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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7000
} | Medical Text: Admission Date: [**2171-6-1**] Discharge Date: [**2171-6-6**]
Date of Birth: [**2098-4-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
CC: L hand weakness
Major Surgical or Invasive Procedure:
[**2171-6-4**] right craniotomy for sdh evacuation
History of Present Illness:
This is a 73 year old man who hit his head while working in the
yard 3 weeks ago. He started steroids for PMR about 3 days ago
and noted transient
left hand weakness after steroids.
He was seen in the ED and CT head showed SDH.
Past Medical History:
HTN
Colon-rectal cancer w/ met to liver, s/p rsxn, no recurrence
Social History:
Married, lives with wife, former [**Name2 (NI) 1818**] > 30yrs ago, 3-4 beers
week
Family History:
Family Hx:
NC
Physical Exam:
On Admission:
PHYSICAL EXAM:
O: T: 99.0 BP: 130/72 HR: 98 R 18 O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-8**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: L dysmetria, rapid alternating movements intact
Exam: AAOx3, PERRL, left facial droop at nasolabial fold, Motor
[**6-8**], sensory intact to light touch, no drift, incision with
staple c/d/i
Pertinent Results:
Sinus rhythm. Normal tracing. No significant change compared to
previous
tracings.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 188 82 340/396 47 -10 25
CT [**2171-6-1**]
FINDINGS: There is a large right frontal and parietal subdural
hematoma.
There are linear hyperattenuating lines mixed in with
lesser-attenuating
fluid. Suggest that there may be components of hemorrhage that
are old and
acute. There is a small subdural hematoma at the left frontal
lobe (2:13). There is no subarachnoid hemorrhage. There is a
trace suggestion of mass effect at the level of the right
frontal [**Doctor Last Name 534**] (2:12). There is 4 mm of leftward shift of the
third ventricle, which is normally midline. The basal cisterns
cisterns are patent. There is a tiny focus of hemorrhage in the
temporal [**Doctor Last Name 534**] of the right lateral ventricle (2:10).
IMPRESSION: Large right subdural and small left subdural
hematomas. The
heterogeneity of the right subdural hematoma suggests that there
may be an
older component of blood in addition to acute hemorrhage.
[**2171-6-1**] CXR
FINDINGS: PA and lateral views of the chest were obtained
demonstrating low lung volumes, though no focal consolidation,
effusion or pneumothorax. Cardiomediastinal silhouette is
normal. Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
[**2171-6-4**] CT head
1. Status post evacuation of right subdural hematoma, with
expected
post-operative change, and subdural drain in situ. No
superimposed acute
process detected.
2. Unchanged appearance of chronic-appearing left frontal
subdural
collection
Brief Hospital Course:
Mr. [**Known lastname **] was admitted through the emergency room after
discovery of a right acute on chronic SDH. He was admitted and
placed on seizure prophylaxis. He was noted to have focal
seizure activity in the LUE and so he was bolused with Keppra
and his dosing increased. He remained neurologically intact
otherwise with just a left pronator drift. He was prepped for
surgery for Tuesday morning, CXR and UA were wnl. He was taken
to the OR on [**6-4**] and a drain was left after evacuation of the
hematoma CT showed expected post-op changes. He was observed in
the ICU overnight without neurologic decline. His drain was
removed on [**6-5**] and he was transferred to the floor.
He remained stable and was evaluated by PT and was deemed stable
for discharge. he was eating and ambulating appropriately and
was discharged home on [**6-6**]
Medications on Admission:
Cialis 20mg prn, HCTZ 25mg Qam, Prednisone 20mg Qd, Zolpidem 5mg
Qhs, Univasc 15mg
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: 0.5 Capsule PO DAILY
(Daily).
2. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. moexipril 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
right sided subdural hematoma
focal motor seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
[**Street Address(1) 15947**] X 6 MONTHS
General Instructions
You have a staples at your drain site. This needs to be removed
on [**6-12**] at home or at rehab.
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Dressing may be removed on Day 2 after surgery.
?????? If you have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? If your wound was closed with staples or non-dissolvable
sutures then you must wait until after they are removed to wash
your hair. You may shower before this time using a shower cap to
cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
- If you have been discharged on Keppra (Levetiracetam),
you will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????All your staples need to be removed on [**2171-6-12**]. Please return to
the office or have them removed at rehab. Call([**Telephone/Fax (1) 88**] for
this appointment and to schedule an appointment with Dr. [**First Name (STitle) **],
to be seen in 4_weeks.
??????You will need a CT scan of the brain without contrast.
- You will need follow-up with neurology regarding your focal
motor seizures. Please call Dr. [**Last Name (STitle) 1274**] office to schedule
follow-up at [**Telephone/Fax (1) 8139**].
Completed by:[**2171-6-6**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7001
} | Medical Text: Admission Date: [**2174-10-17**] Discharge Date: [**2174-10-22**]
Date of Birth: [**2096-1-15**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Headache and confusion.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Name13 (STitle) 7518**] is a 78 yo right handed man who presents for
evaluation of confusion. The history is given both by the
patient and his daughter. Apparently, the patient lives
predominantly alone. His daughter recalls speaking to him on
Saturday and he appeared to be his typical self. This morning,
around 9am she received a phone call from her father- he was
asking for the phone number to his office, something he should
know very well. She became concerned and he told her that he
was
not feeling well and was lying in bed (also unlike him). They
hung up the phone and just minutes later, he called back, again
asking the same questions and without recalling that he had just
spoken to her. This prompted his daughter to go to his home
where she found things in disarray- he had apparently soiled
himself as well as vomited on the floor as well as a nose bleed
and had no cleaned it up. She is not sure how long things had
been like that. The patient refused to go to the ED and
requested calling his PCP [**Name Initial (PRE) **]. Upon hearing this, the PCP
rightfully referred the pt to the ED.
On arrival to the ED, the patient was noted to be extremely
hypoxic (O2 sat 65% off oxygen). ABG at the time showed mild
bicarb retention and normal COhb. EKG was notable for PACs. A
head CT was obtained which identifed a large intraventricular
bleed in the left caudate, extending into the ventricular
system.
Neurosurgery was consulted but felt there was no issued for an
acute intervention. His sats quickly correctly and neurology
was
consulted.
Mr. [**First Name (Titles) 104720**] [**Last Name (Titles) 104721**] feeling "Plunky" that last few hours but
he cannot give a further description of his overall well being
other than feeling fatigued. His daughter feels his fatigue
predates his presentation, stating he has been a bit more quiet
and down over the past few weeks than he typically is. He
denies
any recent head injuries or falls. He reports a mild headache
(0.5/10) which is a central pressure and which appears to be
resolving. On further neurologic review of systems, the
patient
denied loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denied difficulties producing or comprehending
speech. Denied focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denied difficulty with
gait.
On general review of systems, the patient denied recent fever or
chills. No night sweats or recent weight loss or gain. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denied arthralgias or myalgias. Denied rash.
Past Medical History:
- Sleep Apnea, on CPAP
- Emphysema (baseline O2 84% on RA. Goal ~88 RA)
- "Leaky Valve", per most recent ECHO, multiple valve disease
with mild regurge from mitral, aortic and tricuspid valves.
- Nephrolithiasis
- Spinal Stenosis (lumbar)
- GI Bleed/BRBPR, no off ASA
- s/p Cataract [**Doctor First Name **] (bilaterally)
- s/p resection of skin lesion on his head.
- s/p B/L knee replacements
- s/p cholecystectomy
- s/p appendectomy
- s/p tonsillectomy
Social History:
Semi retired- works in real estate part time. Lives alone but
son comes and stays with him 3 days per week. He spends a good
amount of time at [**Location (un) **]. He has 4 children, 2 of which are
in
the area. Remote smoking history of 2ppx, quit 30 years ago.
No
alcohol in years, no drugs.
Family History:
Gm HYPERTENSION, LIVER DISORDER (SECONDARY TO DAILY
ACETAMINOPHEN
Father- diabetes type I, ? bone ca?
Physical Exam:
Exam changes during the admission:
Patient remained afebrile. Was hypertensive briefly,
particularly on exertion, until antihypertensives added to 170s
at maximum. His oxygen saturation was typically low, often in
80's - he appears to have habituated to this, with some
polycythemia and no symptoms. His neurologic examination is
essentially normal now, with some confusion in the evening on
two nights. His family judge that he is approaching his
cognitive baseline.
T 99.3 BP 162/85 (prepeat 115/70) HR 94 RR 92 O2% 4L
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormalities, no scleral icterus
noted, mmm, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: irregular rate (PV/PAcs on tele). [**1-29**] diffuse murmur.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: 1+ radial, DP pulses bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to hospital, "[**2174-10-27**])".
Able to relate history with some difficulty and amnestic
regarding some of the events of the last 2 days; confabulates.
Attentive (DOW backwards 23 seconds). Language is fluent with
intact repetition and comprehension. Normal prosody. There
were
no paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. There was no evidence of apraxia or neglect,
calculations intact. Registered [**2-23**] after 4 tries; and recalled
0/3 at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL irregularly shaped, 3 to 2mm and sluggish, b/l lens
replacements, + red reflex. Visual fields full on bedside
testing with red pin. Unable to view fundus
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: decreased hearing on right compared to left ear to finger
rub.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No rigidity. No adventitious movements, such as
tremors, noted. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, decreased pinprick and
temperature sensation in bilateral feet to ankles. Also
decreased vibratory sense on right to shin and left to ankle.
Impaired proprioception to fine movements at the toes
bilaterally. No extinction to double simultaneous stimuli.
-Deep tendon reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 1 1 1 1
R 2 1 1 1 1
Plantar response was flexor bilaterally.
-Coordination: Mild bilateral intention tremor, no
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
-Gait: initially deferred
Pertinent Results:
[**2174-10-17**] 12:00PM BLOOD WBC-11.6* RBC-5.58 Hgb-18.6* Hct-58.1*
MCV-104* MCH-33.2* MCHC-32.0 RDW-14.1 Plt Ct-229
[**2174-10-21**] 05:45AM BLOOD WBC-15.2* RBC-5.75 Hgb-19.6* Hct-58.5*
MCV-102* MCH-34.1* MCHC-33.5 RDW-14.2 Plt Ct-223
[**2174-10-17**] 12:00PM BLOOD Neuts-80.3* Lymphs-12.0* Monos-5.2
Eos-0.8 Baso-1.7
[**2174-10-17**] 12:00PM BLOOD PT-14.0* PTT-28.8 INR(PT)-1.2*
[**2174-10-21**] 05:45AM BLOOD PT-16.1* PTT-29.4 INR(PT)-1.4*
[**2174-10-21**] 05:45AM BLOOD Ret Aut-2.0
[**2174-10-17**] 12:00PM BLOOD Glucose-135* UreaN-12 Creat-0.8 Na-139
K-4.1 Cl-102 HCO3-27 AnGap-14
[**2174-10-20**] 05:50AM BLOOD Glucose-117* UreaN-14 Creat-0.7 Na-140
K-4.3 Cl-102 HCO3-31 AnGap-11
[**2174-10-18**] 02:51AM BLOOD ALT-40 AST-31 LD(LDH)-196 CK(CPK)-97
AlkPhos-63 TotBili-1.4
[**2174-10-18**] 02:51AM BLOOD CK-MB-5 cTropnT-<0.01
[**2174-10-17**] 12:00PM BLOOD Calcium-9.4 Phos-2.3* Mg-1.9
[**2174-10-20**] 05:50AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.0
[**2174-10-21**] 05:45AM BLOOD UricAcd-4.1
[**2174-10-17**] 04:35PM BLOOD %HbA1c-6.0* eAG-126*
[**2174-10-18**] 02:51AM BLOOD Triglyc-101 HDL-37 CHOL/HD-3.7 LDLcalc-79
[**2174-10-17**] 12:11PM BLOOD Type-[**Last Name (un) **] O2 Flow-4 pO2-55* pCO2-45
pH-7.40 calTCO2-29 Base XS-1 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2174-10-17**] 12:11PM BLOOD Lactate-1.8
[**2174-10-21**] 12:40PM BLOOD JAK2 MUTATION (V617F) ANALYSIS, PLASMA
BASED-PND
[**2174-10-21**] 12:40PM BLOOD ERYTHROPOIETIN-PND
EKG
Sinus rhythm and frequent atrial ectopy. Left atrial
abnormality. Right ventricular conduction delay. Compared to the
previous tracing of [**2172-5-16**] the axis is indeterminate. There are
new repolarization abnormalities in leads V1-V4 and increase in
rate which may represent anterior myocardial ischemia. Followup
and clinical correlation are suggested.
Rate PR QRS QT/QTc P QRS T
85 148 96 350/393 51 0 4
CT Head [**2174-10-17**]
FINDINGS: There is a large intraventricular hemorrhage which
appears to be extending from a small focus of intraparenchymal
hemorrhage within the left caudate (2:12). There is no evidence
of obstructive hydrocephalus. There are no other foci of
hemorrhage, major vascular territorial infarction, edema or
shift of normally midline structures. There are no fractures or
soft tissue injuries. The visualized sinuses and mastoid air
cells are well pneumatized.
IMPRESSION: Intraventricular hemorrhage likely from ventricular
extension of left caudate hemorrhage. No obstructive
hydrocephalus.
Addendum: Upon further review, there is bihemispheric
subarachnoid hemorrhage manifested as subtle hyperdensity within
the sulci most conspicuous along the cerebral vertex on the
right.
CT Head [**2174-10-19**]
FINDINGS: Again identified is diffuse bilateral subarachnoid
hemorrhage, not significantly changed in size and distribution.
There is intraventricular hemorrhage with increased ventricular
size concerning for early obstructive hydrocephalus. In
particular, the third ventricle now measures 14 mm (2, 13),
previously measuring 11 mm. There is also increased dilatation
of the temporal horns bilaterally. There has been slight
redistribution of the intraventricular hemorrhage with blood now
identified in right occipital [**Doctor Last Name 534**] (2, 17) and resolved from the
right frontal [**Doctor Last Name 534**]. The previously identified hemorrhage within
the third ventricle has resolved. The hemorrhage within the left
ventricular system is stable in configuration. Small amount of
hemorrhage within the fourth ventricle is now present within the
bilateral foramen of Luschka.
There is no new hemorrhage identified. There is no shift of
normally midline structures or acute major vascular territorial
infarction. There is normal [**Doctor Last Name 352**]-white matter differentiation.
No evidence of acute fracture. The visualized paranasal sinuses
are unremarkable.
IMPRESSION:
1. Intraventricular hemorrhage with increased dilatation of the
ventricular system concerning for early obstructive
hydrocephalus.
2. Extensive subarachnoid hemorrhage, unchanged. No new
hemorrhage
identified.
CT Head [**2174-10-21**]
Ventricular size reduced by comparison on [**2174-10-19**]
MRA/MRI Head [**2174-10-17**]
TECHNIQUE: Sagittal T1-weighted and axial T1-weighted,
T2-weighted, FLAIR, gradient echo, and diffusion-weighted images
of the head were obtained. Three-dimensional time-of-flight MRA
of the head and two-dimensional time-of-flight MRV of the head
were obtained, with a three-dimensional maximal intensity
projection images. Two-dimensional time-of-flight MRA of the
neck was obtained, with three-dimensional maximal intensity
projection reformatted images. During intravenous gadolinium
administration, dynamic coronal VIBE imaging of neck was
performed. Following intravenous gadolinium administration,
multiplanar T1-weighted images of the head were obtained.
FINDINGS:
HEAD MRI: There is a small focus of blood in the left
caudothalamic groove. There is a large amount of blood within
the left lateral ventricle, third ventricle and fourth
ventricle, as well as a small amount of blood in the frontal and
occipital horns of the right lateral ventricle. The septum
pellucidum is shifted to the right. These findings are
unchanged. There is high signal on FLAIR images and low signal
on gradient echo images in the hemispheric sulci bilaterally,
corresponding to the subarachnoid hemorrhage seen on the
preceding CT scan. There is no evidence of an enhancing mass or
abnormal blood vessels. Multiple small foci of high T2 signal in
the supratentorial white matter and pons, probably represent
chronic microvascular infarcts, given the patient's age.
HEAD MRV: Flow is visualized in the major dural sinuses without
evidence of thrombosis.
HEAD MRA: The study is limited by motion artifacts. The
intracranial right vertebral artery is hypoplastic, better
visualized on the concurrent neck MRA with gadolinium. There is
no evidence of a hemodynamically significant arterial stenosis
or intracranial aneurysm. This study does not cover the entire
head as it is targeted for evaluation of the circle of [**Location (un) 431**],
but no evidence of an arteriovenous malformation is seen within
the area of coverage.
NECK MRA: The gadolinium-enhanced dynamic neck MRA is slightly
limited due to suboptimal injection timing. However, no
hemodynamically significant stenosis is seen in the cervical
carotid or vertebral arteries.
IMPRESSION:
1. Extensive intraventricular hemorrhage, bilateral subarachnoid
hemorrhage, and a small parenchymal hemorrhage in the left
caudothalamic groove, as seen on the preceding CT scan.
2. No evidence of an intracranial mass.
3. No evidence of venous sinus thrombosis.
4. Slightly limited MRAs of the head and neck. No evidence of an
intracranial aneurysm. No evidence of an intracranial
malformation within the area of coverage, though the entire head
is not covered by the MRA.
Brief Hospital Course:
Intraventricular Hemorrhage
Typical causes of intraventricular hemorrhage include dissection
into the ventricle from periventricular strucutres, particulary
after hypertension hemorrhage into striatum. Other possibilities
include periventricular neoplasm with necrosis and bleeding,
aterovenous malformation, arising from choroid. In this case, a
small amount of disrupted tissue adjacent to the left lateral
ventricle, next to the head of the causeal is seen - we think
that blood likely dissected into the ventricle from this
possible hypertensive lesion. We will need to repeat MRI of the
head in about six weeks to reevaluate for an underlying lesion
at this site. Again the hypertensive hypothesis seem somewhat
odd given quite reasonable blood pressure values while here. We
started antihypertensive agents, as listed below. We will see
him in clinic for follow-up after repeat MRI.
Systemic Hypertension
Not very elevated. Response to exercise/exertion brought to 170s
while here, but was typically from 110s to 140s at rest. We
added agents as listed below.
Chronic Obstructive Pulmonary Disease
Patient has previously refused day-time oxygen therapy and
tolerates a very low oxygen saturation in the 80s. This
hypoxemia, perhaps along with sleep apnea, has resulted in
pulmonary hypertension, possibly worsening his respiratory
status. He has actually been symptom free, however. Hypoxemia is
also the likely cause of his polycythemia.
Pulmonary Hypertension
Likely secondary to COPD and hypoxia, perhaps with a
contribution from OSA.
Obstructive Sleep Apnea
The patient used BiPAP while an inpatient.
Polycythemia
Was seen by Hematology while here, who recommended no phlebotomy
at this time. JAK2 mutation and EPO level were pending at the
time of discharge, but it seems more likely attributable to
hypoxemia.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled every 6-8 hours as needed for shortness of breath
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day rinse after use
OXYGEN - - 4L via nasal cannula use 24/7 Please provide liquid
oxygen system. Saturation 83% on RA, 86-88% on 4LNC. Diagnosis
COPD. Please call patient when oxygen is available as he would
li
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Capsule - 1 Capsule(s) by mouth once daily
MULTIVITAMIN - (OTC) - Capsule - Capsule(s) by mouth once a
day
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- Dosage uncertain
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
8. multivitamin with minerals Capsule Sig: One (1) Capsule
PO once a day.
9. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO twice a
day.
10. Omega-3 Fish Oil 1,000 (120-180) mg Capsule Sig: One (1)
Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary
Intracerebral hemorrhage with intraventricular extension
Secondary
Chronic obstructive pulmonary disease/emphysema
Obstructive sleep apnea
Pulmonary hypertension
Systemic hypertension
Polycythemia, likely secondary to hypoxemia (from chronic
obstructive pulmonary disease and, to a lesser extent, pulmonary
hypertension)
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 came to the hospital after having a hemorrhage in your
brain, which erupted into the ventricles (fluid filled spaces
inside the brain). This blocked your ventricular system, leading
to the build-up of some fluid in your brain. Given this, you
needed close monitoring. You recovered quickly and well from
this event. Repeat imaging demonstrated that your ventricular
system was again draining, so we thought that you were safe to
go to rehabilitation. Please take your medications as written
below and as specified by rehabilitation at your discharge from
there. You will need to follow-up with our stroke team after
discharge, as detailed below.
Followup Instructions:
Please see our stroke team as follows:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2174-12-7**] 1:30
Prior to this appointment, you will need a repeat CT then MRI of
your brain (imaging). The CT will need to be in two weeks (about
[**2174-11-6**]), then the MRI in six weeks. Please call to schedule a
time - the order is in, but the exact time is not booked. You
can have this done in the week prior to the appointment, i.e. in
the week [**11-29**] to [**12-6**]. Please call [**Telephone/Fax (1) 327**].
Please make an appointment to see your primary care doctor -
make this appointment to see your doctor a few days after
discharge - please see your doctor within a week.
[**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 3329**]
We also note other appointments in our system:
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2174-11-29**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2308**], MD Phone:[**Telephone/Fax (1) 3965**]
Date/Time:[**2175-3-30**] 7:30
ICD9 Codes: 431, 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7002
} | Medical Text: Admission Date: [**2116-3-29**] Discharge Date: [**2116-4-8**]
Date of Birth: [**2048-5-25**] Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Bactrim
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Nausea vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is poor historian at baseline, unable to get story from
patient.
.
67M ho Dm2, HTN, autism and dementia (baseline: A+Ox1) who
presened to ED for abdominal pain and emesis and unsteady gait
(usualy wheelchair bound). He has a poor baseline mental status
secondary to dementia (A+O to self and place only). As of last
night, had abdominal pain and emesis so was brought to [**Hospital1 **]. Mental status did not change from baseline. No fevers.
Was given rectal compazine by EMS and then vomited twice more 6
hrs later.
.
[**Hospital3 **]: T 98.3, HR 96, RR 21, 99/73, 96%RA
He was supposedly hypotensive at [**Hospital1 **]. Lactate 1.7, Na 136, Cl
99, BUN 36, K 4.3, HCO3 27, Cr 1.2, Ca [**14**]. WBC 21, Hb 17, HCT
51.8. UA suggestive of cystitis (cathed urine that was bloody).
Trop I 1.66, EKG with inverted T waves.
CT Abd A+P showed bilateral perinephric stranding findings
(although this is not seen in the final report) and question R
lower pulmonary artery defect although artifact in final read.
? CXR RLL infiltrate.
He was given: Zosyn and vanco for infiltrate and urine, insulin
for glucose 420, zofran, 2L NS, aspirin 325mg, started in
heparin gtt at 1530 and tranfered to [**Hospital1 18**].
.
In the [**Hospital1 18**] ED, initial VS were: 97.6 74 116/71 (lowest BP
90/58 when sleeping) 16 96% 4L
-giving 3rd L NS, heparin running at 1530.
EKG showed NSR @ 79, LAD, long QTC, deep T waves in V2-V5, poor
r-wave progression.
Guiac neg.
Access: two 20 g IVs
Transfer vitals: HR 74, RR 21, O2 sat 98% on 3L NC, BP 94/59
Pt transfered to MICU for ?ACS, complicated cystitis, RLL pna
.
On arrival to the MICU, pt is lethargic, mildly diapharetic,
arrousable, answers yes/no questions. Denies any chest pain.
States he has some abdominal pain. When asked if he is drinking
at eating at home he says no.
Past Medical History:
([**First Name8 (NamePattern2) **] [**Hospital1 **] records, pt unable to give a history)
dementia
psychosis
autism
BPH
urinary incontinence
HTN
HLD
DM2
Communicating hydrocephalus
Chronic abdominal pain
Depression
(of note, no history of cardiac disease, no prior MIs)
Social History:
Lives in [**Hospital 16662**] nursing home, [**Location (un) 6409**]. A+O x2 at
baseline. Gradually worse over the years. Currently wheelchair
bound. Initialy from [**Country 4754**]. No drugs.
Family History:
Unknown
Physical Exam:
ADMISSION EXAM:
Vitals: T 98.1, HR 78, BP 107/71, RR 12, 98% RA
General: lethargic, diapharetic, moist mucus membranes, good
capillary refil
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated (JVP at clavicle when upright),
no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: crackles in bases bilaterally
Abdomen: right upper quadrant discomfort in deep palpation, no
flank pain
GU: foley with dark urine and bloody urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+O x1, lethargic
Stage 2 ulcers on coccyx, left heel
.
DISCHARGE EXAM:
VS: 97.3 147/77 59 18 100% RA
General: NAD, lying in bed, short appropriate verbal responses
to questioning
HEENT: NC/AT, sclerae anicteric, PERRL, EOMI, OP clear, MMM
CV: RRR, nl S1 S2, no MRG
Resp: breathing comfortably on RA without accessory muscle use,
slight rales b/l, no wheezes or ronchi
Abd: soft, non-tender, non-distended.
GU: Foley present with slight evidence of bleeding at meatus.
UOP the color of fruit punch wihtout irrigation.
Ext: warm, well perfused, no cyanosis, clubbing or edema.
Neuro: A&O x1, lethargic
Stage 2 ulcers on coccyx, left heel. Waffle boots in place on
feet, coccyx with Mepilex in place
Pertinent Results:
ADMISSION LABS
[**2116-3-29**] 05:37AM GLUCOSE-324* UREA N-30* CREAT-0.9 SODIUM-138
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17
[**2116-3-29**] 05:37AM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-5.2*
MAGNESIUM-2.2
[**2116-3-29**] 05:37AM ALT(SGPT)-13 AST(SGOT)-22 ALK PHOS-81 TOT
BILI-0.6
[**2116-3-29**] 05:37AM LIPASE-16
[**2116-3-29**] 05:37AM WBC-17.0* RBC-5.40 HGB-15.9 HCT-49.5 MCV-92
MCH-29.4 MCHC-32.1 RDW-12.8
[**2116-3-29**] 05:37AM NEUTS-87.7* LYMPHS-7.6* MONOS-3.5 EOS-0.4
BASOS-0.8
[**2116-3-29**] 05:37AM PLT COUNT-296
[**2116-3-29**] 05:37AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-300 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
[**2116-3-29**] 05:37AM URINE RBC->182* WBC-34* BACTERIA-FEW
YEAST-NONE EPI-0
[**2116-3-29**] 05:40AM LACTATE-1.9
.
CARDIAC ENZYMES
[**2116-3-29**] 05:37AM BLOOD cTropnT-0.33*
[**2116-3-29**] 09:30AM BLOOD CK-MB-5 cTropnT-0.34*
[**2116-3-29**] 02:42PM BLOOD CK-MB-5 cTropnT-0.28*
[**2116-3-30**] 11:38AM BLOOD CK-MB-4 cTropnT-0.18*
.
ABG
[**2116-3-29**] 07:22AM BLOOD Type-ART pO2-74* pCO2-42 pH-7.43
calTCO2-29 Base XS-2
[**2116-3-31**] 04:50PM BLOOD Type-ART Temp-36.7 pO2-67* pCO2-35
pH-7.47* calTCO2-26 Base XS-1 Intubat-NOT INTUBA
.
[**Hospital3 **]:
[**2116-3-29**] 05:37AM BLOOD TSH-1.9
[**2116-3-29**] 05:40AM BLOOD Lactate-1.9
[**2116-3-29**] 07:22AM BLOOD Lactate-1.6
[**2116-3-30**] 12:08AM BLOOD Vanco-11.8
[**2116-4-1**] 06:37AM BLOOD Vanco-19.8
[**2116-4-6**] 08:00AM BLOOD Vanco-38.9*
[**2116-3-29**] 05:37AM BLOOD Lipase-16
[**2116-3-29**] 05:37AM BLOOD ALT-13 AST-22 AlkPhos-81 TotBili-0.6
.
Discharge Labs:
[**2116-4-8**] 05:32AM BLOOD WBC-10.6 RBC-3.46* Hgb-10.1* Hct-31.1*
MCV-90 MCH-29.2 MCHC-32.5 RDW-14.3 Plt Ct-344
[**2116-4-8**] 05:32AM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-137
K-4.0 Cl-103 HCO3-26 AnGap-12
[**2116-4-8**] 05:32AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0
.
EKG [**3-29**]
Baseline artifact. Sinus rhythm. Probable underlying inferior Q
wave
myocardial infarction. Extensive inferior and anterolateral T
wave inversions raise strong consideration of ischemia. Q-T
interval prolongation is also noted along with left axis
deviation. No previous tracing available for comparison.
Clinical correlation is suggested.
.
EKG [**3-31**]:
Sinus rhythm. Compared to tracing #1 deep T wave inversions
persist but
are improving. Clinical correlation is suggested.
.
EKG [**4-3**]:
Sinus bradycardia with a single ventricular premature beat or
aberrantly conducted atrial premature beat. Prior inferior wall
myocardial infarction. Minor right ventricular conduction delay.
Left axis deviation. Q-T interval prolongation (484). Inferior
and anterolateral T wave inversions may be due to ischemia, etc.
Early R wave transition. Compared to the previous tracing of
[**2116-3-31**] no diagnostic change.
.
ECHO [**3-29**]:
Left ventricular wall thicknesses and cavity size are normal.
There is mild to moderate regional left ventricular systolic
dysfunction with near akinesis of the distal septum and distal
inferior wall and severe hypokinesis of the apex which is mildly
aneurysmal. There is moderate hypokinesis of the remaining
segments (LVEF = 25-30 %). No masses or thrombi are seen in the
left ventricle. Right ventricular cavity size is growwly normal.
Free wall motion is not well seen. The aortic valve leaflets are
mildly thickened. No aortic regurgitation is seen The mitral
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with extensive regional and global systolic
dysfunction. Normal right ventricular cavity size. No definite
pathologic valvular flow identified.
.
CT HEAD [**3-29**]:
FINDINGS: There are no prior studies for comparison. There is
moderate
prominence of ventricles and sulci. The ventricular enlargement
is not out of proportion for sulci nor there is significant
dilatation of the temporal horns beyond the dilatation of the
lateral ventricles. These findings indicate atrophy. The CT
appearances are not typical for normal pressure hydrocephalus.
Mild-to-moderate changes of small vessel disease seen. There is
no midline shift seen. No acute hemorrhage identified. No large
area of loss of [**Doctor Last Name 352**]-white matter differentiation seen.
IMPRESSION: No acute abnormalities. Brain atrophy.
.
CXR [**3-30**]:
FINDINGS: In comparison with the study of [**3-29**], the areas of
opacification at the bases are less prominent. The right lower
lobe lung mass is less well seen than on the CT examination.
Cardiac silhouette is less prominent and the pulmonary vascular
congestion has decreased.
.
KUB [**3-31**]:
FINDINGS: A single supine frontal view of the abdomen shows a
nonspecific bowel gas pattern with gas in the small and large
bowel. No free air is detected on this supine film. A moderate
amount of fecal material is noted in the right colon. No dilated
loops of bowel are seen. Air is noted within the bladder which
is likely due to recent instrumentation.
IMPRESSION:
1. Nonspecific bowel gas pattern with moderate fecal material in
the right colon. No bowel obstruction or ileus.
2. Air within the bladder is likely due to recent
instrumentation.
Brief Hospital Course:
67 M with history of autism and dementia (A+O x 1 at baseline),
HTN, DM2, HLD who presents to ED with emesis and abdominal pain,
found to have positive troponin and TWI on EKG in
anterior/lateral leads concerning for possible ACS event, UA
suggestive of cystitis, and RLL infiltrate.
.
# NSTEMI of uncertain chronicity: Troponins were elevated at the
[**Hospital 99401**] hospital and on presentation here to 0.3, although in
the context of CHF exacerbation. His EKG demonstrated diffuse
TWI in anterior, inferior leads concerning for NSTEMI. He was
started on heparin and aspirin. He underwent an ECHO which
showed regional wall motion abnormalities and EF 25-30%.
Cardiology recommended catheterization however prior to the
procedure he developed frank hematuria believed to be from
traumatic foley insertion in setting of heparin so
anticoagulation was held and catheterization was deferred. EKG
continued to show TWI, although slightly impoved in V1 and V3.
Some of this may be [**2-6**] cerebral T-waves, and chronicity is
unclear, particularly given the patient's lack of chest pain or
dyspnea. It was determined that medical management would be
appropriate given this uncertain timing. We cannot be certain
that this is NSTEMI, as the changes may be chronic or due to his
known cerebral injury. Heparin gtt was stopped [**4-6**] to allow
hematuria to resolve, low risk of acute clot. Discharged on
aspirin 325, statin, lisinopril and metoprolol.
.
# Global hypokinesis and apical aneurysm: Chronic systolic HF
with EF 25-30%. Given global hypokinesis and LV apex aneurysm,
we initially wished to continue anti-coagulation to lower
clotting risk. However, given continued hematuria the risk of
this treatment is higher than the limited benefit. The risk of
thrombus with a chronic LV aneurysm is low, and anti-coagulation
is not necessary unless other risk factors are present. Given
his persistent hematuria and associated reduction in functional
status, the risk-benefit of stopping heparin was clear. Focus
on improving his functional status and maintaining cardiac
function. No long-term anti-coagulation is necessary given low
risk of clotting.
.
# Health Care Associated Pneumonia: He presented with cough,
elevated WBC count and CXR with RLL infiltrate. He was started
on vancomycin, cefepime, and levofloxacin for HCAP. He was noted
to have a long QT so his levofloxacin was switched to
azithromycin. Urine legionella antigen was negative and blood
cultures were unrevealing. He was treated with azithromycin for
5 days and a 7 day course of vancomycin/cefepime for possible
aspiration or HCAP. Noted to be MRSA positive from nasal swab.
.
# Dementia/autism: He presented with lethargy. Per report his
baseline is A+Ox1. He normally takes Zyprexa 2.5mg at 9am, 5mg
at 9pm, Ativan 0.5mg [**Hospital1 **] standing and 1mg PRN. In setting of
lethargy and concern for prolonged QT, his home meds were held.
At time of transfer out of MICU his mental status improved back
to his baseline. On the floor he triggered [**3-31**] for somnolence,
but vital signs were stable, ABG showed mild hypoxia, and he
became rousable without intervention. Continued to hold Zyprexa
and Ativan with good result, no agitation. We suggest using
these only PRN to avoid QT prolongation.
.
# Pyuria: His inital UA was suggestive of UTI. OSH CT report did
not show perinephric stranding or signs of pyelonephritis. He
was started on broad spectrum antibiotics for his pneumonia as
above. His urine culture did not grow any organisms.
.
# Hematuria: Believed to be from traumatic foley insertion in
setting of BPH and heparin. Urology was consulted and felt that
continuous bladder irrigation could help heal any prostatic
injury. He was also started on finasteride to improve prostate
healing. This was continued for several days with success. Hct
trend 46.0 on [**3-31**] --> 39.7 [**4-1**] --> 38.4 [**4-2**] --> 38.7 [**4-3**] -->
37.9 [**4-4**] --> 34.9 [**4-5**] --> 34.9 [**4-6**] --> 31.0 [**4-7**] --> 31.1 [**4-8**].
[**4-6**] patient began to complain of pain at Foley site, blood clot
and minor bleeding visible at meatus. Heparin gtt stopped [**4-6**]
(as per above), hematuria then began slowly clearing.
Continuous bladder irrigation stopped [**4-7**], patient was monitored
for clotting of Foley causing retention, however has not had
problem in 24 hours with urine output. Urology follow-up as an
outpatient was scheduled to ensure resolution of these
symptoms.Please maintain Foley until urology appointment on
[**2116-4-15**], at this point they will reassess.
.
.
# Pressure ulcers: Patient observed to have pressure ulcers on
heel and sacrum. These were present on transfer to our care,
may be related to his relative inactivity at the facility and
recent hospitalization. Managed with wound care, waffle boots.
.
Chronic Issues:
# DM2: Continued home lantus and ISS.
.
Transitional Issues:
- Outpatient follow up of pulmonary nodule found on CT scan
- Outpatient follow up of hematuria with Urology. Please
maintain Foley until urology appointment on [**2116-4-15**], at this
point they will reassess.
. Monitor UOP, if < 200cc in 4 hours please bladder scan. If
bladder scan > 400 cc, hand irrigate Foley to remove any clot.
Continue finasteride until hematuria resolves or Urology
appointment.
- Patient has two pressure ulcers; left heel, sacrum. Please
continue wound care
- Please check weight, provide additional diuresis (Lasix 20mg
PO) for weight gain > 3 lbs
- The patient's sister, [**Name (NI) **], called the hospital for an
update. She was not known to the patient's guardian, it is not
clear what level of information she can have access to from our
facility. Phone number: [**Telephone/Fax (1) 110562**]
Medications on Admission:
per Millenium pharmacy from [**2116-3-4**]
Asa 81mg daily
ativan 0.5mg [**Hospital1 **]
ativan 1mg prn anxiety
colace 100 [**Hospital1 **]
compazine 10mg [**Hospital1 **] standing
humalog ISS
Lantus 39 qhs
nitro patch 0.2mg/hr from 9pm-9am
zyprexa 2.5mg at 9am, 5mg at 9pm
bisacodyl 10mg supp prn
fleet enema prn
loperamide 2mg q4hr prn diarrhea
maalox prn
MOM prn
tylenol 500mg prn
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety: Please only use as needed due to QT
prolongation.
4. Zyprexa 2.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for agitation: Please only use as needed due to QT
prolongation. .
5. Lantus 100 unit/mL Solution Sig: Thirty Nine (39) units
Subcutaneous at bedtime.
6. Humalog 100 unit/mL Solution Sig: Two (2) units Subcutaneous
four times a day as needed for FSBS > 150: per sliding scale.
7. bisacodyl 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation: if not relieved by senna,
bisacodyl.
10. Maalox Maximum Strength 400-400-40 mg/5 mL Suspension Sig:
Fifteen (15) ml PO three times a day as needed for heartburn.
11. Milk of Magnesia 400 mg/5 mL Suspension Sig: Fifteen (15) ml
PO twice a day as needed for indigestion.
12. loperamide 2 mg Tablet Sig: 1-2 Tablets PO four times a day
as needed for loose stools.
13. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: no more than 4g/day.
14. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
16. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days: or until resolution of hematuria.
17. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
18. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Rehab and Nursing
Discharge Diagnosis:
pneumonia
urinary tract infection
evidence cardiac ischemia of unknown chronicity, possibly NSTEMI
hematuria [**2-6**] prostatic injury
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred to this hospital with
pneumonia and a urinary tract infection. You were treated with
antibiotics and these infections resolved. You were found to
have signs of heart damage, however it was not clear if this was
old or new. We found that there was no evolution of this
damage, so we managed this with anti-clotting medicine and other
medications to help your heart work more effectively.
A Foley catheter was placed while you were in the ICU, but
unfortunately this caused injury to your prostate. You were on
an anti-clotting medication, so you experienced ongoing blood in
the urine for several days. Once the anti-clotting medication
was stopped this began to resolve. Although your blood count
dropped, it did not reach a dangerously low level and you were
not transfused. The blood in the urine should continue to
improve, although it may take 1-2 weeks to go away entirely.
We made the following changes to your medications:
- CHANGE Ativan and Zyprexa to PRN, as he was stable without
anxiety or agitation without these medications and has QT
prolongation per EKG
- INCREASE aspirin to 325 daily
- STOP compazine due to QT prolongation
- STOP nitro patch
- START Senna for constipation (in addition to bisacodyl, Fleet
enema PRN)
- START atorvastatin
- START metoprolol and lisinopril for hypertension and cardiac
ischemia
- START finasteride until hematuria resolves or per Urology
- START Nystatin swish and swallow PRN thrush
- START multivitamin daily for nutritional support
Please follow-up with a Cardiologist and Urologist as listed
below. Weigh yourself every morning, adjust diuretics if weight
goes up more than 3 lbs. Suggest Lasix 20mg PO daily.
Followup Instructions:
Department: SURGICAL SPECIALTIES/UROLOGY
When: WEDNESDAY [**2116-4-15**] at 2:00 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2116-4-22**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 486, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7003
} | Medical Text: Admission Date: [**2181-4-25**] Discharge Date: [**2181-4-30**]
Date of Birth: [**2133-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
atrial fibrillation s/p ablation, unable to extubate
Major Surgical or Invasive Procedure:
Atrial Fibrillation s/p ablation
Cardioversion
Intubation
History of Present Illness:
This patient is 48 yo male with a past medical history of
paroxysmal afib, hyperlipidemia, mitochondrial muscular disorder
with gait instability who presented today for an atrial
fibrillation ablation following which he was difficult to
extubate and hypotensive.
The patient was diagnosed with paroxysmal atrial fibrillation in
[**2174**], was cardioverted, started on aspirin and rate controlled.
Next, in [**2177**] he went into afib, was again cardioverted and
started on Propafenone. He had a recent episode of atrial
fibrillation/flutter and was started on Coumadin. He underwent
cardioversion for a third time in [**2181-3-4**]. He saw Dr.
[**Last Name (STitle) **] in electrophysiology consultation on [**2181-3-27**] for
treatment of his atrial fibrillation. He is not felt to be a
good candidate for long-term Coumadin therapy due to his history
of falls secondary to the neuromuscular disorder, and had
pulmonary vein isolation today. In terms of symptoms, per CMI
note, he is reports feeling more fatigued and short of breath
when he is in atrial fibrillation. He denies chest pain,
dizziness or syncope.
Today, the patient had afib ablation. At the end of the case he
was given protamine to reverse his anticoagulation and systolic
blood pressure dropped to the 60's after the protamine requiring
bolused vasopressors. He was also difficult to extubate, likely
secondary to the neuromuscular disorder. An ECHO at the bedside
in the lab showed no effusion. The patient has 3 femoral sheaths
still in place for access until the AM.
.
On floor, patient was intubated and sedated, unable to do review
of systems.
Past Medical History:
- Paroxysmal atrial fibrillation (first in [**2174**] s/p
cardioversion, [**2177**] cardioverted and on propafenone, now more
often recently)
- mitochondrial myotonic dystrophy
- Hyperlipidemia
CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, - Hypertension
CARDIAC HISTORY:
-CABG: no
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: no
Social History:
He is married with no children. He does not smoke but
drinks socially. He is currently on medical disability. He is
from [**Country **], but has been living in america for >10 years.
Family History:
He claims his both parents may have arrhythmias, they are alive
into their 70s. His father may also have a neuromuscular
disorder. He has one sister age 44. [**Name2 (NI) 6419**] his father and his
sister apparently have a slow heart rate, although they do not
have pacemakers at this time.
Physical Exam:
VS: 98.4 hr 79, 91/72, rr 15, 95% on 100% Fi02
GENERAL: intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. OG tube and ET tube in
place
NECK: supple, no LAD
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: clear anteriorly and laterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. 2 left femoral sheaths, 1 right femoral
sheath.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: b/l pedal pulses palpable
Pertinent Results:
Admission Labs
[**2181-4-25**] 10:58AM BLOOD WBC-7.0 RBC-5.21 Hgb-16.4 Hct-49.4 MCV-95
MCH-31.5 MCHC-33.2 RDW-14.1 Plt Ct-172
[**2181-4-25**] 10:58AM BLOOD PT-28.5* PTT-35.7* INR(PT)-2.9*
[**2181-4-25**] 10:58AM BLOOD Glucose-109* UreaN-14 Creat-0.7 Na-144
K-4.2 Cl-105 HCO3-32 AnGap-11
[**2181-4-25**] 10:04PM BLOOD Type-ART pO2-95 pCO2-52* pH-7.40
calTCO2-33* Base XS-5
.
[**2181-4-26**]
CT chest with contrast:
1. No evidence of pulmonary embolism.
2. Unchanged low lung volumes and atelectasis.
3. Improved visualization of a 6-mm nodular opacity at the right
upper lobe.
Three-month CT followup is recommended.
4. Heterogeneous left thyroid nodule. Consider ultrasound if
warranted
clinically.
.
[**2181-4-26**] Ct chest without contrast:
1. Enlarged left lobe of the thyroid with some low-attenuation
foci.
Consider ultrasound if warranted clinically.
2. Low lung volumes. Parenchymal opacities at the bases are
associated with
volume loss and most suggestive of atelectasis.
3. Minimal retained secretions within the trachea.
4. Mild thickening of the anterior trachea wall, which is
nonspecific
but could potentially be due to a sequelae or prior intubation
or tracheostomy
placement.
5. Mild enlargement of the main pulmonary artery.
.
[**2181-4-28**] Echo:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
right atrium is moderately dilated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Transmitral and tissue Doppler imaging suggests normal
diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). The right ventricular cavity is mildly
dilated with normal free wall contractility. 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 regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild right ventricular cavity enlargement with
preserved global free wall motion. Biatrail enlargement.
CLINICAL IMPLICATIONS:
Based on [**2179**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
[**4-27**] CXR:
Lung volumes are lower with increased bibasilar atelectasis.
Bilateral
pleural effusions, if any, would still be tiny. There is no
other overall
change.
Brief Hospital Course:
48M with history of neuromuscular disorder, paroxysmal atrial
fibrillation s/p ablation complicated by hypotension and
difficulty with extubation.
#Respiratory distress: Patient was difficult to extubate after
case. Extubation was attempted briefly, but since patient was
hypotensive, was sent to CCU. He received 2L IVF in EP lab.
Apparently in prior intubation O2sats had been low likely due to
underlying neuromuscular disorder and baseline as wife said
patient has a lot of am secretions. Patient appeared volume
overloaded on xray so was diuresed with good response. He
tolerated extubation well on [**4-26**] but remained hypoxic. Chest CT
was negative for PE but was consistent with low lung volumes and
atelectasis. Pulm was consulted and reported low NIF consistant
with decreased diaphragmatic weakensss likely [**3-5**] to underlying
neuromuscular disorder. He continued to be hypoxic with
ambulation requring 4L by nasal canula to keep sats at 94%.
Patient will get PFTS and be followed by pulm as outpatient as
his disorder is likely progressing and will need home oxygen at
the very least for now.
#Hypotension: Patient hypotensive after receiving protamine in
the EP lab. Likely protamine reaction, since it can cause
sudden, transient drop in blood pressure. Required minimal
phenylephrine which was weaned off. Afebrile and no white count
so sepsis unlikely. Resolved and beta blocker was restarted.
#Atrial fibrillation: s/p ablation. Has been in sinus since.
Continue coumadin, propafenone and atenolol. Followed INR.
Follow up with EP.
#Mitochondrial Neuromuscular disorder: Likely reason why low
sats with intubation and weak cough post intubation. Should
follow up with neurology as outpatient. Evaluate my physical
therapy who believe he is safe to go home but should get home PT
eval.
Medications on Admission:
Atenolol 12.5mg daily
Propafenone 225mg twice daily
simvastatin 40mg daily
Warfarin 5mg everyday except 7mg on MWF
Aspirin 81mg
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Propafenone 225 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAYS
(MO,WE,FR).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,TH,SA).
6. Home Oxygen
3-4L continuous pulsed dose for portability, O2 sat 86% on RA.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Atrial Fibrillation
2. Mitochondrial Myotonic Dystrophy
3. Hypoxia
.
SECONDARY DIAGNOSIS:
1. Hyperlipidemia
Discharge Condition:
Stable. Patient is ambulating, tolerating oral intake, and has
returned to his baseline condition.
Discharge Instructions:
You were admitted to the hospital for treatment of your atrial
fibrillation. You underwent a procedure to return your heart to
normal rhythm. You had some difficulty breathing after your
procedure and you were monitored in the intensive care unit for
2 days after your procedure. You are now in a normal sinus
rhythm. We made an appt with Dr. [**First Name (STitle) **] from pulmonology to get
breathing tests. These appts are listed below.
.
We made the following changes to your medication:
1. Increase your aspirin to 325 mg daily
2. Take Ibuprofen for any chest burning or ache that you may
have. If the ibuprofen does not alleviate the symptoms, call Dr.
[**Last Name (STitle) **].
.
Please seek immediate medical care if you develop shortness of
breath, light-headedness, dizziness, loss of consciousness,
fevers, shaking chills, night sweats, abdominal pain, back pain,
or pain in your lower extremities.
.
You will be going home on a monitor to evaluate your heart
rhythm. Please follow the instructions given to you. You will
send strips daily and the monitor will trigger if you go back
into atrial fibrillation.
Followup Instructions:
Please follow-up with your cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD on
[**2181-5-28**] 3:40.
.
Pulmonology:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 513**]
Date/time: Wednesday [**5-16**] at 3:30 with Dr. [**Last Name (STitle) 18309**] on
[**Hospital Ward Name 23**] 7
Pulmonary function tests before the appt at 2:30pm on [**Hospital Ward Name 23**] 7,
Clinical Center, [**Hospital Ward Name 516**], [**Location (un) **]
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 74550**] Date/time: [**5-14**] at 3:30pm.
Completed by:[**2181-4-30**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7004
} | Medical Text: Admission Date: [**2167-1-23**] Discharge Date: [**2167-1-29**]
Date of Birth: [**2167-1-23**] Sex: M
Service: Neonatology
HISTORY: This is a 34 [**6-6**] week twin number 1 admitted due to
issues of prematurity who was born to a 32-year-old G3, P0-2-
2 mom, [**Name (NI) 37516**] [**2167-3-2**]. [**Name2 (NI) 60050**]l labs were not available on
the day of delivery except for maternal blood type O
positive, antibody negative, rubella immune, hepatitis B
surface antigen later confirmed as negative. By parental
report, pregnancy without complications and normal prenatal
fetal survey. Mom's history significant for asthma, but she
was not on medications during the pregnancy.
Mom presented on the day of delivery in pre-term labor with
rupture of membranes. GDS status was unknown. There was no
maternal fever, no fetal tachycardia. Mom received
antibiotics 5 hours prior to delivery. Patient delivered via
C-section due to fetal decelerations in both infants, emerged
with good respiratory effort, tone slightly decreased but
appropriate for age, Apgars of 8 at 1 minute and 8 at 5
minutes, brought to the NICU for further evaluation.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2280 (50th
percentile), length 19 inches (75th to 90th percentile), head
circumference 33 cm (75th percentile), heart rate 136,
respiratory rate 38, blood pressure 68/39 with a mean of 49,
saturating 100 percent on room air. Patient is an active
infant. Anterior fontanel open and flat. Heart with a
normal S1, S2; no murmur. Breath sounds clear. Abdomen:
Soft, nontender, nondistended. Extremities: Well perfused.
Tone appropriate for gestational age. Hips stable. Normal
premature male genitalia. Anus patent. Spine intact. Skin
notable for pustular lesions diffusely over the body and some
areas with scale.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Patient is breathing comfortably on room air
throughout admission, maintaining normal oxygen
saturation. No episodes of apnea and bradycardia of
prematurity.
2. Cardiovascular: Patient remained cardiovascularly stable
throughout admission with normal blood pressures and no
murmur.
3. FEN: Patient initially NPO and on IV fluids. Feeds were
initiated on day of life 1 and were gradually advanced.
The patient tolerated feeding and advanced well. By
[**2167-1-27**] patient was taking full p.o. ad lib feeds of
breast milk 20. Was started on Fer-In-[**Male First Name (un) **] and Vi-Daylin
vitamin supplements. Glucoses remained within normal
limits throughout. Last set of electrolytes was on
[**2167-1-24**] and was sodium 142, potassium 4.0, chloride
109, and bicarbonate 26. Discharge weight on [**1-29**] was 2135g.
4. GI: Patient's bilirubin peaked at 10.1/0.3 on day of life
3 and phototherapy was initiated. Phototherapy was
discontinued on [**2167-1-28**] at a bilirubin of 10.0/0.3
rebound bilirubin on [**2167-1-29**] of 10.9/0.3
5. Hematology: Hematocrit on admission 51.3 with a platelet
count of 302. Patient did not require any blood products
during this hospitalization.
6. ID: CBC and blood cultures sent on admission. White
count of 10 with 36 polys and no bands. Patient was
started on ampicillin and gentamicin. Antibiotics
discontinued when blood cultures negative times 48 hours.
Mom's hepatitis B status was unknown at time of delivery.
Therefore, patient was given hepatitis B vaccine within 12
hours of delivery. Mom's hepatitis B screen was resent
and subsequently came back as negative.
7. Sensory/Audiology: Hearing screen passed
8. Psychosocial: [**Hospital1 18**] Social Work involved with family.
Social worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged to home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) 60051**] of [**Hospital 620**]
Pediatrics.
CARE AND RECOMMENDATIONS: Feeds at discharge q. ad lib
breast milk 20.
MEDICATIONS:
1. Fer-In-[**Male First Name (un) **] 0.2 cc per day
2. Vi-Daylin 1 cc per day
Patient passed a car seat test prior to discharge home.
Newborn state screen sent and pending at time of discharge.
Hepatitis B vaccine given on [**1-23**].
Patient to follow up with Dr. [**Last Name (STitle) 60051**] one day after discharge to
assess for worsening jaundice, monitor weight and po intake.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks gestational age.
2. Rule out sepsis.
3. Hyperbilirubinemia-resolved
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2167-1-27**] 14:25:33
T: [**2167-1-27**] 15:21:15
Job#: [**Job Number 60052**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7005
} | Medical Text: Admission Date: [**2180-9-14**] Discharge Date: [**2180-9-26**]
Date of Birth: [**2107-5-25**] Sex: F
Service: NEUROSURGERY
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Cerebellar Hemorrhage
Major Surgical or Invasive Procedure:
EVD Placement
History of Present Illness:
Patient is a 73 yo female with a PMH of peripheral vascular
disease, s/p thrombolytics and angioplasty for ischemia of left
foot, hypothyroidism and hypercholesterolemia, who presented
with acute onset vertigo, nausea, vomiting, and lethargy.
[**Name (NI) **] sister relates the story stating that the patient was
in a normal state of health this morning when was sitting in a
chair by the window and developed acute nausea,vomiting,
incontinence of stool and diarrhea. She felt weak and
lightheaded and her sister called an ambulance. At the OSH
ED,she was noted to be slightly hypothermic with a temperature
of 93.9 (rectal) F. A bear hugger was applied and sepsis work-up
started. Head CT revealed posterior fossa hemorrhage involving
the right cerebellar hemisphere with intraventricular extension
and filling of the fourth ventricle and filling of the third.
Patient is on plavix and was transfussed platelets in the ED.
Past Medical History:
- Peripheral vascular disease, recent stent to left leg, anatomy
- Hypothyroidism, on Levothyroxine.
- Hypercholesterolemia, not being treated.
- H/o Bell's Palsy.
- H/o cellulitis.
Social History:
Patient lives at home, without services. Speaks English. Smokes
one pack per day. No alcohol. No illicits.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
Gen: intubated.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: arrousable to pain
Cranial Nerves:
eyes fixed to R, pupils reactive to light BL, + gag and
corneals,
Motor: Normal bulk. Tone increased in legs and arms, neck.
Reflexes: Reflexes were symmetric bilaterally. Toes upgoing
bilaterally.
UPon discharge:
Alert and Orieted, Motor exam full.
Pertinent Results:
ADMISSION LABS:
[**2180-9-14**] 03:30PM WBC-4.0 RBC-4.12* HGB-11.2* HCT-33.8* MCV-82
MCH-27.1 MCHC-33.0 RDW-14.6
[**2180-9-14**] 03:30PM PT-12.5 PTT-24.5 INR(PT)-1.1
[**2180-9-14**] 03:35PM GLUCOSE-103 LACTATE-2.0 NA+-141 K+-4.3
CL--104 TCO2-26
DISCHARGE LABS:
IMAGING:
CT Head [**9-14**]:
IMPRESSION:
1. Left cerebellar hemisphere hemorrhage extending into the
fourth, third and bilateral lateral ventricles with minimally
increased blood in the posterior [**Doctor Last Name 534**] of the left ventricle
compared to CT scan obtained earlier today.
2. New focus of subarachnoid hemorrhage in the right parietal
region.
3. Unchanged tonsillar herniation. No evidence of uncal or
subfalcine
herniation.
4. Mildly dilated temporal horns is concerning for impending
hydrocephalus. Dr. [**Last Name (STitle) 49784**] was notified of updated findings at
5:25 p.m. on [**2180-9-14**]
CT Head [**9-14**]:
IMPRESSION:
1. Status post ventriculostomy catheter from a right frontal
approach with
decompression of the lateral ventricles.
2. Relatively unchanged appearance and left cerebellar
intraparenchymal
hemorrhage and intraventricular hemorrhage of the third, fourth,
and occipital horns of the lateral ventricles.
3. Density along the sulcus in the right parietal region may
represent a
component of subarachnoid hemorrhage, although it is not changed
significantly over the prior couple of studies
CT Head [**9-16**]
IMPRESSION:
1. Similar size and configuration of the left cerebellar
hemispheric
hemorrhage with surrounding edema.
2. Similar amount of blood extending into and expanding the
fourth ventricle.
3. Decrease in the amount and density of the blood in the third
ventricle.
4. Unchanged intraventricular hemorrhage and small right
parietal
subarachnoid hemorrhage.
5. The size and configuration of the ventricles is similar to
the most recent prior study.
CT head [**2180-9-18**]
IMPRESSION:
1. Since prior examination, mild increase in size of the lateral
ventricles
and third ventricle, for which close interval followup is
recommended.
2. Interval improvement of hemorrhage within the third
ventricle.
3. Stable areas of intraventricular hemorrhage, subarachnoid
hemorrhage, and left cerebellar intraparenchymal hemorrhage.
CT [**2180-9-23**]:
Status post removal of right EVD. Small amount of
pneumocephalus. Stable left cerebellar hemorrhage. No evidence
of new
hemorrhage. Evaluate for underlying cause of the hemorrhage as
clinically
indicated.
Brief Hospital Course:
The patient was admitted to the NSurg service in the ICU for Q 1
hour neuro checks. An emergent EVD was placed for relief in
increased ICP, and the level was kept at 10mm above the tragus.
Her Blood pressure was kept less than 160. Her plaxix was
discontinued. She was able to be extubated HD#2, she was
following commands and moving all 4 extremities.ICP remained in
normal range. She had trial of EVD clamping on HD#4 but after a
few hours her exam declined even though ICP remained in normal
range and EVD was opened. Clamping trial occured again and was
successful with stable CT and the EVD was removed HD#8.Her exam
was much brighter, her N/V stopped and she passed speech and
swallow evaluation. She developed atrial flutter which was
treated successfully but then returned. Cardiology was consulted
to assist, she has been on Amiodarone IV and transitioned to PO
with resolution of flutter she is to continue a month course of
treatment. Her thyroid function tests were found to be abnormal
with a TSH of 26, T4 4.3, T3 of 32, endocrine recommended
resuming her Levothyroxine at 100mcg daily.
On [**9-26**] family precieved her mental status to be worse in the
afternoon so a head CT was repeated that was unchanged from
previous studies without any acute changes.
She is at the time of discharge alert and oriented with a full
motor exam.
Medications on Admission:
Levothyroxine, Plavix,Simvastatin
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 weeks.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain/fever.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
6. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q4hprn () as needed for wheezing/ sob.
7. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. HydrALAzine 10 mg IV Q6H:PRN SBP > 140
9. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
cerebellar hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair
?????? 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 3 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2180-9-26**]
ICD9 Codes: 431, 5070, 2449, 2720, 3051, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7006
} | Medical Text: Admission Date: [**2165-1-14**] Discharge Date: [**2165-1-21**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: This 74 year old, white male,
has a history of hypertension, hypercholesterolemia and
aortic stenosis and has been experiencing dyspnea and
occasional chest discomfort with walking. He underwent a
stress echo on [**9-8**] which revealed an ejection fraction of
55 to 60%; mild mitral regurgitation; trace tricuspid
regurgitation; mild aortic stenosis with an aortic valve area
of 1.9 cm squared and 2+ aortic insufficiency. His post
exercise echo showed
This report was CUT OFF!
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2165-1-21**] 04:38
T: [**2165-1-21**] 16:42
JOB#: [**Job Number 24411**]
ICD9 Codes: 4241, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7007
} | Medical Text: Admission Date: [**2199-3-11**] Discharge Date: [**2199-3-16**]
Service: MEDICAL ICU
CHIEF COMPLAINT: Cough, shortness of breath.
HISTORY OF PRESENT ILLNESS: This is an 88 year old woman
with a history of interstitial lung disease, who presented
with cough productive of sputum and dyspnea at rest for
several days.
HOSPITAL COURSE: She was found to have a gram negative
pneumonia and was started on Gentamicin and Zosyn for
treatment of pseudomonal pneumonia. She became increasingly
hypercarbic and face mask trial with BiPAP was attempted to
improve oxygenation and ventilation. However, her oxygen and
ventilation continued to be poor on BiPAP and she was
intubated for respiratory failure on [**2199-3-13**].
The family decided that given the patient's poor condition as
well as poor prognosis that comfort measures would be
initiated. A Morphine drip was started and she was extubated
on [**2199-3-14**]. She passed away on [**2199-3-16**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) 8873**] 12-713
Dictated By:[**Name8 (MD) 4123**]
MEDQUIST36
D: [**2199-3-17**] 13:39
T: [**2199-3-18**] 21:04
JOB#: [**Job Number 27449**]
ICD9 Codes: 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7008
} | Medical Text: Admission Date: [**2118-8-5**] Discharge Date: [**2118-8-19**]
Date of Birth: [**2047-4-4**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
female with a 7-day history of flushing and dyspnea on
movement and exertion. She had an echocardiogram which
showed decreased ejection fraction. She also had a cardiac
catheterization which showed left anterior descending artery
proximally calcified with 60% to 70% stenosis and mid 70%
stenosis, left circumflex with minimal narrowing with small
left posterior descending artery, right coronary artery 80%
to 90% proximal and medial segment stenosis, ejection
fraction of 25% to 30%, severe hypokinesis.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Hypercholesterolemia.
3. Pneumonia in the past.
4. Hypertension.
5. Coronary artery disease.
PAST SURGICAL HISTORY:
1. Status post hysterectomy.
2. Status post angioplasty in [**2112**].
ALLERGIES: ASPIRIN (swelling).
MEDICATIONS ON ADMISSION: Glucophage 500 mg p.o. b.i.d.,
Lipitor 10 mg p.o. q.d., Aciphex 20 mg p.o. q.d.,
Toprol-XL 75 mg p.o. q.d., Univasc 15 mg p.o. q.d.,
Plavix 75 mg p.o.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, a pleasant and cooperative lady, in no acute
distress. Heart rate was 85, blood pressure was 186/80.
Chest was clear to auscultation bilaterally. Heart revealed
a regular rate and rhythm, possible third heart sound. The
abdomen was soft, nontender, and nondistended. Extremities
revealed pulses were palpable.
HOSPITAL COURSE: The patient was brought to the operating
room on [**2118-8-5**]. Coronary artery bypass graft times
two off pump was performed with left internal mammary artery
to left anterior descending artery and saphenous vein graft
to ramus. The operation went without complication.
Ventricular pacing wires as well as mediastinal and pleural
chest tubes were placed in the operating room.
The patient had a brief episode of atrial fibrillation
intraoperatively and was successfully cardioverted. She was
also on Neo-Synephrine and nitroglycerin drips
intraoperatively for labile blood pressures.
On postoperative day one, the patient was successfully
extubated; however, she had a fluid requirement. She needed
intravenous blood pressure support. She was transfused 2
units of packed red blood cells. The patient was started on
Lopressor; however, her cardiac index dropped below 2.
Lopressor was discontinued. She was restarted on Nipride as
well as hydralazine. Her urine output was 8 cc to 10 cc per
hour.
On postoperative day three, the patient remained hypertensive
requiring Nipride while captopril was titrated up. The
patient started complaining of nausea. Her abdomen was
distended with hyperactive bowel sounds. She tolerated orals
as well. Cardiology was consulted for the patient's
cardiovascular issues who recommended discontinuation of
dobutamine and staring the patient on lisinopril and
amiodarone; which was done. She was also receiving Reglan
for her continued abdominal discomfort.
The patient had an episode of supraventricular tachycardia at
a rate of more than 200. She responded well to 10 mg of
Lopressor and 150 mg of amiodarone push.
On postoperative day five, the patient was started on
Norvasc. The patient had liver function tests done because
of contiunous abdominal discomfort which showed an ALT of
292, AST was 193, alkaline phosphatase was 264, total
bilirubin was 1.8 which had all increased since [**7-27**]
.................... was done. A right upper quadrant
ultrasound was performed which showed dilated cystic duct,
pericholecystic fluid, but no stones. General Surgery was
consulted who thought that cholecystectomy ? was a very
likely diagnosis. A HIDA scan was done which showed that her
gallbladder did not fill. A cholecystectomy tube was placed
at the bedside with ultrasound guidance. Tube was draining
mild blood, and samples were sent for culture and Gram stain.
The patient remained n.p.o.
On postoperative day six, an echocardiogram showed tricuspid
regurgitation with right ventricular dysfunction. The
patient was started on orals as well and was taking sips.
Her oral intake was not great.
On postoperative day seven, .................... placed for
cardiovascular monitoring. The left subclavian line was
removed after right internal jugular was placed. The patient
had an episode of rapid atrial fibrillation and was placed on
1 mg amiodarone drip.
On postoperative day eight, the patient remained stable.
Abdominal had resolved. The cholecystostomy tube was
draining green bile. On postoperative day nine, the cultures
came back with bile growing enterococcus, and urine growing
Klebsiella and enterococcus. The patient was continued on
intravenous antibiotics. Her liver function tests were
normalizing. Her appetite remained poor.
On postoperative day 10, the patient failed a voiding trial,
and a Foley was placed back in. A peripherally inserted
central catheter line was placed for antibiotic
administration. The patient was transferred to the floor in
stable condition on postoperative day 11.
On postoperative day 12, the patient's oral intake had
improved. She was continued on antibiotic therapy. She was
ambulating with Physical Therapy. The patient again failed a
voiding trial, and a Foley catheter was placed back in on
postoperative day 14. The patient was stable on antibiotics.
She continued ambulating with Physical Therapy. The patient
had good oral intake, and no active issues at this time.
MEDICATIONS ON DISCHARGE:
1. Docusate 100 mg p.o. b.i.d.
2. Tylenol 650 mg p.o. q.4h. as needed.
3. Bisacodyl 10 mg p.o./p.r. q.d. as needed.
4. Plavix 75 mg p.o. q.d. (for three months).
5. Lisinopril 40 mg p.o. q.d.
6. Hydralazine 50 mg p.o. t.i.d.
7. Levofloxacin 500 mg q.d.
8. Amiodarone 400 mg p.o. b.i.d. (times two days); then
amiodarone 400 mg p.o. q.d.
9. Pantoprazole 40 mg p.o. q.24h.
10. Reglan 10 mg intravenously q.6h.
11. Glucovance two tablets p.o. b.i.d.
12. Ampicillin 1 g q.6h. intravenously (times seven days).
13. Flagyl 500 mg p.o. t.i.d. (times seven days).
14. Warfarin 2 mg p.o. q.d.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: The patient was discharged to a
rehabilitation facility.
DISCHARGE INSTRUCTIONS: The patient should come back to see
Dr. [**Last Name (STitle) 1537**] in four weeks for postoperative followup. The
patient should come back to see General Surgery in four weeks
for followup since the patient will need a cholecystectomy in
six to ten weeks from now.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft times two.
3. Status post angioplasty in [**2112**].
4. Hypertension.
5. Hypercholesterolemia.
6. Diabetes mellitus.
7. Status post hysterectomy.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 15509**]
MEDQUIST36
D: [**2118-8-18**] 13:22
T: [**2118-8-18**] 15:13
JOB#: [**Job Number 15510**]
ICD9 Codes: 4271, 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7009
} | Medical Text: Admission Date: [**2174-8-6**] Discharge Date: [**2174-9-8**]
Date of Birth: [**2105-12-29**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Oxycodone Hcl/Acetaminophen / Hydrocodone Bit/Acetaminophen
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal pain/Possible perforated diverticulum
Major Surgical or Invasive Procedure:
1. Exploratory laparatomy
2. Small bowel resection
History of Present Illness:
The patient is a 68 year old male with a 38 year history of
Crohn's disease, coronary artery disease, previous small bowel
obstruction, and congestive heart failure, status post resection
of small bowel three times ([**2136**], [**2154**], [**2164**]) who presented from
[**Doctor Last Name 1495**] [**Hospital 107**] Medical center with abdominal pain.
He was in his usual state of health until approximately 2 months
ago, when he began having increased diarrheal episodes, with up
to 30 bowel movements in a 24 hour period. This is compared to
his baseline for the last decade is [**5-26**] loose stools a day, but
overall has maintained a stable weight and lifestyle on 5-ASA,
Imuran, and prednisone maintenance. He has had occasional
flares of cramps, partial small bowel obstructions treated with
IV fluids and increased doses of prednisone. He also has had
complications involving recurrent perianal fistulas as well.
This resulted in him presenting to the outside institution for a
colonoscopy, and the results demonstrated some ileitis with no
colitis. The the next day ([**2174-7-20**]), Three weeks prior to the
admission to this hospital, the patient experienced the acute
onset of abdominal pain. A CT was suggestive of a potential
small bowel perforation. He was kept NPO, started on TPN, and
was given antibiotics for 2 weeks, and he improved. However, he
had persistent pain that was aggrevated by taking anything by
mouth. He did have some fevers on presentation.
No nausea, vomiting, melena, hematochezia, hematemesis, recent
travel, new foods. Otherwise review of systems was negative
Past Medical History:
1. Crohn's disease status post small bowel resections (see HPI)
2. Coronory artery disease
3. Status post exploratory laparotomy complicated by MI (in
past)
4. Small bowel obstruction
5. Congestive heart failure ([**7-24**] EF=39% with no reversable
defects
Social History:
Retired, Married, no alcohol, no cigarettes
Family History:
No history of crohn's disease
Physical Exam:
Temperature 98.6, Heart rate 76, Blood pressure 110/70,
Respiratory rate 20, oxygen saturation 99% on room air
General: well nourished and well hydrated
Head and neck: pupils equal round and reactive to light. neck
supple, trachea midline, no cervical lymphadenopathy
Chest: clear to auscultation bilaterally
Heart: regular rate and rhythm
Abdomen: obese, distended. some focal tenderness in left upper
quadrant. No guarding or rebound tenderness
Extremities: no clubbing cyanosis or edema
Pertinent Results:
[**2174-8-6**] 11:09PM BLOOD WBC-9.5 RBC-3.77* Hgb-12.6* Hct-36.6*
MCV-97 MCH-33.5* MCHC-34.5 RDW-14.1 Plt Ct-99*
[**2174-8-6**] 11:09PM BLOOD PT-13.2 PTT-25.7 INR(PT)-1.4
[**2174-8-6**] 11:09PM BLOOD Glucose-106* UreaN-46* Creat-1.4* Na-131*
K-4.3 Cl-94* HCO3-27 AnGap-14
[**2174-8-6**] 11:09PM BLOOD ALT-37 AST-21 AlkPhos-65 Amylase-108*
TotBili-0.4
[**2174-8-6**] 11:09PM BLOOD Lipase-62*
[**2174-8-6**] 11:09PM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.5*
Mg-2.1
[**2174-8-7**], [**2174-8-8**], [**2174-8-9**] Blood Cultures:
AEROBIC BOTTLE (Final [**2174-8-10**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
[**2174-8-9**]: Central line tip: Staphlococcus, coagulase negative
CT Abdomen and pelvis [**2174-8-8**]:
The visualized lung bases demonstrate tiny bilateral pleural
effusions and associated atelectatic changes. Allowing for
limitations of a noncontrast exam, the liver, spleen, pancreas,
adrenal glands, and kidneys appear grossly normal. Sludge and
stones are identified within the gallbladder, but no secondary
signs of cholecystitis are identified. Evauation of the bowel is
limited due to the presence of high- contrast barium material
and beam-hardening artifact. Allowing for this, there is a focal
loop of small bowel within the left hemiabdomen, likely mid
jejunum, which demonstrates wall thickening. At least two,
possibly three fluid collections are identified adjacent to this
loop of small bowel. This constellation of findings is most
compatible with active Crohn's disease. No free air is
identified. There are no discernible colonic abnormalities to
indicate the occurrence of perforation from recent colonoscopy.
These fluid collections measure approximately 5.6 x 4.1 and 6.3
x 2.2 cm. These are seemingly discrete collections, but they may
be contiguous by transmural extension. No other abnormal loops
of bowel are identified.
CT OF PELVIS WITHOUT IV CONTRAST: The urinary bladder is
collapsed due to the presence of a Foley catheter, limiting
evaluation. There is high-density contrast material within the
colon, as above, limiting evaluation. The sigmoid colon is
collapsed. No free fluid or air is identified.
IMPRESSION:
1. Focal wall thickening of a loop of mid jejunum with at least
two adjacent small fluid collections. These findings are most
compatible with active Crohn's disease in a patient with this
history.
2. Limited evaluation of colon demonstrates no evidence of
complications from recent colonoscopy.
3. Sludge and stone-containing gallbladder without evidence of
cholecystitis.
4. Tiny bilateral pleural effusions.
Brief Hospital Course:
The patient was admitted to the surgical service on [**2174-8-8**]. He
was kept NPO, was continued on his TPN, and had a CT scan. He
was started on levofloxacin/flagyl. He grew out coag negative
staph from in his blood cultures, and his central line was
pulled and he was started on vancomycin. The GI service thought
that this was not consistent with a crohn's flare, and they
suggested a rapid taper of his steroids. He was stable until
the evening of hospital day number 2, when he had the acute
onset of Left lower quadrant abdominal pain. The pain was
sharp, and his exam was concerning for some questionable
guarding in the left lower quadrant. However, he did not have
any truly positive peritoneal signs. His abdomen was more
distended than it had been. He got an upright chest and
abdominal xray that did not show any free air, but did show
dilated bowel loops. An NG tube was placed, and he had serial
abdominal exams overnight. His exam worsened, and he had clear
peritoneal signs in the left lower quadrant. he also became
tachycardic to the 110s, and his urine output decreased. A
decision was then made to take him to the operating room. Gross
spillage of stool was noted on the exploratory laparotomy, and a
segment of small bowel was resected in the area of jejunal
diverticuli. He was transfered to the intensive care unit,
intubated and required massive fluid resuscititation for his
septic picture. Patient remained in the T/SICU and transferred
to the floor after 5 days and monitored. The patient was
aggresvily diuresed and encouraged to take po. THe patient
continued to be diuresed and had wound changes done twice a day.
Patient was continued on TPN during his stay on the floor. On
[**8-28**], the patient became tachypneic and became
tachycardic. The patient was managed cardiovascularily
overnight, but spiked a tempature. The patient's line was
removed and pan cultured. The patient was transferred to the
unit the next day for closer management of his cardiac status.
The patient did well during the four days in the SICU and
returned again to the floor once cleared by cardiology. His
heart rate was controlled with 75 po tid. The patient had a
repeat episode of chest pain for approxiamtley for 2 hours on
the the 11th and and was evaluted by on surgery and cardiology.
Patient was started on heparin and and IV nitro dip and began to
cycle his enzymes. The patient ruled out for an myocardial
infarction and the nitro drip was discontinued. The patient
remained on the cardiac floor during the remaining part of his
inpatient stay. Psychiatry was consulted to evaluate the
patient's depressed mood and was started on remeron 7.5 and
ritalin as per psychiatry requiest. The patient was evalutated
by speech and swallow and had a video swallow gram performed
which illustrated a normal swallow function and the patient was
re-started on a house diet which he tolerated. The patient has
done well despite of his tumulotous course in the hospital and
is in good condition on discharge to the rehab center. The
patient's abdominal wound will still require dressing changes
[**Hospital1 **].
