIO2 of 40% only at night. She has shown no signs of clinical effects from hypercapnia. She has been awake and alert this entire hospitalization. [Known firstname 1356] had a tracheostomy revision on [2131-7-2], and was found to have a posterior tracheal ulcer that was very early a TE fistula. She had a temperature tracheostomy (6 F ETT via stoma) and was changed finally to a permanent tracheostomy on [2131-7-12]. A recent bronchoscopy has shown that her ulcer has healed. The plan for [Known firstname 1356] is to eventually go home on a home ventilator. We will try to continue to wean her from her ventilator at night. She will remain on her T-piece during the day with blow-by oxygen and if she fails to wean from the ventilator at night, will remain on her pressure support ventilation at night on her home ventilator. 2. CARDIAC: [Known firstname 1356] has a history of biventricular congestive heart failure and cardiomyopathy which brings her ejection fraction to 20%. Her left heart failure is thought secondary to tachycardia induced cardiomyopathy and her right heart failure is thought secondary to cor pulmonale. [Known firstname 30613] resting pulse rate ranges from 100 to 120 in sinus tachycardia and any decrease from or increase from this resting heart rate sends her into respiratory distress and decompensation. She is very volume sensitive and given that component of her congestive heart failure, was causing her failure to wean from the ventilator. She was aggressively diuresed. Her dry weight is about 115 to 120 pounds. She has been on a regimen of Lasix, Zaroxolyn. Her weight had increased to 124 over the past week and her Lasix dose was increased from 60 p.o. twice a day to 100 p.o. twice a day. Her Zaroxolyn was kept at 2.5 mg twice a day. She remained at her baseline weight of 119 to 120 pounds on this diuresis regimen and had no episodes of respiratory distress. [Known firstname 1356] is very sensitive to large fluctuations in her potassium, which is volatile on diuretics, and given her constipation. When [Known firstname 1356] is constipated, she has hyperkalemia which has gone up to 7.9. With hyperkalemia she develops junctional bradycardic rhythms in the 60s which put her into respiratory distress and decompensation. Her junctional bradycardia was quickly resolved with calcium gluconate, insulin, glucose, bicarbonate, nebulizers and Kayexalate. After the calcium carbonate was given, her heart rhythm returned back to her baseline sinus tachycardia. With potassiums less than 3.0, [Known firstname 1356] can go into supraventricular tachycardia and atrial fibrillation to the 170s and 180s. This also causes respiratory distress and decompensation. After correction of her potassium and Diltiazem, her rate usually returns back into her baseline. For these reasons, it is important to keep her potassium from 3.0 to 4.5. Cardiomyopathy: [Known firstname 1356] is on digoxin 0.125 q.o.d. and 0.25 q.o.d. She should have a digoxin level checked prior to being discharged. 3. FLUIDS, ELECTROLYTES AND NUTRITION: As stated above, the patient has a volatile potassium level. With constipation, she develops a hyperkalemia from inability to excrete her potassium through her GI tract. With her large diuresis requirement, she also can drop her potassium. These potassium changes can be rapid, for example, she has had a potassium of 4.4 at 5 a.m. and developed potassium of 7.9 at 8 a.m. after not having a bowel movement for one day. [Known firstname 1356] has been stable on her current regimen of 100 p.o. Lasix twice a day, Metolazone 2.5 twice a day and potassium repletion of 200 mEq per day divided into five doses of 40 mEq. This has kept her potassium mostly from 3 to 4.5. However, she has dropped to 2.4 and her Lasix dose will be reduced today to 80 mg p.o. twice a day. In terms of other electrolytes, [Known firstname 1356] often has low magnesium which are repleted p.r.n. Her dry weight is 115 to 120 pounds and she requires daily weights. [Known firstname 30613] nutrition is delivered via her G-tube with Resbilar tube feeds. Her current volume status is mostly euvolemic for her. [Known firstname 1356] has a baseline metabolic alkalosis with bicarbs of 40 to 50 to compensate for her severely impaired and decreased ventilation. She has a large dead space and a Vv/Vt ratio of 0.8. She tolerates this metabolic alkalosis well. 4. GASTROINTESTINAL: [Known firstname 1356] has a history of constipation, especially when she uses narcotic analgesics. She had been on Percocet for her pain that she had been experienced at her tracheostomy site. These had exacerbated her constipation, which resulted in potasium levels up to 7.9 and junctional bradycardic rhythm that sent her into respiratory distress. At this point, her narcotic analgesics were discontinued. [Known firstname 1356] should not get any more narcotic analgesics. Her pain is relieved with Tramadol, ibuprofen and Tylenol. It is thought that she uses narcotics occasionally as a crutch and not for her analgesic effects. Her constipation is very responsive to Lactulose. She should get Lactulose p.r.n. to titrate her to one bowel movement per day. She also receives Colace and Senna as stool softeners. 5. INFECTIOUS DISEASE: The patient was admitted on inhaled Tobramycin for Pseudomonas prophylaxis. This was on for 28 days and was tried off for 28 days. She then started to have an increasing white blood count and her inhaled Tobramycin was restarted and she was eventually levelled off on a TIW regimen three times a week for this inhaled Tobramycin. She has a chronic leukocytosis from 12 to 20, but no signs of infection. Otherwise, she has no current Infectious Disease issues. 6. PSYCHIATRY: [Known firstname 1356] has a history of anxiety attacks, which complicate her respiratory failure. It was thought that the anxiety is a large component of her respiratory failure. She also is reliant on narcotic pain medications which have been discontinued for her. [Known firstname 1356] has been doing well on a regimen of Amitriptyline which was recently increased to 75 mg q. h.s.; Zyprexa 5 mg q. h.s. She can receive Zyprexa 2.5 mg p.r.n. for acute anxiety and should receive this preferentially over p.r.n. Ativan. 7. TUBES, LINES AND DRAINS: [Known firstname 1356] has a right PICC line, a tracheostomy, and a G-tube, all of which sites are clean, dry and intact. 8. PROPHYLAXIS: [Known firstname 1356] is out of bed with Physical Therapy and Occupational Therapy on a bowel regimen of Lactulose, Colace and Senna. She is on a PPI per her G-tube. 9. COMMUNICATION: This is with mostly [Known firstname 1356] and her mother who will be caring for her mostly when she is discharged home on her home ventilator. Her mother has been taught to care for her tracheostomy site and ventilator. DISPOSITION: Her disposition will be first to CC7 Floor where her potassium levels and diuresis will be maintained and hopefully titrated to keep her at her goal weight of 115 to 120 pounds and keep her potassium levels between 3.0 and 4.5. She will then most likely be discharged to rehabilitation to work on her activities of daily living and give her more intensive Physical Therapy and Occupational Therapy. When she is deemed ready for discharge home, she will be discharged home on her home ventilator with blow-by tracheostomy, oxygen in the days and question of pressure support at night if she cannot be weaned from her pressure support during this hospitalization. Her mother has been suctioning her tracheostomy well since she has been here and has been taught much of her care. She will have home [Hospital6 407] to monitor her potassium levels and to care for her G-tube and she will have respiratory therapy, Physical Therapy and Occupational Therapy also perhaps at home. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3090], M.D. [MD Number(1) 3091] Dictated By:[Last Name (NamePattern1) 9352] MEDQUIST36 D: [2131-8-27] 14:00 T: [2131-9-3] 16:23 JOB#: [Job Number 35554] ICD9 Codes: 2761, 4254, 4280, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6876 }	Medical Text: Admission Date: [2185-9-21] Discharge Date: [2185-9-26] Date of Birth: [2120-3-23] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 65 year old male with a history of dyspnea on exertion for six to 12 months. An echocardiogram performed in [2183-10-3] revealed aortic stenosis with a left ventricular ejection fraction of 55% to 60%. The patient had an exercise tolerance test on [2185-9-1] which showed severe inferior defect with partial reversibility as well as reversible septal ischemia. Cardiac catheterization was performed on [2185-9-14], which revealed a left ventricular ejection fraction of 60%, pulmonary artery wedge pressure of 11 and aortic stenosis with a mean gradient of 22 mm of mercury with a valve area of 1.2 cm2. It also revealed three vessel coronary artery disease. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Noninsulin dependent diabetes mellitus. 3. Hypertension. 4. Degenerative joint disease. 5. Benign prostatic hypertrophy. MEDICATIONS ON ADMISSION: Atenolol, Lipitor, glyburide and aspirin. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On physical examination on admission, the patient had a blood pressure of 171/71, pulse 53, sinus bradycardia, temperature 96.3 and oxygen saturation 98% in room air. General: Well appearing middle-aged male in no acute distress. Head, eyes, ears, nose and throat: Unremarkable with the exception of some jugular venous distention. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, normal S1 and S2, grade II/VI systolic murmur. Abdomen: Soft, nontender, nondistended. Extremities: Without edema, 2+ dorsalis pedis and posterior tibialis pulses bilaterally. LABORATORY DATA: Preoperative electrocardiogram revealed normal sinus rhythm. Preoperative laboratory values were unremarkable with the exception of a glucose of 307. HOSPITAL COURSE: The patient was admitted directly to the preoperative holding area and taken to the Operating Room on [2185-9-21], where he underwent coronary artery bypass grafting times four as well as an aortic valve replacement with a 25 mm pericardial tissue valve. Postoperatively, the patient was transported from the Operating Room to the Cardiac Surgery Recovery Room, where he was being atrially paced. He was on insulin and propofol drips. The patient was hemodynamically stable, however, due to increased chest tube output of approximately 400 cc/hour for the first couple of hours postoperatively, the patient was taken back to the Operating Room for re-exploration for bleeding on the evening of surgery. There was a small distal branch of the right internal mammary artery which was found to be bleeding, and repaired. Postoperatively from the re-operative procedure, the patient was transported again to the Cardiac Surgery Recovery Room, where he remained hemodynamically stable. He was on a low dose Neo-Synephrine drip initially, which was weaned off within the first few hours of arrival. The patient was also on an insulin drip for a short while in the postoperative period. The patient was weaned from the mechanical ventilator and extubated on postoperative day one. He also transferred out of the Intensive Care Unit to the telemetry floor on postoperative day one in stable condition. The patient had a physical therapy evaluation on [2185-9-22], postoperative day one, and was begun on cardiac rehabilitation. On postoperative day two, [2185-9-23], the patient remained in stable condition. His atrial pacing was discontinued and he had remained in normal sinus rhythm with a rate in the 80s and with a stable blood pressure. The patient was noted to have some decreased breath sounds bilaterally. A chest x-ray was obtained at that time, which revealed bibasilar atelectasis and small bilateral pleural effusions. Later that day, the patient's Foley catheter was discontinued as well as his chest tubes, and he began ambulating. On postoperative day three, the patient continued to progress from a physical therapy standpoint and remained stable hemodynamically. Over the next two days, the patient continued to progress well. He remained hemodynamically stable and today, [2185-9-26], postoperative day five, he remains stable and is ready to be discharged to home. CONDITION ON DISCHARGE: Temperature 98.3, pulse 72, normal sinus rhythm, blood pressure 98/58, respiratory rate 18 and oxygen saturation 94% in room air. The patient's weight today is 111 kilograms, which is up seven kilograms from his preoperative weight of 104 and his blood sugar has been in the 90s. PHYSICAL EXAMINATION ON DISCHARGE: The patient is alert and oriented with no apparent neurologic deficits. Lungs are clear to auscultation bilaterally. Heart sounds are a regular rate and rhythm. Sternum is stable with incision clean, dry and intact. Abdomen is soft, nontender and nondistended. Extremities are warm and well perfused with some peripheral edema noted. The patient is also noted to have some blistering at his saphenous vein harvest site, however, there is no erythema or purulent drainage noted; there is a small amount of serous drainage. LABORATORY DATA: The patient's most recent laboratory values are from [2185-9-23], which showed a white blood cell count of 11,000, hematocrit 26, platelet count 119,000, sodium 141, potassium 4.3, chloride 108, bicarbonate 24, BUN 19, creatinine 0.6 and glucose 162. DISPOSITION: The patient is being discharged home today with visiting nurse follow-up due to the wound blistering on the right thigh area. Dressing changes, if the patient is having blistering, should be Vaseline or Neosporin applied to the blistered area and a dry sterile dressing placed over that as long as it continues to have any blistering. FOLLOW-UP: The patient is to follow up with Dr. [Last Name (STitle) 1537] in one month for a postoperative check, telephone number [Telephone/Fax (1) 170]. The patient is also to follow up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 410], in three to four weeks, or sooner if necessary. DISCHARGE DIAGNOSIS: Aortic stenosis, status post aortic valve replacement. Coronary artery disease, status post coronary artery bypass grafting. Noninsulin dependent diabetes mellitus. Hypertension. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Doctor Last Name 28028] MEDQUIST36 D: [2185-9-26] 12:21 T: [2185-9-26] 12:30 JOB#: [Job Number 32717] ICD9 Codes: 4111, 4241, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6877 }	Medical Text: Admission Date: [2151-11-12] Discharge Date: [2151-11-23] Date of Birth: [2151-11-12] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname 916] [Known lastname ] delivered at 37 and 0/7 weeks gestation and was admitted to the Neonatal Intensive Care nursery for management of respiratory distress. Birth weight was 3295 grams (75th to 90th percentile); length 49.5 cm (75th to 90th percentile); head circumference 33 cm (50th percentile). Mother is a 26 year-old, gravida 1 mother, with estimated date of delivery of [2151-12-3]. The prenatal screens included blood type 0 positive, antibody screen negative, hepatitis B surface antigen negative, Rubella immune, RPR nonreactive and group B strep negative. The mother's pregnancy was complicated by gestational hypertension. She was admitted and labor was induced at 37 weeks gestation for mild pregnancy induced hypertension. The mother's membranes were ruptured 8 hours prior to delivery for clear fluid. Mother's temperature after delivery was 100.6. She did not receive antepartum antibiotics. The infant emerged with a tight nuchal cord that was reduced. He was vigorous with Apgars of 8 and 9. PHYSICAL EXAM AT DISCHARGE: An alert, term male. Anterior fontanel soft and flat. Red reflexes present bilaterally. No cleft. Breath sounds bilaterally equal and clear with easy work of breathing. Regular rate and rhythm without murmur. Normal pulses and perfusion. Abdomen soft, nondistended, positive bowel sounds. No hepatosplenomegaly. No masses. Genitourinary: Normal male external genitalia, uncircumcised. Testes descended bilaterally. Patent anus. Back straight without dimple. Extremities: Moves all extremities equally. Hip stable without clicks or clunks. Skin: Pink, jaundiced, diaper rash. Neuro: Alert, normal tone and reflexes for age. HOSPITAL COURSE BY SYSTEMS: Respiratory: Was transferred from labor and delivery for management of respiratory distress. On admission, was placed on nasal cannula oxygen, 500 cc flow, 100% and due to respiratory distress, was placed on continuous positive airway pressure and then intubated, placed on conventional ventilation. Pressures of 23/6, rate of 25 and about 33 to 50%. Received 2 doses of Surfactant. Was extubated on day of life 2 to continuous positive airway pressure. Transitioned to nasal cannula oxygen on day of life 4 and then transitioned to room air on day of life 6. He has been in room air for several days with comfortable work of breathing, oxygen saturations in the high 90's. Respiratory rate remains in the 30's to 50's. Cardiovascular: No murmur. HDS. Current blood pressure is 73/43 with a mean of 53. Heart rate ranges in the 120's to 150's. Fluids, electrolytes and nutrition: Was initially maintained on IV fluids with maintenance electrolytes added at 24 hours of life. Enteral feeds were started on day of life 3 and advanced to full feeds on day of life 4. Initially was a little discoordinated with bottle feeding but, at discharge, is bottle feeding well, taking Enfamil 20 with iron, taking in good volumes and gaining weight. Discharge weight 3195 grams. Gastrointestinal: Bilirubin was followed. It peaked on day of life 4 at total of 17, direct 0.3, was treated with phototherapy. The phototherapy was discontinued on day of life 5 when the total bilirubin was 11.3. Rebound bili 13. Last bili was 12.4 ([11-22]) off phototherapy. Hematology: The patient's blood type is B positive, direct Coombs is positive. Infectious disease: CBC and blood culture were drawn on admission and the infant was started on ampicillin and gentamycin. As we were unable to rule out pneumonia, the baby was treated for 7 days with ampicillin and gentamycin for suspected pneumonia. An LP was done that was within normal limits. Neurology: Examination is age appropriate. Sensory: Hearing screening was performed with automated auditory brain stem responses. Infant passed both ears. Psychosocial: The parents are married and are Mandarin speaking. However, the father does speak some English. The mother's symphysis pubis was separated during delivery and she has been in a lot of pain. After discharge from the hospital, she has been unable to visit. The father visits daily and has been helping to take care of the baby. CONDITION ON DISCHARGE: Stable, term infant. DISCHARGE DISPOSITION: Discharge home with parents. NAME OF PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) 57342] [Last Name (NamePattern1) ], MD, [Hospital3 ] [First Name4 (NamePattern1) 17359] [Last Name (NamePattern1) ] in [Hospital1 392], MA, telephone number [Telephone/Fax (1) 76036], fax [Telephone/Fax (1) 8237]. CARE AND RECOMMENDATIONS: 1. Feeds ad lib of Enfamil 20 with iron. 2. Medications: None. 3. Car seat test performed and passed. 4. State newborn screen sent on [2151-11-15]. Results are pending. 5. Received hepatitis B immunization on [11-22]. FOLLOWUP: Pediatric appointment is scheduled for [11-24]. DISCHARGE DIAGNOSES: 1. Appropriate for gestational age term male. 2. Respiratory distress syndrome, resolved. 3. Suspected pneumonia, resolved. 4. ABO incompatibility. 5. Hyperbilirubinemia. [First Name8 (NamePattern2) 73452] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(2) 73453] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2151-11-21] 19:49:14 T: [2151-11-22] 06:05:57 Job#: [Job Number 76037] ICD9 Codes: 769, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6878 }	Medical Text: Admission Date: [2196-2-5] Discharge Date: [2196-4-11] Date of Birth: [2196-2-5] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname ] is a former 38-6/7, 1485-g male newborn, who was admitted to the Neonatal Intensive Care Unit for management of prematurity. The baby was [Name2 (NI) ] to a 39-year-old gravida 1, para 0 mother. Maternal serologies were O positive, antibody negative, hepatitis negative, rapid plasma reagin nonreactive, group B strep unknown. The pregnancy was uncomplicated until the recent onset of vaginal bleeding and contractions. This was treated with magnesium sulfate and betamethasone; last dose on [2-3]. Progressive cervical dilatation and symptoms of pulmonary edema thought to be secondary to magnesium sulfate were noted. Tocolysis was discontinued, and labor was allowed to progress. Amniocentesis for AMA was normal. Sepsis risks included prematurity, maternal temperature maximum of 100.2, and fetal tachycardia 160. Membranes were intact until just prior to delivery. The Neonatal Intensive Care Unit team attended vaginal delivery. Infant was vertex, emerged with good tone, color, and spontaneous cry. He was dried, suctioned, and stimulated. Early respiratory distress and poor aeration were noted. Facial CPAP was applied, and the infant was transferred to the Newborn Intensive Care Unit for management of prematurity. PHYSICAL EXAMINATION ON PRESENTATION: Admission examination revealed weight of 1485 g (75th to 90th percentile); length was 39.25 cm (50th to 75th percentile); head circumference was 29.25 cm (greater than 75th percentile. Premature male requiring respiratory support, bilateral breath sounds were coarse and equal. A regular rate and rhythm. No murmur was audible. Palate and clavicles were intact. The abdomen was soft and flat. A 3-vessel cord. Straight spine. No dimple. Stable hips. Pale and pink. Appropriate for gestational age. HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY: The baby was initially intubated, received two doses of Survanta. He was extubated on day of life two to CPAP. He remained on CPAP of 5 cm on room air for the next three days and then transitioned to room air. He remained on room air until day 13 when he required some nasal cannula oxygen for increasing apnea and bradycardia. He remained on nasal cannula oxygen until day of life 20 when he required CPAP for increasing apnea and bradycardia. He remained on CPAP until day 27 when he again weaned to nasal cannula oxygen for several days and went to room air on day of life 30. For several days, off and on, he needed nasal cannula oxygen. He now is in room air since [3-23] (which was day of life 47). Baseline respiratory rate is 40s to 60s with occasional mild retractions. No increased work of breathing. He was loaded with caffeine on day of life five for apnea of prematurity and remained on caffeine citrate until day of life 41. At the time of discharge he had been free of apnea and bradycardia of prematurity for greater than five days. 2. CARDIOVASCULAR: The baby required an initial normal saline bolus for marginal blood pressure on admission. He did not require pressor support. He did not require any treatment for a patent ductus arteriosis. He has had no cardiovascular issues. Baseline heart rate was 140s to 160s with blood pressures of 50s to 60s/30s with mean in the 40s. 3. FLUIDS/ELECTROLYTES/NUTRITION: The baby initially had a double lumen umbilical venous catheter through which he received maintenance fluids. Enteral feedings were introduced on day of life two. He did receive some parenteral nutrition. He advanced to full enteral feeds by day of life 10 and had caloric density increased to 30 calories of breast milk with ProMod. As his weight gain improved, calories have been weaned, and he was being discharged on breast milk 20. He is taking all feedings p.o. and breast feeding when his mom is here. He is voiding and stooling. Discharge weight 3680 grams, >90%; length 50 cm, 75%, HC 35 cm, > 75%. His last electrolytes were on [3-17]. Sodium of 137, potassium of 5.3, chloride of 100, bicarbonate of 27, blood urea nitrogen of 11, alkaline phosphatase of 345, albumin of 3.7, calcium of 9.8, and phosphorous of 7. His hematocrit at that time was 32. He is on supplemental iron 0.5 cc which equals 4 mg/kg per day and Poly-Vi-[Male First Name (un) ] 1 cc p.o. q.d. 4. GASTROINTESTINAL: The baby initially demonstrated physiologic jaundice and responded to phototherapy. His peak bilirubin was 7.5/0.3 on day of life two. His rebound bilirubin was 4.8/0.2. 5. HEMATOLOGY: The baby did not require any blood products during this admission. 6. INFECTIOUS DISEASE: The baby initially had a blood culture and complete blood count sent because of issues related to prematurity and rule out sepsis at delivery. Initial white blood cell count was 9.1 (25 polys, 26 bands, 15 lymphocytes), hematocrit of 22.6. A repeat hematocrit on the same day was 39. He was started on ampicillin and gentamicin. He had a repeat follow-up hematocrit on day of life one of 37. He received seven days of ampicillin and gentamicin. He had a lumbar puncture prior to discontinuation of the antibiotics with a white blood cell count of 5, 620 red blood cells, 44 polys, 38 lymphocytes, protein of 252, and a glucose of 28. A repeat complete blood count and blood culture were sent on day of life 12 because of increasing apnea and bradycardia. This showed a white blood cell count of 25 (50 polys and 0 bands), platelets of 456, and a hematocrit of 40. Later in his stay, because of concerns of calcifications on his head ultrasound in the thalamic region, he had a workup for cytomegalovirus that was negative. During routine screening for vancomycin-resistant enterococci (VRE), he was noted to be positive. 7. NEUROLOGY: The baby initially had a head ultrasound on day of life three which showed blood in the occipital [Doctor Last Name 534], and small bilateral intraventricular hemorrhage. A repeat head ultrasound was improved with resolving intraventricular hemorrhage, and a repeat follow-up head ultrasound after that (on [3-8] which was day of life 32) continued to show resolving hemorrhage; however, with a new finding of an echogenic/cystic area in the thalamus, and it was unclear what this finding demonstrated. On [3-22], he had a repeat head ultrasound which again showed an echogenic/cystic area in the thalamic region. This prompted evaluation by the Neurology team (Dr. [Last Name (STitle) ], and a magnetic resonance imaging was performed on [3-24]. This showed a right subependymal/germinal matrix cyst. Also decreased echogenicity with calcification in the globus pallidus/thalamic area possibly representing infarction, or hemorrhagic residuum. CMV infection was ruled out due to the presence of calcifications. Dr. [Last Name (STitle) ] was unclear of what this will mean for Will long-term and will follow him in the Neonatal Neurology Program. The baby's clinical examination was within normal limits at this time for gestational age. 8. SENSORY: Passed audiology screening. 