Medications on Admission:
Medications at home: Immuran 50 mg [**Hospital1 **], Asacol 1200 [**Hospital1 **],
Prednisone 60 mg qd, Saltolol 80 mg [**Hospital1 **], Asprin 81 mg qd,
Lisinopril 5 mg qd, Digoxin 0.125 mg qd.
Meds on transfer: Cefoxitin 1 gram iv q6, Flagyl 500 mg IV TID,
Protonix 40 mg IV qd, TPN, and a methylprednisole drip at 2.4
mg/hour
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. Methylphenidate HCl 5 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Percocet 5-325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours for 20 days.
Disp:*160 Tablet(s)* Refills:*0*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
20 days.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
x-lap and small bowel resection of mid-jejunal perforated
diverticulum with abdominal spillage [**2174-8-10**]
Discharge Condition:
Good
Discharge Instructions:
Please call if you have a fevers >100.5, chills, vomitting,
redness or drainage from the the wound.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 5182**] [**Telephone/Fax (1) 5189**] in [**2-22**] weeks
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2174-9-8**]
ICD9 Codes: 5849, 2761, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7010
} | Medical Text: Admission Date: [**2148-2-6**] Discharge Date: [**2148-2-9**]
Date of Birth: [**2077-5-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5973**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
70M with [**First Name3 (LF) **] with LAD 50% (s/p stent to pLAD '[**34**]), LCX 50%, RCA
s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] in '[**42**], hypertension, DMII, prior stroke residual
right sided weakness, OSA, Morbid Obesity, COPD, CHF EF 45-55%
(diastolic and systolic), pulmonary hypertension,
hyperlipidemia, h/o substance abuse who was found down in
apartment today by apartment staff. Tried to wake him up but he
was combative. Checked his blood sugar and it was 50. He was
given D50 and glu improved, although still with persistent AMS
so he was brought to the ED. The patient is somewhat unclear on
what happened but he does report poor PO intake for 1 week with
diarrhea and nausea but no notable weight loss.
.
Of note the patient has had 2 visits to the Ed for hypoglycemia
since [**Month (only) **], both times it improved with juice and crackers
and he was d/c'd home. He had a similar presentation [**2-13**] for
lethargy and AMS that was improved after hypoglycemia resolved.
.
In the ED, initial vs were: 96.0 70 115/58 10 98 . On exam,
pinpoint pupils, CN fine, strength good. Not oriented, falling
asleep initially. Labs notable for WBC count of 5.1, Creatinine
1.4, BNP 1075, AST 58, Albumin 3.1, CK 483, Tn:0.02. U/A and
urine tox sent but still pending.CT head was negative for bleed.
CXR showed possible vascular congestion. EKG shows multiple
PVCs, appears to have bigemeny? on the monitor. Patient was
given 1 amp d50, then FSG up to 140s, then back down to 50s
received 2nd amp. It was noted that patient was on glyburide so
started on octreotide. Blood sugar at 10pm was 78 so patient
started on a d5 gtt. Likely VBG, 02. Current vitals are 58
128/74 98% on 2L, RR 19.
.
On the floor, the patient's FSG is 86, he is alert and oriented
x3, appropriate. Complains of pain in his legs, several small
cuts related to being combative in the apartment and of back
pain which is chronic. He admits to some cocaine use at a party
over the weekend.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
# PCIs: s/p cath in [**11-10**] with 2 vessel dz.
- LAD proximal stenosis involving the origin of D1 (50%).
- RCA was diffusely diseased with a mid 70% stenosis after AM
and 80% stenosis, s/p 2 Cypher stents overlapping in the RCA.
[**12/2134**] stent to pLAD, [**11-10**] [**Month/Year (2) **] to RCA
# Mitral regurgitation
# CHF: EF 45-50%, diastolic and systolic failure
# Severe Hypertension
# Pulmonary Hypertension
# +PPD (15mm) CXR Negative
# Impotence
# Narcotics Contract: For pain from hip fracture
# Hip fracture [**12-10**]
# Back pain: several MRIs in the past.
# HTN
# DMII: Followed at [**Last Name (un) **]
# COPD
# OSA
# PUD
# Gastric Mass- noted [**12-14**]
# GERD- H. Pylori +, s/p four drug tx.
# Glaucoma
# Prostate Disease
# Elevated D-Dimer: (Received 5 CTAs over 2-3 years)
Social History:
He has blister packs that are prepared by [**Location (un) **]. He gets around
on a scooter. Lives alone in senior housing in a handicapped
apartment. Wife passed away [**2144-10-5**]. Retired [**Hospital Ward Name **] and chef at
[**University/College **] and previously in the Navy. Has 9 children (5 sons, 4
daughters),who help him out with his finances and groceries as
well as VNA services.
- Tobacco: 80 pack year smoking history, still about 1PPD.
- Alcohol: A beer or less a day
- Illicits:history of cocaine abuse, last positive U/A for
cocaine was 12/[**2145**]. Patient admits cocaine use this past
weekend.
Family History:
Father [**Year (4 digits) **] - [**Name2 (NI) **] in his 50s
Mother died last [**2147-10-8**] at [**Age over 90 **] years old
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On transfer to medicine floor:
Vitals: T: BP:138/94 P:74 R:24 O2:88% on RA -> 92% on 2L
General: obese, alert, communicative, " I feel good"
HEENT: Sclera anicteric, dry membranes
Neck: thick
Lungs: Limited due to habitus. Decreased at bases. No crackles
or wheezes
CV: Distant. Regular
Abdomen: Obese, mildly distended but soft with positive bowel
sounds. Non-tender
GU: no foley
Ext: several superficial skin tears over pre-tibial area
bilaterally. Excoriation on right toe.
Pertinent Results:
LABS ON ADMISSION:
[**2148-2-6**] 05:20PM BLOOD WBC-5.1 RBC-5.13 Hgb-16.1 Hct-48.7 MCV-95
MCH-31.4 MCHC-33.1 RDW-14.3 Plt Ct-273
[**2148-2-6**] 05:20PM BLOOD Neuts-79.7* Lymphs-11.9* Monos-7.0
Eos-0.7 Baso-0.7
[**2148-2-6**] 05:20PM BLOOD Plt Ct-273
[**2148-2-6**] 05:20PM BLOOD Glucose-105* UreaN-18 Creat-1.4* Na-142
K-4.0 Cl-104 HCO3-31 AnGap-11
[**2148-2-6**] 05:20PM BLOOD ALT-22 AST-58* CK(CPK)-483* AlkPhos-78
TotBili-0.4
[**2148-2-6**] 05:20PM BLOOD Lipase-24
[**2148-2-6**] 05:20PM BLOOD CK-MB-7 proBNP-1075*
[**2148-2-6**] 05:20PM BLOOD Albumin-3.1* Calcium-9.0 Phos-3.3 Mg-2.2
[**2148-2-6**] 05:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2148-2-6**] 08:38PM BLOOD FiO2-21 pO2-54* pCO2-54* pH-7.39
calTCO2-34* Base XS-5 Intubat-NOT INTUBA
[**2148-2-6**] 08:38PM BLOOD Glucose-56* Lactate-1.0
[**2148-2-6**] 05:24PM BLOOD Glucose-106* Lactate-1.7 Na-146 K-3.3*
Cl-99* calHCO3-30
LABS ON DISCHARGE:
[**2148-2-7**] 02:10AM BLOOD Glucose-125* UreaN-20 Creat-1.4* Na-142
K-3.6 Cl-106 HCO3-29 AnGap-11
[**2148-2-7**] 02:10AM BLOOD ALT-22 AST-50* LD(LDH)-411* CK(CPK)-511*
AlkPhos-69 TotBili-0.3
[**2148-2-7**] 02:10AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1
CARDIAC ENZYMES:
[**2148-2-7**] 02:10AM BLOOD CK-MB-7 cTropnT-0.02*
[**2148-2-7**] 12:45AM BLOOD CK-MB-8 cTropnT-0.01
[**2148-2-6**] 05:20PM BLOOD cTropnT-0.02*
CXR:
The cardiac silhouette remains moderately enlarged. The thoracic
aorta is tortuous but unchanged. There is upper zone vascular
redistribution with pulmonary vascular indistinctness,
compatible with mild pulmonary vascular congestion.
Additionally, there are hazy ill-defined opacities within both
lung bases, likely atelectasis. No sizable pleural effusion is
seen. There is no pneumothorax. There are no acute skeletal
abnormalities.
IMPRESSION: Findings compatible with mild pulmonary vascular
congestion with bibasilar ill-defined opacities, likely
atelectasis.
CT HEAD W/O CONTRAST Study Date of [**2148-2-6**] 5:36 PM
FINDINGS: Exam is slightly limited due to motion artifact.
Within this
limitation, there is no evidence of acute intracranial
hemorrhage or shift of normally midline structures. The
ventricles and sulci are prominent
consistent with age-related atrophy. There is extensive
periventricular and subcortical white matter hypodensity
consistent with chronic small vessel ischemic changes. The
basilar cisterns are preserved. Intracranial vascular
calcifications are again noted.
The visualized paranasal sinuses are clear. There is no evidence
of acute fracture.
IMPRESSION: No acute intracranial hemorrhage. Chronic small
vessel ischemic changes.
.
HGBa1c
[**2147-11-24**] 08:15AM 6.4
[**2147-8-25**] 08:30AM 7.4
[**2147-5-5**] 08:25AM 8.8
[**2146-11-19**] 06:10AM 7.6
[**2146-7-1**] 08:15AM 9.8
[**2145-6-22**] 12:30PM 8.9
[**2145-2-19**] 08:30AM 9.9
[**2144-12-21**] 09:37AM 11.3
.
EKG: Old TWI in I/III/aVF and V2-4
.
Hip films: Four total views are obtained. There are plates and
screws transfixing a
prior acetabular fracture with sclerosis at the fracture site.
In addition,
there is mild sclerosis about the right femoral neck. It is
unclear as to
whether this represents a healing subacute fracture. There are
mild
degenerative changes at the left femoral acetabular joint. The
femoral neck
is obscured by overlying soft tissues. Further assessment with
MR [**First Name (Titles) 151**]
[**Last Name (Titles) 102501**] artifact reduction protocol may be helpful. There are
severe
degenerative changes of the lumbar spine and mild degenerative
changes of the sacroiliac joints.
.
MRI: No proximal right femoral fracture, as questioned.
Prominent osteophytes at the right femoral head-neck junction
likely account for the sclerosis on the recently performed
radiograph.
Brief Hospital Course:
70 year old male with DM2, OSA, COPD, found down in his house
with glucose 50, brought to ED for altered mental status and
admitted to ICU for hypoglycemia and close glucose monitoring.
Positive cocaine toxicology.
# Hypoglycemia: Likely due to poor PO intake, rising creatinine
in the setting of continued high doses of insulin and glipizide
as well as to recent cocaine (prolonged use of sympathomimetics
can result in hypoglycemia). LFTs normal, unlikely cardiac
event. Recently had his lantus decreased due to improvement in
his HgbA1c from 8.8 in [**2147-4-7**] to 6.4 in [**2147-11-7**]. Unclear
if this is from improved diet, increased adherence to
medications or another organic cause. On previous admissions for
hypoglycemia the patient's glyburide was held and he remained
without hypoglycemic episodes in the hospital. As the patient's
hgba1c has improved and he has bubble packs for his meds with
improved adherence, it was felt by the primary medicine team and
[**Last Name (un) **] consultants that patient should not be restarted on
glyburide. In house patient was treated with single dose of
octreotide for glyburide intoxication which was then held as his
sugars resolved. The patient's blood sugars remained in the
80-130 range NPO and then rose to 180-200 after eating
breakfast. Lantus and insulin sliding scale were restarted and
adjusted accordingly by [**Last Name (un) **].
# Altered Mental Status: Most likely [**1-9**] hypoglycemia vs cocaine
use. No evidence of bleed on head CT. TIA possible given
patient's h/o CVA and rapid improvement but less likely in
setting of more possible hypoglycemic etiology. No WBC count, no
fever, rapid improvement making meningitis unlikely.
# Cocaine Use: Patient reporting recent cocaine use one time at
his nephew's party on Friday night. Patient noting that his life
has been empty since his wife died 2 years ago. Social work
consulted for assistance with substance abuse and patient agreed
to abstain from cocaine going forward. Beta blocker held in
setting of possible continued cocaine use.
.
# Right Hip Pain: Patient complained of right hip pain, felt
likely due to trauma from the fall prior to his being found down
on admission. Given previous surgeries in the area, xray films
were ordered. These showed ?subacute fracture and recommended
MRI imaging with [**Month/Day (2) 102501**] artifact signal reduction which was
performed and showed no fractures, some sclerosis and osetophyte
collections which are nonspecific.
# CHF: Lasix held in setting of [**Last Name (un) **] felt likely pre-renal in
etiology. Stopped carvedilol in the setting of cocaine use
initially but was resumed upon discharge given the risk-benefit
of CHF protection and cocaine interactions.
# [**Last Name (un) **]: Creatinine 1.4 on admission then rose to 1.6 shortly
after likely in the setting of pre-renal physiology. Baseline
1.1. Trended down with IVF and PO intake back to normal by day
of discharge.
# [**Last Name (un) **]: TWI in v2 and v3 in MICU that persisted in repeat EKGs on
the Medicine floor. In comparison to previous EKGs, these TWI
also seen in I, III and aVF were not felt to be different/new
but made more prominent by hypoglycemia and recent cocaine use.
[**Last Name (un) 5937**] also found to be prolonged to 480, likely in setting of
cocaine use that gradually normalized to 430s. Ruled out by
cardiac enzymes. Continued on plavix and aspirin.
# Increased CK: CK in 600s on admission, likely [**1-9**]
immobilization (patient found down) vs recent cocaine use.
Cardiac enzymes flat. CK trended down with IVF.
# s/p MCA CVA: Per PCP notes, has residual right sided weakness,
primarily in his leg and with writing, but this has been
improving over time and it was decided not to add coumadin.
# Back/hip pain: On percocet at home, as patient's mental status
back to baseline, and complaining of [**8-16**] pain he was restarted
on home regimen.
# COPD: followed by Dr. [**Last Name (STitle) **]. Continued on home advair and
spiriva.
# Glaucoma: Continued latanoprost after confirming dose with
pt's pharmacy.
# GERD: continue omeprazole but will contact patient's PCP and
cardiologist about plavix/omeprazole interaction.
Medications on Admission:
AMLODIPINE [NORVASC] - 5 mg by mouth once a day
ATORVASTATIN [LIPITOR] - 80 mg Tablet - by mouth once a day
CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - by mouth once a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 inhaled puff twice a day
FUROSEMIDE - 80 mg Tablet - one Tablet(s) by mouth once a day
GLYBURIDE - 5 mg Tablet - 2 Tablet(s) by mouth twice a day
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 35 units per
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - use as
directed
before meals four times a day per sliding scale
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puffs inhaled four times a day as
needed for shortness of breath
LATANOPROST [XALATAN] - Dosage uncertain
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - prn
OMEPRAZOLE - 20 mg Capsule, Delayed Release by mouth once a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1
Tablet(s) by mouth three times a day as needed for pain
POLYETHYLENE GLYCOL 3350 - 17 gram (100 %) Powder in Packet - 1
Powder(s) by mouth once a day as needed for constipation
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day
ASPIRIN, BUFFERED - 325 mg Tablet - by mouth once a day
DOCUSATE SODIUM - 100 mg Capsule - by mouth twice a day
FERROUS SULFATE - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by
mouth DAILY (Daily)
SENNA - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
1-2 puffs Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
13. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO three times
a day as needed for pain.
15. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
16. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes as needed for chest pain: Not to
exceed three doses with an episode of chest pain. If does not
resolve after three doses, go to Emergency Room.
17. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45)
units Subcutaneous with breakfast.
18. Humalog 100 unit/mL Solution Sig: Per NEW sliding scale
Subcutaneous four times a day.
19. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
20. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary: Hypoglycemia, altered mental status, acute renal
failure, cocaine abuse
Secondary: Type II Diabetes, coronary artery disease, congestive
heart failure, hypertension, back/hip pain, peptic ulcer
disease/GERD
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed independently to chair, motorized
scooter or wheelchair
Discharge Instructions:
-You were admitted with low blood sugars that caused you to be
confused. You were treated with intravenous dextrose (sugar) and
your glyburide was stopped with good effect. The [**Hospital **] Clinic
saw you in the hospital and made changes to your insulin
regimen. Your kidneys were also found to not be functioning as
well, likely due to dehydration. They normalized after some
intravenous and oral fluids.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> STOP Glyburide
--> START new insulin regimen with Lantus (Glargine) 45 units
with breakfast and Humalog sliding scale.
.
You complained of some hip pain while you were here, you had a
hip MRI, preliminary results of this do not show hip fracture
.
It is likely that cocaine use contributed to injuring your
kidneys and your low blood sugar. Using cocaine is dangerous
and could be deadly. We recommend never using cocaine again.
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools. For your heart, weigh yourself every
Followup Instructions:
Appointment #1
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2148-2-14**] at 3:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2148-2-14**] at 3:30 PM
With: DR [**Last Name (STitle) **] & DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
APPOINTMENT #2
Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. You have an appointment for Thursday, [**2-16**] at 7:40
am. You can reach his office at [**Telephone/Fax (1) 250**]. It is important
that you make this appointment.
.
APPOINTMENT #3
Please follow-up in the [**Hospital **] [**Hospital 982**] Clinic. You have an
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14116**] on [**2-22**] at 1:30pm.
You can reach their office at: [**Telephone/Fax (1) 2378**].
ICD9 Codes: 5849, 4280, 496, 4019, 4168, 2724, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7011
} | Medical Text: Admission Date: [**2184-9-5**] Discharge Date: [**2184-9-11**]
Date of Birth: [**2103-4-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
: 81 year old male with Alzheimer's dementia, hypothyroidism,
h/o GI bleed, gait abnormality, found in the locked Alzheimer's
unit of his nursing home on the night of [**9-4**] with shortness of
breath, increased secretions, and O2 sat 70% on RA. He was
suctioned and put on O2, and then was taken to the ED.
.
In the ED, his VS on presentation were T 102.6, HR 120, BP
172/110, O2 sat 85% RA. After repeatedly removing his face mask,
he began to appear cyanotic, and was intubated for hypoxic
respiratory failure. His BP dropped to 73/39 after propofol
bolus, but recovered to 113/28 with 200cc NS bolus. He received
ceftriaxone 2g IV, Flagyl 500mg IV, vancomycin 1g IV, and
Tylenol 650mg PR. Patient was DNR and unclear [**Name2 (NI) 835**] status but
when he be continued to remain hypoxic, family decided to have
him intubated and he was transferred to the MICU for further
management.
.
Brief Hospital Course:
Patient was continued on ceftriaxone and vancomycin for empiric
coverage of nosocomial pneumonia. He was ruled out for MI with 4
sets of cardiac enzymes but had flat, mildly elevated troponins
and CKs, likely secondary to demand ischemia. Complained of
intermittent He was extubated on [**9-5**] without complication.
Currently satting 92-100% on 3L NC with occasional need for NG
suctioning due to poor management of secretions. He received 2 L
IVF during his MICU stay and received 20 mg IV lasix just prior
to transfer for suggestion of volume overload on exam. Also some
concern over patient's swallowing ability. He has been on soft
mechanical diet with upright positioning while eating. He has
been able to tolerate his po medications. He has also been
active, trying to leave unit [**1-1**] to his Alzheimer's and poor
short term memory, and has required 1:1 sitter and Posey vest.
Past Medical History:
Alzheimer's dementia
Hypothyroidism
History of GI bleed
diverticulosis
Gait abnormality
Social History:
Lives in Alzheimer's unit of [**Hospital 745**] Health Care Center.
Family History:
noncontributory
Physical Exam:
T 98.0, HR 100, BP 119/56, O2sat 97% on 5LNC
General- pleasant, demented, alert, oriented to person and place
HEENT- NCAT. PERRL. sclerae anicteric. MMM. Sparce petechiae on
post pharynx.
Pulm- Diffusely rhonchorous but cleared post nebs and diuresis.
Now crackles at L base. Otherwise CTAB.
CV- regular rhythm. tachycardic. heart sounds obscured by
respiratory sounds but no audible murmurs.
Abd- NABS. soft, nontender,nondistended. no hepatosplenomegaly
Extrem- venous stasis changes. 2+ DP pulses.
Neuro- Difficult to assess given dementia. Can follow commands
but has decreased attention. EOM grossly intact. PERRL. palate
elevates symmetrically. No facial droop. tongue midline. Moving
all extremities. [**4-2**] grip strength bilat.
Pertinent Results:
CXR [**9-5**]: Left lower lobe opacity likely represents pneumonia in
the proper clinical setting.
.
CXR [**9-8**]: Bedside AP chest radiograph compared to AP radiograph
dated [**2184-9-6**]. In the interval, there has been
development of possible right and left pleural effusions,
bibasilar atelectasis, doubt pneumonia. Cardiac silhouette and
mediastinal contours are unchanged. The rest of the exam is
unchanged compared to the last study.
.
[**2184-9-5**] 12:20AM BLOOD WBC-12.3* RBC-3.78* Hgb-11.4* Hct-33.2*
MCV-88 MCH-30.2 MCHC-34.4 RDW-16.0* Plt Ct-228
[**2184-9-5**] 04:20AM BLOOD WBC-11.8* RBC-3.13* Hgb-9.5* Hct-27.9*
MCV-89 MCH-30.5 MCHC-34.2 RDW-16.0* Plt Ct-188
[**2184-9-6**] 04:27AM BLOOD WBC-8.2 RBC-3.47* Hgb-10.6* Hct-30.5*
MCV-88 MCH-30.6 MCHC-34.8 RDW-16.0* Plt Ct-195
[**2184-9-7**] 05:15AM BLOOD WBC-8.2 RBC-3.30* Hgb-10.0* Hct-28.7*
MCV-87 MCH-30.3 MCHC-34.8 RDW-15.6* Plt Ct-209
[**2184-9-8**] 05:10AM BLOOD WBC-6.8 RBC-3.47* Hgb-10.2* Hct-30.5*
MCV-88 MCH-29.5 MCHC-33.5 RDW-15.6* Plt Ct-242
[**2184-9-5**] 12:20AM BLOOD PT-12.6 PTT-25.1 INR(PT)-1.1
[**2184-9-5**] 04:20AM BLOOD PT-13.3* PTT-27.6 INR(PT)-1.2*
[**2184-9-6**] 04:27AM BLOOD PT-13.9* PTT-38.7* INR(PT)-1.2*
[**2184-9-5**] 12:20AM BLOOD Glucose-203* UreaN-25* Creat-1.2 Na-137
K-4.1 Cl-97 HCO3-24 AnGap-20
[**2184-9-5**] 04:20AM BLOOD Glucose-135* UreaN-25* Creat-1.3* Na-137
K-4.4 Cl-101 HCO3-25 AnGap-15
[**2184-9-6**] 04:27AM BLOOD Glucose-105 UreaN-17 Creat-1.0 Na-141
K-3.7 Cl-105 HCO3-28 AnGap-12
[**2184-9-7**] 05:15AM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-143
K-3.3 Cl-104 HCO3-29 AnGap-13
[**2184-9-8**] 05:10AM BLOOD Glucose-131* UreaN-14 Creat-0.9 Na-144
K-3.2* Cl-103 HCO3-29 AnGap-15
[**2184-9-5**] 12:20AM BLOOD CK(CPK)-224*
[**2184-9-5**] 07:17AM BLOOD CK(CPK)-416*
[**2184-9-5**] 03:36PM BLOOD CK(CPK)-424*
[**2184-9-5**] 08:51PM BLOOD CK(CPK)-433*
[**2184-9-5**] 12:20AM BLOOD CK-MB-6 cTropnT-0.04*
[**2184-9-5**] 07:17AM BLOOD CK-MB-7 cTropnT-0.02*
[**2184-9-5**] 03:36PM BLOOD CK-MB-6 cTropnT-0.02*
[**2184-9-5**] 08:51PM BLOOD CK-MB-7 cTropnT-0.02*
Brief Hospital Course:
81M with Alzheimer's dementia, hypothyroidism, admitted to MICU
for hypoxic respiratory failure secondary to pneumonia now
extubated with stable respiratory status, concern for
aspiration, and overnight agitation.
.
Patient was febrile to 102 on admission with elevated WBC count
and LLL inflitrate but WBC count was back to within normal
limits after 2 days of antibiotics. Respiratory failure was
believed likely secondary to pneumonia: nosocomial vs.
aspiration. Given baseline dementia and concern for aspiration
in unit, aspiration thought to be more likely. Sputum gram stain
showed gram positive rods and gram positive cocci in pairs. Gram
positive rods suggestive of aspiration of oral flora. Gram
positive cocci c/w staph or strep. He was continued on
ceftriaxone and vancomycin for empiric coverage of nosocomial
pneumonia. After being called out from the unit, patient became
febrile to 101 on ceftriaxone and vancomycin and was in
increased respiratory distress. A repeat CXR was suggestive of
new aspiration with possible aspiration pneumonia. He was
started on flagyl for anaerobic coverage. Patient continued to
be unable to manage his oral secretions requiring frequent
suctioning. A meeting with the family was held to discuss goals
of care. It was explained that patient would likely continue to
aspirate as he was unable to manage his oral secretions or
swallow any food. Patient was uncomfortable and was requesting
to be left alone. The family decided to make the patient DNR/DNI
and eventually decided to make him CMO once it became clear that
he ability to manage his airway and secretions was not
improving. His antibiotics were stopped as were his
antihypertensive medications and vital sign checks. He was
started on IV morphine but his IV was lost so it was switched to
SC and SL. Patient was very comfortable with morphine dosing.
Feeding was attempted as patient was requesting food but he
aspirated all consistencies. His breathing greatly worsened and
he became uncomfortable so it was recommended to the family that
he eat a very limited amount of thick liquids such as pudding
for pleasure but not for nutrition. Morphine continued to
titrated to keep patient comfortable and he was continued on
hyoscyamine to help decrease his secretions. Patient spent the
remainder of his hospital stay comfortable, with his family at
his side, and died 2 days after the institution of comfort
measures.
Medications on Admission:
Levothyroxine 100mcg qd
Klonopin 0.5mg qam, 1.0mg qhs
Metoprolol 25mg [**Hospital1 **]
Aricept 5mg qhs
Namenda 5mg [**Hospital1 **]
Seroquel 150mg qhs
Paxil 10mg qam
Senokot 8.6mg qhs
Multivitamin qd
Discharge Medications:
expired
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
1. hypoxic respiratory failure
2. aspiration pneumonia
.
Secondary:
1. Alzheimer's dementia
2. hypothyroidism
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 5070, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7012
} | Medical Text: Admission Date: [**2199-3-5**] Discharge Date: [**2199-3-5**]
Service: MEDICINE
Allergies:
Heparin Sodium
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 year old woman with hx of CAD s/p stenting, COPD (02
dependent), PAfib, recent DVT and multiple admissions for
pneumonia since [**2198-11-27**] for shortness of breath presenting
from nursing home with hypoxia. The patient was recently
discharged from [**Hospital1 2025**] on [**2199-3-1**] following being admitted on
[**2199-2-13**] for pneumonia. Prior to that she had been discharged to
rehab on [**2199-2-6**] to complete a course of abx (which completed on
[**2199-2-11**]). During that admission she was found to have a DVT.
She was re-admitted to [**Hospital1 2025**] on [**2199-2-13**] with shortness of breath,
weakness, and poor PO intake. She was found a low grade temp
and had a chest xray that showed atelectasis and residual
pneumonia. Her course was complicated by acute on chronic renal
failure with Cr upto 2.5. A right PICC line was placed for
access.
On the evening of [**2199-3-4**] she was noted to be moaning. Vital
signs at that thime were notable for T(tympanic) 99.3 HR 87
143/40 88%2L NC. She received nebs, tylenol, KCl (for
hypokalemia), ativan, metoprolol, and isordil prior to transfer
to the ED. Per the patient's daughter, the patient had not been
coughing or choking on food recently but did have temporary
swallowing difficulties during her most recent admission at [**Hospital1 2025**].
Also of note, the
In the ED she was 100.3 96 116/41 22 95%NRB. She had a CXR
that showed RLL infiltrate and RML collapse. She received
vanc/zosyn. Per discussion with the patient she reversed her
DNR/DNI status. She was admitted to the ICU.
ROS:
no weight loss. no pain. no chest pain. no abd pain. no dysuria.
Constitutional: No(t) Weight loss
Eyes: No(t) Blurry vision, No(t) Conjunctival edema
Ear, Nose, Throat: No(t) Dry mouth, Epistaxis, No(t) OG / NG
tube
Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)
Orthopnea
Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t)
Parenteral nutrition
Respiratory: No(t) Cough, No(t) Wheeze
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t)
Emesis, No(t) Diarrhea
Genitourinary: No(t) Dysuria, No(t) Dialysis
Musculoskeletal: No(t) Joint pain, No(t) Myalgias
Integumentary (skin): No(t) Jaundice, No(t) Rash
Heme / Lymph: No(t) Lymphadenopathy
Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t)
Seizure
Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t)
Delirious, No(t) Daytime somnolence
Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza
vaccine
Signs or concerns for abuse : No
Pain: No pain / appears comfortable
Past Medical History:
COPD O2 dependent
CAD s/p stenting x3 ~3 years ago
Depression
CHF with apical ballooning
Hypothyroidism
Chronic kidney disease (Cr baseline 1.5-2)
Atrial fibrillation (PAF)
Hx of GI bleeding
DVT (found in early [**2199-1-26**])
Social History:
Occupation: retired
Drugs: unknown
Tobacco: unknown
Alcohol: unknown
Other: per daughter has been in an out of hospitals and rehabs
ever since [**2198-11-27**] with only a few days at home each time
before being re-admitted
Family History:
unknown
Physical Exam:
Tmax: 37.7 ??????C (99.8 ??????F)
Tcurrent: 37.7 ??????C (99.8 ??????F)
HR: 83 (83 - 83) bpm
BP: 133/47(69) {133/47(69) - 133/47(69)} mmHg
RR: 17 (17 - 17) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: No(t) No acute distress, No(t) Thin, No(t)
Anxious, No(t) Diaphoretic
Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Sclera edema
Head, Ears, Nose, Throat: No(t) Endotracheal tube, No(t) NG
tube, No(t) OG tube
Lymphatic: No(t) Cervical adenopathy
Cardiovascular: (S2: No(t) Distant, No(t) Loud, No(t) Widely
split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur:
No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished). blue right [**11-29**] toe tips
Respiratory / Chest: (Expansion: No(t) Paradoxical),
(Percussion: No(t) Hyperresonant: , No(t) Dullness : ), (Breath
Sounds: No(t) Clear : , Crackles : bibasilar, No(t) Bronchial: ,
No(t) Wheezes : , Diminished: right base, No(t) Absent : , No(t)
Rhonchorous: )
Abdominal: No(t) Distended, No(t) Tender:
Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice, sacral pressure ulcer
Neurologic: Responds to: Not assessed, Oriented (to): self,
hospital, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed,
Tone: Not assessed
Pertinent Results:
[**2199-3-4**] 10:45PM WBC-19.6* RBC-3.87* HGB-11.8* HCT-33.9*
MCV-87 MCH-30.6 MCHC-35.0 RDW-15.4
[**2199-3-4**] 10:45PM PLT COUNT-155
[**2199-3-4**] 10:45PM PT-29.5* PTT-33.2 INR(PT)-3.0*
[**2199-3-4**] 10:45PM GLUCOSE-151* UREA N-71* CREAT-2.0* SODIUM-134
POTASSIUM-3.9 CHLORIDE-91* TOTAL CO2-29 ANION GAP-18
[**2199-3-4**] 10:45PM ALT(SGPT)-29 AST(SGOT)-30 LD(LDH)-368* ALK
PHOS-69 TOT BILI-1.1
CXR: [**2199-3-5**] 7am
CXR - The study is markedly limited by patient rotation. The
cardiac and mediastinal silhouettes are difficult to evaluate.
The right mid and lower lung are somewhat obscured by overlying
mediastinal structures due to rotation; there is right lower
lobe atelectasis. In the visualized right upper lung and left
lung, no consolidation is appreciated. There may be bilateral
costophrenic angle blunting. A right-sided PICC line tip is not
well visualized, but at least extends to the SVC.
CHEST (PORTABLE AP) [**2199-3-5**] 2:37 PM
Reason: eval for [**Hospital 78194**]
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with pneumonia and probable RML collapse
REASON FOR THIS EXAMINATION:
eval for re-expansion
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: History of pneumonia and probably right middle lobe
collapse. Evaluate for re-expansion.
FINDINGS: AP single view of the chest has been obtained with
patient in sitting semi-upright position and analysis is
performed in direct comparison with a preceding similar study
obtained approximately ten hours earlier. The on previous
examinations ([**3-4**] and [**3-5**]) identified PICC line appears
in unchanged position and terminates overlying the SVC at the
level 1 cm below the carina. No pneumothorax or any other
placement-related complication is noted. The accessible
pulmonary vasculature does not show any congestive pattern. The
previously described right-sided basal density terminating
rather straight and probably related to the slightly downwards
placed minor fissure, is unchanged and consistent with right
middle lobe and probably also right lower lobe atelectasis. As
on previous examinations, there is some suggestion of mild
right-sided mediastinal shift in support of this diagnosis.
There is a plate thin atelectasis on the left base but no
evidence of pleural effusion.
IMPRESSION: Persistent findings compatible with right lower lobe
and middle lobe atelectasis. Cause unknown. Chest followup
examination after airway exploration is recommended.
Alternatively, a CT chest examination may clarify the cause of
the abnormality.
Telephone call delivered to referring physician.
GENERAL URINE INFORMATION [**2199-3-5**] 02:00AM
Type Color Appear Sp [**Last Name (un) **]
Amber1 Clear 1.009
1 ABN COLOR [**Month (only) **] AFFECT DIPSTICK
DIPSTICK URINALYSIS
Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks
NEG POS TR NEG NEG SM NEG 5.0 NEG
MICROSCOPIC URINE EXAMINATION
RBC WBC Bacteri Yeast Epi TransE RenalEp
0 0-2 OCC NONE 0
Brief Hospital Course:
84 year old woman with MMP including CAD s/p PCI, CHF, COPD,
DVT, and multiple recent admissions for pneumonia presenting
with worsening hypoxia and leukocytosis.
1) Hypoxia: Most likely related to pneumonia potentially
from aspiration and complicated by lobar collapse. Have no
comparison with prior imaging but likely current infitrates are
not new but lobar collapse may be. Other possibilities are CHF,
COPD exacerbation but these are less likely in the setting of
low grade fever and elevated WBC#. Low probability for ACS
presenting in this manner. Also with therapeutic
anti-coagulation PE would be unlikely. Rapid improvement in
oxygenation upon arrival to ICU would suggest plugging or fluid
shifts present.
- repeat CXR essentially unchanged
- sputum culture, blood culture, urine legionella Ag
- abx: vancomycin/ zosyn with azithromycin until
legionella Ag negative
- hold on steroids
- continue home COPD treatments (nebs, spiriva)
- chest PT
- wean O2 as able
- OOB as tolerated
2) CAD: low probability for ACS.
- will continue beta-blocker, aspirin, statin
3) Atrial fibrillation: currently in sinus rhythm with
normal rate and INR at goal.
- hold coumadin dose tonight
- continue metroprolol
- for now switch diltazem to short acting
4) DVT- continue coumadin. Hold tonight??????s dose
5) Anemia ?????? given recent Hct was 38.6 now down to ~31% in
the setting of prior GI bleeds and active anti-coagulation would
be most concerned for acute blood loss. Currently not showing
any sign of hemodynamic compromise. No RDW expansion or
elevated bili to suggest hemolysis although LDH is elevated.
- check Hct [**Hospital1 **] for now
- guaiac all stools for now
6) Acute on Chronic renal failure: baseline Cr range from
1.5-2. likely etiology pre-renal from combination of CHF, fever,
poor PO intake. No clear meds prior to admission to blame.
Relatively low sp [**Last Name (un) **] on UA could suggest concentrating defect
(i.e. tubular damage)
- UA lytes, Uosm
- Dose meds for GFR~20
- IVF
- Aluminum hydroxide x3 days for phos management
ICU Care
Nutrition: NPO for now
Glycemic Control: adequate for now
Lines: right PICC and PIV
Prophylaxis:
DVT: anti-coagulated, pneumoboots
Stress ulcer: continue home PPI
Communication: Comments: daughter/HCP : [**Name (NI) 11705**] [**Name (NI) 4135**] (c)
[**Telephone/Fax (1) 78195**]
Code status: DNR/DNI confirmed with HCP
Disposition: requested transfer to [**Hospital1 2025**] in process
Medications on Admission:
Torsemide 60 mg daily
MVI with minerals daily
Hydralazine 25 mg QID
Metoprolol 37.5mg TID
Diltizem CD 360 mg daily
Cholecalciferol 800 units daily
Colace 100 mg TID
Fluticasone 220 mcg 2 puffs [**Hospital1 **]
Atrovent Neb q6hours
Levothyroxine 75 mcg daily
Singulair 10 mg daily
Prilosec 20 mg daily
Miralax 17 g daily
Salmeterol diskus 50 mcg [**Hospital1 **]
Senna 8.6 mg 2 tabs daily
Sertraline 25 mg daily
Spiriva 1 cap daily
Atorvastatin 10 mg daily
Calcium Carbonate 1250 mg [**Hospital1 **]
Albuterol NEB q4hrs PRN
Coumadin 3 mg daily (goal INR 2.5-3.5)
Roxanol 20 mg/mL 5 mg SL q8H: prn
Nitroglycerin sL q5min x3 PRN
Discharge Medications:
1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Five (5)
ML PO TID (3 times a day) for 3 days.
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed.
9. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
16. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
17. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
18. Vancomycin 1000 mg IV Q48H HAP
19. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) as needed for HAP.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Fair
Discharge Instructions:
You were admitted with shortness of breath and findings on chest
xray consistent with pneumonia. You were not found to have any
evidence of heart attack. You were treated with antibiotics and
at your request transferred to [**Hospital1 2025**].
Followup Instructions:
Follow up with your primary care physician after hospital
discharge
ICD9 Codes: 5070, 5849, 5180, 496, 2449, 5859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7013
} | Medical Text: Admission Date: [**2175-7-12**] Discharge Date: [**2175-7-15**]
Date of Birth: [**2096-3-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
79M with history of afib on coumadin and recent diagnosis of CML
on gleevec, history of diverticulosis, and hemmorhoids was
transfered to [**Hospital1 18**] from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2175-7-12**] with 10 days of
bright red blood srurrounding his stool associated with
presyncopy and exertional SOB. He had a recent bone marrow
biopsy around one month ago to investigate sources of the anemia
and was found to have CML. He has been on iron and always has
black stool. He reported having blood only with bowel movements
and did not have any increase in bowel movements. However he
felt the blood in the stool had worsened 2-3 days prior to
admission. He reports that he has been worked up for a new
anemia for some time now with a capsule that was negative in may
as well as an EGD in [**Month (only) 116**] showed [**Last Name (un) 865**], some ?healed erosions,
nothing active; ; [**Last Name (un) **] 5 years ago with ?polyps and was due for
repeat in the next two weeks. He presented to OSH ED where labs
showed BUN 77, creat 2.8 (up from 31/0.99 on [**7-3**]),and Hct 19.7
(24.2 on [**7-10**]), WBC 11.3, INR 3.3. He was transfed two units of
pRBC and one unit of ffp and transfered to [**Hospital1 18**] for further
management. He was admittied directly to MICU.
.
In the MICU, patient was started on golytely prep last night. He
had been transfused two units of pRBC and 1 FFp yesterday
without an appropriate bump in HCT. He recived another another
unit PRBCs today and 1 of FFP and 40IV lasix prophylactically.
He is continueing his bowel prep for tonight and has had 4
bottle of golytely yet he is still not clear.
.
Currently on the floor patient reports that he has noticed more
blood in his during bowel movment without stool. He is feeling
fatigued however he [**Doctor First Name 1638**] any fevers, chill, abdominal pain,
vomiting, hemoptysis, diarrhea, SOB, chest pain or coughing.
Past Medical History:
DM - TYPE 2 DIABETES MELLITUS
CML (chronic myelocytic leukemia)
ATRIAL FIBRILLATIONS
CAD s/p stenting [**6-18**]
Lung nodule
Morbid Obesity
PULMONARY HYPERTENSION
DIVERTICULOSIS
COLONIC POLYPS
CANCER - SKIN, SQUAMOUS CELL, lft forearm, r flank
HYPERLIPIDEMIA
BASAL CELL CARCINOMA
CATARACT - NUCLEAR SCLEROTIC SENILE
OPTIC NERVE CUPPING, SUSPICIOUS
HEART FAILURE - DIASTOLIC, CHRONIC
GLAUCOMA SUSPECT W OPEN ANGLE
HYPERTENSION, ESSENTIAL
DISC DISORDER OF LUMBAR REGION
ASTHMA
Social History:
Retired literature teacher, just celebrated 55th wedding
anniversery.
- Tobacco: Quit 30+ years ago, 10 pack year history
- Alcohol: social
- Illicits: None
Family History:
Non-contributory
Physical Exam:
Vitals: T:afebrile BP:110/54 P:67 R:19 O2:98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregular 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, 1+ clubbing, no cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
.
Discharged Physical Exam:
VS: 98.1 124/72 HR 72 18 99%RA. Not orthostatic -- BP
130/70 and HR 80 lying, sitting, standing.
GENERAL: Pleasant, well developed older man sitting up in chair
[**Location (un) 1131**], no acute distress, AOX3.
Pertinent Results:
Admission Labs:
[**2175-7-12**] 12:40PM BLOOD WBC-10.5 RBC-2.43* Hgb-7.2* Hct-21.6*#
MCV-89 MCH-29.6 MCHC-33.3 RDW-15.6* Plt Ct-296#
[**2175-7-12**] 12:40PM BLOOD Neuts-83.6* Lymphs-10.3* Monos-3.6
Eos-0.6 Baso-1.9
[**2175-7-12**] 12:40PM BLOOD PT-26.2* PTT-37.1* INR(PT)-2.5*
[**2175-7-12**] 12:40PM BLOOD Glucose-152* UreaN-73* Creat-2.5*# Na-135
K-5.9* Cl-102 HCO3-21* AnGap-18
[**2175-7-13**] 05:30AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.9*
.
Discharge Labs:
[**2175-7-15**] 08:00AM BLOOD WBC-7.7 RBC-2.87* Hgb-8.2* Hct-25.6*
MCV-89 MCH-28.6 MCHC-32.0 RDW-16.0* Plt Ct-267
[**2175-7-14**] 10:30AM BLOOD PT-18.4* PTT-34.2 INR(PT)-1.7*
[**2175-7-14**] 10:30AM BLOOD Glucose-118* UreaN-23* Creat-1.3* Na-144
K-4.5 Cl-109* HCO3-26 AnGap-14
[**2175-7-14**] 10:30AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.5
.
Colonoscopy: [**2175-7-14**]
Findings: Flat Lesions A localized AVM that was actively
bleeding was seen in the cecum. APC was applied to this lesion
with subsequent hemostasis. Protruding Lesions Small
non-bleeding grade 2 internal hemorrhoids were noted in the
sigmoid [**Last Name (un) **]. Excavated Lesions A few non-bleeding diverticula
were seen in the sigmoid. Diverticulosis appeared to be of mild
severity.
Impression:
Grade 2 internal hemorrhoids
Diverticulosis of the sigmoid
Angioectasia in the cecal
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
79M with history of afib (on coumadin) and recent diagnosis of
CML on gleevec, history of diverticulosis, and hemorrhoids
transferred from OSH to [**Hospital1 18**] on [**2175-7-12**] with 10 days of bright
red blood per rectum associated with presyncope and SOB on
exertion, found to have AVM cauterized on colonoscopy.
.
# AVM: Patient was admitted because of large bloody bowel
movements for 10 days. On admission his hematocrit was found to
be 21.6% down from 29.2 a month ago. He was admitted directly
to the MICU where he received 2 units of blood transfusion and 1
unit of FFP to reverse his INR. After prep, he had a
colonoscopy which showed bleeding AVMs which were then
cauterized. Patient's hematocrit remained stable after the
colonoscopy, he tolerated full diet and did not have any further
episodes of bloody bowel movements. Per gastroenterology, his
coumadin will be held for five days after colonoscopy. (See
Below) He was discharged to follow p with PCP.
.
# Anemia and CML: Anemia most likely from GI bleeding with
possible contribution from his CML. Hematocrit on discharge was
stable. His Gleevec was stopped on admission. He will follow
with his Oncologist on [**7-18**] to resume his Gleevec.
.
# Afib: CHADS2 of 4 for CHF, htn, age, diabetes. No prior
history of stroke. Patient's coumadin was held on admission and
his INR reversed for colonoscopy. Per GI, his Coumadin should
be held for five days after colonoscopy. Patient will restart
his Coumadin on [**2175-7-19**] and follow up with his PCP titrate
his Coumadin dose. Patient's home atenolol was also stopped on
admission because of [**Last Name (un) **] (see below). PCP will resume atenolol.
.
# [**Last Name (un) **]: On admission patient's Cr was 2.5 up from baseline of 0.7
most likely prerenal. After blood transfusions and volume
resuscitation his Cr continued to trend down with discharge Cr
of 1.3. On admission home, lasix, lisinopril and atenolol were
held. Patient will follow up with PCP to resume these
medications.
.
# CAD and CHF: PTCA and stenting of the distal LAD on [**6-18**].
Patient did not have any chest pain during this admission. No
evidence of congestive heart failure. He was discharged on
aspirin and simvastatin. Atenolol, Lisinopril and lasix to be
restarted by PCP.
.
# Type II DM: A1c 6.0 from [**6-20**]. Blood sugar well controlled
during this admission. Patient discharged on home metformin.
.
# Asthma: Not active. Continued on Albuterol Inhaler and advair.
.
# GERD: Not active. Continued on Omeprazole.
.
# BPH: Not active. Continued on Doxazosin and finasteride.
.
#Code: Full Code
.
Transitions of care:
- No pending studies.
- Patient will resume his Coumadin on [**2175-7-19**] and follow
up with PCP for INR monitoring and dose adjustment.
- PCP will resume Lisinopril, lasix, and atenolol when
appropriate given his [**Last Name (un) **] in the hospital.
- Patient will see his Oncologist on [**7-18**] to resume his
gleevac.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientAtrius.
1. Omeprazole 20 mg PO DAILY
2. Imatinib Mesylate 400 mg PO DAILY
3. Doxazosin 2 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
Per INR nurses
6. Furosemide 60 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
9. Simvastatin 20 mg PO DAILY
10. Lisinopril 40 mg PO DAILY
11. Atenolol 12.5 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Aspirin 81 mg PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Psyllium 1 PKT PO TID:PRN constpipation
16. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -600 unit
Oral daily
17. Magnesium Oxide 800 mg PO DAILY
18. Fish Oil (Omega 3) 1000 mg PO DAILY
19. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea
2. Aspirin 81 mg PO DAILY
3. Doxazosin 2 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -600 unit
Oral daily
11. Ferrous Sulfate 325 mg PO DAILY
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Psyllium 1 PKT PO TID:PRN constpipation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Dignosis: Angioectasia (AVM) in the cecal
.
Secondary Diagnosis: Atrial Fibrillations
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 13964**], it was a pleasure taking care of you during
your hospitalization at [**Hospital1 18**]. You were admitted because you
were having bloody bowel movements at home. On admission your
blood count was low and you recived blood transfusions. You
then had a colonoscopy which showed bleeding vessel (AVM) in
your colon which was couterized to stop the bleeding. Your
blood count remained stable after the colonoscopy and you did
not have any further bloody bowel movements. You were disharged
to follow up with your PCP and your oncologist.
.
During this admission your Coumadin has been stopped
temporarily. Since you are at increased risk of bleeding after
the colonoscopy, our gastroentestinal specialists recommend that
you not take your Coumadin until [**2175-7-19**]. You can start
taking your usual dose of Coumadin On [**2175-7-19**] and follow
up for your routine INR checks.
Followup Instructions:
Please see your Oncologist Dr. [**First Name (STitle) **] on Tuesday, [**7-18**] for
followup. Please call his office on Monday to clarify the time
of Tuesday's appointment.
.
Please call your PCP ([**Telephone/Fax (1) 17476**]) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to make a
follow up appointment in the next 3-7 days.
Department: DIGESTIVE DISEASE CENTER
When: WEDNESDAY [**2175-7-19**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 85582**], MD [**Telephone/Fax (1) 85583**]
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
Department: ENDO SUITES
When: WEDNESDAY [**2175-7-19**] at 11:30 AM
Completed by:[**2175-7-16**]
ICD9 Codes: 5849, 4254, 2851, 4168, 2724, 4019, 4280, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7014
} | Medical Text: Admission Date: [**2172-3-5**] Discharge Date: [**2172-3-10**]
Date of Birth: [**2120-11-28**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 51-year-old male
patient with insulin dependent-diabetes mellitus. He is
status post an inferior wall myocardial infarction in [**2162**],
which was treated with thrombolytics as well as an
angioplasty and a stent to the right coronary artery. He has
had subsequent instent restenosis in [**2165**] and a subsequent
angioplasty in [**2168**] for unstable angina. Routine stress test
in [**Month (only) 956**] of this year was positive and the patient was
referred for cardiac catheterization. This revealed left
ventricular ejection fraction of 40%, left ventricular end
diastolic pressure of 23, a 50% left main occlusion, as well
as three-vessel coronary artery disease. Patient was
referred for coronary artery bypass graft.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Insulin dependent-diabetes mellitus.
4. Status post appendectomy.
5. Status post eye surgery.
6. Multiple angioplasties with stents as previously mentioned
in history of present illness.
7. He has also advanced diabetic neuropathy.
8. Sleep apnea, and has been advised to use a CPAP mask at
home, but does not use it on a regular basis.
PREOPERATIVE MEDICATIONS:
1. NovoLog insulin 70/30, 80 units in the morning and 50
units before dinner.
2. Aspirin 325 p.o. q.d.
3. Plavix 75 p.o. q.d.
4. Lopressor 75 mg p.o. b.i.d.
5. Lasix 40 mg p.o. q.d.
6. Folate 2 mg p.o. q.d.
7. Crestor 10 mg p.o. q.d.
8. Neurontin 600 mg p.o. b.i.d.
9. Diovan 320 mg p.o. q.d.
10. Vitamin C b.i.d.
11. Multivitamins once a day.
12. The patient was previously on antibiotics for an upper
respiratory admission in [**Month (only) 956**] of this year.
PHYSICAL EXAMINATION UPON ADMISSION TO THE HOSPITAL:
Unremarkable.
Patient was a same-day admission on [**2171-3-5**], and was
taken to the operating room at that time with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**], where the patient underwent a coronary artery
bypass graft x4 with a LIMA to the LAD, saphenous vein to the
PDA, saphenous vein to OM-1, and saphenous vein to D1.
Postoperatively, patient was phenylephrine and milrinone IV
drips and was transported in stable condition from the
operating room to the Cardiac Surgery Recovery room.
By postoperative day one, the patient was weaned off his
vasoactive drips. Was hemodynamically stable. Was in normal
sinus rhythm and had been weaned from mechanical ventilation
and extubated, and was beginning to progress with cardiac
rehabilitation and physical therapy, and the patient was
transferred to the telemetry floor on postoperative day one.
On postoperative day two, the patient was begun with Physical
Therapy and cardiac rehab, and began ambulation. Remained
hemodynamically stable in normal sinus rhythm. [**Last Name (un) **]
service was consulted to assist with diabetes management, and
increasing his insulin doses according to his needs. Patient
continued to progress over the next couple of days from a
physical therapy standpoint.
On postoperative day four, the patient was a little bit
lightheaded with ambulation and although he did not drop his
blood pressures significantly, he was a little unsteady on
his feet. The Physical Therapy service did re-evaluate his
ability to ambulate independently today.
On postoperative day five, the patient states he feels much
better and is anxious to go home. No longer complains of
dizziness or lightheadedness and is able to climb the stairs
asymptomatically. Patient's chest tubes had been
discontinued on postoperative day two, and his epicardial
pacing wires have also been discontinued. Patient remains
hemodynamically stable and is ready to be discharged to home
today on postoperative day five.
PHYSICAL EXAMINATION: Neurologically: The patient is
grossly intact with no apparent neurologic deficits. His
lungs are clear to auscultation bilaterally, although has
slightly decreased breath sounds in bilateral bases. Cardiac
examination is regular rate and rhythm. Abdomen is soft,
obese, and nontender. His sternum is stable with
Steri-Strips intact. There is no erythema or drainage, and
his leg incision is also clean and intact.
DISCHARGE MEDICATIONS:
1. NovoLog 70/30 insulin 80 units q.a.m. and 50 units before
dinner.
2. Aspirin 325 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Ranitidine 150 mg p.o. b.i.d.
5. Metoprolol 75 mg p.o. b.i.d.
6. Lasix 40 mg p.o. q.12h. for one week.
7. Potassium chloride 20 mEq p.o. b.i.d. x1 week as well.
8. Crestor 10 mg p.o. q.d.
9. Neurontin 300 mg p.o. b.i.d.
10. The patient is to resume his vitamins as he was taking
preoperatively.
FOLLOW-UP INSTRUCTIONS: Patient is to followup with his
primary cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Known lastname **] in [**1-28**] weeks. He is
to followup with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6700**]
in [**12-27**] weeks regarding his diabetes management, and the
patient is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in [**4-30**] weeks
upon discharge from the hospital today.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
graft.
2. Insulin dependent-diabetes mellitus.
3. Hypertension.
4. Hypercholesterolemia.
5. Sleep apnea.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2172-3-10**] 10:19
T: [**2172-3-10**] 10:20
JOB#: [**Job Number 19343**]
(cclist)
ICD9 Codes: 4019, 2720, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7015
} | Medical Text: Admission Date: [**2128-10-25**] Discharge Date: [**2128-11-9**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Burning in throat
Major Surgical or Invasive Procedure:
[**2128-10-27**] Four Vessel Coronary Artery Bypass Grafting utilizing
left internal mammary to left anterior descending artery; vein
grafts to ramus intermedius, obtuse marginal and right coronary
artery.
History of Present Illness:
81 y/o male experiencing burning in throat with activity.
Referred for ETT. +ETT and then referred for cardiac cath. Cath
revealed 3 vessel disease: RCA 70-90%, LCX 70-75%, LAD 80-90%,
EF 50%. After cath at outside hospital, pt was transferred to
[**Hospital1 18**] for CABG.
Past Medical History:
Hypercholesterolemia
Hypothyroid
Depression
Glaucoma
Osteoarthritis
Kidney Stones
s/p Right Total Knee Replacement
s/p Hernia repair
s/p Carpal tunnel release
Social History:
Widowed, lives alone with children
-Tobacco or ETOH
Family History:
Brother and Sister with CAD
Physical Exam:
VS: 5'1-" 188# 97 59 155/66 20 99%RA
General: Lying comfortably in bed in NAD
Neuro: A&O x 3, MAE, follows command, Non-focal
HEENT: Perrl/EOMI, Anicteric, -buccal lesions
Neck: Supple, -JVD, -Bruits, -LA/TM
Resp: CTAB
Cor: RRR +S1S2
Abd: Soft NT/ND, NABS
Ext:Warm, -edema, mild varicosities lower legs
Pertinent Results:
[**2128-10-31**] 05:15AM BLOOD WBC-12.0* RBC-3.65* Hgb-11.7* Hct-33.0*#
MCV-91 MCH-32.2* MCHC-35.5* RDW-14.2 Plt Ct-102*
[**2128-11-2**] 06:35AM BLOOD PT-14.9* PTT-62.1* INR(PT)-1.5
[**2128-11-3**] 06:35AM BLOOD PT-16.8* INR(PT)-2.0
[**2128-11-1**] 06:58AM BLOOD Glucose-103 UreaN-36* Creat-1.0 Na-142
K-3.5 Cl-105 HCO3-30 AnGap-11
[**2128-11-2**] 06:35AM BLOOD UreaN-30* Creat-1.0 K-4.0
[**2128-11-2**] 09:40AM BLOOD ALT-41* AST-36 AlkPhos-81 Amylase-40
TotBili-2.0*
Brief Hospital Course:
Patient was admitted and underwent routine preoperative
evaluation. Laboratory values were unremarkable while a carotid
ultrasound found minimal disease of both internal carotid
arteries. He was noted to have short runs of NSVT on telemetry
but otherwise remained stable and pain free on medical therapy.
On [**10-27**], Dr. [**Last Name (STitle) **] performed four vessel coronary
artery bypass grafting. The operation was uneventful and he was
brought to the CSRU in stable condition. Within 24 hours, he
awoke neurologically intact and was extubated. He was transfused
with packed red blood cells to maintain hematocrit near 30%. On
postoperative day one, he was noted to have an elevated lactate,
amylase and lipase. An abdominal ultrasound was obtained and
notable for cholelithiasis without evidence of cholecystitis.
Serial abdominal examinations remained benign. He maintained
stable hemodynamics and weaned from inotropic support without
difficulty. On postoperative day two, he transferred to the SDU.
He went on to experience atrial fibrillation. Beta blockade was
resumed while Amiodarone therapy was initiated. Heparin was also
initiated and stopped once INR became therapeutic under Coumadin
titration. Additional units of packed red blood cells were
transfused. K and Mg levels were monitored closely and repleted
per protocol. He was noted to have some erythema at his LLE
saphenectomy incision site on post-op day seven and Keflex was
initiated and will be continued for 1 week. Pt made a steadily
post-operative recovery, but was unable to achieve level 5
status and will be discharged to rehab facility for further
physical therapy. Pt. remained in Atrial fibrillation at time of
discharged and will be followed by rehab for Coumadin dosing and
INR checks.
Medications on Admission:
1. Atenolol 25mg qd
2. Fosamax 60mg qwk
3. Lescol
4. Lovastatin 20mg qd
5. Zoloft 50mg qd
6. Levoxyl 50mg qd
7. MVI
8. Xalatan qh
9. ASA 81mg qd
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: Then 200mg [**Hospital1 **] for 2 weeks, then 200mg qd
until stopped by cardiologist.
5. Metoprolol Tartrate 50 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
once a day.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Warfarin 1 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily) as
needed for Titrate dose for INR 1.5-2: Coumadin to be adjusted
for goal INR between 1.5-2.
13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 18979**] HealthCare in [**Location (un) **] House. [**Location 9583**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Post-op Atrial Fibrillation
Hypercholesterolemia
Hypothyroid
Depression
Glaucoma
Discharge Condition:
Good
Discharge Instructions:
INR and Coumadin will be followed by Rehab. Coumadin will be
titrated for goal INR 1.5-2.
[**Month (only) 116**] take shower. Wash incisions with warm water and gentle soap.
Gently pat dry. Do not bath or swim.
Do not apply any lotions, creams, ointments, or powders to
incisions.
Do not drive for 1 month.
Do not lift greater than 10lbs for 2 months.
Call with any fever>101, redness or drainage from incisions.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks.
Dr. [**Last Name (STitle) 5017**] in [**1-15**] weeks.
Dr. [**Last Name (STitle) **] in [**12-14**] weeks.
Completed by:[**2128-11-3**]
ICD9 Codes: 2724, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7016
} | Medical Text: Admission Date: [**2153-5-30**] Discharge Date: [**2153-6-11**]
Date of Birth: [**2102-1-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
left heart catheterization,coronary angiogram
coroanry artery bypass grafts x3(LIMA-LAD,SVG-ramus,SVG-PDA)
[**2153-6-5**]
History of Present Illness:
This 51 year old white male presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital
with chest pain where he ruled in for a myocardial infarction by
enzymes (trop 0.39). He was transferred to [**Hospital1 18**] for cardiac
catheterization which revealed severe three vessel coronary
artery disease. Surgical evaluation was requested.
Past Medical History:
coronary artery disease
s/p coronary artery bypass grafts
Hypertension
Hyperlipidemia
s/p coronary angioplasty
Hepatitis C with cirrhosis
h/o alciohol induced seizures
Depression
Chronic back pain
Scoliosis
benign prostatic hypertrophy
h/o gastrointestinal bleed
Carpal Tunnel Syndrome
s/p left total hip replacement
Social History:
Lives with:sister
Occupation:on disability
Tobacco:+ 70 pk year, down to 3 cigs/day on Chantix
ETOH:H/o ETOH abuse, sober x7 years
Recreational drugs: denies
Family History:
Father died of "[**Last Name **] problem" age 45, had
rheumatic fever
Physical Exam:
Admission:
Pulse:72 Resp: 20 O2 sat:
B/P Right:194/117 Left: 177/108 (prior to cath)
Height:6'3" Weight:195lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema 0 Varicosities +
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2153-6-11**] 04:40AM BLOOD WBC-9.4 RBC-3.18* Hgb-9.1* Hct-28.3*
MCV-89 MCH-28.6 MCHC-32.1 RDW-15.5 Plt Ct-305
[**2153-6-10**] 05:45AM BLOOD WBC-9.8 RBC-3.32* Hgb-9.5* Hct-30.1*
MCV-91 MCH-28.4 MCHC-31.4 RDW-15.3 Plt Ct-263
[**2153-6-11**] 04:40AM BLOOD UreaN-15 Creat-0.9 K-4.1
[**2153-6-10**] 05:45AM BLOOD UreaN-19 Creat-0.9 K-4.5
[**2153-6-8**] 09:31AM BLOOD Glucose-151* UreaN-21* Creat-1.0 Na-141
K-4.0 Cl-105 HCO3-24 AnGap-16
Brief Hospital Course:
The patient was evaluated and cleared by the hepatology service
with Child's Class A Cirrhosis. He underwent the routine
preoperative evaluation. Mr.[**Known lastname 1661**] was brought to the
Operating Room on [**2153-6-5**], where he underwent coronary artery
bypass x 3. See operative note for details. He weaned from
bypass on Neo Synephrine and Propofol infusions. He weaned from
pressors and the ventilator easily and was begun on beta-
blockers and diuresed towards his preoperative weight as usual.
Physical therapy worked with him, however, he was appropriate
for rehab prior to returning home. Wounds were clean and dry
and healing. Pacer wires and CTs had been removed per protocol.
His pain was well controlled on oral analgesics. POD# 6 He was
cleared for discharge to [**Hospital **]Rehabilitation for
further increase in strength and mobility. All follow up
appointments were advised.
Medications on Admission:
Clonidine patch 0.2 qTues
Celexa 60mg po daily
MS Contin 60mg po TID
MSIR 30mg po TID PRN pain
Plavix 75mg po daily
Keppra 500mg po BID
Folate 1mg po daily
Doxepin 10mg po qHS
Coreg 25mg po BID
Lisinopril 10mg po daily
Simvastatin 80mg po daily
Varenicline 0.5mg po daily
ASA 81mg po daily
Calcium Carbonate 500mg +Vit D
Colace 100mg po BID
Ferrous Sulfate 65mg po daily
Magnesium Oxide 400mg po daily
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Varenicline 0.5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Morphine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO three times a day.
6. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO once a day: Q
Thursady.
7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day.
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever or pain.
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
20. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32944**] Village & Rehabilitation Center - [**Location (un) 32944**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
Hypertension
Hyperlipidemia
s/p percutaneous coronary interventions
Hepatitis C with cirrhosis
h/o alcohol induced seizures
Depression
Chronic back pain
Scoliosis
benign prostatic hypertrophy
h/o gastrointestinal bleed
Carpal Tunnel Syndrome
s/p laeft total hip replacement
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]), on [**2153-7-23**] at 1pm
Please call to schedule appointments
Primary Care: Dr. [**First Name (STitle) **],[**First Name3 (LF) 30129**]-[**Doctor First Name **] ([**Telephone/Fax (1) 28612**]) in [**2-3**] weeks
Cardiologist: Dr. [**Last Name (STitle) 86515**] [**Name (STitle) 82705**] ([**Telephone/Fax (1) 65733**]) in [**2-3**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2153-6-11**]
ICD9 Codes: 496, 2724, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7017
} | Medical Text: Admission Date: [**2159-4-30**] Discharge Date: [**2159-5-5**]
Date of Birth: [**2117-12-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Fever, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41 year old male with DMI c/b retinopathy, ESRD s/p renal and
pancreas tranplant in [**2149**], on immunosuppresion who has been
having 2 days of fever and generalized weakness and headache.
He resides in prison and an inmate noted that he was stumbling
to get out of the bathroom and collapsed. He was caught and did
not hit the floor. He did not lose consciousness. He was
brought to the clinic at the prison by where he was noted to
have a temp of 104.9, HR of 130s at (approx: 8pm on [**4-29**]). His
indwelling foley at that time was draining "dark amber colored"
urine. On [**4-27**], he had moved from one unit of the prison to
another unit as he had a "respiratory illness", vitals at the
time were HR of 70s, BP of 104/60's, not orthostatic. Since
then he has been having lethargy and staying in bed. He does
complain of occasional RUQ pain. Of note he has a chronic
indwelling catheter for urinary retention, diagnosed recently.
.
Of note, he had a recent admission at [**Hospital3 **] from
[**Date range (1) 61876**]/[**2158**] for presistent N/V/abd pain for 4-5 days prior.
Creatinine documented at that time was 2. Per d/c summary, he
had CT scan of abd and pelvis on [**4-8**] which showed no abnormality
to explain abd pain. He was treated for urinary retention,
placed on tamsulosin for dystonic bladder and discharged with a
foley. His pancrease and kidney are connected to bladder, thus,
he has chronic metabolic acidosis [**1-3**] bicarb excreted into
urine, he is taking outpatient NaHCO3 and was give Isotonic
bicarb in NS during that admission. He had a f/u appt with Dr.
[**Last Name (STitle) 43125**] on [**2159-5-2**].
.
He was tranfered from prison to [**Hospital1 498**] ED. At OSH ED he was
found to have a temp to 103.3 and had a positive UA and a CXR
was done that was clear. He was given Vancomycin 1g, Gent
100mg, zosyn 3.325mg and hydrocortisone 200mg and tylenol. He
was given dilaudid for pain. He was then tranfered to [**Hospital1 18**] ED
for further work-up.
.
At [**Hospital1 18**] ED initial vitals were: 97.0 90 128/75 20 94%. He was
noted to be diffusely diaphoretic and occasional somnolent
although he could be aroused and woken up. His renal transplant
site was normal and did not have any erythema or fluccuance. He
requires translator, but was appropriate. Pt denied abdomainl
pain. Labs significant for bicarb of 8, K of 6.7, Na 122, WBC
of 23, lactate of 1.5, creatinine of 3.1, INR of 1.6. Given the
fact that he had a headache an LP was planned. However the
patient refused an LP as he had one in the past and did not want
it. In addition to the antibiotics given at OSH ED he was given
ceftriaxone 2g iv, Insulin/D50, Calcium, and 4L of NS.
.
On the floor, he is tachycardiac and rigoring.
Past Medical History:
Urinary retention
blodder stone removal vai cycstocopy in [**2153**]
chronic metabolic acidosis
legally blind in the let eye
DM type 1 c/b retinopathy, nephropathy s/p kidney and pancreas
transplant in [**2149**] at [**Location (un) 10866**].
Transplant-related erythrocytosis
HLD
HTN
GERD
L. Kidney soft tissue mass
Social History:
incarcerated at [**Last Name (un) **]. No current use of tobacco, etoh, or
ivdu.
Family History:
Grandfather had throat cancer
Physical Exam:
Admission Vitals
Vitals: T: 103 BP: 130/60 P: 140 R: 25 O2:100% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, diffusely
blanching erythema.
Neck: supple, JVP not elevated, no LAD, +
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Vitals: T: 97.8 Tmax: 99.1 BP: 142/80 (114-142) P: 64 (58-64)
R: 18 (18-20) O2: 94-99% RA
Fingersticks: 102->103->134->117
General: Alert, oriented, no acute distress. Afebrile.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, no meningismus, no
tenderness to palpation over spine
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, no
tenderness over transplanted kidney in LLQ.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
ADMISSION LABS:
.
[**2159-4-30**] 02:15AM BLOOD WBC-23.5* RBC-6.42* Hgb-17.7 Hct-57.8*
MCV-90 MCH-27.6 MCHC-30.6* RDW-17.1* Plt Ct-153
[**2159-4-30**] 02:15AM BLOOD Neuts-88* Bands-0 Lymphs-1* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2159-4-30**] 02:15AM BLOOD PT-18.0* PTT-38.1* INR(PT)-1.6*
[**2159-4-30**] 02:15AM BLOOD Glucose-130* UreaN-53* Creat-3.1* Na-122*
K-6.7* Cl-111* HCO3-8* AnGap-10
[**2159-4-30**] 08:35AM BLOOD Albumin-3.0* Calcium-10.7* Phos-4.9*
Mg-1.9
.
DISCHARGE LABS:
[**2159-5-5**] 06:51AM BLOOD WBC-5.8 RBC-5.38 Hgb-14.8 Hct-47.0 MCV-87
MCH-27.4 MCHC-31.4 RDW-17.3* Plt Ct-161
[**2159-5-5**] 06:51AM BLOOD Neuts-61.9 Lymphs-27.3 Monos-8.1 Eos-2.5
Baso-0.2
[**2159-5-5**] 06:51AM BLOOD Plt Ct-161
[**2159-5-5**] 06:51AM BLOOD Glucose-99 UreaN-22* Creat-1.6* Na-142
K-4.0 Cl-110* HCO3-22 AnGap-14
[**2159-5-3**] 05:50AM BLOOD ALT-26 AST-25 AlkPhos-56 TotBili-0.2
[**2159-5-5**] 06:51AM BLOOD Lipase-119*
[**2159-5-5**] 06:51AM BLOOD Calcium-9.4 Phos-2.1* Mg-1.5*
[**2159-5-5**] 06:51AM BLOOD tacroFK-19.0
[**2159-5-5**] 06:51AM BLOOD rapmycn-12.3
IMAGING STUDIES:
TRANSPLANT U/S:
1. Left lower quadrant renal transplant, with no hydronephrosis,
but elevated segmental arterial resistive indices measuring 0.80
to 0.87.
2. Pancreatic transplant possibly seen within the right lower
quadrant, with possible ductal dilation althought this could
also represent bowel with thickened walls. If there remains a
high concern for an acute process, a CT examination should be
considered.
3. No focal fluid collections.
TRANSTHORACIC ECHOCARDIOGRAM [**5-3**]:
IMPRESSION: No echocardiographic evidence of endocarditis. Mild
symmetric LVH. Normal regional and global biventricular systolic
function. The valves are well seen without significant
regurgitation making endocarditis unlikely.
CONTRAST CT ABDOMEN AND PELVIS AND NON-CONTRAST CHEST CT [**5-4**]:
No intrathoracic, abdominal or pelvic evidence of infectious
etiology.
Dilatation of the left native proximal ureter with high-density
material and abnormal soft tissue density just inferior to the
dilated ureter which could represent a ureteric process or lymph
node, possibly causing obstruction of the native proximal
ureter. Further evaluation with MR urogram should be considered.
Air within the non-dependent portion of the urinary bladder may
be related to prior instrumentation and clinical correlation is
recommended.
CXR:
No previous images. The right PICC tip is in the upper portion
of
the right atrium and should be pulled back about 3 cm for
optimal placement. This information has been telephoned to the
IV nurse by the resident on call at 9:40 a.m. on [**5-5**]. (this was
done to PICC line)
.
Micro:
[**4-30**] Blood:
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 4 S
VANCOMYCIN------------ 1 S
.
[**4-30**] Urine:
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ 1 S
Brief Hospital Course:
41-year-old man with diabetes and ESRD s/p pancreas and kidney
transplant now with fevers, GPC bacteremia, pyuria, and
leucocytosis, presumably transplant pyelonephritis.
.
# Fevers/UTI/Bacteremia: Patient started on emperic vancomycin
and zosyn [**4-30**]. UTI . Patient did have dental work several
weeks ago, thus endocarditis was also on the differential.
Foley catheter was switched out. ID was consulted and
recommended staying on zosyn/vancomycin until speciation.
Abdominal US negative for fluid collection. Blood culture grew
enterococcus and urine grew e coli and enterococcus. Zosyn
transitioned to PO cipro on [**5-2**] and vancomycin transitioned
ampicillin on [**5-3**] in response to sensitivities. TTE was normal
with good quality study. The patient was feeling clinically
well by [**5-2**] except for headache and several episodes of loose
stool [**5-1**]. C-diff toxin negative x2 and diarrhea and headache
resolved. Patient continued to spike fevers evening of [**5-2**] and
[**5-3**]. Further urine/blood cultures as well as contrast abdominal
and non-contrast chest CT scan, BK virus and adenovirus urine
and blood studies were sent for fever work-up. CT scan was
negative for infectious process, and patient remained afebrile
following 22:05 on [**5-4**]. Plan is for 2 weeks total of amp until
[**5-15**] for bactermia and course of cipro for UTI to end [**5-7**].
.
# ARF: Cr from recent baseline of 2.0 up to 3.1 on admission.
Likely prerenal from UTI and spesis. Improved with fluids to
2.4 on [**5-1**] and he had appropriate urine output. With clinical
improvement, his Cr continued to fall to 1.6 on day of
discharge. Of note, patient received IV contrast for CT scan on
[**5-4**]. He was pre-hydrated. Please monitor for worsening ARF
after discharge.
# Transplant: Continued on sirolimus and tacrolimus. Was
followed by renal transplant service throughout stay. Levels of
sirolimus and tacrolimus were slightly low on admission,
suggesting the patient missed meds recently. Following 24hr
troughs were [**Month/Day (4) 25486**] 5.2-5.7 and rapamycin 7.5-7.9. Ultrasound
showed increased arterial indicies read as concerning for mild
rejection, but renal team did not feel this was the case. Of
Note: his PPI dose was doubled on this admission, which can
increase levels of tacrolimus.
.
# Urinary Retention: Had foley in place on admission, which was
changed for clean foley initially. He had a planned outpatient
voiding trial on [**5-2**], so foley was removed on [**5-2**] and patient
was able to void. Post-void residual on [**5-3**] was 108cc. He was
continued on flomax.
.
# HyperK: Given D50/Insulin, kayalxylate, calcium, 6-liter IV
NS. K+ trended down over 24 hours and remained stable.
.
# Metabolic acidosis: Secondary to infection and pancreatic
excretion, continued on home bicarb repletion 650mg TID but the
patient's levels fell to 12, on renal reccomendations, increased
to 1950mg PO TID and levels stablized in the normal range. This
should be his new dose and his electrolytes should be checked
two days after discharge. Then should then be checked as you
deem appropriate.
.
# Diarrhea: had 4 episodes watery stool on day 1 and additional
infrequent episodes. C. diff stool toxins were negative x 2.
Stool culture [**5-3**] negative for salmonella, shigella, enteric
GNRs and campylobacter.
.
#Headache: Patient complained of neck, shoulder and occipital
soreness starting day 1 of hospitalization, this was most MSK
pain likely secondary to sleeping position. Tylenol was
inadequate for controlling this pain, but resolved with
oxycodone 5mg Q6hr PRN while inpatient. Patient did not have
significant analgesia needs by [**5-4**]. This should not be
continued on discharge.
.
# Diabetes Mellitus: The patient is s/p pancreatic transplant
with no insulin requirement at home; was slightly hyperglycemic
here most likley due to infection. H received low doses of
insulin per sliding-scale regimen while inpatient.
.
# GERD: Continued on omeprazole, but dose doubled to 40mg PO
daily on [**5-3**] in response to ongoing complaints of heartburn by
the patient. This has been known to ocassionally interact with
tacrolimus, so please check dose to make sure it is stable on
Monday. He did get good relief on the higher dose of
omeprazole.
.
# Transplant-related erythrocytosis: HCT 58 at admission, in 40s
since IV fluid hydration. Baseline is around 50 and he receives
periodic phlebotomy as an outpatient. The acute elevation may
have been secondary to dehydration. HCT remained in high 40s
after hospital day 1, no intervention aside from IV hydration
and frequent laboratory draws.
.
# Hyperlipidemia: Continued on simvastatin.
Medications on Admission:
Aspirin 81mg
Fludricortisone 0.1mg TID
Methylprednisolone 4mg daily
Omeprazole 20mg daily
Simvastatin 20mg daily
Tamsulosin 0.4mg daily
Sirolimus 3mg daily
Tacrolimus 2mg [**Hospital1 **]
Sodium Bicarbonate 650mg TID
Bactrim 400/80 M/W/F
PCN VK 500mg Q6H for 6 days (completed on [**4-17**])
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO M W F ().
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
10. methylprednisolone 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. sodium bicarbonate 650 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: LAST DOSE: AM of [**5-7**].
14. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
15. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours) for 2 weeks: First dose: PM [**5-3**].
Continue for 2 weeks total. Last day [**5-17**].
16. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 68789**] [**Hospital 16843**] Campus
Discharge Diagnosis:
Primary:
Urinary Tract Infection with sepsis
Discharge Condition:
Vital Signs Stable
Mental Status: Alert and Oriented
Ambulates at will
Discharge Instructions:
You were admitted to the hospital after feeling weak and having
fevers for several days. You had developed new kidney failure.
It was found that you had a urinary tract infection. Bacteria
were found in your urine and in your blood. You received
antibiotics intravenously and orally and your infection began to
clear and your kidney function improved. You will need to be on
two weeks of IV antibiotics. We also increased your dose of
bicarb and ompeprazole. Omeprazole can sometimes interact with
your [**Last Name (LF) 25486**], [**First Name3 (LF) **] please make sure to have your levels checked.
Followup Instructions:
Follow-up with outpatient urology providers for urinary
retention
Will continue IV Ampicillin for total of 2 weeks. Should have
labs checked at least weekly to monitor infection. Infectious
disease follow-up with possible trans-esophogeal endocardiogram
if he develops new fevers.
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
Completed by:[**2159-5-6**]
ICD9 Codes: 5856, 5849, 2762, 2767, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7018
} | Medical Text: Admission Date: [**2165-11-5**] Discharge Date: [**2165-11-10**]
Date of Birth: [**2098-11-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD [**2165-11-6**]: no complications.
History of Present Illness:
This is a 67 y.o. gentleman with h/o Atrial Fibrillation s/p
elective ventral hernia repair with mesh placement on [**2165-10-30**]
at [**Hospital6 33**] now transferred with upper GI Bleed. He
did well post-op but had mild heartburn without nausea or ABD
pain. On POD #3 he was started on heparin for his Afib and had
melanotic stools and small volume hemoptysis (less than a cup).
There was concern for PE leading to hemoptysis and a CT Chest
was obtained which although negative for PE, demonstrated an
intraluminal mass in the distal esophagus. On [**2165-11-5**] he had
melanotic stools and his Hct dropped from 37 to 33. An EGD was
performed demonstating a large clot at the GE junction with
question of intramural mass. He was transferred to [**Hospital1 18**] for
further evaluation and endoscopic ultrasound.
ROS:
POSITIVE: NSAID use at home.
NEGATIVE: no prior colonoscopy, black stools, bloody stools,
tums or pepto bismol use, eating spinach, fevers, dysphagia,
odynophagia, wt change, chest pain, dyspnea, palpitations,
edema, weakness, numbness.
Past Medical History:
Chronic Atrial Fibrillation s/p attempted cardioversion x 2.
Gout
Benign Prostatic Hypertrophy
Chronic Ankle Edema
Hypertension
Obesity
Left Total Hip Repair
Laryngeal Polyps removed in [**2149**] with subsequent tracheostomy
for 1 month
s/p Ventral hernia repair [**2165-10-30**]
Social History:
Lives in [**Location **], MA. Quit smoking 15 years ago. 15 py history.
EtOH <2x/week. Worked for the City of [**Hospital1 8**]. No exposures.
Now retired and runs a charter fishing boat business.
Family History:
No GI disorders
Sister: CNS Malignancy with resutling cervical cord compression
and paraplegia
Father: HTN
Physical Exam:
Temp:99.9 BP:140/85, HR:120 irreg irreg RR:16 O2:96% 2L
Wt:132 kg Ht:5'8"
Gen: NAD, A/O x3
HEENT: PEARLA. EOMI. OP: dry membranes. No LAD. Right ear
with 1x1 cm lesion on pinna, well circumscibed.
CV: irreg irreg, tachy, No M
Pulm: CTA b/l
ABD: Horizontal surgical incision with staples in place c/d/i.
JP Drain with serosanginous fluid, c/d/i. Non-TTP. Soft.
Ext: Trace brawny edema b/l. 1+DP/PT b/l
Neuro: Motor [**4-4**] at all flex/ex. Sensation: GI to LT. CN
II-XII GI.
Rectal: Guaiac + Brown Stool. No hemorrhoids
Pertinent Results:
Ventral hernia tissue: Fibroconnective and Fibroadipose Tissue
with Non-specific Degenerative Changes
[**2165-11-5**] KUB: Illeus. Improved compared to prior
[**2165-11-5**]: Cardiomegaly. No infiltrates/effusions
[**2165-11-4**]: CT Chest: No PE. Moderate left-sided effusion and left
basilar atelectasis. 5.5 maximal diameter oval low attenuation
structure lateral to the distal esophagus which may represent a
diverticulum or mass. The structure does not fill with oral or
IV contrast.
[**2165-11-5**] 08:23PM GLUCOSE-107* UREA N-19 CREAT-0.9 SODIUM-147*
POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-28 ANION GAP-13
147 109 19
-------------<107
3.1 28 0.9
ALT(SGPT)-11 AST(SGOT)-14 LD(LDH)-169 ALK PHOS-45 AMYLASE-14 TOT
BILI-0.5
LIPASE-17
WBC-9.0 RBC-3.51* HGB-11.2* HCT-31.3* MCV-89 MCH-31.8 MCHC-35.6*
RDW-14.2
PLT COUNT-194
Brief Hospital Course:
67 year old male with atrial fibrillation. He was on his
post-operative day #8 post ventral hernia repair complicated by
upper GI Bleed after starting heparin and found to have question
of a mass at GE Junction.
1. Question of Mass at GE Junction: On CT a 5.5 cm low
attenuation mass lateral to distal esophagus was seen which may
represent a diverticulum or mass. GI performed EGD in MICU on
[**11-7**] that showed esophagitis and question of mild bulging at
distal esophagus. EUS scheduled as an outpatient for further
evaluation of the mass
.
2. Recent GI bleed: Patient found to have melanotic stool after
being started on heparin post-op for anti-coagulation for Afib.
EGD showed clot at GE junction initially which was likely
source of bleed. A later EGD did not show active bleed. He
remained hemodynamically stable.
.
3. Atrial fibrillation: He is not being anti-coagulated
secondary to recent GI bleed. Patient was discharged on home
regimen of metoprolol and nifedepine
.
4. HTN: Patient is on 5 anti-hypertensive agents at home. SBPs
elevated at 150-170.
He was restarted on PO Metoprolol, ACE-I and nifedipine in
house. Further blood presssure management is deferred to
outpatient physician. [**Name10 (NameIs) **] lasix had been discontinued because he
was having diarrhea
.
5. Left pleural effusion on CT: patient's o2 sats are stable.
This is likely from congestive heart failure. Patient refuse to
consider thoracentesis
.
6. Post-op from ventral hernia repair
Medicine team spoke with Dr. [**First Name (STitle) **] at [**Hospital6 33**]
([**Telephone/Fax (1) 57700**]). Patient will follow up with Dr. [**First Name (STitle) **] on
discharge.
7. infection: Patient had blood culture growing [**12-4**] GNR on the
day of discharge. Patient have been informed that his blood
culture is positive. However, he was adamant about leaving the
hospital despite knowing potential risk. He had been advised to
finish all his antibiotic and closely follow up with his PCP.
[**Name10 (NameIs) 65228**] blood culture was sent and he was advised to follow
up with his PCP for that. He also developed UTI and was started
on ciprofloxacin.
Medications on Admission:
Meds on transfer: Protonix 40 daily, Heparin SC, Kcl, Tylenol,
lopressor 5 IV q6, Phenergan, Lasix prn, Ativan prn, diltiazem
prn, percocet.
Meds at home: Metoprolol daily, Lisinopril 40 daily, Allopurinol
300 daily, coumadin 6 daily, lasix 20 daily, dyazide 1 daily,
Doxazosin 4 daily, Nifedical XL 60 daily
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:*2*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
Disp:*33 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 13 days.
Disp:*26 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal Mass
UGI bleed
Atrial Fibrillation
Discharge Condition:
Stable with no further episodes of bleeding and stable
hematocrit.
Discharge Instructions:
Please take your medications as prescribed.
.
Please do not take your coumadin until after your biopsy on
[**11-19**].
.
You have been informed that your blood culture is positive. You
have also been inform that this is potentially dangerous and
that you need to stay until we have another [**Month/Year (2) **]
culture. However, after understanding your risk, you have chosen
to leave the hospital. Please be vigilent in monitoring your own
symptoms. If you have fever, chills, more severe diarrhea, chest
pain, shortness of breath, abdominal pain, cannot keep up with
oral intake, dizziness or any concerns at all, please return to
the hospital.
.
Your lasix has been discontinued since you are having diarrhea,
your blood pressure is well controlled and your potassium is
low. Please discuss with your doctor [**First Name (Titles) 4120**] [**Last Name (Titles) 9533**] that.
.
Please finish all the antibiotics prescribed.
Followup Instructions:
You have an appointment for an endoscopic ultrasound (EUS)
scheduled on [**2165-11-19**]. You should go to the information desk on
the [**Location (un) 448**] of the [**Hospital Ward Name 1950**] building in [**Hospital Ward Name 516**] at 6:40
AM on [**2165-11-19**] to find out where you should go for your
procedure. Please call [**Telephone/Fax (1) 65229**] with any questions or if you
need to change your appointment.
.
You have an appointment with Dr. [**First Name (STitle) **] on [**2165-11-11**] at 2pm. You
will have your staples removed at this appointment and your JP
drain evaluated.
.
Please follow up withyour PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39411**], next week to check
your potassium. Also follow up with him after [**11-19**] to discuss
resuming your coumadin. You also need to recheck your urine
after you finish your antibiotic to make sure that you cleared
your infection. You should also ask your doctor regarding the
pending blood culture.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2166-1-17**]
ICD9 Codes: 5789, 5990, 7907, 5119, 2749, 4019, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7019
} | Medical Text: Admission Date: [**2200-10-16**] Discharge Date: [**2200-11-8**]
Date of Birth: [**2142-1-23**] Sex: M
Service: MEDICINE
Allergies:
Chlohexadine
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
metastatic melanoma
Major Surgical or Invasive Procedure:
1. Right frontal craniotomy.
2. Excision of tumor with stereotactic navigation.
History of Present Illness:
HPI: Patient is a 58 year old gentleman with a history of
malignant melanoma who presented to an outside hospital
complaining of nausea and headaches. He was previously on
hospice care but had a change of heart. His melanoma had
previously metastasized to his lungs,brain, and bowels, which
required surgical intervention. CT scan recently at OSH showed
new lesions in the head necrosis vs. new mets. The patient
changed his mind RE hospice care and would like this treated. An
MRI today at the OSH showed edema concerning for metastatic
disease at R frontal parietal. There was also increase vasogenic
edema, and 5mm osseous neoplastic disease. Was transfered here
to get Thallium PET. [**Month (only) 116**] get cyberknife vs resection.
Past Medical History:
PAST MEDICAL HISTORY:
HTN(?)
Atrial fibrillation, [**2195**], resolved
Depression
Bradycardia
Social History:
Lived with his brother [**Name (NI) **]. Was a Polaroid technician. Never
smoked tobacco, rare EtOH use.
Family History:
Mom and dad with diabetes. Aunt with unknown malignancy, cousin
with breast ca.
Physical Exam:
On Admission
Vitals - T:97.6 BP:116/64 HR:74 RR:18 02 sat:94
GENERAL: slow to respond, but AAOx3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, some hemangiomas throughout body.
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD. Eyes dysconjugate.
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
.
On Discharge:
Vitals - 96.6, 122/70, 87, 16, 95RA
GENERAL: lying in bed
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, some hemangiomas throughout body.
HEENT: AT/NC, EOMI, anicteric sclera, MMM, nontender supple
neck, no LAD, no JVD.
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
On Admission:
[**2200-10-17**] 05:35AM BLOOD WBC-8.0 RBC-4.87 Hgb-14.1 Hct-43.5 MCV-89
MCH-29.0 MCHC-32.5 RDW-12.4 Plt Ct-260
[**2200-10-17**] 05:35AM BLOOD Plt Ct-260
[**2200-10-17**] 05:35AM BLOOD Glucose-83 UreaN-16 Creat-0.8 Na-138
K-4.0 Cl-101 HCO3-29 AnGap-12
[**2200-10-21**] 06:00AM BLOOD ALT-21 AST-13 LD(LDH)-170 AlkPhos-87
TotBili-0.2
[**2200-10-17**] 05:35AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0
[**2200-10-31**] 02:09PM BLOOD Type-ART pO2-174* pCO2-24* pH-7.61*
calTCO2-25 Base XS-4
[**2200-10-31**] 02:09PM BLOOD Glucose-98 Lactate-1.1 Na-135 K-2.8*
Cl-107
[**2200-10-31**] 02:09PM BLOOD freeCa-0.99*
.
Pertinent Results:
.
CT head [**2200-11-7**]
IMPRESSION: No acute hemorrhage or mass effect. Expected
post-surgical
changes.
.
CXR [**2200-11-2**]
FINDINGS: Right internal jugular vascular catheter has been
repositioned, now terminating in the mid superior vena cava,
with no visible pneumothorax. Endotracheal tube and nasogastric
tube have been removed. Cardiomediastinal contours are stable in
appearance. Persistent right lower lobe scarring versus
atelectasis adjacent to surgical chain sutures as well as a
small right pleural effusion versus pleural thickening. No new
or worsening lung or pleural abnormalities.
.
ECG [**2200-11-2**]
Sinus tachycardia, rate 107 with frequent ventricular premature
beats. There is moderate baseline artifact. Left atrial
abnormality. Compared to the previous tracing of [**2200-10-28**],
except for the change in rate and the presence of frequent
ventricular premature beats, no diagnostic interval change.
.
Brain Tissue Biopsy
DIAGNOSIS:
I. Brain, right craniotomy:
Necrosis and changes consistent with radiation changes. See
note.
II. Brain, right craniotomy:
Necrosis and changes consistent with radiation changes. See
note.
.
MRI BRAIN [**2200-10-28**]
IMPRESSION:
1. Right frontal enhancing mass from tumor/radiation necrosis at
the
resection site with associated significant perilesional edema/
radiation
induced changes. There is extensive perilesional FLAIR and T2
hyperintensity
surrounding this mass. There is mild decrease in enhancement as
compared to the previous MRIS with no change in the perilesional
hyperintensity. This mass is likely to represent radiation
induced necrosis rather than residual/ recurrent neoplasm. For
surgical planning.
2. No evidence of new enhancing lesion.
.
Discharge Labs:
.
[**2200-11-7**] 01:45PM BLOOD WBC-8.5 RBC-4.32* Hgb-13.1* Hct-37.1*
MCV-86 MCH-30.2 MCHC-35.2* RDW-12.9 Plt Ct-227
[**2200-10-30**] 07:45AM BLOOD WBC-12.0* RBC-4.84 Hgb-14.7 Hct-41.6
MCV-86 MCH-30.3 MCHC-35.3* RDW-12.7 Plt Ct-270
[**2200-11-7**] 01:45PM BLOOD Glucose-91 UreaN-15 Creat-0.5 Na-134
K-3.7 Cl-97 HCO3-27 AnGap-14
[**2200-11-7**] 01:45PM BLOOD ALT-24 AST-20 AlkPhos-95 TotBili-1.2
[**2200-11-7**] 01:45PM BLOOD Albumin-3.5 Calcium-8.6 Phos-2.6* Mg-1.6
[**2200-11-1**] 08:01PM BLOOD Type-ART pO2-147* pCO2-40 pH-7.45
calTCO2-29 Base XS-4
Brief Hospital Course:
Mr. [**Name14 (STitle) 102120**] presented from an outside hospital with severe
headaches and nausea. Thallium scan that was inconclusive. The
neurosurgical team saw the patient and agreed to do a craniotomy
and biopsy. Following the surgery, was cared for by the
neurosurgical team for several days. The patient had some relief
to nausea and headache, but symptoms were not completely
resolved. The pathology shows necrosis and arrangements were
made for an outpatient family meeting with neuroncology next
week. In the meantime, he will go to a living facility. During
his stay, Mr. [**Known lastname 76901**] received PT for general weakness.
Palliative care provided significant input regarding medication
for pain and anxiety.
Medications on Admission:
Scopolamine patch 1.5mg TD q3days (next change [**2200-10-17**])
Dilaudid 4mg PO q4h prn pain [**1-22**]
Dilaudid 6mg PO q4h prn pain [**6-27**]
Senna 2tabs PO qhs
Bisacodyl 10mg PR qod
Fentanyl 25mcg TD q3days (next change [**2200-10-16**])
Dilaudid 6mg PO q4h
Decadron 4mg PO q6h
Ativan 1mg PO q6h prn
Compazine 10mg PO q6h prn
Keppra 750mg PO BID
MVI 1tab PO daily
Miralax 17g PO daily
Fioricet 2tab PO daily
Haldol 2mg PO daily
Valium 10mg PR prn q15min x 4 doses until seizure activity
subsides
Maalox 15mL q4h prn
Baclofen 5mg PO TID prn
Effexor 37.5mg PO daily
Zofran 4mg PO q6h prn
Levsin 0.125mg PO daily QIDACHS
Levsin 0.125mg PO q6h prn secretions
Reglan 10mg PO QIDACHS
Colace 100mg PO BID
Discharge Medications:
1. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q 12h () for
4 days.
6. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
8. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea or anxiety.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
12. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation and Nursing Center - [**Location (un) 701**]
Discharge Diagnosis:
Metastatic Malignant Melanoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 76901**], you presented to us with severe headaches and
nausea and were to be worked up for possible new brain
metastasis of your pre-existing cancer. While with us, you
underwent several imaging studies of your brain, and had
neurosurgical intervention to remove the mass from your head.
We have changed several of your medications. Please only take
the medications listed below. Do not take any medications not
listed below.
Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2200-11-11**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2200-11-9**]
ICD9 Codes: 2930, 5990, 2767, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7020
} | Medical Text: Admission Date: [**2143-4-15**] Discharge Date: [**2143-4-18**]
Date of Birth: [**2064-6-19**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Fall down stairs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo male on ASA reportedly found unconscious at the bottom of
10 stairs of his home by his daughter. [**Name (NI) **] was taken to an area
hopsital where he underwent CT imaging; head CT showing IPH and
SDH without shift. He was then
transferred to [**Hospital1 18**] for further care.
Past Medical History:
MI
COPD
Family History:
Noncontributory
Pertinent Results:
[**2143-4-15**] 10:44PM CK(CPK)-860*
[**2143-4-15**] 09:08AM GLUCOSE-142* LACTATE-2.0 NA+-138 K+-3.7
CL--100 TCO2-26
[**2143-4-15**] 08:50AM UREA N-10 CREAT-1.0
[**2143-4-15**] 08:50AM WBC-19.6* RBC-4.37* HGB-13.6* HCT-40.2 MCV-92
MCH-31.1 MCHC-33.7 RDW-13.2
[**2143-4-15**] 08:50AM PLT COUNT-344
[**2143-4-15**] 08:50AM PT-12.5 PTT-23.4 INR(PT)-1.1
[**4-15**] CT HEAD W/O CONTRAST
IMPRESSION:
1. No change in left temporal intraparenchymal hemorrhage, small
focus of hemorrhage within the septum pellucidum and small acute
subdural hematoma along the left temporal lobe.
2. Chronic bifrontal subdural collections with interval slight
increase in density compared to the study today at 9:17 a.m.
consistent with rebleed or possible communication with the left
temporal subdural .
3. Mildly displaced fractures of the right medial and lateral
pterygoid plates, not completely included in the field of view.
Fractures are better evaluated on today's companion CT of the
facial bones.
[**2143-4-16**] MR HEAD W/O CONTRAST
IMPRESSION:
1. 9-mm focus of hemorrhage within the septum pellucidum is
unchanged. Susceptibility artifact and blooming on the gradient
echo images is evidence that this does not represent a colloid
cyst as on the non-contrast CT done earlier, there is no
evidence of calcification in this to explain the susceptibility
effect.
Follow-up CT can be helpful to assess resolution.
2. No short interval change in the left temporal parenchymal
contusion.
CHEST (PORTABLE AP)
FINDINGS: In comparison with the study of [**4-15**], there are again
multiple rib fractures on the right. However, no evidence of
pneumothorax or definite opacification consistent with hematoma.
IMPRESSION: Little overall change.
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery and Plastic
Surgery were consulted given his injuries; both of which were
nonoperative. He was loaded with Dilantin and will continue with
this for a total of 1 month; follow up with Dr. [**Last Name (STitle) **] for an
MRI of the brain at that time. Serial head CT scans have been
stable. His mental status is alert and oriented x2-3; very
cooperative with his care and he is very hard of hearing.
Plastic Surgery was consulted for his multiple facial fractures
and these were managed conservatively. It was recommended that
he be on a soft diet and he can follow up if needed in Plastic
Surgery clinic for any issues that may arise.
His foley catheter was removed and his Flomax was restarted.
Physical and Occupational therapy were consulted and have
recommended rehab after acute hospital stay.
Medications on Admission:
ASA
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. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 1 months: Conitue for 1 month until
follow up with Neurosrugery.
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
hold for loose stools.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
s/p Fall
Left temporal lobe contusion
Subdural hematoma
Right zygomatic arch fracture
Right styloid process fracture
Right ptyerygoid plate fracture
Right rib fractures [**1-25**]
Chest wall hematoma
Discharge Condition:
Good
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **], your Neurosurgery, in one
month. Please call [**Telephone/Fax (1) 77236**] to arrange a follow-up
appointment. Please inform the office that you will need a 'MRI
Brain with and without gadolinium contrast' prior to your
appointment.
Follow up in Plastic surgery clinic as needed for any issues
surrounding your facial fractures; call [**Telephone/Fax (1) 5343**] for an
appointment if one is needed.
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7021
} | Medical Text: Admission Date: [**2113-6-7**] Discharge Date: [**2113-6-14**]
Date of Birth: [**2052-8-26**] Sex: M
Service: NEUROLOGY
Allergies:
Tapioca Flavor / Cabbage
Attending:[**First Name3 (LF) 46915**]
Chief Complaint:
vertigo, imbalance
Major Surgical or Invasive Procedure:
MRI/MRA head and neck
CT head
History of Present Illness:
60 year old man with a history of lung cancer
(no known mets as per patient) now presenting with dizziness
since yesterday am. The patient tells me he awoke this am to
the
sensation of everything spinning. This sensation worsened over
the next 3 hours. While walking to the bathroom, his legs gave-
out beneath him and he fell to the ground. He believes he lost
consciousness for a few seconds and then was "okay". He did not
hit his head when he fell. He denies any associated double or
blurry vision, headache, or focal weakness (has had increased
overall fatigue recently). Because of the persistant dizziness,
he presented to an OSH ER where a head ct was performed which
showed a midline cerebellar bleed. He was then transferred here
for further management.
Past Medical History:
-h/o lung ca dx in [**12-31**]
-CAD s/p MI last year
Social History:
-lives with friend
-1 ppd smoking history but quit this [**Month (only) **]
-social etoh
-h/o abestos exposure in navy
Family History:
-strong cancer history
-no h/o seizures or strokes
Physical Exam:
General: older man in no acute distress
Neck: supple
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema
Neurologic Examination:
Mental Status:
Awake and alert, cooperative with exam, normal affect
Oriented to person, place, month and president
Attention: Can say months of year backward and forward
Language: Fluent, no dysarthria, no paraphasic errors, naming
intact
Fund of knowledge normal
Registration: [**3-30**] items, Recall [**3-30**] items at 3 minutes
No apraxia, No neglect
[**Location (un) **] and writing intact
Cranial Nerves:
Visual fields are full to confrontation. Pupils equally round
and
reactive to light, 3 to 2 mm bilaterally. Extraocular movements
intact with some horizontal nystagmus on right gaze and rotary
nystagmus on upgaze. Facial sensation and facial movement normal
bilaterally. Hearing intact to finger rub bilaterally. Tongue
midline, no fasciculations. Sternocleidomastoid and trapezius
normal bilaterally
Motor:
Normal bulk and tone bilaterally
No tremor
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Left 5- 5- 5 5 5 5 5 5- 5 5 5- 5 5 5 5
slight left pronator drift
Sensation was intact to light touch, pin prick, temperature
(cold), vibration, and proprioception
Reflexes: B T Br Pa Pl
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes were downgoing bilaterally
Coordination: FNF with
Gait: ataxic gait.
Pertinent Results:
MRI/MRA head and neck [**2113-6-7**]:
FINDINGS: There are no areas of diffusion abnormality. On
T1-weighted images, there is a 2.0 x 2.6 cm mass, which appears
bright on T1-weighted images and isointense to low signal on
T2-weighted images with areas of increased T2 signal with a
possible fluid-fluid level. Following administration of
gadolinium, there is enhancement in a portion of this lesion.
Additional 1cm homogeneously enhancing lesion is visualized
within the left parietal lobe near the sensory gyrus with
moderate peritumoral edema. Minimal amount of edema is also seen
surrounding the mid-cerebellar lesion. On gradient echo images,
there are areas of susceptibility within these two lesions,
which are consistent with hemorrhage. No other areas of abnormal
enhancement are noted.
There is mass effect as a result of the cerebellar lesion with
slight anterior displacement of the posterior wall of the fourth
ventricle. No hydrocephalus, however, is present.
IMPRESSION: Likely two hemorrhagic metastatic foci, one to the
mid cerebellum and one to the left parietal lobe in the region
of the sensory gyrus. There is mild to moderate edema
surrounding both lesions with no evidence of hydrocephalus.
Clinical correlation is recommended as to the source of these
lesions.
Head CT with and without IV contrast [**2113-6-8**]:
FINDINGS: Consistent with the MRI performed yesterday, there is
no change in the high-attenuation masses within the cerebellar
vermis and left parietal lobe, which show a small degree of
contrast enhancement. There is low attenuation surrounding these
lesions, more pronounced within the left parietal lobe,
consistent with edema. Both of these masses are consistent with
hemorrhagic metastases. There is no change in the size of the
ventricles to indicate development of hydrocephalus. The
[**Doctor Last Name 352**]-white matter differentiation otherwise remains intact.
There is no evidence of new intracranial hemorrhage or mass
effect. The osseous structures are normal. There is mucosal
thickening within both maxillary sinuses, right greater than
left.
IMPRESSION: Stable appearance of the brain with two presumed
hemorrhagic metastases within the cerebellum and left parietal
lobe. No new hydrocephalus.
CT chest, abd, pelvis [**2113-6-8**]:
CT OF THE CHEST WITH CONTRAST: There is an evidence of prior
right-sided lobectomy. There is a small right-sided pleural
effusion. Surgical sutures and soft tissue density are present
within the right hilum, presumably reflecting post-surgical
change. Centrilobular emphysematous change is seen within the
left lung which is clear. No definite pulmonary nodules are
identified.
CT OF THE ABDOMEN WITHOUT AND WITH CONTRAST: The liver,
gallbladder and , both kidneys, and spleen are unremarkeable.
Both adrenal glands demonstrate nodularity that is new when
compared to a prior CT. A lesion within the left adrenal gland
measures 1.8 x 1.1 cm. There is also fullness within the medial
limb of the right adrenal gland, also new when compared to the
prior examination. There is a hypo-enhancing lesion within the
tail of the pancreas (series 3, image 60) measuring 2.5 x 2.8
cm. An additional low attenuation lesion measuring 1.6 cm is
seen within the mid body of the pancreas. No pathologically
enlarged retroperitoneal or mesenteric lymph nodes are seen.
CT OF THE PELVIS WITH CONTRAST: The appendix, urinary bladder,
distal ureters, prostate gland, and rectum are within normal
limits. No pathologically enlarged pelvic lymph nodes are seen.
Bone windows show no suspicious lytic or sclerotic lesions.
IMPRESSIONS:
1. New nodules within both adrenal glands as well as at least
two hypo- enhancing lesions within the pancreas that are
consistent with metastatic disease.
2. Postoperative change within the right lung consistent with
prior right upper lobectomy with soft tissue density and sutures
at the right hilum.
3. Small right-sided pleural effusion.
Brief Hospital Course:
Pt admitted to Neuro ICU where he was started on IV decadron
which improved his symptoms throughout his hospital course. He
underwnet MRI and CT head which revealed tumour in the
cerebellar vermis impingoing onthe 4th ventricle and a second
lesion in the L parietal region. There was no hydrocephalus.
CT of the chest/abd/pelvis revealed metastatic disease involving
the bilat adrenal glands, pancreas, lung. He was evaluated by
the medical and neuro-onc teams who thought given his prognosis
that Neurosurgical intervention was not in the best interest of
the patient therefore he was evaluated by the radiation oncology
team who suggested evaluation for rad-onc closer to his home at
[**Hospital3 3583**]. He was evaluated by PT/OT and arrnagements
were made for home PT after discharge. He was discharged to
home in stable condition on PO Decadron and f/u in [**Hospital **]
clinic on [**2113-6-19**].
Medications on Admission:
ASPIRIN 325 mg--1 tablet(s) by mouth once a day
COMPAZINE 5 mg--1 tablet(s) by mouth four times a day as needed
for nausea
DECADRON 4MG--5 pills by mouth the night before chemotherapy and
5 pills by mouth the morning of chemotherapy
HYDROXYZINE HCL 25 mg--[**1-29**] tablet(s) by mouth four times a day
as needed for itching
LIPITOR 80 mg--1 tablet(s) by mouth once a day
LISINOPRIL 5 mg--1 tablet(s) by mouth once a day
METOPROLOL SUCCINATE 50 mg--1 tablet(s) by mouth once a day
PERCOCET 5-325 mg--[**1-29**] tablet(s) by mouth every four (4) hours
as needed for pain
PHENERGAN 25 mg--1 tablet(s) by mouth every six (6) hours as
needed for nausea
PLAVIX 75 mg--1 tablet(s) by mouth once a day
ROXICET 5-325 mg--2 tablet(s) by mouth every four (4) hours as
needed for pain
TRAZODONE HCL 50 mg--[**1-29**] tablet(s) by mouth at bedtime as needed
for insomnia
ZETIA 10 mg--1 tablet(s) by mouth once a day
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-29**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 inh* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*45 Tablet(s)* Refills:*0*
8. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
metastatic lung cancer to brain, adrenals, pancreas
Discharge Condition:
stable
Discharge Instructions:
Take all medications as prescribed.
Follow-up with all appointments as directed.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 15108**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2113-6-20**] 11:30
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 Where: SC [**Hospital Ward Name **]
CENTER HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2113-6-20**]
11:30
Provider: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2113-6-20**] 12:00
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2113-6-19**] 1:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 46916**]
Completed by:[**2113-6-14**]
ICD9 Codes: 431, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7022
} | Medical Text: Admission Date: [**2188-10-16**] Discharge Date: [**2188-10-23**]
Date of Birth: [**2107-11-16**] Sex: F
Service: MEDICINE
Allergies:
Amiodarone / Zocor
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Thoracentesis.
History of Present Illness:
Ms. [**Known lastname 7049**] is an 80 year-old woman with a history of COPD, severe
pulmonary artery hypertension, atrial fibrillation on Coumadin
and Alzheimer's who initially presented on [**10-16**] with dyspnea,
initially admitted to the ICU, then transitioned to the medical
floor.
Based on review of her record, ICU notes and discussion with
admitting physicians, the day prior to admission, patient's
family called her cardiologist to report worsening dypsnea while
sleeping and after showering. Lasix was increased without relief
so she presented to an outside hospital. There she was found to
have large pleural effusions.
Upon transfer to [**Hospital1 18**], initial thoracentesis was deferred given
INR >2.0. She was noted to have a WBC of 14.7 and a positive UA,
and she receieved Levofloxacin and Vancomycin empirically.
After arrival to the floor, patient triggered for respiratory
distress with a recorded respiratory rate of 34 and increased
work of breathing; an ABG showed 7.47/47/97. After little
improvement with lasix and increasing O2 requirement, she was
transferred to the ICU.
ICU course: After receiving 5mg vitamin K and FFP, underwent
thoracentesis with removal of 1800cc of serous fluid. BP
initially dropped to 60/50 after [**Female First Name (un) 576**], then improving to 80/50
within one minute. Results were consistent with transudative
effusion. Dyspnea improved, as did initial chest film though
repeat film showed reaccumulation of fluid.
In addition, while in the MICU, she was transiently hypotensive
(as low as a recorded value of 59/43); as such, she received no
doses of verapamil and just one dose of lasix. HR ranged from
70s up to low 100s.
Her breathing and BP stabilized, and she was transferred to the
medical floor. On the medical floor.
Past Medical History:
1. Coronary artery disease
- Cath ([**5-24**]): only mild plaqueing and no significant
obstructive coronary disease in the LAD, LCX or RCA; mid RCA
stent patent
- PCI ([**2-19**]) DES to prox and mid RCA
2. Mitral valve prolapse with severe MR
3. Atrial fibrillation
4. Hypercholesterolemia: [**4-23**] -- TC 162, TG 142, HDL 56, LDL 78
5. COPD
6. Alzheimer's Disease
7. History of sciatica in [**2185**]
8. Macular degeneration
9. s/p Appendectomy
Social History:
Remote 30 pack/year smoking history, rare EtOH, denies drugs.
Patient lives with husband and daughter in home and is retired
from office work. They typically go to [**State 108**] in the winter
though do not plan on doing so this year.
Family History:
Non-contributory; Pt reports mother may have had anginal sxs
Physical Exam:
Vitals: T: 98.9, BP: 120/78, HR: 110, RR: 26-30, O2: 96% 5L
General: Awake, alert, pursed-lip breathing, moderate
respiratory distress, occasionally having to stop to breathe.
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: Supple, No LAD, no JVD
CV: S1, S2 nl, irregular rhythm, no m/r/g appreciated
Lungs: Decreased BS on R>L w/ bronchial BS at the right base,
fine crackles scattered bilaterally, no wheezes, no egophany
Abd: Soft, NT, ND, + BS
Ext: No c/c/e
Neuro: grossly intact; oriented x 3
Pertinent Results:
[**2188-10-16**] 03:15PM BLOOD WBC-14.7* RBC-4.57 Hgb-13.9 Hct-40.2
MCV-88 MCH-30.4 MCHC-34.5 RDW-14.7 Plt Ct-234
[**2188-10-16**] 03:15PM BLOOD Neuts-89.2* Lymphs-5.8* Monos-4.7 Eos-0.2
Baso-0.1
[**2188-10-16**] 04:38PM BLOOD PT-25.7* PTT-28.5 INR(PT)-2.5*
[**2188-10-16**] 03:15PM BLOOD Glucose-143* UreaN-16 Creat-0.9 Na-141
K-3.3 Cl-94* HCO3-33* AnGap-17
[**2188-10-16**] 03:15PM BLOOD CK(CPK)-63
[**2188-10-16**] 03:15PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-4825*
[**2188-10-16**] 09:50PM BLOOD Calcium-9.0 Phos-3.8
[**2188-10-16**] 03:21PM BLOOD Lactate-4.3*
[**2188-10-16**] 07:38PM BLOOD Lactate-3.6*
ECG: Atrial fibrillation with a rapid ventricular response.
Leftward axis. Consider inferior myocardial infarction. Right
bundle-branch block. Since the previous tracing of [**2188-9-12**] the
rate has increased.
CXR ([**2188-10-16**]): Increased size of bilateral pleural effusions,
right greater than left with bilateral lower lobe opacities,
which may represent atelectasis, although an underlying
pneumonia cannot be excluded.
CXR ([**2188-10-17**]; post [**Female First Name (un) 576**]): In comparison with study of [**10-16**],
there has been a dramatic decrease in the right pleural
effusion. No evidence of pneumothorax.
CXR ([**2188-10-17**]): In comparison with the study of [**10-17**], there has
been increased opacification in the right lower lung zone
consistent with the re-accumulation of pleural fluid. There is a
linear stripe running along the right lateral chest wall in the
mid and low end lower lung zones. It is unclear whether this
represents a pneumothorax, since it does not extend to the apex
and there is the vague suggestion of lung markings lateral to it
that suggests merely a skin fold.
CXR ([**2188-10-20**]): Increase in the amount of right pleural fluid
compared to the prior study with stable right and left lower
lobe opacities and mild pulmonary vascular congestion.
CXR ([**2188-10-21**]): IMPRESSION: Little change
ECHO ([**2188-10-17**]):
- left atrium is elongated
- mild symmetric LVH
- LVEF>55%
- RV cavity mildly dilated with mild global free wall
hypokinesis (there is abnormal septal motion/position consistent
with right ventricular pressure/volume overload
- partial mitral leaflet flail with moderate to severe (3+) MR
- severe pulmonary artery systolic hypertension
- trivial/physiologic pericardial effusion.
Brief Hospital Course:
This is an 80 y.o. female, which severe (3+) MR, severe
pulmonary hypertension (likely as a result), who presented with
worsened dyspnea and pleural effusions.
# Dyspnea/Pleural effusions: Primary cause of dyspnea likely
the large pulmonary effusions, which are most likely secondary
to severe mitral reguritation and pulmonary HTN. Symptoms
improved greatly after thoracentesis though this was transient
as the fluid reaccumulated. Repeat echo showed severe MR [**First Name (Titles) **] [**Last Name (Titles) 29618**]m htn, not significantly changed from prior echo. She was
diuresed but this was difficult with blood pressure in the
90s-100s systolic. Afterload has been attempted on an admission
in [**7-25**], though lisinopril was stopped on a subsequent
outpatient follow-up due to relateive hypotension. A
conversation with her outpatient cardiologist revealed that she
is a poor surgical candidate for MVR given her advanced
dementia. A discussed about percutaneous MV repair followed;
this procedure is not performed at [**Hospital1 18**] and not by any
experiened physician in [**Name9 (PRE) 86**]. Given the risk of such a
procedure, unknown amount of benefit, and likely stress on the
patient to travel to have such a procedure performed, her family
and outpatient cardiologist opted not to pursue this. Goals of
care were addressed and her family (HCP is daughter [**Name (NI) **])
decided that her comfort was the primary goal. She was set up
for home hospice, and given morphine prn for shortness of
breath. Supplemental oxygen was continued and she will go home
on it. She was made DNR/DNI.
# Positive blood cultures: GPC in [**1-21**] bottles, treated with
vancomycin until speciated as multiple species of coag neg staph
as well as strep. It was felt this was likely a contaminent,
and vancomycine stopped after 3 days. She had no further fever
or evidence of bacteremia.
# Urinary tract infection: Urine culture grew Ppansensitive
e.coli treated with ciprofloxacin x 7 days. Course completed
[**2188-10-22**].
# Atrial Fibrillation: Given relative hypotension, verapamil
was held early in course with heart rates running in the high
90s / low 100s. Coumadin was held peri-[**Female First Name (un) 576**] and restarted
afterwards. As her BP improved, she was placed back on her
home dose of verapamil.
# CAD: Continued on pravastatin. Not on aspirin per Dr.
[**Last Name (STitle) 696**] (her cardiologist's) notes.
# Alzheimer's: The patient's home regimen of namenda and aricept
were continued.
# CODE: DNR/DNI (confirmed with HCP, daughter [**Name (NI) **])
Medications on Admission:
Amoxicillin 2 grams PRN (prior to dental procedures)
Citalopram 20 mg PO QD
Donepizil 10 mg PO QD
Futicasone 220 mcg 2 puffs [**Hospital1 **]
Furosemide 40 mg PO BID
Potassium Chloride 20 mEq PO QD
Memantine 10 mg PO BID
Pravastatin 40 mg PO QD
Spiriva
Verapamil 120 mg PO BID
Warfarin 3mg 3x/wk; 2mg 4x/wk
MVI
Discharge Medications:
1. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Verapamil 120 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day.
5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO AS DIRECTED ():
Mon/Wed/Sat.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO AS DIRECTED ():
Sun/Tue/[**Last Name (un) **]/Fri.
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Fluticasone 220 mcg/Actuation Aerosol Sig: Two (2)
Inhalation twice a day.
10. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. oxygen by nasal cannula
2-4 liters continuous. Pulse dose for portability
14. Morphine 20 mg/5 mL Solution Sig: 2-5 mg PO Q1H as needed
for shortness of breath or pain.
Disp:*QS ML* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
1. Pleural effusions, secondary to mitral regurgitation
2. Mitral regurgitation
3. Urinary tract infection, completed 7 day course of
ciprofloxacin on [**2188-10-22**]
4. Bacteremia, GPC
Secondary:
1. Coronary artery disease
2. Atrial fibrillation
3. Hypercholesterolemia
4. COPD
5. Alzheimer's Disease
Discharge Condition:
Hemodynamically stable. Needs 2 liters nasal canula at all
times
Discharge Instructions:
You were admitted with shortness of breath and found to have
large pleural effusions (fluid around the lung space) which were
likely a large contributor. The most likely cause of this is
back flow of blood from your heart, caused by a leaky heart
valve. After discussing the options, you and your family
decided against a higher risk mitral valve repair, and instead
opted for hospice care to maximize your comfort.
- No changes were made to your medications, with the exception
of a prescription of a Comfort Pack of medications to be
explained by your Hospice nurse. In addition you provided with
a prescription for morphine to be used for shortness of breath.
- You should use oxygen, by nasal progs, 2 liters at all times.
If you feel short of breath, you may increase the dose up to 4
liters
- You should be with your family member (husband, daughter, or
other family/friend) at ALL times for your safety.
- Please call your hospice nurse as a first contact, if you have
any symptoms.
Followup Instructions:
You should call your hospice nurse or primary care provider if
you have any questions.
Your cardiologist, Dr. [**Last Name (STitle) 696**], is also available to you.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2188-10-23**]
ICD9 Codes: 4240, 5119, 5990, 2720, 4280, 4168, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7023
} | Medical Text: Admission Date: [**2109-7-7**] Discharge Date: [**2109-7-24**]
Date of Birth: [**2037-10-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Hypotension, Encephalopathy
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
71 male with EtOH cirrhosis brought to the ED by his wife for 1
week of increased abdominal girth, LE edema, confusion. Prior to
this, the pt had good functional status, working up until last
week at which time, the pt started to c/o "dizziness." At PCPs
office, BP was 90s/60s, so his nadolol was D/Cd. Pt also noted
increased weight. Otherwise, the pt denies melena, BRBPR,
fevers/chills. Because of continued weight gain along with
confusion, he was brought in to the ER.
.
In the ER, labs showed Cr 1.3. BP 82/68, HR 125, T 94.6, 96% RA,
BP increased to 100s/60s with 500ml NS. Pt received kayexalate
for K of 6. RUQ U/S showed no pocket to perform paracentesis so
empiric CTX was given for presumed SBP. Lactulose was also given
for encephalopathy. Lopressor 5mg IV was given for ? atrial
flutter, new-onset. He was then admitted to the MICU for
tachycardia
Past Medical History:
1. Alcoholic cirrhosis complicated by portal hypertension,
nonocculsive portal vein clot, grade II esophageal varices
2. Splenomegaly
3. Diabetes mellitus
4. Anemia status post EGD in [**4-16**] showing ulcers (H pylori +)
and varices and colonoscopy showing internal hemorrhoids and
diverticula
5. Thalassemia minor, no history of transfusions
6. H. pylori positive status post treatment
7. Pancytopenia, status post bone marrow biopsy showing MDS
versus sideroblastic anemia
8. Cataracts
9. Status post hernia repair
10. Status post appendectomy
Social History:
The patient has a 50+ pack per year smoking history, quit four
years ago. Past heavy alcohol use, now none. Patient is married.
Family History:
Italian descent
- mom died of appendicitis when he was young
- father had atherosclerosis, but the patient does not know if
he had an MI (myocardial infarction) or stroke
- brother did die of an MI (myocardial infarction) at age sixty
- denies any colon cancer or liver disease in his family.
Physical Exam:
VS: Tc 96.1 BP 98/60 P 71 RR 20 99% 3L NC, FS 180, 197; wt
217.9# (baseline wt 81kg or 178# per report)
Gen: elderly bronzed man lying flat in bed, appearing
comfortable, answering questions appropriately, with wife at
bedside
[**Name (NI) 4459**]: [**Name (NI) 3899**], mild icteris, no nystagmus, MM moist
Neck: supple, JVD to mandible
Lungs: crackles halfway up on the right from ant exam, no wheeze
CV: distant heart sounds, irregularly irregular, [**3-19**] holosyst
murmur at LLSB with rad to axilla
Abd: distended, nontender, not tense, hyperactive bs, no
palpable liver or spleen
Groin: R cath site with dressing c/d/i, minimal dried blood, no
fluid collection or ecchymosis
Ext: 3+ bilateral LE edema to groin; +palmar erythema; unable to
palpate DP or PT pulses
Neuro/Psych: approp affect, no evid of encephalopathy; no
asterixis
Pertinent Results:
[**2109-7-7**] 10:21AM AMMONIA-125*
[**2109-7-7**] 10:26AM PT-16.2* PTT-33.3 INR(PT)-1.5*
[**2109-7-7**] 10:26AM PLT COUNT-160
[**2109-7-7**] 10:26AM HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-2+ POLYCHROM-1+ TARGET-2+ SCHISTOCY-1+
STIPPLED-1+ TEARDROP-2+ ELLIPTOCY-1+
[**2109-7-7**] 10:26AM NEUTS-54.6 BANDS-0 LYMPHS-34.8 MONOS-6.6
EOS-3.2 BASOS-0.8
[**2109-7-7**] 10:26AM WBC-6.3 RBC-4.51* HGB-11.4* HCT-35.7* MCV-79*
MCH-25.3* MCHC-32.0 RDW-23.7*
[**2109-7-7**] 10:26AM CALCIUM-9.5 PHOSPHATE-5.0* MAGNESIUM-2.1
[**2109-7-7**] 10:26AM CK-MB-NotDone cTropnT-0.09*
[**2109-7-7**] 10:26AM LIPASE-21
[**2109-7-7**] 10:26AM ALT(SGPT)-23 AST(SGOT)-43* LD(LDH)-233
CK(CPK)-24* ALK PHOS-78 AMYLASE-31 TOT BILI-2.5*
[**2109-7-7**] 10:26AM GLUCOSE-175* UREA N-43* CREAT-1.3*
SODIUM-131* POTASSIUM-6.0* CHLORIDE-93* TOTAL CO2-32 ANION
GAP-12
[**2109-7-7**] 11:58AM LACTATE-1.7
[**2109-7-7**] 12:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2109-7-7**] 12:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2109-7-7**] 03:04PM HGB-12.0* calcHCT-36
[**2109-7-7**] 03:04PM K+-5.0
[**2109-7-7**] 03:04PM COMMENTS-GREEN
[**2109-7-7**] 06:49PM URINE OSMOLAL-465
[**2109-7-7**] 06:49PM URINE HOURS-RANDOM CREAT-132 SODIUM-11
[**2109-7-7**] 08:27PM ALBUMIN-3.8 CALCIUM-8.8 PHOSPHATE-5.4*
MAGNESIUM-2.1
[**2109-7-7**] 08:27PM GLUCOSE-188* UREA N-40* CREAT-1.2 SODIUM-130*
POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-26 ANION GAP-15
.
RUQ US ([**7-7**]): LIMITED ULTRASOUND OF THE ABDOMEN: Comparison is
made to the prior ultrasound dated [**2109-2-7**]. There is
moderate amount of ascites surrounding the liver in the upper
abdomen, slightly increased since prior study. Small amount of
free fluid is seen in the lower abdomen; however, there is no
fluid pocket sufficient for marking. Again note is made of
cirrhotic liver.
IMPRESSION: Moderate amount of ascites surrounding the liver and
small amount of ascites in the lower abdomen. No spot is marked.
.
CXR ([**7-7**]): FINDINGS: There is a new left IJ central catheter
with tip in the left brachiocephalic vein. The right pleural
effusion has increased in size, now moderate-to-large.
Persistent shift of the heart to the right indicates partial
collapse of the right lower and possibly middle lobes. There is
a small left pleural effusion. Diffuse opacity of the abdomen
suggests ascites.
IMPRESSION:
1. Worsening right pleural effusion and associated collapse of
the right lower and probably right middle lobes.
2. Ascites.
.
RUQ US w/ Doppler ([**7-8**]): LIMITED ABDOMINAL ULTRASOUND: The
liver is diffusely hyperechoic and has a nodular contour,
compatible with cirrhosis. The main, left, anterior right portal
veins are patent. Since the prior study, the posterior right
portal venous flow has diminished noticeably, and it is
difficult to get flows within this structure. The splenic, SMV
are patent as is the IVC. There is marked splenomegaly.
Additionally, ultrasound in the four quadrants of the abdomen
was performed, and a spot was marked in the right lower
quadrant.
IMPRESSION:
1. Diminished flow in the posterior right portal vein since the
prior study of [**Month (only) 1096**]. The main, left, and anterior right
portal veins have similar flows to the prior study.
2. Cirrhosis. Splenomegaly.
3. Moderate ascites. A position for paracentesis was marked in
the right lower quadrant.
.
Echo ([**7-9**]):
Conclusions:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
right atrium is moderately dilated. The estimated right atrial
pressure is 16-20 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is moderate global hypokinesis
without regionality. The right ventricle is mildly dilated with
moderate global free wall hypokinesis. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) are
mildly thickened. No aortic stenosis is seen. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a very small,
primarily anterior pericardial effusion withtout
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2109-2-7**],
there has been a decline in left and right ventricular systolic
function. The severity of tricuspid regurgitation has increased,
the effusion is more prominent (but remains very small) and
atrial fibrillation is now present. Ascites was also present on
the prior study. An atrial septal defect is not seen on the
current study (may be related to technical differences).
.
CXR ([**7-10**]): There is stable cardiomegaly. The aorta is calcified
and tortuous. Pulmonary vasculature is unremarkable. The
moderate-sized right pleural effusion has slightly decreased in
size. There continues to be associated compressive atelectasis.
A small left pleural effusion is also noted. Osseous and soft
tissue structures are stable.
IMPRESSION: No radiographic evidence of pneumonia or CHF. Slight
decrease in size of moderate right pleural effusion. Small left
pleural effusion.
.
CXR ([**7-12**]): The cardiomegaly is moderate and stable. The tortuous
aorta is unchanged. Pulmonary vasculature is unremarkable.
Bilateral pleural effusions are demonstrated, right more than
left, grossly unchanged. The bibasal atelectasis is unchanged as
well. There is new linear opacity in the left lower lobe
representing additional plate-like atelectasis.
Brief Hospital Course:
71 yo M with alcoholic cirrhosis, grade II varices,
non-occlusive portal vein thrombosis with recannulization
admitted to the MICU with hypotension and atrial
flutter/fibrillation with resolution s/p fluids and rate control
subsequently called out to the floor for continued management.
The following issues were investigated during this
hospitalization:
.
# Hypotension: Etiology thought to be secondary to cirrhosis vs
Afib/flutter with RVR, resolved with IVF and HR control. Sepsis
was considered initially, but seemed unlikely. While on the
general medicine floor, the patient was continued on Ceftriaxone
and Azithromycin for possible PNA and or presumed SBP.
Additionally, he was aggressively diuresed for new CHF. In the
setting of diuresis, the patient at one point became hypotensive
to 80/50. At this time he received a small bolus with good
effect. Diuresis thereafter for obvious fluid overload was
difficult given the tenuous blood pressure. While the etiology
of the tenuous blood pressure was felt to be from 3rd spacing
while being intravascularly depleted it was also thought that
the patient might be becoming symptomatic in his continued
atrial fibrillation/atrial flutter. For this reason, the
electrophysiology cardiology team was consulted and Digoxin was
loaded for rhythm control. The patient's blood pressure remained
low, but stable for the remainder of his hospitalization.
.
# Arrhythmia: New-onset Afib/Aflutter on presentation was
thought to be related to discontinuation of Nadolol as an
outpatient. He was loaded with Digoxin in the MICU, which was
not continued on the floor because of rate control with Nadolol
(for varices). However, because of hypotension as detailed
above, additional rate control agents could not be added and yet
the patient was intermittently tachycardic to the 140s. He was
not symptomatic, but continued management, mainly of his heart
failure became complicated. For this reason, additional
mechanisms for control of the arrythmia were considered, to
include cardioversion and anti-arrhythmics. Cardioversion was
not an option given the patient's relative contraindication to
anticoagulation given known grade 2 esophageal varices. For this
reason, the patient was loaded with Digoxin again and continued
on Nadolol for both rhythm and rate control.
.
# Heart Failure: Patient's echo on [**7-9**] showed biventricular
heart failure, changed from prior imaging, with no evidence of
infarct on EKG. Most likely etiology was overall fluid overload
from decompensated cirrhosis, worsened by atrial
fibrillation/flutter. The CHF service was consulted in house and
recommended diuresis with Lasix and Aldactone. This was
initiated reaching a maximum of Aldactone 50 mg and Lasix 40 mg
IV BID, before the patient's blood pressure proved to be
problem[**Name (NI) 115**]. With this diuresis, the patient's creatinine bumped
predictably and he had a contraction alkalosis on daily labs.
Additionally, his O2 requirement decreased from 3 liters to 1
liter. However, he continued to have 3+ pitting edema beyond his
knees in both LEs with a normal albumin. For this reason, the
CHF service was reconsulted and the patient was taken for a
right and left heart cardiac catheterization, after which he was
transferred to the acute cardiac floor for continuous diuresis
with a Lasix drip. Unfortunatelty due to hypotension he was
unable to be furtehr diuresed and the gtt discontinued.
# Decompensated cirrhosis: RUQ U/S revealed diminished flow in
the posterior right portal vein since the prior study of
[**Month (only) 1096**]. AFP was normal. Tbili was elevated, but stable. The
patient's encephalopathy resolved with Lactulose, which was
continued PRN for a goal of [**4-14**] BMs/day. Given documented
esophageal varices in house, the patient was continued on
Nadolol. Prophylactic treatment of presumed SBP was continued
with Ceftriaxone and he was maintained on a PPI. Patient was
diuresed as tolerated with Lasix and Aldactone as detailed above
until complicated by hypotension.
.
# ARF: Creatinine was elevated initially to 1.3, which was
likely in the setting of poor forward flow from cirrhosis. This
resolved with diuresis but then in the setting of further
diuresis, hypotension and worsening decompensated liver failure
complicated by CHF his Cr started to rise most likely mised ATN
amd pre-renal azotemia.
.
# Thrombocytopenia: Patient's platelet count continued to drop
from admission reaching 70,000. While this was thought to be
most likely from his liver disease, his prophylactic,
subcutaneous Heparin was discontinued and HIT antibodies were
sent off. He was given TEDS instead for DVT prophylaxis as well
as for LE edema. He never had any obvious bleeding or signs of
bleeding.
.
# Goals of Care: Due to worsening decompensated liver failure
and CHF discussion as to goals of care were had between patient,
wife and primary team. Decision made to concentrate on comfort
and means to get patient home with family. He was discharged to
home with hospice on [**2109-7-24**].
Medications on Admission:
Neurontin 300 daily
Omeprazole 20 daily
Aldactone 50mg [**Hospital1 **]
Lasix 60 AM, 40 PM
Humalog sliding scale
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
Disp:*1 tube* Refills:*0*
2. Cortisone 1 % Cream Sig: One (1) Appl Topical TID (3 times a
day) as needed.
Disp:*1 tube* Refills:*0*
3. morphine Sig: 5-10 mg Sublingual every four (4) hours as
needed for pain.
Disp:*1 bottle* Refills:*0*
4. ativan Sig: One (1) mg Sublingual every 4-6 hours.
Disp:*60 tabs* Refills:*2*
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours) as needed.
6. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice Care
Discharge Diagnosis:
cirrhosis
chf
AFIB
hyponatremia
Discharge Condition:
poor
Discharge Instructions:
please take medications as prescribed
call your pcp if you have any discomfort or other concerns
Followup Instructions:
please call your PCP and update him on your clinical status
ICD9 Codes: 5845, 2761, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7024
} | Medical Text: Admission Date: [**2164-3-21**] Discharge Date: [**2164-3-27**]
Date of Birth: [**2099-3-29**] Sex: M
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: This is a 64-year-old male who
presented with progressive right sixth nerve palsy followed
by facial numbness and difficulty walking. An MRI showed a
large right petroclival meningioma severely compressing the
brain stem and encasing the basilar artery, superior
cerebellar artery, and probable several cranial nerves.
Surgery was recommended to remove this tumor as safely as
possible.
PAST MEDICAL HISTORY:
1. MI in [**2155**].
2. Hypercholesterolemia.
PAST SURGICAL HISTORY: Bilateral inguinal hernia repair.
MEDICATIONS ON ADMISSION:
1. Lipitor.
2. Aspirin 81 mg.
3. Prevacid.
ALLERGIES: None known.
SOCIAL HISTORY: He does smoke. He does not drink alcohol.
HOSPITAL COURSE: The patient was brought to the operating
room on [**2164-3-21**], where he had a right posterior
transpetroval approach for subtotal resection of petroclival
meningioma. He had frameless stereotactic navigation and
abdominal fat graft. The surgery was done in conjunction
with Dr. [**First Name (STitle) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1906**]. Findings were a difficult
vascular tumor encasing the basilar artery and right superior
cerebellar artery. The tumor was very stuck to the pons and
the midbrain, so it was not be completely removed. There
were no complications intraoperatively. The patient was
brought to the recovery room where his vital signs were as
follows: 97.8, 134/60, pulse 68, respirations 16, 100% on
room air. The patient was intubated and sedated when he was
brought to the recovery room. He had been off propofol and
briskly localized in both his upper and lower extremities.
His right pupil was found to be fixed and dilated as a result
of his cranial nerve injuries from the meningioma. His left
pupil was reactive at 2.5 to 2.
The patient was monitored overnight in the recovery room. As
he woke up, he followed commands in all fours. Postop labs:
White count 19, hematocrit 38.2, platelets 278, sodium 145,
potassium 4.6, chloride 111, 20 bicarb, 15 BUN, 0.8
creatinine, glucose 157.
The patient was placed on 8 mg of decadron q 4 h. His blood
pressure was kept between 100-150. He was extubated the next
morning without difficulty and transferred to the ICU for
continued observation. The morning following his surgery, he
was awake, alert, oriented. Again, the third nerve palsy was
noted. His strength was 4+ bilaterally in both his upper and
lower extremities.
On his second postoperative day, the patient was needing
slight Nipride to keep his blood pressure less than 140. He
again continued with the persistent third nerve palsy with
ptosis. His right pupil was 7 mm. His left pupil was 3 to
2. He had a right facial droop and a right drift. His
strength was 5- in right lower, 5 through in the remainder of
his motor exam. His dressing was clean, dry and intact, and
no drainage.
The patient was transferred out of the unit on the 12. The
patient was transferred to the regular surgical floor where
he was able to ambulate with assistance using a walker.
Also, he was tolerating a regular diet and voiding without
difficulty. His incision remained clean, dry and intact. He
continued to have a right facial droop and a right complete
ptosis. His steroids were weaned.
On the 15, he was seen by physical therapy who recommended
home PT, and that he should stay in the hospital until the [**3-27**]. The patient remained awake, alert, oriented x 3,
was gradually able to improve with his gait while working
with physical therapy and occupational therapy. His steroids
continued to be weaned. He will be discharged on the 16 with
home physical therapy. He will follow-up for staple removal
10 days from his surgery. He should watch the incision for
redness, drainage, or if he develops fever greater than 101.
His follow-up at this time is unclear. [**Name2 (NI) **] may follow-up in
the Brain [**Hospital 341**] Clinic, or with Dr. [**First Name (STitle) **], and that will be
clarified prior to his discharge.
DISCHARGE MEDICATIONS:
1. Colace 100 mg 1 capsule po bid while taking percocet.
2. Percocet 5/325 tablets [**1-13**] q 4-6 h prn pain.
3. Famotidine 20 mg 1 po bid while on decadron.
4. Decadron 4 mg tablet, taper down to off; he should
complete his taper on [**2164-4-1**].
He can resume preadmission medication except for aspirin. He
will most likely follow-up in the Brain [**Hospital 341**] Clinic with Dr.
[**First Name (STitle) **]. The patient was discharged neurologically stable.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 23588**]
MEDQUIST36
D: [**2164-3-26**] 10:09
T: [**2164-3-26**] 10:16
JOB#: [**Job Number 55276**]
ICD9 Codes: 412, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7025
} | Medical Text: Admission Date: [**2140-5-17**] Discharge Date: [**2140-5-28**]
Service: NEUROLOGY
Allergies:
Codeine / Quinidine/Quinine / Norvasc / Pravachol
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Lightheadedness, dizziness, palpitations.
Major Surgical or Invasive Procedure:
Cardioversion
History of Present Illness:
Briefly, Mrs. [**Known lastname 107414**] is a very pleasant [**Age over 90 **] yo woman with CAD,
paroxysmal atrial fibrillation s/p failed cardioversion (most
recent on [**2140-5-5**]), CKD (Stage III) who initially presented [**5-17**]
with 4 weeks of lightheadedness and vertigo and 3 days of SOB.
.
She was seen by her primary cardiologist [**5-16**], at which time her
flecainide was d/c'ed and her metoprolol and diltiazem were
increased for rate control. Apparently she had not been taking
the prescribed doses of BB/CCB and presented to the [**Hospital1 18**] ED
with chest pressure and atrial fibrillation with RVR. Initially
she was admitted to [**Hospital1 1516**] where she was noted to be in volume
overload and diuresed with furosemide, 40 mg IV. She was also
given metoprolol (at increased dose from 12.5 to 25 then 50 [**Hospital1 **]
over the course of two days) and verapramil (180 mg qd) for rate
control. This morning she complained of chest pain, was noted to
be bradycardic (60s) and hypotensive (SBP in mid 70s). She was
given 1.5 lt of IVF bolus and started on dopamine (uptitrated to
20 mcg). After these interventions her pressure improved to the
100s but then decreased again to the 90s. Her urine output
remained low. She had cardiac enzymes drawn, the first set being
negative, an ECG without ST changes, and a TTE, which showed
global hypokinesis with EF of 25%. Reportedly her EF from a TEE
done in early [**Month (only) **] was near normal (reported as mild depressed
LVEF. Last ECHO before that was in 90s with normal EF. Also has
had a cath in the 90s with normal coronaries, per report.
Notably her INR is also elevated to 3.7, presumably secondary to
warfarin.
.
Several days prior to presentation her VNA found her to be
tachycardic to 120s, and was referred Dr. [**Last Name (STitle) **] saw her [**5-16**] and
d/ced her fleicanide and increased her metoprolol, which the
patient did not take as she did not pick up prescirption. She
also reports having chest pain/pressure o/n 4d PTA,
non-radiating, no n/v/diaphoresis resolved w/ burping. Patient
was recently admitted with Afib w/ RVR, was cardioverted on [**5-5**]
and discharged home on flecainide, verapamil, metroprolol. She
has had no palpitations, no syncope, no PND or orthopnea. Pt.
also reports persistent RLE edema, since her rehab discharge,
this is unchaged, pt. takes lasix prn for this.
.
In the CCU, the patient admits to feeling cold. She denies,
chest pain, palpitations, fevers, chills, cough, abdominal pain,
or bleeding. There is no difficulty w/ speech. No dysuria, no
abdominal pain, constipation/diarrhea.
Past Medical History:
FROM OMR:
#. Paroxysmal atrial fibrillation
#. HTN
#. ? coronary artery disease - clean coronaries on C Cath [**2127**].
#. Chronic renal failure - baseline Cr 1.0
#. Left distal femur fracture w/ ORIF during hospitalization
[**Date range (1) 107373**]. [**Hospital **] rehab stay with complications incl
cellulitis, PNA.
#. ? hyperparathyroidism
#. Osteoporosis
#. Cervical disc disease
#. Osteoarthritis
#. GERD
#. B12 deficiency
.
Surgical history:
#. s/p b/l tonsillectomy
#. Cholecystectomy
#. Left knee replacement
#. Appendectomy
#. [**2104**] Colon resection with colostomy (since reversed) -
patient does not recall specifics
#. Hysterectomy for excessive bleeding
Social History:
Lives alone in apt in [**Location 1268**] with VNA. She is a retired
accountant having graduated from [**University/College 82741**]. She has no
children. Her neice is her only family, is involved, and lives
in [**Location (un) 1411**]. Is independent in ADLs and uses walker.
.
-Tobacco history: Never
-ETOH: None
-Illicit drugs: Never
.
Family History:
Denies h/o HTN, DM, hyperlipidemia, heart disease.
Physical Exam:
VS: 97.4F 98/64 107 22 100% 2L NC.
Gen: Lying in bed, NAD.
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
Back: No point tenderness or erythema
CV: irregularly irregular S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, nontender, non-distended. No masses or megalies.
Percussion within normal limits. +BS.
Ext: no edema, no DVT data. Pulses ++ and symmetric.
Neurologic examination:
No meningismus. No photophobia.
MS:
General: alert, awake,
Attention: Follows simple/complex commands.
Speech/Language: mute
Praxis/ agnosia: Able to brush teeth. No field cuts.
CN:
I: not tested
II,III: VFF to confrontation, PERRL 3mm to 2mm, fundus
w/o papilledema.
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial droop LEFT
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**6-7**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor:
Normal bulk.
Tone: normal.
+Postural/action tremor but no asterixis or myoclonus.
Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7
Left 3+ 4 4 5 5-
Right 5 5 5 5 5
IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex
Left 5 5 5 5 5
Right 5 5 5 5 5
Deep tendon Reflexes:
Bicip:C5 Tric:C7 Brachial:C6 Patellar:L4 Toes:
Right 1 1 1 1 DOWNGOING
Left 1 1 1 1 DOWNGOING
Sensation: Intact to light touch
Coordination:
*Finger-nose-finger normal.
*Rapid Arm Movements normal.
*Fine finger tapping: normal.
*Heal to shin: normal.
*Gait/Romberg: normal.
1a LOC = 0
1b Orientation = 0
1c Commands =0
2 Gaze =0
3 Visual Fields =0
4 Facial Paresis = 1
5a Motor Function R UE = 0
5b Motor Function L UE= 0
6a Motor Function R LE= 0
6b Motor Function L LE= 0
7 Limb Ataxia = 0
8 Sensory perception = 0
9 Language = 3
10 Dysarthria = 1
11 Extinction/Inattention = 0
TOTAL = 5
Pertinent Results:
[**2140-5-17**] 09:40PM CK(CPK)-36
[**2140-5-17**] 09:40PM CK-MB-NotDone cTropnT-<0.01
[**2140-5-17**] 12:25PM GLUCOSE-162* UREA N-31* CREAT-1.3* SODIUM-142
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
[**2140-5-17**] 12:25PM CK(CPK)-45
[**2140-5-17**] 12:25PM cTropnT-<0.01
[**2140-5-17**] 12:25PM CALCIUM-9.6 PHOSPHATE-3.4 MAGNESIUM-2.1
[**2140-5-17**] 12:25PM CK-MB-NotDone
[**2140-5-17**] 12:25PM WBC-6.0 RBC-3.77* HGB-10.2* HCT-32.5* MCV-86
MCH-27.2 MCHC-31.4 RDW-16.4*
[**2140-5-17**] 12:25PM NEUTS-76.1* LYMPHS-16.8* MONOS-5.8 EOS-0.7
BASOS-0.6
[**2140-5-17**] 12:25PM PLT COUNT-272
[**2140-5-17**] 12:25PM PT-34.6* PTT-32.6 INR(PT)-3.6*
CXR: Relatively stable examination with marked cardiomegaly and
no
acute pulmonary process.
.
EKG: Afib, 120, Nl axis. no change in ST-T segments since [**5-5**].
No ECG showing sinus rhythm from last admission.
.
TELEMETRY: None
.
TTE: The left atrium is dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = 20-25 %). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. 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.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets fail to fully coapt. Moderate [2+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. Significant pulmonic regurgitation is seen.
There is no pericardial effusion.
.
IMPRESSION: Severe global LV systolic dysfunction with somewhat
better function of the basal inferior and inferolateral segments
and the apical segments. There is akinesis of the anterior and
anterolateral segments. The right ventricle is dilated and
hypokinetic. Mild mitral and moderate tricuspid regurgitation.
CT HEAD ([**5-25**]):
Probable acute/subacute infarct in the left posterior frontal
lobe, though evaluation is limited given the extent of
background chronic
microvascular ischemic disease. Recommended MRI with DWI for
confirmation.
MRI HEAD ([**5-26**]):Acute infarct involving the subcortical white
matter within the
left frontal and temporal lobes. No evidence of hemorrhagic
transformation or mass effect.
Brief Hospital Course:
This is a [**Age over 90 **]yo F with h/o a fib s/p recent 2nd cardioversion on
[**5-5**], HTN, ? CAD s/p clean cath [**2127**], s/p recent femur fx, PNA
and cellulitis who p/w afib w/ RVR, persistent weakness,
lightheadedness, vertigo and DOE.
.
1. Afib w/ RVR. Pt. was admitted with presyncopal symptoms and
vertigo, likely from central hypoperfusion, though cerebellar
dysfunction could not be ruled out given positive romberg in
setting of intact proprioception. She was HD stable on
admission and her INR was 3.6. Her Afib recurrence was felt to
be exacerbating CHF as evident on last TEE. Patient was
restarted on Verapamil of 180mg, her BB was increased to 37.5mg
[**Hospital1 **] and her coumadin was held. On HD#2, patient developed afib
with slow VR, chest pain, diaphoresis and nausea, her ECG was
unchanged and her CE were negative x1. She subsequently
developed hypotension to mid 70s mmHgs, which did not respond to
IVF and required dopamine for HD stability. She was temporarily
transferred to CCU where pressors were weaned within few hours
of arrival. It was felt that her hypotension was secondary to
poor inotropy in setting of bradycardia from multiple nodal
blocking agents. Throughout stay in CCU she was borderline
tachycardic and was eventually placed back on small dose of
lopressor for HR control. On HD#3 she was transferred to the
floor w/ HR of 100bpm and only on 12.5mg [**Hospital1 **] of metoprolol. She
remained HD stable and converted to atrial tachycardia vs. slow
aflutter. Her BB was increased and she was started on low dose
digoxin without loading, 0.125 mg EOD.
.
On this regiment her HR was difficult to control. She continued
to remain in Afib/flutter with HR in 100s despite 50mg TID of
BB, digoxin. She was started on amiodarone and underwent
cardioversion on [**2140-5-24**]. This was successful, pt. was in sinus
rhythm. Her BB was decreased to 12.5 [**Hospital1 **] due to temporary
bradycardia to high 40s, digoxin was discontinued and amiodarone
decreased to 200mg [**Hospital1 **]. With this regimen, HR maintained in
50s, her DOE improved significantly and her lightheadedness and
dizziness resolved. On [**5-25**] at ~ 11pm patient was noted be
unable to speak. Her neurological deficits included R facial
droop and eye lid muscle weakness. Code stroke was called, CT
head showed a L distal MCA stroke in insular region. No tPA was
administered due to INR of 2.9. Her INR became supratherapeutic
with INR 3.9 on her day of discharge hence Coumadin is held for
now. It needs to be restarted at 1mg once daily once INR <3.0
and needs daily monitoring until stable. Dosing may need to go
up once Amiodarone dosing decreases to daily dosing on [**6-2**].
Also, patient should be started on lisinopril for heart
protection on [**6-2**].
.
2. CAD - Pt. had h/o CAD with no h/o MI, CABG or PCI. She had a
clean cath in [**2127**]. Based on above PMHx it was not suspected
that she had flow limiting CAD, especially with no elevation of
CEs in setting of cardiogenic shock. She ruled out for MI. She
was continued on BB as above.
.
3. Systolic CHF. Pt. had a nl EF in [**2127**] Echo, but no other
imaging except a TEE, where it was noted that she had mild
systolic dysfunction. TTE here prior to hypotensive episode
showed global vertricular dysfunction w/ EF of 20-25% Given
lack of significant CAD, this was felt to be most likely
tachycardia-related cardiomyopathy and treatment was focused on
HR control. Pt. was volume overloaded on exam, likely
contributed by the tachycardia and poor filling. She was
continued on home dose of lasix. She was started on ACE-I,
Lisinopril 5mg daily, however due to renal failure, Cr. 1.5 this
was discontinued. Her lasix was held on [**5-26**]. This should be
restarted within a day as tolerated by volume status, likely
[**5-27**] (home lasix dose of 40mg PO).
.
4. Acute on Chronic RF: Cr on admission up to 1.3 Likely due
decreased CO w/ LV CHF in setting of afib. Cr recovered to 1.1,
near baseline after complications with hypotension, however
bumpted back up s/p cardioversion in setting of receiving extra
10mg IV lasix. Cr improved to 1.2 on [**5-26**]. Her lasix is
currently being held.
.
5. Left MCA infarct in the setting of therapeutic INR: Most
likely cardioembolic given the risk factor and patient returned
to Afib rhythm from sinus after cardioversion. Pt was not a
thrombolytic or endovascular therapy candidate due to high INR
hence high bleeding risk. Patient was transferred to the
neurology service on [**5-26**] and MRI showed that she has acute
superior division of L MCA infarct (precentral gyrus) but not a
large infarct hence safe for anticoagulation.
Patient remains unable to speak, but can make vocalizations, and
is able to swallow. She has mild R facial droop with weakness,
more in the arm than leg. Physical and occupational therapy
recommended acute rehab.
Medications on Admission:
on discharge from [**2140-5-6**]:
1. Flecainide 25 mg PO Q12H - d/ced on [**5-16**]
2. Furosemide 40-80mg PO DAILY - taking 40mg daily
3. Hydralazine 25 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Calcium Carbonate 500 mg Chewable PO BID
6. Cholecalciferol 400 unit PO DAILY
7. Multivitamin PO DAILY
8. Ranitidine HCl 150 mg PO HS
9. Isosorbide Mononitrate 15 mg PO DAILY - pt taking 20mg daily
10. Verapamil 180 mg PO Q24H - patient taking 120mg daily
11. Warfarin 5 mg PO Once Daily.
12. Potassium Chloride 10 mEq PO BID
13. Metoprolol Succinate 25 mg PO once a day - patient taking
12.5mg [**Hospital1 **].