9. OPHTHALMOLOGY: He has had serial eye examinations; his last one being on [3-23] which showed mature retinae with followup in eight months. 10. PSYCHOSOCIAL: This is a single mother who visits daily and looks forward to Will's transition home. Of note, Will will have a last name of [Name (NI) 38247] upon discharge. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: To home. Passed car seat positioning screening. PEDIATRICIAN: Name of primary pediatrician is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [First Name3 (LF) 745], [State 350] (telephone number [Telephone/Fax (1) 38248]; fax number [Telephone/Fax (1) 38249]). CARE RECOMMENDATIONS: 1. Continue ad lib breast feeding. 2. Medications: Fer-In-[Male First Name (un) ] 0.5 cc p.o. q.d. (which equals 4 mg/kg per day), Poly-Vi-[Male First Name (un) ] 1 cc p.o. q.d. 3. State newborn screens: He has had serial screens done; the last two being within normal range on [2-25] and [3-9]. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine #1 on [3-7], #2 on [4-10]; DTaP #1 on [4-8]; HIB #1 on [4-9]; IPV #1 on [4-9]; Prevnar #1 on [4-10], Synagis [4-11]. IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial virus prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: (1) [Month (only) ] at less than 32 weeks. (2) [Month (only) ] between 32 and 35 weeks with plans for day care during respiratory syncytial virus season, with a smoker in the household, or with preschool siblings; and/or (3) With chronic lung disease. Influenza immunization should be considered annually in the Fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other care givers should be considered for immunization against influenza to protect the infant. DISCHARGE FOLLOWUP: 1. Follow-up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (primary care pediatrician) to make appointment. 2. Follow-up with Neonatal Neurology Program (telephone number [Telephone/Fax (1) ]), Dr. [Last Name (STitle) ] in six weeks in conjunction with follow-up program at the [Hospital3 1810] (telephone number [Telephone/Fax (1) 38250]). 3. Early intervention referral has been offered to the mom; she refused at this time. The program that would follow him, if she changes her mind/reconsiders, would be [Location (un) 15953] Early Intervention Program in [Location (un) 620] (telephone number [Telephone/Fax (1) 38251]). 4. [Hospital6 407] will also be doing home visits during the transition period. This was through Partners' [Name2 (NI) ] Care (telephone number [Telephone/Fax (1) 38252]). DISCHARGE DIAGNOSES: 1. Former 28-6/7 week male; corrected gestational age of 38-3/7 weeks. 2. Status post respiratory distress syndrome. 3. Status post presumed sepsis. 4. Status post intraventricular hemorrhage. 5. Colonized with vancomycin-resistant enterococcus. 6. Status post apnea and bradycardia of prematurity. 7. Anemia of prematurity. 8. Status post physiologic jaundice. [First Name8 (NamePattern2) 36400] [Name8 (MD) ], M.D. [MD Number(1) 37201] Dictated By:[Last Name (NamePattern1) 38253] MEDQUIST36 D: [2196-4-9] 10:07 T: [2196-4-9] 10:51 JOB#: [Job Number 38254] ICD9 Codes: 769, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6879 }	Medical Text: Admission Date: [2100-8-24] Discharge Date: [2100-8-29] Date of Birth: [2047-10-18] Sex: M Service: CARDIOTHORACIC Allergies: Tylenol / Simvastatin Attending:[First Name3 (LF) 1406] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2100-8-24] Coronary Artery Bypass Graft x 3 - left internal mammary artery to left anterior descending artery, saphenous vein grafts to diagonal and PDA History of Present Illness: 52yo man with known CAD s/p inferior MI([2089]) and stenting in [2090] and [2096]. Now with recurrent chest pain over the last 2 months. Had +ETT then referred for cardiac cath. Cath revealed multivessel disease and he was referred for surgical revascularization. Past Medical History: - Coronary artery disease s/p inferior MI([2089]) with BMS to distal RCA. S/p PTCA [2090] of distal RCA secondary to in-stent restenosis, s/p DES of PLB([6-/2099])& LAD([8-/2099]) - Diabetes Mellitus II w/peripheral neuropathy(feet) - Hypertension - Hypercholesterolemia - + tobacco use - Tremors-primary - MVA ([2098])w/concussion and rib fx Social History: Race:caucasian Last Dental Exam: Lives with: 2 children-Daughter 16yo, son 18yo (divorced-exwife deceased) Occupation:electrician Tobacco: ongoing- 1ppd 30Pk yrs ETOH:1 drink/wk Family History: father died of MI @57yo Physical Exam: Pulse: 52 Resp: 16 O2 sat: 94%-RA B/P 120/90 Right: Left: Height: 73" Weight: 224 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM []paresthesia/sensitivity from jaw extending behind left ear Chest: Lungs w/insp/exp wheezes Heart: RRR [x] Irregular [] Murmur-none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: mild [] Neuro: Grossly intact-essential tremors Pulses: Femoral Right: Left: DP Right: Left: PT [Name (NI) 167]: Left: Radial Right: Left: Carotid Bruit Right: Left Pertinent Results: Pre CPB: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage, the Left atrial appendage ejection velocities were aproximately 20cm/s (borderline) . A small secundum atrial septal defect is present. There is bidirectional flow. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild focal left ventricular hypokinesis (LVEF = 40 %). There is hypokinesia of the apical and mid portions of the inferior wall and inferoseptal walls. The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is mild mitral regurgitation. Dr. [Last Name (STitle) ] was notified in person of the results. Post CPB: There is mild hypokinesis of the anteroseptal wall, otherwise all other prebypass findings are unchanged. Mild mitral regurgitation persists. The aortic contours are intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 1509] [Name8 (MD) 1510], MD, Interpreting physician [Last Name (NamePattern4) ] [2100-8-24] 12:24 Brief Hospital Course: Mr. [Known lastname ] was a same day admission after undergoing a pre-operative work-up prior to admission. On [8-24] he was brought directly to the operating room where he underwent a coronary artery bypass grafting x3 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein grafts to the posterior descending artery and the first diagonal artery. This procedure was erformed by Dr. [Last Name (STitle) ]. Please see the operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in critical but stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. His home propanolol was restarted. He was transferred to the surgical step down floor. His chest tubes and wires were removed. He did develop right calf pain and tenderness. Ultrasound did not reveal evidence of DVT. The physical therapy service assessed him and felt he would be safe for discharge to home. By post-operative day 5 he was ready for discharge to home. All follow-up appointments were advised. Medications on Admission: Propanolol 160 mg [Hospital1 ] Ibuprofen 800 mg TID Soma 350mg TID prn Metformin 500 mg [Hospital1 ] Prilosec 20mg daily MVI daily ASA 81 mg daily Glyburide 1.25 mg daily Clonazepam 1 mg daily" Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Clonazepam 1 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). 5. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough for 2 weeks. Disp:90 Capsule(s) Refills:0 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Propranolol 40 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [12-5] Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:1 MDI Refills:1 12. Glyburide 2.5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 15. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 1 weeks. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA, [Hospital1 1559] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft Past medical history: - s/p inferior MI([2089]) with BMS to distal RCA. S/p PTCA [2090] of distal RCA secondary to in-stent restenosis, s/p DES of PLB([6-/2099])& LAD([8-/2099]) - Diabetes Mellitus II w/peripheral neuropathy(feet) - Hypertension - Hypercholesterolemia - + tobacco use - Tremors-primary - MVA ([2098])w/concussion and rib fx Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema trace bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr.[Last Name (STitle) ] for Dr. [Last Name (STitle) ] Thursday [9-16] @ 9:15 AM @[Hospital1 ] [Telephone/Fax (1) 109410] Cardiologist: Dr. [Last Name (STitle) 31888] [9-27] @ 9:30 AM @ [Hospital1 ] Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 54160] [Name (STitle) ] in [3-8] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2100-8-29] ICD9 Codes: 5119, 3572, 412, 4019, 2720, 3051, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6880 }	Medical Text: Admission Date: [2101-3-14] Discharge Date: [2101-3-25] Date of Birth: [2036-8-26] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 65-year-old gentleman admitted to the CCU following catheterization for an ST elevation MI. The patient was home at rest when 2:00 pm of admission noted acute onset of substernal chest pain associated with shortness of breath, nausea, vomiting, diaphoresis. He presented to the [Hospital1 ] Emergency Room at 4:00 and noted to have ST elevations in V1 through V4 and reciprocal inferior depressions, given IV Nitroglycerin, morphine, Plavix, aspirin without resolution of the pain, and transferred emergently to [Hospital1 18] for cath. In the cath lab, his RA pressure was 14, PA 51/27, pulmonary wedge pressure 25. He had a thrombotic occlusion in the proximal LAD and stenotic distal LAD about 90% which were treated with Hepacoat bare metal stents. Also noted to have an 80% lesion of the mid left circumflex and co-dominant right RCA with proximal PDA lesion which was not intervened on. The patient required dopamine and Neo drips, as well as intra-arterial balloon pump. The patient had runs of VT and was started on lidocaine drip. The patient had temporary pacing wires placed, rate of 60. The patient was started on bivalirudin and low dose heparin for anticoagulation. On admission to the CCU, the patient was pain-free and comfortable, and no shortness of breath, chest pain, cough, lightheadedness, on lido, dopa, neo, heparin, bivalirudin drips. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. 3. GI bleed, status post colonoscopy in [2101-1-30] with diverticulosis. EGD in [2098-12-30] with gastritis. 4. TIA, ?CVA with residual left-sided findings without any palsy. 5. Hypercholesterolemia. ALLERGIES: No known drug allergies. MEDS AT HOME: 1. Insulin, lente, 25 in the am, 15 q pm, and regular sliding scale. 2. Glucophage. 3. Pravachol. 4. Prilosec. SOCIAL HISTORY: He is a retired police officer. Greater than 40 pack year tobacco history. He quit 7 years ago. No alcohol or drugs. Lives at home with his daughters. FAMILY HISTORY: Noncontributory. PHYSICAL EXAM ON ADMISSION: He is afebrile with an arterial blood pressure of 95/57, PA pressure 39/20, heart rate 110, respiratory rate 18, sats 94% on 2 liters. In general, he was pleasant, alert, in no acute distress, with flattened bed with intra-arterial balloon pump in place. Extraocular muscles were intact. Pupils equal, round, reactive to light. No lymphadenopathy. JVP at about 8 cm. Regular, tachycardic. Heart sounds obscured by the balloon pump. Lungs clear anteriorly. Abdomen with normally active bowel sounds, soft, nontender. The balloon pump was audible throughout. Groin was negative by cath lab report. Extremities - no edema, 2+ distal pulses. Sheath in the left groin. Intra-arterial balloon pump in the right groin. No hematoma or bruits. Neuro exam was awake, alert and oriented x 3. Cranial nerves - III was weak on the left. Otherwise, cranial nerves were intact. LABS AT OUTSIDE HOSPITAL: White count 10.4, hematocrit 44.7, platelets 179, INR 1.35, sodium 135, K 4.4, chloride 100, bicarb 23, BUN 20, creatinine 1.0, glucose 383, calcium 9.6. Cardiac cath results - Again, right atrial pressure 14, PA pressure 51/27, wedge pressure 25, cardiac output/cardiac index 4.2 and 2.2, SVR 1448. HOSPITAL COURSE: This was a 65-year-old gentleman, with an ST elevation MI of the LAD, now admitted with cardiogenic shock. 1) CAD: He was stable after cath on bivalirudin and heparin. His enzymes were followed, and he was continued on aspirin, anticoagulation and Plavix for his recent stent. He was also continued on his statin which was titrated to a maximal dose which he tolerated fine. The patient remained chest pain free throughout the course of his stay, status post stent. He subsequently underwent stenting of the LCX and RCA. 2) CARDIOGENIC SHOCK: The patient initially came in under cardiogenic shock and was initially on Neo-Synephrine and dopamine drips, in addition to the interatrial balloon pump, which he tolerated well. Eventually, these were weaned off, and the patient's blood pressures remained stable. Eventually, the patient had an echocardiogram which showed an ejection fraction of [10-14]%, and the patient was started on vasodilators and beta blockers for his cardiac regimen, as he was off pressors, and his blood pressure was stable. He was initially started on low dose ACE and low dose Toprol XL, and was started on Coumadin for prophylaxis for LV thrombus, in light of his large MI and decreased wall motion abnormality. The patient will actually go home on Lovenox, as he will return for an ICD placement per the electrophysiology team secondary to his low EF and episodes of NSVT. 3) ARRHYTHMIAS: The patient did have a run of V. tach secondary to his MI. He was otherwise stable, but then throughout the course of his stay he had recurrent episodes of NSVT, and plans were made per electrophysiology team to return in 3 week's time to have an ICD placed. 4) ATRIAL FIBRILLATION: This was new onset likely secondary to his MI and worsening heart failure. The patient did have an episode of atrial tachycardia during the course of his stay which did respond to low dose beta blockers, and again the patient will return for ICD placement. No plans for an EP study at this time. The patient was also started and loaded on digoxin which he will continue. VT post MI - he was initially on lido drip secondary to this and this was weaned, and the patient's VT remained stable. 5) DIABETES: Patient with poor glucose control throughout the course of his stay. Eventually was restarted on his home regimen which was titrated up, and this can be continued to be monitored closely upon DC. For patient' atrial fibrillation, he was converted with amiodarone and milrinone which was eventually discontinued. Amiodarone was eventually weaned off as well, and the patient remained in sinus with occasional episodes of atrial tachycardia as described above. The patient was seen by physical therapy and recommended continued rehabilitation for deconditioning after his MI. The patient will go for cardiac rehab. 6) ANEMIA: The patient had a history of GI bleed and was transfused over the course of his stay to keep a goal hematocrit greater than 30. This remained stable over the course of his stay. 7. Thrombocytopenia: resolved after unfractionated heparin was discontinued. DISCHARGE CONDITION: Good. Patient ambulating without difficulty, not requiring oxygen. Deconditioned requiring cardiac rehabilitation. DISCHARGE STATUS: Discharge to cardiac rehab. DISCHARGE DIAGNOSES: 1. ST elevation myocardial infarction. 2. Arrhythmias - ventricular tachycardia, atrial tachycardia, paroxysmal atrial fibrillation, nonsustained ventricular tachycardia. 3. Anemia. 4. Diabetes mellitus 5. Cardiogenic shock 6. Thrombocytopenia. DISCHARGE MEDICATIONS: 1. Aspirin 325 po qd. 2. Plavix 75 mg po qd. 3. Pantoprazole 40 mg po qd. 4. Colace 100 mg po bid. 5. Senna 1 tab po bid prn. 6. Percocet 1-2 tabs po q 4-6 h prn. 7. Digoxin 0.125 mg po qd. 8. Lasix 20 mg po qd. 9. Captopril 50 mg po tid. 10.Atorvastatin 80 mg po qd. 11.Toprol XL 25 mg po qd. 12.Lovenox 80 mg subcu q 12. 13.Insulin sliding scale and insulin, lente, 32 U in the morning and 24 U at night. DISCHARGE FOLLOW-UP: 1. The patient is to return in 3 week's time for ICD placement. 2. The patient is to follow-up with his PCP [Last Name (NamePattern4) ] [7-9] days. 3. The patient is to follow-up with his cardiologist in [2-2] week's time. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 8227] Dictated By:[Name8 (MD) 264] MEDQUIST36 D: [2101-3-24] 14:16 T: [2101-3-24] 14:49 JOB#: [Job Number 55316] ICD9 Codes: 4271, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6881 }	Medical Text: Admission Date: [2105-8-24] Discharge Date: [2105-9-2] Date of Birth: [2031-5-28] Sex: M Service: MEDICINE Allergies: Lipitor Attending:[First Name3 (LF) 3276] Chief Complaint: ICU callout, orginally admitted with fevers, chills, neutropenia s/p chemo in afib with RVR. Major Surgical or Invasive Procedure: PICC placement History of Present Illness: Mr. [Known lastname 4401] is a 74 year-old male with PAF off anticoagulation, and recently diagnosed extensive stage small cell lung cancer status post Y stent tracheal placement for obstruction, status post Carboplatin/Etoposide chemotherapy on [2105-8-11], who presented from the ED with febrile neutropenia and AF with RVR. He was recently admitted to [Hospital1 18] [2105-8-6] -> [2105-8-14] to expedite work-up of his newly diagnosed lung mass, as above confirmed as extensive stage SCLC. During this admission, he underwent placement of a Y tracheal stent, and received chemotherapy. He was also treated with Unasyn for presumed post-obstructive pneumonia. His Coumadin was discontinued after finding encroachment of his mass on his pulmonary artery. He was in NSR at the time of discharge. * He now presented with a 1-week history of progressive cough, and increased sputum production, which he describes as whitish. In the ICU, the patient also complained of moderately severe "throat pain", which he has had for about a month, worsening, with associated hoarseness as well as odynophagia with both solids and liquids. No clear dysphagia. No hemoptysis. He reports some RS pain with coughing, no other chest pain. No increase in SOB. No lower extremity swelling. He denies abdominal pain, no rectal pain, no GU complaints. + Chills at home. Tmax at home 100.5, which prompted his daughter to bring him to the [Name (NI) ]. * In the ICU, antibiotics were continued (vanc, cefepime), and ENT evaluation was requested for hoarseness, odynophagia. The patient's afib was controlled with IV diltiazem pushes and metoprolol PO. The patient remained hemodynamically stable. Past Medical History: PAF HTN Hyperlipidemia CRI PVD AAA S/P repair 4 mon ago ? Etoh abuse Social History: Lives alone. Family lives in [State 38104]. Has five kids and many grandchildren. Divorced. Quit smoking 4 mon ago. Smoked 1 pack per week for 50 years. Denies history of ETOH abuse, however, OMR notes report this. Has 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: 97.1, HR 83-120 (afib); BP 116/82, 99%2L GEN: WDWN male in NAD sitting on the side of the bed. HEENT: PERRL. EOMI. OP clear. MMM. NECK: supple, no LAD. LUNGS: Decreased BS on R over mid-lung field, also dull to percussion. Mild wheezes, no rhales or rhonchi heard. CV: RRR. Normal S1S2 NO M/R/G ABD: soft, NT/ND, no HSM. EXT: No C/C/E. BACK: No spinal tenderness, no CVAT. NEURO: Strength 5/5 b/l. Sensation grossly intact b/l UE and LE. Pertinent Results: [2105-8-24] 07:40AM PT-13.3* PTT-29.1 INR(PT)-1.2* [2105-8-24] 07:40AM PLT SMR-LOW PLT COUNT-92# [2105-8-24] 07:40AM WBC-0.7# RBC-4.24* HGB-11.7* HCT-33.8* MCV-80* MCH-27.6 MCHC-34.6 RDW-16.9* [2105-8-24] 07:40AM NEUTS-5* BANDS-0 LYMPHS-60* MONOS-35* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-0 [2105-8-24] 07:40AM cTropnT-<0.01 [2105-8-24] 07:40AM GLUCOSE-127* UREA N-28* CREAT-1.7* SODIUM-135 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14 [2105-8-24] 08:02AM LACTATE-1.7 .................. [2105-9-2] 12:00AM BLOOD WBC-8.4 RBC-3.62* Hgb-10.0* Hct-29.4* MCV-81* MCH-27.7 MCHC-34.1 RDW-18.8* Plt Ct-284 [2105-9-2] 12:00AM BLOOD Glucose-108* UreaN-12 Creat-1.2 Na-138 K-4.0 Cl-104 HCO3-26 AnGap-12 [2105-9-2] 12:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0 [2105-8-28] 12:12AM BLOOD calTIBC-179* Hapto-315* Ferritn-479* TRF-138* [2105-8-27] 07:45AM BLOOD CRP-135.5* .................... Cultures: Sputum: 9/12,13,14,16,17- all neg for AFB, 16,17 with <10 epithelial cells. . Blood cultures: [8-24]: 1/4 bottles Strep bovis pan sensitive, [8-25] and [8-27] negative to date . Imaging: Swallowing study: IMPRESSION: 1) No penetration or aspiration. CXR: IMPRESSION: Decreased size of the right hilar mass since the prior study. Improved aeration of the right lung. No infiltrate. . CT Chest: IMPRESSION: 1. No pulmonary embolism. 2. Decrease in size of large dominant right hilar mass. 3. Tracheobronchial stent in unchanged position. Although the right hilar mass narrows the right upper and middle lobe bronchi they remain patent. 4. New tree-in-[Male First Name (un) 239] opacity of the peripheral right upper and middle lobes is nonspecific but may be infectious, inflammatory, or possibly represent lymphangitic spread of tumor. 5. New small areas of posterobasilar consolidation at both lung bases may be due to atelectasis but could represent infection. . ECHO [2105-8-26]: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure (<12mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. 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. Compared with the prior study (images reviewed) of [2105-4-17], the focal thickening of the aortic leaflets is slightly more pronounced, but no aortic regurgitation is identified. If the clinical suspicion for endocarditis is moderate or high, a TEE may be better able to define the aortic valve morphology and to evaluate for possible vegetations. . Colonoscopy [2105-9-1]:Pt with multiple polyps that were removed and sent for pathology. Brief Hospital Course: ASSESSMENT AND PLAN: 74 year-old male with extensive stage SCLC with tracheal obstruction status post tracheal stent, status post first cycle of chemotherapy [2105-8-11], with febrile neutropenia, AF with RVR now improved. * 1. Strep bovis baceremia with Hx of Febrile neutropenia: On admission patient was found to have febrile neutropenia. As such, the patient was pancultured and found to have 1/4 bottles positive for Strep bovis. Given previous history thickened aortic valve and aortic valve vegetation, the patient was diagnosed with presumed bacterial endocarditis. As recommended by infectious disease, he will be treated with IV penicillin for 4 weeks. Additionally, patient received colonoscopy given suspicious nature of strep bovis bacteremia for colonic lesions. Pathology is pending. PICC was placed for long term Abx. The patient will likely need lifelong S Bovis suppression per ID (as pt has aortic graft). Therefore, the patient will follow up with ID ([First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9404]) after discharge. Neutropenia did resolve as patient had gotten neulasta. - Penicillin 3 mill U IV Q4 x 4 weeks (Finishes [9-23]) - VNA for IV Abx - F/U per ID * 2. Tree-in-[Male First Name (un) 239] opacity CT findings: CT chest showed findings that could represent fungal or mycobacterial. However, patient had multiple induced sputum samples as well as fungal blood tests that were all negative. Therefore, the patient was take off respiratory precautions. Therefore, the abnormal findings likely represent progression of lung cancer. . 3. Odynophagia/cough: Concomitant hoarseness could be secondary to recurrent laryngeal nerve involvement of neoplasm versus related to odynophagia. Improved with symptomatic treatment and decreased coughing as odynophagia is likely due to persistent coughing that is secondary to lung cancer. Pt was given symptomatic control with viscous lidocaine and narcotics with nebs as needed for comfort * 4. Paroxysmal Atrial Fibrillation: Initially patient had elevated heart rate and was evaluated in ICU. However, pt converted to sinus rhythm spontaneously after metoprolol administration. He was kept on telemetry for duration of hospitalization but did not have elevated heart rate in days prior to discharge. Pt was discharged with home medications amniodarone and [Last Name (LF) ], [First Name3 (LF) ] titrate as needed. Not on anticoagulation at present given mass encroachment on pulmonary vessels. * 5. Oral Herpes: pt with small lesion on left lip. This is new and pt has a history of previous lip sores. - Acyclovir 400 mg PO Five times daily x 14 days . 6. Extensive stage SCLC: Some radiographic response status post 1 cycle of chemotherapy. Pt received 1st day of second course of chemotherapy while inpatient to be followed up for second and third days as outpatient. (Carboplatin day 1, Etoposide day [12-16] q 21 d Cycle 1 and cycle 2 day 1 given in hospital Carboplatin AUC 5 465 mg, Etoposide 80 mg/m2 = 160 mg.) Additionally pt was to return for neulasta on Saturday. * 7. Anemia : Anemic (although hematocrit low at baseline), Suspect secondary to recent chemotherapy. - Colonoscopy shows multiple polypoid lesions, likely cause of bleeding. Await path report. Pt received multiple transfusions with goal hct of 30 while in pre-chemotherapy status. * 8. FEN: Pt refused low Na diet. Electrolytes WNL. . 9. Prophylaxis: Heparin SC BID. No need for protonix. Bowel regimen prn. Medications on Admission: amidodarone 200 mg QD ASA 81 mg QD coumadin 5 mg QD lisinopril 20 mg QD Metoprolol 50 mg [Hospital1 ] Discharge Medications: 1. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback Sig: Fifty (50) mL Intravenous Q4H (every 4 hours) for 21 days: Finishes course on [9-23]. Disp:6300 mL Refills:0 2. PICC PICC line care per protocol 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:1 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:60 Tablet Sustained Release(s) Refills:2 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for Insomnia. Disp:30 Tablet(s) Refills:1 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp:60 Capsule(s) Refills:0 13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for coughing. Disp:1 1 Refills:0 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:0 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for Pain. Disp:180 Tablet(s) Refills:0 17. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO 5X/D (5 times a day) for 14 days. Disp:70 Capsule(s) Refills:0 18. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal [Hospital1 ] (2 times a day). Disp:1 1 Refills:2 19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for nausea, anxiety. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (un) 6438] Discharge Diagnosis: Small cell lung cancer Streptococcus bovis Endocarditis Discharge Condition: stable Discharge Instructions: You will need an outpatient colonoscopy. Please call your PCP to arrange. -please see page 1 for specific line care instructions Followup Instructions: Please follow up with Dr. [Last Name (STitle) 3274].([Telephone/Fax (1) 3280] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 3280], to arrange plans for further chemotherapy . please return to clinic (7F outpatient clinic) for neulasta injection on [2105-9-5] (saturday). Please attend the following appointments: Provider: [Name10 (NameIs) 8111] [Name11 (NameIs) 8112], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2105-9-3] 11:30 . Provider: [Name Initial (NameIs) 4426] 19 Date/Time:[2105-9-3] 11:30 . Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]/ONCOLOGY-CC9 Date/Time:[2105-9-3] 11:30 Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]/ONCOLOGY-CC9 Date/Time:[2105-9-3] 11:30 Provider: [Name Initial (NameIs) 4426] 19 Date/Time:[2105-9-3] 11:30 Provider: [Name10 (NameIs) 8111] [Name11 (NameIs) 8112], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2105-9-3] 11:30 . Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9404], infections disease clinic, [Hospital Ward Name 23] Building; [2105-9-22], 11am. [First Name8 (NamePattern2) 251] [Name8 (MD) ] MD [MD Number(1) 3282] ICD9 Codes: 5859, 4439, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6882 }	Medical Text: Admission Date: [2191-6-30] Discharge Date: [2191-7-16] Date of Birth: [2191-6-30] Sex: M Service: NB HISTORY: Baby [Name (NI) ] [Known lastname ] is a 2175-gram product of a 33-2/7 week gestation pregnancy born to a 37-year-old G5, P1 woman whose pregnancy was complicated by PPROM requiring admission to [Hospital1 18] on [2191-6-26], treated with betamethasone and antibiotics. PRENATAL SCREENS: O-, antibody negative, hepatitis B surface antigen negative, rubella immune, GBS unknown, afebrile, and did get antibiotics prior to delivery. Labor progressed on day of delivery, prompting C-section in context of previous C-section. No other risk factors at time of delivery. Patient emerged vigorous. Received blow-by O2 and stimulation. Apgars 7 at 1 minute, 9 at 5 minutes. Transferred to the Newborn Intensive Care Unit after visiting with parents. PHYSICAL EXAMINATION ON ADMISSION: Pink, active, nondysmorphic, well saturated and perfused on room air. Skin: Without lesions. HEENT: Within normal limits. Cor: Normal. S1, S2 without murmur. Lungs: Clear, comfortable. Abdomen: Benign. Genitalia: Normal premature male. Patent anus. Hips: Normal. Spine: Intact. Neuro: Nonfocal and age appropriate. REVIEW OF HOSPITAL COURSE BY SYSTEMS: Birth weight 2175 (greater than 75th percentile), length 45.5 (greater than 75th percentile), head circumference 32.5 (75th percentile). Respiratory: Baby remains in room air. Did not require any respiratory support. Has not had any apnea, bradycardia or desaturations. Baseline respiratory rate is 40s-60s. Cardiovascular: Baby has had no cardiovascular issues. Patient had a G2 murmur heard on LSB without radiation. Chestfilm/EKG/Hyperoxiatest/4 quadrant bloodpressures were done on [7-12] and normal. Murmur was not heard the last few days prior to dischar Baseline heart rate 120-170. Blood w days prior to discharge. Cardiology felt exam normal. However they read the QTc as upper limits of normal and requested a repeat EKG prior to discharge. Results pending from CHMC and I will phone pediatrician when the results are available. Fluid and electrolytes: Initially a baby had a D stick of 22. Received 2 D10W boluses to achieve D sticks of greater than 50, and had D10W IV fluids started at 60, increased to 80 cc/kg per day via a peripheral IV. Enteral feedings were introduced. Baby has advanced to breast milk or Special Care ad. lib. Is voiding and stooling, and dextrose sticks have been stable. Initial electrolytes on day of life 1: Sodium 128, potassium 4.5, chloride 96, bicarbonate 16. Repeat was sodium 129, potassium 5, chloride 96, CO2 19. Electrolytes on [7-3]: Sodium 135, potassium 4.9, chloride 101, dextrose stick 20. Discharge3 weight was 2340. Baby was noted to have a distended abdomen, resulting in a contrast enema on [7-1] which was within normal limits, possibly meconium plug. Baby soon after that started passing stool. Has had no further distention and no further issues. Baby is voiding and stooling. GI: Peak bilirubin on [2198-7-4].2, 0.3, and was under phototherapy for several days.Rebound bili was 7.3/0.3. Baby O pos/Mom O neg,Coombs neg. Hematology: Baby has not required any blood products during this admission. Admission hematocrit was 51.7. Infectious disease: Baby initially had a blood culture and a CBC sent on admission because of prolonged rupture of membranes and prematurity. Initial white count was 11.3 with 42 polys, 0 bands, platelets of 252, and hematocrit of 51.7. Blood culture was sent. Baby was started on ampicillin and gentamicin. At the time of distended abdomen on day of life 1 a repeat CBC was sent. White count was 11.4, 62 polys, 0 bands, platelets of 240, and hematocrit of 52. Antibiotics at 48 hours were discontinued as the baby was clinically well, contrast study was negative, and blood cultures were negative. There have been no further issues with inspection. Neurology: Baby is appropriate for gestational age on exam. Sensory: Audiology screening has not been done at time of dictation. Ophthalmology exam not indicated based on gestational age of greater than 32 weeks. IMMUNIZATIONS: Hepatitis B given on [7-11]. PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Location (un) 1468] [Hospital1 35174]. Telephone number is [Telephone/Fax (1) 50457]. Psychosocial: Parents are pleased with [Known lastname 61806] progress. Look forward to him transitioning home with his 6-year-old sibling. CARE RECOMMENDATIONS: Continue ad. lib. feeding. Medications: None at transfer. Car seat position screening: Pending. State newborn screen: Initial sent on [7-4]. Immunizations received: None at time of dictation. DISCHARGE DIAGNOSES: 1. Former 33-2/7 week premature male status post rule out sepsis. 2. Status post hypoglycemia. 3. Meconium Plug. Status post abdominal distention with negative contrast study. 4. Possible prolonged QTc, awaiting cardiology's review of repeat ECG. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 37691], [MD Number(1) 55783] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2191-7-4] 21:18:25 T: [2191-7-4] 22:28:30 Job#: [Job Number ] ICD9 Codes: 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6883 }	Medical Text: Admission Date: [2109-9-15] Discharge Date: [2109-9-18] Date of Birth: [2042-10-23] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2777] Chief Complaint: Lacerated axillary artery Major Surgical or Invasive Procedure: Ultrasound-guided access for vascular access, first order axillary and extremity arteriography, covered stent the left axillary artery followed by repair of axillary artery and vein patch angioplasty of left brachial artery after a brachial cutdown. History of Present Illness: 66 F emergent transfer from OSH for axillary artery hemorrhage. Patient fell down at 3:00 p.m. today and developed a hematoma of her left chest but had no shoulder dislocation. Due to neurologic symptoms in her left hand, the patient was taken urgently to the operating room despite no active extravasation of contrast on the chest CT. In the operating room from OSH, the surgeon's exposed the artery but found massive bleeding and decided to transport the patient to [Hospital1 69] by med flight. The surgeon came in the helicopter with manual pressure being held on the artery and the patient was brought emergently to the endovascular room. At this point, the patient had artery had already lost 2 liters of blood and received 4 units of packed red blood cells and 2 units of FFP. She arrived intubated and hemodynamically stable. Past Medical History: L shoulder dislocation 2 months ago Vaginal hysterectomy in [2102] Social History: Drinks socially Denies tobacco and IVDU Family History: mother with arthritis, father with brain tumor (unclear pathology) Physical Exam: Tmax 97, Tc 97, HR 91, BP 117/76, RR 19, SaO2 100%, CMV/AC (FiO2 0.5, Peep 5, TV 500, RR 18), Neo 1.3, Prop 20 Gen: intubated, sedated CV: RRR Pulm: CTA BS Abd: soft, NT, ND, act BS L ext - dopplerable ulnar, radial, brachial R ext - dopplerable ulnar, radial Ext: no clubbing, cyanosis, gross edema Pertinent Results: AP shoulder: Three views of the left shoulder were reviewed. The patient is after surgery of the left upper chest/area of axilla. Vascular stent is noted. No evidence of fracture is present. No evidence of dislocation is seen. [2109-9-15] 01:20AM BLOOD WBC-12.9* RBC-3.31* Hgb-10.6* Hct-29.7* MCV-90 MCH-31.9 MCHC-35.6* RDW-15.2 Plt Ct-121* [2109-9-15] 04:35AM BLOOD WBC-18.3* RBC-4.09* Hgb-13.0 Hct-36.0 MCV-88 MCH-31.8 MCHC-36.2* RDW-15.0 Plt Ct-102* [2109-9-15] 10:35AM BLOOD Hgb-10.5* Hct-28.1* [2109-9-16] 02:58PM BLOOD Hct-27.5* [2109-9-17] 03:40AM BLOOD WBC-6.3 RBC-2.70* Hgb-8.9* Hct-24.0* MCV-89 MCH-33.0* MCHC-37.2* RDW-15.7* Plt Ct-71* [2109-9-18] 06:30AM BLOOD WBC-4.3 RBC-2.90* Hgb-9.3* Hct-26.1* MCV-90 MCH-32.2* MCHC-35.7* RDW-15.8* Plt Ct-91* [2109-9-15] 02:00AM BLOOD PT-22.8* PTT-150* INR(PT)-2.2* [2109-9-15] 04:35AM BLOOD PT-15.1* PTT-115.9* INR(PT)-1.3* [2109-9-16] 04:40AM BLOOD PT-11.9 PTT-24.9 INR(PT)-1.0 [2109-9-17] 03:39AM BLOOD PT-12.0 PTT-25.0 INR(PT)-1.0 [2109-9-15] 04:35AM BLOOD Glucose-240* UreaN-19 Creat-0.5 Na-138 K-5.1 Cl-109* HCO3-20* AnGap-14 [2109-9-15] 10:35AM BLOOD Glucose-158* K-4.7 [2109-9-16] 04:40AM BLOOD Glucose-107* UreaN-16 Creat-0.5 Na-134 K-4.0 Cl-105 HCO3-25 AnGap-8 [2109-9-17] 03:40AM BLOOD Glucose-100 UreaN-9 Creat-0.4 Na-139 K-3.7 Cl-109* [2109-9-15] 01:36AM BLOOD Type-ART pO2-92 pCO2-62* pH-7.16* calTCO2-23 Base XS--7 [2109-9-15] 02:27AM BLOOD Type-ART pO2-330* pCO2-46* pH-7.28* calTCO2-23 Base XS--4 [2109-9-15] 04:44AM BLOOD Type-ART pO2-178* pCO2-44 pH-7.28* calTCO2-22 Base XS--5 [2109-9-15] 06:32AM BLOOD Type-ART pO2-196* pCO2-37 pH-7.34* calTCO2-21 Base XS--5 [2109-9-15] 09:33AM BLOOD Type-ART pO2-224* pCO2-38 pH-7.40 calTCO2-24 Base XS-0 [2109-9-15] 11:48AM BLOOD Type-ART pO2-74* pCO2-37 pH-7.40 calTCO2-24 Base XS-0 Brief Hospital Course: Patient was transferred via [Location (un) 7622] to [Hospital1 18] and taken directly to the OR by Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] on [2109-9-15] for L axillary arterioplasty, covered stent, L brachial artery cutdown with vein patch arterioplasty. During transportation, patient was intubaed and remained hemodynamically stable. Estimated blood loss intraoperatively was one liter with additional two liters from the OSH. She had received 4 units of packed red blood cells and 2 units of FFP. At the completion of the case, the patient had a palpable brachial pulse and a palpable radial pulse. Her hand looks markedly improved compared to preoperatively. She was taken intubated to the intensive care unit in guarded condition. Plesse see dictated operative note for more detail. . POD1, patient required neo pressors and fluids for hemodynamic support. She was awoken briefly for routine vascular and neuro exams to check left upper extremity. Pulses remained palpable throughout his postoperative course. Ortho asked to follow for question of possible brachial plexus injury or nerve impingement by hematoma. Question of acute thrombocytopenia with platelets dropping to 77 from 100's. Anticoagulation held and HIT panel antibodies sent. Results are pending. She was weaned to extubate from the ventilator without any respiratory complications. . POD2, she was transfused 1u pRBC for Hct of 24. Hct responded to 27.5 and remained stable during remained of hospital course. Occupational therapy consulted for evaluation. On discharge, she continues to have decreased coordination, grasping and sensation, strength and functional use of her left upper extremity. She will be discharged home with outpatient occupational therapy to follow for strengthening and conditioning. . POD3, patient discharged home with services. She will follow occupational therapy as outpatient. Her vitals signs are stable. She is tolerating regular food. Hct remained stable at 26.1. She will follow up with Dr. [Last Name (STitle) ] in clinic in [12-5] weeks for postoperative follow up. She is to continue her aspirin and plavix as well. Medications on Admission: None Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 28 days. Disp:30 Tablet(s) Refills:0 2. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Laceration or Right axillary artery Discharge Condition: VSS, ambulating, pain well controlled with Po pain meds, hematocrit stable Discharge Instructions: What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day; you may walk and you may go up and down stairs ??????Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the arm you were operated on: ?????? Elevate your arm above the level of your heart (use [1-6] pillows) every 2-3 hours throughout the day and at night 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your arm or the ability to feel your arm ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [Name10 (NameIs) ],[First Name3 (LF) ] L. [Telephone/Fax (1) 2625] Follow-up appointment should be in 2 weeks ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6884 }	Medical Text: Admission Date: [2204-9-10] Discharge Date: [2204-9-14] Date of Birth: [2142-12-26] Sex: F Service: MEDICINE Allergies: Norvasc / Infed Attending:[First Name3 (LF) 4765] Chief Complaint: Burning chest pain and shortness of breath Major Surgical or Invasive Procedure: Dialysis Removal of tunneled dialysis catheter History of Present Illness: Pt is a 61 yo F w/ CAD s/p MI (in [2-3]) and previous 2 stents in RCA and LAD, scleroderma, HTN, ESRD on HD MWF ([12-28] scleroderma) s/p transplant x2 currently failing with initiation of dialysis since [Month (only) 205], and systolic HF (EF 20-25%) who comes in with substernal, burning chest pain that feels like "fire." She reports this pain has been ongoing and intermittent for months, and has been occuring every night for the past few weeks. She notes this pain only occurs at night and begins after she lays flat to sleep. She reports that it is exacerbated by food. She finds herself having to sit almost upright to help relieve her pain. She has tried antacids, maalox, and omeprazole with no relief. She has also tried nitroglycerin which will relieve her pain for about 1/2-1 hour, but then the pain returns. She has requested oxygen at her last two dialysis sessions which helps her and she usually feels better after her HD sessions. She also has associated dyspnea along with the pain that is much improved with oxygen and sitting in an upright position. . Of note, she was admitted to [Hospital1 18] last in [6-4] w/ pulmonary edema and dyspnea, had a tunneled IJ line placed and was initiated on dialysis in the setting of her renal transplant failure and volume overload. She was intubated for respiratory distress and had good relief with lasix gtt with return of adequate oxygen saturations on room air. She was discharged on furosemide 80mg [Hospital1 ] but reports now that she does not make any urine, a few drops if any. . She was evaluated by PCP for this chest pain most recently 5 days ago. He noted that she hasn't had any weight changes nor increase swelling in her BLEs. He believes chest pain is GI in origin patient is scheduled for outpatient endoscopy for further evaluation this Thursday along with treatment with omeprazole. . In the ED, vitals 97.1 104 118/65 22 97%. CXR with pulmonary edema, EKG with LAD, IVCD without changes compared prior. Patient started on CPAP in ED given tachypnea was unable to wean off. Vitals prior to transfer HR: 91, 100% on Bipap, BP 107/66. Pt arrived to the CCU floor on a NRB, but then slowly transitioned to 4L NC w/ oxygen saturations 92-95%. Pt felt comfortable as long as she was sitting up straight and felt better with the oxygen. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, ankle edema, palpitations, syncope or presyncope. Past Medical History: -- Multivessel CAD, S/P anterior STEMI 03/[2203]. s/p RCA and LAD stenting previously. -- Ischemic CMP, LVEF 30% -- HTN -- Dyslipidemia -- PVD s/p R to L fem-fem bypass, R external iliac stenting -- Scleroderma -- ESRD on HD, s/p renal transplant x2 in [2197], now w/ rejection -- osteoporosis -- hx GI bleed Social History: Lives at home with husband - [Name (NI) 1139] history: Heavy [Name (NI) 1818] ~ [11-27] PPD for > 30 years, quit in [Month (only) 205] - ETOH: Denies - Illicit drugs: Denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: DM, passed away 4 years ago - Father: [Name (NI) ] cancer, died in his 30s Physical Exam: ADMISSION PHYSICAL EXAM VS: Afebrile, BP=118/65 HR= 95 RR=30 O2 sat= 93 GENERAL: In mild respiratory distress but calm. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry mucous membranes. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, JVD 8cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were slightly labored. Crackles on b/l lung fields mid-way up the lung. No wheezes/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+ . DISCHARGE PHYSICAL EXAM Vitals - Tm/Tc: 98.8/98.8 HR:85 BP:89-97/53-56 RR: 02 sat: 95% RA In/Out: Last 24H: 240/anuric Last 8H: Weight: 66.9( ) Tele: SR, rate 60's-80's, few runs of WCT, irregular, unclear if VT vs aberrency, asymptomatic GENERAL: 61 yo F in no acute distress, stitting in chair HEENT: PERRLA, no pharyngeal erythemia, mucous membs dry, no lymphadenopathy, JVP non elevated CHEST: Crackles left base only, no rhonchi or wheezes CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp, no edema. DPs, PTs 2+. NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. gait WNL. SKIN: no rash PSYCH: A/O, pleasant and cooperative Pertinent Results: ADMISSION LABS [2204-9-10] 11:00AM BLOOD WBC-5.0 RBC-2.91* Hgb-8.7* Hct-27.4* MCV-94 MCH-29.8 MCHC-31.7 RDW-15.3 Plt Ct-216 [2204-9-10] 11:00AM BLOOD Neuts-73.0* Lymphs-15.2* Monos-4.7 Eos-6.4* Baso-0.7 [2204-9-10] 11:00AM BLOOD PT-13.7* PTT-28.1 INR(PT)-1.2* [2204-9-10] 11:00AM BLOOD Glucose-159* UreaN-44* Creat-6.6* Na-137 K-4.8 Cl-96 HCO3-27 AnGap-19 [2204-9-10] 11:00AM BLOOD CK-MB-4 proBNP- > [Numeric Identifier ] [2204-9-10] 11:00AM BLOOD cTropnT-0.16* [2204-9-10] 05:56PM BLOOD CK-MB-10 MB Indx-15.4* cTropnT-0.22* [2204-9-11] 04:00AM BLOOD CK-MB-23* MB Indx-16.4* cTropnT-0.75* [2204-9-11] 12:10PM BLOOD CK-MB-14* MB Indx-12.1* cTropnT-0.82* [2204-9-10] 11:00AM BLOOD CK(CPK)-33 [2204-9-10] 05:56PM BLOOD CK(CPK)-65 [2204-9-11] 04:00AM BLOOD CK(CPK)-140 [2204-9-11] 12:10PM BLOOD CK(CPK)-116 [2204-9-11] 04:00AM BLOOD Calcium-9.7 Phos-5.2* Mg-1.8 . DISCHARGE LABS [2204-9-14] 07:01AM BLOOD WBC-5.0 RBC-2.85* Hgb-8.7* Hct-26.1* MCV-92 MCH-30.5 MCHC-33.2 RDW-15.1 Plt Ct-202 [2204-9-13] 05:55AM BLOOD PT-13.2 PTT-32.2 INR(PT)-1.1 [2204-9-14] 07:01AM BLOOD Glucose-191* UreaN-44* Creat-5.2# Na-134 K-4.5 Cl-94 HCO3-28 AnGap-17 [2204-9-14] 07:01AM BLOOD Calcium-10.1 Phos-2.5* Mg-1.8 [2204-9-11] 04:00AM BLOOD tacroFK-4.7* [2204-9-12] 05:35AM BLOOD tacroFK-5.4 [2204-9-12] 11:22AM BLOOD tacroFK-3.9* [2204-9-14] 07:01AM BLOOD tacroFK-4.9 [2204-9-12] 11:22AM BLOOD Fibrino-461* [2204-9-12] 11:22AM BLOOD LD(LDH)-236 TotBili-0.7 DirBili-0.3 IndBili-0.4 [2204-9-12] 11:22AM BLOOD Hapto-216 . MICROBIOLOGY [2204-9-10] MRSA SCREEN: No MRSA isolated . IMAGING [2204-9-10] CHEST (PORTABLE AP): There is bilateral diffuse reticulonodular opacity in the lower lung fields and ground-glass haziness. These findings are compatible with pulmonary edema. Dialysis catheter is in unchanged position with tip seen in the distal SVC/cavoatrial junction. Cluster of calcifications in the right mid lung are unchanged. The aorta is tortuous and calcified. There is mild cardiomegaly. No definite pleural effusions are seen. . [2204-9-11] TTE: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with inferior akinesis and near akinesis of the distal half of the septum and anterior walls. The apex is aneurysmal and akinetic. The remaining segments contract well (LVEF 30%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and extensive regional systolic dysfunction c/w multivessel CAD or other diffuse process. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [2204-6-4], the severity of mitral regurgitation is increased and global left ventricular systolic function is improved with slight decrease in cavity size. Regional left ventricular dysfunction is similar. . [2204-9-11] CHEST (PORTABLE AP): In comparison with the study of [9-10], there has been substantial decrease in the pulmonary [Month/Year (2) 1106] congestion with the pulmonary vessels now only mildly engorged. Minimal atelectatic change is seen at the left base and there may be blunting of the costophrenic angle. Hemodialysis catheter remains in place. Brief Hospital Course: 61 yo F w/ CAD s/p MI (in [2-3]) and previous 2 stents in RCA and LAD, scleroderma, HTN, ESRD on HD s/p transplant x2, and systolic HF (EF 20-25%) who comes in with chronic burning chest pain and acute systolic heart failure. . # Acute Systolic CHF: Patient presented with increased dyspnea and chest x-ray showed pulmonary edema. Physical exam demonstrated rales to mid lung fields. Patient reports increased dyspnea prior to dialysis recently and may need change to dry weight. She had a session of ultrafiltration the night of admission and then a truncated 2-hour session of dialysis the following day. In keeping with her outpatient schedule, the pt went for a full session of dialysis on Wednesday. ECHO showed an EF of 30% and so she was started on metoprolol succinate 25mg qHS, with lisinopril 2.5mg to possibly be started as an outpatient (and to be titrated up as her blood pressure will tolerate it and also to be held on her dialysis days). After her dialysis session, pt's symptoms improved, physical exam demonstrated clear lung fields, and chest xray showed interval improvement in pulmonary edema. . #. Chest Pain/Burning: Pts pain was atypical. Her symptom has bothered her each evening for a very long time, and is exacerbated when she lies on her back. It is thought to be GI related per outpatient providers and will follow up with GI in one week. EKG was without changes, and discomfort resolved on arrival and with subsequent nitroglycerin. Her cardiac enzymes were trended until they peaked. She was put on PPI and carafate, which seemed to provide relief of her pain. . #. ESRD sp transplant on HD: Pt had a session of ultrafiltration on the night of admission and was continued on her outpatient schedule of dialysis, Monday, Wednesday, Friday. Her graft is well-functioning and her tunneled catheter was pulled. She was continued on her home prednisone, cellcept, tacrolimus, and calcitriol. Her tacrolimus levels were within target. The amount of fluid they were able to take off and the length of time spent on dialysis was limited by pt's low blood pressure. She will continue to have 4 hours of dialysis, three times a week, with the next session on Monday and an estimated dry weight of 67.5kg. . # CAD: Pt was continued on her home statin and ASA. . # RHYTHM: Pt was in sinus rhythm, and had no active issues with her rhythm during the admission. She was monitored on telemetry . #. Normocytic Anemia: At recent baseline. Secondary to ESRD. She was continued on Aranesp with dialysis per her outpatient regimen and given 1 unit pRBC with an appropriate increase in her hematocrit. . # HTN: Blood pressure was well controlled on presentation. She was started on metoprolol succinate 25mg qHS, with lisinopril to possibly be started as an outpatient as long as her blood pressure can tolerate it. Her lisinopril should be held on hemodialysis days due to low blood pressures. . # HLD: Pt was continued on her home Lipitor. . TRANSITIONAL ISSUES # Recommend initiating lisinopril 2.5mg daily as an outpatient as long as her blood pressures can tolerate it. This medication should be held on hemodialysis days. STOP taking calcitriol START nephrocaps as a vitamin for your kidneys START pantoprazole twice daily for your heartburn START carafate up to four times per day for your heartburn, do not take this within 1 hour of your other medications START taking Maalox (calcium and simethicone) as needed for your heartburn START Metoprolol at night to lower your heart rate and avoid chest pain. Medications on Admission: - Lipitor 80 mg daily - Aspirin 81 mg daily, - Nitroglycerin sublingual p.r.n. - Calcitriol 0.25 mcg daily - Aranesp - Albuterol MDI p.r.n. - Prednisone 2 mg daily, - Tacrolimus 1 mg b.i.d. - CellCept [Pager number *] mg b.i.d. Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual as directed as needed for chest pain. 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 5. prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day. 7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Maalox Max Quick Dissolve 1,000-60 mg Tablet, Chewable Sig: One (1) tab PO three times a day as needed for heartburn. tab 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day): Do not take within 1 hour of your other medications. Disp:120 Tablet(s)* Refills:2 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 12. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 13. Aranesp (polysorbate) Injection Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Acute on chronic systolic congestive heart failure Ends stage renal disease Coronary artery disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at [Hospital1 18]. You had some chest discomfort that brought you into the hospital. We think that some of this discomfort is because of your stomach and have started you on a new medicine and scheduled an appt with a gastroenterologist on Tuesday [9-18]. At the same time, you had too much fluid in your lungs and we removed a little more fluid with dialysis and adjusted your dialysis medications. Your weight this morning is 150 pounds. This should be considered your new dry weight. Weigh yourself every morning, call your nephrologist if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. You were also anemic and received one unit of blood. Please call Dr. [Last Name (STitle) 171] or [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP[MD Number(3) 37741] have chest pain/burning at home that is worse than the mild chest burning you have experienced for the last few months. You may take Calcium carbonate for this burning, sit up straight in a chair and avoid spicy or acidic foods. . We made the following changes to your medicines: 1. STOP taking calcitriol 2. START nephrocaps as a vitamin for your kidneys 3. START pantoprazole twice daily for your heartburn 4. START carafate up to four times per day for your heartburn, do not take this within 1 hour of your other medications 5. START taking Maalox (calcium and simethicone) as needed for your heartburn 6. START Metoprolol at night to lower your heart rate and avoid chest pain. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [2204-9-25] at 1:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2003], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GASTROENTEROLOGY When: TUESDAY [2204-9-18] at 1:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6970], MD [Telephone/Fax (1) 463] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital3 249] When: TUESDAY [2204-10-9] at 10:20 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1879], M.D. [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 5856, 4280, 412, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6885 }	Medical Text: Admission Date: [2150-11-11] Discharge Date: [2150-11-17] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 30] Chief Complaint: Urinary retention Major Surgical or Invasive Procedure: Foley catheter placement with continuous bladder irrigation History of Present Illness: 89 y/o w/ chronic systolic CHF (EF 35%, s/p 4v CABG in [2132]), DM2 with neuropathy, h/o stroke s/p L ICA stenting, CKD, peripheral and carotid artery disease, and BPH, presents from rehab for inability to void. He was recently discharged from an admission to the CCU for an acute on chronic CHF exacerbation thought to be due to dietary incompliance and underdosing of his home diuretic. He was aggressively diuresed, metoprolol was increased, and he was continued on his home doses of ramipril and digoxin. During the admission, Foley placement was traumatic and resulted in persistent hematuria. The Foley was removed, but hematuria continued prompting replacement of Foley with bladder irrigation. His terazosin was discontinued and tamsulosin and finasteride were started. He was discharged with the Foley to rehab. Two days ago, the Foley was removed, but he failed the voiding trial. The catheter was replaced, but was not draining, thought to be due to presence of blood clots and thus the catheter was removed. He presented to the ED today with a markedly distended bladder with inability to void. Initial ED vitals were: 98.0 62 100/50 20 98%. A 3 way Foley was placed by the ED team with poor urine output. Urology was then consulted who placed a larger bore catheter and irrigated approximately 1L of clotted blood and achieved improved urine output. He was placed on continuous bladder irrigation. Labs were notable for HCT 23 (baseline high 20's to 30's), acute renal failure (Cr 2.1 baseline Cr 1.5-1.8), hyperkalemia (K 6.5) with a newly widened QRS on ECG. He was given 10 units of insulin, 1 amp of D50, and 30gm of kayexalate with repeat ECG showing narrow QRS. Most recent set of vitals: afebrile 80 112/68 100% RA. On arrival to the MICU, he reported feeling much better. His abdominal distention is improved. Feels thirsty. Feels tired and slightly lightheaded after receiving morphine in the ED. Review of systems: (+) Per HPI (-) Denies fever, chills, headache, cough, shortness of breath, chest pain, palpitations. Denies nausea, vomiting, diarrhea, constipation (last BM yesterday), or changes in bowel habits. Past Medical History: 4v CABG (LIMA-LAD, SVG-D1, SVG-OM, SVG-AM in [2132]) Chronic systolic CHF, EF 35% with chronic stable angina Aortic insufficiency DM2 with neuropathy Chronic renal insufficiency hypercholesterolemia Peripheral and carotid artery disease with chronic claudication BPH h/o CVA s/p left ICA stenting Sciatica Anemia Social History: lives with wife who is suffering from [Name (NI) 11964]. Denies alcohol or smoking history. family members present and active in life. Retired worked as a book keeper and accountant. Family History: Mother died of breast Ca [99]'s Father expired from gastric CA [99]'s Brother MI [99]'s Physical Exam: General: Alert, oriented, no acute distress, pleasant HEENT: Sclera anicteric, MMdry, oropharynx clear Neck: supple, JVP flat, no LAD CV: RRR, normal S1 + S2, [4-19] holosystolic murmur at apex, no R/G Lungs: CTAB, no wheezes, rales, ronchi Abdomen: soft, non-tender, mildly distended, NABS, no organomegaly Ext: warm, well perfused, 2+ pulses, no edema Pertinent Results: ADMISSION LABS [2150-11-11] WBC-13.2* RBC-2.69* Hgb-8.1* Hct-23.9* MCV-89 MCH-30.1 MCHC-33.8 RDW-16.3* Plt Ct-288 PT-13.2 PTT-25.7 INR(PT)-1.1 Glucose-298* UreaN-41* Creat-2.1* Na-126* K-6.5* Cl-91* HCO3-25 AnGap-17 Brief Hospital Course: URINARY RETENTION/BLADDER STONES/HEMATURIA: Likely secondary to heavy clotting in the setting of multiple traumatic catheter placements and BPH. Urology placed a 3-way foley catheter with irrigation of approximately 1L of clots. He was placed on continuous bladder irrigation and continued on tamsulosin and finasteride. Unfortunately, after catheter removal he was still retaining urine, so it was replaced pending outpatient urology follow-up. Clopidogrel was stopped on [2150-11-12] due to persistent hematuria; aspirin was continued. ACUTE RENAL FAILURE: Obstructive, resolved HYPERKALEMIA: Related to ARF, resolved. ACUTE BLOOD LOSS ANEMIA: Secondary to hematuria, treated with 3 units of PRBC CORONARY ARTERY DISEASE: Stable, asprin continued, plavix held due to bleeding ISCHEMIC CHRONIC SYSTOLIC HEART FAILURE: Stable HISTORY OF EMBOLIC CVA S/[Initials (NamePattern4) ] [Last Name (NamePattern4) 3098] STENT: Stable DIABETES MELLITUS TYPE II: treated with insulin until renal failure resolved. Medications on Admission: 1. ramipril 2.5 mg daily 2. glyburide 5 mg qHS 3. nitroglycerin PRN chest pain 4. metoprolol succinate 75mg daily 5. ranitidine HCl 150 mg [Hospital1 ] 6. simvastatin 10 mg daily 7. acarbose 25 mg TID 8. albuterol sulfate 90 mcg/Actuation HFA PRN 9. clopidogrel 75 mg daily 10. Aranesp (polysorbate) 100 mcg/0.5 mL q3weeks 11. digoxin 250 mcg every third day 12. torsemide 20 mg daily 13. gabapentin 300 mg qHS 14. tiotropium bromide 18 mcg daily 15. aspirin 81 mg daily 16. cyanocobalamin 1,000 mcg daily 17. polyethylene glycol 17 gram daily PRN 18. Milk of Magnesia PRN 19. finasteride 5 mg daily 20. tamsulosin 0.4 mg qHS Discharge Medications: 1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. 2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acarbose 25 mg Tablet Sig: One (1) Tablet PO three times a day. 4. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual every 15 minutes as needed for chest pain. 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [2-15] puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. Aranesp (polysorbate) 100 mcg/0.5 mL Syringe Sig: One (1) Injection every 3 weeks. 8. digoxin 250 mcg Tablet Sig: One (1) Tablet PO EVERY THIRD DAY (). 9. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 15. Milk of Magnesia Oral 16. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 18. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 19. ramipril 2.5 mg Capsule Sig: One (1) Capsule PO once a day. 20. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day: RESTART MEDICATION ON [2150-11-28]. 21. oxycodone-acetaminophen 2.5-325 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. 22. Instructions Check FSBS TID, [Name6 (MD) 138] covering MD if > 250 Discharge Disposition: Extended Care Facility: [Hospital3 8221] - [Location (un) 583] Discharge Diagnosis: Primary: - Urinary retention - Hematuria - Bladder stones - Acute blood loss anemia - Acute renal failure Secondary: - Anemia of chronic disease - Chronic ischemic systolic heart failure - CAD s/p CABG - CVA s/p ICA stent - Diabetes mellitus type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with urinary retention and hematuria (bloody urine). Urology placed a large catheter and helped to relieve the obstruction. You will need to follow-up with urology for definitive therapy. Given the bleeding you experienced, please STOP clopidogrel (Plavix). This was discussed with your cardiology and neurologist. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [2150-11-18] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SURGICAL SPECIALTIES When: WEDNESDAY [2150-11-18] at 3:30 PM With: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD [Telephone/Fax (1) 164] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: NEUROLOGY When: TUESDAY [2151-9-14] at 1 PM With: [Name6 (MD) ] [Name8 (MD) ], M.D. [Telephone/Fax (1) 2574] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 5849, 4168, 2761, 3572, 2851, 4280, 2767, 496, 4241, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6886 }	Medical Text: Admission Date: [2128-4-13] Discharge Date: [2128-4-19] Date of Birth: [2066-5-10] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1283] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [2128-4-13] - Right Thoracotomy (Minimally Invasive Approach), Redo Mitral [Month/Day/Year ] Replacement (29mm St. [Male First Name (un) 923] Mechanical [Male First Name (un) ]) History of Present Illness: This is a 61-year-old male who had a mitral [Male First Name (un) ] repair done 5 years ago which consisted of an annuloplasty ring trade. He developed severe mitral regurgitation recently and it was recommended that he undergo replacement of his mitral [Male First Name (un) ]. The risks and benefits were explained to him and he has agreed to proceed. Past Medical History: Hyperlipidemia Lower back pain MV Repair [2123] Hernia Repair Social History: Lives with wife. Does not smoke or use alcohol. Family History: Father died of MI at age 40 Physical Exam: 74 Reg BP 120/80 GEN: WDWN in NAD SKIN: Well healed ministernotomy, no C/C/E HEENT: NCAT, PERRL, Anicteric sclera, OP Benign NECK: Supple, No JVD LUNGS: Clear HEART: RRR, Nl S1-S2, II/VI SEM ABD: Benign NEURO: Nonfocal Pertinent Results: [2128-4-16] 05:56AM BLOOD Hct-33.1* [2128-4-15] 05:00AM BLOOD WBC-10.8 RBC-3.67* Hgb-11.2* Hct-32.8* MCV-89 MCH-30.6 MCHC-34.3 RDW-13.0 Plt Ct-176 [2128-4-19] 06:04AM BLOOD PT-23.4* PTT-89.6* INR(PT)-2.3* [2128-4-18] 05:25AM BLOOD UreaN-17 Creat-1.0 K-4.3 [2128-4-13] ECHO PRE CPB: The left atrium is normal in size. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 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. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic [Month/Day/Year ] leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Trace aortic regurgitation is seen. The mitral [Month/Day/Year ] leaflets are mildly thickened. There is moderate/severe mitral [Month/Day/Year ] prolapse. A mitral [Month/Day/Year ] annuloplasty ring is present. There is no systolic anterior motion of the mitral [Month/Day/Year ] leaflets. Severe (4+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The tricuspid [Month/Day/Year ] leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. POST CPB: Well-seated mechanical [Month/Day/Year ] in the mitral position. Trace MR [First Name (Titles) ] [Last Name (Titles) ] discs. Trivial paravalvular or stitch leak that is not visible after protamine administration . AI is trace and verified by Dr. [Last Name (STitle) 3318]. Normal biventricular systolic function on phenylephrine drip. 2+ TR, trace PI as described. [2128-4-14] CXR Endotracheal tube has been removed, but there has been no appreciable change in lung volumes. Moderate degree of atelectasis at both lung bases, more severe on the right, has improved on the left. Upper lungs are clear. Widening of the postoperative cardiomediastinal silhouette has improved. There is no appreciable pleural effusion or any indication of pneumothorax. Right pleural tubes are in standard placements. Tip of the Swan-Ganz catheter projects over the bifurcation of the pulmonary artery. [Last Name (NamePattern4) 4125]ospital Course: Mr. [Known lastname 15716] was admitted to the [Hospital1 18] on [2128-4-13] for elective surgical management of his mitral [Date Range ] regurgitation. He was taken directly to the operating room where he underwent a mini right thoracotomy with a redo mitral [Date Range ] replacement utilizing a 29mm St. [Male First Name (un) 923] mechanical [Male First Name (un) ]. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, Mr. [Known lastname 15716] had awoke neurologically intact and was extubated. His drains were removed and he was transferred to the nursing floor for further recovery. Mr. [Known lastname 15716] was gently diuresed towards his preoperative weight. Heparin as a bridge to Coumadin was started for anticoagulation. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Mr. [Known lastname 15716] was slow to reach a therapeutic INR however by postoperative day six, he was within range. He was thus discharged home and will follow-up With Dr. [Last Name (Prefixes) ], his cardiologist and his primary care physician as an outpatient. On discharge, his wound was clean, dry and intact and his vitals signs were stable. Medications on Admission: Aspirin 81mg Daily Lipitor 20mg daily Lisinopril 5mg daily Toprol XL 37.5mg twice daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:20 Capsule, Sustained Release(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:10 Tablet(s) Refills:0 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Disp:120 Tablet(s) Refills:2 9. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: 7.5 mg on [4-19] & [4-20], then check with Dr.[Name (NI) 41457] office for continued dosing. Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: MR Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions Coumadin to managed buy Dr. [Last Name (STitle) 17863] for a target INR of 2.5-3.5. [Last Name (NamePattern4) 2138]p Instructions: with Dr. [Last Name (STitle) 17863] in [1-16] weeks with Dr. [Last Name (STitle) 109359] in [1-16] weeks with Dr. [Last Name (Prefixes) ] in 4 weeks Completed by:[2128-5-6] ICD9 Codes: 4240, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6887 }	Medical Text: Admission Date: [2169-6-16] Discharge Date: [2169-6-24] Date of Birth: [2105-3-13] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 668] Chief Complaint: Admitted for reversal of colostomy Major Surgical or Invasive Procedure: 1. Exploratory laparotomy 2. takedown of colostomy. History of Present Illness: 64 y/o male who underwent a CABG on [2168-6-17]. His post op course was complicated by a GI bleed, requiring takeback to the OR for ex-lap and sigmoid and rectal resection with creation of end colostomy. He has done well since the time of surgery and is now requesting colostomy reversal. He denies chest pain, shortness of breath. He was recently cleared by cardiology for the procedure. Past Medical History: CAD s/p MI, PTCA/stent to LAD 4 vessel CABG [2168-6-17] c/b: -postoperative Atrial fibrillation s/p cardioversion. -acute cholecystitis s/p perc cholecystostomy and cholecystectomy -pericardial effusion -ventilator associated pneumonia -lower GI bleed s/p IR coiling then s/p rectal resection -g-tube postoperatively CHF Sigmoid and partial rectal resection [2168-6-28] with end colostomy Type 1 IDDM Gastroparesis Rheumatic fever as child OSA Rheumatoid arthritis Chronic LBP BPH GERD Diverticulitis Social History: Married, no tob, EtOH, or drugs. Lives with wife in [Name (NI) 1110]. Quit smoking [2152]. Obese. Family History: CAD Physical Exam: Post Op: VS: 100.9, 121 (sinus tach), 116/60, 28, 97% 4L NC Gen: A+O, MAE Card: RRR Lungs: few crackles Abd: Obese, incision c/d/i, 2 JP bulbs in place Extr: 1+ edema Pertinent Results: POD 1: [2169-6-17] WBC-32.1# RBC-4.23 Hgb-10.5* Hct-33.0* MCV-78* MCH-24.8* MCHC-31.8 RDW-16.8* Plt Ct-231 Glucose-175* UreaN-11 Creat-0.8 Na-137 K-4.4 Cl-108 HCO3-20* AnGap-13 Calcium-7.6* Phos-2.3* Mg-1.8 Brief Hospital Course: 64 y/o male who presented for reversal of his colostomy and also hernia repair. He underwent exploratory laparotomy, takedown of colostomy and ventral hernia repair. He was taken to the OR by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. In summary he underwent a ventral hernia repair as well as succesful reversal of the pre-existing colostomy. He was extubated in the OR. Please see the operative note for surgical detail. He was transferred to the surgical ICU for close mom[Name (NI) ] of blood pressure and blood sugar. He was tachycardic and hypertensive maintained on IV lopressorHe was initially on an insulin drip. He was also started on Levaquin and Flagyl due to the abdominal surgery. Despite the antibiotics he persisted with fevers to 101.2 through POD 3. Blood cultures from [6-17] grew MRSA and a swab taken [Last Name (un) 834] the wound was also MRSA. He was continued on Vancomycin and will continue that for an additional two weeks. Other antibiotics were d/c'd. The abdominal incision was opened and a wound VAC placed on [6-22] (POD 7) The wound is very deep due to patients obese abdomen. He started to defervesce by POD 7 and remained afebrile. He was seen by PT who assessed his needs as amenable to a rehab facility A PICC line was placed on [6-23] for continued requirement for IV antibiotics. Medications on Admission: asa 81, ativan 2mg hs, atorvaastatin 80', combivent, detrol 4mg, ezetimibe 10', folic acid, insulin - lantus 80U am, 30U bedtime, iron, methotrexate 2.5mg', toprol 25', calcium Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed. 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [1-18] Puffs Inhalation Q6H (every 6 hours) as needed. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 13. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 2 weeks. 14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed for line flush. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Ileostomy needed takedown and reanastamosis of intestines. Status post left colonic resection for bleeding. Discharge Condition: stable to rehab Discharge Instructions: Patient requests transfer to [Hospital1 ] [Location (un) 47] for any emergency situation as his primary physicians are affiliated with that institution. Call your doctor or return to the Emergency Department if develop fever 101 or greater, any increased redness or swelling around your incisions, worsening of nausea, you begin vomiting, you are passing significant blood or stool from the rectum or you develop any other concerning symptoms. . Do not drive or drink alcohol while taking narcotic pain medications. Take a stool softener while taking narcotics. . No heavy lifting. Followup Instructions: Please follow-up with Dr. [First Name (STitle) ]. Please call to make an appointment: ([Telephone/Fax (2) 3618]Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 2310], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2169-8-17] 4:30 Completed by:[2169-6-24] ICD9 Codes: 7907, 4280, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6888 }	Medical Text: Admission Date: [2183-2-27] Discharge Date: [2183-3-6] Date of Birth: [2140-11-29] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 26411] Chief Complaint: 41-year-old man who sustained a traumatic injury to the left hand using a wood shaver in [7-6], now with poor tissue coverage over left forearm. Major Surgical or Invasive Procedure: 1. Microvascular transfer of right anterolateral thigh fascia cutaneous flap from the right thigh to the left forearm. 2. Local wound rearrangement, left forearm. 3. Preparation of left forearm recipient site. 4. Neurorrhaphy for sensory input of flap using medial antebrachial cutaneous nerve of left forearm. 5. Split-thickness skin grafting of right thigh donor site. History of Present Illness: Mr. [Known lastname 496] is a 42 year old male that sustained a mangling injury to his left forearm with a wood shaper approximately 2 years ago. He has had multiple reconstructive surgeries on left forearm/hand, and at this point, the primary issue appears to be thinning of skin graft right over the plate that is holding his ulna. Because of impending plate exposure, the decision was made to take him to the operating room for removal of the old skin graft on this area and resurfacing with a full-thickness flap. The additional benefits of this would be subsequent ability to do tendon transfers and possibly to remove the plate and do bone grafting of the ulna. Past Medical History: None Social History: Pt is divorced. Has a son. Was working as a fence maker. Admits to regular ETOH use. Family History: Non-contributory to trauma Physical Exam: Pre-Procedure PE as documented on Anesthesia record [2183-2-27]: General: nad Mental/psych: a/o Airway: as documented in detail on Anesthesia record Dental: good Head/Neck Range of motion: Free range of motion Heart: rrr no M or bruits Lungs: clear to auscultation Extremities: no LE edema, traumatic deformities L hand Other: ruddy complex, anicteric, no thryomeg, no LAD, tatooes entire upper body, 2+ L radial pulse, brisk cap refill, deformed left forearm. Brief Hospital Course: The patient was admitted to the plastic surgery service on [2183-2-27] and had a free anterolat flap from right thigh to left forearm, skin grafting from left frearm to right thigh. The patient tolerated the procedure well. Patient had a wound vac placed to his right thigh skin graft site x 5 days and this was removed on [2183-3-6] by the Plastics team. Right thigh flap donor site/skin graft site appeared clean, without drainage, dark, crimson red in color. Left forearm flap recipient site was maintained in splint continuously s/p surgery and flap was monitored with doppler and manual flap checks per protocol. Vioptix values were also monitored closely. Flap checks and vioptix values remained stable during 5 days of monitoring. . Neuro: Post-operatively, the patient received morphine PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#1. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cephalexin on [2183-3-5]. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay and aspirin as well, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD# 7, the patient was doing well, afebrile with table vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: None Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. Disp:1 Bottle/tube Refills:2 2. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily). Disp:45 Tablet, Chewable(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: Do not exceed 4000mg per day. 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain not controlled by acetaminophen for 7 days. Disp:84 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 79619] homecare Discharge Diagnosis: traumatic injury to the left hand using a wood shaver in [7-6] Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted on [2183-2-27] for a free flap from right thigh to left forearm and local tissue re-arrangement with skin grafting of right thigh & left forearm. Please follow these discharge instructions. . Followup Instructions: -You should continue taking the antibiotics as prescribed. -Elevate your left arm as much as possible and maintain it in a splint. -Please keep your left arm dry - If your left arm begins to worsen after discharge home with an acute increase in swelling or pain, please call the Hand Clinic at the number given and ask to speak with a doctor. -Your right thigh should have a dressing change daily: apply Xeroform over graft site and then a sterile gauze with some tape to secure into place and then an ACE wrap should be applied from top of your knee, over dressing, and up to groin. This maintains some gentle pressure over your skin graft. . Medications: * Resume your regular medications unless instructed otherwise. * You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. * Take prescription pain medications for pain not relieved by tylenol. * Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication to prevent constipation. You may use a different over-the-counter stool softerner if you wish. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. Followup Instructions: Hand Clinic: ([Telephone/Fax (1) 32269] [Hospital Ward Name 516], [Hospital Ward Name 23] Building, [Location (un) ] Please follow up in the Hand Clinic on Tuesday, [2183-3-11]. You must call ([Telephone/Fax (1) 32269] to make an appointment so they know you are coming. The clinic is open from 8-12pm most Tuesdays and you may show up at any time between those hours, despite your formal appointment time. The clinic is located on the [Hospital Ward Name 5074], [Hospital Ward Name 23] Building, [Location (un) ]. Please make sure that you obtain a referral from your insurance company prior to your clinic appointment. Completed by:[2183-3-6] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6889 }	Medical Text: Admission Date: [2191-2-7] Discharge Date: [2191-2-20] Date of Birth: [2137-1-17] Sex: F Service: CHIEF COMPLAINT: Spinal metastases. HISTORY OF THE PRESENT ILLNESS: The patient is a 54-year-old white female with recent new upper lobe mass in the left lung, liver masses, as well as spine metastases seen on the recent MRI. She had several weeks of severe low back pain associated with bilateral lower extremity weakness, left greater than right. She also complained of left shoulder weakness and numbness. She denied any GU or GI incontinence. She was referred for an MRI by her PCP and was found to have multiple vertebral metastases. REVIEW OF SYSTEMS: Positive for chronic shortness of breath times the past two months. On review of systems, the patient denied any fevers, chills, nausea, vomiting, diarrhea. She has a history of constipation. No bright red blood per rectum or melena. The patient does have a decreased appetite, no abdominal pain, no chest pain. Minimal cough. PAST MEDICAL HISTORY: 1. Ovary removal with endometriosis. 2. Status post phyllodes tumor with a wide excision in [2186]. She had a normal mammogram in [2190]. 3. History of oophorectomy. MEDICATIONS ON ADMISSION: 1. Zoloft. 2. Wellbutrin. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: She is a former teacher. She has a 27-year-old son in [Name (NI) ]. Two packs per day since age 18. Two glasses of wine per day. No drug use. FAMILY HISTORY: Notable for a family history of lung cancer in her father. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 96.4, pulse 91. The blood pressure was 164/94, respirations 18, saturating 97% on room air. General: The patient was a pleasant female in no acute distress. Alert and oriented times three. HEENT: The pupils were equal and reactive to light. The extraocular muscles were intact, 3 to 2 mm bilaterally. The neck was supple. Heart: Regular rate and rhythm. Lungs: The lungs were with diffuse wheezing bilaterally. Abdomen: Positive bowel sounds, soft, nontender, nondistended. Extremities: With no edema, clubbing, or cyanosis. Neurological: The patient had cranial nerves II through XII intact, 5/5 strength bilaterally. Sensation grossly intact. LABORATORY DATA UPON ADMISSION: White count 4.6, hematocrit 30.9, platelets 101,000. Sodium 138, K 3.0, chloride 95, bicarbonate 27, BUN 19, creatinine 0.6, glucose 114, calcium 10.7, ALT 171, AST 90, alkaline phosphatase 217, lipase 53, total bilirubin 0.4, free calcium 1.36. HOSPITAL COURSE: The patient had a hospital course which is notable by systems as follows. 1. HEMATOLOGY/ONCOLOGY: The patient is a 54-year-old female with a left upper lobe lung mass with multiple liver and bony metastases in the spine seen by imaging studies over the last month. The ultimate diagnosis of small cell lung cancer was made and the patient had been treated with cisplatin and etoposide. In further detail, the patient had a CT scan on [2191-2-4] of the chest, abdomen, and pelvis. The CT of the chest, abdomen, and pelvis at this time showed a new large mass in the left upper lobe of the lung concerning for lung cancer. There were multiple liver masses concerning for metastatic disease. The lung mass in the upper lobe measured approximately 5 by 10 by 6.5 cm. There was also a precarinal lymph node measuring 13 mm. The patient also had an MR of the cervical lumbar spine. The MR of the cervical and lumbar spine dated [2191-2-6] were notable for diffuse marrow signal abnormalities, indicative of marrow hypoplasia or infiltrative processes. Focal signal abnormalities involving L1, L3, and L4 vertebra were seen consistent with metastatic disease. Degenerative changes in the lumbar spine lesion were noted as well. In regards to the cervical spine, the study was limited since only sagittal T2 images could be obtained because of patient discomfort. This was a limited examination but on a sagittal T2 weighted images of the cervical area, there were no foci or abnormal signal intensities in these regions. Further hematology/oncology workup included a bone marrow biopsy on [2191-2-10]. The bone marrow biopsy showed that the aspirate was almost entirely infiltrated with neoplastic cells with high nucleocytoplasmic ratio. The biopsy slides also showed marrow packed with approximately 90% of the trabecular space infiltrated by malignant cells showing scant amount of cytoplasm. By immunohistochemistry, the cells were diffusely positive for pankeratin and exhibit extremely weak diffuse immunoreactivity for synaptophysin. They were negative for chromogranin. The remaining of the 10% of the space had positive cellularity of 80% with trilineage hematopoiesis and increased M:E ratio. Finally, of note, the patient had her left upper lobe lung biopsy which showed cells consistent with small cell carcinoma. The corresponding bronchial washings obtained with the biopsy were positive for malignant cells consistent with small cell carcinoma. The cells were positive for cytokeratin, very rare tumor cells were positive for chromogranin. The cells were negative for LCA. This was on the bronchial brushings. Since diagnosis, the patient had received chemotherapy with cisplatin and etoposide. The patient received 80 mg per meter squared of cisplatin on day number two and 80 mg per meter squared of etoposide on days one, two, and three. Since the treatment with the chemotherapy, the patient had afterwards become neutropenic with white blood cell count of approximately 0.3. During the hospital course, the patient had received blood cell transfusions with red blood cells. She also had platelet transfusion for low platelets as well. 2. PULMONARY: The patient, during her hospital course, presented with a left upper lobe nodule. During the hospital course, she had episodes of desaturation and hypoxia. Her 02 saturations on [2191-2-7] had gone down to the mid 80s on room air which had improved to the low 90s on nasal cannula. She had a CT angiogram at that time which revealed no evidence of PE; however, the study was somewhat limited due to motion artifact. In addition, the CT angio revealed a large left upper lobe mass and hilar adenopathy which had been seen on previous CTs. The mass almost surrounded the left pulmonary artery, nearly compressing it. In addition, on the CT, there were new patchy bilateral opacities predominantly in the upper lung zones. At this time, the patient was noted to have a temperature to 101.7 and had been started on a ten day course of levofloxacin and clindamycin for the infiltrate and fever. Otherwise, regarding the remainder of the patient's pulmonary course, she had undergone bronchoscopy on [2191-2-9]. The left upper trunk was noted to be occluded with an overlying mucosal abnormality and the lower trunk was significantly narrowed, probably due to extrinsic compression. To the lower trunk was an additional abnormal white nodular area. The valvular segments were patent. The left upper lobe occlusion/mucosal abnormality was brushed. Following the brushing, there was significant bleeding with rapid clot formation of that nodule. At the end of the procedure, the left main stem was almost completely occluded by clot. Given these findings, the patient was transferred to the MICU for further observation. A repeat bronchoscopy showed complete obstruction of the left main stem bronchus with multiple clots. These clots were resectioning the mass completely and included the left upper lobe bronchus. Since then, the patient had been noted to have an increase in shortness of breath and increasing tachypnea with 02 saturations decreasing to the mid 80s on 6 liters which had improved on nonrebreather. Chest x-ray at that time revealed partial clot to the left upper lobe and interstitial involvement of the right lung field. The patient had been transferred to the MICU for further evaluation of her respiratory status. The patient's respiratory status had improved with continuing her treatment of the pneumonia as well as some diuresis. She had an echocardiogram performed at the bedside to further evaluate the etiology of the patient's shortness of breath. The echocardiogram had a left ventricular systolic function low normal at 50-55%, mild 1+ aortic regurgitation, mild 1+ mitral regurgitation. There was mild pulmonary artery systolic hypertension with this study. The patient's pulmonary status had improved during this hospital course and oxygen had been decreased as she had tolerated this. 3. INFECTIOUS DISEASE: The patient is a 54-year-old female who presented during this hospital course on her second day with increasing shortness of breath and new upper lobe infiltrates seen on CT. The infiltrates showed that there were patchy bilateral infiltrates, predominantly in the upper lung zones. There may have been a pulmonary edema; however, given that the patient spiked a fever at this time, the development of the pulmonary infiltrates had developed, she had been started on levofloxacin and clindamycin for a ten day course for treatment of a potential aspiration pneumonia. Otherwise, during this hospital course, the patient's infectious disease status had been notable for the development of herpetic lesions which have been on her lower back. The patient has had these lesions in the past. She had been started on Valtrex for these lesions. The patient had developed thrush in her mouth and had been started on fluconazole for the thrush. After the patient had completed her treatment course with levofloxacin and clindamycin for the pneumonia, she developed a fever to 102.1 on [2191-2-18] in the evening. At this time, the patient had been neutropenic with a white blood cell count of 0.3. For febrile neutropenia, she had been started on cefepime and Flagyl for coverage of febrile neutropenia. At this time, the patient had significant diarrhea associated with this. A chest x-ray at this time revealed the persistent left hilar mass with collapse of the left upper lobe; however, the remainder of the lung fields were well aerated and the opacities previously seen on the right side were not observed and there was interval improvement of the pleural effusion on the left side. Of note, this is a preliminary discharge and will be addended upon the patient's discharge. Dictated By:[Last Name (NamePattern4) 17418] MEDQUIST36 D: [2191-2-20] 02:58 T: [2191-2-20] 15:19 JOB#: [Job Number 17419] ICD9 Codes: 5070
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6890 }	Medical Text: Admission Date: [2142-7-20] Discharge Date: [2142-7-27] Date of Birth: [2065-8-22] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 783] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Bronchoscopy Intubation (prior to admission) Intensive care unit monitoring History of Present Illness: Ms. [Known lastname ] is a 76 yr old woman with h/o HTN, DM, CHF on digoxin, Afib on coumadin, who presented to [Hospital3 ] for altered mental status. Pt was last seen acting normally at 4:30pm, at which time she reported feeling dizzy and went to lay down. Around 7pm, she was found by her husband laying on her right side, moaning and unresponsive. No tremors or bladder or bowel incontinence noted. She was brought by EMS into the OSH ED for evaluation. There she was reportedly nonverbal but combative and received ativan 2mg IV x 2. CT head was negative for intracranial hemorrhage. CXR was significant for a RLQ pneumonia and pt was given levofloxacin 750mg IV. A digoxin level was checked which was elevated to 2.8; K was 5.7. She was given 2 vials of digibind and intubated under succinylcholine with propofol for sedation prior to transport for airway protection due to diminished gag reflex in the setting of altered mental status. ABG 7.4/41/111 on AC 500/12/70%/5. In our ED, VS: T 97.3, HR 41, BP 154/49, O2sat 99% on AC at TV 500, rate 14, PEEP 5, and FiO2 100%. Her CXR showed a sizeable RML infiltrate, and vanco dose given with 500cc NS. EKG showed HR in low 40s. 3 vials of digibind drawn up. Toxicology was consulted and recommended holding further digibind at this time unless pt drops blood pressure as may overcompensate and affect her baseline therapeutic level of digoxin. She was transferred to MICU for monitoring. On the MICU floor, pt report is intubated and sedated. Per her husband, she had no fevers, chills, cough, or shortness of breath suggestive of pneumonia; no choking or coughing with po intake; no recent sick contacts or hospitalizations. Pt eats small meals throughout day; husband did not note any recent change in po intake. She did not complain of any vision changes, N/V, abd pain, diarrhea, headache, confusion, or hallucinations. Of note, was seen in Cardiology clinic the day prior with discontinuation of propanalol and clonidine. Past Medical History: A fib on coumadin Diabetes mellitus Hypertension Congestive heart failiure H/o TIA 15 years ago with sx described as a weak arm and slurred speech. Gout GERD L-TKR Social History: Patient lives with her husband. She is a former manager with [Location (un) 23944] Farms, now retired. H/o 2 cigarettes/wk for "years" but quit years ago. Occasional EtOH. Denies illicit drug use. Family History: Mother with possible CAD Physical Exam: ON ADMISSION GEN: Sedated, occasionally agitated HEENT: NCAT, intubated, mucous membranes dry LUNGS: CTA anteriorly HEART: RRR, S1-S2 nl, II/VI SEM radiating to carotids ABD: BS+, soft, ND, hepatomegaly EXTREM: No edema, pulses 2+ b/l NEURO: PERRL, opens eyes, moves all extremities, withdraws to noxious stimuli. ON DISCHARGE GEN: NAD, pleasant, alert and orientedx4 HEENT: NCAT, PERRL, EOMI LUNGS: CTAB except crackles in right middle lobe, much imporved HEART: RRR, S1-S2 nl, II/VI SEM radiating to carotids, also II/VI systolic murmur at apex ABD: BS+, soft, ND, EXTREM: No edema, pulses 2+ b/l Pertinent Results: Outside Hosptial prior to admission: WBC 17, Plt 264 N 86.7, L 6.8, M 5.1, E 1, Bas 0.4 Na 134, K 5.7, Cl 100, Bicarb 25, BUN 49, Cr 1.9, Gluc 208 AST 55, ALT 46, AP 84, TB 0.6, DB 0.1, TP 9, Alb 4.2 CK 106 Trop T 0.03 ProBNP 2664 TSH 3.61 Ferritin 86.6 Vit B12 1219 Dig 2.83 . [2142-7-20] WBC-14.8# RBC-3.62 Hgb-12.1 Hct-34.7* MCV-96 MCH-33.4* MCHC-34.8 RDW-14.2 Plt Ct-258 Neuts-87.3* Lymphs-8.5* Monos-3.8 Eos-0.2 Baso-0.2 PT-38.2* PTT-34.7 INR(PT)-4.0* Glucose-165* UreaN-49* Creat-1.9* Na-140 K-4.6 Cl-103 HCO3-25 AnGap-17 ALT-40 AST-43* Calcium-9.7 Phos-3.4 Mg-2.3 CK(CPK)-96 CK-MB-NotDone cTropnT-0.02* Lactate-2.8* URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.011 Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG RBC-[4-5]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 Eos-NEGATIVE UreaN-557 Creat-38 Na-86 DISCHARGE LABS [2142-7-27] 05:25AM BLOOD WBC-7.9 RBC-2.87* Hgb-9.3* Hct-27.5* MCV-96 MCH-32.4* MCHC-33.7 RDW-14.2 Plt Ct-335 [2142-7-27] 05:25AM BLOOD Glucose-98 UreaN-31* Creat-1.3* Na-140 K-3.8 Cl-108 HCO3-23 AnGap-13 [2142-7-24] 05:50AM BLOOD proBNP-[Numeric Identifier 23945]* [2142-7-26] 06:34AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.4 [2142-7-24] 05:50AM BLOOD T3-74* Free T4-1.1 [2142-7-23] 06:05AM BLOOD TSH-8.9* [2142-7-23] 06:05AM BLOOD VitB12-GREATER TH . [2142-7-20] 10:47 am Influenza A/B by DFA Source: Nasal swab. DIRECT INFLUENZA A ANTIGEN TEST (Final [2142-7-20]): Negative for Influenza A viral antigen. DIRECT INFLUENZA B ANTIGEN TEST (Final [2142-7-20]): NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN. URINE NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN EKG: Sinus bradycardia with first degree atrio-ventricular conduction delay. Non-specific QRS widening with left axis deviation and diffuse repolarization abnormalities. Compared to the previous tracing of [2141-12-23] cardiac rhythm is now sinus mechanism with A-V conduction delay. CHEST (PORTABLE AP) Study Date of [2142-7-20] 12:52 AM 1. Right perihilar pneumonia or hemorrhage. 2. Left retrocardiac atelectasis or aspiration. 3. Moderate cardiomegaly, without pulmonary edema. KNEE (AP, LAT & OBLIQUE) RIGHT Study Date of [2142-7-22] 2:46 PM The bones are diffusely demineralized. Degenerative changes are present predominantly in the medial compartment where there is joint space narrowing and subchondral sclerosis. Minimal osteophyte formation is also noted in the patellofemoral compartment. No discrete fracture is evident and there is no evidence of dislocation. An equivocal small suprapatellar joint effusion is demonstrated as well as extensive vascular calcifications within the soft tissues. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [2142-7-24] 1:09 AM 1. No PE. 2. Diffuse septal thickening, small bilateral pleural effusions, cardiomegaly, and ground-glass opacities in the dependent portion of the upper and lower lobes. The constellation of findings is most compatible with CHF. 3. Subcentimeter hypodensity in the right lobe of the thyroid, for which further evaluation with ultrasound can be performed on a non-emergent basis. TTE (Complete) Done [2142-7-25] at 1:51:57 PM FINAL The left atrium is moderately dilated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the septum and inferior walls. The remaining segments contract well (LVEF = 30-35 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal with mild global free wall hypokinesis. The ascending aorta and arch are normal in diameter. The aortic valve leaflets (3) are moderately thickened. There is severe aortic valve stenosis (valve area 0.8cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([2-2]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is a no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. Severe aortic valve stenosis. Mild-moderate mitral regurgitation. Brief Hospital Course: 76 yo female with PMH of atrial fibrillation admitted with confusion and found to have digoxin toxicity, pneumonia and acute renal failure. # Digoxin toxicity: Digoxin levels elevated in toxic range with bradycardia and PR prolongation. Likely in setting of hyperkalemia from acute renal failure from dehydration, possibly secondary to pneumonia. No recent medication changes other than discontinuation of propanolol and clonidine, which do not affect the metabolization of digoxin. Patient was monitored on telemetry with frequent EKGs and labs for hyperkalemia. Her EKGs remained stable. She remained hemodynamically stable with gradually improving HRs. Toxicology was consulted and recommended holding off on digibind unless HD unstable or EKGs worsened. This did not occur and no further digibind was given. Digoxin was 1.0 on [7-24] and mental status resolved to baseline. Will defer to outpatient provider regarding restarting digoxin. Once bradycardia resolved patient was restarted on Metoprolol without any unstable hemodynamics. #Hypoxemia. The patients oxygen requirements increased to using a non-rebreather mask on [7-23]. It is likely that this was due to CHF exacerbation (supported by BNP > [Numeric Identifier 389] and findings on CT) as furosemide was being held vs effusions present on CT likely secondary to the pneumonia. PE was initially considered and ruled out by CT angiogram. The patient was gradually diuresed and her respiratory status improved, though this was also likely contributed to by treatment of pneumonia. Discharged on 2-3L/min NC with stable oxygen status to be weaned at nursing facility. # Altered Mental Status: Likely [3-5] digoxin toxicity although may also have delirium in setting of infection. Was intubated at OSH for airway protection, however, after bronchoscopy here (See below) she was extubated without difficulty. CXR notable for large right middle lobe infiltrate concerning for pneumonia. Less likely neuro process; no h/o of seizures, CT head negative for acute changes. Digoxin toxicity and pneumonia were treated as described elsewhere and mental status improved to baseline. # Pneumonia: Large RML (right middle lobe) infiltrate and leukocytosis suggestive of infectious process although patient was afebrile and asymptomatic per husband. [Name (NI) ] likely ventilator-acquired pneumonia vs aspiration from altered mental status. Received levofloxacin and vanco prior to arrival on floor. In setting of digoxin toxicity concern for QT prolongation, she was changed to Azithromycin/Clindamycin due to a PCN allergy. After legionella antigen returned negative, azithro was discontinued. She underwent bronchoscopy and cultures which grew oropharyngeal flora. Blood cultures were negative. On [7-21], she spiked a fever and antibiotics were changed to ceftriaxone. She again spiked on [7-23] and coverage broadened by changing antibiotics to cefipime and vancomycin. She should complete a 8 day course for ventilator associate pneumonia. Vancomycin is being dosed Q24 hours for renal insufficiency but will be monitored at her nursing facility should her renal function improve. # Acute renal failure: Cr elevated above baseline here 1 year ago of 0.9. BUN/Cr ratio suggested prerenal etiology, likely in setting of pneumonia. Creatinine improved with IVF. Renally dosed meds. Held ACE-I. On [7-23], the patient was found to have increased oxygen requirments and was placed on a non-rebreather mask. In the setting of respiratory distress and concern for PE vs decompensated heart failure, the risks of renal insult were outweighed by the need for CT-angio with IV contrast and diuresis. Pt received N-acetylcysteine course and cautious fluid resusitation. Upon discharge, Cr 1.3 and Lisinopril continuing to be held with possible restart at her nursing facility. # CHF - acute on chronic, systolic: Prior TTEs not in system; EF unknown prior to admission but appeared dry here when first admitted and received gentle IVF. Held lasix in setting of dehydration. Also initially held beta blocker and ACE inhibitor as PR prolongation and ARF. When patient developed new O2 requirment, Lasix was restarted for diuresis. TTE obtained at that time revealed AS and EF = 30-35%. Continued to hold ACE inhibitor for hospitalization but beta blocker was restarted and patient was continued on statin, fish oil and ASA. # Atrial Fibrillation: Held digoxin, metoprolol and amiodarone in setting of digoxin toxicity as did not want to contribute to nodal blockade given bradycardia. INR was supratherapeutic on admission and coumadin was held. Warfarin restarted on [7-22] and INR has been therapeutic. Metoprolol was restarted and she remained rate controlled during the rest of her admission. Amiodarone and Digoxin were not restarted. # Hypertension: Held metoprolol and lisinopril as above. Continued amlodipine for BP control. Restarted metoprolol, but contiue to hold lisinopril for ARF. #Aortic stenosis: classified as severe on echocardiogram. Diuresed gently as patient was preload-dependent. Remained hemodynamically stable. Advised to manage as outpatient # Swollen righ knee: Seen by rheumatology, whose assessment was polyarticular gout flare. The joint was aspirated and crystals were noted by Rheum fellow but not in final report. Synovial fluid with neutrophilic infiltrate. Cultures negative. Acute gout flare was treated with indomethacin and colchicine. Indomethacin was discontinued the following day given ARF. The patinet improved and has not complained of joint pain since [7-24]. Colchicine discontinued on [7-27]. Continued home dose of Allopurinol. # Urinary incontinence: Detrol and oxybutynin were discontinued on suspicion that they might contribute to AMS. The patient now reports feeling that she is able to adequately control her bladder, and we will defer to outpatient provider regarding these medications. # History of TIA: No evidence of bleed on OSH CT head. Continued ASA. Therapeutic on warfarin and statin therapy. # Hypothyroid - elevated TSH, T3 low. Patient without clinical signs or symptoms of hypothyroidism. Difficult to evaluate laboratory abnormalities in setting of acute illness and will defer treatment for now and recommend evaluation by PCP. [Name10 (NameIs) ] supplemental medication started. # Thyroid hypodensity: Noted on imaging as described above. This should be followed by PCP for further evaluation and management post-discharge. #Diabetes mellitus type 2. Managed on sliding scale insulin with basal glarigne while holding Metformin. Started home medication metformin the day of discharge as patient was 72 hours after her contrast load. Additionally, should patient Cr worsen to > 1.5 would stop as will poorly cleared. # Code: FULL # Communication: With husband [Name (NI) 401] ([Telephone/Fax (1) 23946]) and son [Name (NI) 4648] ([Telephone/Fax (1) 23947]) Medications on Admission: ASA 81mg daily Allopurinol 100mg daily Amiodarone 200mg daily Amlodipine 10mg daily Atorvastatin 5mg daily Darvocet prn pain Detrol LA 2 mg daily Digoxin 125 mcg Tablet daily Diphenoxylate as needed Fish oil 1g daily Furosemide 80mg daily Lisinopril 40mg daily Metformin 500mg [Hospital1 ] Metoprolol 100mg daily Oxybutynin 5mg [Hospital1 ] Zaroulyn 5mg prn 30 min before lasix Warfarin 2mg qhs Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain: This is a new medication since admission. 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 doses: This medication to be given [2142-7-27] PM. On [2142-7-28] AM patient should start Metoprolol Succinate 100mg daily. 8. Hydrocortisone 1 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for pruritis: This is a new medication since admission. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for dermatitis: This is a new medication since admission. 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for itching: This is a new medication since admission. 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. 13. Cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q24H (every 24 hours) for 4 days. 14. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 4 days. 15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): Start [2142-7-28] AM. 16. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. Insulin Sliding Scale Please see attached insulin sliding scale. Patient was on insulin sliding scale while inpatient while Metformin was being held after a CT scan with contrast. If patient does not require insulin after resumption of her Metformin, this may be discontinued. 19. Supplemental oxygen Patient should have supplemental oxygen via nasal cannula at 2-3L/min or at rate as needed to keep O2 saturation > 92%. Wean as tolerated to room air. Discharge Disposition: Extended Care Facility: Lifecare Center of Attelboro Discharge Diagnosis: Primary: Digoxin toxicity, congestive heart failure (acute on chronic), Pneumonia likely due to aspiration, Acute renal failure, Acute gout flare, altered mental status, delirium, aortic stenosis Secondary: Atrial fibrillation Chronic heart failure (EF 30% to 35%) Discharge Condition: Good. Hemodynamically stable and afebrile. Discharge Instructions: You were admitted to the hospital with confusion and were found to have an elevated digoxin level in your blood. You were also unable to get enough oxygen to your blood and needed to wear a mask. The following changes were made to your medications: 1) STOP digoxin 2) HOLD amiodarone, please discuss with your cardiologist whether to restart this medication 3) START vancomycin and cefepime, to be continued for 4 additional days 4) HOLD lisinopril, this may be restarted while in your nursing facility depending on whether your kidney function returns to baseline 5) Hold Darvocet, Detrol LA 2mg, Diphenoxylate, Oxybutynin until advised to restart them by a physician. Followup Instructions: Please contact your primary care physician and your Cardiologist upon discharge from the skilled nursing facility to schedule follow-up appointments to discuss your recent hospitalization. At these appointments please bring your medication list to discuss any changes. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] ICD9 Codes: 5070, 5849, 2930, 4280, 4019, 2749, 2767, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6891 }	Medical Text: Admission Date: [2118-9-19] Discharge Date: [2118-9-30] Date of Birth: [2057-11-22] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Aortic valve replacement with 19mm St. [Male First Name (un) 923] Mechanical valve, mitral valve ring with a 26mm ring, tricuspid valve ring with a 26mm ring, coronary artery bypass grafting times one (saphenous vein graft to posterior descending artery) [2118-9-20] History of Present Illness: 60 year old female with complex past medical history who has developed progressive and worsening dyspnea and fatigue. Workup revealed single vessel coronary artery disease, moderate to severe mitral regurgitation, moderate tricuspid regurgitation and mild to moderate aortic insufficiency. A nuclear stress test was performed which did not reveal any perfusion defects or myocardial ischemia. Originally it was planned to manage her medically however she has been severely limited by dyspnea with minimal to no exertion and fatigue which classifies her as a grade [2-4] heart failure. Additionally, cardiac cath reveals single vessel Coronary Artery Disease. Given the severity of her symptoms and extent of her disease, she has been referred to Dr. [Last Name (STitle) ] for surgical management. Past Medical History: - Coronary artery disease - Mitral,aortic and tricuspid regurgitation - Likely rheumatic heart disease - Peripheral vascular disease - Atrial fibrillation on dabigatran/Coumadin. Both stopped [2118-8-10] - Hypertension - Diabetes mellitus - Hyperlipidemia - IgA nephropathy s/p DCD kidney transplant in [2111], with subsequent CKD - Osteoporosis - Breast CA ~ [2106]. No radiation. - Hearing Impaired - Varicose veins with history of venous ulcer - Asthma - Kidney Transplant [2111] - Appendectomy - Right thumb surgery - Right Mastectomy Social History: Ms. [Known lastname 31001] [Last Name (Titles) ] tobacco, alcohol or illicit drug use. Family History: Ms. [Known lastname 31002] mother died at 71 from myocardial infarction, her father died at 71 from myocardial infarction, and her brother died at 62 from myocardial infarction. Physical Exam: Pulse: 80 AF Resp: 18 O2 sat: 100% B/P Right: R Mastectomy Left: 102/58 Height: 60" Weight: 122 General: WDWN in NAD Skin: Warm, Dry and intact. Well healed RLQ/Flank scar. HEENT: NCAT, PERRLA, EOMI, sclera anicteric, Neck: Mild JVD, Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: Irregular rate and rhythm, III/VI systolic and I/VI diastolic rumble Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Mild hepatomegally. No frank ascites appreciated. Extremities: Warm [X], well-perfused [X] trace Edema Varicosities: Legs grossly varicosed posteriorly. Vein stripped from left leg below knee. Varicosities noted below knee in both legs and upper groin region. Right thigh appears best area for vein. Neuro: Grossly intact [X] Pulses: Femoral Right:1 Left:1 DP Right:Tr Left:Tr PT [Name (NI) 167]:Tr Left:Tr Radial Right:2 Left:2 Carotid Bruit Transmitted vs. Bruit R>L Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 31003] (Complete) Done [2118-9-20] at 10:12:45 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2057-11-22] Age (years): 60 F Hgt (in): 60 BP (mm Hg): 110/45 Wgt (lb): 110 HR (bpm): 70 BSA (m2): 1.45 m2 Indication: Atrial fibrillation. Coronary artery disease. Mitral valve disease. Valvular heart disease. ICD-9 Codes: 427.31, 786.51, 395.1, 424.1, 396.9, 424.0 Test Information Date/Time: [2118-9-20] at 10:12 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16164], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16164], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW-:2 Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Aorta - Sinus Level: 2.8 cm <= 3.6 cm Aorta - Ascending: 2.2 cm <= 3.4 cm Aorta - Arch: 2.1 cm <= 3.0 cm Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. Dilated coronary sinus (diameter >15mm). LEFT VENTRICLE: Normal LV wall thickness and cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in ascending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Minimal AS. Moderate to severe (3+) AR. MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion. Severe (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PREBYPASS: Normal LV systolic function with LVEF >55%, with no segmental wall motion abnormalities. The left atrium is moderately dilated. The coronary sinus is dilated (diameter >15mm) and left arm contrast is seen entering coronary sinus prior to entering RA confirming persistent left svc. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is a minimally increased gradient consistent with minimal aortic valve stenosis but this is in the setting of decreased LV antegrade stroke volume with severe MR . Moderate to severe (3+) aortic regurgitation is seen. AI jet height/LVOT diameter > 65%, AI vena contracta > 0.6 cm. The mitral valve leaflets are severely thickened/deformed. The mitral valve shows characteristic rheumatic deformity. Severe (4+) mitral regurgitation is seen due type 3a [Last Name (un) 3843] leaflet motion (restricton in both systole and diastole). Moderate to severe [3+] tricuspid regurgitation is seen. Initially the TR was moderate but this changed to severe during the exam (holosystolic hepatic venous flow reversal was initially not present, but this developed during the exam and the vena contracta increased to > 0.7 cm). There is no pericardial effusion. POSTBYPASS: Post Aortic Valve replacement, Mitral Valve repair, Tricuspid Valve repair single vessel CABG on Epi and Milrinone. AV mechanical st-[Male First Name (un) ] valve with good function. TV repair with good result, trace to mild TR with no Tricuspic stenosis. MV with moderate to severe MR following mitral valve annuloplasty ring. No aortic dissection seen after cannula removed. Normal LV systolic function. Normal RV funciton initially post pump, but there was mild RV dysfunction at the end of the exam. Results discussed with the surgical team. [2118-9-30] 05:40AM BLOOD WBC-8.2 RBC-3.63* Hgb-12.0 Hct-36.5 MCV-101* MCH-33.0* MCHC-32.8 RDW-18.7* Plt Ct-478* [2118-9-29] 04:48AM BLOOD WBC-8.2 RBC-3.50* Hgb-11.2* Hct-34.1* MCV-98 MCH-32.0 MCHC-32.8 RDW-17.8* Plt Ct-472* [2118-9-30] 05:40AM BLOOD PT-29.9* INR(PT)-2.9* [2118-9-29] 10:52AM BLOOD PT-26.2* INR(PT)-2.5* [2118-9-28] 02:05AM BLOOD PT-23.9* PTT-40.5* INR(PT)-2.2* [2118-9-27] 02:16AM BLOOD PT-31.3* PTT-45.6* INR(PT)-3.1* [2118-9-26] 04:06AM BLOOD PT-57.8* PTT-45.8* INR(PT)-6.3* [2118-9-26] 02:31AM BLOOD PT-52.1* PTT-46.0* INR(PT)-5.6* [2118-9-25] 05:34AM BLOOD PT-43.8* PTT-43.1* INR(PT)-4.6* [2118-9-24] 07:43PM BLOOD PT-29.2* PTT-41.6* INR(PT)-2.8* [2118-9-24] 10:54AM BLOOD PT-65.1* PTT-55.1* INR(PT)-7.2* [2118-9-24] 09:09AM BLOOD PT-59.0* PTT-52.5* INR(PT)-6.4* [2118-9-23] 03:22AM BLOOD PT-16.7* PTT-32.3 INR(PT)-1.5* [2118-9-22] 01:35AM BLOOD PT-13.2 PTT-27.4 INR(PT)-1.1 [2118-9-30] 05:40AM BLOOD Glucose-125* UreaN-150* Creat-4.7* Na-130* K-4.9 Cl-90* HCO3-24 AnGap-21* [2118-9-29] 04:48AM BLOOD Glucose-97 UreaN-151* Creat-5.5* Na-136 K-4.5 Cl-94* HCO3-23 AnGap-24* [2118-9-28] 02:05AM BLOOD Glucose-76 UreaN-148* Creat-5.5* Na-135 K-4.5 Cl-96 HCO3-24 AnGap-20 Brief Hospital Course: The patient underwent the routine pre-operative work-up. She was found to have a positive urinalysis and was started on Cipro. The patient was brought to the Operating Room on [2118-9-20] where the patient underwent AVR (19mm mechanical), MVr (26mm ring), TVr (26mm ring), CABG x 1 (SVG-PDA) with Dr. [Last Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Anti-coagulation was started with coumadin and Heparin bridge for the mechanical valve. Renal followed for her history of renal transplant. Anti-rejection drugs were resumed. Bactrim was discontinued per the renal team. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. She did develop tachypnea and was transferred to the ICU for Lasix drip. Echo showed small pericardial effusion without evidence of tamponade. She improved with diuresis and was transferred back to the floor. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 10 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [Hospital 31004] Care Center of [Location (un) 1468] in good condition with appropriate follow up instructions. Of note- lung nodule was found on pre-op chest CT and 1 year follow-up is recommended. Medications on Admission: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day AZATHIOPRINE - 50 mg Tablet - one Tablet(s) by mouth once a day DABIGATRAN ETEXILATE [PRADAXA] - (Prescribed by Other Provider) - 150 mg Capsule - 1 Capsule(s) by mouth twice a day LD friday (ON HOLD since [2118-8-10]) DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1 Tablet(s) weekly- wednesdays FENOFIBRATE - 54 mg Tablet - 1 Tablet(s) by mouth once a day INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100 unit/mL Solution - 15 units daily before dinner INSULIN GLARGINE [LANTUS SOLOSTAR] - (Prescribed by Other Provider) - 100 unit/mL (3 mL) Insulin Pen - 30 units qhs CARVEDILOL 50 MG TWICE DAILY LASIX 40 MG DAILY PREDNISONE - (Prescribed by Other Provider) - 1 mg Tablet - 2 Tablet(s) by mouth once a day SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth daily TACROLIMUS [PROGRAF] - (Prescribed by Other Provider) - 0.5 mg Capsule - 1.5 Capsule(s) by mouth twice a day Medications - OTC FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg Elemental Iron) Tablet - 1 Tablet(s) by mouth once a day FISH OIL-DHA-EPA [FISH OIL] - (Prescribed by Other Provider) - 1,200 mg-144 mg Capsule - 1 Capsule(s) by mouth twice a day Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication Mechanical AVR Goal INR 2.5-3.0 First draw [2118-10-1] 2. tramadol 50 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:60 Tablet(s) Refills:0 3. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 4. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Dose to change daily for goal INR 2.5-3.0. 13. aluminum hydroxide gel 600 mg/5 mL Suspension Sig: Five (5) ML PO Q 8H (Every 8 Hours) for 3 days. 14. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 16. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itchy skin. 17. fenofibrate micronized 48 mg Tablet Sig: One (1) Tablet PO daily (). 18. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 19. sodium chloride 0.65 % Aerosol, Spray Sig: [12-5] Sprays Nasal QID (4 times a day) as needed for dry nares . 20. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Outpatient Lab Work check BUN, Cr on [2118-10-6] Results to Dr. [Last Name (STitle) ] Fax: [Telephone/Fax (1) 21335] 22. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): per attached sliding scale. Discharge Disposition: Extended Care Facility: [Hospital 3137] Care Center - [Location (un) 1468] Discharge Diagnosis: Moderate to severe mitral regurgitation. Mild mitral stenosis. Mild to moderate aortic regurgitation. Moderate tricuspid regurgitation. Simple aortic atheroma. Discharge Condition: Alert and oriented x3 nonfocal Deconditioned Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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: [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2118-10-26] 1:15 Cardiologist: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 62] Date/Time:[2118-11-14] 11:30 [Name6 (MD) 2105] [Name8 (MD) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2118-10-14] 10:20 Please call to schedule appointments with your Primary Care Dr.[Last Name (STitle) ],[Location (un) 9655] S. [Telephone/Fax (1) 12071] in [3-8] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication Mechanical AVR Goal INR 2.5-3.0 First draw [2118-10-1] *4mm nodule noted on Chest CT- recommend f/u in 1 year* Completed by:[2118-9-30] ICD9 Codes: 5990, 5849, 2724, 5859, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6892 }	Medical Text: Admission Date: [2178-5-22] Discharge Date: [2178-5-26] Date of Birth: [2105-7-16] Sex: M Service: MEDICINE Allergies: Valium Attending:[First Name3 (LF) 5129] Chief Complaint: Abdominal pain, jaundice and fevers Major Surgical or Invasive Procedure: ERCP History of Present Illness: 72 yo M with DM, A Fib, CAD and CHF admitted with obstructive cholecytsitis with possible cholangitis s/p ERCP with large ampullary clot. . The patient originally presented to [Hospital3 417] Hospital approximately 1 week prior to admission his current admission. At that time he presented with jaundice and abdominal pain. He was found to have elevated LFT's with concern for cholecystitis. He underwent ERCP at that time with sphincterotomy without identification of a clear source of obstruction. Per patient preference, cholecystectomy was delayed for elective removal in the future. The patient re-presented on [2178-5-19] with fevers, jaundice and abdominal pain. He was noted again to have a transaminitis to the 200's with T Bili of 5 and leukocytosis to 11.5. Cultures were sent and he was initiated on amp-sulbactam 3g IV q8h. Repeat ERCP on [2178-5-22] revealed large blood clot at the sphincterotomy site as well as periampullary diverticulum. The patient was transferred for repeat ERCP. He had fevers overnight and was continued on amp-sulbactam and flagyl. The patient went for repeat ERCP today where he was found to have a large clot in the area of his prior sphincterotomy. The clot was snared (75% of clot removed). He received epinephrine and a biliary stent was placed. He is transferred to the ICU out of concern for bleeding and infection risk. . ROS: Notes hematuria. Denies headache, blurry vision, chest pain, shortness of breath, cough, dysuria, black or bloody stools, rash, edema, weight gain. Past Medical History: A. Fib chronic failed maze procedure Porcine AVR 2 years ago diabetes HTN HL CHF CAD s/p cabg and stent last placed [2174] not on plavix. DM Social History: Denies tobacco, EtOH and drugs Family History: non contributory Physical Exam: VS: 69 112/52 19 98% 2L Gen: Jaundiced. No acute distress, comfortable. HEENT: PERRL. CV: Irregularly irregular rhythm. Normal S1 and S2. No M/R/G. Pulm: CTA bialterally. Abd: Soft, nontender, no organomegaly. Bowel sounds present. Ext: No edema. Neuro: A&Ox3. Pertinent Results: Na 140, K 3.9, Cl 102, Bicarb 26, BUN/Cr 28/0.9, glucose 221, Ca 8.5, Mg 1.8, Phos 2.7, WBC 12.5, Hct 33.1, platelets 358. . ALT 241, AST 146, AP 515, T Bili 8.6, Alb 3.1, LDH 187, [Doctor First Name ] 19, Lip 17 . INR 1.3 . EKG ([2178-5-19]): A fib at a rate of approximately 80. Normal axis. QTc 498. Right bundloid pattern. No acute ST or T wave changes. . Micro: Blood culture ([2178-5-22]): [2-27] Enterococcus, vancomycin, ampicillin, PCN G resistant, linezolid sensitive. Blood Culture, Routine (Final [2178-5-25]): ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of streptomycin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R . Imaging: ERCP ([2178-5-23]): Blood clot in the major papilla causing biliary obstruction. Blood clot in the lower third of the common bile duct, the rest of the tree was normal. Papilla was injected. Biliary stent placed. Brief Hospital Course: Mr. [Known lastname 1007] is a 72 yo M with DM, A Fib, CAD and CHF admitted with acute obstructive cholangitis transferred to the MICU s/p ERCP where he was found to have a large obstructive ampullary clot at site of prior sphincterotomy and enterococcus bacteremia. 1) Obstructive cholecystitis/cholangitis - Likely due to obstructive clot at site of recent sphincterotomy. He had ERCP on [5-22] with removal of the blood clot and placement of a biliary stent. Post procedure symptoms now resolved. He had remained afebrile with resolving transaminitis. He was also found to have enterococcus bacteremia likely [12-27] recent ERCP/sphincterotomy which was likely cause of his fevers. He was hypotensive immediately post ERCP but remained hemodynamically stable overnight. He had slight drop in his hematocrit but did not require transfusion or have any evidence of significant blood loss. The patient was transferred to the medical floor where he clinically remained asymptomatic with only only occasional low-grade fevers on unasyn. On the afternoon of [5-25], the sensitivities on the patient's [5-22] blood cxs growing enterococcus faecium returned revealing VRE. The patient's unasyn was discontinued and the patient was started on linezolid. He will complete a 14 day course of linezolid. His citalopram will be held during that time to minimize any risk of serotonin syndrome He will require outpatient cholecystectomy once bacteremia adequately treated and will need repeat ERCP in 4 weeks for stent removal. His coumadin and aspirin are to be held until [2178-5-29] at which time the patient should resume the medications. 2) VRE bacteremia - likely due to recent ERCP/sphincterotomy and biliary obstruction. He was initially treated with unasyn, flagyl and vancomycin but regimen was tapered to unasyn only on [5-24] once blood cultures returned with enterococcus. Regimen changed to linezolid on [5-25]. 3)Atrial fibrillation - his coumadin and aspirin were held on admission due to concern for bleeding and possible re-obstruction of biliary tract. His metoprolol was initially held due to hypotension post procedure but was restarted on [5-24] at 25mg [Hospital1 ] and patient was discharged on home dose. # Hyperlipidemia. Continue statin therapy. . # CHF. EF unavailable currently. . # CAD. S/p CABG and stent placement, not on plavix at home. # DM. Pt d/c'd on home regimen. Medications on Admission: Home Meds: citalopram 10mg daily glipizide 5mg [Hospital1 ] lasix 40mg daily toprol 100mg daily metformin 1000mg [Hospital1 ] gabapentin 100mg tid zocor 40mg daily coumadin 2.5mg daily aspirin 81mg daily glucosamine colace Discharge Disposition: Extended Care Facility: [Hospital3 13990] Health Care Center Discharge Diagnosis: Cholangitis VRE Bacteremia CBD Obstruction secondary to blood clot Porcine AVR A-fib on coumadin Discharge Condition: Vital Signs Stable Afebrile Discharge Instructions: Return to ED if having fevers, chills, sweats, lethargy, abdominal pain, worsening jaundice. 1)Restart coumadin on [2178-5-29]. 2)Patient can restart citalopram 10 mg po qd in 2 weeks after he has finished his antibiotics (Linezolid) 3) Please check fingerstick BS [Hospital1 ]-qid Followup Instructions: Patient to return for repeat ERCP in 4 weeks for CBD stent removal. Patient needs to schedule very close f/u appointment with PCP [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] at [Telephone/Fax (1) 3183] in 2 weeks to monitor clinical status after he completes his linezolid antibiotic course. Patient to schedule f/u for elective cholecystectomy either with [Hospital1 18] surgery clinic or outside surgeon through PCP. ICD9 Codes: 7907, 4280, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6893 }	Medical Text: Admission Date: [2163-5-10] Discharge Date: [2163-6-6] Date of Birth: [2098-2-11] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1781] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: exploratory laparotomy placement of 16mm dacron aortic tube graft placement of PA catheter percutaneous tracheostomy bronchoscopy endoscopy History of Present Illness: 65F with known infrarenal AAA who presents with 4 days of worsening left lower quadrant abdominal pain, radiating to her back & down legs. She denied any fevers, chills, nausea, vomiting, prior episodes, urinary or bowel symptoms. No prior episodes. Past Medical History: CAD s/p CABG [2155] A fib HTN DM2 s/p C section x3 ventral hernia Social History: +cigs, smokes 1 ppd lives with husband, [Name (NI) ], in [Location (un) 11333], MA daughter [Name (NI) ] is health care proxy ([Telephone/Fax (1) 95768]) Family History: noncontrib Physical Exam: Afeb, VSS AOx3, NAD RRR, no bruits CTA bilat Soft obese LLQ>RLQ TTP (no rebound), no CVAT, guaiac neg Pulses: palp throughout Pertinent Results: See carevue for specific results. * * * --RADIOLOGY-- CT ABD W&W/O C [2163-5-10] 9:47 PM CT ABD W&W/O C; CT PELVIS W&W/O C Reason: please eval AAA size, rupture; please also evaluate for kidn Field of view: 42 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 65 year old woman with abdominal pain radiating to back, says she has a known AAA (?size); I suspect renal stone REASON FOR THIS EXAMINATION: please eval AAA size, rupture; please also evaluate for kidney stones CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 65-year-old woman with abdominal pain radiating to back. No abdominal aortic aneurysm. TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis were obtained with and without the administration of IV contrast [Doctor Last Name 360], with CTA technique. No comparison. FINDINGS: Note is made of 5.3-cm infrarenal abdominal aortic aneurysm with mural thrombus, surrounded by hyperdense fat stranding and soft tissue measuring up to 46 [Doctor Last Name ], most likely representing abdominal aortic aneurysm with impending rupture. No definite abscess is identified, however, the possibility of infection cannot be totally excluded. Celiac, SMA, and iliac vessels are patent. No evidence of active extravasation is noted. Left kidney is atrophic, with very small left renal artery. Right kidney is unremarkable. Note is made of fatty liver. No focal liver lesion. The bladder, spleen, pancreas, adrenal glands, and the visualized portions of large and small intestines are within normal limits. No lymphadenopathy. PELVIS: Note is made of sigmoid diverticulosis. Otherwise, the visualized portions of the small intestines are within normal limits. No ascites. No lymphadenopathy. In the visualized portion of the chest, note is made of coronary artery calcification in this patient who is status post CABG. Note is made of 5-mm noncalcified pulmonary nodule in the left lower lobe, which needs to be followed in three months. Note is made of atherosclerotic disease of the thoracoabdominal aorta. There is no suspicious lytic or blastic lesion in skeletal structures. IMPRESSION: 1. 5.3-cm infrarenal abdominal aortic aneurysm with mural thrombus, surrounded by hyperdense soft tissue and fat stranding suggestive of impending rupture with hematoma. No definite abscess is identified, however, superimposed infection cannot be totally excluded. No evidence of active extravasation. 2. Sigmoid diverticulosis. 3. Fatty liver. 4. 5-mm noncalcified pulmonary nodule in left lower lobe. Please follow in three months. The information was discussed with the ED physicians and surgery resident, including Dr. [Last Name (STitle) ] in person at the time of examination, and it was also flagged to ED dashboard. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 7210] [Name (STitle) 7211] [Doctor Last Name 7205] DR. [First Name (STitle) 7204] [Name (STitle) 7205] Approved: WED [2163-5-11] 7:51 AM POST-PYLORIC FEEDING TUBE PLACEMENT UNDER FLUOROSCOPIC GUIDANCE: A 120 cm 8 French [Location (un) 2174]-[Doctor First Name 1557] feeding tube was inserted into the fourth portion of the duodenum under fluoroscopic guidance. The position was confirmed by injection of approximately 10 cc of Gastrografin. No immediate complications were seen. IMPRESSION: Successful post-pyloric feeding tube placement. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [First Name (STitle) 46933] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7832] Approved: SAT [2163-5-28] 6:29 PM Procedure Date:[2163-5-27] * * * --MICROBIOLOGY-- [2163-5-23] 11:17 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [2163-5-23]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [2163-5-26]): OROPHARYNGEAL FLORA ABSENT. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. YEAST. SPARSE GROWTH. SERRATIA MARCESCENS. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. GRAM NEGATIVE ROD(S). SPARSE GROWTH. GRAM NEGATIVE ROD #3. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- 1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S FUNGAL CULTURE (Preliminary): YEAST. [2163-5-23] 10:56 am MRSA SCREEN Site: RECTAL Source: Rectal swab. FINAL REPORT [2163-5-25] MRSA SCREEN (Final [2163-5-25]): NO STAPHYLOCOCCUS AUREUS ISOLATED. [2163-5-23] 10:56 am SWAB Source: Rectal swab. FINAL REPORT [2163-5-26] R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [2163-5-26]): ENTEROCOCCUS SP.. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN------------ =>64 R VANCOMYCIN------------ =>32 R * * * EKG [Known lastname 95769],[Known firstname ] S.: [Hospital1 18] ECG Detail - CCC Record #[Numeric Identifier 95770] ELECTROCARDIOGRAM PERFORMED ON: [2163-5-24] 18:12:04 The rhythm is likely sinus with A-V conduction delay. P-R interval 0.22. There is much baseline artifact. Right bundle-branch block. Low precordial lead voltage. Compared to the previous tracing of [2163-5-17] no diagnostic interim change. Read by: [Last Name (LF) 578],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 579] Intervals Axes Rate PR QRS QT/QTc P QRS T 49 0 138 446/426 0 23 132 Brief Hospital Course: After being diagnosed in the ER with a rupturing AAA, Ms [Known lastname ] was rapidly consented for ex lap & brought emergently to the OR by the vascular team. Please refer to the previosuly dictated op note from [5-10] by Dr. [Last Name (STitle) ] for procedure details. She was then transferred to the Surgical ICU, where she remained for 23 days. This extended ICU course can be summarized in an organ systems based approach. NEURO: Her pain was controlled with fentanyl drips & she was sedated with propofol during her intubation. She moved all extremities soon after surgery & was interactive, although nonverbal bc of her tracheostomy, at the time of discharge. Her pain/sedation regimen currently consists of a fentanyl patch & intermittent roxicet & ativan as needed. CV: She remained hemodynamically stable before being taken to the OR on [5-10]. Postop, she did develop rapid atrial fibrillation, which was controlled with amiodarone and beta blockade. Later postop, she had signficant hypertension & with the assistance of cardiology, was placed [Female First Name (un) ] regimen of prazosin, clonidine, norvasc & intermittent hydralazine. RESP: She developed a postoperative vent-associated pneumonia (serratia), which was successfully treated with 21 days of levaquin. This impaired her ability to vean from the ventilator & on [5-26], she was taken to the OR by thoracic surgery for a percutaneous tracheostomy. She has developed significant coughing episodes when suctioned via her tracheostomy. FEN: She was maredly fluid requiring postop, ultimately reaching about 15kg above her baseline weight (92kg). After treating her penumonia, she was successfully diuresed back to 95kg at the time of discharge. Her creatinine only developed a small rise to 2.0 from postoperative ATN, but normalized to 1.2 at the time of DC. GI: She had a prolonged postoperative ileus & required TPN to sustain her during this time. She was transitioned over to novasource tube feeds once her GI tract was functional. She is currently tolerating tube feedings at a goal rate of 45cc/hr. HEME: She is prophylaxed against DVTs with TID SQ heparin. Her current hematocrit is 28. She required multiple transfusions for her blood loss anemia. ID: pneumonia as above. She also was noted to be VRE by rectal swab on [5-23]. ENDO: Her perioperative blood glucose was tightly controlled via insulin gtt & then sliding scale. Prior to DC, an attempt to restart her oral hypoglycemics resulted in hypoglycemia. She is controlled currently on just sliding scale. Medications on Admission: coumadin 5/7.5 (A fib) aspirin lopressor norvasc enalapril glyburide glucophage lipitor Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 5. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). Disp:qs container Refills:2 6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-13] Drops Ophthalmic PRN (as needed). Disp:qs container Refills:2 7. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). Disp:5 Patch Weekly(s) Refills:2 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Prazosin 5 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 11. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:10 Patch 72HR(s) Refills:2 12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) dose PO DAILY (Daily): 30mg PGT qD. Disp:30 dose Refills:2 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). Disp:90 ML Refills:2 14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:1 inhaler Refills:5 15. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:qs containter Refills:0 16. Docusate Sodium 150 mg/15 mL Liquid Sig: Two (2) teaspoons PO BID (2 times a day). Disp:120 teaspoons Refills:2 17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed for constipation. Disp:30 Suppository(s) Refills:0 18. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:250 ML(s) Refills:0 19. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection every six (6) hours: follow attached sliding scale. Disp:qs ml Refills:2 20. Hydralazine 20 mg/mL Solution Sig: One (1) ML Injection Q4-6H (every 4 to 6 hours) as needed for breakthrough SBP > 160. Disp:50 ML Refills:0 21. Ativan 1 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for anxiety. Disp:30 Tablet(s) Refills:0 22. Roxicet 5-325 mg/5 mL Solution Sig: [12-13] teaspoons PO every six (6) hours as needed for pain. Disp:250 ML Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Hospital1 ] Discharge Diagnosis: hypertension CAD s/p CABG atrial fibrillation type 2 diabetes, controlled ruptured AAA hyperalimentation/TPN vent associated pneumonia postoperative ileus blood loss anemia acute renal failure acute tubular necrosis Discharge Condition: improved Discharge Instructions: Tube feeds via dobhoff as tolerated. Contact your MD if you develop fevers>101, redness or drainage about your wound, or if you have any questions or concerns. Followup Instructions: Contact Dr.[Name (NI) 7257] office at [Telephone/Fax (1) 2395] to arrange a follow up appointment in about 1 month. Completed by:[2163-6-2] ICD9 Codes: 5185, 5845, 2851, 4280, 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6894 }	Medical Text: Admission Date: [2200-10-29] Discharge Date: [2200-11-2] Date of Birth: Sex: Service: HISTORY OF PRESENT ILLNESS: The patient is a 71 year old woman with a history of hypertension, who presented to [Hospital 1474] Hospital the day prior to admission with chest pain. She described the pain as dull, aching, burning and lasting one half hour. She states that the pain is five out of ten associated with nausea and vomiting. The patient denies palpitations, shortness of breath, light-headedness, fever or chills. Electrocardiogram showed left bundle branch block. At the time, there was no old electrocardiogram available for comparison although now it is known that the patient has had left bundle branch block at least since [2193], per report. CKs at the outside hospital were 77 up to 751 with a MB of 176. Troponin I was 2.6. Index was 22.4. Potassium 2.7. Lipid panel from outside hospital was total cholesterol 142, HDL 54. The patient was treated on Aspirin, Nitroglycerin, Metoprolol, normal saline and Enoxaparin and kept overnight. In the morning, she was transferred to [Hospital1 190] pain free on Aspirin, Lovenox, Lopressor, Hydrochlorothiazide, Calor, and Zocor. While in the holding area, a code was called at 7:00 a.m. for ventricular tachycardia arrest. The patient was shocked with 200 joules and converted to normal sinus rhythm. She was immediately taken to catheterization on Lidocaine. The patient had diffuse disease in the left anterior descending including a 30% mid and 40% proximal lesion. Right coronary artery and left circumflex showed no flow limiting disease. Left ventriculogram was not done secondary to ectopy but anterior akinesis and lateral hypokinesis were noted. No interventions were done. The patient was subsequently not started on Heparin, Integrilin or Plavix. PAST MEDICAL HISTORY: 1. Hypertension. 2. Right arm fracture secondary to fall, possibly resulting from arrhythmia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Hydrochlorothiazide 25 mg p.o. twice a day. FAMILY HISTORY: Mother died of stroke. No myocardial infarction history known. SOCIAL HISTORY: No smoking and no alcohol. PHYSICAL EXAMINATION: On admission, heart rate 65, blood pressure 145/56, oxygen saturation 99% in room air. HOSPITAL COURSE: The patient was monitored on telemetry and was found to have runs of nonsustained ventricular tachycardia. An AICD was placed ([Last Name (un) 19961] DR [Last Name (STitle) ] [Name (STitle) 1543], serial #[Serial Number 45049], PJN245896V, TDG028536V). The patient was monitored in the CCU. She received an echocardiogram which showed an ejection fraction of 30% with left to right shunt across the interatrial septum consistent with the presence of a small atrial septal defect. There was severe anteroseptal, apical akinesis and anterolateral hypokinesis. There was trace aortic regurgitation, 2+ mitral regurgitation, 2+ tricuspid regurgitation but no mitral valve prolapse was noted. A mobile echo-dense structure in the right atrium was seen felt to present a Chiari network. The patient's vital signs were monitored closely and Lisinopril and Atenolol were titrated up to adequate levels. The patient was anticoagulated on Heparin drip for her akinesis. Coumadin was started and will be followed up as an outpatient. Liver function tests were checked and were found to be normal. The patient was continued on Simvastatin. Of note, the patient did receive Vancomycin one gram intravenously times six doses periprocedure. The patient's cardiac status was felt to be stable and she displayed no further runs of ventricular tachycardia. Occupational therapy was consulted as the patient's right arm is broken and in a cast and her left arm is in a sling. They had concerns about the patient maintaining precautions and ability to carry on activities of daily living and home management. The patient does have supportive family members nearby. However, occupational therapy strongly recommended home occupational therapy. Unfortunately, the patient and her husband refused to have "strangers" come to the house. Therefore, no home occupational therapy or VNA is set up for the patient at this time. FOLLOW-UP: The patient is to follow-up with the patient's primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ] [Name (STitle) 17996], telephone [Telephone/Fax (1) 29354], fax [Telephone/Fax (1) 45050], within a week of discharge. Her INR will be checked the Tuesday after discharge and will be faxed to his office. In addition, the patient has an appointment at Device Clinic on [2200-11-5]. Dr. [Last Name (STitle) ] will be the patient's cardiologist and will call her for follow-up appointment. DISCHARGE DIAGNOSES: 1. Status post inferior myocardial infarction. 2. Ejection fraction 30% with anteroseptal and apical akinesis and anterolateral hypokinesis. 3. Coronary artery disease with 30% mid and 40% proximal left anterior descending lesion per catheterization on [2200-10-30]. 4. Ventricular tachycardia arrest. 5. Status post AICD placement. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. once daily. 2. Nitroglycerin sublingual p.r.n. 3. Simvastatin 10 mg p.o. once daily. 4. Coumadin 5 mg p.o. q.h.s. (to be followed by primary care physician). 5. Atenolol 50 mg p.o. once daily. 6. Lisinopril 40 mg p.o. once daily. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-255 Dictated By:[Last Name (NamePattern1) 42053] MEDQUIST36 D: [2200-11-2] 13:20 T: [2200-11-2] 14:15 JOB#: [Job Number 45051] ICD9 Codes: 4271, 4275, 4240, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6895 }	Medical Text: Admission Date: [2136-1-15] [Year/Month/Day ] Date: [2136-1-25] Date of Birth: [2064-2-24] Sex: F Service: MEDICINE Allergies: Streptomycin / Versed / Fentanyl Attending:[First Name3 (LF) 689] Chief Complaint: back pain Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: 71 YO Russian-speaking F with recent admission for LBP presenting with LBP and chest pain (similar to her last admission. LBP: [10-14], sharp, mid-right side of back and down her legs. Nothing makes it better or worse. Tried tylenol and did not help much. It is constant. No loss of bowel or bladder function. H/o of recent diarrhea. No leg weakness, no recent trauma. Has had this problem for 2 years, but in the past couple of months has gotten worse. MRI performed in [3-13] showed No evidence of cord compression or cord signal abnormality abd multiple vertebral body compression fractures, none of which appear acute CP is left breast radiating to back and right side, [7-14], sharp and has gotten better with percocet. No ekg changes noted and patient states she has had this pain before. last admission, not found to be cardiac. p-Mibi done in [10-13] showed normal cardiac perfusion. . Initial VS in the ED: 98 67 128/78 14 100%. Was tachypneic on exam. CXR and BNP elevated. Given percocet, asa and lasix. Baseline anemia and chronic renal failure. VS upon transfer: 120/61 72 97% 2L 15. Pt reports she wears 2L O2 at home for sleep. . . 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 palpitations. Denied nausea, vomiting, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias Past Medical History: 1. Atrial fibrillation 2. Hypertension 3. Dyslipidemia 4. Obstructive sleep apnea with secondary pulmonary HTN 5. Chronic diastolic heart failure 6. Type 2 Diabetes Mellitus - [2135-1-31] HbA1c 7.9 7. Chronic Renal Failure 8. S/p lap appy ([9-11]) 9. Diabetic neuropathy 10. Osteoporosis 11. h/o cataract surgery Social History: Home: lives with her husband Occupation: EtOH: Denies Drugs: Denies Tobacco: Denies Family History: non-contributory. Physical Exam: Vitals: T: 95.5 BP: 100/62 P: 64 R: 16 O2: 99% 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN 2-12 intact/ 5/5 strength in BUE/BLE, sensation in tact M/S: TTP in middle right back Pertinent Results: Admission Labs: [2136-1-15] 02:46AM PT-39.2* PTT-31.0 INR(PT)-4.1* [2136-1-15] 02:19AM GLUCOSE-310* UREA N-22* CREAT-1.4* SODIUM-135 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-30 ANION GAP-10 [2136-1-15] 02:19AM estGFR-Using this [2136-1-15] 02:19AM cTropnT-<0.01 [2136-1-15] 02:19AM proBNP-1545* [2136-1-15] 02:19AM WBC-8.7 RBC-3.43* HGB-8.5* HCT-30.0* MCV-88 MCH-24.8* MCHC-28.3* RDW-16.8* [2136-1-15] 02:19AM NEUTS-76.3* LYMPHS-17.6* MONOS-4.6 EOS-1.2 BASOS-0.3 [2136-1-15] 02:19AM PLT COUNT-193 CXR: IMPRESSION: 1. Cardiomegaly, with mild fluid overload. 2. Stable multiple compression deformities of the thoracolumbar spine T spine/L spine: pending Brief Hospital Course: Assessment and Plan: 71 yo F h/o LBP with compression fractures presenting with 10/10 back pain. . # Lower Back Pain: Likely related to compression fractures as seen on x-ray. Initially admitted for pain control. Given her serious allergies, she was not given strong pain medication. She was given acetaminophen, lidocaine [Last Name (LF) 18539], [First Name3 (LF) ] gay and 25 mg of ultram every six hours as needed. This appeared to moderately control her pain. On the first night of admission, she was started on Gabapentin 300 mg given this may be related to neuropathic pain. The following morning, the patient appeared confused and at times lethargic. An ABG showed patient had hypercapnic respiratory failure. Patient with known history of OSA with pulmonary hypertension. Patient stated on admission she did not use CPAP at night, but on further questioning with family the following day, she does use this machine. It was felt that the combination of not using CPAP the night prior and possibly Gabapentin could have contributed to this event. She was transferred to the MICU for BiPAP. During her MICU course, she developed fever and found to have Moraxella pneumonia confirmed by sputum culture. She was started on levofloxacin. Her respiratory status improved, she was weaned off of BiPAP and transferred back to the medical floor. She continued to use CPAP at night and did not have further episodes of this. # Atrial Fibrillation: Patient was noted to have three episodes of afib with RVR to 150s. Each time she was given 10 mg IV dilt x 2 which broke her fast rate. Diltiazem was uptitrated to 90 mg [First Name3 (LF) ]. She was noted the night of this uptitration to have brief rates into the 20s-30s. She was asymptomatic and asleep during these episodes. Upon waking, her HR improved. Since her heart rate ranged from bradycardia to tachycardia, and a concern for further intervention may need to be pursued EP was consulted. It was felt no intervention should be done during this hospitalization, since she does have an active infection. She was continued on metoprolol and diltiazem, and will follow up closely with Dr. [Last Name (STitle) 171] in the outpatient. She was noted to have a supratherapeutic INR (4.1) and coumadin was held while until her INR was at goal. Of note, she became subtherapeutic to 1.8 [1-19], but once warfarin was restarted, she became therapeutic throughout the rest of the hospitalization. # Acute on Chronic diastolic CHF: Upon ambulation her O2sats would decrease to 88% on Room air. Crackles notable on exam and chest x-ray consistent with marked pulmonary edema. This was felt due diastolic dysfunction. This may have been exacerbated in the setting of afib with RVR. Her home lasix dosage was increased to 80 [Hospital1 ] and she would intermittently receive 80 IV lasix to help with further diuresis. Upon [Hospital1 ] she was breathing at room air in the mid-90s and upon ambulation saturate 90% on room air. She was felt to be euvolemic. # Acute on Chronic Kidney Disease: With aggressive diuresis, her creatinine increased to 1.8, but upon [Hospital1 ] decreased to 1.3, which is in her baseline range. # DMT2: continue 70/30 40 units q AM and 25 units q hs plus HISS. Glipizide was held while inpatient, but restarted upon [Hospital1 ]. # HTN: Stable. Continued metoprolol and diltiazem as above. # Hypothyroidism: Continued levothyroxine. # HLD: Continued lipitor and fenofibrate. Medications on Admission: Lipitor 10 mg q.d., omeprazole 20 mg q.d., levothyroxine 100 mcg p.o. q.d., amitriptyline 10 mg 2 tablets at h.s., folic acid 1 mg p.o. q.d., fenofibrate 145 mg p.o. q.d., Coumadin 5 mg q.d., Lasix 80 mg q.d., Toprol-XL 50 mg 2 tablets q.d., Cartia XT 240 mg p.o. q.d., glipizide 5 mg 2 tablets b.i.d., Humulin insulin 70/30 40 units q.a.m. and 25 units at h.s. Senna and Colace are on hold. [Hospital1 ] Medications: 1. Methyl Salicylate-Menthol Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for Back Pain. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Tramadol 50 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for to back. Disp:12 Adhesive Patch, Medicated(s) Refills:0 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for back pain: Do not exceed more than 4 grams in 24 hours. 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 11. Fenofibrate Nanocrystallized 145 mg Tablet Sig: One (1) Tablet PO once a day. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: One (1) Subcutaneous twice a day: 40 Units q AM and 25 Units q HS. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 17. Diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO q AM. Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 18. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 [Hospital1 ] Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services [Hospital1 ] Diagnosis: Primary: Pneumonia Lower Back Pain Atrial Fibrillation Obstructive Sleep Apnea Acute on Chronic Diastolic Heart Failure Secondary: Diabetes Type 2 Hypertension Hyperlipidemia [Hospital1 ] Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent [Hospital1 ] Instructions: You were initially admitted because you were having lower back pain. You were pain controlled with Tylenol, lidocaine [Hospital1 18539], and very small doses of ultram. Due to your allergies, you are limited to what you can take for pain. You felt this regimen helped your pain. During your hospitalization, you were having difficulty breathing. You were transferred to the intensive care unit for BiPaP. This helped your breathing. You were found to have Pneumonia. Your difficulty breathing was likely due to a combination of things: Not using your CPAP machine for one night prior, an infection in your lungs, some fluid overload meaning blood backing into your lungs from your heart, and possibly a sedating medications for pain that was given to you, Gabapentin. To solve these problems, you used your CPAP every night while in the hospital. You were given antibiotics for your lung infection. You were given lasix through your veins to remove some of the excess fluid in your lungs, and you were not given Gabapentin any more while in the hospital. Your breathing improved. You also had episodes where your heart rate would become very fast (into the 150s-160s). This is due to your atrial fibrillation. Sometimes, with atrial fibrillation, your heart rate can get very fast. You were given IV Diltiazem to slow your heart rate. Since this occurred repeatedly, we increased your diltiazem to a higher dosage. We asked Dr.[Name (NI) 5103] colleagues to evaluate your heart rate and it was felt you should continue these medications and follow up with your cardiologist in the outpatient. Your appointments are below. Since you continued to need oxygen during the day to breathe. We repeated a chest x-ray that showed you had a lot of fluid in your lungs. This is from your congestive heart failure. We gave you more lasix through the IV to get rid of the extra fluid in your lungs and your breathing improved. We increased your home lasix dose to 80 mg twice a day. You will follow up with your primary care doctor for further management of this medication. On your last day of [Name (NI) ], upon walking your oxygen level was 89-90% on Room air. Your weight on the day of [Name (NI) ] is 86.9 kg (191 lbs). This is very close to your "dry weight." This information is very important for your cardiologist and primary doctor to know. you should tell them this when you see them. Your Medication changes include: 1. Diltiazem XR 360 mg daily to be taken every morning. (This is an increase from your home dosage of 240 mg daily) 2. Ultram 25-50 mg to be taken once every 6 hours as needed for pain. 3. Lasix 80 mg to be taken twice a day. (This is an increase from your home medication of lasix 80 mg once a day) You should contact your primary care doctor or go directly to the emergency room if you experience shortness of breath, chest pain, a very fast heart rate, severe back pain, inability to walk or any other symptom that is concerning to you. Followup Instructions: Your follow up appointments are scheduled below: Appointment #1: PRIMARY CARE: MD: Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8682] Date/ Time: Thursday, [1-26] at 10:45am Location: [Street Address(2) 3375], [Location (un) ], MA Phone number: [Telephone/Fax (1) 133] Special instructions for patient: This appt was already scheduled for follow up for your [2136-1-10] visit with Dr [Last Name (STitle) 8682]. Be sure to discuss your hospital stay. Appointment #2: CARDIOLOGY Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2136-2-13] 1:40 Appointment #3: SLEEP/PULMONARY MEDICINE Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ]/DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time: [2136-2-7] 10:00 ICD9 Codes: 5849, 2762, 4280, 3572, 2724, 4168, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6896 }	Medical Text: Admission Date: [2187-10-28] Discharge Date: [2187-11-13] Date of Birth: [2117-5-28] Sex: F Service: SURGERY Allergies: Bactrim / Amoxicillin / Iodine; Iodine Containing Attending:[First Name3 (LF) 5880] Chief Complaint: Abdominal wound infection Major Surgical or Invasive Procedure: [2187-10-31] Exploratory laparotomy; repair of gastric perforation; chest tube insertion History of Present Illness: 70-year-old female who had had undergone a splenectomy for massive splenomegaly 3 weeks ago. She returned with a smoldering abdominal wound infection and illness; gastric juice pouring out of the wound. She was admitted for evaluation and exploratin of her wound. Past Medical History: -splenomegaly--as above. -cholecystectomy -ventral and inguinal hernia repair -Hypertension -Atrial fibrillation -Chronic UTI -Anemia -Ovarian cysts -Appendectomy -TAH-BSO . Allergies: IV contrast, Bactrim, PCN Social History: SH: Married, works as a director of religious education for a Catholic organization. No alcohol, tobacco or drugs. Family History: HTN Pertinent Results: [2187-10-28] 07:05PM CALCIUM-8.7 PHOSPHATE-4.2 [2187-10-28] 07:05PM WBC-20.3* RBC-2.65* HGB-7.7* HCT-26.0* MCV-98 MCH-28.9 MCHC-29.5* RDW-20.5* [2187-10-28] 02:30PM ALT(SGPT)-14 AST(SGOT)-10 ALK PHOS-158* AMYLASE-41 TOT BILI-1.5 [2187-10-28] 02:30PM cTropnT-<0.01 [2187-10-28] 02:30PM ALBUMIN-2.4* CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-2.4 [2187-10-28] 02:30PM PLT COUNT-650* [2187-10-28] 02:27PM GLUCOSE-317* LACTATE-2.5* NA+-134* K+-5.4* CL--97* TCO2-28 [2187-11-10] UNILAT UP EXT VEINS US LEFT LEFT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler examination of the left internal jugular vein, axillary vein, basilic vein and cephalic veins were performed. The left cephalic vein is distended, non-compressible, with hypoechoic intraluminal thrombus, and no flow. The left internal jugular vein, axillary vein, and basilic veins demonstrate normal compressibility, augmentability and respiratory variation and flow. IMPRESSION: Thrombosis of the left cephalic vein, likely acute. CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: eval for possible leakplease give oral contrast & infuse con [Hospital 93] MEDICAL CONDITION: 70 y/o female s/p open splenectomy with copious drainage from abdominal wound REASON FOR THIS EXAMINATION: eval for possible leakplease give oral contrast & infuse contrast into the 2 abdominal drains CONTRAINDICATIONS for IV CONTRAST: None. [2187-11-8] CT OF THE ABDOMEN AND PELVIS WITHOUT CONTRAST: IMPRESSION: 1. Bilateral pleural effusions. The right pleural effusion has increased in size since the prior study. 2. Overall, marked improvement in previously seen amount of gas and fluid in the upper abdomen, now with expected post-surgical changes. Streak artifact from the residual high- density barium in the stomach and proximal small bowel makes it difficult to determine whether the oral contrast is within or immediately adjacent to the bowel lumen. 