14. Cyanocobalamin 1,000 mcg/mL qmonth
15. Nitroglycerin 0.3 mg prn
16. Ginko
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q12H (every 12 hours).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 6 days: Starting [**6-2**], please titrate down to once
daily dosing.
10. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for once INR < 3.0: Dosing may need to be titrated as
Amiodarone dosing gets changed to onec daily on [**6-2**]. Please
check INR daily until Coumadin dosing becomes more stable.
11. Outpatient Lab Work
Daily INR until Coumadin dosing stable - Coumadin dose will
likely need to be increased once Amiodarone decreases to dialy
dosing on [**6-2**]. Goal INR 2~3
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please start on [**6-2**].
13. Outpatient Lab Work
Please check weekly TSH while on Amiodarone
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary: Atrial fibrillation with rapid ventricular response,
atrial flutter, atrial tachycardia, cardiogenic shock
Secondary: Left MCA (middle cerebral artery) infarct while INR
therapeutic.
Discharge Condition:
Hemodynamically stable, improved heart rate - mostly
non-verbal/mute with new left MCA stroke with right facial droop
and some right arm weakness (more proximal and distal) but
strong in the lower extremities.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with recurrence of your rapid heart
rate and lightheadedness. This was felt to be due to your
failed cardioversion. You were treated with medications to
reduce your heart rate.
Your course was complicated by a rapid slowing of your heart and
very low blood pressures that require temporary stay in an
intensive care unit. It was also determined that your heart's
pumping action was also poor. For this reason and your heart
rate control, your medications were readjusted.
You undewent cardioversion on [**5-24**] but afterwards was found to
have right facial droop due to left MCA infarct. This was while
your INR was therapeutic hence you were not candidate for
thrombolysis or endovascular therapy given high risk of
bleeding.
You were transferred to neurology service on [**5-26**] and evaluated
per physical and occupational therapy who recommend acute rehab
given your new stroke. Speech therapist also evaluated who
recommended pureed diet with nectar liquid and crushed meds in
puree.
You were restarted on Amiodarone 200mg twice daily on [**5-27**] which
is to be continued for 1 week then starting on [**6-2**], please
switch to 200mg once daily. Starting [**6-2**], please also start
low dose ACEI (e.g. lisinopril) for your severe CHF.
You will also need a repeat echo i 2~3 months and follow-up
appointment with Dr. [**Last Name (STitle) **] within 4~8 weeks.
You are going to an acute rehabilitation facility for aggressive
physical and occupational therapy plus speech therapy. You will
also need telemetry to for heart rate monitoring plus daily labs
including INR for Coumadin dosing. Coumadin dose may need to be
increased once Amiodarone dose decreases plus please continue to
monitor TSH while on Amiodarone.
Should you develop chest pain, shortness of breath, dizziness,
lightheadedness, severe weakness, worsening leg swelling,
difficulties with balance, worsening palpitations or any other
symptoms concerning to you, please call your primary care
doctor, your cardiologist or go to the nearest emergency room.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 216**], within 2 weeks of discharge from the acute rehab
facility in [**Location (un) 38**], please call [**Telephone/Fax (1) 1247**] for an
appointment.
Repeat echo in 2~3 months plus follow-up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] within 4~8 weeks. Please call [**Telephone/Fax (1) 62**] to
reschedule your appt given that the current appointment is too
remote.
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2140-7-6**] 1:00 Neurology ([**Hospital Ward Name 23**] Clinical Center floor
8)
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2140-7-12**] 9:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2140-7-12**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2140-9-9**] 10:00
Completed by:[**2140-5-28**]
ICD9 Codes: 5849, 9971, 4280, 4254, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7026
} | Medical Text: Admission Date: [**2149-11-5**] Discharge Date: [**2149-11-28**]
Date of Birth: [**2149-11-5**] Sex: M
Service: NBB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] [**Name2 (NI) **] is the 1450 gm
product of a 31 and [**2-8**] week di-di twin gestation born to a
37-year-old G4 P1 mom with prenatal screens B positive,
antibody negative, RPR nonreactive, rubella immune, hepatitis
B negative, GBS unknown. The pregnancy was complicated by
maternal rheumatoid arthritis and hypothyroidism. Membranes
noted to be ruptured morning of delivery. There were no
sepsis risk factors present. She was treated with prednisone
which was given in stress doses prior to cesarean section.
Ampicillin, erythromycin, and a single dose of betamethasone
hours prior to delivery. This infant was born was cesarean
section because of abruption of placenta. The infant emerged
breech with Apgar scores of 7 at 1 minute, 8 at 5 minutes.
PHYSICAL EXAMINATION ON ADMISSION: 1450 gm (75th
percentile), 41 cm in length (25th percentile), head
circumference of 29.5 cm (50th percentile). Normocephalic,
atraumatic. Anterior fontanelle open and flat. Palate
intact. Red reflex present bilaterally. Neck supple. Lungs
persistent grunting. Intercostal retractions noted with
minimal aeration. Cardiovascular regular rate and rhythm.
No murmur. Femoral pulses 2 plus bilaterally. Abdomen soft.
No active bowel sounds. A 2-vessel cord. No masses or
hepatosplenomegaly. Genitourinary normal premature male.
Testes not descended.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY: [**Known lastname 3979**] initially was intubated and received
one dose of surfactant for management of respiratory
distress syndrome. He was extubated to CPAP at 24 hours
of age and remained on CPAP for a total of 12 hours at
which time he was transitioned to room air. He remained
stable in room air for one week with increasing apnea-
bradycardia episodes. Infant was then placed back on CPAP
for a total of two weeks and was weaned to room air on
[**2149-11-26**]. He is currently receiving caffeine
citrate for management of apnea-bradycardia of
prematurity.
1. CARDIOVASCULAR: Has been cardiovascular stable throughout
hospital course with intermittent soft murmur noted. No
cardiac evaluations have been performed.
1. FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was 1450
gm. Discharge weight was 1865 gm. Infant initially
started on 80 cc per kg per day of FD10 PN. Enteral
feedings were initiated on day of life number two. Full
enteral volumes were achieved by day of life number nine.
Max caloric intake was 150 cc of breast milk or Special
Care 30 calories of ProMod. He is currently on 150 cc of
Special Care 30 with ProMod working on p.o. enteral
feeding skills.
1. GASTROINTESTINAL: Peak bilirubin was on day of life
number three at 9.6/0.3. He was treated with phototherapy
for a total of seven days. This issue has since resolved.
1. HEMATOLOGY: Hematocrit on admission was 51.8. He has not
required any blood transfusions during this hospital
course. His most recent hematocrit was on [**11-24**] and
was 39.1.
1. INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC was benign. Blood culture remained
negative at 48 hours, at which time ampicillin and
gentamicin were discontinued. Infant had sepsis
evaluation on [**11-24**] for thick, yellow, blood-tinged,
nasal secretions. Received vancomycin and gentamicin for
a total of 48 hours. CBC was benign. Blood cultures
remained negative. He was also empirically treated with
Bactroban ointment to nares.
1. NEUROLOGIC: Has been appropriate for gestational age. He
had a germinal matrix hemorrhage noted on [**11-19**]
which was day of life 14. He should have one more head
ultrasound at about 1 month of age.
1. SENSORY: Audiology has not been performed. Should be
done prior to discharge.
1. OPHTHALMOLOGY: Was seen most recently on [**11-26**].
Eyes were noted to be immature zone 2 with recommended
followup in two weeks.
A social worker has been involved with the family, and [**First Name5 (NamePattern1) 553**]
[**Last Name (NamePattern1) **] can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 **] level 2 care.
PRIMARY PEDIATRICIAN: Name of primary pediatrician is
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital 38746**] Pediatrics.
Feeds at discharge 150 cc per kg per day of Special Care 30
with ProMod. Medications Fer-In-[**Male First Name (un) **] supplementation and
vitamin E supplementation as well as caffeine citrate. State
newborn screens have been sent per protocol and have been
within normal limits.
IMMUNIZATIONS RECEIVED: The infant has not received any
immunizations at this time.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: 1) born at less than 32
weeks gestation; 2) born between 32 and 35 weeks gestation
with two of the following: daycare during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school-age siblings; or 3) with chronic
lung disease. Influenza immunization is recommended annually
in the fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the child's
life, immunization against influenza is recommended for
household contacts and out of home caregivers.
DISCHARGE DIAGNOSES:
1. Former twin born at 31 and [**2-8**] week gestation.
2. Status post mild respiratory distress syndrome.
3. Ruled out sepsis.
4. Hyperbilirubinemia.
5.
Anemia of prematurity.
6. Apnea-bradycardia of prematurity.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2149-11-28**] 15:53:49
T: [**2149-11-28**] 16:39:58
Job#: [**Job Number 57040**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7027
} | Medical Text: Admission Date: [**2181-9-20**] Discharge Date: [**2181-10-2**]
Date of Birth: [**2102-1-24**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Iodine / Lisinopril /
Amoxicillin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
SOB, lethargy
Major Surgical or Invasive Procedure:
Intubation
PICC line placement
History of Present Illness:
79 year old woman with history of severe oxygen dependent COPD,
and recent diagnosis of likely metastatic lung cancer (diagnosed
on imaging, no biopsy yet) who presents with 2 days of
difficulty breathing, fatigue, slight confusion, and
irritablity. At baseline, the patient is on [**2-24**] L O2 at home
for severe COPD. Per her daughter and son, she has had
increasing shortness of breath over the past 2 days with new
production of green thick sputum. No observed fevers or chills.
Symptoms are associated with increasing fatigue and appearance
of anxiety. The patient's family increased her O2 to 6L, but
symptoms continued to progress. They called her PCP who
recommended admission to the hospital.
In the ED, initial VS: 98.7 84 186/80 24 96% 4L. The patient
was non-responsive, and was intubated for airway protection.
She was started on PCV with FIO2 40%, Peep 10, Rate 18,
Inspiratory pressure 35. ABG following intubation: pH 7.25 pCO2
105 pO2 422 HCO3 48. The patient underwent CXR that showed 1.
New widespread right pulmonary opacities, concerning for
infection versus edema. 2. Persistent right upper lobe mass.
She received 1 dose of vancomycin and zosyn for likely
pneumonia. She was transferred to the MICU for further
management. VS prior to transfer: 98.2 76 90/51 18 98%.
In regards to the patient's recent diagnosis of lung cancer, it
was diagnosed in [**7-3**] by CT scan. Scan revealed an enlarging
right upper lobe mass, bulkly mediastinal lymphadenopathy, and a
presumed large liver metastasis. No biopsy was performed, as
the patient would likely be a poor candidate for both surgery
and chemotherapy. Multiple goals-of-care discussions were held
between the family and the patient's PCP that resulted in "full
code" status for the time being, in accordance with the
patient's prior wishes. However, the family is now considering
a "do not resuscitate" order given her poor prognosis. The
patient was supposed to be evaluated by palliative care today,
when her status changed acutely. OF NOTE, the patient is not
aware that she carries a diagnosis of cancer, as the family is
worried that it will make her give up hope.
On arrival to the MICU, patient's VS. 98.6 108/56 83 94% on
CMV with FIO2 40%, TV 350, PEEP 10. Patient was intubated and
lightly sedated.
Past Medical History:
1. Postherpetic neuralgia.
2. COPD.
3. Productive cough chronically.
4. Diabetes type 2.
5. Hypertension.
6. Hypothyroidism.
7. Dementia.
Social History:
Patient lives in a 2 family home. Her son lives with her, and
her daughter lives in the house below her. She has a caretaker
who comes in approximately four hours per day. Her daughter also
spends a significant amount of time caring for her. She is a
retired postal clerk. She has a significant smoking history of
one to two packs over 50 years; however, she quit in [**Month (only) 404**]
[**2178**] when she first was initiated on supplemental oxygen. No
alcohol.
Family History:
1. Father question of lung disease, diabetes.
2. Mother, diabetes.
3. Daughter hypertension.
4. Son prostate cancer and diabetes
Physical Exam:
On admission
Vitals: VS. 98.6 108/56 83 94% on CMV with FIO2 40%, TV 350,
PEEP 10
General: Intubated, sedated. Opens eyes and moves all 4
extremities to command; able to answer yes/no questions with
nodding
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: Mild right-sided crackles; prolonged expiratory phase
with poor air movement
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Moves all 4 extremities on command.
On discharge: expired
Pertinent Results:
[**2181-9-20**] 06:00PM BLOOD WBC-9.9 RBC-4.07* Hgb-11.8* Hct-40.4
MCV-99* MCH-28.9 MCHC-29.2* RDW-14.1 Plt Ct-266
[**2181-9-23**] 04:10AM BLOOD WBC-12.6* RBC-3.43* Hgb-10.7* Hct-33.4*
MCV-98 MCH-31.2 MCHC-32.0 RDW-15.1 Plt Ct-211
[**2181-9-28**] 04:23AM BLOOD WBC-13.0* RBC-3.02* Hgb-8.7* Hct-28.8*
MCV-95 MCH-28.7 MCHC-30.1* RDW-15.7* Plt Ct-320
[**2181-10-2**] 03:56AM BLOOD WBC-15.6* RBC-2.83* Hgb-8.0* Hct-26.9*
MCV-95 MCH-28.0 MCHC-29.7* RDW-16.9* Plt Ct-349
[**2181-9-20**] 06:00PM BLOOD Neuts-92* Bands-0 Lymphs-6* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2181-9-23**] 04:10AM BLOOD Neuts-83.6* Lymphs-8.9* Monos-6.5 Eos-1.0
Baso-0.1
[**2181-9-30**] 03:49AM BLOOD Neuts-71* Bands-6* Lymphs-8* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-3*
[**2181-9-20**] 06:00PM BLOOD Glucose-186* UreaN-22* Creat-0.7 Na-142
K-4.4 Cl-93* HCO3-43* AnGap-10
[**2181-9-25**] 03:12AM BLOOD Glucose-251* UreaN-45* Creat-1.4* Na-133
K-5.7* Cl-99 HCO3-27 AnGap-13
[**2181-9-27**] 03:56AM BLOOD Glucose-138* UreaN-66* Creat-2.5* Na-135
K-4.6 Cl-100 HCO3-29 AnGap-11
[**2181-10-1**] 03:50AM BLOOD Glucose-121* UreaN-113* Creat-4.6*
Na-132* K-6.3* Cl-95* HCO3-21* AnGap-22*
[**2181-10-2**] 03:56AM BLOOD Glucose-164* UreaN-122* Creat-5.2*
Na-124* K-GREATER TH Cl-96 HCO3-17*
[**2181-9-21**] 03:40AM BLOOD ALT-92* AST-142* LD(LDH)-1576*
AlkPhos-356* TotBili-0.9
[**2181-9-28**] 04:23AM BLOOD ALT-72* AST-84* LD(LDH)-798* AlkPhos-328*
TotBili-0.7
[**2181-10-1**] 03:50AM BLOOD ALT-72* AST-98* LD(LDH)-768* AlkPhos-376*
TotBili-1.0
[**2181-9-21**] 03:40AM BLOOD Calcium-8.9 Phos-2.3* Mg-1.6
[**2181-9-25**] 10:00PM BLOOD Calcium-8.8 Phos-4.2 Mg-2.6
[**2181-9-30**] 03:49AM BLOOD Albumin-2.8* Calcium-9.3 Phos-6.6*
Mg-3.0*
[**2181-10-2**] 03:56AM BLOOD Calcium-9.0 Phos-10.3*# Mg-3.4*
Imaging:
CXR (on admission):
IMPRESSION:
1. New widespread right pulmonary opacities, concerning for
infection versus edema.
2. Persistent right upper lobe mass.
CXR ([**9-24**]):
Cardiac size is normal. Patient has known right upper lobe lung
mass and
hilar lymphadenopathy. Diffuse heterogenous opacities in the
right lung are unchanged. There is most likely complication of
lung cancer , less likely pneumonia. If any there are small
bilateral pleural effusions. The lungs are hyperinflated. Left
lower lobe opacity is new worrisome for focus of pneumonia.
There is no pneumothorax. ET tube is in the standard position.
NG tube tip is in the stomach.
CXR ([**10-1**]):
As compared to the previous radiograph, there is minimal
improvement of the extensive parenchymal opacity on the right,
notably the level of the right lower lobe. Otherwise, no
relevant change is seen. A slight increase in lung density on
the left is caused by positional factors. Endotracheal tube,
left PICC line and nasogastric tube are in unchanged
position. Unchanged appearance of the cardiac silhouette.
Brief Hospital Course:
79 year old woman with history of severe oxygen dependent COPD,
and recent diagnosis of likely metastatic lung cancer who
presents with difficulty breathing, fatigue, confusion, and
irritablity; found to have hypercarbic respiratory failure and
likely pneumonia.
# Hypercarbic respiratory failure [**2-22**] pneumonia and pulmonary
malignancy: She has baseline severe COPD and new diagnosis of
lung cancer complicated by acute decompensation. She was
intubated in the ED for airway protection due to
unresponsiveness. Acute fluffy infiltrates on CXR (R > L), and
worsening cough productive of green sputum concerning for large
aspiration pneumonia as a source of decompensated lung disease.
This is an addition to the diseased, cancerous lung that was
likely difficult to ventilate at baseline. She completed a
course of vancomycin and cefepime for pneumonia. She became
very difficult to ventilate, given the 2 entirely different
physiologic properties of the 2 lungs (congested, cancer-filled
lung vs. hyperinflated, COPD lung). Her peak airway pressures
remained quite elevated and she required a large amount of
sedation in order to be comfortable. She could not ultimately
be weaned off the ventilator prior to her passing.
# Acute kidney injury and hyperkalemia: As her condition
continued to worsen, her creatinine started to rise and her
urine output dropped off precipitously. Concomitantly, her
potassium increased markedly, likely secondary to the metabolic
acidosis as well as severe constipation. Rather than continuing
to give enemas, these measures were stopped in favor of comfort
measures. Her hyperkalemia eventually caused her to become
increasingly bradycardic and eventually pass away.
# Goals of care: Many discussions were initiated with the
family, involving Palliative Care early on. While they did not
want to withdraw care (i.e. pull out the breathing tube), they
did acknowledge that they wanted to maximize her comfort. Her
daughter and son were by her side at the time of death, just as
they would have wanted. After her passing, Dr. [**Last Name (STitle) **] was
[**Last Name (STitle) 653**] with the information.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver[**Name (NI) 581**].
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
4. Gabapentin 100 mg PO HS
5. Glargine 31 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Memantine 5 mg PO DAILY
7. Methimazole 5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Pravastatin 20 mg PO HS
10. PredniSONE 2.5 mg PO DAILY
11. Sertraline 25 mg PO HS
12. Tiotropium Bromide 1 CAP IH DAILY
13. Verapamil SR 180 mg PO Q24H
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 5070, 5845, 486, 2762, 2761, 2767, 4019, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7028
} | Medical Text: Admission Date: [**2126-6-20**] Discharge Date: [**2126-6-28**]
Date of Birth: [**2070-8-28**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Aspirin
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55 yo woman s/p head injury 1.5 weeks ago who presented with
n/v/lethargy. She has been having ongoing nausea and vomiting
and decreased PO intake for a few months [**1-3**] decreased taste in
her mouth. She reports she has not been eating because the man
that lives with her is eating all of her foods. She has been
taking her diuretics as prescribed. In the ED, she got 3L IVF
and Levo/Amp/Flagyl. A CT of the head was unremarkable and CT
of the abdomen showed a distended gallbladder with sludge but no
evidence of cholecystitis. She was admitted to the ICU for
hypotension.
Past Medical History:
- GERD
- Migraines
- Depression
- Fifteen surgeries on her hips, neck, knees, lower spine,
shoulders s/p MVC w/ resulted chronic pain
- Hypothyroidism.
- s/p MVC [**6-10**]; head CT (-)
Social History:
Disabled from car accident. She smoked in the past for 40 years
and quit 1yr ago. Denies alcohol or drug use.
Family History:
Mother died of liver cancer. Dad died of DM/CAD
Physical Exam:
Physical Exam:
T: 98.7 BP:101/59--->77/54 P:64 RR:18 O2 sats:99%RA
Gen:sleepy but arousable. poor historian. "i just want to go to
sleep".
HEENT: PERRL, EOMI, sclera white. mmdry. OP clear
Neck:No JVD or LAD
CV:RRR nl s1-s2, no m/r/g
Resp: CTAB
Abd:soft, NT/ND hypoactive BS. well healed mid line scar. No
mass or HSM. Neg [**Doctor Last Name **]
Ext: Thin, ppp no edema
Neuro:[**Last Name (un) 108148**], OX3.
CN: II-XII intact
Sensation: intact to light touch
Strength: able to resist gravity
Pertinent Results:
ECHO [**2126-6-25**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left
ventricular cavity size is normal. Left ventricular systolic
function is
hyperdynamic (EF 70-80%). Tissue velocity imaging demonstrates
an E/e' <8
suggesting a normal left ventricular filling pressure (<12mmHg).
No masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. There is
no aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
PMIBI:
TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 49
SYMPTOMS: ATYPICAL PEAK INTENSITY: 1
ST DEPRESSION: NONE
INTERPRETATION: 55yo female with history of depression and
orthopedic surgeries is referred to the lab for evaluation of
chest pain
and recent NSTEMI. The patient was administered 0.142mg/kg/min
of
Persantine IV over 4 minutes. The patient complained of breif
chest
pressure for 30 seconds after the infusion was finished. There
were no
ST segment changes during infusion or recovery. The rhythm was
sinus
with one APC. The hemodynamic response to Persantine was
adequate. Three
minutes after MIBI injection, the patient was administered 125mg
aminophylline IV.
IMPRESSION: Transient atypical chest pain with no ischemic EKG
changes.
Nuclear report sent separately.
.
IMPRESSION:
No evidence of myocardial perfusion defect at peak pharmacologic
stress. Normal left ventricular cavity size and systolic
function.
.
EKG [**6-20**] NSR @ 80 bpm, normal axis, QTC mildly prolonged at 445
(415 in '[**10**]), [**Street Address(2) 4793**] dep V4-5 o/w no ischemic changes
.
Imaging:
[**6-20**] Abd U/S: No evidence of hydronephrosis. Small amount of
gallbladder sludge without evidence for cholecystitis.
.
[**6-20**] Head CT: No evidence of intracranial hemorrhage. Thickening
of the bony wall of the right maxillary sinus now with interval
development of mucosal thickening in the right greater than left
maxillary sinuses consistent with history of chronic sinusitis.
.
[**6-20**] CXR: No free intraperitoneal air. The lung bases are clear.
The heart size is normal. The visualized osseous structures are
unremarkable. At the most inferior aspect of the image, there
are two circular metallic densities within the intervertebral
disc space, likely representing spacers.
.
[**6-20**] CT Abd/pelvis w/o contrast: No evidence of pancreatitis or
appendicitis. Mildly distended gallbladder with no surrounding
fluid collections. Some air-fluid levels within a stool filled
colon with mild distention. These findings are suggestive of
gastroenteritis
.
[**6-21**] CXR PA/lat: Nasogastric tube terminates in the stomach.
Diffuse interstitial edema, likely due to fluid overload
.
Blood cx [**6-20**]: 1 draw w/ coag neg staph, 2nd draw no growth
Blood cx [**6-23**]: pending
Blood cx [**6-25**]: pending
Urine cx [**6-23**]: < 10K organisms
.
[**2126-6-20**] 11:26AM WBC-13.7* RBC-4.43 HGB-13.7 HCT-36.8 MCV-83#
MCH-31.0 MCHC-37.3*# RDW-12.9
[**2126-6-20**] 11:26AM NEUTS-82.8* LYMPHS-12.7* MONOS-3.2 EOS-0.7
BASOS-0.7
[**2126-6-20**] 11:26AM PLT COUNT-479*
[**2126-6-20**] 11:26AM GLUCOSE-130* UREA N-90* CREAT-7.6*#
SODIUM-135 POTASSIUM-2.3* CHLORIDE-90* TOTAL CO2-23 ANION
GAP-24*
[**2126-6-20**] 11:26AM ALT(SGPT)-41* AST(SGOT)-61* CK(CPK)-73 ALK
PHOS-289* AMYLASE-279* TOT BILI-0.7
[**2126-6-20**] 11:26AM CK-MB-NotDone cTropnT-0.05*
[**2126-6-20**] 12:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG
[**2126-6-20**] 10:37PM PT-14.0* PTT-32.8 INR(PT)-1.2*
[**2126-6-20**] 10:59PM LACTATE-1.0 NA+-137 K+-2.3* CL--111
[**2126-6-20**] 10:59PM freeCa-0.97*
Brief Hospital Course:
# Hypotension:
Likely due to severe dehydration in the setting of poor po's,
gastroenteritis, and concurrent diuretics. Cortisol stim test
appropriate (34->53). Cultures were all negative (1 set of
cultures with coag neg staph, thought to be contaminant; all
other blood cultures negative) and no evidence of infection
identified. LFTs bumped but attributed to shock liver;
hepatitis panel was negative (Hep Bs Ab and Ag, Hep C ab, and
Hep A ab negative). ECHO shows hyperdynamic heart without
significant valvular disease. P-MIBI showed no inducible
ischemia. Patient has about [**1-4**] bowel movements per day. She
was encouraged to drink plenty of fluid and to avoid further use
of diuretics. On the day of discharge, bp standing 93/56 (she
was not orthostatic). She was mentating normally and making
good urine. She will follow-up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 61447**]y for a repeat blood pressure check.
.
# Demand ischemia:
Patient had troponin peak of 0.22 in the setting of her
hypotension. Her CK and MB remained flat. Cardiology was
consulted when patient developed acute pulmonary edema in the
setting of aggressive IVF resuscitation. They suspected CHF due
to aggressive resuscitation + mild demand ischemia with the peak
in troponin due to her acute renal failure. They recommended an
ECHO which showed a hyperdynamic heart. Given persistent low
blood pressure, her stress was done in house and showed no
evidence of inducible ischemia. Her beta blocker and aspirin
were thus discontinued.
.
# ARF:
Patient bumped her creatinine to 7.6 in the setting of
hypotension and dehydration. She denied recent NSAID use.
Renal was consulted and noted muddy brown casts on micro exam,
consistent with acute tubular necrosis. No rbc or wbc casts
were seen and urine eos were negative. A renal ultrasound
showed no evidence of hydronephrosis. Her creatinine improved
to 1.0 by the time of discharge. SPEP and UPEP were negative.
.
# Transaminitis:
Likely due to shock liver. Peak AST 211 (35 on day of
discharge) and peak ALT 190 (42 on day of discharge). Hep panel
was negative. Her statin, zetia, and topamax were held. Her
topamax was restarted on the day of discharge.
.
# Fever:
Patient was afebrile during her admission but did spike a
temperature of 101.3 on [**2126-6-25**]. Cultures were sent and were
negative. She had no complaints and no signs of localized
infection on exam. Her admission CT abd was concerning for
gastroenteritis and she continued to have [**1-4**] loose bowel
movements per day through most of her stay. Of note, her best
friend had a similar GI bug. Given her history of weight loss
and acute renal failure, SPEP and UPEP were sent but were
negative. She was encouraged to follow-up with her PCP for
routine cancer screening, including c-scope and [**Last Name (un) 3907**]. Of note,
iron studies normal.
.
# Hypocalcemia:
Patient required calcium repletion during her admission and
complained of cramping in her hands with blood pressure
readings. PTH was appropriately increased (165) and vitamin D
1,25 was pending at the time of discharge. Her magnesium was
concurrently low and may have been a contributing factor. She
was discharged home on tid calcium and vitamin D, in addition to
[**Hospital1 **] magnesium. She will follow-up with her PCP on Tuesday for
repeat labs.
.
# Depression:
Patient was continued on her home paxil, klonopin, and remeron.
Multiple attempts were made to contact her outpatient providers
[**Name (NI) 30143**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 108149**]) and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 108150**]) at
[**University/College 23633**] Mental Health. SW was consulted but patient
expressed no needs. Patient agrees to follow-up with [**Last Name (un) **] on
Thursday. She denied any suicidal ideation. She does appear to
be under a considerable amount of stress. I spoke with her
close friend and health care proxy who feels the stress in
[**Known firstname 108151**] life was a contributing factor to her poor appetite.
.
# Chronic pain: Patient was continued on her gabitril and her
topamax was restarted at discharge.
.
# Poor po: Nutrition was consulted regarding her poor po and
recommended supplements such as boost, but patient refused.
LFTs normalized this admission and CT of the abdomen showed only
a question of gastroenteritis. Patient was taking consistently
good po in house.
.
# Anemia: Hematocrit 27-30, down from 36. Iron studies, folate,
haptoglobin, TFTs, and B12 were all normal. Reticulocyte count
was low. Patient will follow-up with her primary care for
continued monitoring and additional work-up, including screening
c-scope.
.
# PPX: PPI (home med), sc heparin
.
# Dispo: PT was consulted but patient stated "I'm walking fine,"
assist of her cane. She was thus discharged home without
services.
Medications on Admission:
fluoxetine 80 mg po qd
mirtazepine 30 mg po qd
topamax 150 mg po bid
nexium 40 mg po qd
triampterene/HCTZ 37.5/25 qd
premarin 1.25 mg po qd
klonopin 1 mg po qd
zyrtec 10 mg po qd
gabitril 6 mg po qhs
crestor 20 mg po qd
zetia 10 mg po qd
Discharge Medications:
1. Outpatient Lab Work
sodium, potassium, chloride, bicarbonate, urea nitrogen,
creatinine, ALT, AST
To be drawn [**2126-7-1**]
2. Tiagabine 4 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at
bedtime)).
3. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO once a day.
7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. TOPAMAX 50 mg Tablet Sig: Three (3) Tablet PO twice a day.
9. Premarin 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
12. Magnesium 300 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
13. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO three
times a day.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
primary: hypotension
secondary: demand ischemia, acute renal failure, shock liver,
hypocalcemia, hypomagnesemia, hypokalemia, pulmonary edema
Discharge Condition:
good - ambulating at baseline, making good urine, normal
mentation, not orthostatic
Discharge Instructions:
Please call your doctor or go to the emergency room if you
experience temperature > 101, weakness, or other concerning
symptoms.
You have been diagnosed with low calcium and magnesium. Please
take the magnesium, calcium and vitamin D as prescribed. You
will need to follow-up with your doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**] below to
have your calcium and magnesium rechecked on Monday. In
addition, he will be able to tell you the results of your
vitamin D test at that time.
It is important to avoid dehydration to avoid hurting your
kidneys and heart again. Thus, you need to drink AT LEAST eight
8 ounce glasses of water each day. PLEASE avoid tea and
caffeinated drinks as these cause you to lose fluid.
Please DO NOT take your diuretics (HCTZ/triamterene) anymore.
Please do not restart your crestor or zetia until instructed by
your doctor.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 172**] on Monday, [**7-1**] at 1:45 PM
to have blood work done and your blood pressure checked.
Please call to schedule an appointment with your therapist as
you are under a considerable amount of stress.
ICD9 Codes: 5849, 4280, 4019, 2720, 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7029
} | Medical Text: Admission Date: [**2198-11-27**] Discharge Date: [**2198-12-2**]
Service:
CHIEF COMPLAINT: Increased lethargy, decreased
responsiveness, question of a gastrointestinal bleeding,
hypotension, hypoxia. This was a transfer from [**Hospital3 **].
HISTORY OF PRESENT ILLNESS: This is an 81-year-old white
male with a history of metastatic colon cancer, history of
lung, testicular and basal cell cancer, hypertension, history
of deep vein thrombosis, status post an ICD filter with
recurrent C. difficile colitis here with hypotension,
hypoxia, lethargy, "congestion", and unresponsiveness for two
days. Got Levaquin yesterday and was transferred from
[**Hospital1 **] for further evaluation at [**Hospital1 190**]. The patient is usually alert and verbal
however, cannot do activities of daily living at baseline.
Chest x-ray at [**Hospital1 **] revealed a "mild bilateral
pneumonitis" and a 3 cm new right upper lobe nodule. Today
increasing lethargy and no p.o. intake. Was sent to [**Hospital1 1444**] for further evaluation ( on
route the patient decompensated with sats dropping to 80% on
room air and agonal breathing. (In the Emergency Room the
temperature was 101.8, blood pressure 118/32, heart rate 101,
respiration rate of 20 and 98 to 100% on a non-rebreather).
The patient was intubated for respiratory failure. Following
this blood pressures decreased to 78/34 responding to
intravenous fluid boluses back to a systolic blood pressure
of 110. However, blood pressures decreased in the 80's and
the patient required to be started on Dopamine. Got
Ceftriaxone, Flagyl, Protonix. A right subclavian central
line was placed as well as an A-line.
PAST MEDICAL HISTORY:
1. Metastatic colon cancer. Status post colectomy diagnosed
in [**2188**].
2. Lung cancer diagnosed in [**2191**], status post left lower
lobe lobectomy.
3. Testicular cancer diagnosed in [**2153**], status post
orchiectomy.
4. Basal cell carcinoma.
5. Hypertension.
6. Bipolar disorder.
7. Deep vein thrombosis. Status post an IVC filter.
8. Recurrent C. diff colitis however, a last C. diff was
negative on [**2198-11-7**].
9. A mild chronic renal insufficiency with creatinines
ranging from 1.1 to 1.3.
10. Anemia with a baseline hematocrit of 26.
11. Sacral decubitus, status post a failed flap in [**2198-1-26**] with wound dehiscence.
12. Pseudo gout.
ALLERGIES: Gentamicin, Clindamycin, Erythromycin.
MEDICATIONS:
1. Folic Acid 1 mg q day.
2. Ativan 0.5 mg q h.s.
3. Tegretol 20/100, 200/100, 200 mg q day.
4. Multivitamins.
5. Flomax 0.5 mg q day.
6. Verapamil 40 mg twice a day.
7. Protonix 40 mg twice a day.
8. Iron 325 mg twice a day.
9. Zyprexa 5 mg q h.s.
10. Loperamide p.r.n.
11. Benadryl p.r.n.
12. Tylenol p.r.n.
13. Fibercon p.r.n.
14. Vitamin C.
15. Lactate.
16. Keflex between [**11-2**] to [**11-9**].
17. Vancomycin fro two week course that finished on [**10-30**].
PHYSICAL EXAMINATION: Temperature 100.8, heart rate 96,
blood pressure 117/53, O2 sats 86% General: Intubated,
sedated, cachectic and wasted appearing male. Head, eyes,
ears, nose and throat: Pinpoint pupils, poor dentition,
Entrotracheal tube in place. Right subclavian in place.
Cardiovascular: Tachycardiac, regular, no murmurs, rubs or
gallops appreciated. Lungs: Generally clear to auscultation
bilaterally, decreased breath sounds at the right base.
Abdomen soft, slightly distended, normal active bowel sounds.
Rectal bag and Foley in place. Extremities: Right hip
Tegaderm, right heel ulcer, no edema. Rectal: Per the
Emergency Room, brown, OB positive stool. Sacrum: A deep,
approximately 6x6 open ulcer with necrotic bone exposed.
LABS: White blood count 32.1, hematocrit 31.8, platelets 462
with a differential of 83 polys, 7 bands, 1 lymphocyte. INR
of 1.9, sodium 147, potassium 5.2, chloride 110, bicarbonate
21, BUN 82, creatinine 3.2. Glucose 170. CK 46, Troponin
1.4.
Urinalysis revealed 1.025/5.5, small bili, trace leukocyte
esterase, nitrate negative, moderate blood, greater than 300
protein, trace ketones, white blood count greater than 50, 11
to 20 red blood cells, many bacteria, no yeast, no squamous
epi's.
Chest x-ray revealed an endotracheal tube in place, an
nasogastric tube in place, right subclavian tip in the
SVC/right atrial junction, no pneumothorax. Bilateral
parenchymal opacities, possible effusion. Arterial blood
gases: 7.06/68/337 on an SIMV 600 times 12 with 5 of PEEP
and 100% FIO2.
Electrocardiogram revealed left axis deviation, rate of 101
and normal sinus rhythm, question of a Q in lead 5, T-wave
inversions in Lead 1 and L. Lactate was 1.5.
IMPRESSION: This is an 81-year-old white male with a history
of metastatic colon cancer, lung cancer, history of
testicular basal cell cancer, hypertension, deep vein
thrombosis, status post an IVC filter, a recurrent C. diff
and a sacral decubitus here with sepsis likely from bilateral
aspiration pneumonia. Urosepsis, question of osteo and
possible C. diff colitis. The patient had low grade
temperature with an elevated white blood count. Hypoxia
likely resulting in increase somnolence, change in mental
status. He is also here in acute renal failure.
HOSPITAL COURSE: On arrival the patient was in hypoxic
respiratory distress and electively intubated. Given
Ceftriaxone, Levofloxacin, Flagyl and then Vancomycin
empirically. Had copious guaiac positive green stools. Got
three liters of intravenous fluid but required Dopamine to
maintain adequate pressures. White blood count was 72 with
10% bands. Stool returned C. diff positive and subsequently
was started on p.o. Vancomycin in addition to the intravenous
in order to treat this stubborn C. diff colitis. Also as
cultures returned the patient was found to have Methicillin
resistant Staphylococcus aureus pneumonia, Klebsiella,
urosepsis and 1/4 bottles with gram negative diplococci that
was likely a contaminant.
His urine output continued to fall and renal was consulted
and he was determined to have oliguric ATN, likely secondary
to hypoperfusion. He also had a metabolic acidosis which was
likely multi-factorial and secondary to his diarrhea, lactic
acidosis and uremia. Treatment with bicarbonate was
initiated. Because he had become hyponatremic, free water
boluses were initiated.
The patient had a TTE revealing an EF of 40 to 50%, left
atrium mildly dilated, no Arteriosclerotic disease, anterior
septum and anterior free wall may be slightly more
hypokinetic.
Plastic Surgery was consulted about possible vacuum dressing
to the severe sacral decubitus however, they recommended
supportive care as it was operatively unable to fix and
vacuum dressing was not indicated.
After five days Mr. [**Known lastname **] had not responded to antibiotics
and was still intubated requiring pressors. Several days of
discussion with both daughters had occurred and they were
updated on his poor prognosis. On day five admission they
decided to change the focus of his care to comfort and to
stop aggressive measures. The patient passed away on [**2198-12-2**]
at 4:40 AM.
[**Last Name (LF) **], [**First Name3 (LF) **],A.
Dictated By:[**Name8 (MD) 210**]
MEDQUIST36
D: [**2198-12-9**] 18:14
T: [**2198-12-11**] 10:24
JOB#: [**Job Number 44109**]
ICD9 Codes: 5070, 0389, 5845, 2762, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7030
} | Medical Text: Admission Date: [**2135-1-6**] Discharge Date: [**2135-2-10**]
Date of Birth: [**2061-9-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Right hip fracture.
Major Surgical or Invasive Procedure:
Right ORIF
Bronchoscopy
Lumbar puncture.
History of Present Illness:
The patient is a 73 yo male with h/o CLL, CAD, and autoimmune
hemolytic anemia who was admitted after a mechanical fall at
home which resulted in a fractured R femur. The patient was
unable to wean from ventilation so was admitted to the ICU for
further management.
Per report, the patient reached over to pick up a pill and fell
out of bed onto his right hip, hitting his head. No LOC. He
reported R hip pain and inability to ambulate, plain film
showing a comminuted intertrochanteric fracture of R femur.
Head CT showed no intracranial hemorrhage or fracture. The
patient went to the OR for repair (R hip nail and ORIF) and was
unable to be extubated. Per [**First Name3 (LF) **] resident report, patient did
not tolerate wean of PSV, but not clear what the issue was.
Appears from PACU notes that patient had large amounts of
secretions and unable to wean below PS of 12. Currently on PSV
[**11-19**] on arrival to the floor, weaned to [**9-19**]. Of note, the
patient rec'd 0.2 mg IV dilaudid x8, lasix 10 mg IV x4. Patient
had a total of 3.6L in (LR, D51/2NS with 20 KCL and propofol)
and 1.0L out. Also rec'd a total of 3 units prbcs and 3 bags
platelets between the ED and intraOP over the course of the day.
In terms of history, as per OMR and prior admission notes, the
patient has had cough for ~ 2 months, was given a course of
levaquin in [**10-23**] with minimal improvement and return of the
cough. CT chest on [**2134-11-16**] showed no focal pna, sputum neg for
PCP, [**Name10 (NameIs) 103758**] negative, and AFB was neg x3. He did have rare
[**Last Name (un) 4904**] of gram neg bacteria. He required 2 doses of neupogen for
decreased cell counts and 2 blood transfusions. He had been on
cefepime but it was discontinued as it likely caused his
decrease in cell counts. Readmitted on [**2134-11-15**] due to cough and
shortness of breath. CT chest at that time was negative but
showed pleural effusions which were tapped and pt was started on
lasix. He subsequently rec'd Rituxan as an outpatient. He was
readmitted on [**12-8**] for cough/fever and nasal washes were RSV+.
Pulm and ID at ths time did not feel there was involvement of
the lower respiratory tract, though pulm thought that the
chronic cough may be a result of lung scarring/pathology from
neoplastic related previous effusion, chronic sinusitis, and
reflux. Patient rec'd 5 days of levaquin and IVIG. Repeat CXR
was concerning for developing infiltrate and levaquin was
continued for a total of 15 day course on [**2134-12-23**]. On [**2134-12-27**],
per OMR notes, the patient spiked a fever of 101 with increased
cough, productive of clear/whitish sputum. CXR at the time
showed interval development of a multilobar, right sided pna.
Repeat RSV washes were positive. Additionally, blood cultures
were positive for strep pneumo, pan sensitive. He was treated
with ctx 1gm IV (10 day course) and azithromycin x5 days. He
was sent home on cefpodoxime on [**1-2**] to complete 7 more days of
therapy.
The patient apparently tolerated surgery well. He is now s/p
pinning and ORIF with approximately 200 cc EBL. Patient's
pressures and vital signs have been stable, afebrile. Unable to
obtain ROS due to sedation/intubation.
Past Medical History:
-CLL/SLL, on Rituxan/Bedamustine
-Recurrent pleural effusions, status post right pleurodesis on
[**2131-10-1**]. He has continued with loculated effusion on the
right, although currently improved
-Hypogammaglobulinemia, receiving IVIG q. monthly during winter
months in particular, most recently [**2134-11-17**]
-Recurrent pneumonias, requiring admissions periodically
-Peptic ulcer disease
-Status post right inguinal hernia repair
-Status post skin biopsies of the left neck, left shoulder, left
ear biopsy consistent with hypertrophic actinic keratoses
-Basal cell carcinoma with Mohs procedures of the left chest,
left scalp area, area of squamous cell carcinoma noted on the
right forehead with Mohs procedure
-Status post left hip femoral head stress fracture [**2131-2-14**].
-Status post T5 and T12 vertebral fractures on [**2131-10-23**].
-RSV
-IVC compression by RP LAD causing lower extremity edema
-Autoimmune hemolytic anemia related to CLL, on prednisone x10
years
Social History:
Mr. [**Known lastname 103757**] lives with his wife in [**Name (NI) **]. He is retired
and previously worked doing maintenance. Prior to this he was a
soccer coach in his home country of [**Location (un) 3156**]. He moved from the
[**Location (un) 3156**] before Chernobyl. He is a prior smoker, previously
smoked 10 cigarettes for 10 years but quit approximately 25
years ago. He denies any alcohol or IVDU.
Family History:
Notable for his son who has AML in remission.
Physical Exam:
Physical Exam: lungs clear anteriorly, ett in place, pale skin,
dry MM, abdomen distended, mildly tympanic, hypoactive bowel
sounds, 2+ bilateral lower extremity pitting edema, multiple
healed scars on scalp from prior excisions
Pertinent Results:
ADMISSION LABS:
.
[**2135-1-6**] 09:30AM BLOOD WBC-6.2 RBC-2.62* Hgb-9.1* Hct-27.1*
MCV-103* MCH-34.9* MCHC-33.8 RDW-17.4* Plt Ct-33*
[**2135-1-6**] 09:30AM BLOOD Neuts-39* Bands-1 Lymphs-52* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2135-1-6**] 09:30AM BLOOD PT-13.8* PTT-25.6 INR(PT)-1.2*
[**2135-1-6**] 09:30AM BLOOD Plt Smr-VERY LOW Plt Ct-33* LPlt-1+
[**2135-1-6**] 09:30AM BLOOD Glucose-93 UreaN-21* Creat-0.9 Na-143
K-3.5 Cl-105 HCO3-29 AnGap-13
[**2135-1-7**] 04:20AM BLOOD ALT-16 AST-34 LD(LDH)-362* AlkPhos-79
Amylase-39 TotBili-2.8* DirBili-0.8* IndBili-2.0
[**2135-1-6**] 06:43PM BLOOD Calcium-8.6 Phos-4.8*# Mg-1.8
[**2135-1-6**] 05:50PM BLOOD Type-ART pO2-115* pCO2-51* pH-7.32*
calTCO2-27 Base XS-0 Intubat-INTUBATED
[**2135-1-6**] 05:50PM BLOOD Glucose-110* Lactate-3.6* Na-140 K-4.2
Cl-104
[**2135-1-6**] 05:50PM BLOOD Hgb-10.2* calcHCT-31
[**2135-1-6**] 05:50PM BLOOD freeCa-1.03*
.
.
PERTINENT LABS/STUDIES:
.
[**2135-2-10**] 12:32AM BLOOD WBC-5.9 RBC-2.67* Hgb-9.3* Hct-27.5*
MCV-103* MCH-34.7* MCHC-33.6 RDW-22.9* Plt Ct-30*
[**2135-2-9**] 01:17AM BLOOD Neuts-48* Bands-0 Lymphs-49* Monos-1*
Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 NRBC-4*
[**2135-2-7**] 12:00AM BLOOD Gran Ct-2800
[**2135-2-10**] 12:32AM BLOOD Glucose-94 UreaN-18 Creat-0.6 Na-138
K-4.1 Cl-102 HCO3-29 AnGap-11
[**2135-2-10**] 12:32AM BLOOD ALT-8 AST-19 LD(LDH)-334* AlkPhos-132*
TotBili-1.4
[**2135-1-19**] 12:00AM BLOOD proBNP-6544*
[**2135-2-10**] 12:32AM BLOOD Calcium-9.5 Phos-2.2* Mg-2.1
[**2135-2-4**] 12:00AM BLOOD VitB12-1465* Folate-18.3
[**2135-1-22**] 11:00AM BLOOD TSH-7.3*
[**2135-1-23**] 12:00AM BLOOD Free T4-1.3
[**2135-1-17**] 03:40PM BLOOD PTH-6*
[**2135-1-14**] 06:15AM BLOOD ANCA-NEGATIVE B
[**2135-1-11**] 07:30PM BLOOD ANCA-NEGATIVE B
[**2135-1-14**] 06:15AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2135-1-11**] 07:30PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2135-1-22**] 11:00AM BLOOD VITAMIN D [**1-9**] DIHYDROXY- 10
[**2135-1-22**] 11:00AM BLOOD PARATHYROID HORMONE RELATED PROTEIN-PND
at discharge
[**2135-2-7**] 02:17PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-12* Polys-2
Lymphs-89 Monos-0 Macroph-9
[**2135-2-7**] 02:17PM CEREBROSPINAL FLUID (CSF) TotProt-53*
Glucose-61
CSF: No Malignant cells; No culture growth at discharge.
Most recent Imaging:
CXR:
FINDINGS: As seen on the prior study, there are bilateral
pleural effusions and hazy opacity over both lower lungs. While
this could all be due to the fluid and volume loss, an
underlying infectious infiltrate cannot be excluded. There is a
right-sided PICC with tip in the SVC/RA junction.
MRI Head:
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Normal MRA of the intracranial vessels.
3. Small vessel ischemic disease.
4. Bone marrow infiltration versus hyperplasia. Clinical
correlation
recommended.
5. Soft tissue change in the right maxillary sinus and mastoid
air cells.
Clinical correlation recommended.
Hip XR: IMPRESSION: Status post open reduction internal fixation
of a comminuted right intertrochanteric femoral fracture. No
evidence of hardware complication.
Brief Hospital Course:
Patient is a 73 year-old male with a history of CLL complicated
by hemolytic anemia, hypogammaglobulinemia, and recent RSV
infection/multifocal pna, who presented s/p fall for ORIF and
subsequent had failure to extubate.
.
# Respiratory Infection: The patient had been admitted multiple
times over the past two months for shortness of breath and was
recently found to be RSV positive. The patient was difficult to
wean off the vent s/p ORIF, which was thought to be secondary to
fluid overload and presence of RSV bronchiolitis and multifocal
PNA. the patient was eventually extubated and was started on a
standing dose of Lasix. He was diuresed and then underwent a CT
Chest on [**1-10**], which showed an increase in multifocal lung
nodules. The patient was started on Meropenem and Voriconazole,
and he underwent a bronchoscopy on [**2135-1-12**]. The BAL showed
[**Female First Name (un) **] which was suspected not to be the cause of his
infection. The patient continued to improve clinically. It was
suspected that he had a fungal infection other than [**Female First Name (un) **] as
his B-GLucan was positive. He will need a repeat B-Glucan and
should stay on fluconisole for now until his B-Glucan is
negative.
.
# Cough: Continued cough that is likely multifactorial. Patient
had RSV infection while in hospital, presumed fungal pneumonia
as well as volume overload with pleural effusions all which are
likely contributing to his cough. He does not tolerate high
doses of codeine at night as he is to sleepy in the am. We were
using 7.5mg codeine after dinner to help his supress his cough
enough to sleep through the night.
.
# Hip fracture: status post R ORIF: The patient presented with
right Femur fracture and had an ORIF on [**2135-1-6**]. The patient
was followed by the Orthopedic Surgery team during this
admission, and he worked with physical therapy to improve his
functional capacity. The patient continued to experience pain
in his right leg, for which he took Oxycodone as needed. He was
also started on Lovenox for DVT prophylaxis after his surgery,
and completed his course of four weeks of Lovenox while in the
hospital. He was in the hospital for his first [**Date Range **] follow up.
X-rays were taken and reviewed with [**Date Range **], his fracture is
healing well and he has another [**Date Range **] follow up as outpatient.
.
# Hemolytic anemia: The patient has a history of hemolytic
anemia secondary to CLL, for which he takes Prednisone 25 mg
daily. Given the patient's stable hemolytic anemia and his
current lung infection, the patient's steroids were tapered
during this admission and he was dischared on 10mg of prednisone
daily.
.
# Pleural effusions: Volume overload versus infectious from
probable fungal pneumonia. Patient was diuresed and continued
on lasix. He did not have an oxygen requirement at discharge.
.
# CLL: The patient has a history of CLL, for which he is taking
Rituxan and monthly IVIG. The patient received IVIG on [**2135-1-4**],
prior to this admission. The patient had a CT of his abdomen on
this admission, which showed an increase in his retroperitoneal
lymphadenopathy. His lymphocytes were elevated and so on
[**2135-1-27**] the patient was given a dose of Rituxan. He also
recieved intrathecal methotrexate on [**2135-2-7**].
.
# Thrombocytopenia: The patient has a history of
thrombocytopenia, which is most likely related to his CLL.
During this admission, the patient was transfused platelets to
maintain a count >50K intitially which eventually was weaned
down to 10K while on Lovenox treatment. He should continue to
be transfused to > 10K even after his Lovenox is stopped.
.
# Mental status change: Patient had been in hospital for a long
time and became more lethargic and introverted. At times he was
noted to be confused and likely delerious. This was attributed
to hospital delerium, hypercalcemia or CLL involvment of the
CNS. He recieved one dose of Pamindronate which brought his
calcium down and had a dose of intrathecal methotrexate. His LP
showed some atypical lymphocytes but there was not enough for
flow. He improved when his calcium went down and after the
methotrexate.
Medications on Admission:
Medications at home:
-Acyclovir - 400 mg Tablet - 1 (One) Tablet(s) by mouth three
times a day
-Fentanyl - 25 mcg/hour Patch 72 hr - Change patch every 3 days
-Folate - (Dose adjustment - no new Rx) - 1 mg Tablet - 3
(Three) Tablet(s) by mouth once a day
-Lasix - (Prescribed by Other Provider) - 40 mg Tablet - 0.5
(One half) Tablet(s) by mouth once a day
-Nystatin - (Prescribed by Other Provider) - 100,000 unit/mL
Suspension - 5 Suspension(s) by mouth four times a day as needed
-Oxycodone - (Dose adjustment - no new Rx) - 5 mg Capsule - 1
Capsule(s) by mouth q 4-6 hours as needed for pain
-Protonix - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once a day
-Pentamidine - 300 mg Recon Soln - 300 mg inhaled every month
for
6 months Diluted in 6 ml sterile water administered via aerosol
-Potassium Chloride - (Prescribed by Other Provider) - 10 mEq
Capsule, Sustained Release - one Capsule(s) by mouth once a day
-Prednisone - (Prescribed by Other Provider) - 20 mg Tablet -
1.5
(One and a half) Tablet(s) by mouth DAILY (Daily)
-Cyanocobalamin - 500 mcg Tablet - 2 Tablet(s) by mouth once a
day
-Docusate - (Prescribed by Other Provider) - 100 mg Capsule - 1
(One) Capsule(s) by mouth three times a day as needed for
constipation
-Senna - 8.6 mg Tablet - 2 (Two) Tablet(s) by mouth twice a day
as needed for constipation
-Atovaquone 750 mg/5 mL Suspension Ten (10) ml by mouth once a
day.
-Cefpodoxime 200 mg Tablet One (1) Tablet by mouth twice a day
for 7 days: take first dose on morning of [**2135-1-3**].
-Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization
One (1) Inhalation twice a day for 15 days. Starting [**1-3**]
-Codeine Sulfate 15 mg Tablet One (1) Tablet by mouth qhs: PRN
or q8hrs:PRN as needed for cough for 10 days.
-Furosemide 20 mg Tablet One (1) Tablet by mouth DAILY (Daily).
Medications on transfer:
Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO Titrate to
tolerate vent
Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
HYDROmorphone (Dilaudid) 0.2-0.6 mg IV Q5MIN:PRN PAIN
Maximum total dose not to exceed 0.1 mg/kg. PACU ONLY.
Ondansetron 4 mg IV X1 PRN nausea/vomiting
Do not administer if previous ondansetron dose administered
within 6 hours. PACU ONLY.
Haloperidol 0.25-0.5 mg IV MRX1:PRN nausea/vomiting
Rate should not exceed 5 mg/min. PACU ONLY.
Prochlorperazine 2.5-5 mg IV MRX1:PRN nausea/vomiting PACU ONLY.
Change DC Promethazine HCl 6.25-12.5 mg IV MRX1:PRN
nausea/vomiting PACU ONLY
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Atovaquone Suspension 750 mg PO DAILY
FoLIC Acid 1 mg PO TID
Acyclovir 400 mg PO Q8H
Docusate Sodium 100 mg PO TID
Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours SUSTAINED
RELEASE
Cefpodoxime Proxetil 200 mg PO Q12H
PredniSONE 10 mg PO DAILY
Cyanocobalamin 500 mcg PO DAILY
Furosemide 40 mg IV DAILY
Nystatin Oral Suspension 5 mL PO QID:PRN iew
Senna 1 TAB PO BID:PRN
Codeine Sulfate 15 mg PO Q8H:PRN
Fentanyl Patch 25 mcg/hr TP Q72H
Pantoprazole 40 mg PO Q24H
Acetaminophen 325-650 mg PO Q6H:PRN
HYDROmorphone (Dilaudid) 0.125-0.250 mg IV Q3H:PRN
Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN. [**1-6**] @ 1819 View
DiphenhydrAMINE 25 mg IV Q6H:PRN prior to red blood cell
transfusion
OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain hold for
sedation or rr<10
Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR
Discharge Medications:
1. Outpatient Lab Work
B-Glucan to be drawn on [**2135-2-16**]
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
4. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day as needed for constipation.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-24**]
MLs PO Q4H (every 4 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
14. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
17. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO tid () as needed for cough.
18. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
19. Codeine Sulfate 15 mg Tablet Sig: 0.5 Tablet PO every [**3-21**]
hours: Please offer patient a dose after dinner to help him
sleep through the night.
20. Line Care
Flush PICC with saline and 20 U heparin daily.
21. Heparin Flush 10 unit/mL Kit Sig: Two (2) Intravenous once
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Right hip fracture.
CLL
Fungal Pneumonia
Discharge Condition:
Stable for rehab
Discharge Instructions:
You were admitted to the hospital because of a hip fracture.
You had surgery on your hip. You had a difficult revocery
period complicated by a probable fungal infecction of your lung,
worsening of your CLL and some confusion. Your infection is
being treated with anti-fungals. You recieved a dose of Rituxan
for your CLL and a dose of methotrexate in your spinal fluid.
You were given some medicine to bring your calcium down.
Medication changes: Please take all medications as directed upon
discharge from the hospital. You will need to take the
fluconazole until your primary care doctor tell you to stop.
You will need to take Prednisone 10mg until your oncologist
tells you to stop.
Please return to the hospital or call your doctor if you have
temperature greater than 100.4, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2135-3-29**] 8:40
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2135-3-29**] 9:00
Test for consideration post-discharge: Modified Acid-Fast stain
for Nocardia
Outpatient lab: B-Glucan every 1-2 weeks until negative.
ICD9 Codes: 5185, 7907, 2930, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7031
} | Medical Text: Admission Date: [**2113-8-11**] Discharge Date: [**2113-8-23**]
Date of Birth: [**2035-12-2**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77F with COPD (4.5L baseline O2 req), HTN, CHF, morbid obesity
brought in for concern for dehydration. Her VNA had noted
decreased UOP, poor PO intake and intermittent confusion for
three days. Per Atrius notes, she may have been taking too much
lasix "ran out of her 20 mgm tab and may have been taking 140 mg
[**Hospital1 **]" She has also reported some abd discomfort/fullness. no
fevers/diarrhea/vomiting.
.
In the ED, initial vitals were 59 94/52 16 89 4LNC. She given
vanc and zosyn empirically in the ED and 2.5L NS. She had a CXR
that showed cardiomegaly, and vasc congestion. CTA showed no PE
and no abdominal process. She was admitted to the ICU for her
hypotension on presentation and renal failure. Hypoxia is near
baseline.
.
Patient states that she has been feeling more short of breath
for the past month. She thinks that her weight is increased and
that her abdominal girth has as well. She has a cough that is
chronic and unchanged. Not productive. No fevers or chills. She
has a chronic foley that is changed every 4-6 weeks and was
changed today in the ED. She denies any change in her urine.
Also denies chest pain, n/v/c/d.
Past Medical History:
# recent admission to [**Hospital1 112**] (d/c [**7-30**]) for removal of retained wire
from R knee (overnight for obs, no complications, local
anesthesia)
# CHF: admitted to [**Hospital1 112**] [**3-10**]: discharge weight was 200lbs and 202
from d/c from rehab [**3-17**]
# HTN
# DM
# Chronic lung disease on home o2
# pulmonary hypertension: echo [**3-10**]: PASP of 84.3 mm Hg,
# s/p R THA/TKA c/b MRSA in [**2109**]
# s/p L TKA [**2106**]
# morbid obesity
# depression
# restless leg syndrome
# urinary incontinence with chronic indwelling foley to reduce
risk of bedsores and difficult transfers for toiletting
# cervical cancer s/p resection
# Bilateral Renal masses - per PCP [**Name Initial (PRE) 626**] "have grown slowly and
in this pt are inoperable
# Bilateral pelvic cystic masses - MRI [**11-6**] most consistent
with postmenopausal ovarian cystic lesions...grossly stable but
L appears to have increased in size"
# GERD
Social History:
- Tobacco: Former Smoker ([**2101-1-28**]) 1 ppd, 48 pack-years
- Alcohol: very rarely
- Illicits: denies
Family History:
htn, stroke, cancer (unspecified)
Physical Exam:
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL, subconjunctival hemmorhage
Cardiovascular: rrr no m/g/r
Respiratory / Chest: crackles b bases
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+, incision from knee surgery c/d/i
Neurologic: oriented x 3 but sometimes less alert
.
Discharge Exam:
96.5 96/60 72 RR 18 90% on 4L
Eyes / Conjunctiva: PERRL, subconjunctival hemmorhage
Cardiovascular: rrr no m/g/r
Respiratory / Chest: crackles b bases
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+, incision from knee surgery c/d/i
Neurologic: oriented x 3
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2113-8-20**] 07:35 4.6 4.61 12.2 37.5 81* 26.4* 32.5 18.4* 204
[**2113-8-19**] 07:35 5.1 4.70 11.9* 37.4 80* 25.2* 31.7 18.6* 223
[**2113-8-18**] 04:47 4.3 4.47 11.6* 36.4 81* 25.9* 31.8 18.6* 224
[**2113-8-17**] 07:15 5.5 4.73 12.2 38.5 81* 25.8* 31.8 18.9* 212
[**2113-8-15**] 06:55 5.3 4.59 12.1 36.7 80* 26.3* 32.9 18.7* 254
[**2113-8-14**] 07:00 5.5 4.62 12.4 37.4 81* 26.8* 33.1 18.7* 284
DIFF ADDED [**8-14**] @ 12:44
[**2113-8-13**] 07:05 4.8 4.67 12.1 37.3 80* 25.9* 32.4 18.9* 265
[**2113-8-12**] 06:19 4.7 4.79 12.4 38.7 81* 25.9* 32.2 18.5* 317
[**2113-8-11**] 12:10 4.1 4.75 12.3 38.8 82 25.9* 31.8 19.1* 275
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2113-8-22**] 04:47 841 28* 1.3* 143 3.4 109* 28 9
[**2113-8-21**] 13:00 105*1 29* 1.4* 142 3.6 108 28 10
[**2113-8-20**] 07:35 751 28* 1.5* 144 3.9 106 26 16
[**2113-8-19**] 07:35 701 21* 1.1 143 3.5 106 27 14
[**2113-8-18**] 16:12 981 24* 1.1 145 3.7 109* 24 16
[**2113-8-18**] 04:47 751 27* 1.2* 145 3.8 109* 28 12
[**2113-8-17**] 07:15 701 26* 1.2* 145 3.6 111* 21* 17
[**2113-8-16**] 05:20 851 28* 1.1 144 3.4 110* 25 12
[**2113-8-15**] 06:55 991 33* 1.2* 143 3.4 111* 24 11
[**2113-8-14**] 07:00 114*1 37* 1.1 144 3.4 110* 24 13
[**2113-8-13**] 07:05 931 36* 1.1 142 3.5 111* 22 13
[**2113-8-12**] 06:19 711 36* 1.1 144 3.7 109* 22 17
[**2113-8-12**] 05:09 65*1 34* 1.0 141 6.0*2 112* 20* 15
[**2113-8-11**] 12:10 50* 1.4* 137 3.8 103 22 16
.
IMMUNOLOGY [**First Name9 (NamePattern2) 32906**] [**Doctor First Name **] Titer
[**2113-8-15**] 06:55 POSITIVE * 1:6401
[**2113-8-15**] 06:55 15*2
MISCELLANEOUS HEMATOLOGY ESR
[**2113-8-15**] 06:55 21*
ENZYMES & BILIRUBIN
[**2113-8-18**] 21:15 CK 30
[**2113-8-18**] 16:12 CK 35
[**2113-8-18**] 04:47 ALT 27 AST 20 CK 37 AP 52 TB 0.3
.
CPK ISOENZYMES CK-MB cTropnT proBNP
[**2113-8-18**] 21:15 2 <0.011
[**2113-8-18**] 16:12 2 <0.011
[**2113-8-18**] 04:47 2 <0.011
.
COMPLEMENT C3 C4
[**2113-8-18**] 04:47 114 30
.
ACE, SERUM 32 [**9-/2069**] U/L
.
CXR
Single semi-erect AP portable view of the chest was obtained.
There are relatively low lung volumes. The cardiac silhouette is
enlarged. The aorta is calcified. Prominence of the central
vasculature suggests pulmonary vascular engorgement. Bibasilar
opacities are seen, which could relate to vascular congestion,
but underlying infectious process is not excluded. No large
pleural effusion or pneumothorax is seen. Severe degenerative
changes are seen at the partially imaged shoulder joints.
CTA and abd - Wet
1. No pulmonary embolism or acute aortic pathology
2. Prominent interstitial markings in the upper lobes likely
reflect an element of chronic pulmonary disease, though
comparisons with prior and history is recommended.
3. 6 mm right upper lobe nodule. Follow up in 6 months if high
risk and 12 months if low risk.
4. Enlarged PA and RA/RV suggests pulmonary hypertension with
right heart failure.
5. 1.1cm right infrahilar node with right greater than left
lower lobe
peribronchovascular soft tissue thickening without discrete
lesions. Could be inflammatory but given lack of priors
malignancy must be considered. Follow up in 3 months is
suggested.
6. Bilateral renal lesions with internal hyperdensity that may
reflect
enhancement, evaluation by MRI is recommended.
7. Heterogeneous liver with wedge-shaped areas of hyper and hypo
enhancement, could be perfusional. Correlation with history and
lab values is suggested. Can also be evaluated at time of MRI.
8. Trace perihepatic and perisplenic ascites with trace pelvic
free fluid.
9. Bilateral adnexal cysts, 5.4cm on left. Given age and size of
lesions should be evaluated by pelvic US.
.
CT head
Motion limited examination without acute intracranial process.
White matter hypodensities likely reflect small vessel ischemic
disease.
.
EKG: sinus, right axis deviation, bilatrial enlargement,
non-specific t wave abnormalites
ECHO ([**2113-8-14**]) -
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is unusually small. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with depressed free wall contractility. There is abnormal
systolic septal motion/position consistent with right
ventricular pressure overload. 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 mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severe pulmonary hypertension with RV
dilation/dysfunction secondary to chronic pressure overload.
.
Echo ([**2113-8-21**]):
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler. The IVC is
dilated (>2.5cm)
LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity.
Normal regional LV systolic function. Overall normal LVEF
(>55%). No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Markedly dilated RV cavity. Moderate global RV
free wall hypokinesis. Abnormal systolic septal motion/position
consistent with RV pressure overload.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
MS. LV inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild to moderate [[**1-29**]+] TR. Severe PA systolic hypertension.
Conclusions
The left atrium is normal in size. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity is small. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
normal (LVEF>55%). There is no ventricular septal defect. The
right ventricular cavity is markedly dilated with moderate
global free wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. 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. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is severe
pulmonary artery systolic hypertension.
.
CXR ([**2113-8-19**]):
REASON FOR EXAMINATION: Worsening hypoxia after diuresis.
Portable AP radiograph of the chest was reviewed in comparison
to [**2113-8-18**] and CT torso from [**2113-8-11**].
Since the prior chest radiograph there is significant
improvement up to almost complete resolution of pulmonary edema.
Severe cardiomegaly with prominence of the main pulmonary artery
and right heart is re-demonstrated with still present bilateral
pleural effusions. There is no evidence of pneumothorax. Still
present interstitial edema is mild. Continued surveillance is
recommended.
The study and the report were reviewed by the staff radiologist.
.
TTE: [**2113-8-21**]
The left atrium is normal in size. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity is small. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
normal (LVEF>55%). There is no ventricular septal defect. The
right ventricular cavity is markedly dilated with moderate
global free wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. 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. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is severe
pulmonary artery systolic hypertension. Compared with the prior
study (images reviewed) of [**2113-8-14**], no change.
Brief Hospital Course:
77F with dCHF, pulmonary hypertension and chronic lung disease
that presented with dyspnea, hypotension, and altered mental
status found to have Klebsiella UTI and [**Last Name (un) **].
.
ACTIVE ISSUES:
# Hypotension: Pt presented with a low BP compared to her
baseline of SBP 100 - 110, but this improved rapidly with IVF.
It was felt that overdiuresis with her outpatient Lasix regimen
may have contributed to her volume depletion, although there was
also a likely infectious component, as the patient was
ultimately diagnosed with a Klebsiella pneumoniae UTI .
Throughout the hospitalization, the pt's BP continued to remain
stable, with good urine output. A repeat ECHO during this
admission did not show any evidence of new systolic heart
failure. The patient's BP tolerated the restarting of her Lasix
regimen without any difficulty. The pts SBPs on discharge was in
high 90s, mentating at baseline.
.
# Dyspnea and Hypoxemia: At baseline, the patient carries a
diagnosis of diastolic heart failure, pulmonary HTN, and COPD,
on home oxygen of 4.5 liters with sats in the high 80s-low 90s.
She was admitted with low oxygen saturation, requiring 5 liters
of oxygen. This requirement improved only slightly during her
hospitalization, ultimately at 4.5 liters (her home oxygen
amount). CXR did not show any evidence of infiltrate, nor did
she have symptoms or exam consistent with pneumonia. Although
her BNP suggest possible heart failure, her exam and recent
history of increased Lasix use did not support a diagnosis of
CHF exacerbation. Furthermore, an ECHO done during this
admission did not show any evidence of worsening diastolic heart
failure or new systolic heart failure. Although CTA of her
chest showed no evidence of PE, it did show findings consistent
with severe pulmonary hypertension. Please see below regarding
additional details on her pulmonary hypertension. She developed
worsening shortness of breath and hypoxemia on [**8-18**] with a chest
xray that was consistent with acute on chronic diastolic
congestive heart failure. She was diuresed with intravenous
lasix however this was somewhat limited by acute renal failure.
Ultimately, she was discharged on the Lasix 120mg [**Hospital1 **].
.
# Acute Toxic Metabolic Encephalopathy: Pt presented with waxing
and [**Doctor Last Name 688**] mental status. She was oriented x3 but showed poor
attention. Per family has been confused for past month and seems
improved to them now. A CT head was negative and an ABG showed
she was not hypercarbic. The initial thought on admission to the
ICU was that her delirium was likely due to either infection,
effect of her medications, or a combination of both. She was
started on broad-spectrum IV antibiotics on admission with
Vancomycin and Zosyn, and her medications including Mirapex,
Xanax, trazodone, and gabapentin were all held. By morning
following admission, the patient's mental status had already
improved significantly. She was re-started on her medications
one at a time, and tolerated them well, with the exception of
trazodone, which she now uses PRN sleep and Xanax which
continues to be held now. Please see below for further details
regarding her Xanax. Additionally, the patient's urine culture
grew Klebsiella pneumoniae, and she was treated with
ciprofloxacin to treat a complicated UTI. Her mental status
has continued to be at baseline and stable since her admission.
.
# Chronic diastolic CHF: The patient presented with a low BP and
elevated BNP to suggest an acute flare of her CHF. However,
clinically she appeared volume depleted rather than volume
overloaded. In speaking with her outpatient nurse as well as
her daughters, the patient had been taking increased doses of
her Lasix in an attempt to reduce the edema in her legs.
However, given her right-sided heart failure, the patient is
extremely volume sensitive, and the diuresis may have been
exacerbating the situation, rather than alleviating her
symptoms. Given her low BP's and poor mental status on
admission, the Lasix was held over the next few days. The
patient was then followed clinically with daily weight, I+O's,
and physical exam. Once her BP and Cr stabilized, she was
restarted on Lasix at a lower dose, and has since been titrated
back up to 120 mg twice daily. A repeat ECHO on this admission
confirmed evidence of right-sided heart failure in the setting
of elevated pulmonary pressures. Of note, the patient's
discharge weight from her last hospital admission approximately
2 weeks prior was in the range of 200 - 202 pounds. She then
developed recurrent dyspnea and was found to have pulmonary
edema, likey due to acute on chronic diastolic CHF. She was
diuresed with IV lasix with good effect for her breathing but
resultant renal failure. Her diuretics were then again held.
Ultimately, these were restarted at Lasix 120BID. Her discharge
wt was 208lbs.
.
# Pulmonary HTN: The patient had not carry a formal diagnosis of
pulmonary hypertension, and her hypoxia has always been
attributed to a presumed diagnosis of COPD given her extensive
prior tobacco use. Previous ECHO did show elevated pressures,
suggesting pulmonary hypertension. CTA on this admission did
not show any evidence of PE, but was also consistent with with
severe pulmonary hypertension. A repeat ECHO done during this
admission also confirmed findings consistent with severe
pulmonary hypertension. After her transfer from the ICU, the
Pulm Consult service saw the patient, and felt that the patient
likely had a multi-factorial etiology to her pulmonary
hypertension. At Mixed connective tissue disease screen ([**Doctor First Name **],
ESR, ACE, and RF levels) to initiate the work-up of pulmonary
hypertension. She should follow-up with Pulmonary Clinic as an
outpatient, where she will likely undergo additional studies,
including full PFT's with spirometry, lung volumes, DLCO and
bronchodilator challenge. Additional she will need a full sleep
study and possibly a right heart cath.
.
# Klebsiella Pneumoniae Urinary Tract Infection: Pt with hx of
urinary incontinence with chronic indwelling foley: The patient
had her Foley catheter changed on admission. Her UA was
positive for pyuria with 85 WBC's. She initially received broad
spectrum coverage with Vancomycin and Zosyn in the ICU. Her
final urine culture grew pan-sensitive Klebisella pneunomiae,
and she was tailored to ciprofloxacin. She completed a total of
a 10-day course of ciprofloxacin for complicated UTI on [**2113-8-22**]
given the presence of a chronic Foley catheter.
.
# Anxiety: The patient takes standing Xanax as an outpatient.
This medication was held during this admission due to the
patient's mental status on admission. However, even after her
mental status improved to baseline, this medication was held
after conversation with the patient. It was discussed with the
patient that benzodiazepenes in the elderly can have serious
side effects, and that benzodiazepenes are not optimal for
long-term management of anxiety given their potential for
dependence and withdrawl. Pt expressed that she was not
experiencing any symptoms of her anxiety off the medication, and
would not require the Xanax. She will follow-up with her
outpatient PCP to monitor her anxiety and to hold off on taking
Xanax for now.
.
INACTIVE ISSUES:
# h/o MRSA infection: The patient has a history of septic
arthritis with MRSA, and has had hardware removed from her right
knee recently. She is on chronic prophylactic oral antibiotics
with Bactrim. Given her [**Last Name (un) **] on admission to the hospital, and
also that she received Vancomycin in the ER, her Bactrim was
initially held. After her renal function stabilized, she was
restarted on the Bactrim without any issues.
.
# GERD: The patient was asymptomatic during this admission and
was kept on her home does of omeprazole.
.
# Hypothyroidism: The patient's recent TSH at outpt PCP visit
was WNL. She was continued on her home dose of levothyroxine.
.
# Depression: The patient was continued on her outpatient
regimen of sertraline, and she denied any depressed mood or
suicidal ideation during this admission.
.
# Restless leg syndrome: Pt is on Mirapex and Neurontin as an
outpatient for her RLS. However, given her mental status on
admission, both of these medications were withheld for their
possible sedating effect. After the patient's mental status
improved with fluids and antibiotics, she was restarted on both
of these medications and tolerated them without any side
effects.
.
# Bilateral renal and Pelvic masses: These are known masses and
have been stable on outside images. The patient will need to
follow-up with her PCP to evaluate and monitor these masses.
.
# Diabetes Mellitus: diet controlled. has not required therapy
and A1C's all below 6. patient had her fingersticks checked, but
did not require any insulin.
.
TRANSITIONAL ISSUES
# Code Status: Full Code
Daughter is contact: [**Telephone/Fax (1) 88893**]
Medications on Admission:
Alprazolam 0.25 mg 1 to 2 tabs [**1-29**] x daily prn anxiety
Pramipexole 0.25 mg Oral Tablet take three tablets daily at
bedtime
Furosemide 120 mg TWICE DAILY
Sertraline 100 mg Oral Tablet TAKE 2 TABLETS DAILY
Oxycodone 5 mg [**1-29**] TID prn (not needing often)
Levothyroxine 75 mcg Oral Tablet TAKE ONE TABLET DAILY
Gabapentin 300 mg Oral Capsule TAKE 1 CAPSULE DAILY AT BEDTIME
Simvastatin 40 mg Oral Tablet take 1 tablet every evening
Fluticasone (FLOVENT HFA) 110 mcg/INHALE 2 PUFFS BY MOUTH TWICE
DAILY
Ipratropium-Albuterol 3mL in nebulizer EVERY SIX HOURS AS NEEDED
Omeprazole 20 mg 1 capsule once daily
Trazodone 50 mg Oral Tablet 1 pill at nightime
POTASSIUM CHLORIDE ORAL 40 meq every day
Sulfamethoxazole-Trimethoprim 800-160 mg Oral Tablet TAKE 1
TABLET TWICE DAILY to take life ling for joint infection s/p
replacement
Multivitamin Oral Capsule 1 TABLET DAILY
Aspirin 81 mg Oral Tablet Take 1 tablet daily.
PROAIR HFA 90 MCG 2 puffs FOUR TIMES DAILY AS NEEDED
FERROUS SULFATE 325 MG (65 MG IRON) TAB 1 tablet a day
SENNA 8.6 MG TAB (SENNOSIDES) 1-2 tablets as needed for
constipation
CALCIUM CARBONATE W/VITAMIN D TABLET 600-200 PO one [**Hospital1 **]
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: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath/wheeze.
4. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath/wheeze.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
14. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
15. pramipexole 0.25 mg Tablet Sig: Three (3) Tablet PO qhs ().
16. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
17. Outpatient Lab Work
Please have a basic metabolic panel checked and faxed to the
patients PCP [**First Name8 (NamePattern2) 22997**] [**Last Name (NamePattern1) 31**], Phone: [**Telephone/Fax (1) 2115**]
Fax: [**Telephone/Fax (1) 6808**] on Friday [**8-25**].
18. Oxygen
Patient is on 4.5L with 02 sats 88% to 90% at baseline.
19. furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Primary Diagnosis
- Urinary Tract Infection
- Acute Kidney Injury
Secondary Diagnoses
- Pulmonary Hypertension
- Chronic Diastolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with confusion, shortness of
breath and low oxygen saturations. This was most likely due to a
urinary tract infection. In this setting you were probably
slightly dehydrated on admission. The medication Xanax has been
stopped because it seems like it was making you confused.
Please make sure to weigh yourself every day and call your
doctor if your weight increases.
Followup Instructions:
Please have your labs checked and sent to Dr. [**Last Name (STitle) 31**] on
[**2113-8-25**]
Phone: [**Telephone/Fax (1) 2115**]
Fax: [**Telephone/Fax (1) 6808**]
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital1 641**]
Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 2115**]
When: Monday, [**8-21**], 9:40AM
*Please discuss booking a Pulmonary appointment at [**Location (un) 2274**] with Dr.
[**Last Name (STitle) 31**].
ICD9 Codes: 5849, 5990, 2762, 4280, 2449, 5859, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7032
} | Medical Text: Admission Date: [**2125-1-2**] Discharge Date:[**2125-2-16**]
Date of Birth: [**2125-1-2**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 59854**] is a former 29
and [**2-2**] week premature infant admitted to the Neonatal
Intensive Care Unit for management of prematurity and
respiratory distress.
A 1260 gram product of a 29 and [**2-2**] week gestation pregnancy
born to a 26 year old gravida 1, para 0, now 1 mother.
Prenatal laboratory studies included blood type B positive,
antibody negative, rubella immune, RPR nonreactive and
hepatitis B surface antigen negative. Mother was hospitalized
approximately one week prior to delivery after presenting
with fevers, shortness of breath and chest pain. She was
eventually found to have multiple problems including
pericardial effusion, cardiac tamponade, a small pleural
effusion, swollen knee with a joint effusion and joint pain.
Evaluations that were available at the time of delivery have
been notable for elevated ESR, pericardial fluid cultured
positive only for rare [**Female First Name (un) 564**] albicans, urine culture
positive for [**Female First Name (un) 564**] albicans and thrush on examination and
throat culture positive for yeast. Multiple blood, urine,
pericardial fluid and joint fluid cultures have been
otherwise negative. An extensive rheumatologic evaluation
has also been negative.
She has been treated with antifungal therapy for positive fungal
cultures but the fungal infection is not thought to be the
primary cause of her symptoms and findings. Her underlying
diagnosis remains unknown. She has also been treated
empirically with ceftriaxone, azithromycin and steroids. She
received betamethasone on [**12-27**], and [**12-28**] and
prednisone subsequently.
Respiratory distress has been managed with oxygen and BiPAP
although she has had ongoing issues with respiratory acidosis
and increased work of breathing. Pericardial effusion was
drained on admission and has not re accumulated by repeat
echocardiograms. Overall symptoms have not improved over the
course of her hospitalization. 24 hours prior to delivery,
the mother had increasing right upper quadrant abdominal pain
and mildly elevated liver function tests with AST and ALT of
approximately 100.
Secondary to concerns that atypical preeclampsia may be
complicating maternal illness and given severity of maternal
symptoms and lack of clinical improvement, a decision was
made to deliver the infant by cesarean section. Fetal
assessments have been reassuring with normal fetal heart
tracing and biophysical profile of [**11-5**].
The infant was delivered by cesarean section through intact
membranes emerging with moderate tone and weak respiratory
effort. He responded well to drying and stimulation with
improvement in respiratory effort. Blow-by oxygen was given
for 2 to 3 minutes for duskiness with improvement in color.
Apgars were 6 at 1 minute and 8 at 5 minutes. The infant was
transferred to the Neonatal Intensive Care Unit in free flow
oxygen.
PHYSICAL EXAMINATION: Birth weight 1260 grams, 50th
percentile; head circumference 26.5 cm, 25 to 50th
percentile; length 39 cm, 50th percentile. Premature infant
active with examination, moderate respiratory distress.
SKIN: Warm, pink, no rashes. Capillary refill 1 to 1.5
seconds.
HEENT: Anterior fontanel soft and flat. Palate intact.
Ears and nares normal.
CHEST: Moderate aeration with moderate grunting starting
retractions. Coarse breath sounds bilaterally. HEART:
Regular rate and rhythm. No murmurs.
ABDOMEN: Soft. No masses. No hepatosplenomegaly. Three
vessel cord. Normal male genitalia. Testicles not palpated.
Anus patent.
EXTREMITIES: No edema. No injuries. Warm and well perfused.
Tone appropriate. Moving all extremities.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Shortly
after admission to the Neonatal Intensive Care Unit, the
infant continued to have increased respiratory distress and
was intubated and received one dose of Surfactant and
extubated shortly after to CPAP. He remained on CPAP until
day of life 2 and transitioned to nasal cannula at that time.
He weaned to room air by day of life 6 and he has remained in
room air throughout this hospitalization with oxygen
saturations greater than 95 percent. Respiratory rate 40s to
60s. He was not treated with caffeine during this
hospitalization and he has not had any apnea or bradycardia
during this hospitalization.
CARDIOVASCULAR: He has remained hemodynamically stable
during this hospitalization with mean blood pressures 40s to
50s. No murmur. Heart rate 140 to 170.
FLUIDS, ELECTROLYTES AND NUTRITION: He was initially
receiving nothing by mouth. 80 cc per kg per day D10W,
starter PN. An umbilical arterial catheter was placed on
admission and was discontinued on day of life 2. He advanced
to total fluids of 150 cc per kg per day by day of life 4.
Enteral feedings were started on day of life 3 and he
advanced to full volume feedings by day of life 8. Maximum
caloric density of special care 30 calories per ounce with
ProMod was achieved by day of life 15. He continued to show
adequate weight gain and was weaned to 24 calories per ounce
and he is currently taking in a minimum of 130 cc per kg per
day of Similac 24 calories per ounce PO. He has tolerated
his feedings without difficulty. His most recent
electrolytes on day of life 5 showed sodium of 144, potassium
4.6, chloride 116, bicarb 22. On day of life 23, calcium was
9.9, alkaline phosphatase was 535, phosphorous 6.5. His
dischargeweight is 2530 grams , head circumference is 32.5 cm,
length 43 cm.
GASTROINTESTINAL: He required single phototherapy from day
of life 3 to day of life 6. The maximum bilirubin level on
day of life 3 was 6.9 with a direct of 0.3. Rebound
bilirubin level on [**1-9**], was 3.1 with a direct of 0.3.
HEMATOLOGY: CBC on admission showed white blood cell count of
4000, hematocrit 39.7 percent, platelet count 280,000, 40
neutrophils, 2 bands. Repeat CBC on day of life 2 showed
white blood cell count of 12.9, hematocrit 41 percent,
platelets 243,000, 79 neutrophils, 3 bands. He has not
received any blood transfusions during this hospitalization
and his most recent hematocrit on [**1-25**] was 24.8
percent with a retic of 6.5 percent. Due to maternal [**Female First Name (un) 564**]
infection, AmBisome was started on admission and fungal
cultures were obtained including cerebrospinal fluid cultures
for fungus. He was also started on ampicillin and gentamycin
due to respiratory distress and prematurity. AmBisome and
ampicillin and gentamicin were all discontinued after 48
hours as all of the cultures were negative. The LP result
showed white blood cell count of 3, red blood cells 17,
protein 109, glucose 82. He has not had any other issues
with sepsis during this hospitalization.
NEUROLOGY: He has had three head ultrasounds during this
hospitalization. His first head ultrasound on day of life 2
showed bilateral germinal matrix hemorrhages a repeat head
ultrasound on day of life 7 showed resolving right germinal
matrix hemorrhage, left normal. A follow up head ultrasound
on [**2-2**], showed bilateral germinal matrix hemorrhages,
the same result as [**1-4**].
SENSORY - Hearing screening was performed automated auditory
brain stem responses. Infant passed in both ears.
OPHTHALMOLOGY: His most recent eye examination was on [**2-5**], revealing mature retinal vessels. A follow up examination
is recommended at 9 months of age.
PSYCHOSOCIAL. [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] social
work is involved with the family. The contact social worker
can be reached at [**Telephone/Fax (1) 8717**]. The mother's primary support
person is the maternal grandmother. The father of the baby
has not been involved and he lives in [**State 2690**]. The mother is
still recovering from her illness and continues to have
increased work of breathing. It is still unclear as to what
the etiology of her infection was. All of her cultures other
than the fungal cultures have been negative.
CONDITION ON DISCHARGE: Former 29 and [**2-2**] weeker, now 35 and
4/7 weeks corrected, stable in room air.
DISCHARGE DISPOSITION: Home with mother.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18296**], phone No.
[**Telephone/Fax (1) 37584**].
CARE RECOMMENDATIONS: Feedings at discharge - Similac 24
calories per ounce PO minimum 130 cc per kg per day.
Medications - ferrous sulfate 25 mg per ml dose 2 mg per kg
per day once daily PO.
CAR SEAT POSITION SCREEN: The infant passed the infant car
seat position screen test.
THE STATE NEWBORN SCREEN: The State Newborn Screens were
sent on [**1-5**], [**1-16**], and [**2-13**]. [**2-13**]
results are pending. The prior two screens have been within
normal limits.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2-5**],
and Synagis vaccine on [**2-9**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following
three criteria.
A. Born within 32 weeks.
B. Born between 32 and 35 weeks with two of the following:
2. daycare during the RSV season.
3. a smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings.
4. with chronic lung disease.
1. 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 SCHEDULED/ RECOMMENDED:
1. Primary pediatrician on [**2125-2-19**].
2. [**Hospital6 **].
3. Dr. [**Last Name (STitle) **], ophthalmology at 9 months of age.
DISCHARGE DIAGNOSIS:
1. Prematurity.
2. Status post respiratory distress syndrome.
3. Status post rule out sepsis, ruled out.
4. Status post rule out fungemia, ruled out.
5. Status post indirect hyperbilirubinemia.
6. Status post circumcision on [**2125-2-14**].
7. Anemia of prematurity.
8. Bilateral germinal matrix hemorrhages.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2125-2-16**] 00:17:34
T: [**2125-2-16**] 01:16:33
Job#: [**Job Number 60189**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7033
} | Medical Text: Admission Date: [**2150-2-25**] Discharge Date: [**2150-3-1**]
Date of Birth: [**2086-12-19**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
left sided brain lesion
Major Surgical or Invasive Procedure:
[**2-25**] Left Craniotomy for mass resection
History of Present Illness:
[**Known firstname **] [**Known lastname 1852**] is a 62-year-old left-handed man who is here for a
follow up of his left sphenoid meningioma. I last saw him on
[**2149-11-17**] and his head CT showed growth of the left sphenoid
meningioma. He is seizure free. Today, he is here with his
wife
and daughter. [**Name (NI) **] does not have headache, nausea, vomiting,
urinary incontinence, or fall.
His neurological problem began on [**2142-6-22**] when he became
confused and disoriented in a hotel bathroom. At that time, he
was visiting his daughter for a wedding. His wife found him
slumped over in the bath tube. According to her, his eyes
looked
funny. He could not stand up. His verbal output did not make
sense. He was brought to [**Doctor First Name 1853**] Hospital in Placentia,
CA. He woke up 7 to 8 hours later in the emergency room. He
felt very tired after the event. He was hospitalized from
[**2142-6-22**] to [**2142-6-25**]. He had a cardiac pacemaker placement due
to irregular heart rate and bradycardia. He also had a head MRI
that showed a less than 1 cm diameter sphenoid meningioma.
Past Medical History:
Cardiac arrhythmia as noted above, has a
pacemaker in place, prostate cancer with prostatectomy, and
hypertension.
Social History:
Lives with his wife. Retired, works parttime
driving a school bus.
Family History:
NC
Physical Exam:
Temperature is 97.8 F. His blood pressure
is 150/92. Pulse is 80. Respiration is 16. His skin
has full turgor. HEENT is unremarkable. Neck is supple.
Cardiac examination reveals regular rate and rhythms. His lungs
are clear. His abdomen is soft with good bowel sounds. His
extremities do not show clubbing, cyanosis, or edema.
Neurological Examination: His Karnofsky Performance Score is
100. He is awake, alert, and oriented times 3. There His
language is fluent with good comprehension. His recent recall
is
intact. Cranial Nerve Examination: His pupils are equal and
reactive to light, 4 mm to 2 mm bilaterally. Extraocular
movements are full. There is no nystagmus. Visual fields are
full to confrontation. Funduscopic examination reveals sharp
disks margins bilaterally. His face is symmetric. Facial
sensation is intact bilaterally. His hearing is intact
bilaterally. His tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: He does not have a drift. His muscle
strengths are [**5-16**] at all muscle groups. His muscle tone is
normal. His reflexes are 0 in upper and lower extremities
bilaterally. His ankle jerks are absent. His toes are
down going. Sensory examination is intact to touch and
proprioception. Coordination examination does not reveal
dysmetria. His gait is normal. He can do tandem. He does not
have a Romberg.
PHYSICAL EXAM UPON DISCHARGE:
non focal
incision c/d/i, dissolvable sutures
Pertinent Results:
[**2-25**] CT Head: IMPRESSION:
1. Likely meningioma along the greater [**Doctor First Name 362**] of the left sphenoid
bone,
measuring 18 mm in diameter, unchanged since the most recent
study of [**11/2149**], with reactive bony changes, as above.
2. Bifrontal cortical atrophy, which has progressed slightly
over the series of studies since the earliest studies of [**2142**].
[**2-25**] CT Head: IMPRESSION:
Expected post-operative changes with the left frontal craniotomy
including
subcutaneous air and soft tissue swelling, moderate
pneumocephalus overlying predominantly the bilateral frontal
lobes, and foci of hemorrhage in the surgical bed. No evidence
of residual tumor on this non contrast CT.
[**2-26**] CXR: FINDINGS: The lung volumes are rather low. There is
moderate cardiomegaly without evidence of overt pulmonary edema.
No areas of atelectasis or pneumonia. Right pectoral pacemaker
in situ, with correct lead placement.
[**2-28**] Head CT /c contrast: IMPRESSION: Status post left frontal
craniotomy changes with improvement of pneumocephalus and stable
3 mm left to right midline shift; focus of hemorrhage
with/without residual tumor in the resection bed is similar in
appearance to prior exam but now with more surrounding vasogenic
edema. Stable appearance of subarachnoid hemorrhage. Followup to
assess for residual tumor/ interval change.
Brief Hospital Course:
Patient presented electively on [**2-25**] for left sided craniotomy
for mass resection. he tolerated the procedure well and was
taken to the Trauma ICU post-operatively still intubated.
Shortly thereafter he was deemed fit for extubation which was
done without difficulty. At post-op check he was neurologically
intact.
On [**2-26**] he was neurologically intact and cleared for transfer to
the stepdown unit. This did not happen due to bed shortage. A CT
with contrast was ordered for post op evaluation.
On [**2-27**] he was again stable and cleared for transfer to the
floor. Decadron taper was initiated. He was seen by PT and
cleared for discharge home.
On [**2-28**] the patient was being prepped for discharge but was
noted to have intermittent heart rate in the 130-170's. His
other vitals were stable. Electrophysiology was consulted and
they recommended increasing the metoprolol XL dose to 100mg
Qday. The patient was kept overnight to monitor this new dose.
On [**3-1**] her remained stable neurologically and hemodynamically
therefore he was cleared for discharge.
Medications on Admission:
coumadin, keppra, toprol xl, diovan, zocor
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain or fever > 101.4.
5. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
8. 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*
9. metoprolol succinate 100 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*
10. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 6
days: 3mg Q8hr on [**3-1**], then 2mg Q8hr x2 day, 1mg Q8hr x2 day,
1mg Q12hr x1 day then d/c.
Disp:*qs Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left sided brain lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You have dissolvable sutures so you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????You need an appointment in the Brain [**Hospital 341**] Clinic. The Brain
[**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the
[**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**].
They will call you with an appointment within the next 2 weeks.
Please call if you do not hear from the, you need to change your
appointment, or require additional directions.
?????? Changes were made to your heart rate/blood pressure
medication while you were in house. You were seen by the
cardiology team who made these recommendations. Please follow up
with your PCP within one week to check your heart rate and blood
pressure.
Completed by:[**2150-3-1**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7034
} | Medical Text: Admission Date: [**2150-6-19**] Discharge Date: [**2150-6-23**]
Date of Birth: [**2070-6-19**] Sex: F
Service: NEUROLOGY
Allergies:
Iodine / Epinephrine / Gentamicin / Ivp Dye, Iodine Containing /
Aleve
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Called by Dr. [**First Name (STitle) **] in Neurosurgery to evaluate for
intraparenchymal hemorrhage.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 79-year-old right-handed woman who presentswith
headache. She was in her USOH until Sunday (5 days prior) when
she developed a severe, acute onset, pounding headache. A
headache of any sort is unusual for her. This was associated
with some nausea but no vomiting and no other symptoms. She took
frequent Tylenol and went to bed early. There was some
improvement by the next day, and it had resolved within 24
hours. She did see her PCP on Tuesday.
On Wednesday, she had a recurrence of this headache. Again a
sharp pain bifrontally maximal at onset that then spread to the
back of her neck and eventually became a severe pounding
throughout her head. Tylenol provided little relief. She had
nausea, but no other symptoms, including no frank vertigo or
disequilibrium, no focal weakness, no dysphagia, no diplopia.
When the headache persisted through the next day, she called her
PCP. [**Name10 (NameIs) **] referred her to the [**Hospital3 417**] ED. There, a head CT
revealed an intracerebral hemorrhage in near the cerebellar
vermis, 1 cm in diameter. As her INR was elevated due to her
Coumadin, she was given 2 units of FFP there. She was then
transferred here.
After arrival at [**Hospital1 18**], her INR was 2.0. She was given 2 more
units of FFP and 10 mg of SQ Vitamin K. She was admitted to the
neurosurgical service, but as there is no surgical intervention
warranted, they have consulted us for further recommendations on
management and for possible transfer to our service.
On neuro ROS, Ms. [**Known lastname **] [**Last Name (Titles) **] headache now, as well as loss of
vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. [**Last Name (Titles) 4273**]
difficulties producing or comprehending speech. [**Last Name (Titles) 4273**] focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. [**Last Name (Titles) 4273**] difficulty with gait.
On general review of systems, she [**Last Name (Titles) **] recent fever or chills.
No night sweats or recent weight loss or gain. [**Last Name (Titles) 4273**] cough,
shortness of breath. [**Last Name (Titles) 4273**] chest pain or tightness,
palpitations. [**Last Name (Titles) 4273**] nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. [**Last Name (Titles) 4273**] arthralgias or myalgias. [**Last Name (Titles) 4273**] rash.
Past Medical History:
PMH:
Atril fibrillation on Coumadin until admission
CAD
CHF
Tachy-brady syndrome s/p pacemaker in [**2137**]
s/p Sub-total colectomy and splenectomy with ileostomy in [**2144**]
with subsequent reversal of ileostomy
c. diff
diverticulosis
PSH:
[**10-14**] ileostomy takedown, wedge of stomach
[**5-13**] subtotal colectomy and ileostomy
[**5-15**] tracheostomy
splenectomy
CCY
appy
parathyroid excision
Social History:
[**Month/Year (2) 4273**] use of tobacco and alcohol. 80th birthday tomorrow.
Family History:
NC
Physical Exam:
Vitals: T: 98.6 P: 73 R: 23 BP: 114/46 SaO2: 97% 4L NC
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM,
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Speech was not dysarthric. Able to follow
both
midline and appendicular commands. The pt. had good knowledge of
current events.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus but with saccadic intrusion.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch. No extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 1 2 1
R 3 2 1 3 1
Plantar response was mute bilaterally.
-Coordination: No intention tremor, mild dysdiadochokinesia on
left. Mild ataxia on FNF on left.
-Gait: Good initiation. Slow but Narrow-based, normal stride and
arm swing.
Pertinent Results:
Laboratory Data:
141 103 21 105
4.3 28 1.4
Ca: 9.7 Mg: 2.2 P: 2.7
WBC: 7.9; Hct: 30.7; Plt: 237
PT: 16.0 PTT: 29.0 INR: 1.4
EKG: Paced
Radiologic Data:
NCHCT: Small, 11 mm hyperdense lesion in the superior
cerebellum adjacent to the tentorium in the midline. This should
be a very
unusual location for isolated subdural hemorrhage. As this
lesion
appears extra-axial, it most likely represents a mass lesion
such
as meningioma. Less likely consideration would be a metastatic
focus. MRI may be helpful for further characterization.
NOTE ADDED AT ATTENDING REVIEW: There is a small region of
hypodensity in the vermis adjacent to this lesion. This may
represent edema, which would argue for an intra axial
abnormality. I agree with the recommendation of an MR exam, but
I
raise the possibility that this may reflect an intra axial
lesion, perhaps hemorrhage. Unfortunately, I do not have access
to the outside study, so I cannot comment about any changes
since
the prior study.
REPEAT HEAD CT w/wo CONTRAST: In comparison to the non-contrast
head CT, there is no definite change in size of a
well-circumscribed focal hyperdensity in the superior aspect of
the cerebellum measuring 14 x 7 mm. The difference in
measurements are within the possible difference due to slice
selection. There is a small region of hypodensity in the vermis
adjacent to this lesion, which likely represents a small amount
of edema. Therefore, an intra-axial location is likely. This
lesion does not demonstrate enhancement on contrast-enhanced
imaging, and the density is unchanged on delayed images.
Therefore, a small focus of hemorrhage is the likely etiology.
EKG: A-V sequential paced rhythm. Compared to the previous
tracing of [**2146-11-23**] there is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 0 162 442/466 0 118 -60
CXR [**6-21**] Cardiac silhouette remains enlarged, and there is
persistent pulmonary vascular engorgement. Bilateral diffuse
interstitial opacities have improved, consistent with improving
interstitial edema. However, more confluent airspace opacities
in the lower lungs have slightly worsened, particularly in the
left lower lobe. Although possibly due to dependent areas of
edema, superimposed process such as a pneumonia should be
considered in the appropriate clinical setting. Small right
pleural effusion has decreased in size, but a small-to-moderate
left effusion is slightly larger.
KUB [**2150-6-21**] Non-obstructed bowel gas pattern is visualized.
Surgical clips are noted within the pelvis. Examination was not
obtained in upright or lateral decubitus view; thus, free
intraperitoneal air cannot be assessed. Right hemidiaphragm is
moderately elevated.
U/S RUQ [**2150-6-22**]
1. No biliary dilatation. Status post cholecystectomy.
2. Incidental finding of a 9-mm cystic lesion in the neck of the
pancreas. If clinically indicated, an MRI could be helpful for
better characterization.
3. 1.1 cm simple cyst in the lower pole of the left kidney.
4. Right pleural effusion.
ECHO [**2150-6-23**]
The left atrium is mildly dilated. There is asymmetric left
ventricular hypertrophy, involving the anterior septum and
inferior wall. The left ventricular cavity size is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
These findings are consistent with hypertrophic non-obstructive
cardiomyopathy (HCM). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is no
systolic anterior motion of the mitral valve leaflets. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Hypertrophic cardiomyopathy with preserved
biventricular systolic function. Mild aortic regurgitation.
Moderate mitral regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed on videotape) of
[**2144-5-6**], asymmetric LV hypertrophy pattern is better
appreciated (technically-superior study). The other findings are
similar.
Brief Hospital Course:
NEURO - Briefly observed in the ICU, uncomplicated coarse. The
patient had a virtually unremarkable exam throughout her
hospital stay. She may have displayed a minor limb ataxia on the
left initially, but this has virtually completely recovered. Her
gait ataxia preventer her from being discharged on her birthday,
and she stayed in the hospital for non-neurological reasons as
well, as outlined below. There were no neurological
complications during her stay.
* Etiologically, her CT W&WO CONTRAST did not reveal any
enhancement. An MRI was not pursued given her pacemaker. The
bleed is most likely primary.
CARDIAC - Patient received FFP during admission to correct for
her INR (see HEME). She also received a 500 cc fluid bolus in
the ICU due to perceived orthostasis. She experienced a mild CHF
exacerbation by the time she was back on the floor, which
warranted 10 mg of Lasix. EKG and ECHO (see results) unchanged.
PULM - Saturations ran typically in the lower 90's (91 - 94)
with at times supplemental oxygen. However, she never experieced
any dyspnea nor an increased RR, indicating that the
supplemental oxygen was likely mainly esthetic. Also, she showed
improvement of her sats with ambulation suggesting some
atelectasis in bed. On her CXRs, she had some mild CHF and a
small R basal pleural effusion, the latter may have caused some
RUQ pain. She was encouraged to do incentive spirometry a few
times per hour.
GI - She became constipated, and was started on a more aggresive
bowel regimen. A KUB was unremarkble (see "results"). She
complained of some RUQ pain, and anorexia. An U/S was performed
showing no biliary dilation. It did reveal a 9 mm pancreatic
cyst, coincidental. Extensive review of systems did not reveal
any suggestion of malignancy, but she will need definetely need
follow-up on this.
HEME - She developed an anemia, with Hct lowest values down to
26.6, however, serial measurements showed great fluctuations. At
time of dischartge her Hct was back to her admit values of ~30.
Guiacs were not obtained since there were no BM. Extensive iron
studies, vitamin assays and hemolysis labs were pending at time
of discharge, and can be followed up on as an outpatient.
RENAL - She developed an acute on chronic RF, likely due to IV
contrast for the CT. She peaked at a BUN/Cr of 44/2.0 but at
time of discharge was coming down to 32/1.7.
ID - She was treated with Bactrim for a UTI discovered on
[**2150-6-20**] ([**7-21**] whites, many bact, nitr +), last dose on [**6-22**].
Since she needed only a few more doses when her ARF was
detected, it was finished despite it's potential impact on RF.
Medications on Admission:
Metoprolol 50 mg po BID
Diltiazem XR 120 mg po daily
Digoxin 0.125 mg po daily
Calcium 650 mg [**Hospital1 **]
Coumadin 2.5 mg po QOD alternating with 1.25 mg po QOD
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
4. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day: **
NOTE THAT YOU CAN TAKE YOUR OWN 650 mg TABLETS **.
-- TO BE STARTED AFTER YOU SEE YOUR PCP:
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO every other
day: START SATURDAY THE [**12-4**] ** ALTERNATING WITH 1.25 mg
EVERY OTHER DAY **.
6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO every other day:
START SUNDAY THE [**12-5**] ** ALTERNATING WITH 2.5 mg EVERY
OTHER DAY **.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
1. Cerebellar infarct, hemorrhagic
Secondary:
1. Coronary artery disease
2. Congestive heart failure
3. Atrial fibrillation
4. Chronic kidney disease
Discharge Condition:
Good condition. Mild dysmetria of left arm, gait instability but
sufficiently safe per PT.
Discharge Instructions:
You have been evaluated for a small stroke caused by bleeding in
your brain. This will not significantly impact your daily
functioning. Your Coumadin has been stopped for now.
Specific instructions:
1 Please practice your walking with HOME-PT, as presribed.
2 We have contact[**Name (NI) **] your PCP Dr [**Name (NI) **], and he is aware of
the situation. Please make sure that BEFORE restarting your
Coumadin, you visit him for follow-up. He will also follow-up
with you regarding the pancreatic cyst that was found on the
ultrasound - this likely represents a coincidental finding and
needs to be monitored over time.
Please take all medications as directed. Please keep all
follow-up appointments.
If you have any new headaches, or if you develop dizziness,
double vision, difficulty swallowing, difficulty speaking,
difficulty understanding others, weakness, or numbness, please
call your neurologist or go to the nearest hospital emergency
department.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2150-8-25**] 3:30
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 8725**] to be
seen in [**2-11**] weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2150-6-23**]
ICD9 Codes: 431, 5849, 4254, 5990, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7035
} | Medical Text: Admission Date: [**2146-2-25**] Discharge Date: [**2146-3-3**]
Date of Birth: [**2079-10-11**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Rollover motor vehicle crash
Major Surgical or Invasive Procedure:
[**2146-2-26**]
1. Open reduction, internal fixation of medial distal tibia
fracture with a buttress plate and cortical screws.
2. Open reduction, internal fixation of distal fibular
fracture.
3. Examination under anesthesia with external rotation stress
under fluoroscopy for assessment of mortise and
syndesmosis disruption.
[**2146-2-27**]
1. Inferior vena cavagram.
2. Insertion of inferior vena cava filter.
History of Present Illness:
66F s/p rollover motor vehicle crash reportedly traveling @ 60
mph +airbags +seatbelt ?LOC. Prolonged extraction ~45 mins. GCS
15. Needle thoracotomy @ scene for tension pneumothorax. She was
taken to an area hospital and transferredto [**Hospital1 18**] with multiple
injuries.
Past Medical History:
Non-Insulin Dependent Diabetes Mellitus
HTN,
Hypothyroidism, s/p thyroid surgery
Depression,
Hypercholesterolemia
.
PSH:
Cholecystectomy
Hysterectomy, (endometriosis)
Bilateral knee replacement
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Vitals: 99, 111/59, 18, 99%
General: Sedated, but alert, oriented, responding appropriately
to questions.
Left hand - large open wound to dorsum of hand, extending
horizontally across entire dorsal surface of the hand, with
exposed extensor tendons. Approximately 2-3 cm wide at largest
dimension, by 10 cm long. Radial and ulnar pulses are intact by
palpation and Doppler. Sensation and movement intact to
fingers,
although with extension significantly limited in ring finger.
Cap refill intact, 1-2 seconds.
Pertinent Results:
[**2146-2-25**] 11:35PM GLUCOSE-180* UREA N-17 CREAT-0.8 SODIUM-144
POTASSIUM-4.9 CHLORIDE-111* TOTAL CO2-26 ANION GAP-12
[**2146-2-25**] 11:35PM CALCIUM-7.4* PHOSPHATE-4.4 MAGNESIUM-1.7
[**2146-2-25**] 11:35PM WBC-16.4* RBC-3.91* HGB-11.8* HCT-34.2*
MCV-87 MCH-30.1 MCHC-34.5 RDW-14.1
[**2146-2-25**] 11:35PM PLT COUNT-201
[**2146-2-25**] 11:35PM PT-11.9 PTT-24.2 INR(PT)-1.0
[**2146-2-25**] 06:06PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
IMAGING:
[**2146-2-28**] 12:28 PM CHEST (PORTABLE AP)
Interval removal of left basal chest tube with small
pneumothorax. Persistent left lower lobe atelectasis. Short-term
radiographic follow-up of the small pneumothorax is recommended.
.
[**2146-2-28**] MR CERVICAL SPINE W/O CONTRAST
1. Prevertebral fluid/soft tissue thickening extending from the
atlanto-occipital articulation to the C4 vertebral body with
signal
abnormality involving the interspinous ligaments at C3-4. Slight
anterior step-off of C4 on C5 is likely degenerative in nature.
No cord signal abnormality identified.
2. Minimal degenerative changes of the cervical spine as
described above without evidence of spinal canal or neural
foraminal narrowing at any level.
3. Asymmetric prominence of the left thyroid lobe. Recommend
clinical
correlation.
.
[**2146-2-27**] BILAT LOWER EXT VEINS
Grayscale and color Doppler ultrasounds were performed. There is
a non-occlusive thrombus in the right common femoral veins. The
right common femoral as well as the superficial femoral veins
bilaterally and the popliteal veins bilaterally are unremarkable
and show normal color flow, compressibility and Doppler signal.
IMPRESSION: Non-occlusive clot in the right common femoral
veins.
.
[**2146-2-26**] UGI SGL CONTRAST W/ KUB
No evidence of contrast extravasation along the course of the
esophagus.
.
[**2146-2-25**] HAND (AP, LAT & OBLIQUE) LEFT
Left forearm two views and three views of the left wrist
demonstrate fractures involving the base of the proximal phalanx
of the ring finger and to the third metacarpal head. There is
also a small fracture off the ulnar styloid. There is
irregularity of the radial styloid with suggestion of the small
nondisplaced fracture which exits out the lateral articular
surface, best seen on the oblique view. Degenerative changes of
the first CMC and triscaphe joint are noted. Images of the
forearm demonstrate no fractures in the region of the ulnar
radial shaft or in the region of the elbow.
.
[**2146-2-25**] CHEST (PORTABLE AP)
1. Left-sided chest tube has been pulled back. Subcutaneous
emphysema on that side.
2. Right upper lobe volume loss.
.
[**2146-2-25**] TIB/FIB (AP & LAT) LEFT
Patient is status post left total knee arthroplasty. There are
no signs of hardware-related complications. There is a fracture
dislocation of the ankle with a vertically oriented fracture
through the medial malleolus and a transversely oriented
fracture through the lateral malleolus, 1.5 cm above the
tibiotalar joint. There is abnormal widening of the ankle
mortise suggesting a syndesmotic ligament and injury. Dedicated
images of the left foot show no displaced fractures. The base of
the fifth metatarsal is intact. There is bipartite tibial and
fibular sesamoids.
.
[**2146-2-25**] CT HEAD W/O CONTRAST
1. No fracture or hemorrhage. 2. Large subgaleal hematoma at the
cranial vertex, with numerous skin lacerations.
.
[**2146-2-25**] CT CHEST/ABDOMEN/PELVIS W/CONTRAST
1. Extensive left-sided rib fractures, pneumomediastinum,
subcutaneous emphysema and loculated pneumothorax. 2. Pulmonary
contusion and areas of atelectasis or aspiration. 3.
Malpositioned left chest tube in the posterior mediastinum
between the esophagus and aorta at the level of T9. Removal is
highly recommended given the extreme proximity to the aorta and
heart. 4. Acute pulmonary embolus in left lower lobar artery. 5.
Left transverse process fracture of L1 and possibly L2.
.
[**2146-2-25**] CT C-SPINE W/O CONTRAST
1. No fracture or malalignment.
2. Moderate degenerative change of the cervical spine.
3. Extensive subcutaneous emphysema, and pneumomediastinum
better evaluated on concurrent CT torso. Numerous left-sided rib
fractures, the most displaced being left 9th ribfracture.
Pneumomediastinum, small left pneumothorax, no tension.
Leftlower lobar pulmonary artery somewhat eccentric filling
defect; may represent non-acute pulmonary embolus.
.
Brief Hospital Course:
She was admitted to the Trauma Service. Her head and cervical
spine imaging studies did not reveal any acute injuries. CT
imaging of her chest however revealed an acute pulmonary embolus
in left lower lobar artery; a lower extremity ultrasound was
done to evaluate for thrombus which showed a non-occlusive clot
in the right common femoral veins.
Orthopedics was consulted and she was taken to the operating
room on [**2-26**] for repair of her left ankle bimalleolar fracture
with shear medial tibia fracture. Her weight bearing status on
her left leg is touchdown on the toes only. She will remain in
the splint until follow up in 2 weeks in [**Hospital 5498**] clinic.
On [**2-27**] she was taken back to the OR for an IVC filter
placement. Postoperatively she was taken to the Trauma ICU for
close monitoring.
Plastics was consulted for the open fractures to left hand and
large open dorsal wound. The wound was irrigated extensively;
wound edges approximated with 4-0 Ethilon and Prolene
interrupted sutures. The wound was dressed and splinted. She
will follow up as an outpatient in Plastic's clinic with Dr.
[**First Name (STitle) **]. She is to remain non weight bearing on her left upper
extremity until cleared by Plastics.
She was also evaluated by the Acute Pain service for thoracic
epidural catheter given her multiple rib fractures. Intravenous
Fentanyl was also added. The epidural catheter unfortunately
dislodged and was removed. She was then started on an IV and
oral pain regimen requiring several adjustments. Currently she
is on standing Tylenol and Oxycodone [**9-2**] every 3 hours prn. An
aggressive bowel regimen is in place.
Hematology was consulted for concern re: hypercoagulability
given the pulmonary embolus and DVT found on imaging at time of
admission. It was noted by Hematology that the inferior vena
cava filter offered theoretically sufficient protection against
recurrent pulmonary embolism in the meantime and precludes the
necessity to monitor thrombus migration. Anticoagulation was
indicated for at least 3-6 months. A Heparin drip was started on
[**3-1**] with Coumadin starting on [**3-2**]. Her INR was 1.1 on [**3-3**].
Because she has an IVC filter it was felt by trauma Attending
that she did not require Lovenox as a bridge. Her INR will need
to be checked daily until goal [**12-22**] reached and then at least
2x/week based on need for dose adjustments.
Once hemodynamically stable she was transferred to the regular
nursing unit where she continued to progress. She was able to
tolerate a regular diet. Physical therapy was consulted who
recommended rehab after her acute hospital stay.
Medications on Admission:
ASA 81 mg QD
Simvastatin 40 mg QD
Amitriptyline 75 mg QD
Primidone 50 mg QD
Fluoxetine 40 mg QD
Synthroid 0.125 mg QD
Atenolol 25 mg [**Hospital1 **]
Diovan 160 mg PO BID
Aricept 10 mg QD
Metformin 500 mg PO BID
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Amitriptyline 25 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Primidone 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Goal INR [**12-22**]. Dose adjustments daily based on INR.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3
hours) as needed for pain.
14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) Grams PO DAILY (Daily) as needed for constipation.
15. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose
Subcutaneous four times a day as needed for per sliding scale:
see attached sliding scale.
16. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1122**] Center - [**Hospital1 3597**]
Discharge Diagnosis:
s/p Motor vehicle crash
Pulmonary embolus
Right calf deep vein thrombosis
Left posterior rib fractures [**3-29**]
Left trimalleolar fracture
Left third metacarpal fracture
Left fourth proximal hand phalanx fracture
L1,L2 transverse process fracture
Left pneumothorax
Pneumomediastinum
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:
DO NOT bear any weight on your left hand at all; you may
TOUCHDOWN weight bear on your toes only on your left leg. NO
FULL WEIGHT BEARING AT ALL ON YOUR LEFT LEG.
You were started on blood thinners in the hospital because of
the blood clot in your lung and in your right leg. The
medication is called Coumadin, you will need to have blood drawn
at least 2x/week to make sure that your blood remains thin
enough. The Coumadin dose will need to be adjusted accordingly.
While you are taking this medication your should not take any
aspirin proucts or NSAIDS such as Alleve, Ibuprofen, Naprosyn as
these medication can further increase your chances of bleeding.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma surgery for
evaluation of your rib fractures. You will need an upright end
expiratory chest xray for this appointment. Call [**Telephone/Fax (1) 6429**]
for an appointment.
Follow up in [**Hospital 5498**] clinic in 2 weeks with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 86500**], NP
for your ankle. Call [**Telephone/Fax (1) 1228**] for an appointment.
Your left hand sutures were placed on [**2146-2-25**] and should be
removed on or around [**2146-3-7**]. You may follow up in Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], Plastic Surgery Clinic to have this done. Please call
([**Telephone/Fax (1) 9144**] for an appointment.
Completed by:[**2146-3-3**]
ICD9 Codes: 4019, 2720, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7036
} | Medical Text: Admission Date: [**2182-2-18**] Discharge Date: [**2182-2-28**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
female with a complex medical history who was admitted after
a cardiac arrest on [**2182-2-18**]. She was initially taken to the
CCU, thought to be in congestive heart failure. Subsequently
developed sepsis, acute ARDS, respiratory-cardiopulmonary
failure. On [**2182-2-28**], at 3:15 p.m., the patient was
pronounced dead. Family was at bedside.
Date of death [**2182-2-28**]. Time of death 3:15 p.m.
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 2462**], [**MD Number(1) 2463**]
Dictated By:[**Last Name (NamePattern4) 2464**]
MEDQUIST36
D: [**2182-5-20**] 16:12:18
T: [**2182-5-21**] 01:55:14
Job#: [**Job Number 2465**]
ICD9 Codes: 0389, 4275, 5185, 5849, 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7037
} | Medical Text: Admission Date: [**2200-11-26**] Discharge Date: [**2200-12-1**]
Date of Birth: [**2145-9-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2200-11-26**] - Coronary artery bypass grafting x5.
(LIMA>LAD,SVG>diag Y>OM1,SVG>OM2,SVG>PLB)
History of Present Illness:
55 yo M who presented to his PCP's office in early [**Month (only) **]
[**2200**]
with chest pain and EKG changes. Pt was sent to the ED at
[**Hospital3 1443**], subsequently admitted, and transferred to
[**Hospital1 18**] for cardiac catheterization which revealed severe three
vessel coronary artery disease. Surgery was delayed secondary to
persistent fevers. He was found to C. Diff and was treated with
flagyl. Workup at that time was also notable for multiple
pulmonary emboli and he has been placed on lovenox until his
surgery. He returns today for evaluation and rescheduling of
surgery. He has felt very well since discharge and denies any
symptoms of fever, chest pain or dyspnea.
Past Medical History:
Coronary Artery Disease, Ischemic Cardiomyopathy
Hypertension
Hyperlipidemia
History of MI 6 years ago
Pulmonary Emboli
Social History:
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Works as a cook.
Family History:
Father died at 69 with MI, mother died at 72 from MI.
Physical Exam:
Pulse:58SB Resp:18 O2 sat: 99%
B/P Right: 148/76 Left:140/70
Height:5'5" Weight:81.6 kg, 180 lbs
General: middle aged male in no acute distress
Skin: Dry [x] intact [x]. Healed burn on L hand, no surrounding
erythema, a few maculopapular lesions/petechiae in R and L
antecubital fossae. A few erythematous small (1-2mm) papules on
R
anterior chest.Blanching erythematous patch mid sternal line.
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] No Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]
Neuro: Grossly intact
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: none
Discharge:
VS: T: 98.0 HR: 62 SR BP: 120/70 Sats: 95% RA
General: sitting in chair no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR normal S1,S2 no murmur
Resp: bilateral crackles 1/4 up otherwise clear
GI: benign
Extr: warm tr edema
Incision: sternal and LLE clean dry intact
Neuro: non-focal
Pertinent Results:
[**2200-11-26**] ECHO
PRE-BYPASS: No atrial septal defect is seen by 2D or color
Doppler. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
anterior, anteroseptal and apical hypokinesis. Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen. Mild to moderate
([**2-14**]+) mitral regurgitation is seen. A very eccentric posterior
directed MR was seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is in
sinus rhythm
1. Biventricular function is normal
2. Eccentric MR still present
3. Aorta is unchanged post decannulation
4. Other findings are unchanged
[**2200-11-27**] BC-17.0* RBC-3.27* Hgb-9.7* Hct-28.2 lt Ct-211
[**2200-11-26**] WBC-12.4*# RBC-2.92*# Hgb-8.8*# Hct-25.4* Pt [**Name (NI) **]188
[**2200-11-30**] PT-15.9* INR(PT)-1.4* [**2200-11-29**] PT-14.6* PTT-29.7
INR(PT)-1.3*
[**2200-11-28**] PT-14.4* INR(PT)-1.2* [**2200-11-26**] PT-16.6* PTT-35.3*
INR(PT)-1.4*
[**2200-11-29**] Glucose-97 UreaN-22* Creat-1.2 Na-142 K-4.4 Cl-103
HCO3-30 Mg-2.1
CXR [**2200-11-29**]: Marked cardiomegaly is unchanged. Postoperative
mediastinal widening is stable. There is no pneumothorax. Small
bilateral pleural effusions are associated with adjacent
bibasilar atelectases. Standard wires are aligned. Patient is
post CABG. Small left pneumothorax has decreased in size. There
is mild vascular congestion.
[**2200-11-29**] 07:10AM BLOOD WBC-13.4* RBC-3.02* Hgb-8.9* Hct-27.1*
MCV-90 MCH-29.6 MCHC-33.0 RDW-15.7* Plt Ct-190
[**2200-11-26**] 03:40PM BLOOD WBC-12.4*# RBC-2.92*# Hgb-8.8*#
Hct-25.4*# MCV-87 MCH-30.2 MCHC-34.8 RDW-15.4 Plt Ct-188
[**2200-12-1**] 06:05AM BLOOD PT-17.4* INR(PT)-1.6*
[**2200-11-26**] 03:40PM BLOOD PT-16.6* PTT-35.3* INR(PT)-1.4*
[**2200-11-29**] 07:10AM BLOOD Glucose-97 UreaN-22* Creat-1.2 Na-142
K-4.4 Cl-103 HCO3-30 AnGap-13
[**2200-11-27**] 01:57AM BLOOD Glucose-111* UreaN-10 Creat-0.9 Na-140
K-3.8 Cl-109* HCO3-26 AnGap-9
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2200-11-26**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to five vessels(Left Internal Mammary Artery >Left
Anterior Descending artery ,Saphenous Vein Grafted >diag
Y>Obtuse Marginal 1,>OM2,SVG>PLB). Please refer to Dr[**Last Name (STitle) **]
operative report for further details. Postoperatively he was
transferred to the intensive care unit for monitoring. Over the
next several hours, he awoke neurologically intact and was
extubated. Beta blockade, aspirin and a statin were resumed.All
lines and drains were discontinued in a timely fashion. On
postoperative day one, he was transferred to the step down unit
for further recovery. He was gently diuresed towards his
preoperative weight. His electrolytes were repleted as needed.
He was started on Coumadin for a history of PE. On POD2 he
experienced rapid atrial fibrillation converted to sinus rhythm
with amiodarone IV converted to PO. The ACE was restarted.
Physical therapy was consulted for evaluation of increasing
mobility and strength and cleared him for discharge to home.
POD4 he had a brief episode of atrial fibrillation with
spontaneous conversion to sinus rhythm. The remainder of his
postoperative course was essentially uneventful. He continued to
progress and was cleared by Dr.[**Last Name (STitle) **] for discharge to home
with VNA on POD# 5. Dr.[**Last Name (STitle) 5686**] will follow the Coumadin
dosing, with first INR draw to be done on Thurs. [**12-4**]. All
follow up appointments were advised.
Medications on Admission:
Lovenox 70", Lisinopril 20', Lopressor 150", Simvastatin 80',
ASA 325', Colace 100'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Carvedilol 6.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: then 200 mg daily.
Disp:*60 Tablet(s)* Refills:*1*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: INR Goal 2.0-3.0.
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 5 days.
Disp:*5 Tablet Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p CABG
Ischemic Cardiomyopathy
Hypertension
Hyperlipidemia
History of MI 6 years ago
Pulmonary Emboli
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
-Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
-Please follow-up Dr. [**Last Name (STitle) 5686**] in [**3-18**] weeks.
***-Coumadin dosing/INR draws will be followed by Dr.
[**Last Name (STitle) 5686**], first INR draw to be done via VNA on Thursday
[**12-4**], with results called to Dr.[**Last Name (STitle) 5686**] #[**Telephone/Fax (1) 11554**].
Completed by:[**2200-12-1**]
ICD9 Codes: 4111, 9971, 412, 4280, 2859, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7038
} | Medical Text: Admission Date: [**2114-11-9**] Discharge Date: [**2114-12-6**]
Date of Birth: [**2061-11-17**] Sex: F
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy
History of Present Illness:
Patient intubated and history is per report and record review.
Ms. [**Known lastname **] is a 52-year-old female with ALL s/p chemo and single
cord blood transplantation complicated by CMV viremia,
streptococcal bacteremia, VRE UTI, and suspected GVHD-induced
hepatitis who presents with fever and productive cough. The
cough started 3 weeks ago and has been productive of green
sputum, and associated with mild shortness of breath,
nausea/vomiting (attributed to Gleevec), and fatigue. She saw
her oncologist on [**2114-11-6**] for a followup, was afebrile with O2
sat 91,RA, and was noted to have a WBC of 11.2. She was started
on azithromycin and advised to return to clinic in 3 days.
Today, she noted difficulty breathing and fevers/chills/night
sweats, as well as cough, with symptoms worse the past two days.
She also reports anorexia and [**7-1**]# wt loss. Her O2 sat was noted
to be 86 on RA, improving to 95 on 3L NC. Blood cultures and flu
swab were obtained and she was referred to the ED.
.
In the ED, her initial vitals were: 99.5 88 120/76 28 96% on 5L
NC. On exam, she was dry with diminished breath sounds and right
sided crackles, and tachycardia. A CT of the chest was ordered
looking for possible PCP and showed evidence of infection with
multifocal airspace opacities. She was started on vancomycin and
aztreonam, in addition to continuing her current azithromycin.
While in the ED, her respiratory status worsened, becoming more
tachypneic and hypoxic requiring intubation. Her recent vitals
(prior to intubation) show RR 32, HR 124, 127/83 and O2 sat of
76,RA -> 96,3L. She received 4L IVF in the ED. Cannot perform
ROS as pt is intubated and sedated.
Past Medical History:
ONCOLOGIC HISTORY
====================
Diagnosed with [**Location (un) 5622**] Chromosome positive pre-B cell ALL
in [**2113-11-25**]
- [**2113-12-13**]: Part A of hyperCVAD cycle 1 was started on and
imantinib 600mg po qdaily was started on [**2113-12-21**] when the Ph
chromosome came back as positive.
- [**2113-12-22**]: First LP performed by IR and cytarabine was
administered. Fluid non-diagnostic but as high suspicion for CSF
disease started on twice weekly methotrexate
---[**2113-12-28**]: CSF sample from confirmed CNS involvement of ALL
---[**2115-1-1**] CSF sample from was negative for ALL so IT MTX
discontinued
- [**2114-1-17**]: Part B hyperCVAD of cycle 1 was started (IT chemo
was
limited to D6 ara-C on [**2114-1-22**] to minimize neurotoxicity)
- [**2114-2-2**]: Cycle 2 (Part A) of hyperCVAD started
- [**2114-3-5**]: Cycle 2 (Part B) hyperCVAD chemotherapy started
- [**2114-4-5**]: IT MTX administered
OTHER PAST MEDICAL HISTORY
============================
- Latent tuberculosis: PPD with 12mm of induration in [**2111**] at
[**Hospital1 2177**] after which received [**1-26**] mos of INH discontinued due to
transaminitis, she has been on moxifloxacin suppression since
starting chemotherapy
-Hypertension
-Hyperlipidemia
-Diabetes Mellitus (not on medications)
-Vitamin D deficiency
- Hepatitis B Ab positive (core +), maintained on lamuvidine
Social History:
She is Mandarin-speaking only and immigrated from [**Country 651**] in [**2100**].
She previously worked in customer service. She denies any
history of tobacco, alcohol, or illicit drugs. She's married.
Family History:
There is no family history of cancer or blood disorders that she
is aware of.
Physical Exam:
GENERAL: Intubated, initially responsive to verbal stimuli, but
sedation increased for agitation.
HEENT: Pupils are equal and minimally reactive to light. ETT in
place.
LUNGS: R lung fields with diffuse crackles. L side clear.
HEART: RRR no M/R/G
ABDOMEN: + BS. Soft, nontender, nondistended with no
hepatosplenomegaly. There are no palpable masses.
EXTREMITIES: There is no edema. 2+ peripheral pulses. Moves all
ext spontaneously.
SKIN: No rashes. The skin is warm and dry.
Pertinent Results:
Admission Labs:
[**2114-11-9**] 01:37PM LACTATE-1.5
[**2114-11-9**] 09:15AM GLUCOSE-156* UREA N-17 CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-22 ANION GAP-17
[**2114-11-9**] 09:15AM ALT(SGPT)-24 AST(SGOT)-27 LD(LDH)-349* ALK
PHOS-189* TOT BILI-0.8
[**2114-11-9**] 09:15AM WBC-13.5* RBC-2.96* HGB-10.0* HCT-29.7*
MCV-101* MCH-33.8* MCHC-33.6 RDW-13.9
[**2114-11-9**] 09:15AM NEUTS-68.1 LYMPHS-17.8* MONOS-13.3* EOS-0.5
BASOS-0.3
Discharge Labs:
Radiology:
CT Chest w/o contrast:
IMPRESSION: New-onset airspace opacification with air
bronchograms of the
right upper lobes, lower lobes and middle portion of the right
middle lobe
with patchy diffusely distributed opacification in the left lung
with an
associated right pleural effusion, suggests the possibility of
an infectious process, such as multifocal bacterial pneumonia.
However, considering the patient's clinical history of recent
bone marrow transplantation, an atypical pneumonia must be
included in the differential diagnosis (fungal, mycobacterial,
viral organisms). Pulmonary edema and pulmonary hemorrhage are
less likely, as the patient's history does not have
corroborating symptoms for the same.
TTE:The left atrium is normal in size. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
Brief Hospital Course:
ASSESSMENT AND PLAN: 52-year-old female with ALL s/p chemo and
single cord blood transplantation complicated by CMV viremia,
streptococcal bacteremia, VRE UTI, and suspected GVHD-induced
hepatitis who presents with pneumonia/sepsis and respiratory
failure.
.
# Respiratory failure:
Consistent with ARDS in setting on severe PNA. Very large A-a
gradient on admission. Placed on ARDS-NET protocol.
Nasopharyngeal aspirate for influenza was negative, and flu
cultures were negative. TB was ruled out with negative BAL,
despite patient's history of latent TB. Sputum cultures did not
show any bacteria. On Bronchoscopy, nothing significant was
visualized in the airways. BAL was negative for PCP; there was
some concern that inhaled pentamidine could make a BAL appear
falsely negative and diagnosis could require a tissue biopsy,
but the beta-glucan was also negative, which was reassuring for
rule out of PCP. [**Name10 (NameIs) **] patient had been started empirically on
treatment doses of bactrim for PCP until the first beta-glucan
returned negative. She was restarted on prophylactic doses of
bactrim, per BMT recommendations. Since her LFTs were beginning
to rise, bactrim was discontinued, as she has a history of
elevated LFTs in the setting of this medication.
.
Cardiac causes of respiratory failure were considered, but a TTE
showed hyperdynamic function with LVEF> 55%, mild pulm htn,
trivial pericardial effusion, and no valvular disease, so this
was not likely to cause a compromise in respiratory function.
.
The patient was very difficult to oxygenate for much of her ICU
stay. She was often desynchronous with the ventilator, often
over-breathing the ventilator on volume control but not able to
tolerate pressure control or pressure support ventilation
modalities intitially. Eventually, she was able to tolerate AC
settings with increased sedation, and only brief trials on
pressure support with less sedation. She would often desaturate
with positional changes, likely also had some mucus plugging.
Multiple attempts to wean down PEEP were unsuccessful as she
would desaturate. Muscle paralytics had to be emploted to assure
syncronized ventilation.
On [**11-25**], the patient was switched to Airway Pressure Release
Ventilation (APRV). This resulted in increased sats to ~93%, but
unable to wean FiO2 down from 100%. The patient was placed on a
RotaProne bed. Pronation resulted in some shortterm improvement
in saturation with the ability to wean oxygen to FiO2 of 80%.
On [**11-28**], the patient was switched to Triadyne II bed and was
continued on APRV. Nitric oxide was used as well with some
modest improvement in oxygenation.
On [**11-29**], the patient became hypotensive with SBP in 70s. The
patient desatted to low 70s/high 60s with IV bolus. The patient
was repositioned patient on left side and noticed decreased
breath sounds on left in new position. Adjusted ventilator
settings and started nitric oxide with no improvement in
oxygenation. Got stat CXR which showed large left pneumothorax.
Chest tube was immediately placed with vital signs improved
immediately upon chest tube placement. FiO2 was weaned to 90%.
On [**12-3**], the patient developed massive upper GI bleed. EGD was
performed at bedside which revealed massive amounts of clotted
blood in the fundus of the stomach, but no clear eveidence of
active bleed. The patient was started on IV PPI and was given
multiple blood products including pRBCs and FFP. The patient's
oxygenation worsened, and she continued to desat on FIO2 of 100%
and maximum nitric oxide. Given clinical deterioration,
extensive discussion was held with the patient's husband and
family about goals of care and a decision was made about no
further escalation in care, including no blood products or lab
draws. The patient expired the following day.
.
# Septic shock:
The patient was hypotensive requiring levophed and vasopressin
initially, likely due to septic shock secondary to multifocal
PNA, as seen on CT chest. Levophed was weaned down [**11-11**] and
vasopressin was stopped [**11-13**]. There was a wide differential
given her immunosuppression which included usual pathogens
(Strep, etc), viral (flu, CMV), PCP (esp with elev LDH),
atypicals. She was started empirically on broad antibiotic
coverage with vancomycin, aztreonam, and azithromycin. The
aztreonam was broadened to meropenem on [**11-12**] per ID
recommendations.
On admission, she was empirically started on PCP treatment doses
of bactrim and stress dose steroids with IV hydrocortisone. She
was also empirically started on oseltamivir for flu coverage
which was discontinued on the fifth day of treatment due to a
negative flu culture. The urine legionella antigen was negative,
and the patient did not grow any bacteria from her urine or
blood cultures. Once the beta-glucan was negative, the
treatment doses of bactrim for PCP were discontinued;
prophylactic doses re-started on [**11-18**] per BMT recommendations.
Serum beta-glucan and beta-galactomannan were negative on
multple occasions.
Patient was fluid overloaded after initial fluid resusciation.
Her urine output at times was low likely due to hypotension and
a component of ATN. She was given IVFs and albumin
intermittently. Urine output picked up successfully with fluids
and increases in blood pressure. After vasopressin was stopped,
she was diuresed on a lasix drip with successful output.
On [**11-24**], an inverse correlation between fever curves and
Bactrim use was found and Bactrim was re-started again. IVIG
was administered. On [**11-29**], mild CMV viremia (VL 1000) was
detected. Metropenem was discontinued on [**11-29**] per ID recs.
#Non-gap acidosis: Related to normal saline and a component of
renal failure. As renal failure improved and normal saline was
stopped, her acidosis stabilized. During her lasix drip
administration, the patient developed a metabolic contraction
alkalosis. She was started on acetazolamide.
#Ileus: Due to the high dose of fentanyl patient received, it
appeared she developed an ileus. An extensive bowel regimen plus
PO narcan alleviated her symptoms.
.
# ALL: On chronic immunosuppression s/p single cord blood
transplantation. Was not neutropenic. She was continued on
acyclovir for prophylaxis, and her tacrolimus was discontinued.
She was started on stress dose steroids of hydrocortisone 100mg
IV Q8hours; when the stress dose steroids were tapered down
slowly, the patient seemed to make less progress with her
respiratory status, so her steroid dose was increased back.
.
# Anemia: The patient intermittently needed blood transfusions
due to low Hematocrits. She received 2 units prbcs from
admission to the ICU to [**2114-11-16**]. Her anemia is likely due to
her CA, anemia of chronic inflammation and the daily blood draws
that were needed during her ICU course.
.
# Hep B: The patient was continued on lamivudine. A hep B viral
load was sent [**11-15**] and no DNA could be detected.
.
Medications on Admission:
ACYCLOVIR - 400 mg TID
AMLODIPINE - 5 mg daily
Azithromycin 500mg, then 250mg daily x5 days total, started
[**2114-11-6**]
IMATINIB 100mg daily (on hold)
LAMIVUDINE - 100 mg daily
LORAZEPAM - 0.5 mg Tablet - [**1-26**] Tablet(s) by mouth every six (6)
hours
OMEPRAZOLE - 20 mg Capsule daily
PENTAMIDINE [NEBUPENT] - (received in IP) - 300 mg Recon Soln -
1 ihnalation(s) po monthly received on [**11-6**]
PREDNISONE - 5 mg tablet daily
TACROLIMUS [PROGRAF] - 0.5 mg qAM (decreased from [**Hospital1 **] on
[**2114-11-6**])
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 WITH D] - 500 mg
(1,250
mg)-400 unit Tablet - 2 tabs daily
PYRIDOXINE - 100 mg Tablet two times per week
SENNA - 8.6 mg Tablet - [**1-26**] Tablet prn constipation
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2115-8-5**]
ICD9 Codes: 0389, 486, 5845, 2760, 2761, 2875, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7039
} | Medical Text: Admission Date: [**2134-9-30**] Discharge Date: [**2134-10-5**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
DKA.
Major Surgical or Invasive Procedure:
Right inguinal CVC placement [**9-30**]
History of Present Illness:
Ms. [**Known lastname 18741**] is a 55 year-old woman with DMI, severe
gastroparesis, HTN, Grave's Disease and Hepatitis C who
presented to the ED [**9-30**] with hyperglycemia. She has had
multiple admissions to [**Hospital1 18**] for DKA, most recently discharged
[**2134-8-11**]. She initially c/o fevers, dysuria, thirst, and
nausea and [**Year (4 digits) **]. PTA her blood glucose readings were
300-600. She had no cough or sputum production. She did have one
episode of diarrhea. She also is bothered by chronic lower leg
and back pain, both of which also prompted her ED presentation.
She reports some mild abdominal pain which is typical for her
when she has DKA. She reports she has been compliant with taking
her Lantus and sliding scale.
In the ED, her initial vital signs were: temperature of 98.8,
blood pressure of 124/65, heart rate of 95, respiratory rate of
20, and oxygen saturation of 98% on RA. A finger stick glucose
was critically high at triage. The ED team had a difficult time
obtaining access, so a right femoral central line was placed.
She was started on an insulin drip at 7 units per hour and she
was started on intravenous fluids, on her first liter at time of
transfer.
In the ICU she was transitioned off the insulin gtt, back to
bolus insulin [**10-1**]. She was given 6L IVF. Her nausea improved.
She had no clear infctious etiology, with clear urine, so was
given 1 dose of cipro but this was stopped. She was thought to
have a viral syndrome as etiology of her DKA.
Currently she feels generally unwell, with global achiness, but
overall improved from admission. She continues to have dysuria
despite negative UA/CX. She has a dry cough but no shortness of
breath. She c/o bilateral lower back pain, which is not normal
for her and started prior to admission. She has not been out of
bed since admission.
ROS: 10 point review of systems negative except as noted above.
Past Medical History:
1. DM Type 1: Years w/ DM: 5 Age of Diag: 48 Year Diag: [**2127**].
Several episodes of DKA, managed on 28U Lantus [**Hospital1 **] plus HISS
2. Diabetic polyneuropathy and gastroparesis
3. Hypertension
4. Grave's disease s/p RAI [**2129**]
5. Reactive airway disease
6. Seronegative arthritis, followed in rheumatology
7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
never been on antiviral therapy, acquired via blood transfusion
during surgery in [**2110**]
8. GERD
9. Migraines
10. Bilateral knee arthroscopy in [**5-24**]
11. s/p TAH and pelvic floor surgery with bladder lift
12. Depression
13. Bone spurs in feet
14. Bilateral foot drop requiring wheelchair use
Social History:
Patient lives in a multi apartment building in the same
apartment with a daughter, grandaughter, and grandson. She has a
son, daughter and another brother who live on another floor. She
is a never smoker and does not use alcohol or drugs. She has not
worked for many years. She uses a wheelchair at baseline.
Family History:
Her mother died of colon cancer. There are multiple family
members with DM
Physical Exam:
VS: T 98.1 HR 91 BP 107/58 RR 11 Sat 99% RA; BG 308 (1700), 219
(2100)
Gen: Well appearing woman in NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light (2.5mm->2mm), sclera anicteric, not injected,
no exudates
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
Extremities: Trace pedal edema bilaterally, no cyanosis,
clubbing, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, speech fluent
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
Admission labs:
WBc 5.6 hct 36.5, hgb 10.9, plt 389->25.2.
BMP: 125/5.7/89/18/20/1.3
UA: negative
ECG [**9-30**]: NSR (96), nl axis/intervals, no acute ST-T changes.
CXR [**9-30**]: Normal chest radiograph.
[**2134-10-5**] 07:00AM BLOOD WBC-4.8 RBC-3.48* Hgb-9.3* Hct-30.1*
MCV-87 MCH-26.8* MCHC-30.9* RDW-15.7* Plt Ct-272
[**2134-10-5**] 07:00AM BLOOD Glucose-232* UreaN-15 Creat-0.8 Na-131*
K-4.3 Cl-99 HCO3-28 AnGap-8
[**2134-10-5**] 07:00AM BLOOD Phos-3.7 Mg-1.7
[**2134-10-2**] 05:37AM BLOOD TSH-0.54
[**2134-10-1**] 08:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2134-10-1**] 08:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2134-10-1**] 10:42AM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-1
Micro:
[**2134-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2134-10-1**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2134-10-1**] URINE URINE CULTURE-FINAL INPATIENT
Brief Hospital Course:
55 year old female with type 1 diabetes mellitus with many
admissions for DKA, who presented with DKA.
1. Diabetic Ketoacidosis, type I DM with complications: Patient
has history of many admissions for DKA. It is not entirely
clear what prompted this episode, likely viral syndrome as no
evidence of UTI, pulmonary infection, no evidence of cardiac
ischemia. Patient improved with IV fluids, and insulin. Pt
initially received insulin drip, converted to SQ insulin, with
fair control. At time of discharge, glucose 100-259; but
generally in mid to high 100's. Pt was returned to her home
insulin regimen, and will follow up with [**Last Name (un) **] the day
following discharge.
2. Global achiness: suspect viral syndrome as no clear evidence
of other infection. Pt also with some localization to
sacroiliac joints bilaterally. Pt was briefly given tramadol to
treat pain, but this was not continued at discharge.
3. Hypertension: continued losartan, well-controlled.
4. [**Doctor Last Name 933**] disease: TSH 0.54. Methimazole continued at home dose.
5. Asthma: Asymptomatic.
- Contiued home medications
6. Anemia: Normocytic. Near baseline.
7. GERD: Continued protonix
8. Depression, anxiety: Continue amitriptyline and diazepam
9. Chronic pain: Continue home regimen of percocet, neurontin,
amitriptyline. Briefly treated with Tramadol as well, not
continued at discharge.
10. Seronegative arthritis: continued sulfasalazine.
Dispo: to home. F/u with [**Last Name (un) **] as outpt.
Medications on Admission:
At home:
- Amitriptyline 25 mg
- Cozaar 50 mg
- Diazepam 5 mg [**Hospital1 **]
- Colace 100 mg
- Flovent
- Humalog sliding scale TID
- Lantus 28 units [**Hospital1 **]
- Naprosyn 500 mg [**Hospital1 **]
- Neurontin 900 mg TID
- Percocet q6H PRN Pain
- Protonix 40 mg daily
- Reglan 10 mg daily
- Singulair 10 mg daily
- Serevent diskus
- Sulfasalazine 1000 mg [**Hospital1 **]
- Tapazole 10 mg TID
- Zocor 10 mg
- Zomig 2.5 mg
- ASA 81 mg
On transfer:
Amitriptyline 25 mg PO HS
Metoclopramide 10 mg PO QIDACHS
Aspirin 81 mg PO DAILY
Methimazole 10 mg PO TID
Diazepam 5 mg PO BID
Montelukast Sodium 10 mg PO DAILY
Docusate Sodium 100 mg PO BID
Oxycodone-Acetaminophen 1 TAB PO Q6H:PRN pain
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Pantoprazole 40 mg PO Q24H
Gabapentin 600 mg PO TID
Heparin 5000 UNIT SC TID
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose:
Glargine 28units, humalog sliding scale
Simvastatin 10 mg PO DAILY
Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Diazepam 5 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. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Insulin Glargine 100 unit/mL Solution Sig: as dir units
Subcutaneous twice a day: 28 units [**Hospital1 **].
7. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
13. Sulfasalazine 500 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
14. Methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
15. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Zomig 2.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for headache.
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. Humalog 100 unit/mL Solution Sig: as dir units Subcutaneous
as dir: Insulin SC Fixed Dose Orders
Breakfast Bedtime
Glargine 28 Units Glargine 28 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL [**1-22**] amp D50 [**1-22**] amp D50 [**1-22**] amp D50 [**1-22**] amp D50
71-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-180 mg/dL 5 Units 5 Units 5 Units 0 Units
181-240 mg/dL 7 Units 7 Units 7 Units 0 Units
241-300 mg/dL 9 Units 9 Units 9 Units 2 Units
301-360 mg/dL 11 Units 11 Units 11 Units 3 Units
361-420 mg/dL 13 Units 13 Units 13 Units 4 Units
421-480 mg/dL 15 Units 15 Units 15 Units 5 Units
481-540 mg/dL 17 Units 17 Units 17 Units 6 Units
>541 mg/dL 19 Units 19 Units 19 Units 7 Units
.
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
# Diabetic Ketoacidosis
# Type I diabetes, poorly controlled, with complications
# Sacroilitis
# Hypertension
# [**Doctor Last Name 933**] disease
# Chronic pain syndrome; peripheral neuropathy
Discharge Condition:
stable
Discharge Instructions:
You were admitted with another episode of DKA. You were
provided IV fluids and insulin to improve your glucose control.
You have been converted back to your previous home insulin
regimen. Please follow up with your [**Last Name (un) **] appointment
tomorrow.
Please seek medical attention if you develop nausea, [**Last Name (un) **],
persistent poor glucose control, fevers, chills, or any other
concern.
Followup Instructions:
Please follow up with your [**Last Name (un) **] appointment tomorrow.
Please follow up with your primary care doctor within the next
several weeks.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2134-10-19**] 9:15
ICD9 Codes: 5849, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7040
} | Medical Text: Admission Date: [**2130-6-24**] Discharge Date: [**2130-7-14**]
Date of Birth: [**2048-11-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Ciprofloxacin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain, Palpitations
Major Surgical or Invasive Procedure:
-Aortic valve replacement with a 21 mm [**Doctor Last Name **]
pericardial tissue valve, model number 3300 TFX.
-Coronary artery bypass grafting x1 with the saphenous
vein graft to the right coronary artery.
History of Present Illness:
Pt is an 81 y/o F with PMHx significant for HTN, DM, Afib,
asthma, and aortic stenosis who is being transferred from [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 4117**] for further management of her critical aortic stenosis.
She initially presented to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4117**] on [**2130-6-21**] with chest
pain ("heaviness"), palpitations, lightheadedness, headache, and
diaphoresis. She also experienced left hand numbness at that
time. On presentation, she was noted to be afebrile with a HR in
the 80's. She underwent an echo, which showed critical AS ([**Location (un) 109**]
0.6 cm2, gradient of 73 mmHg), moderate pHTN,and LVEF was 60%.
Cardiac surgery was consulted for surgical correction.
Past Medical History:
- Aortic stenosis
- HTN
- Chronic Back Pain
- GERD
- DM
- Anxiety
- Depression
- Afib on coumadin
- Hemorrhoids
- ?Asthma
- Epistaxis
- S/p Appendectomy
- S/p Hysterectomy
- S/p Cataract Sx
- Several episodes of bursitis
- 2 sinus surgeries
- Knee surgery, unspecified
Social History:
Lives alone. Has a homemaker that helps around the appt;
daughter in law visits frequently. No alcohol. Remote tobacco
use (quit 30 years ago). Worked at [**Company 2676**] in electronics.
Family History:
Breast cancer in mother. [**Name (NI) 3495**] dz and DM in siblings.
Physical Exam:
(Admission Exam)
VS - T 97.6, BP 124/59, HR 66, RR 18, 95% on RA, FS 156
GENERAL - 81 y/o F in NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM
NECK - supple, no JVD, AS murmur radiating to carotids
CV: Irregular, rate ~80s, 3/6 systolic murmur with
LUNGS - CTA bilaterally, non-labored respirations, no accessory
muscle use, good air movement
ABDOMEN - BS present, soft, NT/ND, no masses or HSM
EXTREMITIES - WWP, ankles appear full but no pitting edema, 2+
DP pulses
SKIN - No rashes or lesions noted
Pertinent Results:
[**2130-7-13**] 07:10AM BLOOD WBC-18.8* RBC-3.95*# Hgb-10.5*#
Hct-31.1*# MCV-79* MCH-26.7* MCHC-33.9 RDW-18.1* Plt Ct-335
[**2130-6-25**] 05:30AM BLOOD WBC-13.8* RBC-4.42 Hgb-10.5* Hct-33.6*
MCV-76* MCH-23.8* MCHC-31.3 RDW-17.7* Plt Ct-367
[**2130-7-13**] 07:10AM BLOOD PT-12.4 INR(PT)-1.0
[**2130-6-25**] 05:30AM BLOOD PT-21.4* PTT-26.5 INR(PT)-2.0*
[**2130-7-13**] 07:10AM BLOOD Glucose-163* UreaN-26* Creat-1.2* Na-131*
K-3.8 Cl-92* HCO3-30 AnGap-13
[**2130-6-25**] 05:30AM BLOOD Glucose-129* UreaN-24* Creat-1.1 Na-140
K-4.8 Cl-100 HCO3-34* AnGap-11
[**2130-7-1**] 07:20AM BLOOD ALT-20 AST-31 LD(LDH)-287* AlkPhos-115*
TotBili-0.3
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 80274**]
(Complete) Done [**2130-7-10**] at 10:45:59 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2048-11-26**]
Age (years): 81 F Hgt (in): 64
BP (mm Hg): 120/60 Wgt (lb): 184
HR (bpm): 60 BSA (m2): 1.89 m2
Indication: aortic valve stenosis
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2130-7-10**] at 10:45 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 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: 4.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *42 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 28 mm Hg
Aortic Valve - LVOT diam: 1.8 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Moderate to severe spontaneous echo contrast in the
body of the LA. Depressed LAA emptying velocity (<0.2m/s) Cannot
exclude LAA thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Normal
aortic arch diameter. Focal calcifications in aortic arch.