3. No frank contrast extravasation and no free intraperitoenal air is seen. 4. Stable right groin hematoma. Cardiology Report ECG Study Date of [2187-11-2] 1:05:50 AM Baseline artifact. Atrial fibrillation with an average ventricular response about 95 per minute. Relatively low voltage diffusely. Non-specific ST-T wave changes. Compared to the previous tracing of [2187-10-30] atrial fibrillation is now seen. Clinical correlation is suggested. Intervals Axes Rate PR QRS QT/QTc P QRS T 95 0 96 350/411 0 64 0 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2187-11-13] 08:50AM 13.371 2.65 7.7* 25.1* 95 29.2 30.9* 18.8* 970* Source: Line-PICC 1 VERIFIED [2187-11-12] 03:01AM 15.141 2.52 7.1* 24.0* 96 28.4 29.7* 19.0* 8462 Source: Line-PICC 1 VERIFIED 2 FEW CLUMPS SEEN [2187-11-11] 04:04AM 20.3 2.70* 7.8* 25.7* 95 28.7 30.1* 18.7* 770* Source: Line-Rt PICC [2187-11-10] 02:47AM 18.11 2.56 7.4* 24.2* 95 28.9 30.5* 18.4* 705* Source: Line-PICC 1 CHECKED FOR NRBC [2187-11-9] 03:24AM 20.81 2.75 7.8* 25.8* 94 28.6 30.5* 18.0* 676* Source: Line-Right PICC 1 CHECKED FOR NRBCS [2187-11-8] 04:30AM 18.11 2.97 8.4* 27.3* 92 28.4 30.8* 17.8* 610* Source: Line-PICC 1 VERIFIED BY SMEAR CHECKED FOR NRBC'S [2187-11-7] 04:27AM 22.4* 3.25# 9.5# 29.9# 92 29.1 31.6 18.0 633* Source: Line-CVL [2187-11-6] 04:04AM 20.81 2.34 6.4* 21.5* 92 27.5 30.0* 18.9* 640* Source: Line-Left CVL 1 VERIFIED BY SMEAR [2187-11-5] 02:02AM 22.71 2.51 7.1* 22.9* 91 28.1 30.9* 18.8* 559* Source: Line-CVL 1 CHECKED FOR NRBC'S [2187-11-4] 04:40AM 22.0* 2.62* 7.3* 24.2* 92 28.0 30.3* 18.8* 563* Source: Line-triple lumen [2187-11-3] 04:37PM 18.7* 2.69* 7.5* 24.6* 92 27.9 30.5* 19.1* 547* Source: Line-CVL [2187-11-3] 05:35AM 18.01 2.51 7.3* 23.6* 94 29.0 30.8* 19.5* 546* Source: Line-triple lumen 1 VERIFIED BY SMEAR [2187-11-2] 03:03AM 28.901 2.73 7.9* 24.9* 91 29.0 31.8 19.5* 454* Source: Line-arterial 1 CHECKED FOR NRBCS [2187-11-1] 04:38AM 23.51 3.48 10.0* 31.2* 90 28.8 32.1 19.5* 536* 1 CHECKED FOR NRBCS [2187-11-1] 01:38AM 19.91 3.30# 9.6# 29.7# 90#2 29.0 32.2 19.3* 499* Source: Line-aline 1 CHECKED FOR NRBCS 2 VERIFIED [2187-10-30] 09:25PM 13.3* 2.29* 6.5* 22.2* 97 28.5 29.5* 20.3* 648* [2187-10-30] 05:35AM 11.51 2.23 6.6* 22.5* 101* 29.6 29.3* 21.0* 640* 1 VERIFIED [2187-10-29] 04:09AM 19.4* 2.45* 7.1* 24.5* 100* 28.8 28.8* 20.8* 606* [2187-10-28] 07:05PM 20.31 2.65 7.7* 26.0* 98 28.9 29.5* 20.5* 724* 1 VERIFIED BY SMEAR [2187-10-28] 02:30PM 17.81 2.64 7.7* 26.5* 100.2#2 29.3 29.2 20.7* 650* 1 VERIFIED BY SMEAR 2 ID CHECKED DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [2187-11-13] 08:50AM 88* 0 4* 4 4 0 0 0 0 Source: Line-PICC RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [2187-11-13] 08:50AM 1+ 2+ NORMAL 2+ NORMAL NORMAL Source: Line-PICC BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [2187-11-13] 08:50AM VERY HIGH 970* Source: Line-PICC BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [2187-11-1] 01:38AM 346# Source: Line-aline Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2187-11-12] 03:01AM 174* 29* 0.8 135 4.4 105 22 12 Source: Line-PICC ESTIMATED GFR (MDRD CALCULATION) estGFR [2187-11-12] 03:01AM Using this1 Source: Line-PICC 1 Using this patient's age, gender, and serum creatinine value of 0.8, Estimated GFR = 71 if non African-American (mL/min/1.73 m2) Estimated GFR = >75 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2187-11-10] 03:20PM 8 21 832* 153* 31 0.9 Source: Line-picc OTHER ENZYMES & BILIRUBINS Lipase [2187-11-10] 03:20PM 30 Source: Line-picc CPK ISOENZYMES CK-MB cTropnT [2187-10-30] 09:25PM NotDone1 0.022 1 NotDone CK-MB NOT PERFORMED, TOTAL CK < 100 2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI [2187-10-30] 07:20PM NotDone1 0.012 1 NotDone CK-MB NOT PERFORMED, TOTAL CK < 100 2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI [2187-10-30] 10:25AM NotDone1 0.042 SAMPLE MODERATELY HEMOLYZED 1 NotDone CK-MB NOT PERFORMED, TOTAL CK < 100 2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron Cholest [2187-11-12] 03:01AM 7.6* 3.9 2.1 Source: Line-PICC HEMATOLOGIC calTIBC Ferritn TRF [2187-11-10] 03:20PM 169* 1084* 130* Source: Line-picc LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc [2187-11-3] 11:45AM 86 771 23 3.7 48 Source: Line-cvl 1 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE ANTIBIOTICS Vanco [2187-11-6] 04:04AM 23.81 Source: Line-Left CVL 1 UPDATED REFERENCE RANGE AS OF [2186-9-27] == REPRESENTS THERAPEUTIC TROUGH LAB USE ONLY HoldBLu [2187-10-28] 02:30PM HOLD1 1 HOLD DISCARD GREATER THAN 24 HRS OLD Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS [2187-11-1] 01:51AM ART 139 41 7.41 27 1 WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl calHCO3 [2187-11-1] 01:51AM 1.8 HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT [2187-10-28] 02:27PM 7.9* 24 CALCIUM freeCa [2187-11-1] 01:51AM 1.07* Blood Urine CSF Other Fluid Microbiology Recent Last Day Last Week Last 30 Days All Results Hide Comments From Date To Date Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2187-11-13] 08:50AM 13.371 2.65 7.7* 25.1* 95 29.2 30.9* 18.8* 970* Source: Line-PICC 1 VERIFIED DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [2187-11-13] 08:50AM 88* 0 4* 4 4 0 0 0 0 Source: Line-PICC RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [2187-11-13] 08:50AM 1+ 2+ NORMAL 2+ NORMAL NORMAL Source: Line-PICC BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [2187-11-13] 08:50AM VERY HIGH 970* Source: Line-PICC BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [2187-11-1] 01:38AM 346# Source: Line-aline Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2187-11-12] 03:01AM 174* 29* 0.8 135 4.4 105 22 12 Source: Line-PICC [2187-11-11] 04:04AM 67* 32* 0.8 139 4.5 108 23 13 Source: Line-Rt PICC [2187-11-10] 02:47AM 137* 38* 0.7 139 4.0 108 23 12 Source: Line-PICC [2187-11-9] 03:24AM 95 40* 0.8 140 4.4 108 26 10 Source: Line-Right PICC [2187-11-8] 04:30AM 79 43* 0.9 140 4.1 107 28 9 Source: Line-PICC [2187-11-7] 04:27AM 99 39* 0.9 140 3.8 103 32 9 Source: Line-CVL [2187-11-6] 04:04AM 50* 34* 0.8 139 3.5 102 35* 6* Source: Line-Left CVL [2187-11-5] 02:02AM 60* 31* 0.8 137 3.6 99 33* 9 Source: Line-CVL [2187-11-4] 04:40AM 108* 27* 0.8 136 4.0 100 31 9 Source: Line-triple lumen [2187-11-3] 05:35AM 170* 22* 0.8 135 4.7 103 29 8 Source: Line-triple lumen [2187-11-2] 03:03AM 85 18 0.8 135 4.4 103 26 10 Source: Line-arterial [2187-11-1] 04:38AM 188* 17 0.7 137 4.3 104 24 13 [2187-11-1] 01:38AM 188* 16 0.7 136 4.3 103 24 13 Source: Line-aline [2187-10-30] 09:25PM 186* 19 0.9 134 4.8 100 27 12 [2187-10-29] 04:09AM 82 18 0.7 134 4.7 103 23 13 [2187-10-28] 07:05PM 268* 20 0.9 135 6.21 99 24 18 Brief Hospital Course: She had previously been hospitalized in early [Month (only) ] with long history of splenomegaly with undefined non-malignant hematologic abnormality, followed closely by Hematology/Oncology for this. After much discussion with patient, family and her providers the decision was made for therapeutic splenectomy. She underwent successful splenic artery embolization on [2187-10-9] in order to reduce the operative risk of splenectomy and on [10-10] she underwent splenectomy. She was eventually discharged to home with services. She returned with a smoldering wound infection and illness, and then began to pour gastric juice out of the wound. She was brought back to the operating room for exploration of her wound and repair of gastric perforation. Postoperatively she remained sedated and vented in the Surgical ICU. TPN was started. She was eventually weaned and extubated and was later transferred to the regular nursing unit. A VAC dressing to her abdomen was later applied; the JP drains which were placed intraoperatively have remained in place because of continued high output. A regular diet was started and she is tolerating this without difficulty. She was trialed on Octreotide; this was eventually discontinued. IV antibiotics will need to continue for an additional 2 days and then discontinue; follow up with Dr. [Last Name (STitle) ] in 1 week. She underwent LUE ultrasound for swelling noted in her left arm that was noted several days after central line removal; it did reveal a thrombus in the cephalic vein. She was maintained on tid Heparin. A right PICC line was placed eventually for continued IV antibiotics. Because of her deconditioned status she was evaluated by Physical and Occupational therapy and it was recommended that she go to an acute rehab following hospitalization. Discharge Medications: Continue with IV antibioitcs for 2 more days * 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold fro SBP <110, HR <60. 4. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose Subcutaneous four times a day as needed for per siding scale: See Attached sliding scale. 5. Ciprofloxacin 400 mg IV Q12H 6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 7. Fluconazole 200 mg IV Q24H 8. Vancomycin 1000 mg IV Q 24H 9. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 10. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Gastric Perforation Abdominal Abscess Necrotizing Pancreatitis Discharge Condition: Good Followup Instructions: Follow up with Dr. [Last Name (STitle) ] in 1 week, call [Telephone/Fax (2) 19012] for an appointment. You have an appointment with Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 3749], MD that was scheduled for you prior to this hospitalization. Phone:[Telephone/Fax (1) 3241] Date/Time:[2187-11-21] 1:00 ICD9 Codes: 5119, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6897 }	Medical Text: Admission Date: [2116-6-6] Discharge Date: [2116-6-26] Date of Birth: [2044-11-20] Sex: M Service: MEDICINE Allergies: Celebrex Attending:[First Name3 (LF) 613] Chief Complaint: Right sided weakness Major Surgical or Invasive Procedure: Required a G-tube([6-15]) and Intubation for respiratory distress ([6-17]) History of Present Illness: Mr [Known lastname 8147] is a 71yo R handed man with hx of severe OSA on CPAP, OA who was found down per roommate 10pm [6-5] and brought to outside hospital where he was found to have R MCA stroke. Per family/roommate, pt has been complaining of fatigue for several days including the day of admission - pt took an afternoon nap and was found to be in his usual state at 6pm. Then around 9pm, pt was noted to have difficulty using his L leg and getting up but it was assumed to be secondary to his chronic L knee pain (s/p knee replacement). At 10pm - about an hour later, pt was found down on the floor per roommate with no movements in L leg plus slurred speech and L facial droop. EMS was called and pt was trasported to outside hospital where he was given ASA 325mg in the ED but no lytics given that pt arrived in ED outside the 3hr window for tPA. Pt's initial vitals per EMS was 154/80 for BP and HR 58~60. Then while in ED, SBP ranged from 154~189 with DBP 73~86. Pt remained afebriel. Pt had CT scans which showed hypodensity in the R perieto-occipital lobes with no evidence of hemorrhage and R dense MCA sign. MRI and MRA were also done which showed large defects involving both R frontal, temporal, parietal and parieto-occipital lobes with no evidence of hemorrhagic transformation. FLAIR showed mild evidence of mass effect on R lateral ventricle but all ventricles were patent. MRA showed absent beginning of R ICA at the petrous portion and absence of distal flow of R MCA. On Neurology service, the patient had a RIGHT hemiplegia. With bulbar dysfunction, he underwent PEG [2116-6-15]. He continued to use nightly CPAP at outpatient pressures. Past Medical History: 1. OSA - CPAP at 16/8 at night 2. Asthma 3. GERD 4. BPH 5. s/p L knee repair and replacement 6. s/p ventral hernia repair 7. s/p L hand surgery after fracture 8. s/p L elbow surgery Social History: SH: Quit smoking in [2074] and sober for 7 years. Works as full-time maintenance person at [Hospital1 11485] School in [Location (un) 2624]. Has three children and sevral grandchildren. Family History: FH: Father died of CAD and mother died of stomach cancer. No FH of strokes, seizures and bleeding issues. Physical Exam: O: Vitals: T 98.8 (Tmax 100.2), BP 146/52, HR 66, RR 20, SpO2 91% FiO2 0.3, heparin rate 1300, +10L (+753/24 h) General: CPAP mask on, looks edematous CVS: JVD 9 cm, S1+2 no added sounds Resp: Coarse crackles B/L GI: slighly distended abdomen w normal BS Neurological Examination: MS-Follows simple commands. Speech not assessed (on CPAP). CN-PERRL, EOMI, nods "yes" when asked whether he perceives soft touch on his face Motor-R UE and LE [4-6] w/ normal tone. L UE 0/5, L LE [12-7] w/ nox stim only. Sensation difficult to assess on the arms and legs, but appears to be in tact throughout. Reflexes-(no change from previous note) L/R bic [2-2], tri [1-4], pat [2-2]+, Ach [1-3] Brief Hospital Course: Pt admitted from OSH with large R MCA stroke, treated only with aspirin. Was monitored on the neurology floor and began physical therapy. He continued his nighttime home CPAP regimen of 18/6. Was not changed from his home settings while in the hospital. . MRI/MRA showed large defects in R frontal, temporal and parietal with no evidence of hemorrhagic transformation. No flow in dital R MCA. Had no midline shift and no hydrocephalus. . Pt failed a speech and swallow study and had a GJ tube placed. It was initially hard to thread the tube into the jejunum, so it had to be revised. The patient now was a G tube and J tube. The G tube was clogged while in the SICU, and there was concern for ileus, but with motility agents, the residual volume decreased and the patient started having bowel movements. . Was being treated on the floor for significant Left hemiplegia with bulbar dysfunction. Had PEG placement on [2116-6-15], and was using CPAP as he had been doing at home. Overnight the [Date range (1) 21036] pt was noted to have O2 sat in 70s with tachypnea. Sats increased with stimulation. ABG showed mile hypercarbia (48). WBC 15.8 and CXR showed worsening atelectasis. CE normal x1. Intubated that night in the SICU for increased work up breathing likely secondary to aspiration pneumonitis. . The patient was then found to have bilateral PE on CT of chest. Heparin therapy was initiated and 3 days before discharge, coumadin therapy with started with 5 mg. His INR is subtherapeutic now. We recommend increasing his coumadin to 7.5 mg (he is likely having interaction with his antibiotics, especially the erythromycin he was on for motility). Continue to monitor INR and when therapeutic over 2.0, can take off heparin drip. . Pt also developed what was thought to be ventilator acquired pneumonia. Was treated with one day of vanco and a course of zosyn. He was 2 days remaining of his 8 day zosyn course. He is clinically improving and maintaining high saturations on between 2-3 L NC. His leukocytosis is resolving. . Pt was extubated on [6-23] in the SICU. Pt did well overnight. Can talk in short sentences. Continues to have L sided neglect and L hemiplegia. Follows commands. Obviously snores loudly even when just resting. . Pt is discharge with a central line still in place for the heparin drip. He has difficult access, so we felt central line was appropriate and the rehab facility could decide if a PIV would work. Pt also has working GJ tube in place and has a tube feed regimen that has been reevaluated by nutrition today. He is in stable condition and his ongoing medical issues now just include completing a course of zosyn for the next two days, and reaching a therapeutic INR and removing the heparin drip. . Physical therapy should be started for his stroke deficits. He should have repeat speech and swallow evaluation in one to two weeks to determine if he can start taking food and medicines PO. Medications on Admission: flomax 0.4 mg qHS advair 100/50 [Hospital1 ] prilosec 40 mg daily Discharge Medications: 1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for pain. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 8. Enalapril Maleate 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): Please continue heparin drip until INR >2.0, then can stop and just anticoagulate on coumadin. 12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 13. Zosyn 4.5 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 2 days: Please complete 8 day course of zosyn. Thanks. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary Diagnosis: 1. R MCA stroke 2. Aspiration pneumonitis 3. Pneumonia 4. Bilateral Pulmonary embolism . Secondary Diagnosis: 1. GERD 2. Obstructive Sleep Apnea Discharge Condition: Patient afebrile three days, currently breathing during the day on 2-3L NC with saturations in high 90s, using CPAP at night at his home settings, systolic blood pressures in 130s-140s. Pt has L sided hemi-paralysis from the stroke. Is communicative and appropriate in short sentences. Nutrition support from a GJ tube. Discharge Instructions: You were transferred to [Hospital1 18] from an outside hospital for a severe stroke. The left side of your body is now paralyzed, but the physical therapists have seen you and started working with you for rehabilitation. . While in the hospital you had a tube placed into your intestine so we could continue to give you nutrition. You are not able to swallow safely due to your stroke. . While on the floor, you seemed to aspirate some gastric contents into your lungs and develop a pneumonitis (an inflammation of your lungs). It made you work so hard at breathing, that we needed to intubate you. While you were intubated, we also found some pulmonary embolisms in both lungs. We started treating you with a blood thinner to break up the clots. You also developed a pneumonia while on the ventilator. We treated you with antibiotics and you improved. You still need O2 during the day, and use your CPAP at night. . You are being transferred to a rehabilitation facility with hospital level care, and you'll be continually cared for. In the near future, we hope to get your INR therapeutic on coumadin and take off the heparin drip. You will also complete 2 more days of Zosyn for your pneumonia. . Please return to the hospital for worsening respiratory status, chest pain, shortness of breath, increasing weakness, bleeding in your stool or urine or any other problems. Followup Instructions: You will go to a rehabilitation facility where they have 24 hour doctor supervision. He will continue to monitor your INR and your breathing. . Neurology Provider: [First Name8 (NamePattern2) ] [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2116-7-24] 1:00 [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2116-6-26] ICD9 Codes: 5070, 486, 5180
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6898 }	Medical Text: Admission Date: [2103-11-25] Discharge Date: [2103-11-30] Date of Birth: [2036-1-6] Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5272] Chief Complaint: RIGHT flank pain Major Surgical or Invasive Procedure: [2016-11-24] Attempted IR embolization of right renal segmenal artery History of Present Illness: 67M with a history of HTN and HL. On date of admission he developed acute R flank pain while raking leaves. He took 3 ASA to alleviate pain with no relief. He also had one episode of bilious emesis at home. He presented to [Hospital3 4107] where a non contrast CT scan showed a right sided retroperitoneal hematoma. He had a hypotensive episode with SBP in 60s associated with syncope. He was then transferred to [Hospital1 18] for further management. He received 4L crystaloid en route. SBP in 110s on arrival, but patient had an episode of hematemesis. Past Medical History: Hypertension, HyperlipidemiaPMH: HTN, HLD PSH: L wrist nerve repair Social History: No tabacco, no illicit drug use, rare alcohol Family History: non-contributory Physical Exam: WdWn Caucasion male, NAD, AVSS Abdomen soft, nt/nd, benign No flank pain no peripheral edema circumcised Pertinent Results: CTA ABD W&W/O C & RECONS Study Date of [2103-11-24] 11:09 PM IMPRESSION: 1. Large subcapsular right renal hematoma, with two sites of active extravasation from the capsular arteries in the mid and upper poles. 2. Blood products extending to the anterior pararenal space and along the right paracolic gutter into the pelvis. 3. Uniform but slightly delayed perfusion of the right kidney, likely secondary to compression of the left main renal vein. 4. Right rneal cysts, one hemorrhagic, and other lesions with increased density that are too msall tocharacterize. An MRU examination is recommended following complete resolution of acute issues, to confirm there is no underlying mass as the source of bleeding. [2103-11-29] 06:26AM BLOOD WBC-5.9 RBC-2.92* Hgb-9.5* Hct-26.4* MCV-91 MCH-32.5* MCHC-35.9* RDW-13.0 Plt Ct-186 [2103-11-28] 02:50AM BLOOD WBC-5.6 RBC-2.54* Hgb-8.3* Hct-22.5* MCV-89 MCH-32.9* MCHC-37.1* RDW-12.4 Plt Ct-104* [2103-11-27] 02:15PM BLOOD WBC-6.0 RBC-2.73* Hgb-8.9* Hct-24.3* MCV-89 MCH-32.4* MCHC-36.5* RDW-12.2 Plt Ct-100* [2103-11-27] 03:32AM BLOOD WBC-5.0 RBC-2.53* Hgb-8.1* Hct-22.5* MCV-89 MCH-32.1* MCHC-36.2* RDW-12.3 Plt Ct-85* [2103-11-26] 08:17PM BLOOD Hct-23.8* [2103-11-26] 11:44AM BLOOD Hct-26.6* [2103-11-26] 12:24AM BLOOD WBC-7.3 RBC-2.86* Hgb-9.0* Hct-25.8* MCV-90 MCH-31.5 MCHC-34.9 RDW-12.3 Plt Ct-116* [2103-11-25] 11:59AM BLOOD WBC-10.9 RBC-3.10* Hgb-9.8* Hct-27.9* MCV-90 MCH-31.6 MCHC-35.2* RDW-12.3 Plt Ct-150 [2103-11-24] 10:16PM BLOOD WBC-14.9* RBC-4.00* Hgb-12.5* Hct-36.3* MCV-91 MCH-31.4 MCHC-34.5 RDW-12.1 Plt Ct-16 [2103-11-28] 02:50AM BLOOD PT-11.8 PTT-27.4 INR(PT)-1.0 [2103-11-28] 02:50AM BLOOD Glucose-104* UreaN-18 Creat-1.2 Na-139 K-3.6 Cl-107 HCO3-28 AnGap-8 [2103-11-24] 10:16PM BLOOD Glucose-158* UreaN-24* Creat-1.5* Na-140 K-3.9 Cl-107 HCO3-22 AnGap-15 [2103-11-28] 02:50AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.9 [2103-11-26] 12:24AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0 Brief Hospital Course: 67M with spontaneous right kidney bleed with active extravasation of contrast noted on CT scan who is admitted to Dr.[Name (NI) 825] service after referral/transfer from [Hospital1 ] where he presented earlier on [11-24]. He was admitted for interventional radiology plan for embolization which was attempted. Please see the full detailed notes for further information. Mr. [Known lastname ] was closely monitored throughout his hospital course for changes in his vital signs that would have warranted immediate intervention. He was kept on telemetry and he was transfused with packed red blood cells. Throughout his hospital stay his pain was minimal and he remained afebrile. He was initially monitored in the intensive care unit before transfer to the general surgical floor. He was discharged home on a regular diet, ambulating independently and with pain well controlled and without other complaints to included dizziness, lightheadedness, palpitations. He will follow-up as advised. Medications on Admission: Aspirin 81, Atenolol 50, Hctz 25 /Triamterene 37.5, Lisinopril 10, Multivitamins 1, Niaspan [2092] MG qHS Discharge Medications: 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:25 Tablet(s) Refills:0 7. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: R renal bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -No vigorous physical activity for 2 weeks. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. Replace Tylenol with narcotic pain medication. Max daily Tylenol dose is 4gm, note that narcotic pain medication also contains Tylenol (acetaminophen) -Do not drive or drink alcohol while taking narcotics -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -Resume all of your home medications, except hold NSAID (aspirin, and ibuprofen containing products such as advil & motrin,) and fish oil until you see your urologist in follow-up -Resume all of your home medications, but please avoid aspirin/advil for one week. -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: -Call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] office ([Telephone/Fax (1) 7707] ‎for follow-up AND if you have any questions (page Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 770] at [Telephone/Fax (1) 2756]). -Follow up in Acute Care Surgery Clinic Phone: ([Telephone/Fax (1) 37488] in one month for f/u of possible R inguinal hernia. Completed by:[2103-12-2] ICD9 Codes: 4589, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 6899 }	Medical Text: Admission Date: [2133-10-14] Discharge Date: [2133-10-20] Date of Birth: [2057-1-18] Sex: F Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[First Name3 (LF) 922] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2133-10-15] Coronary Artery Bypass Graft x 3 (Left internal mammary artery to left anterior descending, Saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) [2133-10-14] Cardiac catheterization History of Present Illness: 76 year old female with history of hypertension and hyperlipidemia with complaints of chest tightness and throat burning with minimal exertion. She had a positive stress test and was referred for cardiac catheterization to further evaluate. Now asked to evaluate for surgical revascularization. Past Medical History: Hypertension Hyperlipidemia Gastroesophageal Reflux Disease Social History: Race: Phillipino Lives with: daughter, widowed Occupation: retired Tobacco: quit 10 yrs ago smoked 1ppd x 20 yrs ETOH: denies Family History: none Physical Exam: Pulse:58 Resp:14 O2 sat: 100%RA B/P Right: 230/82 Left: 241/89 post procedure on IV Nitro Height:4'9" Weight:106 lbs (48.1kg) General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [Name (NI) 167]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:- Left:- Pertinent Results: [2133-10-14] Cardiac Cath: 1. Selective coronary angiography of this right dominant system revealed 3 vessel coronary artery disease. The LMCA was normal. The LAD had a 60% stenosis proximally, and a 70% stenosis in the mid portion at the bifurcation of D3. The LCX had a 90% proximal stenosis. The RCA had a 95% proximal stenosis at the conus, and was occluded in the mid portion. The distal RCA was a large vessel with posterior ventricular branches filling via extensive left-to-right collaterals from the LAD and LCX. 2. Limited resting hemodynamics revealed moderate to severe systemic arterial hypertension with central aortic pressures of 175/70mm Hg. [2133-10-14] Carotid U/S: Right ICA with no stenosis. Left ICA with stenosis <40% . [2133-10-15] Echo: PRE BYPASS The left atrium is mildly dilated. The left atrium is elongated. 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 thickness, cavity size, and global systolic function are normal (LVEF>55%). 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. 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 a centrally directed jet of mitral regurgitation that is at least mild to moderate but does border on moderate. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) 914] was notified in person of the results in the operating room at the time of the study. [2133-10-20] 05:20AM BLOOD WBC-7.8 RBC-3.19* Hgb-9.2* Hct-26.5* MCV-83 MCH-28.7 MCHC-34.6 RDW-15.6* Plt Ct-333 [2133-10-14] 11:00AM BLOOD WBC-5.8 RBC-3.77* Hgb-11.3* Hct-31.9* MCV-85 MCH-30.0 MCHC-35.4* RDW-12.6 Plt Ct-320 [2133-10-20] 05:20AM BLOOD Glucose-105 UreaN-14 Creat-0.9 Na-134 K-4.4 Cl-98 HCO3-29 AnGap-11 [2133-10-14] 11:00AM BLOOD Glucose-244* UreaN-25* Creat-1.1 Na-138 K-3.6 Cl-103 HCO3-28 AnGap-11 [2133-10-14] 11:00AM BLOOD ALT-23 AST-26 AlkPhos-45 Amylase-61 TotBili-0.3 [2133-10-20] 05:20AM BLOOD Mg-2.4 [2133-10-14] 11:00AM BLOOD Triglyc-103 HDL-33 CHOL/HD-4.6 LDLcalc-99 Brief Hospital Course: She was admitted and underwent cardiac catheterization on [10-14] following an abnormal ETT. Cardiac catheterization revealed severe three vessel coronary artery disease and she was referred for surgical intervention. She underwent appropriate pre-operative work-up and was brought to the operating room on [10-15] where she underwent a coronary artery bypass graft surgery. Please see operative report for surgical details. Vancomycin was given for perioperative antibiotics. Following surgery she was transferred to the CVICU for hemodynamic monitoring. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one her chest tubes were removed and she was transferred to the telemetry floor for further care. Epicardial pacing wires were removed on post-op day three. She continued to make good progress while working with physical therapy for strength and mobility. On post-op day five she was discharged home with daughter who she lives with. Medications on Admission: Atenolol 50mg po daily, Fenofibrate 67mg po daily, Cozaar 75mg po daily, Omeprazole 20mg po daily, Pravastatin 20mg po daily, ASA 81mgpo daily Discharge Medications: 1. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 932] Area VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Past medical history: Hypertension Hyperlipidemia Gastroesophageal Reflux Disease Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming Monitor wounds for infection and report any redness, warmth, swelling, tenderness or drainage Please take temperature each evening and Report any fever 100.5 or greater Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month 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] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [1-20] weeks Dr. [Last Name (STitle) ] [Name (STitle) 76675] in [1-20] weeks Wound Check [Hospital Ward Name 121] 6 - please schedule with RN [Telephone/Fax (1) 3071] Completed by:[2133-10-20] ICD9 Codes: 4111, 2761, 4019, 2724, 2859

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