AORTIC VALVE: Moderately thickened aortic valve leaflets.
Critical AS (area <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The rhythm appears to be atrial fibrillation.
patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. The left atrial appendage emptying velocity
is depressed (<0.2m/s). A left atrial appendage thrombus cannot
be excluded. 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%).
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
complex atheromas seen in the thoracic descending aorta.
The aortic valve leaflets (3) are moderately thickened. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Dr..[**Doctor Last Name **] was notified in person of the results on Mrs. [**Known lastname 303**]
before surgical incision.
POST-BYPASS:
Normal RV systolic function.
LVEF 50%. No regional wall motion abnormalities.
Intact thoracic aorta.
Minimal MR.
The aortic b ioprosthesis is intact and functioning well.
Residual mean gradient is 12 mm of Hg.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2130-7-12**] 11:36
Brief Hospital Course:
81 y/o F with PMHx significant for HTN, DM, chronic Afib-on
Coumadin, asthma, and aortic stenosis who was transferred to
[**Hospital1 18**] for further management of her critical aortic stenosis.
She underwent preoperative testing which included cardiac
catheterization. This was complicated by postprocedure
pseudoanuerysm that was corrected with thrombin injection by IR.
In addition, a right apical neural sheath tumor was found
incidentally during pre-operative evaluation. Neurosurgery team
was consulted and believed changes to be chronic in nature with
no need to delay AVR/CABG. Patient will undergo MRI as an
outpatient with follow up with Dr. [**Last Name (STitle) 739**].
Ms.[**Known lastname 80275**] preoperative chest CT also revealed hepatic
fibrosis,and hepatology was consulted for evaluation, management
and recommendations before surgery for AVR. No intervention was
required.
[**Last Name (un) **] was also consulted preoperatively for glucose control
recommendations, and followed postoperatively as well.
On [**2130-7-10**] Ms.[**Known lastname **] was taken to the operating room and
underwent an Aortic valve replacement with a 21 mm [**Doctor Last Name **]
pericardial tissue valve, model number 3300 TFX/Coronary artery
bypass grafting x1 with the saphenous vein grafted to the right
coronary artery. Please refer to Dr[**Doctor Last Name **] operative report for
further details. She tolerated the procedure well and was
transferred to the CVICU for further invasive monitoring. She
was intubated and sedated, requiring Propofol and Phenylephrine.
She awoke neurologically intact and was extubated
postoperatively without incident. All lines and drains were
discontinued in a timely fashion. She weaned off pressors and
Beta-blocker/Statin/Aspirin, and diuresis was initiated. POD#2
she was transferred to the floor for further monitoring.
Anticoagulation was resumed with Coumadin for her chronic Atrial
fibrillation.
Physical Therapy was consulted for evaluation of strength and
mobility. The remainder of her postoperative course was
essentially uneventful. On POD#4 she was cleared by Dr.[**Last Name (STitle) **] for
discharge to [**Hospital 38**] Rehabilitation in [**Location (un) 1110**]. All follow up
appointments were advised.
Medications on Admission:
- Lantus 20 units qAM, 60 units qHS
- Advair 250/50 1 puff [**Hospital1 **]
- Metformin 500 mg [**Hospital1 **]
- Restoril 30 mg qHS
- Zoloft 100 mg daily
- HCTZ 25 mg daily
- Lisinopril 10 mg daily
- Ativan 1 mg HS
- Digoxin 0.125 mg daily
- Neurontin 600 mg qHS
- Toprol XL 50 mg TID
- Colace
- Senna
- Prevacid 30 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHS (once a
day (at bedtime)): home dose 600mg qhs.
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
14. Warfarin 1 mg Tablet Sig: as directed for Afib Tablet PO
Once Daily at 4 PM: goal INR 2.0-2.5.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: check BMP in 2 days - if elevated may need to chnage to
diamox until at pre-op weight.
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days: while on lasix.
17. Lantus 100 unit/mL Solution Sig: Fifty (50) units SQ
Subcutaneous once a day: Usual dose is 20 units qam and 60 units
qhs
.
18. regular insulin
based on qid sliding scale finger stick
19. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Start when Creatinine stable.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
- Aortic stenosis (valve area 0.5 cm2)
-Aortic valve replacement with a 21 mm [**Doctor Last Name **]
pericardial tissue valve, model number 3300 TFX.
2. Coronary artery bypass grafting x1 with the saphenous
vein graft to the right coronary artery.
Secondary:
Hypertension
Aortic Stenosis
Diabetes Mellitus
Atrial Fibrillation on coumadin
?Asthma
GERD
Irritable Bowel Syndrome
Stress incontinence
h/o fainting spells dating back to childhood
Iron deficiency anemia
Chronic back pain
Anxiety/Depression
Bursitis
Epistaxis
Hemorrhoids
Past Surgical History:
s/p appendectomy
s/p hysterectomy
s/p cataract surgery
s/p sinus surgery x2
s/p left knee surgery
- Hypertension
- Type II diabetes mellitus
- Atrial fibrillation
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema: 1+
bilat LE edema
Discharge Instructions:
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.
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**]).
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of sternal wound.
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
please take all of your medications as prescribed and follow up
with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below.
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) **], [**First Name3 (LF) **] appointment was arranged for Wednesday, [**8-9**] at 1pm
Please call to schedule appointments with your
Primary Care: PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] [**Telephone/Fax (1) 60570**] in [**2-4**] weeks
Cardiologist: Dr. [**First Name (STitle) **] [**Doctor Last Name 2194**] in [**2-4**] weeks
Your pre-operative workup revealed a neural sheath tumor located
at the top of your right lung. We consulted the neurosurgery
team who believed this change to be chronic in nature requiring
no immediate intervention. After you recover from surgery, you
will have an MRI with follow up with Dr. [**Last Name (STitle) 739**] of
Neurosurgery as an outpatient. Plaese call and schedue a
Neurosurgery appointment with Dr.[**Last Name (STitle) 739**] in 3 weeks.
.....
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Labs: PT/INR for Coumadin ?????? indication-Atrial Fibrillation
Goal INR: 2.0 -2.5
Completed by:[**2130-7-14**]
ICD9 Codes: 4241, 4019, 4168, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7041
} | Medical Text: Admission Date: [**2187-10-27**] Discharge Date: [**2187-10-31**]
Date of Birth: [**2143-1-6**] Sex: F
Service: CCU
CHIEF COMPLAINT: Inferior myocardial infarction, status post
cardiac arrest.
HISTORY OF PRESENT ILLNESS: The patient is a 44 year old
female with a history of insulin dependent diabetes mellitus,
asthma and seizure disorder, who presented to an outside
hospital with complaints of shortness of breath, difficulty
breathing which began the night prior to admission. The
patient did not have a cough, no chest pain, no
light-headedness and no weakness. The patient was given
Combivent in the ambulance with improvement. She had run out
of her medications a couple days prior to admission.
In the Emergency Department, she had an asystolic arrest and
was given Atropine multiple times which converted her to
ventricular fibrillation arrest and then to ventricular
tachycardia. At this time, the patient was intubated and put
on a ventilator. The patient also received Epinephrine,
Amiodarone, and Morphine. She became hypotensive and was
started on Dopamine subsequently. There was a question of
whether the patient had had a seizure prior to her cardiac
arrest.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus.
2. Asthma.
3. Seizure disorder.
4. Irregular heart rate.
5. Bronchitis.
MEDICATIONS:
1. Insulin.
2. Tegretol.
3. Zocor.
4. Combivent.
5. Theophylline.
6. Avandia.
7. Zantac.
ALLERGIES: Aspirin and Penicillin.
SOCIAL HISTORY: The patient is a two pack per day smoker.
PHYSICAL EXAMINATION: Vital signs on admission were 99.2
temperature, blood pressure 90/50, heart rate 80s with normal
sinus rhythm, respiratory rate approximately 25 on an assist
control ventilator with FIO2 of 0.6, tidal volume 600 and
PEEP 5 with pressure support 22. In general, the patient was
intubated and on the ventilator. Head, eyes, ears, nose and
throat examination - Multiple freckles, skin discoloration on
eyelids. The pupils are equal, round, and reactive to light
and accommodation. Eyes midline when open. Neck - jugular
venous distention not appreciated, no lymphadenopathy. No
carotid bruits. Cardiovascular - regular rate and rhythm, no
murmurs, rubs or gallops. Pulmonary - good breath sounds
with ventilation, decreased breath sounds at the bases
bilaterally. Abdomen reveals positive bowel sounds, soft,
obese. Extremities - no cyanosis, clubbing or edema. Good
pulses bilaterally. Bilateral groin lines. No bleeding,
hematomas or bruits.
LABORATORY DATA: On admission, laboratories were significant
for a white blood cell count of 22.3, hemoglobin 10.8,
hematocrit 36.4 and platelet count 296,000. Coagulation
studies showed partial thromboplastin time of 26.5 and INR of
1.0. Potassium 4.6, blood urea nitrogen 14, creatinine 0.9.
Tegretol level was subtherapeutic at 1.9 and Theophylline
level was less than 0.8. The patient's cardiac enzymes,
haptoglobin and lipid panel were pending.
Cardiac catheterization showed right dominant system with
normal left main coronary artery, normal left anterior
descending, normal left circumflex. Her right coronary
artery was occluded and was stented. The electrocardiogram
was consistent with this and showed left axis deviation,
possible left bundle branch block, ST elevations in leads II,
III and aVF, reciprocal depressions in I, aVL and V1 through
V6.
CT of the head at the outside hospital was negative per
report.
HOSPITAL COURSE: The patient was admitted to the CCU service
and was slowly weaned off Dopamine and weaned off the
ventilator.
The remainder of her hospital course is to be addended.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Name8 (MD) 10249**]
MEDQUIST36
D: [**2187-10-31**] 17:11
T: [**2187-10-31**] 18:34
JOB#: [**Job Number 46758**]
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7042
} | Medical Text: Admission Date: [**2168-9-25**] Discharge Date: [**2168-10-1**]
Date of Birth: [**2135-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
lower extremity weakness & numbness (right>left)
Major Surgical or Invasive Procedure:
Laminectomy T9 and 10, removal of epidural cyst, and dural
closure.
History of Present Illness:
HPI: 33 yo male with a history of alcohol dependence and
peripheral neuropathy who presents with two days of bilateral
lower extremity weakness and numbness. Mr. [**Name14 (STitle) 79121**] was in his
usual state of health until two days ago when he woke up with
numbness and pain in both of his legs (R>L), starting at the
feet and tracking upward. Though he has had peripheral
neuropathy in his legs in the past, the current episode of pain
was by far the most severe of his life, and in fact he was
unable to walk or even bear weight. He was seen at [**Hospital 47**]
Hospital where MRI of the thoracic spine revealed a mass at the
level of T10, initially thought to be consistent with an
epidural abscess. He was transferred to [**Hospital1 18**] for surgical
consideration. The mass was reomoved and found to be consistent
with a cyst. It was not felt that this mass could explain the
presenting symptoms, and in fact Mr. [**Known lastname 6483**] reports little or
no improvement since surgery. Currently, he reports numbness and
pain in both legs (R>L)most intense at the foot and extending up
to the ankle.
Past Medical History:
alcohol dependence with h/o withdrawal (shakes, DTs) and seizure
peripheral neuropathy lower extremities reportedly ascribed to
alcohol abuse
asthma
psoriasis
Social History:
Lives in [**Location 1110**] with parents, recently separated from wife and 2
[**Name2 (NI) 25400**] (6,8). Works as a [**Hospital1 **] carpenter.
Alcohol: [**1-27**] gallon/day vodka daily or almost daily for 16
years. Has experienced periods of sobriety for up to 2 months.
Expresses desire to cut down.
Tobacco: [**1-29**] PPD x years
Drugs: Denies past or present use, inclduing IVDU.
Family History:
Parents, children healthy.
Physical Exam:
VS - Temp 99.9F, BP 128/73, HR 94, R 20, O2-sat 97% RA
GENERAL - young man lying in bed on his back, complains of pain
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM
NECK - supple, no LAD or thyromegaly
LUNGS - CTA bilat, no r/rh/wh
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft/NT/ND, liver not palpated
EXTREMITIES - WWP, no c/c/e, 2+ DPs
SKIN - no jaundice or stigmata of chronic liver disease
NEURO - Awake, A&Ox3, attentive, + calculations, average fund of
knowledge
CN II-XII intact
Motor Normal bulk and tone. No fasciculations.
[**5-30**] BUE throughout; 4+/5 left thigh extension, 2-3/5 plantar
flexion b/l, [**3-1**] dorsiflexion, otherwise [**5-30**] throughout BLE
Sensation to soft touch, temperature decreased in both feet to
the level of the ankle. Normal BUE and face. ? deficit or
proprioception in both feet, but intact BUE.
Reflexes: 2 patellar b/l, 0 ankle b/l, babinski down on left,
mute on right
Cerebellar signs: No deficit of finger-to-nose, rapid
alternating movements.
Gait: deferred
Pertinent Results:
Admission labs:
[**2168-9-25**] 09:15PM WBC-7.5 RBC-4.28* HGB-14.2 HCT-40.1 MCV-94
MCH-33.3* MCHC-35.5* RDW-13.9
[**2168-9-25**] 09:15PM NEUTS-73.4* LYMPHS-21.1 MONOS-4.6 EOS-0.4
BASOS-0.4
[**2168-9-25**] 09:15PM PLT COUNT-152
[**2168-9-25**] 09:15PM PT-12.0 PTT-29.3 INR(PT)-1.0
[**2168-9-25**] 09:15PM GLUCOSE-90 UREA N-12 CREAT-0.7 SODIUM-134
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-21* ANION GAP-22*
[**2168-9-25**] 09:15PM CALCIUM-7.9* PHOSPHATE-2.1* MAGNESIUM-1.9
[**2168-9-25**] 09:50PM URINE RBC-0 WBC-0 BACTERIA-0 YEAST-NONE EPI-0
[**2168-9-25**] 09:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
Discharge Labs:
WBC 6.5, hct 31.9, plt 127
CK 1610
.
Imaging:
MRI T-Spine ([**2168-9-26**]):Dorsal and right lateral epidural fluid
intensity lesion at T9-10 level. The absence of enhancement
centrally or peripherally argues against the finding being an
epidural phlegmon or abscess, and favors an arachnoid cyst.
.
MRI L-Spine ([**2168-9-27**]): No evidence of discitis, osteomyelitis, or
epidural abscess. Mild spondylosis at L4/5 and L5/S1. A left
paracentral disc protrusion at L5/S1 may contact to the left S1
nerve root in the lateral recess.
.
CXR ([**2168-9-27**]): In comparison with the study of [**9-26**], there is no
interval change. Specifically, there is no evidence of pneumonia
to explain the postoperative fever.
.
TTE [**9-27**]: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
.
No vegetation seen (cannot definitively exclude).
.
EMG ([**2168-9-28**]): Complex, abnormal study. The electrophysiologic
findings suggest a mild-to- moderate chronic generalized
sensorimotor polyneuropathy with axonal features. The absence of
motor unit activity in right tibialis anterior, gastrocnemius,
and extensor hallucis longus suggests either central nervous
system dysfunction or a severe, acute neurogenic lesion. Coupled
with the ongoing denervation present in right L5 paraspinal
muscles, these findings may reflect an acute (<3 weeks) right
L5-S1 radiculopathy. There is no evidence for a primary
demyelinating polyradiculoneuropathy, as in Guillain- [**Location (un) **]
syndrome.
.
LP: protein 75, glucose 61, wbc 10, RBC 425, Poly 27%, Lymph
35%, Mono 38%
.
Micro:
Urine culture Neg.
Blood culture [**9-25**], [**9-26**], [**9-27**] Negative
Blood culture [**9-28**]: pending at discharge, NGTD
HCV VL pending
Lyme Ab negative
RPR negative
Brief Hospital Course:
ASSESSMENT AND PLAN: 33 yo male with a h/o alcohol dependence
(previous withdrawal and seizures) and peripheral neuropathy who
presented with acute onset bilateral lower extremity weakness
and numbness (R>L), still of uncertain etiology. Patient is now
s/p surgical laminectomy T9/T10 and removal of epidural cyst.
.
1) Lower extremity numbness and weakness: Patient presented with
sudden onset of this weakness/numbness on [**2168-9-25**]. Initial
imaging was suspicious for an epidural abscess, which later
proved to be an epidural cyst upon resection. Laminectomy and
removal of the cyst did not ameliorate the symptoms. Over the
course of the hospitalization, the LLE improved to 5/5 strength
throughout with minimal sensory deficits. In contrast, the RLE
remained with 1-2/5 strength on plantar flexion and dorsiflexion
at the ankle, and [**4-30**] flexion at the knee, otherwise [**5-30**].
Sensory deficits in the LLE also improved though not completely.
The patient could ambulate with confidence only with a walker,
but dragged his right foot. He was started on gabapentin for
neuropathic pain which provided some symptomatic relief. This
can continue to be uptitrated as an outpatient.
.
These findings were felt to most likley represent a peripheral
neuropathy over a central process. There was no evidence of
demyelination on EMG, arguing against [**Last Name (un) 4584**]-[**Location (un) **]. B12,
folate, TSH, HIV, RPR, Lyme, HBV were normal. HCV antibody was
positive, and this was a new finding to Mr. [**Known lastname 79122**]
knowledge, though viral load was pending at discharge. An LP was
perfomed, revealing protein 75, glucose 61, 10 WBC. An MRI of
the L-Spine was remarkable only for question of a possible disc
protrusion affecting the L5/S1 nerve root on the left, though
Mr. [**Known lastname 79122**] major findings were on the right. A blood smear
did not reveal evidence of lead toxicity (basophilic stippling).
The differential continues to include neuropathy secondary to
alcoholism, heavy metal poisoning (lead, arsenic),
cryoglobulinemia secondary to HCV. He will follow up with
neurology as an outpatient for LP results and further
evaluation. He was discharged home with outpatient PT to work
on strength and balance.
.
2) Alcohol withdrawal: Patient was maintained on the CIWA scale
with prn valium, though he required minimal dosing after
transfer from the MICU to the floor on HD3. Patient expresses
some desire to cut down on drinking, and options such as AA and
pharmacologic assistance with naltrexone, acamprosate, etc were
discussed. Given his new diagnosis of Hep C we reinforced the
importance of abstaining from alcohol.
.
3) Elevated CK: Patient on admission had a CK>6000, which
trended downward. He was initially given IVF for renal
protection and his CK trended down. Last CK value was 1610.
Etiology was unclear but it was possibly alcohol related
myopathy. There was no history of trauma or drug use. His renal
function remained normal throughout the admission.
.
4)Pain: Mr. [**Known lastname 6483**] required significant opiate doses to
control the pain both in his legs and at his surgical site in
his back. He was maintained on satnding acetaminophen,
ibuprofen, and started on MS contin. His morphine dose was
uptirated with good effect to a discharge dose of 30 mg [**Hospital1 **]. He
was also started on gabapentin as above.
.
5) Anti-HCV Antibody positive: THis is a new diagnosis for this
patient. The significance of this finding was explained to Mr.
[**Known lastname 6483**]. He does not know how he could have gotten this, but
does note mutliple tattoos including one obtained in prison.
Viral load was sent and was pending at discharge. He will
follow up with Hepatology as an outpatient.
.
6)Disposition: To home with services. Mr. [**Known lastname 6483**] will need to
continue work up as an outpatient. He will follow up with Dr.
[**Last Name (STitle) 1206**] in Neurology, and plans to establish a PCP at [**Hospital1 18**].
.
Medications on Admission:
albuertol inhaler prn
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
2. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
4. 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*
5. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours) for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Physical Therapy
Work on strength and balance
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral lower extremity weakness
Peripheral neuropathy
Epidural cyst
Hepatitis C
Alcohol dependence
Asthma
Discharge Condition:
Afebrile. Able to ambulate with assistance. Stable for
discharge.
Discharge Instructions:
You were admitted to the hospital with weakness in your legs.
An MRI of your spine showed a lesion in your thoracic spine that
was concerning for infection. You had an operation to remove
this and it was found to be a cyst without any infection. We
did not feel that your symptoms were related to this finding.
.
You had multiple tests looking for a cause of your weakness that
were all negative. You also had an EMG that showed a
neuropathy, however the cause of this is still unknown. You
also had a lumbar puncture and the results of this were pending
at the time of discharge.
.
While in the hospital you had significant pain. We started you
on a medication called gabapentin for "nerve" pain. This can be
increased by your PCP if needed. We also started you on
long-acting morphine. As your pain improves this will need to
be weaned off by your doctor.
.
You were found to have a new diagnosis of Hepatitis C based on a
positive antibody test. You may need treatment for this and you
will need to follow up with a liver specialist to discuss this
further. We encouraged you to abstain from drinking which with
the Hepatitis C could cause significant problems with your
liver.
.
Please keep follow up appointments as outlined below.
.
Call your doctor or return to the emergency department if you
experience worsening weakness, pain, high fevers, chills,
breathing difficulties or other concerning symptoms.
Followup Instructions:
You will need to follow up with Neurology, Dr. [**Last Name (STitle) 1206**]. Please
call [**Telephone/Fax (1) 44311**] to schedule this appointment for as soon as
possible. You will need to follow up the results of your lumbar
puncture at this visit.
.
You should follow up with your PCP [**Last Name (NamePattern4) **] [**1-27**] weeks. You expressed
interest in finding a new PCP. [**Name10 (NameIs) **] can call the clinic here at
[**Telephone/Fax (1) 250**] to schedule an appointment with a new PCP if you
choose. You should check with your insurance whether this is
possible.
.
You will need to follow up with your Orthopedic surgeon Dr.
[**Last Name (STitle) 363**] in 10 days. You can call [**Telephone/Fax (1) 3573**] to schedule this
appointment.
.
You will also need to follow up with a liver specialist for your
new diagnosis of Hepatitis C. Please call ([**Telephone/Fax (1) 1582**] to
schedule this appointment.
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7043
} | Medical Text: Admission Date: [**2141-5-6**] Discharge Date: [**2141-5-21**]
Date of Birth: [**2141-5-6**] Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname **] is the 2.23 kg product of a 34 and
[**3-6**] week gestation born to a 41-year-old G5, P1, now 2 woman
with past medial history notable for anxiety (no medications
currently charted) and past obstetrical history notable for
40 week normal spontaneous vaginal delivery in [**2136**],
spontaneous abortion with trisomy 16 in [**2137**], 21 week twin
demise in [**2139**], 9 week missed abortion with trisomy 21 in
[**2139**]. Prenatal screens are as follows: A positive, direct
Coombs' negative, hepatitis surface antigen negative, RPR
nonreactive, rubella immune, GBS unknown. CF negative. [**Doctor Last Name **]-
[**Doctor Last Name 3450**] negative.
Antenatal course - [**Last Name (un) **] of [**2141-6-16**], by IVF dating.
Pregnancy was complicated by cervical insufficiency, leading
to cerclage placement at 13 weeks gestation. Normal fetal
survey but note made in chart of bilateral choroid plexus
cyst with spontaneous rupture of membranes 15 hours prior to
delivery leading to oxytocin induction for variable
decelerations and spontaneous vaginal delivery under epidural
anesthesia.
The infant was vigorous at delivery, orally and nasally bulb
suctioned, dried , free flow oxygen provided. Subsequently
pink in room air with mild intercostal retractions. Apgars
were 8 at 1 minute, and 8 at 5 minutes.
PHYSICAL EXAMINATION: Weight 2.23 kg, head circumference 33
cm, length 47 cm, anterior fontanel soft and flat.
Nondysmorphic. Palate intact. Neck and mouth normal.
Normocephalic. No nasal flaring.
CHEST: Without retractions. Good breath sounds bilaterally.
No crackles.
CARDIOVASCULAR: Well perfused. Regular rate and rhythm.
Femoral pulses normal. S1 and S2 normal. No murmurs.
ABDOMEN: Soft. Nondistended. No organomegaly. No masses.
Bowel sounds active. Anus patent. Three vessel umbilical
cord. Normal female genitalia.
NEUROLOGIC: Active, alert and responsive to stimulation. Tone
appropriate for gestational age and symmetric. Moves all
extremities. Suck, gag intact. Grasp symmetric.
INTEGUMENTARY: Normal.
MUSCULOSKELETAL: Normal spine, limbs, hips and clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: She has been stable in room air throughout
hospital course without any issue. No apnea or bradycardia of
prematurity.
CARDIOVASCULAR: He has been stable throughout hospital
course. No cardiac murmur auscultated.
FLUIDS, ELECTROLYTES AND NUTRITION: The infant was initially
started on 80 cc per kg per day of D10W. Abdominal distention
noted within first day of life. [**Last Name (un) 37079**] tube placed. [**Hospital **]
transferred to [**Hospital3 1810**] for barium enema which
revealed normal structure. The infant then passed a mucus
plug with large meconium stool and the abdominal distention
has since resolved.
The infant has been tolerating all po feedings for the past
48 hours. She is breast-feeding ad lib with the addition of
supplemental bottles of expressed breast milk with 4 added
calories with Similac Powder.
Discharge weight is 2295 grams.
GASTROINTESTINAL: Peak bilirubin was on day of life No. 4,
at 14.6/0.4. She received phototherapy with subsequent
resolution. Last total bilirubin level was 8.6 on [**5-20**].
HEMATOLOGY: Hematocrit on admission was 48. The infant has
not required any blood transfusions during this hospital
course.
INFECTIOUS DISEASE: CBC and blood culture were obtained on
admission. Antibiotics were initiated. The infant remained on
ampicillin and gentamycin until day of life 3, when abdominal
issues were resolved. She has had no further issues with
sepsis during this hospital course.
NEUROLOGIC: Appropriate for gestational age. Prenatal
history of bilateral choroid plexus cysts which are of no
clinical concern.
SENSORY - AUDIOLOGY: Hearing screen was performed prior to
discharge and she passed in both ears.
PSYCHOSOCIAL: The family is a very involved, invested family.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) 1887**]
Pediatrics. Telephone No. [**Telephone/Fax (1) 37518**].
CARE RECOMMENDATIONS:
1. Breast feeding po ad lib with supplemental breast milk 24
cals/oz with [**Doctor Last Name **] powder.
2. Medications: None
3. Car seat position screen performed prio to discharge and
the infant passed.
THE STATE NEWBORN SCREEN: The first State Newborn Screen was
sent on [**2141-5-9**], and was within normal limits with the
exception of an increased 17-OH progesterone (CAH) which was
179, normal being less than 80. A repeat specimen was sent
on [**5-12**], and the results were normal.
IMMUNIZATIONS RECEIVED: The infant received the first
Hepatitis B vaccine on [**2141-5-15**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following
three criteria.
A. Born less than 32 weeks.
B. Born between 32 and 35 weeks with two of the following:
i. daycare during the RSV season
ii. a smoker in the household,
iii. neuromuscular disease,
iV. airway abnormalities, or
v. school age siblings.
C. with chronic lung disease.
2. Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for
household contacts and out of home caregivers.
DISCHARGE DIAGNOSES:
1. Sepsis evaluation with antibiotics, ruled-out.
2. R/O Intestinal obstruction, ruled out by normal lower GI
study by contrast enema.
3. Hyperbilirubinemia, resolved.
4. Immature feeding skills, resolved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 58682**]
MEDQUIST36
D: [**2141-5-13**] 00:28:52
T: [**2141-5-13**] 02:40:15
Job#: [**Job Number 61255**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7044
} | Medical Text: Admission Date: [**2114-11-9**] Discharge Date: [**2114-11-11**]
Date of Birth: [**2064-2-26**] Sex: M
Service: [**Hospital Ward Name **] ICU
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old
male with end stage amyotrophic lateral sclerosis, who is
ventilator dependent at home. The patient was in his usual
state of health at home when his sister (not his usual care
giver), gave him an Albuterol nebulizer treatment prior to
going to bed and was unable to figure out how to reattach his
ventilator. The patient subsequently developed respiratory
distress and became cyanotic. EMS was called and the patient
was found to be cyanotic and apneic at arrival. The patient
was bagged with FIO2 100% and quickly regained consciousness
and mental status. The patient was brought to [**Hospital1 346**] Emergency Room where the patient was
found to be mentating and breathing with normal CBC and
Chem-7. He was placed on a ventilator A/C with 100% FIO2 and
transferred to [**Hospital Ward Name 332**] Intensive Care Unit for monitoring
overnight on ventilator status post respiratory arrest.
PAST MEDICAL HISTORY:
1. Amyotrophic lateral sclerosis status post tracheostomy
and PEG in [**2113-5-17**]. The patient is able to talk through
chronic cuff leak and eat p.o. diet.
2. Status post non-Q wave myocardial infarction in setting
of a respiratory arrest in [**2113-5-17**]. No history of
congestive heart failure.
3. Hypertension.
4. History of prostatitis.
5. Chronic constipation.
6. History of heavy alcohol use.
7. Anxiety.
MEDICATIONS:
1. Tamoxifen.
2. Klonopin.
3. Lactulose.
4. Lopressor.
5. Aspirin.
6. Relutek.
7. Celexa.
8. Combivent MDI.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married to a former [**Hospital1 1444**] nurse who is able to manage
medical condition and ventilator at home, thus the patient is
vent dependent and bed bound living at home with his wife and
two children. The patient has a history of heavy alcohol use
and continues to drink alcohol on a regular basis. He does
not smoke. No intravenous drug use. The patient is
completely paralyzed and unable to move out of bed.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Heart rate is sinus tachycardia at
110; blood pressure 121/73; temperature afebrile; saturation
100% on FIO2 100%. General appearance: A paralyzed male in
no acute distress breathing comfortably through tracheostomy;
able to speak through cuff leak. HEENT: Mucous membranes
were moist. Oropharynx clear. Pupils equally round and
reactive to light. Extraocular movements are intact. Neck
with tracheostomy site without erythema or purulence.
Positive moderate to severe cuff leak. Cardiovascular is
tachycardic, normal S1 and S2. No S3, S4, no murmurs.
Pulmonary: Vented breath sounds bilaterally, decreased at
the bases without rhonchi, wheezing or crackles. Abdomen
soft, nontender, nondistended. G-tube site clean, dry and
intact without purulence. Extremities with no cyanosis,
clubbing or edema, two plus distal pulses. Neurologic
examination is cranial nerves II through XII intact. Motor
strength zero out of five diffusely. Deep tendon reflexes
unable to be elicited. Sensation intact.
LABORATORY: CBC and chem-7 within normal limits. ABG with
pH of 7.41.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
[**Hospital Ward Name 332**] Intensive Care Unit for monitoring of hemodynamics and
respiratory status overnight. He did extremely well and
remained stable on his usual ventilator settings of assist
control 780 by 17 with FIO2 of 40% and PEEP of 5. The
patient required frequent suctioning of thick clear sputum
which he states is no different from normal. The patient
remained afebrile throughout this hospital admission.
Chest x-ray did show question of left lower lobe atelectasis
versus consolidation, however, as the patient was afebrile
with a normal white blood cell count it was felt that this
could be monitored at home.
The patient remained in the Intensive Care Unit for
approximately 48 hours until his care giver who was able to
manage his ventilator returned home. The patient remained
medically stable and was subsequently transferred to home on
[**2114-11-11**]. His wife is his full time care giver and
manages his respiratory needs, including ventilation and
suctioning at home.
Of note, the patient was placed on Methicillin resistant
Staphylococcus aureus precautions while in the Intensive Care
Unit given his recent three week hospital admission for
Methicillin resistant Staphylococcus aureus pneumonia. The
patient will have follow-up with his physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], or on an as needed basis for fevers and pneumonia,
given his high risk status. His cuff leak was also
discussed, however, it was felt that this was unchanged from
prior and that the patient likes to be able to talk around
his cuff leak, thus, no further work-up was done for changing
tracheostomy tube.
DISCHARGE DIAGNOSES:
1. Respiratory arrest status post mechanical dysfunction due
to operator error.
2. End stage amyotrophic lateral sclerosis, ventilator
dependent.
3. History of alcohol abuse.
4. History of prostatitis.
5. Hypertension.
6. Anxiety.
7. Constipation.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient is discharged to home with
ventilator and medical management per his wife. [**Name (NI) **]
follow-up with primary care physician on as needed basis and
wife will monitor closely for fevers and evidence of
pneumonia.
The patient will follow-up with pulmonologist on a p.r.n.
basis for management of cuff leak should this become more
problem[**Name (NI) 115**].
DISCHARGE MEDICATIONS: Unchanged from admission medications.
1. Temazepam.
2. Klonopin.
3. Lactulose.
4. Lopressor.
5. Aspirin.
6. Relutek.
7. Celexa.
8. Combivent MDI.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 8038**]
Dictated By: [**Name6 (MD) **] [**Name8 (MD) **], M.D.
MEDQUIST36
D: [**2114-11-14**] 12:44
T: [**2114-11-14**] 18:21
JOB#: [**Job Number 108306**]
ICD9 Codes: 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7045
} | Medical Text: Admission Date: [**2194-8-16**] Discharge Date: [**2194-8-19**]
Date of Birth: [**2149-8-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation, central line
History of Present Illness:
44 man with history of HIV, methamphetamine abuse, presenting
with altered mental status. He was found down and then brought
in by BIBEMS after a witnessed tonic/clonic seizure lasting
about 5 minutes. When EMS arrived, he was post-ictal. He
denied substance abuse other than pot. Blood sugar was 85 and
he was not incontinent. A friend arrived while he was in the [**Name (NI) **]
and reported that he had taken GHB, and was depressed after he
recently lost his job and home
.
In the ED, initial vs were: 98.2 68 131/80 20 96. He was
initially ambulatory, alert and oriented. He then became
altered in the ED with significant agiatation. He did not
improve after 5 mg haldol, and 2 + 4 mg ativan. He had periods
of apnea while agitated lasting about 10 sec with sats dropping
to 80s. He was intubated for airway protection and agitation.
He had a very [**Location (un) 45918**] with difficult airway and initial ET
attempts were unsucessfull. NT intubation was also attempted
resulting in a bloody nose. He was eventually intubated
sucessfully with Versed and Fentanyl. He was also given
ceftriaxone 2 gm and 5 L IVF. His urine was noted to be dark.
He had no tongue lesions. An LP was showed normal cellularity,
glucose, and protein. Prior to trasfer, VS: T 99.9 80 125/74
Sat 100 on RR 14 peep 5 fiO2 60
.
On the floor, he was intubated and sedated. He was unable to
answer questions.
.
Review of systems: Unable to obtain
Past Medical History:
HIV since ~[**2168**], CD4 425 in [**6-30**], never on HAART
PITYRIASIS VERSICOLOR
AMPHETAMINE DEPENDENCE
DEPRESSIVE DISORDER
PANIC DISORDER
NICOTINE ADDICTION
MRSA infections: L leg, waist, other sites. Treated as OP with
bactrim since it has been bactrim sensitive in the past.
CONDYLOMA ACUMINATUM
Social History:
Per [**2190**] admission: Smoked for 20 years 1 ppd, recently quit.
Occasional Etoh use.
Remote hx of cocaine use, and reports been "mostly" sober for
the last 5 years since last detox. Occasional Etoh use. Male
who has sex with males.
.
Was to fly to [**State 8449**] to be with his mother as he has multiple
worsening social stressors including homelessness. Currently
unemployed and living with friends
Family History:
NC
Physical Exam:
MICU ADMISSION:
Vitals: T: 97 BP:102/68 P:71 R:18 O2:100 Tidal volume: 500 cc
Respiratory rate: 14 PEEP: 5 cm/h2o FIO2: 50 %
General: Sedated, GCS 4
HEENT: pupils 3->2, Sclera anicteric, oropharynx intubated with
dried blood
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, mildy hyperdynamic precordium
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: Abdomen with 5-mm papule with central excoriation (c/w
injection?), minor bruising on arm, hypopigmented macules over
face.
FLOOR ADMISSION:
Vitals: T: 99 BP:122/94 P:92 R:16 O2:100 % on RA
Respiratory rate: 16
General: NAD, sleeping but easily arousable. Pleasant
HEENT: PERLA, Sclera anicteric, oropharynx clear with minor
erythema
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm- sl. tachycardic, normal s1-s2, no
murmurs, gallops or rubs
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. Mild
erythema on right hand
Skin: Abdomen with 5-mm papule with central excoriation (c/w
injection?), minor bruising on arm, hypopigmented macules over
face. small healing ulcers, scabing around mouth and forehead
along hair line.
Pertinent Results:
[**2194-8-16**] 9:45 pm CSF;SPINAL FLUID TUBE 3.
GRAM STAIN (Final [**2194-8-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TOXOPLASMA IgG ANTIBODY: NEG
TOXOPLASMA IgM ANTIBODY:NEG
CRYPTOCOCCAL ANTIGEN (Final [**2194-8-17**]): CRYPTOCOCCAL ANTIGEN NOT
DETECTED.
.
Images:
Chest X-ray - [**2194-8-16**] - 1. Endotracheal tube tip at the level
of thoracic inlet. The endotracheal cuff balloon is
overinflated.
2. Satisfactory placement of orogastric tube placement.
3. Mild fluid overload. Left basilar atelectasis
CHEST XRAY- [**2194-8-17**]: The ET tube is 6 cm above the carina. The
NG tube tip is off the film. There has been interval improvement
in the appearance of the pulmonary vasculature which now
demonstrates less vascular redistribution. There is no new
infiltrate. There are some small areas of subsegmental
atelectasis in both lower lungs.
IMPRESSION: Improved appearance to the lungs.
CT Head W/ & W/O Contrast - [**2194-8-16**] -
1. No evidence of hemorrhage. No enhancing masses.
2. Aberrant vessel coursing through the left centrum semiovale
may represent a developmental venous anomaly and could be
further evaluated in a non- emergent setting with MRI/MRA.
3. Fluid and opacification within the nasal cavity as well as
paranasal sinuses, likely due to intubated status.
.
EKG: NSR@ 115, LAD, borderline LVH, Q and TWI in II, III, aVF.
[**2194-8-16**] 04:45PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-POS mthdone-NEG
LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2194-8-19**] 06:40AM 3.6* 4.13* 12.4* 34.8* 84 30.0 35.7* 13.3
319
[**2194-8-18**] 03:32AM 5.4# 4.08* 12.0* 35.5* 87 29.5 33.8 13.2
319
[**2194-8-17**] 05:00AM 3.4* 3.71* 10.5* 32.5* 88 28.2 32.1 13.2
304
[**2194-8-16**] 04:45PM 5.6 4.23* 12.7* 36.2* 86 29.9 35.0 12.9
393
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2194-8-19**] 06:40AM 63.4 29.3 5.0 1.9 0.5
[**2194-8-17**] 05:00AM 63.5 31.3 4.1 0.7 0.5
[**2194-8-16**] 04:45PM 70.5* 24.4 4.1 0.4 0.4
T LYMPHOCYTE SUBSET
[**2194-8-16**] 04:45PM BLOOD WBC-5.6 Lymph-24 Abs [**Last Name (un) **]-1344 CD3%-84
Abs CD3-1132 CD4%-25 Abs CD4-342* CD8%-57 Abs CD8-767*
CD4/CD8-0.45*
[**2194-8-19**] 06:40AM: Glucose-113* UreaN-5* Creat-0.7 Na-138 K-4.0
Cl-103 HCO3-28 AnGap-11
[**2194-8-18**] 01:34PM Glucose-98 UreaN-6 Creat-0.8 Na-139 K-4.1
Cl-107 HCO3-29 AnGap-7*
[**2194-8-16**] 04:45PM UreaN-22* Creat-1.3* Na-143 K-3.4 Cl-107
HCO3-23 AnGap-16
[**2194-8-18**] 05:14PM CK(CPK)-676*
[**2194-8-18**] 01:34PM CK(CPK)-712*
[**2194-8-18**] 03:32AM CK(CPK)-829*
[**2194-8-16**] 04:45PM ALT-35 AST-55* CK(CPK)-1255* AlkPhos-83
TotBili-0.3
[**2194-8-18**] 01:34PM CK-MB-8 cTropnT-<0.01
[**2194-8-18**] 03:32AM CK-MB-10 MB Indx-1.2
[**2194-8-17**] 05:57PM CK-MB-19* MB Indx-1.6 cTropnT-<0.01
[**2194-8-19**] 06:40AM Calcium-8.3* Phos-3.2 Mg-1.7
[**2194-8-18**] 01:34PM Calcium-8.3* Phos-2.6* Mg-2.0
[**2194-8-18**] 03:32AM Calcium-7.8* Phos-2.6* Mg-1.7
[**2194-8-18**] 05:14PM BLOOD TSH-1.4
Brief Hospital Course:
This is a 44 year-old man with a history of HIV not on HAART, +
MRSA and polysubstance abuse who presenting with altered mental
status, rhambdomyolysis, and fever after ingesting GHB
(methamphetamine).
.
# Altered mental status: Most likely consistent with
methamphetamine and GHB intoxication, with agitation and apnea.
CT head and LP are unconcerning for infection or trauma. Pt was
imtubated and sent to MICU. Pt febrile, and given the history of
HIV cultures were sent. However these symptoms were more likely
due to methamphetamine overdose. Ingestion was concerning for a
suicide attempt.
- Psych evaluation on [**2194-8-18**]: Patient states that this was not
a suicide attempt. He took more GHB than planned. He is not
interested in having substance abuse treatment at this time.
- He was on ativan on CIWA protocol which was changed to Ativan
1mg PRN, last dose on [**8-17**]. Pt has been calm and denies having
symptoms of withdraw
- LP, CT and crypto were negative for infection. Toxoplasma
results were negative
- Tox consult done [**2194-8-18**]: IV fluid for rhambdomylisis, and
supportive care
-He is doing well for now, and has shown no signs of withdraw
.
# FEVER: This is most likely due to methamphetamines, however
given history of HIV and immunosupression. Cultures were sent to
crypto, blood cult and urine cult were negative. Toxoplasma
results were also negative. Pt also had lumbar puncture and CT
scan of head were within normal limits. He complain of cough and
sore throat this morning most likely due to recent intubation.
He had some relief with cepacol lozangers. Cxay was repeated
this AM and showed no acute process. I discuss with patient
importance of close follow-up given that he has been febrile and
that he should go to the ER if develop fever > 101.3 F or
worsening cough. On PE: LCTA bil, except sl. diminished at
bases. Throat with mild erythema, no LAD, no [**Last Name (un) 8527**].
#Elevated CK: Methamphetamine injestion is associated with
rhabdomyalisis. Dark urine in ED. Received IV fluids, overall
CK trending down. 1200s-> 646 yesterday. Patient drinking large
amounts of fluid
.
# HIV: Diagnosed ~ 20 yrs ago, he is followed by Dr. [**First Name (STitle) 6164**] at
the [**Hospital 778**] clinic. He has not been on HAART in the past.
- CD4 count during this hospitalization is 342. Appointment
set-up for Friday with Dr. [**Last Name (STitle) 4754**]
.
# EKG abnormality: Appears old. He was monitor on tele on NSR.
- cardiac enzymes were negative
.
# Anemia: Appears chronic, likely ACD
- Hct stable at 34
- outpatient Iron studies
.
# Possible abberrant vessel in the left centrum semiovale seen
on head CT, uncertain about significance: outpatient follow-up.
.
# FEN: tolerating diet well. Drinking fluids, replete
electrolytes PRN, regular diet
.
.
# Code: FULL
.
# Communication: Patient,
Mother, [**Name (NI) 52155**], [**Telephone/Fax (1) 54114**]; [**Telephone/Fax (1) 54115**] (work); mother is
only next of [**Doctor First Name **] as father not very involved. DID NOT DISCLOSE
HIV STATUS to MOM, MOM did not disclose.
friend [**Name (NI) **] [**Telephone/Fax (1) 54116**]
.
Medications on Admission:
RIFAMPIN 300 MG CAPS 1 by mouth every 12 hours
OXYCODONE HCL TABS 5 MG [**1-24**] po q4-6 hr prn pain
BACTROBAN CRE 2% 1 APPLICATION TO AFFECTED AREAS TID X 7-14 DAYS
PHISOHEX 3 % LIQD Use as a soap daily as prescribed
SULFAMETHOXAZOLE-TMP DS 800-160 MG TABS 2 tabs by mouth three
times a day for 10 days
BACTROBAN 2 % OINT apply [**Hospital1 **] to nostrils X 5 days
.
Allergies: AMOXICILLIN -> Rash
Discharge Medications:
1. Rifampin 300 mg Capsule Sig: One (1) Capsule PO every twelve
(12) hours.
2. Bactroban 2 % Cream Sig: One (1) Application to affected
areas Topical three times a day for 7-14 days.
3. Phisohex 3 % Liquid Sig: One (1) use as a soap Topical once
a day: As prescribed .
4. Bactrim DS 160-800 mg Tablet Sig: Two (2) Tablet PO three
times a day for 10 days: For a total of 10 days as previously
prescribed.
5. Bactroban Nasal 2 % Ointment Sig: One (1) application Nasal
twice a day for 5 days: Apply to nostrils .
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
GHB (methamphetamine) overdose
HIV
MRSA
Secondary:
PITYRIASIS VERSICOLOR
AMPHETAMINE DEPENDENCE
DEPRESSIVE DISORDER
NICOTINE ADDICTION
CONDYLOMA ACUMINATUM
Discharge Condition:
Stable, afebrile with no signs of withdraw.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for changes in your mentation. You
were found to have overdose on GHB (ectasy). You were intubated
for one day and we gave IV fluids and medication to help you
calm down. You were extubated and started to feel better.
We have made no changes to your medications.
It is very important that you follow-up with your primary care
and HIV care provider as noted below. See options given by
social worker for outpatient rehabilitation.
Call your doctor or come to the emergency room if you develop
any chest pain, shortness of breath, palpitations, fever
(temperature greater than 101.3 F), chills, or for any other
concerns.
Followup Instructions:
PROVIDER: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 54117**] Friday, [**2194-8-22**] at 10:00 at
[**Hospital 778**] clinic. Phone # [**Telephone/Fax (1) 5723**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]
ICD9 Codes: 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7046
} | Medical Text: Admission Date: [**2138-3-11**] Discharge Date: [**2138-3-16**]
Service:
HISTORY OF PRESENT ILLNESS: This is a 78-year-old female who
underwent a screening electrocardiogram preoperatively for
follow up cystoscopy status post bladder cancer which showed
question of silent myocardial infarction. The patient also
reports history of increasing dyspnea on exertion. The
patient was admitted to [**Hospital6 256**]
[**2138-3-6**] for cardiac catheterization which showed an ejection
fraction of 75%, 70% left main disease, 50% proximal LAD, 80%
proximal left circumflex, 80% proximal RCA, aortic valve area
of 0.8 with a mean gradient of 19 mmHg. The patient was
discharged post catheterization to return on [**2138-3-11**] for
cardiac surgery.
PAST MEDICAL HISTORY:
1. Status post bladder cancer surgery [**5-24**]
2. Status post total abdominal hysterectomy
3. History of peptic ulcer disease six years ago
4. Coronary artery disease
5. Aortic stenosis
ALLERGIES: PENICILLIN
PREOPERATIVE MEDICATIONS:
1. Synthroid 100 mcg Monday through Friday
2. Lasix 20 mg po q day
3. KCL 20 milliequivalents po q day
4. Glucotrol XL 2.5 mg po q day
5. Fosamax 10 mg po q day
6. Niacin 500 mg po q day
PREOPERATIVE LABORATORY DATA: The patient's hematocrit was
40.4, BUN 20, creatinine 0.8.
Th[**Last Name (STitle) 1050**] was taken to the Operating Room on [**2138-3-11**] with
Dr. [**Last Name (Prefixes) **] for coronary artery bypass graft x3, left
internal mammary artery to LAD, saphenous vein graft to OM,
saphenous vein graft to RCA. The patient also underwent an
aortic valve replacement with a 21 mm pericardial valve. The
patient was transferred to the Intensive Care Unit in stable
condition. The patient was weaned and extubated from
mechanical ventilation on first postoperative evening. The
patient remained in the Intensive Care Unit on postoperative
day #1 requiring Neo-Synephrine infusion which was weaned to
off by postoperative day #2. The patient was transferred out
of the Intensive Care Unit to the floor on postoperative day
#2. At the time of transfer on postoperative day #2, the
patient was noted to be in atrial fibrillation with a
controlled ventricular response. The patient was started on
Lopressor and amiodarone. The patient converted into sinus
rhythm the evening of postoperative day #2.
On postoperative day #3, the patient's wires and chest tubes
were removed. The patient began ambulating with physical
therapy. It was felt that the patient could benefit from
short term rehabilitation per assessment by physical therapy.
On postoperative day #5, the patient was cleared for
discharge to rehabilitation.
DISCHARGE CONDITION: T-max 97.5??????, pulse 72 sinus rhythm,
blood pressure 110/52, room air oxygen saturation 94%. The
patient's weight is 72 kg preoperatively. The patient was 63
kg. Neurologically, the patient is awake, alert and oriented
x3. Neurologically grossly intact and nonfocal.
Cardiovascular: The patient has regular rate and rhythm. No
rub or murmur noted. Respiratory: Breath sounds clear
bilaterally, decreased posteriorly at the bases.
Gastrointestinal: Positive bowel sounds, soft, nontender,
nondistended, tolerating regular diet, bowel movement x2
yesterday. Extremities: 1+ to 2+ edema, left medial leg
incision is clean, dry and intact. Steri-Strips are intact.
There is a moderate amount of ecchymosis to medial thigh;
area is soft. The leg is warm and well perfuse. Sternal
incision staples are intact. The sternum is without click.
There is no erythema, edema or drainage in the sternal
incision.
LABORATORY DATA: White blood cell count 12.0, hematocrit
32.8, platelet count 220. Sodium 138, potassium 4.3,
chloride 100, bicarbonate 28, BUN 13, creatinine 0.8, glucose
99.
DISCHARGE STATUS: The patient is to be discharged to a
rehabilitation facility in stable condition.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft
2. Status post aortic valve replacement
3. Postoperative atrial fibrillation
4. Noninsulin dependent diabetes mellitus
DISCHARGE MEDICATIONS:
1. Synthroid 100 mcg po q Monday through Friday
2. Lopressor 12.5 mg po bid
3. Lasix 20 mg po bid x1 week, then 20 mg po q day
4. KCL 2 milliequivalents po bid x1 week, then 20
milliequivalents po q day
5. Colace 100 mg po bid
6. Ranitidine 150 mg po bid
7. Enteric coated aspirin 325 mg po q day
8. Glucotrol XL 2.5 mg po q day
9. Amiodarone 400 mg po bid x1 week, then 400 mg po q day x1
month
10. Tylenol 650 mg po q6h prn
11. Tylenol with codeine #3 1 to 2 tablets po q6h prn
12. Ibuprofen 400 mg po q6h prn
13. Lactulose 30 cc po tid prn for constipation
14. Regular insulin sliding scale, for blood sugar 150 to 200
give 3 units subcutaneous, for blood sugar 201 to 250 give 5
units subcutaneous, for blood sugar 251 to 300 give 7 units
subcutaneous
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2138-3-17**] 08:20
T: [**2138-3-17**] 08:43
JOB#: [**Job Number 38118**]
ICD9 Codes: 4241, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7047
} | Medical Text: Admission Date: [**2112-7-20**] Discharge Date: [**2112-7-24**]
Date of Birth: [**2049-2-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
fatigue, shortness of breath, melena
Major Surgical or Invasive Procedure:
# EGD
# capsule endoscopy (results pending at discharge)
History of Present Illness:
Mr [**Known lastname 39221**] is a 63 year old male with CAD s/p STEMI ([**2112-1-29**])
with DESx2 to LAD on Aspirin and Clopidogrel, achalasia with
history of GI bleeding with unclear source requiring ICU
admission ([**3-/2112**]) who presents to the ED with one day of
non-specific malaise. Patient reports not feeling well with
lightheadedness/orthostasis, nausea fatigue, shortness of breath
since yesterday. He denies any associated chest pain,
palpitations, cough, vomiting, abdominal pain, melana, BRBPR. He
does report noting dark stools. Given known h/o GIB patient
called daughter today and reported not feeling well so she urged
him to come to ED.
In the ED, initial VS were: 99.6 118 121/47 18 100% RA. His
blood pressure dropped to the 90s. Patient was given 3L NS with
SBPs persistently in low 90s. Exam was significant for black
tarry guiac positive stools. Labs were significant for HCT of
22.8 down from 28 on [**6-26**], WBC of 24, and BUN of 43. NG lavage
was not performed. His CXR revealed clear lung fields and EKG
was stable from prior. Patient was type and crossed, started on
IV PPI and transferred to the ICU. Vitals prior to transfer
were: Pulse 90. Respiratory Rate 19. Blood Pressure 91/52. O2
Saturation 99.
Of note, patient has had multiple admissions for GIB, most
recently in 20/[**2112**], during which he was admitted to the ICU for
hypotension on presentation. He was stabalized with blood
products. Negative NG lavage and +stool guiacs were concerning
for small bowel bleed. Evaluation with MRE and capsule
endoscopy were ultimately non-revealing. He was discharged on
PPI once he was HD stable with resolution of melana. Patient was
subsequently seen by GI in [**Month (only) 958**] at which time it was
recommended that he undergo endoscopy with endoscopic placement
of capsule in the event of repeat bleed.
On arrival to the MICU, the patient's VS were: 98.6 82 82/46
97%RA. He denied shortness of breath and reported feeling
better.
Review of systems:
(+) Per HPI
(-) Denies fever, cough, chest pain, chest pressure,
palpitations, vomiting, diarrhea, constipation, abdominal pain,
dysuria.
Past Medical History:
# CAD: s/p anterior STEMI ([**2112-1-29**])
-- s/p DESx2 to LAD, angioplasty with clot retrieval of Diagonal
-- Post MI had LVEF 30% with apical akinesis
-- Last TTE ([**2112-3-8**]) with LVEF 55-60% and apical hypokinesis
# Dyslipidemia
# Achalasia: massively dilated on recent EGD ([**2112-2-26**])
-- Balloon dilatation ([**2094**])
-- s/p Laparoscopic [**Doctor Last Name **] myotomy ([**2111-12-8**])
# GI Bleeding
-- BRBPR with admission ([**2112-2-20**]) no source found
-- Melena with ICU admission ([**2112-3-4**]) no source found
# Phimosis
# BPH
Social History:
# Home: Divorced and lives alone. Does not have HHA or VNA.
Daughter is HCP - [**Name (NI) **] - Pharmacist at [**Name (NI) 112**].
# Work: Works at Arsenal Mall at photography kiosk.
# Tobacco: None
# Alcohol: None
# Drugs: None
Family History:
Family History: (per records)
# Mother: MI, CVA, and DVT
# Father: DVT
# Brother: Congenital heart disease
# Daughter: Achalasia
Physical Exam:
Admission Examination
Vitals: 98.6 82 82/46 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, pale conjunctiva, MMM, oropharynx
clear, PERRL
Neck: supple, JVP not elevated
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, 1+ edema at ankles
bilaterally
Neuro: grossly intact
Pertinent findings at discharge:
BP remains borderline low, with SBPs 98-120 on day of discharge
No Tachycardia (off BP medications)
No rales or rhonchi on lung exam
No LE or peripheral pitting edema
Pertinent Results:
ADMISSION
.
[**2112-7-20**] 07:45PM BLOOD WBC-24.5*# RBC-2.66*# Hgb-7.0* Hct-22.8*
MCV-86# MCH-26.4*# MCHC-30.8*# RDW-23.2* Plt Ct-326
[**2112-7-20**] 07:45PM BLOOD Neuts-90.0* Lymphs-7.2* Monos-2.7 Eos-0
Baso-0.1
[**2112-7-20**] 07:45PM BLOOD PT-10.5 PTT-20.4* INR(PT)-1.0
[**2112-7-20**] 07:45PM BLOOD Glucose-164* UreaN-43* Creat-0.8 Na-136
K-4.0 Cl-103 HCO3-23 AnGap-14
[**2112-7-20**] 07:53PM BLOOD Lactate-4.8*
[**2112-7-20**] 08:31PM BLOOD Lactate-3.7*
[**2112-7-20**] 11:05PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2112-7-20**] 11:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
.
CXR [**7-20**]
FINDINGS: AP upright and lateral views of the chest were
provided. In this patient with known achalasia and dilated
esophagus, there is no change in the appearance of the dilated
distal esophagus which contains ingested debris. There is no
sign of aspiration. Heart size cannot be readily assessed. No
large pleural effusion. No pneumothorax. Bony structures
intact.
IMPRESSION: Dilated distal esophagus as seen previously
containing ingested food contents. No signs of aspiration.
Please refer to prior CT torso for full descriptive details of
esophageal abnormalities.
.
EKG: NSR, flattening of TWs in lateral leads not very
significant when compared to prior EKG from [**5-/2112**]
.
Discharge:
**EGD with small bowel enteroscopy: Mucosal laceration with
contact bleeding was noted in the lower third of the esophagus.
Evidence of free sloughing of epithelium and contact bleeding
was seen at the lower esophagus.
Tortuous and massively dilated esophagus; moderate amount of
liquid and solid food found in the mid to lower esophagus.
Friability, contact bleeding, and mucosal sloughing were noted
in the lower third of the esophagus. This may be reflective of
underling esophagitis in setting of chemical/acid irritation
from fluid retention within esphagus, and may be a contributing
factor to bleeding.
**A capsule endoscope was synchronized. It was loaded on the
scope by grabbing with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] net. It was inserted and
successfully released in duodenum.
.
[**2112-7-24**] WBC-6.3 RBC-3.62* Hgb-9.9* Hct-30.2* MCV-83 MCH-27.5
MCHC-32.9 RDW-22.4* Plt Ct-298
[**2112-7-20**] Ret Man-4.9*
[**2112-7-23**] Glucose-118* UreaN-10 Creat-0.7 Na-141 K-3.4 Cl-108
HCO3-28 [**2112-7-21**] Albumin-2.7* Calcium-7.5* Phos-3.1 Mg-2.1
Brief Hospital Course:
Mr [**Known lastname 39221**] is a 63 year old male with CAD s/p STEMI ([**2112-1-29**])
with DESx2 to LAD on Aspirin and Clopidogrel, achalasia with
history of GI bleeding with unclear source requiring ICU
admission ([**3-/2112**]), who presents to the ED with fatigue,
shortness of breath and found to have significant anemia with
associated guaiac + stools and hypotension.
# UGI Bleed
Patient has h/o recurrent GIB with multiple admissions,
including recent ICU admission. Previous work-up, including EGD,
colonoscopy, MRE and capsule endoscopy have been unable to
localize source of bleed. Presents with with HCT of 22 and
hypotension with documented melenic guaiac positive stools and
elevated BUN concerning for upper GI source of bleeding. He was
treatd with IV PPI. The patient [**Year (4 digits) 1834**] EGD on [**7-21**] which
showed a mucosal laceration with contact bleeding in the lower
third of the esophagus. There was a small amount of bright red
blood oozing from the underlying tissue. Given suboptimal study
with copious food/fluid in the whole esophagus and proximal
stomach, the patient was placed on a clear liquid diet with plan
for repeat enteroscopy attempt and capsule placement. He was
treated with IV PPI. He received 3 units of PRBCs and about 4L
of fluid during the first 24hours of his [**Hospital Unit Name 153**] course with HCT
increase from 22 to 27. His hematocrit thereafter remained
stable. Capsule endoscopy was initiated on [**7-22**], and he remained
clinically stable. He was transferred to the medical floor on
[**7-23**]. He was started on a clear liquid diet, which he tolerated
well. PPI was switched to po, and Hct remained stable around
28-30. The capsule endoscopy will be read on [**7-25**] and the
patient and his daughter are aware that they should expect a
phone call from the GI clinician [**Location (un) 1131**] the scan at that time.
The patient provided his information at work, including his
telephone number and availability on Monday [**7-25**], which was
passed along to the GI team. Tel: [**Telephone/Fax (1) 39222**].
# Hypotension
Baseline from previous records: 110-130 sbps. Patient with SBP
in 90s s/p 3L NS. Hypotension is secondary to hypovolemia in
setting of acute blood loss. In addition, patient took his
antihypertensives on the morning of admission. Patient does have
elevated WBC but suspicion for infection is very low at this
time. BP improved with blood transfusion in addition to isotonic
IVF. On the medical floor, his antihypertensives were not
reintroduced prior to discharge, given persistent borderline to
low BPs. He was instructed to see his internist, Dr [**Last Name (STitle) **],
within several days following discharge, as we suspect as he
heals these medications will again be needed.
# Acute blood loss anemia
Patient with HCT 40 baseline in [**12/2111**] prior to onset of GIB.
Baseline since then ranges in 26-30, presumably all secondary to
blood loss. Found to have significant iron deficiency with
ferritin of 5 on [**6-25**]. Patient now receiving IV iron infusions
([**2112-6-30**] and [**2112-7-8**]) in outpatient setting. As noted above,
he was transfused a total of 3U PRBCs in the [**Hospital Unit Name 153**], and Hct
stabilized around 27. On the medical floor, Hct remained stable
around 28-30.
# Leukocytosis
Patient with WBC or 24.5 on admission. He is afebrile with no
localizing symptoms of infection. His CXR and u/a are within
normal limits. No indication at this time to start empiric
antibiotics. Likely secondary to stress response to anemia/
acute GIB.
# CAD
Patient with h/o STEMI ([**2112-1-29**]) s/p DESx2 to LAD,
angioplasty with clot retrieval from Diagonal. Post-MI LVEF 30%
with apical akinesis, but recent TTE in [**2112-3-8**] with LVEF 55-60%
and apical hypokinesis. Patient currently on clopidogrel and
ASA. No concerning EKG changes or symptoms. As he had no large
volume GIB overnight, he was continued on ASA 81mg and
clopidogrel 75mg daily.
# HTN
Home regimen of lisinopril 5mg daily and metoprolol ER 50mg
daily were held in the [**Hospital Unit Name 153**] due to hypotension and acute GIB. On
the medical floor, they were not reintroduced prior to
discharge, as noted above. His SBP was 98-120 on the day of
discharge without evidence or symptoms of orthostasis or chest
discomfort. His tamsulosin was also held due to low blood
pressures.
# Achalasia: increased pantoprazole to [**Hospital1 **]. Evidence of
esophagitis on evaluation, s/p prior myomectomy.
# Hyperlipidemia: Statin was held while NPO in [**Hospital Unit Name 153**].
Atorvastatin 80mg was resumed at the time of discharge.
# BPH: Tamsulosin and finasteride were held in [**Hospital Unit Name 153**] in setting
of hypotension. On the medical floor finasteride was restarted,
but the tamsulosin was not, given above-noted relative
hypotension. [**Name2 (NI) **] noted no difficulty with urination during the
admission.
# CODE STATUS: full code
# Communication: Patient and daughter/HCP: [**Telephone/Fax (1) 39223**].
Discharge instructions reviewed with daughter at bedside, and
with patient earlier with assistance of a russian interpreter
via phone as bedside interpreters were not available. The
patient expressed understanding of the important role that his
oral intake including coffee and hard or spicy foods might play
in his esophageal irritation. He was also aware of the central
importance of close follow-up of his medical issues.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
10. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day: This is
increased from once daily prior to admission.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day:
Per your home routine.
Held at discharge, to be restarted in follow-up: (as noted to
patient)
Metoprolol ER 50mg daily
Lisinopril 5mg daily
Tamsulosin 0.4mg qhs
Patient reports not taking bowel regimen, so medications not
restarted.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
#Acute upper GI bleed due to esophageal irritation
#Acute blood loss anemia
#h/o Achalasia s/p myomectomy
Secondary:
Coronary artery disease, s/p STEMI [**12/2111**]
Hyperlipidemia
BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to care for you during your admission. As you
know, you were admitted due to a low blood count that we feel is
related to irritation in your esophagus. While this is not
directly related to your prior surgery, it is likely that
increased acid levels with reflux to your esophagus will
continue to make this worse.
***We have increased your acid blocking [**Doctor Last Name 360**] due to the
irritation seen in your esophagus, and it is very important that
you take the higher dose until your GI doctor tells you to
decrease back down to once a day.***
It is also important that you avoid foods that make you have
your discomfort in your chest/esophagus, as you noted to us.
These foods are likely increasing the irritation, and can put
you at increased risk of having another bleeding episode.
Changes to your medications:
-Increase your pantoprazole from once to twice daily
-Please HOLD your blood pressure medications lisinopril and
metoprolol until you see Dr [**Last Name (STitle) **] due to low blood pressures
(100s) while you were in the hospital. You should see Dr [**Last Name (STitle) **]
within 2-4 days of discharge as we expect you will need these
medications restarted soon.
-Please HOLD your tamsulosin until you see Dr [**Last Name (STitle) **], due to the
same low blood pressures while you were in the hospital.
Continue taking your aspirin and clopidogrel as you were doing
prior to this admission. These are for your stents and heart
disease.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please see Dr [**Last Name (STitle) **] within one week from discharge, and he
should check your blood count. We were not able to schedule this
appointment for you because you were discharged over the
weekend, so please call Monday morning to his office to schedule
an appointment.
Department: CARDIAC SERVICES
When: MONDAY [**2112-8-8**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Gastroenterology:
We were unable to make you an appointment before you left, but
someone from GI will call you to schedule an appointment. In
addition, you should receive a call tomorrow, MONDAY [**7-25**]
with the results of your capsule study. You will be called
either with the Russian Interpreter, or someone will call your
daughter [**Name (NI) **] to give her the results.
Please continue with your previously scheduled appointments:
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2112-9-16**] at 1 PM
With: PELVIC FLOOR UNIT [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2851, 4589, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7048
} | Medical Text: Admission Date: [**2189-6-27**] Discharge Date: [**2189-7-4**]
Date of Birth: [**2110-4-8**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Nsaids
Attending:[**First Name3 (LF) 58653**]
Chief Complaint:
transfered from [**Hospital 8**] hospital to evaluate bilateral leg
weakness by spinal MRI
Major Surgical or Invasive Procedure:
epidural abscess debridement
History of Present Illness:
79 yo Spanish speaking male with a h/o DM2, HTN, Pulm HTN, AF,
CRI was transfered from [**Hospital 8**] Hospital for an MRI of his
spine to evaluate for epidural abscess secondary to bilateral
lower extremity weakness. The physicians at [**Hospital 8**] hospital
were concerned about cord compression or cauda equina syndrome
and wanted him transfered to a hospital with a neurosurgical
service backup. He is also here for an MRI despite the bullet
logged in his buttocks to evaluate for these conditions. He was
recently discharged from [**Hospital1 18**] back to [**Hospital 8**] Hospital after
evaluation for trachealmalacia which he did not seem to have.
His problem list includes recent [**Name (NI) 8974**] bacteremia with an unknown
source (TEE was negative and multiple CT scans of his abdomen
and plevis were negative for abscess or mass), pleural based
mass and now complaining of bilateral lower extremity weakness.
Of note, one CT scan showed sigmoid colitis for which he is
being treated with flagyl and ceftriaxone. With his transfer
paper work, his WBC was noted to be 17.5 with 96%neutrophils.
. Currently, he says he has pain in both legs, right more than
left. He says that he can not stand up and walk and he feels
weak. He denies currently SOB, CP, abdominal pain, HA or change
in vision.
Past Medical History:
[**Name (NI) 8974**] bacteremia on nafcillin since [**2189-6-15**]
CRI- baseline Cr 1.7, Unknown etiology
Paroxysmal A fib
HTN
Pulm HTN
Hypercholesterolemia
DM2
Hepatic steatosis
Osteroarthritis
Bilateral knee replacement
Bullet in buttocks
Social History:
no significant tob use, no drugs. Married.
Family History:
Non-contributory
Physical Exam:
VS T 100.3, BP 112/59 P 84, R 18, O2sat 96%on 2L wt. 118.3 KG
GEN - Obese man lying in bed with sunglasses on, in NAD, Foley
cath in place.
HEENT: EOMI, PERRL, tachy MM, clear OP, no LAD
CV: heart sounds distant secondary to body habitus, RRR normal
S1 S2 no murmur heard
Lungs: distant breath sounds, but lungs sound CTAB
Abdomen: +BS, soft NTND
Extremities: 2+edema in bilateral lower extremities.
Neuro: He can only just slightly move his legs (left more than
right) against gravity. Patellar reflexes can not be elicited
secondary to his bilateral knee replacements. Achilles tendons
showed no reflexes but of note, he is quite edematous and has a
long history of DM. No Babinski reflex bilaterally. Unsure about
sensation in his feet bilaterally given probably neuropathy but
he does have sensation in his thighs bilaterally.
Pertinent Results:
[**2189-6-28**] MRA brain: FINDINGS: Multiple bilateral periventricular
hyperintensities are noted on the FLAIR images, but there is no
evidence of acute stroke on the diffusion- weighted images. On
the MR angiography, there is hypoplastic T1 segment on the right
side with fetal PCA, which is a normal variant. No evidence of
stenosis or occlusion of vessels of Circle of [**Location (un) 431**].
IMPRESSION:
1. No acute infarct.
2. Chronic microvascular disease
.
.
[**2189-6-28**] MRI T- spine: FINDINGS: The study is extremely limited
due to the extensive motion artifacts. However, there appears to
be epidural abscess in the mid thoracic region which is however
not clearly visualized due to the artifacts. Cord compression
cannot be assessed due to the motion artifacts. On the axial
images, there also appear to be pre- and paraspinal soft tissue
signal intensity abnormalities on the right and right paraspinal
pleural-based mass.
IMPRESSION:
Epidural abscess in the mid thoracic region. Cord compression
not adequately assessed due to the motion artifacts. Right
paraspinal pleural-based soft tissue swelling.
Recommend to repeat MRI if possible for better evaluation.
Findings were discussed with Dr. [**Last Name (STitle) 29932**] by Dr. [**Last Name (STitle) **] on [**2189-6-29**]
noon. Please note that the preliminary report is discrepant from
the final report and the final report findings were conveyed to
Dr. [**Last Name (STitle) 29932**].
.
.
[**2189-6-28**] MRI L-spine: FINDINGS: There is evidence of degenerative
disc disease with spinal canal stenosis at L3-4, L1-2 level and
L4-5 level. Degenerative changes are also noted in the vertebral
bodies.
There is linear enhancing tissue noted in the epidural region at
T12-L2 level, likely due to epidural abscess. However, the upper
extent of this is not visualized on the L-spine MRI. Cord
compression cannot be adequately assessed. No pre- or
para-vertebral soft tissue abnormality.
IMPRESSION:
Degenerative disc disease with associated lumbar spinal canal
stenosis.
Epidural abscess at T12-L2 level with superior extent not
demarcated on the L- spine MRI.
Please also see the thoracic spine MRI report, performed on the
same day and dictated separately.
Brief Hospital Course:
Mr. [**Known lastname 46719**] is a 79 yo Spanish speaking male with a history of
[**Known lastname 8974**] bactermia with unknown etiology, DMII, Afib, chronic renal
failure who was transfered to [**Hospital1 **] from [**Hospital 8**] hospital to
evalute his bilateral LE weakness with an MRI of the spine.
On admission, his nafcillin was continued for this [**Hospital 8974**] (first
noted on [**2189-6-12**] at [**Hospital 8**] hospital). The metronidazole and
ceftriaxone were discontinued.
He was noted to have an extremely elevated CK [**Numeric Identifier 67715**] rising to
>[**Numeric Identifier 3652**] in the presence of acute on chronic renal failure. He
was given IVF with bicarb flush his kidneys. THrough this he
continued to make sufficient UOP- with Foley cath in place. THe
reason for this rhabdo is unknown at this time. Nephrology is
following.
MRI of the spine on [**2189-6-28**] showed possible epidural and
paraspinal abscesses with questionable cord compression. He was
noted on physical exam to have no rectal tone.
Orthopedics/spine was consulted. Neurology is also consulted.
After coding in the OR, pt was transferred to the MICU, where he
was maintained on pressors, CVVH and ventilated. on [**7-4**], the
decision was made to convert the patient to CMO, and patient
expired on [**7-4**] at [**2102**].
Medications on Admission:
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Diltiazem HCl 60 mg Tablet Sig: 1 Tablet PO TID (3
times a day).
Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five
(5) units Subcutaneous twice a day.
Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
ceftriaxone 1g IV q24hrs.
Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2)
Intravenous Q4H (every 4 hours).
Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Discharge Diagnosis:
[**Year (4 digits) 8974**] bacteremia, paroxysmal Afib, acute on chronic renal
failure, CAD, HTN, DMII
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17007**] MD [**MD Number(2) 58655**]
Completed by:[**2189-7-4**]
ICD9 Codes: 5845, 4275, 5859, 2875, 2762, 2767, 5185, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7049
} | Medical Text: Admission Date: [**2116-6-29**] Discharge Date: [**2116-7-3**]
Date of Birth: [**2074-12-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
lotions/creams / Adhesive
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic with Aortic Aneurysm
Major Surgical or Invasive Procedure:
Replacement of ascending aorta and hemiarch [**2116-6-29**]
History of Present Illness:
41 year old asymptomatic pleasant female with a history of
bicuspid aortic valve, first diagnosed 20 years ago, followed by
serial echocardiograms. Echo done at [**Hospital3 **] in
[**2114**]
showed dilated proximal aorta dilated at 4.6-4.7cm. Another echo
was performed on [**2116-5-21**] which showed likely bicuspid valve with
mild to moderate aortic regurgitation. The aorta was aneurysmal
with ascending aorta measured at 5cm. She then underwent a chest
CT which showed the aortic root to be aneurysmal at 4.9x4.2cm
and
ascending aorta at 5.2x4.9cm. She currently denies any symptoms
of chest pain, shortness of breath, orthopnea or edema. Due to
the current and increase in size of aneurysm, she presents
for second opinion regarding surgical replacement of aorta.
Past Medical History:
Bicuspid Aortic Valve
Contact Dermatitis
Obesity
Hematuria
Asthma
Past Surgical History:
s/p Novasure Uterine ablation
Social History:
Lives with: Husband
Contact: [**Name (NI) 4906**] Phone #
Occupation: Hair dresser
Cigarettes: Smoked no [] yes [x] last cigarette [**2111**] Hx: 1PPd x
20yrs
Other Tobacco use: -
ETOH: < 1 drink/week [X] [**1-6**] drinks/week [] >8 drinks/week []
Illicit drug use: Occ. MJ use
Family History:
No premature coronary artery disease denies
Mother living w h/o breast cancer, DM, htn
Father living with h/o Monoclonal Gammopathy, CVA, aneurysm
repair
Physical Exam:
Pulse: 86 Resp: 16 O2 sat: 100%
B/P Right: 113/83
Height: 5'4" Weight: 221 lbs
General: Well-developed female in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur []
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema []
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2116-7-2**] 04:32AM BLOOD WBC-12.1* RBC-3.00* Hgb-9.3* Hct-26.2*
MCV-87 MCH-31.1 MCHC-35.6* RDW-12.8 Plt Ct-182
[**2116-7-2**] 04:32AM BLOOD Glucose-118* UreaN-16 Creat-0.8 Na-135
K-4.2 Cl-97 HCO3-30 AnGap-12
Intra-op TEE [**2116-6-29**]
Conclusions
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). The right
ventricular cavity is dilated with normal free wall
contractility. The ascending aorta is moderately dilated. The
dilation occurs just a few centimeters above the sinotubular
junction. The upper extent of the anuerysm can not be
determined. There are simple atheroma in the descending thoracic
aorta. The aortic valve appears to have 3 leaflets congenitally
but the left and right cusps appear fused resulting in a
functionally bicuspid valve. The aortic valve leaflets are
mildly thickened . There is no aortic valve stenosis. Mild to
moderate ([**12-1**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Physiologic mitral regurgitation
is seen (within normal limits). Dr. [**Last Name (STitle) **] was notified in
person of the results in the operating room at the time of the
study.
POST BYPASS The patient is atrially paced. There is normal
biventricular systolic function. The ascending aortic aneurysm
has been resected but that portion of the aorta can not be seen
very well. The aortic valve remains as in the pre-bypass study.
However, the aortic regurgitation appears somewhat improved, now
mild, and is eccentrically directed towards the anterior mitral
valve leaflet. The descending thoracic aorta and aortic arch
appear intact after decannulation.
Brief Hospital Course:
On [**2116-6-29**] Ms.[**Known lastname 57141**] went to the operating room and underwent
Resection of the ascending aortic aneurysm, replacement of the
ascending aorta with a 28-mm
Gelweave tube graft. Cross Clamp time=37 minutes.
Cardiopulmonary Bypass time=56 minutes. Please see operative
report for further surgical details. She tolerated the procedure
well and was transferred to the CVICU intubated and sedated on
Propofol and Neo. She awoke neurologically intact and was
extubated without difficulty. She weaned off pressor and was
started on Beta-blocker/Statin/Aspirin and diuresis. All lines
and drains were discontinued per protocol. POD# 2 she was
transferred to the step down unit for further monitoring.
Physical Therapy was consulted for evaluation of strength and
mobility. The remainder of her postoperative course was
essentially uneventful. POD# 4 she was cleared for discharge to
home with VNA. All follow up appointments were advised.
Medications on Admission:
Zyrtec
Flonase
Albuterol inhaler
Vitamin D
Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
Disp:*10 Tablet Extended 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:*2*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS
DIRECTED).
Disp:*qs * Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Bicuspid Aortic Valve
Contact Dermatitis
Obesity
Hematuria
Asthma
Past Surgical History:
s/p Novasure Uterine ablation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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) **] on [**8-5**] at 1:15pm in the [**Hospital **] medical
office building [**Hospital Unit Name **]
wound check on [**8-9**] at 11:00 in the [**Hospital **] medical office
building [**Hospital Unit Name **]
Cardiologist: Dr.[**Last Name (un) 88905**] call to make an appointment
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 65689**] in [**3-3**] 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:[**2116-7-3**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7050
} | Medical Text: Admission Date: [**2198-12-10**] Discharge Date: [**2198-12-17**]
Date of Birth: [**2124-7-24**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 74 year old with
complaints of fatigue, shortness of breath and dyspnea on
exertion which has increased over the past two years and
especially over the past two weeks. He refused surgery two
years ago for severe mitral regurgitation.
PAST MEDICAL HISTORY: Hypertension, bilateral knee
replacement, colostomy and reversal, bilateral cataract
surgery, severe pulmonary hypertension and atrial
fibrillation.
PHYSICAL EXAMINATION: 83, regular, 135/70, 70, 206 lbs.
General: In no acute distress. Skin: Normal skin turgor,
mucous membranes moist. Head, eyes, ears, nose and throat:
Extraocular muscles intact. Neck: No jugulovenous
distension, no left anterior descending. Chest: Clear to
auscultation bilaterally. Cardiovascular: Regularly
irregular rhythm with II/VI systolic murmur. Abdomen: Soft,
nontender, nondistended, no masses, no hepatosplenomegaly.
Extremities: Right greater than left. Neurological: 5/5
strength bilaterally. Pulses: Femoral right 2+/left 2+,
dorsalis pedis 1+/1+, posterior tibial 1+/1+, radials 2+/2+.
Carotid bruits: None.
LABORATORY DATA: Electrocardiogram, 76, atrial fibrillation,
with [**Street Address(2) 4793**] depressions in V3 through V6.
HOSPITAL COURSE: The patient was admitted [**2198-12-10**]
for mitral valve replacement, maze procedure. The patient
tolerated the procedure well. Postoperative was complicated
by ventricular arrhythmia and then heartblock. The patient
was unable to maintain blood pressure without pressors at
first and then weaned off successfully. The patient was then
in atrial fibrillation with complete heartblock and needed to
be paced with epicardial pacer placed during surgery.
Heparin was started for anticoagulation. Electrophysiology
Study Service was consulted and the patient was electrically
converted to normal sinus rhythm using 200 joules after
holding heparin drip. The patient was stable and transferred
to the surgical floor. The patient was started on 400 q.d.
Amiodarone. Heparin was continued. The patient was started
on Coumadin. The patient is to follow up with Dr.
[**Last Name (STitle) 284**].
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSIS:
1. Status post maze procedure with mitral valve replacement.
FOLLOW UP: Follow up with Dr. [**Last Name (STitle) **] in four weeks, Dr.
[**Last Name (STitle) 284**] on [**2199-1-21**] at 4 PM (Monday), [**Telephone/Fax (1) 285**].
[**Known firstname 275**] [**Name8 (MD) **], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2198-12-19**] 17:05
T: [**2198-12-19**] 17:57
JOB#: [**Job Number 46963**]
ICD9 Codes: 9971, 4271, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7051
} | Medical Text: Admission Date: [**2154-6-8**] Discharge Date: [**2154-6-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Fatigue, n/v
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 3175**] is an 85 yo female with history of atrial
fibrillation, hypertension, chronic kidney disease, who presents
with one week of progressive fatigue. She was feeling like her
usual self until [**5-31**] when she sustained a mechanical fall.
She was walking downstairs backwards carrying a meal tray and
slipped and fell when she miscalculated the number of steps. She
hit her head, R shoulder, and R hip. No loss of consciousness,
no LH or dizziness, no incontinence of stool or urine associated
with the fall. She was able to walk the next few days, but had
some pain in shoulder and hip that progressively worsened to
generalized pain all over. Starting on [**6-3**] she began to develop
progressive general fatigue and malaise. This progressed to the
point that yesterday pt was too tired to move out of bed. She
has also had decreased PO intake over this same time period.
This morning, after eating a bowl of cereal she developed nausea
and vomitted x1. She also notes some SOB and mild non-productive
cough that started today. Her husband and son were worried about
her and so brought her to the ED for further evaluation.
In the ED, initial vitals were: T 101.7, P 92, BP 134/60, RR 20,
O2 sat 88% on RA-->93% on 5L. Her blood pressure dropped as low
as the 80s systolic and she received a total of 2L NS with good
response. Labs were notable for WBC of 11.4 with 96%
neutrophils, lactate of 2.7 (improved to 1.2 after IVF), BNP of
2284, Hct of 26 (baseline low-mid 30s), Na of 128, and Cr 4.3
(from baseline 1.9). CXR showed a new right pleural effusion
along with a right-sided infiltrate. Xrays of the right shoulder
and bilateral hips were negative for fracture. CT head was
negative. Patient was given levofloxacin 750mg PO x 1 and
tylenol 650mg PO x 1. She is being admitted to the ICU for close
monitoring.
On arrival to the [**Hospital Unit Name 153**], she notes feeling a bit shaky and has a
mild non-productive cough. She denies feeling short of breath.
Past Medical History:
Atrial fibrillation (not on anticoagulation)
Hypertension
Congestive Heart Failure
Renal cell carcinoma s/p nephrectomy and radiotherapy
Chronic kidney disease, baseline Cr 1.6-1.7
Rectal ca s/p low ant resection and colostomy
Deaf
Partial R CN III palsy
Osteoarthritis of the hips
s/p Hysterectomy
Social History:
Lives at home with her husband and her son. [**Name (NI) 6419**] the patient and
her husband are deaf, but she is able to read lips. Her son is
able to speak sign language. At baseline, she is independent of
all ADLs and overall high functioning. She formerly worked as a
seamstress for the original Filene's store. No history of
smoking but did have extensive secondhand smoke exposure due to
her husband being a heavy smoker for many years. Very rare EtOH
intake. No history of illicit drug use.
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: T: 99.3, BP: 114/47, P: 81, R: 15, O2: 95% on 4L
General: Alert, oriented, elderly deaf female in no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds at the right base, no wheezes,
rales
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
+colostomy bag, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 1+ LE edema, large echymoses at R
shoulder and hip, FROM in both joints, 2+ pulses, no clubbing,
cyanosis
Discharge:
Afebrile 97.5 155/78 76 20 93% RA
GEN: pleasant, non-toxic, well appearing.
HEENT: eomi, mmm
CV: RRR. no mrg.
RESP: Some mild rales R Lung fields, good AE and insp effort.
Abd: soft, nt/nd. Ostomy in place, pink, brown stool in bag.
Ext: 1+ edema LE B.
Neuro: deaf. otherwise CN2-12 grossly intact. Moves all 4. No
focal defecits.
Pertinent Results:
[**2154-6-8**] WBC-11.4* RBC-2.97* Hgb-9.1* Hct-26.9* MCV-91 MCH-30.6
MCHC-33.8 RDW-13.8 Plt Ct-326
Neuts-96.2* Lymphs-1.9* Monos-1.5* Eos-0.4 Baso-0.1
Iron-12* calTIBC-183 Hapto-565* Ferritn-605* TRF-141* Ret
Man-1.2LD(LDH)-287* TotBili-0.8 CK(CPK)-348*
[**2154-6-8**] 10:20AM BLOOD Glucose-139* UreaN-56* Creat-4.3* Na-128*
K-3.9 Cl-93* HCO3-22 AnGap-17
[**2154-6-8**] 10:20AM BLOOD proBNP-2284*
[**2154-6-8**] 09:46AM Lactate-2.7*
[**2154-6-8**] 01:52PM Lactate-1.2
[**2154-6-8**] 12:18PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2154-6-13**] 06:30AM BLOOD WBC-5.6 RBC-3.17* Hgb-9.5* Hct-28.4*
MCV-90 MCH-30.0 MCHC-33.5 RDW-15.1 Plt Ct-299
[**2154-6-11**] 03:52PM BLOOD Glucose-130* UreaN-80* Creat-5.3* Na-132*
K-3.8 Cl-99 HCO3-18* AnGap-19
[**2154-6-12**] 05:39AM BLOOD Glucose-97 UreaN-81* Creat-5.2* Na-132*
K-3.3 Cl-96 HCO3-23 AnGap-16
[**2154-6-13**] 06:30AM BLOOD Glucose-114* UreaN-80* Creat-4.8* Na-134
K-3.6 Cl-98 HCO3-24 AnGap-16
[**2154-6-14**] 05:40AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
[**2154-6-11**] 04:24AM BLOOD ALT-54* AST-65* AlkPhos-132* TotBili-0.4
[**2154-6-8**] 10:20AM BLOOD cTropnT-0.07*
[**2154-6-9**] 02:00AM BLOOD CK-MB-6 cTropnT-0.06*
[**2154-6-9**] 10:03AM BLOOD CK-MB-5 cTropnT-0.06*
[**2154-6-13**] 06:30AM BLOOD Phos-3.9 Mg-1.8
[**2154-6-14**] 05:40AM BLOOD Phos-PND Mg-PND
[**2154-6-8**] 05:48PM BLOOD calTIBC-183 Hapto-565* Ferritn-605*
TRF-141*
Urine legionella antigen: Positive
Culture data
Urine culture ([**2154-6-8**]): no growth
Blood culture: pending x5
Imaging:
Renal U/S of right kidney:
1. No hydronephrosis in the right kidney.
2. Evidence of RFA treated lesion within the right kidney, as
seen on prior MRI. Several small simple renal cysts in the right
kidney, as seen on prior MRI.
Echo ([**2154-6-10**]): The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
AP portable CXR ([**2154-6-10**]): Bilateral pleural effusion, large on
the right and moderate on the left, has increased since [**6-8**].
Lung bases are largely obscured but pneumonia could be present.
Heart is at least mildly enlarged. Left upper lobe is clear.
Right upper lobe vasculature is engorged suggesting a
substantial component of cardiac decompensation.
Chest CT ([**2154-6-10**]): IMPRESSION: Extensive right lower lobe
consolidation and opacity, strongly suggesting pneumonia, with
an accompanying moderate reactive pleural effusion. Minimal
effusion on the left, with adjacent area of atelectasis.
No evidence of hilar or mediastinal lymphadenopathy, the
other parts of the lung are unremarkable, taking the multiple
motion artifacts into
consideration. No evidence of lymphadenopathy, coronary
calcifications, clips in the left upper abdomen.
U/S of lung to assess for diagnostic purposes: Small area of
fluid in left pleural cavity, not enough to tap.
B LENI:
1. No evidence of deep venous thrombosis in either lower
extremity.
2) Cystic lesion in the right groin, likely representing a
lymphocele, which appears stable from the prior CT scan
performed in [**2147**].
Cardiac Echo:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
Brief Hospital Course:
85 year-old female with CHF, afib, HTN, CKD, recent fall,
presenteed with malaise, cough, hypoxia, new bilateral
effusions, anemia, and acute renal failure. Pt was subsequently
diagnosed with Legionella pneumonia and acute renal failure due
to ATN.
# RLL pneumonia with bilateral pleural effusions: Most likely
etiology of pt??????s leukocytosis and fever. Urine legionella
antigen was positive, so likely cause of pneumonia. CXR showed
pleural effusion on the R with a consolidation in the R lower
lobe. CT scan showed bilateral pleural effusions and R-sided
consolidation in lower lobe. Sputum Cx canceled by lab because
of contamination w/ upper resp. secretions. On Levofloxaxin 250
mg PO daily for treatment of Legionella PNA, suggest continue to
treat for a total of 14 days.
.
# Hypotension: Pt was fluid responsive, however relatively
hypotensive given she carries a history of hypertension on
multiple anti-hypertensive meds as an outpatient. Pt did not
require pressors in the ICU and was treated with fluid boluses
and 1 U PRBCs. LE dopplers ordered w/ no DVT found. On the
medical floor, her blood pressure slowly rose, and her
amlodipine was added back on the evening of [**6-13**] for SBP 196/86.
Multiple other cardiac medications remain held at the time of
discharge.
.
# Bilateral pleural effusions: New compared to CXR from one
year ago. Likely secondary to pneumonia. As of [**6-10**], pt was
planned to undergo thorocentesis to evaluate effusions but on
U/S too little fluid was seen for a succesful tap.
.
# Acute anemia: Concern for blood loss secondary to fall one
week ago, possible hematomas at shoulder and right hip. Hct
dropped from 34.6 one month ago to 28.2 today, but currently
trending up. Hemolysis labs were negative, iron studies
suggestive of anemia of chronic disease. She was transfused 2 U
in the [**Hospital Unit Name 153**] and aspirin and heparin were held. On the medical
floor H/H remained stable, and aspirin as added back at the time
of discharge.
.
# Acute on chronic renal failure: Initially thought to be
pre-renal in setting of hypovolemia and FeNa<1. Seen by renal
who concluded that pt most likely initially had pre-renal but
now has ATN, as a result of her pre-renal azotemia. Pt was
treated with IV fluid with intermittent bicarb and potassium
repletion. At time of discharge, renal function was continuing
to improve significantly, and pt was maintaining good UOP.
# Hyponatremia: Likely secondary to hypovolemia and HCTZ.
Improved with volume repletion and holding of HCTZ.
HCTZ remains held at the time of discharge.
.
# s/p Fall: History consistent with mechanical fall. No
evidence of fracture or ICH. No e/o bleed.
.
# Atrial fibrillation: patient remained in NSR throughout the
hospitalization. At the time of discharge, pt's propafenone was
held, and we suggest adding back as tolerated in the near
future.
.
# Hypertension: All home anti-hypertensives were held in the
ICU given her hypotension; amlodipine was added back as pt's BP
started to rise. HCTZ remains held d/t ARF and hyponatremia.
Lisinopril remains held d/t ARF.
# [**Last Name (LF) 9215**], [**First Name3 (LF) **] >55%: no evidence of decompensation during this
admission. Please add back cardiac medications, particularly
Rythmol 150 mg po TID, as tolerated.
DISPO: pt discharged to LTAC for ongoing medical care and rehab.
Medications on Admission:
ASA 81mg PO daily
Digoxin 125mcg PO 3x/week
HCTZ 25mg PO daily
Norvasc 5mg PO daily
Rythmol 150mg PO TID
Lisinopril 20mg PO daily
Zocor 20mg PO qHS
MVI 1 tab PO daily
SLN prn
Caltrate 600mg PLUS Vit D 200mg PO BID
Cyanocobalamin 1000mcg PO daily
Dairy digestive 9000 units 1-2 tabs PO prior to eating lactose
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days: Please monitor renal function and increase
dose to 500 mg if her renal function significantly improves.
2. Multivitamin 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 once a day.
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as dir as needed for chest pain: Take 1 tab q5 min
prn chest pains, up to 3 tabs. Seek medical attention.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Dairy Digestive 9,000 unit Tablet Sig: 1-2 Tablets PO prn as
needed for prior to consuming dairy (lactose).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection [**Hospital1 **] (2 times a day): discontinue when pt ambulating
frequently.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
# Legionella pneumonia
# Acute on chronic renal failure, acute tubular necrosis
# Hyponatremia
# Hypertension, benign
# Acute anemia, without bleeding
# Hx [**Last Name (LF) 9215**], [**First Name3 (LF) **] >55%
# Hx Paroxysmal afib
# Deafness, communicates via sign language
Discharge Condition:
stable
Discharge Instructions:
You were admitted with legionella pneumonia, and were also found
to have renal failure. You were treated with antibiotics for
your pneumonia, and provided IV fluids while your kidney is
healing. Please take your medications as prescribed. Please
seek medical attention if you develop fevers, chills, shortness
of breath, decreased urine output, or any other concerns.
Followup Instructions:
Please follow up with your primary care provider in late
[**Name9 (PRE) 205**]/early [**Month (only) 216**].
Please follow up with Dr. [**Last Name (STitle) **], Nephrology in mid-late [**Month (only) 216**].
Please call [**Telephone/Fax (1) 60**] if you have not been contact[**Name (NI) **] with an
appointment.
Please follow renal function and electrolytes closely after
discharge while at LTAC and thereafter.
Several of the patient's cardiac medications have been held in
the setting of acute illness. Please add medications back as
tolerated. Pt's cardiac medications currently not being
provided:
Digoxin 125 mcg po 3x/wk (hold until renal function improved)
Rythmol 150 mg po TID (propafenone)
Lisinopril 20 mg po qday
ICD9 Codes: 5845, 2761, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7052
} | Medical Text: Admission Date: [**2161-1-27**] Discharge Date: [**2161-2-12**]
Date of Birth: [**2093-10-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
CC:Spine Hardware protruding through skin. Left shoulder pain
Major Surgical or Invasive Procedure:
Thoracic wound debridement/hardware removal
Placement of VAC dressing
Flap rotation with thoracic wound closure
dobhoff placement
History of Present Illness:
HPI:67 yo male with metastatic thyroid CA to spine, who is well
known to this service presents from home with previously placed
spine hardware externalizing from his skin. There is associated
foul smelling drainage and erythema. He also has left shoulder
pain which began [**2161-1-26**] after feeling a "[**Doctor Last Name **]" in the shoulder
with no associated trauma.
Past Medical History:
Metastatic Thyroid Ca
HTN
Atrial Fibrillation
Pulmonary Embolus [**1-28**] - Anticoagulated with coumadin; has
two small lesions on MRI head c/w mets but not contraindications
to anticoag.
Hypothyroidism
Social History:
Lives with wife. Retired from full time work in [**2157-9-22**].
Smoked approximately 30 years ago (quit in [**2126**])
Family History:
Mother with h/o emphysema.
Physical Exam:
98% O2Sats 4L N/C
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMs full
Neck: Supple. No carotid upstrokes
Lungs: CTA bilaterally. Diminished Lt base
Cardiac: RRR. S1/S2. No gallop, M/R
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T IP Q H AT [**Last Name (un) 938**] G
R 4 4 4 4 4 4 5 5 4
L 4 4 4- 4 4 4 5 5 4
Sensation: Intact to light touch, propioception
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Propioception intact
Toes downgoing bilaterally
Pertinent Results:
CT/MRI: Thoracic Spine with no obvious thoracic fluid
collection.
Air in the prior drain site.
[**2161-1-27**] 08:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2161-1-27**] 08:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2161-1-27**] 12:00PM GLUCOSE-193* UREA N-18 CREAT-0.6 SODIUM-135
POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-31 ANION GAP-13
[**2161-1-27**] 12:00PM CRP-79.1*
[**2161-1-27**] 12:00PM WBC-12.8*# RBC-4.47* HGB-12.8* HCT-38.0*
MCV-85 MCH-28.7 MCHC-33.8 RDW-16.7*
[**2161-1-27**] 12:00PM NEUTS-96.0* LYMPHS-1.9* MONOS-1.7* EOS-0.3
BASOS-0.1
[**2161-1-27**] 12:00PM PLT COUNT-81*
[**2161-1-27**] 12:00PM SED RATE-40*
Brief Hospital Course:
Mr [**Known lastname 20598**] was admitted to the neurosurgery service after it
was noted that his spinal hardware was eroding through the skin.
He went to the OR and the wound was completely irrigated,
fibrous exudate was noted and a cross link was removed. In
conjunction with plastic surgery a VAC dressing was placed over
the wound. Post operatively he was back to his baseline
neurologic status, which was full motor strength with the
exception of his deltoids and slightly weaker left arm due to a
rotator cuff injury. Subsequent cultures showed STAPH AUREUS
COAG + he was placed on Vancomycin on admission that was
continued, a PICC line was also placed. The patient was started
on a calorie count due to his recent weight loss prior to
admission. On [**2-3**] he went to the OR in conjuction with plastic
to have a muscle flap placed for formal closure of the wound.
There were no perioperative complications to report.A dobhoff
feeding tube was also placed for good nutrition status while
wound healing. He has begun to work with PT again on [**2-4**]. He is
tolerating all p.o. food and fluids well with no nausea or
vomiting. Calorie counts have been maintained and nutrition made
recommendations on tube feeds for optimal support. He had JP
drains placed intra-op that are monitored for output and he will
go home with these. His dressings were dry with minimal
staining and monitored by plastic surgery. He was also followed
by hematology for a low platelet count and received platelet
transfusions peri-op.
Plans were made to discharge pt home with hospice but on [**2-6**] he
developed increasing oxygen needs. He recieved multiple doses
of lasix with good diuresis followed by chest xrays but
respiratory distress increased. He was transferred to ICU on
[**2-8**]. Conversations occurred between Dr. [**Last Name (STitle) 548**], the patient and
his wife with information provided by pts oncologist at [**Hospital1 2025**].
After discussions he was made DNR and DNI on [**2-10**]. Morphine IV
q1hr was begun, pt was transferred to the floor. Palliative
care service was consulted. After discussion, family wished
comfort measures. Feeding tube was removed at their request,
morphine drip with bolus doses and scopalamine patch were
initiated. On [**2161-2-12**] he expired.
Medications on Admission:
D
i
g
o
x
i
n
,
A
m
i
o
d
a
r
o
n
e
,
G
a
b
a
p
e
n
t
in,Dexamethasone,Omeprazole,Senna,Oxycodone,OxyconTin,Metoprolol
XL, Levothyroxine,
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic thyroid cancer
MRSA wound infection
pressure ulcer- stage 3, thoracic spine
respiratory distress
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2161-2-12**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7053
} | Medical Text: Admission Date: [**2142-4-7**] Discharge Date: [**2142-4-11**]
Date of Birth: [**2090-7-12**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 51-year-old
male with no significant past medical history who presented
earlier this evening to [**Hospital3 **] Medical Center
complaining of substernal chest pain associated with dyspnea
and diaphoresis times 30 minutes. EKG disclosed ST segment
elevation in II, III, aVF, ST segment depression in I, aVL,
V1 through V4. The vital signs at the outside hospital
included a blood pressure of 98/palpable, heart rate 84,
respiratory rate 20, 02 saturation 98% on room air. The
patient was given Retavase times two. The patient still
complained of chest pain and was transferred by helicopter to
[**Hospital1 18**]. While in the helicopter, the patient became
pain-free.
At [**Hospital1 18**], the patient was immediately taken to the
Catheterization Laboratory. He was found to have occlusion
of the distal RCA. He underwent Angiojet thrombectomy times
one and removal of the thrombus. Two stents were placed in
the RCA. Final residual was 0% stenosis with normal flow.
The patient was transferred to the CCU overnight.
PAST MEDICAL HISTORY: None.
ADMISSION MEDICATIONS: None. The patient takes aspirin
"once a week" for shoulder pain/neck pain.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: The patient's father died in his 50s of a
heart attack. His mother had lung cancer and thyroid
problems.
SOCIAL HISTORY: The patient is a former smoker. He quit
approximately three weeks ago. He smoked a half a pack per
day times ten years. He lives with his wife. [**Name (NI) **] has one
daughter. [**Name (NI) **] is employed as a salesman. He drinks
approximately a six-pack per week. He denied the use of
drugs.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient was
an obese male, lying in bed, in no apparent distress. Vital
signs: Temperature 98.9, blood pressure 130/90, heart rate
90, respiratory rate 16, saturations 96% on 2 liters. HEENT:
Normocephalic, atraumatic. Pupils equal, round, and reactive
to light. Extraocular movements intact. The membranes were
moist. The oropharynx was clear. Neck: JVP at ear. Heart:
Regular rate and rhythm. Normal S1, S2, no murmurs, rubs, or
gallops. No S3. Lungs: Clear to auscultation anteriorly.
Abdomen: Soft, nontender, nondistended, positive bowel
sounds. Extremities: No clubbing, cyanosis or edema.
LABORATORY DATA FROM THE OUTSIDE HOSPITAL: White count 13,
hematocrit 43.8, platelet count 297,000. Chemistries:
Sodium 132, potassium 3.3, chloride 105, bicarbonate 24, BUN
11, creatinine 1.2, glucose 113. Troponin I less than 0.1.
Myoglobin 26.9.
EKG revealed a normal sinus rhythm, 100 beats per minute,
normal intervals, normal axis, ST segment elevation 6 mm in
II, 7 mm in III, 7 mm in aVF, T wave inversions in I, aVL, V1
through V4.
EKG post catheterization revealed a normal sinus rhythm, 93
beats per minute, normal intervals, normal axis, ST segment
elevation in lead II, 3 mm in lead III, 4 mm in lead aVF, 3
mm ST segment depression in I, aVL, V1 through V2.
IMPRESSION: The patient is a 51-year-old male with a
positive family history of coronary artery disease and
history of smoking, status post thrombolysis with Retavase,
now status post catheterization with RCA stent placement.
The patient was noted to have elevated right and left-sided
filling pressures in the Cath Lab. The patient was
transferred to the CCU for management overnight.
HOSPITAL COURSE: The patient was administered aspirin,
Plavix, and statin as his blood pressure tolerated. He was
started on a beta blocker and low-dose ACE inhibitor. His
cardiac enzymes were followed and were noted to peak at 2,200
on [**2142-4-7**]. The patient remained chest pain-free
during the hospital stay.
The patient was noted to have episodes of NSVT. He also
remained tachycardiac and there was concern for alcohol
withdrawal. The patient was monitored on the CIWA scale and
was given empiric benzodiazepines. His level on CIWA scale
was never greater than 10.
On [**2142-4-8**], the patient was noted to spike a
temperature to 101.7. Blood cultures and urine cultures were
obtained and were negative. Chest x-ray did not disclose
evidence of infiltrate or pleural effusion.
Echocardiogram on [**2142-4-9**] disclosed an EF of 50%. The
left atrium was mildly dilated. A symmetric LVH resting
regional wall motion abnormalities included inferior and
basal inferior septal akinesis. The RV cavity was mildly
dilated. The aortic valve leaflets appeared structurally
normal. The mitral valve leaflets were mildly thickened with
1+ MR. There was borderline pulmonary artery systolic
hypotension. There was no pericardial effusion.
The patient remained tachycardiac and his Lopressor was
titrated up to 150 mg t.i.d.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: Home.
FOLLOW-UP: The patient will follow-up with his primary care
physician in one to two weeks. He will also follow-up with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] at [**Telephone/Fax (1) 3183**].
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q.d. times nine months.
2. Folic acid 1 mg p.o. q.d.
3. Lopressor 150 mg p.o. t.i.d.
4. Zestril 5 mg p.o. q.d.
5. Lipitor 40 mg p.o. q.d.
6. Aspirin 325 mg p.o. q.d.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Moderate left ventricular diastolic dysfunction.
3. Acute inferior ST elevation myocardial infarction treated
with rescue PCA post failed lytic therapy.
4. Revascularization of the right coronary artery with good
results.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2142-4-11**] 01:04
T: [**2142-4-13**] 09:31
JOB#: [**Job Number 48839**]
ICD9 Codes: 4280, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7054
} | Medical Text: Admission Date: [**2161-6-4**] Discharge Date: [**2161-6-9**]
Date of Birth: [**2077-3-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Unresponsive, hypotension
Major Surgical or Invasive Procedure:
1. Arterial line
2. Right internal jugular triple lumen catheter
3. PICC placement
History of Present Illness:
84F with h/o HepB, diabetes, C/O unresponsive episode at nursing
home at 1100 am, found hypotensive in the 80's/sys and o2 was in
the 70's. Upon ambulance arrival BP wnl and placed on
non-rebreather.
Pt was transferred to ED. In ED, blood pressure was 70/40
initially. A RIJ and two peripheral IVs were placed and fluid
resuscitation was started as well as IV pressors with norepi at
2mcg/kg/min. A foley was placed and frank pus returned with +
U/A. She was started on vancomycin and zosyn.
Labs were significant for sodium of 150, BUN/Cr of 100/2.7, K of
6.3, lactate of 3.6 and ABG = 7.15/8/159/15.
Imaging significant for head CT unremarkable, cxr with
questionable retrocardiac opacity.
On arrival to the MICU, patient's VS. 97.6, HR 91, SBP 89/37,
rr=16, 96% RA. At time of arrival, she had received 3.5L NS and
was on 0.1 of norepi. She is alert in NAD does not speak
English, so cannot answer questions.
Review of systems:
cannot be obtained due to pt not responsive
Past Medical History:
Diabetes
hepatitis B, no known cirrhosis
dementia
HTN
CKD? - a few months prior to admission BUN went from 20s to 38.
reportedly cr is 1.0
OA with reported femoral neck frx in past
Social History:
Pt lives in nursing home in [**Location (un) **], demented at baseline.
She can feed herself and is interactive at baseline. As per
son, she is alert and oriented to name only at baseline.
Non-ambulatory and incontinent of stool and urine. No smoking
or tobacco history
Family History:
NC
Physical Exam:
On arrival to ICU
Vitals: 97.6, HR 91, SBP 89/37, rr=16, 96% RA.
General: alert, not interacting does not speak english
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, cvp = 1, no LAD
CV: rrr no mrg
Lungs: ctab, no wrr
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: cold, clammy. pulse 1+ b/l in LE. She has a dry ulcer on
lateral calcaneous of R foot.
Back: she has 2 unstagable decubitis dry ulcers on back
Neuro: PERRLA, exam is grossly intact.
Pertinant discharge:
BP 145/75, HR 86
General: Alert oriented to person. Knows she is in the hospital
but does not know date
Skin: 2 unstagable decubitis dry ulcers on buttocks and on each
heal
Pertinent Results:
ADMISSION LABS:
[**2161-6-4**] 12:00PM BLOOD WBC-15.9* RBC-4.39 Hgb-13.1 Hct-43.0
MCV-98 MCH-29.8 MCHC-30.4* RDW-16.9* Plt Ct-326
[**2161-6-4**] 12:00PM BLOOD Glucose-146* UreaN-121* Creat-2.7*
Na-151* K-6.2* Cl-128* HCO3-8* AnGap-21*
DISCHARGE LABS:
[**2161-6-8**] 04:27AM BLOOD WBC-7.3 RBC-3.12* Hgb-9.5* Hct-29.1*
MCV-93 MCH-30.5 MCHC-32.7 RDW-16.6* Plt Ct-216
[**2161-6-8**] 04:27AM BLOOD Glucose-213* UreaN-18 Creat-0.9 Na-141
K-3.7 Cl-116* HCO3-16* AnGap-13
URINE CULTURE ([**2161-6-4**]):
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 8 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 64 I
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
C.DIFF NEGATIVE ([**2161-6-6**])
CT HEAD ([**2161-6-4**]): No acute intracranial process.
CXR ([**2161-6-4**]): The lungs are clear, without focal airspace
consolidation to suggest pneumonia. Linear atelectasis is seen
at the left lung base. A right side IJ catheter tip terminates
in the mid SVC. There is no pleural effusion or pneumothorax.
Apical pleural thickening is seen. The heart size is normal.
Calcifications are present within the aortic
arch.
RENAL U/S ([**2161-6-5**]): Normal renal echotexture without evidence of
hydronephrosis.
Brief Hospital Course:
1. Severe sepsis with shock (hypovolemic/septic): Initial SBP in
the low 70s. When a foley was placed, it drained frank pus. She
required pressor support with norepinephrine and vasopressin.
After 7 Liters of NS, she was weaned off of pressor medications
and after 12L her blood pressure, renal function and mental
status improved.
2. Urinary tract infection: A renal ultrasound was done which
did not show any signs of pyelonephritis. Urine cutlure grew out
two types of Klebsiella, both sensitive to all antibiotics
tested except for intermediate sensitivity to nitrofurantoin.
Ceftriaxone was continued until the day of discharge with
ciprofloxacin presribed to complete a 10-day course (through
[**Date range (1) 112057**]).
3. Encephalopathy, toxic-metabolic: Likely related to
UTI/sepsis. Improved throughout admission. Was oriented to name
and "hospital" at discharge which her son reports as baseline.
4. Acute renal failure: Initial creatinine 2.7 with BUN in 100s.
Improved with fluid resuscitation
5. Hyperkalemia: Potassium 6.2 on admission. As her renal
failure improved, her potassium levels remained within normal
limits.
6. Metabolic acidosis: Her metabolic acidosis was primarily
nongap but she did have a significant gap acidosis most likely
secondary to lactic acidosis and renal failure. Bicarb
autocorrected throughout admission but had not completed
normalized on last check.
7. Hypernatremia: Sodium 150 on admission with increase to 157
on arrival to ICU. Her free water deficit was corrected with
1/2NS in D5w. Over 24hrs her serum sodium corrected to 140s. Her
serum sodium was within normal limits for remainder of hospital
stay.
8. Diarrhea: Developed diarrhea while in the ICU. Cdiff assay
was negative.
9. Pressure ulcers: Gluteal and heel. Wound care recommended:
* Turn and reposition off back q 2 hours and prn
* Limit sit time to 1 hour at a time using a pressure
* Redistribution cushion
* Cleanse wound with wound cleanser then pat dry then place
sacral Mepilex border
change every 3 days
* Critic aid clear [**Hospital1 **] to reddened tissue including labial
ulcer
* No dressing needed to heel - aloe vesta daily for skin
conditioning
* Waffle boots
10. Diabetes mellitus type 2: Her glipizide was held during
hospitalization but restarted at discharge. Long-acting insulin
was also held with finger sticks in the 100-200 range.
11. Hypertension: Olmesartan was held in the setting of
hypotension. On day of discharge BP was 140s/70s.
CHRONIC ISSUES:
1. Dementia: Namenda was held during hospitalization as this is
not a formulary medicatin. Restarted on discharge.
2. Hepatitis B, chronic: Tenofovir was continued, dosed for GFR
TRANSITIONAL ISSUSE:
1. Antibiotics: ciprofloxacin presribed to complete a 10-day
course (through [**Date range (1) 112057**]).
2. Held medications
- Olmesartan: could be restarted if blood pressure remains
elevated
- 70/30 insulin: could be restrated if finger stick blood
glucose remains elevated
Medications on Admission:
tylenol
benicar 10mg daily
glipizide 15mg daily
megace 625mg/5mL
omeprazole 20mg
viread 300mg PO daily
donepezil 10mg q day
amenda 10mg [**Hospital1 **]
cromolyn 4% instill 2 drops each eye TID
Senna
novolin 70/30 24U qAM 14U q5pm
MVI
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO once a day.
4. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. cromolyn 4 % Drops Sig: Two (2) Ophthalmic three times a
day.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 6
days.
10. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
11. glipizide 5 mg Tablet Sig: Three (3) Tablet PO once a day:
15 mg daily.
12. Megace ES 625 mg/5 mL Suspension Sig: One (1) PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
1. Shock (septic and hypovolemic)
2. Urinary tract infection (klebsiella)
3. Acute renal failure
4. Encephalopathy, toxic-metabolic, with underlying dementia
5. Metabolic acidosis
6. Pressure ulcers (heal/buttock), unstageable
7. Diarrhea
8. Anemia
9. Hypertension
10. Diabetes type II
11. Hepatitis B, chronic
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for low blood pressure, which was from a
combination of dehydration and a urinary tract infection. You
improved with IV fluids and antibiotics. You should continue
antibiotics to complete a course (through [**6-15**]).
Followup Instructions:
I spoke with your primary physician. [**Name10 (NameIs) **] will coordinate a visit
to your nursing home.
ICD9 Codes: 0389, 5990, 5849, 2762, 2760, 5859, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7055
} | Medical Text: Admission Date: [**2204-1-14**] Discharge Date: [**2204-2-1**]
Date of Birth: [**2168-10-6**] Sex: F
Service: MEDICINE
Allergies:
Insulin Pork Purified / Insulin Beef / Erythromycin Base /
Codeine / Aspirin / Compazine / Peanut
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Placement of left femoral central venous catheter
Placement of left subclavian central venous catheter
Lumbar Puncture
History of Present Illness:
35 yo female w/med hx of DMI and multiple admissions for DKA, DM
complicated by nephropathy on PD and multiple skin infections,
HTN, asthma initially admitted to the MICU [**1-13**] for witnessed
seizure. Daughter reported to find her seizing with rhythmic arm
and leg movements so EMS called. Pt given valium 10mg with
resolution. Pt had 2 other episodes of seizure in ambulance and
another in the ED. She also had multiple episodes of coffee
ground emesis in the ED so GI was consulted and recommended [**Hospital1 **]
PPI and watch since hct stable and hs of gastritis in the past.
Chem 7 revealed her to be in DKA with a gap of 18 and
hyprglycemic to 600's. She was started on an insulin gtt which
was continued for 48 hours although AG within 7 hours of
starting gtt. Head CT revealed left convexity subdural hematoma.
VS were stable in the ED and pt was transferred to the MICU for
DKA, seizure and SDH. She was evaluated by neurology who
reported pt to have multiple medical reasons to have seizure and
recommended dilantin loading until medical issues controlled.
Neurosurgery was also consulted for SDH but recommended frequent
neuro checks and no need for surgical intervention. Follow-up
MRI revealed foci of signal abnormalities in both frontal lobes,
right greater than left, with faint enhancement of the right
frontal lobe lesion with differential including demyelinating
disorder or infection. LP was attempted on [**1-15**] but aborted due
to pt intolerance. She also continued to have abdominal pain
with elevated WBC so peritoneal fluid was sent for cell count
and cx with cx pending and cell count w/o leukocytosis.
Renal was following and TPA'd PD catheter with good response on
[**1-16**] with 5L of drainage and improvement in pain. Once off
insulin gtt and monitored with frequent neuro checks for 48
hours she was transferred to the floor.
Past Medical History:
1. Diabetes mellitus type 1, diagnosed at age 7. The patient
has had multiple episodes of diabetic ketoacidosis in the past.
Her DM is complicated by neuropathy, nephropathy, and
retinopathy.
2. Chronic renal insufficiency, now failure with creatinine
around 7, starting peritoneal dialysis
3. History of gastroparesis, with episodes of nausea and
vomiting.
4. Atypical chest pain.
5. Hypertension.
6. Asthma.
7. Chronic right foot ulcer being followed by Dr. [**Last Name (STitle) 108352**] of
[**Last Name (STitle) **].
8. Chronic diarrhea- incontinant of stool since abcess removed
([**2194**]).
9. Recurrent pyelonephritis.
10. ECHO [**3-5**]: EF 75%. No WMA/valvular abnormalities.
11. Chronic diarrhea since [**2194**] when she had an abcess removed
from her anus. Since then she has been on chronic loperimide.
12. history of hematemesis and EGD on [**9-21**] revealed Grade IV
esophagitis with contact bleeding was seen in the distal
esophagus, Erythema in the stomach body and fundus compatible
with gastritis.
Social History:
The patient lives in [**Location 686**]. Her PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Per
his OMR note, her children have recently been taken by DSS,
hence they no longer live with her. She has a long history of
medical noncompliance. She previously noted that she smokes 2
packs of cigarettes every 5 days but says that she is smoking
less now. She has smoked for the past 7 years. She denies use of
alcohol or illicit drugs. Had been in abusive home relationship
but has recent restraining order against fiance, who is in jail.
Has close support with multiple family members nearby. Worked
prev as
nurse's aide in [**Hospital1 2025**] psych [**Hospital1 **]. Currently attending classes for
nursing degree.
Family History:
Father with type 2 DM, CHF, CVA
Physical Exam:
T 98.3 HR 85 BP 121/67 25 97%RA
HEENT: PERRL, MMM, no nuchal rigidity, no ant or post cerv LAD,
thyroid nonpalp, no bruits
CVS: RRR nS1S2 3/6 SEM at RUSB w/o rad to carotids
Lungs: Clear bilat
Abd: Soft, diffusely tender and distended, no rebound or
guarding, could not asses organomegaly due to intolerance to
deep palpation
Extr: Warm, 2+ rad and dp pulses, trace bilat LE edema, no
asterixis
Skin: 2 L medial breast incision w/o drainage or surrounding
erythema. Multiple smaller 1-2 cm nodules noted on R shoulder
with one incision and surrounding tegaderm w/ wet to dry
dressing intact and minimal tendernes to palpation. Multiple
excoriated
areas on chest, arms, back., sacral decubitus ulcer stage I with
stool in it
Neuro-CNII-XII intact, 5/5 strength in flexors and extensors of
hip knee ankle shoulder elbow wrist grip bilat, gait not
assessed, pt not compliant with sensory exam or reflexes, toes
downgoing
Pertinent Results:
[**2204-1-14**] 11:49PM GLUCOSE-57* UREA N-66* CREAT-8.6* SODIUM-142
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-20* ANION GAP-16
[**2204-1-14**] 11:49PM CALCIUM-7.5* PHOSPHATE-6.6* MAGNESIUM-1.6
[**2204-1-14**] 11:49PM HCT-29.4*
[**2204-1-14**] 07:57PM GLUCOSE-142* UREA N-69* CREAT-8.6* SODIUM-139
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-19* ANION GAP-17
[**2204-1-14**] 07:57PM CK(CPK)-174*
[**2204-1-14**] 07:57PM CK-MB-4 cTropnT-0.07*
[**2204-1-14**] 07:57PM CALCIUM-7.0* PHOSPHATE-6.8* MAGNESIUM-1.6
[**2204-1-14**] 07:57PM HCT-30.8*
[**2204-1-14**] 04:04PM URINE HOURS-RANDOM CREAT-49 SODIUM-37
[**2204-1-14**] 03:17PM GLUCOSE-146* UREA N-71* CREAT-8.9* SODIUM-140
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-18* ANION GAP-19
[**2204-1-14**] 03:17PM CALCIUM-6.8* PHOSPHATE-7.0* MAGNESIUM-1.6
[**2204-1-14**] 03:17PM HCT-30.1*
[**2204-1-14**] 10:30AM ASCITES TOT PROT-<0.2 GLUCOSE-720 LD(LDH)-10
ALBUMIN-LESS THAN
[**2204-1-14**] 10:30AM ASCITES WBC-6* RBC-68* POLYS-1* LYMPHS-11*
MONOS-0 MACROPHAG-88*
[**2204-1-14**] 10:27AM GLUCOSE-64* UREA N-76* CREAT-8.7* SODIUM-139
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-18* ANION GAP-17
[**2204-1-14**] 10:27AM CK(CPK)-173*
[**2204-1-14**] 10:27AM CK-MB-4 cTropnT-0.08*
[**2204-1-14**] 10:27AM CALCIUM-6.7* PHOSPHATE-6.9* MAGNESIUM-1.7
[**2204-1-14**] 10:27AM HCT-27.3*
[**2204-1-14**] 08:04AM SODIUM-141 POTASSIUM-3.6 TOTAL CO2-17*
[**2204-1-14**] 08:04AM CALCIUM-7.2* PHOSPHATE-6.7* MAGNESIUM-1.6
[**2204-1-14**] 08:04AM OSMOLAL-314*
[**2204-1-14**] 08:04AM HCT-22.7*
Brief Hospital Course:
1. seizure-Pt has no hx of seizure in past but has multiple
reasons for seizure on current admission including hyponatremia,
subdural hematoma, acidemia and new med of flagyl and
hypodensity seen on MRI. She was dilantin loaded but developed
dizinees with uptitration despite subtherapeutic levels although
free % was elevated likely due to CRF. Pt started on Keppra so
that dilantin toxicity would not cloud the diziness and ataxia
picture. Dilantin was then titrated off. Hypodensity on MR [**First Name (Titles) **] [**Last Name (Titles) 108356**]g for cause of seizure focus if infection or
demyelinating lesion although LP showed no WBC's, [**Male First Name (un) 2326**] virus neg,
cytology neg and no oligoclonal bands seen. RPR neg ruled out
neurosyphillis. She suffered no additional seizures and will
continue on keppra with plans to follow up with neurology in
about 1 month.
2. headaches: Pt's headache was initially felt to be most likely
post LP headache and we reconsulted anaesthesia for blood patch,
but they felt that her symptoms were more consistent with
migaraine. Attempted SC sumitriptan to decrese HA frequency
altough it made her more nauseous. She was eventually managed
with RTC tylenol and oxycodone prn. Repeat MR w/o gadolinium
shows no change with possible decrease in size of frontal
hyperintensities. As above pt will follow up with neuro.
3. SDH- size of SDH stable on follow-up MRI and not viusalized
on any of her 4 follow-up CT's. Per neurosurg no need for
intervention since she has no nueurologic deicits and lesion is
stable. [**Month (only) 116**] also be contributing to headache. Repeat Head CT was
normal.
4. High PVR-pt initially had 500cc PVR after foley removal on
[**1-16**]. Pt has no history of urinary retention and repeat PVR 100
so no further intervention required.
5. DMI-FS were high throughout the hospitalization. Pt was
titrated up on her lantus dose and was discharged with 35 units
qhs in addition to humalog SS. She has an appointment to follow
up with Dr. [**Last Name (STitle) 978**] at [**Last Name (un) **].
6. Coffee ground emesis-Patient cont to have nausea and vomiting
but no coffee grounds. Pt has had multiple EGD's with last one
in [**9-4**] which revealed only esophagitis. Seen by GI who
recommend [**Hospital1 **] PPI which will cont. Pt's renal failure is most
likely cause of anemia and has required chronic transfusions in
the past so uptitrated procrit per renal recs.
7. Asthma-No wheeze on PE at this time. Cont on outpt albuterol
MDI.
8. Abdominal pain-Resovled with improved PD drainage improving.
Pt moving bowels well and no sign of obstruction on KUB. PD
fluid cell count not suggestive of infection and cx still has no
growth. She continued to have N/V which she states is a chronic
issue related to her gastroparesis. This was managed with SL
ativan and po phenergan. The patient stated these meds helped a
little, though her N/V is a chronic issue.
9. Elevated WBC-WBC stable and pt afebrile despite no antibiotic
use. She has multiple skin sources for infection although
abscesses healing well. Blood cx and U/A were negative. Pt has
chronic diarrhea and was on flagyl so C. diff was felt to be
unlikely. Flagyl was stopped and her diarrhea did not recur.
10. ESRD on PD -renal diet, potassium elevated despite
kayexalate. Renal was aware and recommended restarting Lasix at
[**Hospital1 **] dosing but improvement was minimal. She will follow up with
Dr.[**First Name (STitle) 805**] regarding her PD and management of renal issues.
Medications on Admission:
Zolpidem Tartrate 5 mg qhs
Insulin Glargine 26U qhs
Humalog slide scale
Loperamide HCl 2 mg qid
Furosemide 40 mg qd
Promethazine HCl 25 mg qid
Metoprolol Succinate 50 mg qd
Ferrous Sulfate 325 qd
Pantoprazole Sodium 40 mg qd
Albuterol MDI q6h prn
Atorvastatin 10mg qd
Hectorol 2.5 mcg qd
Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day).
Calcium Acetate 667 mg 2 tabs tid
Darbepoetin Alfa-Albumin 10000uqwk
Percocet 5-325 mg 1-2 Tablets PO every 4-6 hours
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*1*
3. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous at bedtime: 35 Units qhs.
Disp:*qs one month* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
6. Camphor-Menthol Ointment Sig: One (1) Topical once a
day.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff
Inhalation every six (6) hours.
8. Promethazine HCl 12.5 mg Tablet Sig: One (1) Tablet PO four
times a day as needed for nausea.
Disp:*120 Tablet(s)* Refills:*2*
9. Toprol XL 200 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*
10. Oxycodone HCl 5 mg Capsule Sig: [**12-4**] Capsules PO every six
(6) hours as needed for headache.
Disp:*24 Capsule(s)* Refills:*0*
11. lorazepam Sig: One (1) mg Sublingual every six (6) hours as
needed for nausea.
Disp:*120 tabs* Refills:*2*
12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 (8000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
15. Pantoprazole Sodium 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*
16. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
17. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection Q6H (every 6 hours): heparin flush for
peritoneal dialysis. .
Disp:*[**Numeric Identifier 108357**] units* Refills:*2*
18. Insulin Lispro (Human) 100 unit/mL Solution Sig: qs units
Subcutaneous four times a day: Inject with meals and before bed
according to sliding scale:
BG 150-200 - 2 units, BG 201-250 - 4 units, BG 251-300 - 6
units, BG 301-350 - 8 units, BG 351-400 - 10 units. .
Disp:*qs one month* Refills:*2*
19. prescription
Syringes for humalog and lantus insulin injections qid.
#qs one month.
refills: 2.
20. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal once a week.
Disp:*4 patches* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Seizure NOS
Right Frontal Lobe Lesion NOS
GIB - Coffee Ground Emesis
Clotted PD Catheter
Diabetic Ketoacidosis
Subdural Hematoma
Urinary Retention
Hyperkalemia
Hyperphosphatemia
Secondary/PMH:
Insulin Dependent Diabetes Mellitus
Retinopathy
Neuropathy
ESRD on Peritoneal [**Hospital **]
Medical Non-Compliance
Asthma
Recurrent Pyelonephritis
Atypical Chest Pain
Gastroparesis
Hypertension
Gastritis/Esophagitis
Chronic Lower Extremity Ulcers
Chronic Diarrhea
Recurrent MSSA Skin Abscesses
Perianal Abscess
Anemia
Discharge Condition:
Stable
Discharge Instructions:
If you experience any fevers, chills, increasing headache, neck
stiffness, muscle weakness or loss of sensation, abdominal pain,
or if your peritoneal dialysis fluid is not draining well you
should call Dr. [**First Name (STitle) 805**] but if he is not available you should
go to the emergency room. You were started on a new medication
for seizure called keppra which you should take as prescribed.
Also, please take your increased dose of Metoprolol XL once a
day.
Followup Instructions:
You should follow-up with Dr. [**First Name (STitle) 805**] as you have contracted
for on Thursday [**2-2**] at 1:00 p.m. If you cannot make this
appointment you need to call [**Telephone/Fax (1) 5972**].
You should also followup with Dr. [**Last Name (STitle) **], your PCP, [**Name10 (NameIs) **]
Wednesday, [**2-8**] at 2p.m. Please call [**Telephone/Fax (1) 250**] if you
need to cancel.
Please also follow up with Dr. [**Last Name (STitle) 978**] at the [**Last Name (un) **] Diabetes
center on [**4-18**] at 12 p.m. Please call [**Telephone/Fax (1) 2384**] if you
need to cancel.
You also need to call Neurology [**Telephone/Fax (1) 44**] regarding your
upcoming appointment on [**3-13**] with Dr. [**First Name4 (NamePattern1) 5627**] [**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7056
} | Medical Text: Admission Date: [**2190-5-22**] Discharge Date: [**2190-5-31**]
Date of Birth: [**2110-1-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4963**]
Chief Complaint:
MI/LGIB
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is an 80 year old male with a past medical history of
colitis and diverticulosis with history of bleeds, who was
recently admitted at [**Location (un) 620**] with a diverticular bleed
(discharged day before admission here), represented to the OSH
today with sudden onset dyspnea and acute on chronic epigastric
discomfort and was found to have ST changes consistent with
acute MI (not stemi criteria). Hct was 33 on discharge now back
to 27. EKG with old RBBB, but clear new lateral ST depressions
and ST elevation in III. First set of cardiac enzymes were CK
333 MB 11.8 TnT 1.13. Patient presented hypotensive to low 80s,
but now 95-100 with fluid; HR 90s. Is transferred to [**Hospital1 18**] for
further management. A unit of packed red cells was hung on
transfer.
.
In the ED, the patient remained with stable blood pressures,
dropping only as low as 102 systolic. His initial vitals were
98.7 102/70 20 96%4L. The blood that was hung on transfer
continued to run throughout his ED course and he received an
additional 1L NS. An EKG was rechecked which confirmed the
initial findings, and another troponin was 1.12. He was guaiac
negative, but given his recent history of LGIB and relative
hypotension, he was unable to be anticoagulated or beta blocked.
.
The case was discussed with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] from Cardiology, who
said to medically manage with ASA (which he received x 1 in the
ED) and blood, and admit to the floor and allow the MI to run
it's course as long as he remains asymptomatic. Given his recent
LGIB and initial hypotension, however, he is admitted to the
MICU for further management and monitoring.
.
On ROS, the patient says that he feels much better and denies
chest pain or shortness of breath. He denies dizziness,
abdominal pain or palpitations.
.
Past Medical History:
Diverticulosis s/p recent bleed (treated at [**Location (un) 620**]), and a
prior bleed in [**2188**]
Ulcerative colitis
Hypertension
Dementia
Osteoarthritis
Status post hip replacement in [**2188-2-20**]
Anxiety
Social History:
Lives at home alone. He is independent in all of activities of
daily living. However, he is somewhat forgetful. He denies
tobacco, alcohol or illicit drug use.
Family History:
NC
Physical Exam:
O: Vital signs: 96.9/96.1, 108/60 (96-115/50-71), 85 (80-92),
18, 96%RA
I/O: 1240/1350 +BM
Tele: PVCs
GEN: Resting quietly in bed, pleasant.
HEENT: PERRL, mucus membranes moist. No lymphadenopathy.
CV: Distant heart sounds: RRR, no m/r/g appreciated. JVP appears
mildly elevated, unchaged at 8-10cm. Radial pulses symmetric and
2+.
PULM: URI congestion, but moving air in both lung fields, clear
to auscultation.
ABD: Soft, NTND, + BS.
EXT: Warm and well perfused. [**12-23**]+ pitting edema.
Pertinent Results:
[**2190-5-22**] 11:40PM cTropnT-1.12*
[**2190-5-22**] 11:40PM CK(CPK)-328*
[**2190-5-22**] 11:40PM CK-MB-19* MB INDX-5.8
[**2190-5-22**] 11:40PM WBC-6.6 RBC-3.41* HGB-10.4* HCT-30.8* MCV-91
MCH-30.4 MCHC-33.6 RDW-14.2
[**2190-5-22**] 11:40PM GLUCOSE-86 UREA N-21* CREAT-0.8 SODIUM-135
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-20* ANION GAP-13
Brief Hospital Course:
# NSTEMI: Patient had atypical chest discomfort (acute on
chronic epigastric pain, has history of Barrett's) with EKG
changes and positive biomarkers, likely in the setting of recent
LGIB. He was managed medically because of the recent bleeding
with aspirin, low dose beta blocker, low dose ace inhibitor and
simvastatin. Echo demonstrated EF of 25-30% with severe global
LV hypokinesis. His BP remained SBP 90-110. He developed volume
overload from blood transfusions and volume resuscitation for
his hypotension at admission and was gently diuresed.
# LGIB: Presented to outside hospital with bright red blood per
rectum. Hematocrit was 37.4 to OSH initially, underwent an EGD
and a colonoscopy. Colonoscopy revealed diverticulosis and
incidental tiny polyp, otherwise, it was normal with no evidence
of active colitis or bleeding. He then underwent an EGD which
revealed Barrett's esophagus, but no evidence of upper
gastrointestinal bleeding. His hematocrit drifted down to a
nadir of 28 during his stay at the OSH and was stable at 33
prior to discharge. He did not require blood tranfusions there.
Upon this presentation, with a HCT of 27 and active cardiac
ischemia he was transfused 2 units of blood and subsequetly
maintained stable blood counts. He was repeatedly guaiac
negative.
# HTN - Systolic blood pressure after the MI ranged 90-110s. He
was treated with low dose beta blocker and low dose
ace-inhibitor (started [**2190-5-30**]) and intermittent lasix. His
outpatient medications were stopped.
# Fluid overload/ Hyponatremia - Pulmonary edema present on
admission improved with gentle diuresis (Lasix 10mg IV bolus
prn). Appeared vol overloaded on exam based on peripheral edema,
elevated JVP, and cephalization/ small pleural effusions from
CXR on [**5-27**]. Received 10mg IV lasix but diuresis persistently
difficult to quantify given urine spills and incontinence. Urine
electrolytes showed he is salt avid (FeNa = 0.1%); likely
hypervolemic hyponatremia from CHF and possibly SIADH from
stress of hospitalization. Fluid restriction to 1.5L/day.
Appeared euvolemic despite persistent LE edema on day of
discharge. Weight upon discharge 77 KG.
.
# Upper respiratory infection: Cough accompanied by [**Last Name (un) 1993**]
production and upper respiratory congestion. Pt remained afebile
without an oxygen requirement throughout stay. Given
Azithromycin Day 1 ([**2190-5-29**] day 1. To complete 5 days)
guaifensein, encoraged spirometry, OOB.
# Depression - continued celexa
#CODE: FULL
Medications on Admission:
Celexa 40 mg daily
Asacol 400 mg two tablets three times a day
lisinopril 20 mg daily
hydrochlorothiazide 12.5 mg daily (stopped on [**2190-5-21**])
Prilosec 20 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 doses.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Non ST-segment elevation myocardial infarction
Diverticular bleed-lower gastrointestinal bleed
Systolic congestive heart failure
[**Last Name (un) 27191**] esophagitis
Hypertension
Osteoarthritis
Anxiety
Discharge Condition:
Stable, tolerating normal diet, on room air.
Discharge Instructions:
You were admitted to the hospital with a heart attack and low
blood pressures. You were given 1 unit of blood on transfer here
and 1 additional unit of blood when you arrived. You were
treated with medications for your heart attack. You had no
further bleeding. It was determined that you need rehabilitation
to help your body recover.
Please call your doctor or return to the hospital if you
developing any bleeding from your rectum, chest pain, shortness
or breath, dizziness, or any other concerning symptoms.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 49718**], a cardiologist,on [**6-14**]
at 11:30 at [**Hospital1 18**]-[**Location (un) 620**] for follow-up of your heart attack.
Please arrive at least 15 minutes early to fill to register and
fill out paperwork. Please call his office at [**Telephone/Fax (1) 19946**] if
you need to reschedule this appointment for another time within
the next 2-3 weeks.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 5057**] within 1-2 weeks after discharge from rehabilitation. Her
office can be reached at [**Telephone/Fax (1) 5763**].
Completed by:[**2190-5-31**]
ICD9 Codes: 2761, 4280, 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7057
} | Medical Text: Unit No: [**Numeric Identifier 60540**]
Admission Date: [**2148-4-24**]
Discharge Date: [**2148-5-2**]
Date of Birth: [**2148-4-24**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 60541**] is a 32 and 5/7
weeks gestational male delivered preterm due to preterm
labor. Mother was beta complete at the time of delivery.
Mother is a 30-year-old G1/P0-1 mother with prenatal screens
remarkable for: B positive, antibody negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative, GBS negative.
[**Hospital **] MEDICAL HISTORY: Notable for hypertension, on
atenolol that was stopped during pregnancy. Pregnancy also
notable for depression, for which she was treated with
Celebrex during pregnancy. She had had a fetal ultrasound
notable only for mild renal dilatation. The pregnancy was
otherwise unremarkable until mother presented to [**Hospital3 42966**] with preterm labor. She was found to be 3 cm
dilated. At that point, she was given betamethasone as well
as ampicillin and transferred to the [**Hospital1 190**] where medications were continued, and she was
allowed to progress to labor. Spontaneous rupture of
membranes occurred 5 hours prior to delivery. Delivery was
via NSVD at 4:35 a.m. on [**2148-4-24**]. The baby required
blow-by O2 and routine care in the delivery room. Apgars were
6 and 8 at one and five minutes. However, the infant never
cried despite stimulation. He was breathing adequately in
room air and transferred to the NICU secondary to prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Weight of 2145 grams
which is the 75th percentile, length of 47 cm which is the
80th percentile, and head circumference of 31.5 cm which is
the 60th percentile. The anterior fontanel was open and full.
There was a craniotabes feel to the scalp noted with splits
easily mobile with some marked molding of the head. Very
slightly low set ears were notable that were thought to be
within normal limits. The palate was intact. Clavicles were
intact. There were mild intercostal retractions with adequate
respiratory effort. Breath sounds were clear and equal.
Cardiovascular exam revealed a regular rate and rhythm
without murmur, and 2+ femoral pulses were noted. The abdomen
was benign without hepatosplenomegaly. No masses palpable on
the abdominal exam. Genitourinary revealed normal male with
right testicle descended, left testicle undescended. Normal
back and hips. There was a single palmar crease noted on the
left. Normal creases on the right. He had reducible but
marked bilateral equinovarus and slightly decreased tone
which was noted to be improving over time. His skin was pink
and well perfused.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The patient remained comfortable in room air
throughout his admission. Never had any apnea or
bradycardia of prematurity. He did have 1 desaturation
into the high 70s on the day prior to transfer occurring
with feeding.
2. CARDIOVASCULAR: The patient was noted to have a soft
murmur on day of life #1 which had resolved by day of life
#2. The patient has been without murmur since day of life
#1 with normal blood pressures and hemodynamically stable.
3. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was
initially n.p.o. on total fluids of 80 cc/kg/day. Feedings
were started on day of life #1 and worked up to full
feedings by day of life #4. On day of life #5, calories
were increased to 24 calories per ounce. The patient is
currently on 150 cc/kg/day of Special Care 24 calories per
ounce. Feedings are over 1 hour and 30 minutes secondary
to spitting. Weight at the time of discharge is 2105
grams. An abdominal ultrasound was performed given the
prenatal history of slightly dilated kidneys. Renal
ultrasound was normal on day of life #1 and his left
testicle was noted in the inguinal canal.
4. HEMATOLOGY: Phototherapy was started on day of life #4 for
a maximum bilirubin of 10/0.3. Phototherapy was
discontinued on day of life #6 with a rebound bilirubin of
3.9/0.2.
5. INFECTIOUS DISEASE: The patient was started on ampicillin
and gentamicin secondary to preterm labor. CBC was benign,
and blood culture was negative at 48 hours, and therefore
antibiotics were discontinued.
6. NEUROLOGY: A head ultrasound was performed on day of life
#1 secondary to slight hypotonia as well as a widened
fontanel. Head ultrasound was within normal limits. The
patient's tone had improved considerably throughout his
hospitalization.
7. GENETICS: Genetics was asked to see this baby secondary to
the hypotonia noted at birth as well as some slightly
dysmorphic features including a high forehead and a single
palmar crease. Chromosomes were recommended by the
genetics consult. The chromosomes returned normal at 46
XY. A head ultrasound and renal ultrasound were also
performed as described above as well as an abdominal
ultrasound. The left testicle was noted to be in the
inguinal canal during that exam.
8. SENSORY: A hearing screen has not yet been performed and is
recommended prior to discharge to home.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To [**Hospital3 3765**] Level 2 Intensive
Care Unit.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) 4249**] at [**Hospital 60542**]
Pediatrics (telephone number [**Telephone/Fax (1) 52961**]).
CARE RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feedings are Special Care 24 150 cc/kg/day - we have been
feeding using a pump over 1 hour and 30 minutes
secondary to spitting.
2. Medications: The patient is not currently on any
medications.
3. State screening: State screening was sent on [**4-26**] -
the results are pending.
4. Immunizations: The patient has not yet received any
immunizations.
DISCHARGE DIAGNOSES:
1. Prematurity at 32 and 5/7 weeks.
2. Rule out sepsis - resolved.
3. Hyperbilirubinemia - resolved.
4. Hypotonia - resolved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 58729**]
MEDQUIST36
D: [**2148-5-2**] 11:25:04
T: [**2148-5-2**] 12:40:49
Job#: [**Job Number 60543**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7058
} | Medical Text: Admission Date: [**2187-7-23**] Discharge Date: [**2187-7-27**]
Date of Birth: [**2144-11-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2187-7-24**] Cardiac Catherization with emergent ECMO placement
[**2187-7-24**] Removal ECMO cannula with right CFA open repair
[**2187-7-24**] Emergent BIVAD placement, CABG x2 (SVG>LAD, SVG>OM)
[**2187-7-25**] Re exploration for bleeding
[**2187-7-25**] Quintin Catheter
History of Present Illness:
42 yo male with a hx of DMII, poorly controlled HTN and FH of
CAD who presents with chest pain. Pt reports intermittent
exertional chest pain over the past 2-3 months which he
describes as sharp, L sided SSCP radiating to L arm, pain lasts
5-7 minutes and is relieved with rest. Pain is [**11-7**] at its
worst and has associated SOB, diaphoresis and nausea but no
emesis. He presented to new PCP today whom noted elevated BP
190/100 and sent to ED for further evaluation given exertional
CP and strong fam hx of CAD. Pt occasionally takes his meds and
does not go to doctor [**First Name8 (NamePattern2) **] [**Male First Name (un) 1056**], he was not formally dx
with DM, his FS at home have been in 200s on no treatment for
DM.
Past Medical History:
HTN
DMII
Obesity
Social History:
Social history is significant tobacco - quit 4 months ago
He smoked 1pack per week.
Denies ETOH
Family History:
There is premature coronary artery disease, Father-died of MI at
age 57, Brother MI at 48, Sister MI s/p CABG at age 38.
Mother-HTN, DM
Physical Exam:
Admission
VS: T 100.0, BP 143/70, HR 62, RR 16, O2 99% on 2L
Gen: middle aged male 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 7cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. No M/R/G
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: Non pitting ankle edema. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2187-7-26**] 01:46AM BLOOD WBC-16.2*# RBC-4.14* Hgb-12.9* Hct-34.6*
MCV-84 MCH-31.1 MCHC-37.3* RDW-15.9* Plt Ct-69*
[**2187-7-23**] 04:10PM BLOOD WBC-11.2* RBC-5.00 Hgb-13.3* Hct-37.9*
MCV-76* MCH-26.7* MCHC-35.2* RDW-14.8 Plt Ct-383
[**2187-7-24**] 09:29PM BLOOD Neuts-89.5* Bands-0 Lymphs-8.6*
Monos-1.5* Eos-0.3 Baso-0.1
[**2187-7-23**] 04:10PM BLOOD Neuts-77.8* Lymphs-15.0* Monos-2.9
Eos-3.9 Baso-0.4
[**2187-7-26**] 12:49PM BLOOD Plt Ct-74*
[**2187-7-26**] 12:49PM BLOOD PT-14.3* PTT-45.2* INR(PT)-1.3*
[**2187-7-23**] 04:10PM BLOOD Plt Ct-383
[**2187-7-23**] 04:10PM BLOOD PT-12.3 PTT-26.1 INR(PT)-1.1
[**2187-7-25**] 08:04AM BLOOD Fibrino-128*
[**2187-7-24**] 08:21PM BLOOD Fibrino-174
[**2187-7-26**] 01:46AM BLOOD Glucose-132* UreaN-26* Creat-3.3* Na-139
K-4.9 Cl-104 HCO3-21* AnGap-19
[**2187-7-23**] 04:10PM BLOOD Glucose-118* UreaN-11 Creat-1.0 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2187-7-25**] 02:59AM BLOOD ALT-114* AST-763* LD(LDH)-1827*
AlkPhos-43 TotBili-1.7*
[**2187-7-24**] 03:20PM BLOOD ALT-12 AST-12 AlkPhos-74 TotBili-0.5
[**2187-7-25**] 02:59AM BLOOD Albumin-2.6*
[**2187-7-26**] 01:46AM BLOOD Calcium-8.7 Phos-6.2*# Mg-2.1
[**2187-7-23**] 04:10PM BLOOD Triglyc-250* HDL-40 CHOL/HD-8.5
LDLcalc-249*
[**2187-7-26**] 06:13AM BLOOD Vanco-31.7*
[**2187-7-26**] 03:57PM BLOOD Type-ART pO2-113* pCO2-42 pH-7.36
calTCO2-25 Base XS--1
[**2187-7-24**] 03:49PM BLOOD Type-ART pO2-262* pCO2-68* pH-6.88*
calTCO2-14* Base XS--22 -ASSIST/CON Intubat-INTUBATED
[**2187-7-24**] 04:23PM BLOOD Type-ART pO2-330* pCO2-55* pH-7.16*
calTCO2-21 Base XS--9 Intubat-INTUBATED Vent-CONTROLLED
[**2187-7-24**] 05:15PM BLOOD Type-ART pO2-416* pCO2-38 pH-7.40
calTCO2-24 Base XS-0
[**2187-7-26**] 01:23PM BLOOD Glucose-134* Lactate-2.3* K-5.2
[**2187-7-24**] 08:41PM BLOOD Glucose-188* Lactate-10.8* Na-142 K-4.0
Cl-103
[**2187-7-24**] 04:23PM BLOOD Glucose-375* Lactate-13.6* Na-139 K-2.9*
Cl-105
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2187-7-26**] 10:20 AM
CT HEAD W/O CONTRAST
Reason: r/o cva
[**Hospital 93**] MEDICAL CONDITION:
42 year old man cardiac arrest w/VAD placement
REASON FOR THIS EXAMINATION:
r/o cva
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 42-year-old man status post cardiac arrest with VAD
placement, rule out stroke.
COMPARISONS: None.
TECHNIQUE: Axial MDCT images were performed through the brain
without IV contrast.
FINDINGS: There is a large evolving right PCA distribution
infarction, with significant mass effect, effacing the right
ambiant cistern and effacing the right lateral ventricle. There
is no herniation at this time and no hydrocephalus in the
contralateral ventricular system. No evidence of hemorrhagic
transformation or acute hemorrhage elsewhere in the brain. Tiny
hypodensities involving the anterior aspects of the centrum
semiovale bilaterally likely relate to small infarcts, acuity
indeterminate. Globally, the sulci appear slightly effaced,
however, this may be a normal variant, however, given the
history provided, diffuse global edema is also a consideration.
[**Doctor Last Name **]-white matter differentiation remains preserved at this
time. There is an air-fluid level in the left maxillary sinus
and a smaller air-fluid level in the left sphenoid sinus
presumably from prior intubation.
IMPRESSION:
1) Large evolving right PCA distribution infarction, with
significant local mass effect, effacing the right lateral
ventricle and right ambient cistern, without CT evidence of
herniation at this time. No evidence of hemorrhagic
transformation or acute intracranial hemorrhage elsewhere in the
brain.
2) Two small hypodensities in the anterior aspect of the centrum
semiovale bilaterally, likely representing small infarcts, age
indeterminate.
3) The sulci appear somewhat effaced globally; this could be a
normal variant, however, given the history of cardiac arrest,
global edema must be considered.
Findings were discussed with the covering nurse practitioner
([**Female First Name (un) **]) at the CT scanner at the time of the study.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: [**Doctor First Name **] [**2187-7-26**] 4:49 PM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2187-7-25**] 1:02 AM
CHEST (PORTABLE AP)
Reason: s/p TLC insertion and ETT reposition-check placement
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with LM dissection s/p Emergent [**Hospital1 **]-VAD
placement/CABG x 2. Please [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Numeric Identifier 74168**] with
abnormalities.
REASON FOR THIS EXAMINATION:
s/p TLC insertion and ETT reposition-check placement
PORTABLE SUPINE CHEST 1:22 A.M. [**2187-7-25**]
INDICATION: Recently status post emergent cardiac surgery.
Recent ETT repositioning and central line placement.
FINDINGS: Compared with the previous study at 11:33 p.m. on
[**2187-7-24**], the tip of the ETT has been repositioned and now
lies approximately 2 cm above the carina. The tip of the new
left CVL projects at the upper SVC level.
Otherwise, no obvious interval changes, as detailed in previous
report.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2187-7-26**] 12:35 PM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2187-7-25**] 1:02 AM
CHEST (PORTABLE AP)
Reason: s/p TLC insertion and ETT reposition-check placement
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with LM dissection s/p Emergent [**Hospital1 **]-VAD
placement/CABG x 2. Please [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Numeric Identifier 74168**] with
abnormalities.
REASON FOR THIS EXAMINATION:
s/p TLC insertion and ETT reposition-check placement
PORTABLE SUPINE CHEST 1:22 A.M. [**2187-7-25**]
INDICATION: Recently status post emergent cardiac surgery.
Recent ETT repositioning and central line placement.
FINDINGS: Compared with the previous study at 11:33 p.m. on
[**2187-7-24**], the tip of the ETT has been repositioned and now
lies approximately 2 cm above the carina. The tip of the new
left CVL projects at the upper SVC level.
Otherwise, no obvious interval changes, as detailed in previous
report.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2187-7-26**] 12:35 PM
Cardiology Report ECG Study Date of [**2187-7-24**] 7:39:30 AM
Sinus rhythm. Compared to the previous tracing sinus tachycardia
has given way
to Normal sinus rhythm, rate 80, and ischemic type lateral
repolarization
changes have resolved.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 130 74 348/383.71 18 4 22
Cardiology Report ECHO Study Date of [**2187-7-24**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for emergent CABG, LVAD palcement, Pt
placed emergently on ECMO in cath lab
Height: (in) 68
Weight (lb): 244
BSA (m2): 2.23 m2
Status: Inpatient
Date/Time: [**2187-7-24**] at 17:42
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW209-9:4
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.9 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.6 cm (nl <= 5.6 cm)
Aorta - Valve Level: 2.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.3 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 2.1 cm (nl <= 2.5 cm)
INTERPRETATION:
Findings:
Pt was placed on emergent ECMO in the cath lab. Rhythm was V.
Fib initially.
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color
Doppler.
LEFT VENTRICLE: Depressed LVEF.
RIGHT VENTRICLE: RV function depressed.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Normal aortic arch diameter. Normal descending aorta
diameter.
AORTIC VALVE: Significant AR, but cannot be quantified.
MITRAL VALVE: MR present but cannot be quantified.
TRICUSPID VALVE: TR present - cannot be quantified.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
for the
patient. 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:
POST-ECMO:
1. The left atrium is markedly dilated. No atrial septal defect
is seen by 2D
or color Doppler.
2. LV systolic function appears depressed. The entire LV
lateral, inferior &
anterior wall appear akinetic. LV appears distended.
3. Right ventricular systolic function appears depressed.
4. Significant aortic regurgitation is present, but cannot be
quantified given
that pt is on ECMO.
5. Mitral regurgitation is present but cannot be quantified.
6. Tricuspid regurgitation is present but cannot be quantified.
7. There is a trivial/physiologic pericardial effusion.
POST- BiVAD:
1. BiVAD cannulas are seen in position. The Heart is
decompressed.
[**Location (un) **] PHYSICIAN:
Cardiology Report C.CATH Study Date of [**2187-7-24**]
*** Not Signed Out ***
BRIEF HISTORY:
**PTCA RESULTS
LMCA
**BASELINE
STENOSIS PRE-PTCA [**40**]
**TECHNIQUE
PTCA SEQUENCE 1
GUIDING CATH 6F XBLAD
GUIDEWIRES CHOICE P
INITIAL BALLOON (mm) 2.5
FINAL BALLOON (mm) 2.5
# INFLATIONS 2
MAX PRESSURE (PSI) 180
PTCA COMMENTS: During diagnostic angiography, the left main
was
noted to either have a dissection or a severe ulcer. The plan
was to
put an IABP and send him to surgery emergently as he was stable.
Over
the course of 5 minutes while placing the IABP, the patient
developed
chest pain. The IABP was placed urgently and access in the L
CFA was
obtained. Given the chest pain, the plan was made to emergently
repair
the LMCA. Suddenly the patient became apneic and pulseless.
CPR was
initiated. A 6F XBLAD3.5 guiding catheter was used to engage
the LMCA
and no flow was noted. A Choice PT wire was passed into the Cx.
A
2.5x15 mm Voyager balloon was used to dilate the LMCA at 10 ATM
and flow
was restored to the Cx and OM. The patient was intubated and
CPR was
continued thru this intervention. CT surgery was consulted and
were
immediately there to evaluate the situation. Decision was made
to
convert from IABP support to ECMO and transfer the patient
emergently to
CABG and or LVAD. The patient went into ventricular
fibrillation and
was shocked at 360 J, just before ECMO cannulas were placed in
the R CFA
and CFV. Flows were achieved of 4L/min and the patient was
transferred
to the OR for bypass.
COMMENTS:
1)
2) Emergent PTCA of the dissected LMCA with a 2.5 mm balloon
with flow
restoration into the CX and OM. IABP support initiated and
converted to
ECMO support as the patient clinically and hemodynamically
deteriated.
CPR and intubation required during case. Patient was
transferred
emergently to the OR for CABG and or LVAD.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Emergent PTCA with IABP support for a LMCA dissection.
3. ECMO initiated due to severe cardiogenic shock.
4. CPR and intubation for cardiac arrest.
5. Transfered to OR for emergent CABG and or LVAD.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] S.
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **]
[**Last Name (LF) **],[**First Name3 (LF) **]
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Brief Hospital Course:
42 year old male presented to PCP with [**Hospital 2754**] transferred to ED
with chest pain. Admitted for cardiac work up and underwent
cardiac catherization [**7-24**]. In catherization lab had cardiac
arrest secondary to left main dissection and ECMO was inserted.
He went directly to the operating room where he had a
biventricular assist device placed, coronary artery bypass
graft, removal of ECMO, and repair right CFA. Please see
operative report for details of operation.
Postoperatively, he was taken to the CSRU in critical condition
with his chest left open. He continued to bleed, and was
re-explored at the bedside the night of surgery. He returned to
the OR the following day again for re-exploration for bleeding.
The bleeding has since subsided. He was weaned from vasoactive
drips, and has remained hemodynamically stable on the BiVAD's,
with flows in the 4.5 liter per minute range. On POD # 1, the
patient had progressed into renal failure, and CVVH was
initiated.
A CT scan of his brain was obtained to r/o significant infarct
or bleed. This revealed a Right PCA infarct. The neurology
service was consulted, and it was their belief that the patient
would be left with a left visual field deficit, did not expect
pt. to have permanent disability.
He is being transferred to [**Hospital1 2025**] for continued treatment, and
possible transplant evaluation.
Medications on Admission:
Capoten 50mg daily
ASA 81mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: One Hundred
(100) mcg/hr Injection INFUSION (continuous infusion).
4. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic every eight (8) hours.
5. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Insulin Regular Human 100 unit/mL Solution Sig: Three (3)
units/hr Injection INFUSION (continuous infusion).
8. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig:
1300 (1300) units/hr Intravenous infusion .
9. Midazolam 5 mg/mL Solution Sig: 0.5 mg/hr Injection INFUSION
(continuous infusion).
10. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
Two (2) puffs Inhalation [**Hospital1 **] ().
11. Cisatracurium Besylate 0.06-0.30 mg/kg/hr IV TITRATE TO 0 of
4 train of 4
Patient should be ventilated and sedated prior to initiating
NMBAs.
12. Pantoprazole 40 mg IV Q24H
13. Vancomycin 1000 mg IV Q 24H
please check level in am before dosing
14. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Biventricular failure s/p Bivad
CAD s/p Dissection s/p CABG
Respiratory Failure
Renal Failure
Hypertension
Diabetes Mellitus
Obesity
Discharge Condition:
Guarded
Discharge Instructions:
Transfer to [**Hospital1 2025**] for continued evaluation
Followup Instructions:
Transfer to [**Hospital1 2025**]
Completed by:[**2187-7-27**]
ICD9 Codes: 4275, 5185, 5845, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7059
} | Medical Text: Admission Date: [**2126-6-23**] Discharge Date: [**2126-6-29**]
Date of Birth: [**2060-9-21**] Sex: M
Service: SURGERY
Allergies:
Rabies Immune Globulin
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Left proximal deep venous thrombosis
Major Surgical or Invasive Procedure:
1. Ultrasound-guided vascular access of the right common
femoral vein.
2. First order catheterization into the inferior vena cava.
3. Inferior vena cava filter insertion of a Cook Celect
History of Present Illness:
65M s/p anterior exposure for laminectomy on [**6-10**] and
posterior fusion [**6-14**], presents with hypotension to the 70s,
severe abdominal pain that acutely began this am. His pain is
focused in the LLQ withradiation toward the left leg. He denies
emesis, SOB, and has had BM and gas. No melena or hematochezia.
Of note, intraop anterior exposure involved a small tear to the
left iliac vein which required figure of eight suture for
repair.
Post op course was uneventful. Patient was in rehab with acute
LLE swelling noted yesterday. Duplex revealed a DVT in CFV. He
was started on Dalteparin (Fragmin) with last dose 11pm last
night. He was hypotensive this am at rehab to the 70s and was
transferred to the ER at [**Hospital1 18**] for further management. In ED
patient was hypotensive to the 80s. Hct returned at 14 with Ct
showing RP bleed away from site of iliac vein repair. He was
transfused 3 units, given FFP and Vitamin K for Fragmin
reversal.
Past Medical History:
1. Diabetes. Excellent A1c. Up to date on screening. Of note,
EMG
did not show diabetic neuropathy.
2. Hypertension.
3. Hypothyroidism.
4. Chronic pain-lumbar polyradiculopathy followed by pain
clinic.
Recent EMG reviewed.
5. Atypical chest pain/left upper extremity paresthesias and
weakness-EMG reveals C5-T1 radiculopathy. ETT/echo negative.
6. Rheumatoid arthritis. Followed by Dr.[**Last Name (STitle) **], [**Hospital1 112**]. On
prednisone,
recently started on remicaid for uveitis.
7. Hepatitis C, elevated LFTs.
8. Colon polyps-adenoma [**2113**], normal colonoscopy [**2118**].
9. Foot pain-now followed by Dr. [**Last Name (STitle) **] for multiple issues
including tendon rupture
10. Sleep disorder-uses trazodone for zolpidem.
11. History of positive PPD.
12.? osteoporosis. On alendronate, prescribed by his
rheumatologist. He does not recall a recent bone density study.
Social History:
Ex smoker
2 beers daily
No illicit drug use
Family History:
1. Father: CAD s/p stent, chronic angina, 1st MI at age 70s
2. Mother: deceased from natural causes
3. Sister: DM
4. Brother: emphysema + tobacco
Physical Exam:
98.5 97.6 97 136/76 20 97% RA
Gen: alert and oriented x3, CV: RRR
Pulm: CTAB
Abd: soft, no tender to palpation to palpation
Abdominal and back wound in healing process, clean, dry and
intaact
Foley in place.
Ext: WWP
Pertinent Results:
CXR: Widened appearance of the mediastinum. Recommend repeat
upright PA
radiograph when patient is more stable. Atelectasis at the
bases and low lung volumes. Possible mild pulmonary congestion.
( preoperative xray considered throid mass).
[**2126-6-23**] 09:30AM PT-12.6* PTT-31.9 INR(PT)-1.2*
[**2126-6-23**] 09:30AM WBC-3.9* RBC-1.55*# HGB-4.9*# HCT-14.8*#
MCV-96 MCH-31.7 MCHC-33.2 RDW-15.0
[**2126-6-23**] 09:30AM cTropnT-0.13*
[**2126-6-23**] 01:44PM HCT-16.5*
[**2126-6-23**] 03:34PM HGB-8.3* calcHCT-25
[**2126-6-23**] 03:34PM TYPE-ART PO2-158* PCO2-42 PH-7.38 TOTAL
CO2-26 BASE XS-0 INTUBATED-INTUBATED
[**2126-6-23**] 04:07PM HGB-8.3* calcHCT-25 O2 SAT-97
[**2126-6-23**] 06:44PM PT-10.3 PTT-30.1 INR(PT)-0.9
[**2126-6-23**] 06:44PM PLT COUNT-181
[**2126-6-23**] 06:44PM WBC-5.4 RBC-3.72*# HGB-11.3*# HCT-33.1*#
MCV-89# MCH-30.4 MCHC-34.3 RDW-15.6*
[**2126-6-23**] 06:44PM CALCIUM-7.1* PHOSPHATE-4.3 MAGNESIUM-2.1
[**2126-6-23**] 06:44PM CK-MB-10 MB INDX-2.0 cTropnT-0.12*
[**2126-6-23**] 10:31PM HCT-30.7*
[**2126-6-26**] 06:20PM BLOOD WBC-6.1 RBC-3.25* Hgb-10.0* Hct-29.7*
MCV-92 MCH-30.9 MCHC-33.8 RDW-15.2 Plt Ct-189
[**2126-6-27**] 09:00AM BLOOD WBC-6.1 RBC-3.69* Hgb-11.5* Hct-34.2*
MCV-93 MCH-31.1 MCHC-33.6 RDW-14.9 Plt Ct-212
[**2126-6-28**] 07:20AM BLOOD WBC-5.0 RBC-3.46* Hgb-11.0* Hct-32.3*
MCV-94 MCH-31.9 MCHC-34.1 RDW-14.8 Plt Ct-236
[**2126-6-26**] 06:20PM BLOOD PT-11.6 PTT-30.0 INR(PT)-1.1
[**2126-6-26**] 06:20PM BLOOD Glucose-107* UreaN-11 Creat-1.0 Na-137
K-3.7 Cl-103 HCO3-29 AnGap-9
[**2126-6-27**] 09:00AM BLOOD Glucose-111* UreaN-9 Creat-1.0 Na-140
K-3.3 Cl-102 HCO3-24 AnGap-17
[**2126-6-28**] 07:20AM BLOOD Glucose-86 UreaN-8 Creat-1.0 Na-136 K-3.8
Cl-102 HCO3-26 AnGap-12
[**Last Name (NamePattern4) **] Hospital Course:
Hematoma:
Mr. [**Known lastname **] is a 65yo man s/p laminectomy with anterior exposure
on [**6-10**] complicated by a small tear to the iliac vein which
oversew and takeback for fusion on [**6-14**] with wound vac
placement. He was discharged to rehab and presented with
hypotension to the 70's systolic nd lower abdominal/left lower
extremity pain for the previous day. He began to have LLE
swelling the previous day and underwent duplex ultrasound
demonstrating a DVT in his left common femoral vein. He was
started on dalteparin for this yesterday. Upon presentation to
the ED, he was hypotensive to 80's with Hct 14.8. He was given
3u pRBC, FFP, and Vitamin K. CT scan demonstrated large RP
hematoma and he was taken to IR for possible embolization. They
performed a flush aortogram. Catheterization of left lumbar
arteries at L2, L3 and L4 with
angiography,Common iliac artery angiogram, left internal iliac
artery angiogram and a left internal epigastric artery
angiogram.No source of bleeding was identified despite
catheterization of all visualized lumbar vessels, the left
common iliac, internal and external iliac and left internal
epigastric arteries. He was thereafter transferred to the ICU
where he was resuscitated with four units of PRBCs his first
night. Because of his DVT and his demonstrated tendency to bleed
he required an IVC filter. The hematoma also appeared to
compress the left ureter and Urology was consulted because ehis
creatinine was trending downwards it was determined that the
patient did not require a ureteral stent. There were no acute
events overnight and he was made NPO for his IVC filter
placement. Interventional radiology declined draining the
hematoma because there was no evidence of extravasation. On
[**2126-6-26**] he received his IVC filter placement with no
complications. Post operatively his groin was stable with no
hematoma. He was started on a regular diet and resumed his home
medications. Postoperatively he was re-evaluated by physical
therapy and sent to rehab on [**2126-6-29**]. Urology evaluated the
patient for L ureter compression. Patient d/c with foley, will
do voiding trial if fail to void foley will be replaced and
patient will follow with Dr. [**Last Name (STitle) **] as out patient. Patient will be
follow up with Dr. [**Last Name (STitle) 15492**] in [**12-28**] weeks.
Medications on Admission:
Amoxcillin 500mgq 12hr, tylenol 540,Alendronate 70 mg q
weekly,Amlodipine 10mg', Bisacodyl 10mg", Calcium carbonate
1000mg', Docusate, hydrochlorothiazide 25 mg, levothyroxine 75
mcg, lisinopril 20 mg, metoprolol tartrate 25mg'", oxycodone
15-45 mg q3h, pregabalin 150mg'", prednisone 5 mg , tocilizumab
80 mg/4 mL, trazodone 50 mg, zolpidem 5 -10mg, Nystatin 100,000
brimonidine 0.1, econazole 1 ", ergocalciferol (vitamin D2)
50,000 unit capsule,
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
Hold for SBP<100
2. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry
etes
3. Bisacodyl 10 mg PO DAILY:PRN Constipation
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium 100 mg PO BID
7. Furosemide 40 mg PO DAILY Duration: 3 Days
Re evaluate after dose. Titrate dose to according wiht patient
fluid status
8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
9. Heparin 5000 UNIT SC TID
10. HYDROmorphone (Dilaudid) 1-2 mg IV Q1H:PRN pain
11. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
13. Levothyroxine Sodium 75 mcg PO DAILY
14. OxycoDONE (Immediate Release) 45 mg PO Q4H:PRN pain
This is the actual dose the patient receives at home. Confirmed
with the patient.
15. PredniSONE 5 mg PO DAILY
16. Pregabalin 150 mg PO TID
17. Senna 1 TAB PO BID:PRN Constipation
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
19. traZODONE 50 mg PO HS
20. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
21. Zolpidem Tartrate 5 mg PO HS:PRN sleep
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
DVT on anticoagulation complicated by retroperitoneal bleeding
Diabetes
History of Hep C, Hypertension, Hypothyroidism, Chronic
pain-lumbar Atypical chest pain/left upper extremity
paresthesias and
weakness-EMG reveals C5-T1 radiculopathy, Rheumatoid arthritis
(on prednisone). Remicaid for uveitis, Hepatitis C, PPD,
osteoporosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Division of Vascular and Endovascular Surgery Lower Extremity
Angioplasty
Medications:
?????? Continue all other medications you were taking before
surgery, unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**12-28**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**1-27**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Please follow up with your Primary care regarding your widened
mediastinum on CXR.
Followup Instructions:
PLease schedule an appointment with Dr. [**Last Name (STitle) 1391**] in [**12-28**] weeks.
[**Last Name (LF) 1391**], [**First Name3 (LF) **] R.
[**Telephone/Fax (1) 4852**]
Office Location: [**Hospital1 18**] [**Last Name (NamePattern1) **]; Ste 9A, [**Location (un) 86**] [**Numeric Identifier **]
Department: Surgery
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] at [**Last Name (un) **] Center for blood sugar
control.
Phone: ([**Telephone/Fax (1) 3258**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2126-7-17**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2126-8-28**] 10:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2126-10-16**] 10:00
Completed by:[**2126-6-29**]
ICD9 Codes: 2851, 4589, 2768, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7060
} | Medical Text: Admission Date: [**2180-2-9**] Discharge Date: [**2180-3-7**]
Date of Birth: [**2180-2-9**] Sex: F
Service:
HISTORY: Baby Girl [**Known lastname 3761**] is a former 32 week infant born
to a 36-year-old G4, PO, 1 woman. Pregnancy was complicated
by gestational diabetes requiring insulin treatment and
rupture of membranes the night prior to delivery. There was also
a question of a left hip developmental dysplasia on an antenatal
Prenatal screens: AB positive, antibody negative, otherwise
unknown at the time of delivery. Ultimately Hepatitis B
surface antigen negative.
There were no risk factors for infection. Delivery was via
cesarean section on the day of delivery because of footling
delivery room with Apgars of 7 at one minute and 8 at five
minutes.
PHYSICAL EXAMINATION: On admission pink, active,
nondysmorphic infant with legs held in breech position. Skin
without lesions. Regular rate and rhythm. S1 and S2, no
murmurs. Bilateral breath sounds clear and equal. Abdomen
benign. Spine with deep sacral pit distal neurological
intact. Hips stable bilaterally. Neurological:
Nonfocal, age appropriate.
REVIEW OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory. The baby remained stable in room air, had
no respiratory distress. Baseline respiratory rate is 40 to
60. She has had no respiratory issues.
She did exhibit apnea and bradycardia of prematurity but did
not require methylxanthine treatment. At the time of
discharge she has been free of apnea, bradycardia or
desaturations for greater than five days.
Cardiovascular: Baby has had no issues, is cardiovascularly
stable. Did not require any pressor support on admission.
Fluid, Electrolytes and Nutrition: The baby initially was
NPO, was started on peripheral intravenous fluids of D10-W
for maintenance, enteral feedings introduced on the first day
of life and advanced to full feeds of PE 20 or breast
milk without issue. Caloric density was increased to PE or
breast milk 26 until appropriate growth was maintained.
Calories were diminished and currently the baby is [**Name2 (NI) 37789**]
feeding [**Name (NI) 37112**] 20 with Iron. Mother is not planning on
breast feeding. Her intake has been greater than 140 cc's
per kilo per day without issues. She is currently receiving
supplemental iron .2 cc's p.o. q day which equals 2 mg per
kilo per day.
Birth weight was 1855 grams, in the 50th percentile. Admission
length 40.5 cm in the 25th percentile. Admission head
circumference was 30.5 cm in the greater than 50% percentile.
Discharge weight 2520 grams. Discharge length 47cm. Discharge
head circumference 32.5cm, also appropriate for gestational
age.
Last set of electrolytes were on day of life one: sodium 136,
potassium 5.6, slightly hemolyzed, chloride 101, Co2 22.
Baby had achieved full enteral feeds and had no further
electrolytes drawn as they were not indicated.
Gastrointestinal: Maximum bilirubin was on day of life three
with bilirubin of 9.1/0.2. She was started on single
phototherapy for several days which she responded to and to
rebound bili on day of life six was 4.9/0.5. She has had no
further issues.
Hematology: The baby did not require any blood products
during this admission.
Infectious Disease. On admission baby had a sepsis
evaluation including a CBC and blood cultures with a white
count of 8.5, 22 polys, 1 band, 72 lymphs, platelets of
182,000. Hematocrit 44.5. Blood culture remained negative.
The baby was clinically well, had 48 hours of Ampicillin and
Gentamicin to rule out sepsis, these were discontinued in 48
hours and she has not had any further issues with infection.
Neurology: The baby did not require head ultrasound given the
gestational age of greater than 32-4/7 weeks. Neurological
exam is appropriate for gestational age. Of note, sutures
are split minimally on exam, but anterior fontanel is soft and
flat. No issues.
Musculoskeletal: A post-natal hip ultrasound was performed on
[**3-2**] at approximately three weeks of age. This showed mild
bilateral acetabular hypoplasia but no subluxation. This finding
was thought to be benign and related to the premature
examination date rather than to developmental dysplasia. A
repeat ultrasound should be performed in one month. Of note,
hips have been entirely stable on serial physical examinations
throughout her course.
Sensory: Audiology and car seat screening were both passed.
Ophthalmology: Eye exam is not indicated given gestational age
of greater than 32 weeks.
Psychosocial: Parents are in visiting frequently and look
forward to [**Known lastname **]'s transition home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with family.
PRIMARY PEDIATRIC CARE: Dr. [**Last Name (STitle) 37790**] [**Name (STitle) 37791**], [**Hospital 37792**]
Pediatrics, telephone [**Telephone/Fax (1) 37330**]. Fax #[**Telephone/Fax (1) 37793**].
Pediatric appointment is scheduled for Wednesday [**2180-3-8**].
CARE/RECOMMENDATIONS: Continue [**Month/Day/Year 37789**] feedings of E24 with
iron [**Month/Day/Year 37789**].
MEDICATIONS:
1. Ferinsol .2 cc's which equals 2 mg per kilo per day of
elemental iron, in addition to that in formula.
State newborn screening was sent on [**2180-2-14**], [**2180-2-23**] and one will
be sent at the time of discharge. No results have been received
at the [**Hospital1 69**] at the time
of this dictation.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2180-2-9**].
Immunizations recommended; Synagis RSV prophylaxis should
be considered from [**Month (only) 359**] for infants who meet any of the
following criteria: 1. Born at less than 32 weeks. 2. Born
between 33 and 35 weeks with plans for DayCare during RSV
season with a smoker in the household or with pre-school sibs
or 3. With chronic lung disease.
Influenza immunization should be considered annually in the
Fall for pre-term infants with chronic lung disease, once
they reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect infant.
Follow-up appointments with PCP as stated above.
Visiting nurse to be provided by CareGroup network. First visit
on Thursday [**2180-3-9**], 1-[**Telephone/Fax (3) **].
Repeat hip ultrasound appointment made for Monday [**2180-4-3**] at the
[**Hospital3 1810**] at 11:30 AM. [**Hospital **] [**Numeric Identifier 37794**]. Telephone [**Telephone/Fax (1) 37795**].
DISCHARGE DIAGNOSIS:
1. Appropriate for gestational age premature female born at
32-4/7 weeks gestation.
2. Status post rule out sepsis with 48 hours of antibiotics.
3. Deep sacral pit with spinal ultrasound on [**2180-2-9**] within
normal limits.
4. Mild acetabular hip hypoplasia, likely non-pathological.
5. Status post apnea and bradycardia of prematurity.
5. Status post hyperbilirubinemia.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**First Name3 (LF) 37796**]
MEDQUIST36
D: [**2180-3-6**] 16:21
T: [**2180-3-6**] 16:52
JOB#: [**Job Number 37797**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7061
} | Medical Text: Admission Date: [**2157-9-15**] Discharge Date: [**2157-9-21**]
Date of Birth: [**2094-7-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Pleuritic chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 year old man with recent diagnosis of widely metastatic
undifferentiated adenocarcinoma, likely of the lung, transferred
from [**Hospital1 **] [**Location (un) 620**] for further workup and to consider possible
initiation of palliative chemo or radiation. Patient presented
to OSH [**9-10**] after worsening substernal chest pain since [**Month (only) 205**]. He
first noted the pain after moving TV's, and he assumed it was
musculoskeletal. The pain was continuous, and exacerbated by
breathing and laying flat, and began radiating along the right
and left thorax. He also developed right shoulder pain and low
back pain during this time. Additionally, he has noted
increasing shortness of breath over the last few months and
developed an occasionally productive cough. He denies recent
fevers or chills and has not noted any weight loss. Denies
headache, changes in vision, or focal numbness or weakness.
Denies pain in hi calves. No nausea or vomiting, although his
appetite has been poor as of late. He denies bowel or bladder
incontinence. Review of systems was otherwise unremarkable.
At OSH, an abnomral CXR led to CTA of the chest which showed
likely malignancy and metastatic disease including extensive
mediasitnal hilar LAD, rt chest wall soft tissue mass with bony
destruction of the adjacent right anteriorr second and third
rib, left posteriror chest wasll soft tissue mass with bony
destruction of the left posterior 8th rib, and mutliple
pathologic rib fractures. CT of the abdomen and pelvis showed
multiple metastatic lesions within the liver, right adrenal
gland, left gluteal muscles, right groin, and a pathologic L1
vertebral body fracture with soft tissue impressing upon the
thecal sac. Biopsy of the rib lesion was attempted, but failed
due to patietn's inability to lie flat. Similarly, MRI of the
head could not be obtained due to inability to lie flat. Biopsy
of the gluteal lesion was obtained which preliminary report
showed undifferentiated adenocarcinoma. Of note, patient was
also treated empirically for PNA with levaquin and steroid
taper.
Past Medical History:
- Chronic back pain
- Possible COPD, no formal diagnosis
- Alcohol abuse. Sober for 4 months
- Hx of basal cell ca.
- Cellulitis/MRSA
- Left hip replacement
- Metastatic undifferentiated adenocarcinoma, likely of lung
Social History:
Smokes 1.5 packs per day for 49 years and has history of abusing
alcohol.
Family History:
No family history of lung cancer.
Physical Exam:
Admission Exam:
Vitals: T:97.6 BP:139/73 P:108 R:23 O2:92% 5LNC
General: Pleasant, alert, oriented, sitting up in bed in mild
distress [**1-12**] pain
HEENT: Sclera anicteric, MMM, tongue midline, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Speaks in short sentences, scattered wheezes with low
frequency expiratory ronchi diffusely
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: Tender to palpation diffusely over precordium. No rashes,
erythema, or swelling noted
Abdomen: soft, non-tender, non-distended, soft bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Rectal: Deferred
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. ROM rt should limited by pain.
Neuro: Alert and oriented x4. Good attention. CNII-XII intact.
Strength 5/5 symmetrically throughout lower extremity. Limited
by pain in right upper extremity. Finger-to-nose intact with
good proprioception of feet. Gait not assessed.
Pertinent Results:
[**2157-9-16**] 03:31AM BLOOD WBC-17.2*# RBC-4.54*# Hgb-15.1# Hct-42.3#
MCV-93# MCH-33.2* MCHC-35.7* RDW-12.9 Plt Ct-330#
[**2157-9-16**] 03:31AM BLOOD Glucose-107* UreaN-25* Creat-0.6 Na-136
K-4.2 Cl-100 HCO3-26 AnGap-14
[**2157-9-16**] 03:31AM BLOOD ALT-10 AST-15 LD(LDH)-470* AlkPhos-84
TotBili-0.4
[**2157-9-16**] 03:31AM BLOOD Albumin-3.4* Calcium-10.9* Phos-3.8
Mg-2.1
Brief Hospital Course:
# Metastatic adenocarcinoma of lung: The patient was admitted to
the ICU and was evaluated by oncology, radiation oncology and
palliative care. With his poor performace status and advanced
disease, palliative radiation alone was offered to the patient.
Palliative care made recommendations for pain management with
plan to go home with hospice. The patient was agreeable to the
plan. He received one dose of radiation on [**9-20**] and was
discharged home with hospice services.
# Hypoxia: thought [**1-12**] possible pna with underlying copd and
splinting from pain of bony lesions. He was treated initially
at the osh with steroids and levaquin. The abx completed on
[**9-18**] and the steroid taper was continued on discharge. He will
also go home with supplemental O2 and nebulizer treatments.
# Hypercalcemia: Initial Ca was 10.9 on admission. He was
hydrated and given one dose of pamidronate. Repeat calcium
level was 9.0.
# Goals of Care: patient will go home with hospice care. He was
DNR/DNI.
Medications on Admission:
NSAIDs prn
Discharge Medications:
1. Home Oxygen
Home oxygen 5L NC countinuous
[**Male First Name (un) **] 99 Weeks
Diagnosis Lung Cancer
2. Hospital Bed
Semi-electric with mattress bed + half rails. Please have head
of bed elevated to 30 degrees
[**Male First Name (un) **] 99 weeks
Diagnosis Lung Cancern
3. commode
3 in 1 commode
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 capsules* Refills:*0*
5. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO [**1-16**] as needed for
pain, cough, or difficulty with breathing.
Disp:*60 Tablet(s)* Refills:*0*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
8. prednisone 10 mg Tablet Sig: taper per instructions PO once
a day: Take 2 tablets daily for 7 days, then reduce to 1 tablet
daily for 7 days, then 0.5 tablets daily for 7 days, then stop.
Disp:*25 Tablet(s)* Refills:*0*
9. ipratropium bromide 0.02 % Solution Sig: One (1) dose
Inhalation Q4H (every 4 hours) as needed for wheezing.
Disp:*50 dose* Refills:*0*
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) unit dose Inhalation Q4H (every 4
hours) as needed for SOB/Wheeze.
Disp:*50 unit dose* Refills:*0*
11. ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150)
mg PO BID (2 times a day) as needed for dyspepsia.
Disp:*600 mL* Refills:*0*
12. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-19**]
MLs PO Q6H (every 6 hours).
Disp:*400 ML(s)* Refills:*2*
13. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
14. naproxen 500 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours: give with food as this med may irritate stomach.
Disp:*60 Tablet(s)* Refills:*0*
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
16. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
Disp:*50 Tablet(s)* Refills:*0*
17. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Metastatic Lung Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to evaluate for radiation therapy and or
chemotherapy for lung cancer. The oncologists (cancer doctors)
did not feel that chemotherapy would give you any benefit, but
did want to provide radiation therapy to help with your bone
pain. The radiation was given on [**2157-9-20**]. Pain medication and
home hospice services will be provided to you on discharge.
MEDICATION INSTRUCTIONS:
1. Prednisone taper, take 20 mg daily for 7 days, then 10 mg
daily for 7 days, then 5 mg daily for 7 days, then stop. This
is to help with breathing.
2. Albuterol and Ipratropium nebulizer treatments are also to
help with breathing.
3. Spiriva is an inhaled medication to help with breathing.
4. Naproxen and Fentanyl are pain medications that should be
used regularly.
5. Oxycodone can be used as needed to help with extra pain or
symptoms of shortness of breath.
6. Lorazepam is for anxiety; take as needed.
7. Docusate and Senna are for constipation as Fentanyl and
Oxycodone use can cause constipation.
8. Ranidine is for heartburn or acid reflux.
9. Guaifenesin-Dextromethorphan and Benzonatate are for symptoms
of cough.
Followup Instructions:
You may follow-up with your primary care physician as needed:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] U.
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], WELLESLY,[**Numeric Identifier 23943**]
Phone: [**Telephone/Fax (1) 86362**]
ICD9 Codes: 486, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7062
} | Medical Text: Admission Date: [**2196-10-21**] Discharge Date: [**2196-10-24**]
Date of Birth: [**2118-5-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
ST elevation myocardial infarction status post catheterization
complicated by groin hematoma
Major Surgical or Invasive Procedure:
Cardiac catheterization on [**2196-10-21**]
History of Present Illness:
Ms. [**Known lastname 1007**] is 78 year old female with PMH significant for
hypercholesterolemia, GERD, and arthritis but no CAD history who
presented to an OSH with back pain radiating to L arm and L jaw.
The patient has a history of upper L back pain, which has
worsened in the last 2 weeks. She presented to her PCP on the
morning of admission and was given [**Doctor First Name **] for symptoms
attributed to allergies. The pain then increased in intensity
over the course of the day and began to radiate to L arm/jaw
while the patient was working in her kitchen. Pain did not
alleviate with rest and she called her son who took her to the
[**Hospital3 **] ED.
.
At [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], she was noted to have ST elevations in inferior
leads with a troponin of 0.55. There, she received ASA 325 x1,
Plavix 600, atorvstatin 80 x 1, ativan 1 mg, integrilin, SL NTG
x2, IV lopressor 5 mg * 3, heparin bolus + drip. She was then
transfered here for catheterization.
.
In the cath lab, the patient was noted to have RCA 99% ostial
stenosis; this lesion was stented with bare metal stent with
good result. Her catheterization was complicated by multiple
attempts at venous access which yielded arterial blood. She
developed a large hematoma during the case. Following her cath,
she went to the CCU chest pain free, hemodynamically stable, but
with a large right groin hematoma.
.
On arrival to the floor, the patient denies chest pain, back
pain, shortness of breath, diaphoresis, nausea, and vomiting.
She does have a large ecchymosis in the right groin and thigh
area. She is not having problems walking and states that the
area seems improved. She does not have pain in the right leg.
Past Medical History:
Hypercholesterolemia
GERD
Arthritis
Osteoporosis
Social History:
Nonsmoker, no EtOH, lives alone, son + his family nearby.
Family History:
Denies CAD hx
Physical Exam:
VS- 97.0, 122/51, 84, 18, 99% RA
HEENT- Normocephalic. PERRL. EOMI. MMM & OP clear.
LUNGS- clear to auscultation bilaterally.
HEART- RRR, 2/6 systolic murmur radiating to apex
ABD- soft, ND, NT; 4-5 cm midline scar with distorted umbilicus
EXT- warm. 2+ DP pulses bilaterally. large R groin ecchymosis
covering most of medial thigh and lower abdomen. Small, firm
area in the right groin 3 cm by 3 cm at catheterization site.
Otherwise, soft. Non tender to palpation and non-pulsatile. no
accompanying bruit.
.
Pertinent Results:
labs on admission: significant for HCT 29.1
ekg-
- [**10-21**] 22:43 - NSR 80, nl axis, nl intervals, no LVH/LAE, 1 mm
STE in V2/V3, T wave inversion 3/F; no clear anatomic
distribution of ischemia.
- [**10-21**] 19:00 - NSR 90, nl axis, nl intervals, 2 mm STE in II/III
c ST elevation III > II. T wave inversion in III.
.
Cardiac enzymes: CK peak 472, trending down following cath
CK MB peak 69
Troponin peak 1.29
.
Cardiac catheterization ([**10-21**]): 1. Selective coronary
angiography of this right dominant system revealed 1 vessel
coronary artery disease. The LMCA is free of angiographically
apparent disease. The LAD has 30% stenosis in its mid-portion.
The LCx has mild, diffuse disease. The RCA has a 90% ostial
steosis with moderate diffuse disease. 2. Successful primary
PTCA and stenting of the ostial and proximal RCA with a 2.5 BMS
post dilated with a 3.0 balloon. There was a 20% residual with
TIMI III flow in the distal vessel and no angiographic evidence
of dissection, embolization or peforation. (See PTCA comments)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Normal ventricular function.
3. Acute inferior myocardial infarction, managed by primary PCI
of the
RCA.
.
Femoral ultrasound ([**10-22**]): Hematoma. No evidence of AV fistula
or pseudoaneurysm.
CXR ([**10-22**]): 1. No acute pulmonary process identified. In
particular, no pneumonic infiltrate is identified. Minimal
scarring at right base noted. 2. Lobulated appearance to the
aortic arch - - while this could be an artifact of positioning,
focal aneurysmal dilatation can also account for this
appearance. Evaluation with a dedicated PA and lateral view is
recommended.
ECHO ([**10-22**]): 1. The left atrium is normal in size. 2.There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). 3. Right ventricular chamber size is
normal. Right ventricular systolic function is normal. 4.The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. Trace aortic regurgitation is seen. 5.The
mitral valve leaflets are mildly thickened. No MR seen. 6.There
is an anterior space which most likely represents a fat pad,
though a loculated anterior pericardial effusion cannot be
excluded.
.
Labs at discharge: WBC 6.4, Hgb 12.1, Hct 34.6 (stable),
Platelets 147,000
BMP unremarkable
Cholesterol 162, TG 94, HDL 45, LDL 98
Brief Hospital Course:
Ms. [**Known lastname 1007**] is a 78 year old female with inferior ST elevation
myocardial infarction now status post catheterization
complicated by a large right groin hematoma.
.
#) Status post inferior STEMI - The patient's RCA was found to
be 99% stenosed at catheterization. At that time, she had a bare
metal stent placed with good result.
- She should continue ASA (lifelong) and plavix (for at least
one month and perhaps longer at the discretion of her primary
cardiologist).
- Her groin hematoma on the day of discharge was stable and not
impeding her movement in any way. Her hematocrit at discharge
was stable, though she did require three units of blood
immediately following her catheterization due to falling
hematocrit at that time.
- She should continue atorvastatin 80 mg daily. Her lipids are
near goal with LDL 98.
- She was discharged on Toprol XL 50 mg to be taken daily as
well as a low-dose ACE inhibitor as she is post myocardial
infarction.
- Her echocardiogram does demonstrate a hyperdynamic ejection
fraction. See the full report for details.
- Ms. [**Known lastname 1007**] did not have any concerning arrhythmias on telemetry
during her hospitalization.
- She will follow up with Dr. [**Last Name (STitle) 4469**], who is her primary care
physician as well as a cardiologist, on [**11-1**]. She will
have labs drawn on [**Last Name (LF) 2974**], [**10-28**], to assess her
electrolytes and renal function.
- Ms. [**Known lastname 1007**] was evaluated by physical therapy and deemed safe
for discharge. At the time of discharge, she was hemodynamically
stable and comfortable on room air.
.
#) Right groin hematoma - As above, the area of eccymosis on day
of discharge was large but stable. There was no evidence of
pseudoaneurysm on physical exam or on ultrasound performed on
[**10-22**]. Her hematocrit was stable on day of discharge, and the
patient's movement was not impeded in any way.
- Immediately following her catheterization, she did received
blood transfusions as above.
.
#) GERD - We continued her H2 blocker as per outpatient regimen.
.
#) Code - full
.
#) Prophylaxis - She was kept on aspirin and plavix but no
heparin due to the hematoma. She did receive an H2 blocker
(ranitidine) as above. She was ambulating following her
catheterization.
.
#) FEN - The patient tolerated a cardiac diet without problem.
She had her electrolytes repleted as necesssary.
.
#) Communication - The patient's son is [**Name (NI) **] [**Name (NI) 1007**] H [**Telephone/Fax (1) 68866**],
C [**Telephone/Fax (1) 68867**].
Medications on Admission:
Ranitidine
Fexofenadine
Calcium Supplements
Risedronate
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
7. Outpatient Lab Work
Please have your kidney function (creatinine), electrolytes
checked on [**Last Name (LF) 2974**], [**10-28**]. Fax results to Dr. [**Last Name (STitle) 4469**] at
[**Telephone/Fax (1) 11321**].
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial infarction, status post catheterization
with stent placed in the right coronary artery
Discharge Condition:
Hemodynamically stable, with stable red blood cell count, and
comfortable on room air
Discharge Instructions:
Please take all your medications as prescribed.
Please call your doctor or return to the emergency room should
you develop any of the following symptoms: recurrent back pain,
chest pain or shortness of breath, bleeding from your
catheterization site, increased area of tenderness or firmness
in your groin, numbness or tingling of the right leg or foot,
bleeding from your gums or blood in your stool or urine, or any
other concerns.
Followup Instructions:
Please follow up with your primary care doctor & cardiologist,
Dr. [**Last Name (STitle) 4469**], on [**2196-11-1**] at 2:00 pm. Please have your
kidney function and electrolytes checked on [**Last Name (LF) 2974**], [**10-28**]. Fax the results to Dr. [**Last Name (STitle) 4469**] at [**Telephone/Fax (1) 11321**].
Completed by:[**2196-10-25**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7063
} | Medical Text: Admission Date: [**2147-11-23**] Discharge Date: [**2147-12-24**]
Date of Birth: [**2147-11-23**] Sex: M
HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname **], twin #1, delivered at 30-4/7
weeks, with a birth weight of 1375 grams, was admitted to the
Intensive Care Nursery for management of prematurity.
estimated date of delivery of [**2148-1-27**]. Prenatal screens
included blood type A positive, antibody screen negative,
hepatitis B surface antigen negative, rubella immune, RPR
nonreactive and Group B Streptococcus unknown. The pregnancy
was remarkable for in [**Last Name (un) 5153**] fertilization with
dichorionic-diamniotic twin gestation. In addition to the
twin gestation, the pregnancy was complicated by gestational
at 28 weeks treated with magnesium sulfate. The mother
received a course of betamethasone prior to delivery. On day
of delivery, there was spontaneous rupture of membranes
prompting delivery by cesarean section with spinal
anesthesia.
[**Known lastname **] emerged with spontaneous cry, was dried, bulb suctioned
and received free-flow O2 in the delivery room. Apgar scores
were 7 and 8 at one and five minutes respectively.
PHYSICAL EXAMINATION: On admission, weight 1375 grams (50
to 75th percentile), length 40.5 centimeters (50th
percentile), head circumference 26 centimeters (10 to 25th
percentile). In general, pink bruised non-dysmorphic infant.
Skin with multiple bruises, petechiae on mid-sternum. Head
and Neck: Anterior fontanel open, flat, soft. Eyes with
positive red reflex bilaterally. Ears, Nose and Throat: No
cleft. Clavicles intact. Thorax symmetric. Lungs clear and
equal. Heart: Normal S1, S2, no murmur. Femoral pulses
present. Abdomen with three vessel cord. No
hepatosplenomegaly, no masses. Genitalia: Normal preterm
male. Testes descended bilaterally. Anus patent. Spine
straight and intact. Extremities stable. Hips stable.
Reflexes decreased tone.
HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY: No respiratory distress. Has been in room
air since admission with comfortable work of breathing.
Respiratory rate 40s to 50s.
Had apnea of prematurity with several mild episodes per day
with the last episode on [**2147-12-16**]. Did not require
Xanthine therapy.
2. CARDIOVASCULAR: Received a normal saline bolus on
admission for a low mean blood pressure; has been
hemodynamically stable throughout hospitalization. Has an
intermittent soft murmur heard occasionally. Recent blood
pressure 68/34 with a mean of 44.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Initially maintained
on D10W. Enteral feeds were started on day of life one and
advanced to full volume feeds on day of life seven without
problems. The caloric density was gradually increased to 30
calories per ounce plus ProMod with good growth. Is
beginning to bottle or breast feed. Most recent nutrition
labs were on [**12-20**] which showed a sodium of 138, potassium of
4.3, carbon dioxide of 28, alkaline phosphatase 274, albumin
3.8, calcium 10.1 and phosphorus 6.5. Discharge
weight 2165g, oFC 28cm, length 47cm..
4. GASTROINTESTINAL: Received phototherapy for indirect
hyperbilirubinemia. Peak bilirubin total 7.8, direct 0.3.
5. HEMATOLOGY: Most recent hematocrit was on [**2147-12-1**],
and was 36.9%; did not require any blood transfusion during
this admission. Is receiving supplemental iron around 2 mg
per kg per day of elemental iron.
6 INFECTIOUS DISEASE: Following birth, received Ampicillin
and gentamicin for 48 hours for a rule out sepsis. The CBC
was benign and blood culture was negative. On [**12-3**], started
treatment for Staphylococcus epidermidis sepsis, initially
with Vancomycin and gentamycin for two days, then completed
the seven day course with Vancomycin. Received a seven day
course of erythromycin Ophthalmic Ointment for conjunctivitis
of the right eye starting on [**2147-12-6**].
7. NEUROLOGY: A head ultrasound on day of life seven was
normal. One month ultrasound showed choroid plexus cyst and
small germinal matrix hemorrhage. Repeat ultrasound is
recommended in [**8-23**] days to document stability of the hemorrhage.
8. SENSORY: Hearing screening was performed by Audiology
with automated auditory brain stem responses and passed both
ears.
9. OPHTHALMOLOGY: Eyes were examined most recently on
[**2147-12-20**], revealing mature retinal vessels. A follow-up exam
is recommended at eight months of age.
10. PSYCHOSOCIAL: The parents have visited often and are
looking forward to transfer to [**Hospital3 1280**].
CONDITION ON DISCHARGE: Stable growing preterm infant now a
month old.
DISCHARGE DISPOSITION: Transfer to [**Hospital6 3874**]. Name of primary pediatrician, Dr. [**Last Name (STitle) 45074**] and
[**Location (un) 12670**].
CARE RECOMMENDATIONS:
1. Feeds: Breast milk fortified with four calories per
ounce of human milk fortifier, four calories per ounce of MCT
Oil and two calories per ounce of Polycose and [**2-15**] teaspoon
of ProMod added to 90 cc. of formula or 100 cc. of breast
milk to equal 30 calories per ounce, plus ProMod; thus taking
150 cc. per kilo per day divided every four hours.
2. Medications: Fer-In-[**Male First Name (un) **] 0.15 cc. once a day; Vitamin E 5
International Units once a day.
3. Car seat positioning screening has not been done;
recommend prior to discharge.
4. State newborn screening status: State newborn screen was
sent on [**12-1**] and [**12-7**] and both were within normal limits.
5. Immunizations received: Has not received any
immunizations.
6. Immunizations recommended:
Synagis RSV Prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants that meet any of the three
criteria: 1) Born at less than 32 weeks; 2) born between 32
and 35 weeks with plans for day care during RSV season, with
a smoker in the household, or with preschool siblings or 3)
with chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
7. Follow-up appointments schedule recommended:
1) Repeat cranial ultrasound recommended in [**8-23**].
2) Ophthalmology examination recommended at eight months.
3) Early intervention referral recommended at discharge.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age 30-4/7 weeks preterm
male.
2. Twin #1.
3. Apnea of prematurity.
4. Rule out sepsis.
5. Staphylococcus epidermidis sepsis, resolved.
6. Conjunctivitis resolved.
7. Indirect hyperbilirubinemia, resolved.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 36138**]
MEDQUIST36
D: [**2147-12-22**] 16:32
T: [**2147-12-22**] 16:56
JOB#: [**Job Number 45075**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7064
} | Medical Text: Admission Date: [**2187-7-5**] Discharge Date: [**2187-7-12**]
Date of Birth: [**2109-1-11**] Sex: F
Service: SURGERY
Allergies:
Augmentin / Vicodin / Zocor
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2187-7-5**] - open retroperitoneal abdominal aortic aneurysm repair
History of Present Illness:
Ms. [**Known lastname **] is a 78-year-old woman referred by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 7047**] for evaluation of abdominal aortic aneurysm. She had
this detected several years ago and she has not had any symptoms
referable to this. She has a family history in that her mother
died from a ruptured abdominal aortic aneurysm. She also has a
sister with an abdominal aortic aneurysm and that is being
followed. Over the past year, it grew from 4.2 cm to 5.5 cm on
the ultrasound month ago and she had a CT today. She has
chronic back pain related to fibromyalgia but has not had
anything that has been different in her recent past. She has
coronary artery disease and aortic valvular disease. She is
status post CABG x2 plus AVR on [**2186-6-7**] by Dr. [**Last Name (STitle) **]. She is
a smoker. She has quit several times over the past several
years. She does not have a long history of hypertension but has
been hypertensive recently and has had medication adjustments
for this.
Past Medical History:
Borderline hyperlipidemia
Aortic stenosis
Psoriasis
Coronary artery disease
Osteoporosis
Gastroesophageal reflux disease
Fibromyalgia
Hepatitis treated in [**2143**]
Sleep apnea-does not use CPAP
4.2 cm abdominal aortic aneurysm
Ectopic pregnancy
Past Surgical History
[**2182**] Right total knee replacement
Tonsillectomy
Appendectomy
Social History:
Race: Caucasian
Last Dental Exam: edentulous
Lives with: husband and daughter
Occupation: Retired
Tobacco: 50 pack years (1ppd until several wks ago)
ETOH: Occasional ETOH and denies illicit drug use.
Family History:
grandmother had "heart condition"
Physical Exam:
On physical examination on discharge, she is in no distress.
Pulse is 68. Respirations are 16. Blood pressure is 147/80.
HEENT is unremarkable. Neck is supple. Chest is clear. Heart
is regular. Abdomen is soft and nondistended. Her incision is
clean and intact, with small amounts of serous drainage. She
has palpable femoral and pedal pulses. The popliteal pulses are
not enlarged. She has psoriatic skin lesions in the lower
extremities. She has 1+ edema of b/l lower extremities
Pertinent Results:
[**2187-7-9**] 05:46AM BLOOD WBC-10.3 RBC-3.45* Hgb-10.6* Hct-30.2*
MCV-88 MCH-30.6 MCHC-34.9 RDW-13.6 Plt Ct-154
[**2187-7-12**] 06:50AM BLOOD Glucose-97 UreaN-14 Creat-1.0 Na-140
K-3.5 Cl-101 HCO3-24 AnGap-19
[**2187-7-12**] 06:50AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.1
Brief Hospital Course:
On [**2187-7-5**], Ms [**Known lastname **] [**Last Name (Titles) 1834**] open repair of her abdominal
aortic aneurysm via a retroperitoneal approach. She was
transferred to the ICU intubated postoperatively due to the
large amount of fluid and colloid resuscitation she received
intraoperatively. However, she was extubated successfully the
next day, and transferred to the VICU in stable condition. She
was passing gas and having bowel movements by postoperative day
2. She began to tolerate a regular diet. She was actively
diuresed with lasix. Her appetite was decreased, which she has
had in the past while on narcotic pain medications, so she was
started on marinol and carnation instant breakfast supplements
were added to her diet. She was seen by physical therapy, who
recommended that she go to rehab. She was discharged to rehab
on [**2187-7-12**] in good condition.
Medications on Admission:
Omeprazole, Pravastatin, Metoprolol,Aspirin, and Losartan
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for bronchospasm.
4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for bronchospam.
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
9. pantoprazole 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 Sig: One (1) Tablet PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. cortisone 1 % Cream Sig: One (1) Appl Topical TID (3 times a
day).
14. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
17. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Abdominal aortic aneurysm
Hyperlipidemia
Fibromyalgia
Discharge Condition:
Good condition.
AAOx3
Ambulating with max assist
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-6**]
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 incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-1**]
pillows or a recliner) every 2-3 hours
throughout the day and at night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low
cholesterol) to maintain your strength and assist in wound
healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound,
then place a dry dressing over the area that is draining, as
needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
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 leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2187-8-8**] 2:15
Completed by:[**2187-7-12**]
ICD9 Codes: 2724, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7065
} | Medical Text: Admission Date: [**2140-8-16**] Discharge Date: [**2140-8-18**]
Date of Birth: [**2072-4-27**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Unstable angina
Major Surgical or Invasive Procedure:
-Cardiac catheterization with left circumflex stenting; stenting
of dissected obtuse marginal 1 vessel following deployment of
left circumflex stent
-Transesophageal echocardiogram
-Electrocardioversion
History of Present Illness:
Mr. [**Known lastname 39008**] is a 68 year old male with history of hypertension
and hyperlipidemia, who presented to [**Hospital1 18**] on the morning of
admission for elective catheterization to evaluate intermittent
anginal symptoms. The patient reports that 2 days prior to
admission he climbed the equivalent of 7 flights of stairs,
after which he noted a pain across his hard palate. He denies
any chest pain, or associated shortness of breath, nausea,
vomiting, diarrhea, radiation of the pain to his neck or arm,
however he did have diaphoresis. The pain in his mouth subsided
only after about 2.5 hours of rest. He reports another episode
of mouth pain later that night, while resting in bed, relieved
by getting out of bed and sitting in a chair.
.
The following morning his wife drove him to [**Hospital3 **],
where serial cardiac enzymes were negative. His EKG did not
demonstrate ST changes, however did incidentally demonstrate
atrial flutter with variable block and HR 50-110. He had an
echo there which demonstrated a nondilated LV with mild LVH and
anterior apical hypokinesis and an EF of 45%. He was started on
IV heparin. It was decided to proceed with cardiac
catheterization, for which he was transferred to [**Hospital1 18**].
.
Catheterization on the day of admission revealed a flow-limiting
stenosis of the left circumflex artery that was stented with a
5.0 DES. While finishing the cath, the patient began
complaining of severe substernal chest pain, with noted ST
elevations on monitor. The vessels were re-imaged, now with
complete lack of flow in OM1. Guidewires were able to be
passed, and the entrance to OM1 was stented. It is presumed
that the initial stent partially overlapped the opening of OM1,
with dissection and propagation of clot just underneath,
occluding the vessel lumen. Final images demonstrated resumed
flow in this vessel. He was transferred to the CCU in stable
condition, for monitoring overnight.
.
On further questioning, he describes exertional pain in his hard
palate for at least the last few months. He admits that he
doesn't exercise or go up and down stairs on a regular basis.
He notes that he did have a nuclear stress test in [**2134**] that he
reports was normal. He subsequently has had a stress echo every
two years, last in [**2138**], which have repeatedly demonstrated
borderline LVEF of 50-55%, with LVH.
Past Medical History:
PAST MEDICAL HISTORY:
1) Hypertension with LVH
2) Hyperlipidemia: Last cholesterol panel [**7-28**] with LDL 73, HDL
31, TC 130.
3) Low back pain
4) Colonic polyps
5) Cholecystectomy
6) Hemorrhoidectomy
Social History:
Lives with his wife in [**Location (un) 11790**], RI. Smoked 3 PPD for many
years, but quit in [**2122**]. Drinks 2-4 drinks per day (scotch,
wine). Denies IVDU.
Family History:
Both parents deceased; father with an MI at uncertain age,
mother with a cerebrovascular accident at 89. No family history
of diabetes.
Physical Exam:
PHYISCAL EXAMINATION: 97.7, 113/65, 93, 14, 96% RA
GENERAL: Overweight caucasian male resting supine in bed,
appearing comfortable.
HEENT: Anicteric sclerae, moist mucous membranes.
COR: Distant heart sounds. Regular rhythm, normal rate.
LUNGS: Clear to auscultation anteriorly.
ABD: Normoactive bowel sounds, soft, non-tender, non-distended.
GROIN: Right groin with sheath in place; no evidence of
hematoma.
EXTREMITIES: DP palpable on L, with non-palpable PT. DP
non-palpable on right, PT palpable. No edema. Cool.
Pertinent Results:
[**2140-8-16**] 07:52PM CK(CPK)-71
.
C.CATH Study Date of [**2140-8-16**]
*** Not Signed Out ***
1. Selective coronary angiography of this right dominant system
revealed
a one vessel coronary disease. The LMCA had a separate ostium
from the
LCx and was patent. The LAD had moderate luminal irregularities
but no
flow limiting disease. The LCx had a 90 % proximal stenosis.
The OM1
was a large vessel with a 50% stenosis at its origin. The RCA
had mild
luminal irregularites. It gave off an RV marginal branch that
had an
80% stenosis. The RPLV and RPDA were both widely patent.
2. Left ventriculography was deferred.
--
Percutaneous coronary revascularization of an additional vessel
was
performed using placement of drug-eluting stent(s).
Brief Hospital Course:
68 year old male with HTN, hyperlipidemia, who presented with
presumed unstable angina, with cath revealing a 90% proximal LCx
lesion which was stented, complicated by edge dissection and
occlusion of flow to OM1, subsequently stented as well, with
full restoration of flow. Transferred to the CCU from cath for
monitoring overnight given complication. Also with atrial
flutter of unclear duration. Pt stable post-cath.
.
1) Coronary artery disease/post-procedure ST-elevations:
Following stenting of proximal circ lesion, the pt developed
anginal-equivalent symptoms (jaw pain). Cath lab tele reportedly
showed ST-elevations. Angiography showed occlusion of flow to
OM1, which was just distal to newly placed stent. The OM was
stented and flow returned quickly and fully. Symptoms resolved
& EKG done just after catheterization was without ST elevations.
Pt's CK's did not rise, suggesting that, in fact, he may not
have actually had ST-segment elevations on tele. Nevertheless,
he was managed as having ACS. He was treated with ASA 325 mg
daily, plavix 75 mg daily, atorvastatin to 80 mg, and metoprolol
25 TID. His ACE-I was held during hospitalization (with concern
of possibly developing dye nephropathy). The pt underwent TTE
which revealed an EF of 45-55% as well as suspected distal
septal and inferior hypo to akinesis of the inferior wall. He
had an uneventful recovery from the catheterization.
.
2) Atrial flutter: Noted to be in flutter at OSH of unclear
duration. Started on heparin at outside hospital. Post-cath,
he was restarted on heparin, since he remained in flutter. He
underwent TEE & subsequent cardioversion with conversion to NSR
on day of discharge. Warfarin & lovenox initiated
post-cardioversion with plan of discontinuing lovenox once INR
therapeutic.
.
3) HTN: BP well controlled during hospitalization. Held on
ACE-I (ramipril) for large dye load, though renal function
remained stable after cath.
.
4) Hypercholesterolemia: As above, atorvastatin 80 mg.
Medications on Admission:
Home Meds:
Toprol XL 50 mg daily
Ramipril (Altace) 5 mg daily
ASA 81 mg daily
Atorvastatin 20 mg daily
Multivitamin daily
Lorazepam 1 mg QHS PRN
Naproxen prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
7. Ramipril 5 mg Capsule Sig: One (1) Capsule PO once a day.
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Naproxen Oral
10. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
Disp:*14 * Refills:*2*
11. Outpatient Lab Work
Please place standing order for INR checks every 3-5 days for
the next few weeks. Next check on Monday [**8-22**]. Please have
results faxed to Dr. [**Last Name (STitle) **] (phone number [**Telephone/Fax (1) 2394**]) and Dr.
[**Last Name (STitle) 68506**] (phone number [**Telephone/Fax (1) 69211**]).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1) Unstable angina
2) Dissection of Obtuse Marginal coronary vessel following left
circumflex stenting
3) Atrial flutter
Secondary:
1) Hypertension with LVH
2) Hyperlipidemia: Last cholesterol panel [**7-28**] with LDL 73, HDL
31, TC 130.
3) Low back pain
4) Colonic polyps
5) Cholecystectomy
6) Hemorrhoidectomy
Discharge Condition:
good
Discharge Instructions:
-Please take your new medications: coumadin and lovenox as
prescribed. You will need to give yourself the lovenox
injections (as shown) until your INR level is >2.0. After you
reach this therapeutic INR, you will only need to take the
coumadin and have regular blood tests with your PCP to monitor
INR.
-Please have your blood drawn to check your INR on Monday [**8-22**] with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 68506**] (phone #[**Telephone/Fax (1) 69211**]).
He will monitor your care.
-You have been started on a new medication called Plavix you
need to take this medication along with Aspirin EVERY day, as it
will help to keep your stents open. Do not stop these
medications unless Dr. [**Last Name (STitle) **] instructs you to do so. Also, you
should take aspirin 325mg, instead of 81mg daily.
-Your Lipitor (atorvastatin) dose was increased to 80mg, please
take this new dose daily.
-Please call your doctor or go to the ER if you have chest pain,
jaw pain, shortness of breath, nausea, vomiting,
light-headedness, or any other change in your health.
Followup Instructions:
-Please see Dr. [**Last Name (STitle) **] on [**9-14**] at 2:30pm in his office.
Telephone #[**Telephone/Fax (1) 2394**]. Please call if you have any questions
or need directions.
-Please see Dr. [**Last Name (STitle) 68506**] on [**8-31**] at 11:45am for a
follow-up appointment.
ICD9 Codes: 9971, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7066
} | Medical Text: Admission Date: [**2100-7-11**] Discharge Date: [**2100-7-15**]
Date of Birth: [**2062-12-19**] Sex: F
Service: [**Doctor First Name 147**]
Allergies:
Compazine / Reglan / Elavil / Captopril / Droperidol
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
belly pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57yoF with ESRD with chroni abdominal pain presents with ad ay
of abdominal pain feeling worse. Described as vague with nausea
and vomiting and yellow diarrhea. No fever no chills no icterus.
Past Medical History:
Diabetic myonecrosis or diabetic muscle
infarction.
End-stage renal disease.
Type 1 diabetes.
Hypertension.
Cardiomyopathy. EF 35-40%. Heart murmur
History of methicillin-sensitive Staphylococcus aureus
bacteremia.
Septic arthritis.
Depression.
Social History:
lives with son, no [**Name2 (NI) **]/alc.
Family History:
grandmother with DM, mother with HTN
Physical Exam:
temp 98 pulse 61 bp 145/61
Alert and oriented
no icterus
regular rate and rhythm
lungs clear to auscultation
abdomin no crepitus, obese, distended, tender- distractable
Pertinent Results:
[**2100-7-11**] 07:08PM WBC-5.4 RBC-3.13* HGB-7.9* HCT-28.5* MCV-91
MCH-25.3* MCHC-27.8* RDW-20.9*
[**2100-7-11**] 07:08PM PLT COUNT-241
[**2100-7-11**] 09:33AM GLUCOSE-134* UREA N-16 CREAT-4.0* SODIUM-148*
POTASSIUM-5.7* CHLORIDE-100 TOTAL CO2-35* ANION GAP-19
[**2100-7-11**] 09:33AM ALT(SGPT)-24 AST(SGOT)-38 LD(LDH)-359* ALK
PHOS-206* AMYLASE-51 TOT BILI-0.4
[**2100-7-11**] 09:33AM LIPASE-9
[**2100-7-11**] 09:33AM ALBUMIN-3.0* CALCIUM-9.3 PHOSPHATE-4.0
MAGNESIUM-2.0
[**2100-7-11**] 09:33AM WBC-5.3 RBC-3.26* HGB-8.3* HCT-28.6* MCV-88
MCH-25.4* MCHC-28.9* RDW-20.6*
[**2100-7-11**] 09:33AM PLT COUNT-228
[**2100-7-11**] 09:33AM PT-27.1* PTT-53.4* INR(PT)-4.9
[**2100-7-11**] 03:40AM GLUCOSE-71 UREA N-15 CREAT-3.8* SODIUM-148*
POTASSIUM-6.0* CHLORIDE-101 TOTAL CO2-33* ANION GAP-20
[**2100-7-11**] 01:51AM COMMENTS-GREEN TOP
[**2100-7-11**] 01:51AM K+-5.9*
[**2100-7-10**] 09:11PM GLUCOSE-32* UREA N-13 CREAT-3.5* SODIUM-148*
POTASSIUM-6.4* CHLORIDE-99 TOTAL CO2-35* ANION GAP-20
[**2100-7-10**] 09:11PM ALT(SGPT)-19 AST(SGOT)-41* ALK PHOS-237*
AMYLASE-58 TOT BILI-0.4
[**2100-7-10**] 09:11PM TOT PROT-7.5 ALBUMIN-3.2* GLOBULIN-4.3*
CALCIUM-9.4 PHOSPHATE-3.8 MAGNESIUM-2.1
[**2100-7-10**] 09:11PM WBC-4.6 RBC-3.50* HGB-9.1* HCT-32.0* MCV-91
MCH-26.1* MCHC-28.5* RDW-20.4*
[**2100-7-10**] 09:11PM NEUTS-44* BANDS-4 LYMPHS-38 MONOS-12* EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2100-7-10**] 09:11PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2100-7-10**] 09:11PM PLT SMR-NORMAL PLT COUNT-249
[**2100-7-10**] 09:11PM PT-27.3* PTT-57.4* INR(PT)-4.9
Brief Hospital Course:
ED work up include CT
1. Findings consistent with severe CHF, with nutmeg liver and
severe anasarca.
2. Moderate amount of free intraperitoneal fluid.
3. Air within the bladder. Correlate with urinalysis/culture to
evaluate for gas- producing organism/cystitis.
4. No evidence of bowel obstruction.
5. Small amount of air adjacent to both inferior epigastric
arteries, of unknown etiology.
6. Right renal and uterine/ovarian arteriovenous malformations.
CXR: Compared to the prior study, there has been interval
removal of the previously seen right sided PICC line. There is a
dual lumen catheter via the left subclavian vein with its tip in
the distal SVC, unchanged. There is cardiomegaly with
redistribution of the pulmonary vasculature consistent with mild
CHF. No focal consolidations are seen. No free air under the
diaphram.
KUB:
This study cannot exclude free intraperitoneal air. A left
femoral venous catheter is seen. There is a paucity of bowel gas
throughout the abdomen. Some gas is seen in the colon. There is
ascites throughout the abdomen.
Pt remained afebrile for hospital stay and did not require
antibiotic therapy. Pt became symptomatically better and
continues to have flatus and bowel movements. Pt is ok to leave
hospital and return to nursing home.
Medications on Admission:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
Disp:*15 Capsule(s)* Refills:*2*
3. Mirtazapine 15 mg Tablet Sig: half Tablet PO HS (at bedtime).
Disp:*20 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg IV Q24H
7. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
9. Epogen 10,000 unit/mL Solution Sig: One (1) Injection once a
week.
Disp:*1 * Refills:*2*
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*1 * Refills:*2*
Discharge Medications:
same no changes
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
end stage renal disease on hemodialysis
ascites
cardiomyopathy
aortic regurgitation
mitral regurg
pulmonary hypertension
gastroparesis
congestive heart failure with ejection fraction 35%
Right atrial thrombus
osteomylitis
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
1. Please monitor for the following: fever, chills, nausea,
vomiting, inability to tolerate food/drink. If any of these
occur, please call your physician [**Name Initial (PRE) 2227**].
2. Suture at JP site put in [**2100-7-12**] should be removed in 7-10days
3. Restart all your home medications
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2100-7-21**] 3:00
Please call Dr.[**Name (NI) 106682**] office for an appointment in two weeks.
[**Telephone/Fax (1) 673**]
Completed by:[**2100-7-12**]
ICD9 Codes: 2851, 4280, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7067
} | Medical Text: Admission Date: [**2126-4-10**] Discharge Date: [**2126-4-15**]
Date of Birth: [**2061-3-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
[**2126-4-10**] Coronary artery bypass grafting time one, aortic valve
replacement with 25 mm [**Company 1543**] Mosaic ultra porcine
History of Present Illness:
Mr. [**Known lastname **] is a 64 year old man followed for several years for a
bicuspid aortic valve and aortic stenosis. His most recent
echocardiogram showed worsening stenosis. Therefore he was
referred to cardiac surgery.
Past Medical History:
bicuspid aortic valve
aortic valve stenosis
ascending aortic arch aneurysm
left inguinal hernia
mild benign prostatic hypertrophy
sleep apnea on CPAP
s/p right inguinal hernia repair
bilateral cataract surgery
Social History:
Mr. [**Known lastname **] is an attorney.
Family History:
His family history is non-contributory.
Physical Exam:
At the time of admission, Mr [**Known lastname **] was found to be in no acute
distress. His skin was noted to be warm, dry, and clean, dry,
and intact. His teeth were noted to be in good repair. No
jugular venous distention was noted. Upon auscultation of his
chest, his lungs were clear to auscultation bilaterally. His
heart was of regular rate and rhythmwith a III/VI systolic
ejection murmur. His abdomen was soft, non-tender, and
non-distended with a left sided direct inguinal hernia. His
lower extremities were slightly edematous. Mild varicosities
below the knee were found. He was awake, alert, and oriented
with a steady gate.
Pertinent Results:
[**2126-4-11**] 02:41AM BLOOD WBC-13.8* RBC-3.60* Hgb-11.3* Hct-32.5*
MCV-90 MCH-31.5 MCHC-34.9 RDW-12.9 Plt Ct-168
[**2126-4-11**] 02:41AM BLOOD Plt Ct-168
[**2126-4-11**] 02:41AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-137
K-5.1 Cl-111* HCO3-23 AnGap-8
[**2126-4-15**] 10:28AM BLOOD WBC-7.8
[**2126-4-14**] 06:15AM BLOOD UreaN-9 Creat-0.9 Na-138 K-4.1
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 251**] [**Hospital1 18**] [**Numeric Identifier 58453**]Portable TTE
(Complete) Done [**2126-4-12**] at 12:30:00 PM 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: [**2061-3-23**]
Age (years): 65 M Hgt (in): 72
BP (mm Hg): 102/60 Wgt (lb): 180
HR (bpm): 81 BSA (m2): 2.04 m2
Indication: Pericardial effusion.
ICD-9 Codes: 424.1
Test Information
Date/Time: [**2126-4-12**] at 12:30 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2009W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.5 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Sinus Level: *4.3 cm <= 3.6 cm
Aorta - Ascending: *4.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *39 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 24 mm Hg
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 0.89
Mitral Valve - E Wave deceleration time: *367 ms 140-250 ms
TR Gradient (+ RA = PASP): 19 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Moderately dilated
ascending aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Left pleural effusion.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is moderately dilated at the sinus
level. The ascending aorta is moderately dilated. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: No significant pericardial effusion.
Normally-functioning aortic valve bioprosthesis.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2126-4-12**] 14:44
?????? [**2119**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2126-4-10**] Mr. [**Known lastname **] was taken to the operating room and
underwent a coronary artery bypass graft times one and aortic
valve replacement. This procedure was performed by Dr. [**Last Name (STitle) **].
He tolerated the procedure well and was transferred in critical
but stable condition to the surgical intensive care unit. He
was extubated by the following day and his pressors were weaned.
His chest tubes were removed. By post-operative day he was
transferred to the cardiac surgery step down floor. He was
gently diuresed and his beta blockade was increased as
tolerated. His epicardial wires were removed on POD#3. He was
seen by physical therapy and discharged to home with VNA
services on POD 5. He spiked a fever to 101.5 on POD 4. This
resolved. Cultures were sent and the patient was empirically
started on antibiotics. At the time of discharge, cultures are
pending and will be followed. Chest X-ray did not reveal
infiltrate.
Medications on Admission:
Aspirin 81 mg daily
multivitamin daily
vitamin C daily
ginko biloba 60mg 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:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
AST, ALT, alk phos, tbili, albumin, LDH
Results to Dr. [**Last Name (STitle) 7389**] [**Telephone/Fax (1) 14525**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
aortic valve stenosis, coronary artery disease
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. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7389**] (cardiologist & PCP) in [**1-29**] weeks
([**Telephone/Fax (1) 14525**]) please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Lab draw 1 month for liver function tests
Completed by:[**2126-4-15**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7068
} | Medical Text: Admission Date: [**2185-5-20**] Discharge Date: [**2185-5-27**]
Date of Birth: [**2130-11-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2185-5-23**] Redo, Redo-Sternotomy, Pulmonic Valve Replacement with
25mm [**Company 1543**] Mosaic Aortic Porcine Valve/Right Ventricular
Outflow Tract Reconstruction with pericardial patch
[**2185-5-20**] Cardiac Cath
History of Present Illness:
54 y/o male c/p dyspnea on exertion with h/o congenital aortic
valve disease s/p aortic valve repair ([**2137**]'s) and s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Procedure ([**2173**]). He has been undergoing routine echocardiograms
and most recent has shown worsening pulmonic
stenosis/suprapulmonic stenosis stenosis of homograft (incr.
peak/mean) with moderate TR.
Past Medical History:
Hypertension, Congenital Aortic Valve Disease s/p AV repair
([**2137**]'s) and [**Doctor Last Name **] procedure ([**2173**])
Social History:
Denies tobacco use. Occ. ETOH use.
Family History:
Non-contributory
Physical Exam:
VS: 76 12 118/70 5'8" 205#
Gen: WD/WN male in NAD
Skin: W/D intact
HEENT: NC/AT, EOMI, PERRL, OP benign
Neck: Supple, FROM -JVD
Chest: CTAB -w/r/r with well-healed sternotomy
Heart: RRR w/ 4/6 systolic murmur
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, trace edema, -varicosities, healed
groin incisions
Neuro: A&O x 3, MAE, non-focal
Discharge
99.4, 102/50, 86 SR, 20, 93 RA wt 100.7 kg
Neuro a/o x3 nonfocal
Pulm CTA bilat except scattered crackles at base
Cardiac RRR
Sternal inc healing no erythema no drainage sternum stable
Abd soft, nt, nd +bs
Ext warm +1 edema
Right groin CDI
Pertinent Results:
[**2185-5-20**] Cardiac Cath: 1. Selective coronary angiography in this
right dominant system demonstrated a normal LMCA. The LAD had a
50-60% stenosis in its mid portion. The LCX was normal. The RCA
had luminal irregularities but no angiographically significant
CAD. 2. Resting hemodynamics revealed markedly elevated right
ventricular pressures; RV systolic pressure was 85-90 mmHg and
RV filling presure was 18 mmHg. There was a 60-70 mmHg gradient
between RV and PA. Systemic arterial pressures were normal; LV
filling pressure was mildly elevated. 3. There was a 60-mmHg
gradient at/across the pulmonic valve. There was trivial mitral
regurgitation. Aortography did not demonstrate any significant
AI.
[**2185-5-23**] Echo: PRE-BYPASS: 1. The left atrium is normal in size.
The right atrium is moderately dilated. 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 normal (LVEF>55%). 3. The right ventricular
free wall is hypertrophied. The right ventricular
cavity is moderately dilated. There is mild global right
ventricular free wall hypokinesis. 4. The aortic root is
moderately dilated athe sinus level. There are focal
calcifications in the aortic arch. There are simple atheroma in
the descending thoracic aorta. 5. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. There is
no aortic valve stenosis. Mild to moderate ([**12-21**]+) aortic
regurgitation is seen. 6. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. 7. There is
severe pulmonic valve stenosis. 8. There is no pericardial
effusion. POST-BYPASS: For the post-bypass study, the patient
was receiving vasoactive infusions including phenylephrine 1. A
bioprosthesis is well seated in the pulmonic position. No
significant PR
is seen. Visualization of the valve was suboptimal. 2.
Biventricular function is preserved. 3. Other findings are
unchanged.
[**5-26**] CXR: There is no pneumothorax or increased pleural effusion
after removal of two chest tubes. There is improvement in the
aeration of the bases bilaterally with still residual linear
atelectasis present in the right lung. The heart size and
mediastinal contours are unchanged. The replaced pulmonary valve
is demonstrated. The lucency between the sternal areas is again
noted. The patient's radiograph doesn't demonstrate evidence of
congestive heart failure.
[**2185-5-20**] 09:00AM BLOOD WBC-5.2 RBC-4.55* Hgb-14.1 Hct-38.4*
MCV-84 MCH-30.9 MCHC-36.6* RDW-13.6 Plt Ct-197
[**2185-5-24**] 03:03AM BLOOD WBC-13.9* RBC-3.50* Hgb-10.6* Hct-30.2*
MCV-86 MCH-30.4 MCHC-35.2* RDW-13.5 Plt Ct-142*
[**2185-5-27**] 06:50AM BLOOD WBC-10.7 RBC-3.21* Hgb-9.7* Hct-27.5*
MCV-86 MCH-30.2 MCHC-35.3* RDW-13.4 Plt Ct-192
[**2185-5-20**] 09:00AM BLOOD PT-13.4* PTT-38.5* INR(PT)-1.2*
[**2185-5-24**] 03:03AM BLOOD PT-14.7* PTT-39.9* INR(PT)-1.3*
[**2185-5-20**] 09:00AM BLOOD Glucose-109* UreaN-16 Creat-0.9 Na-136
K-4.3 Cl-106 HCO3-24 AnGap-10
[**2185-5-27**] 06:50AM BLOOD Glucose-107* UreaN-16 Creat-0.9 Na-135
K-4.3 Cl-99 HCO3-28 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 69843**] was admitted pre-operatively to undergo cardiac
cath and other work-up prior to surgery. On [**5-23**] he was then
brought to the operating room where he underwent redo,
redo-sternotomy, Pulmonic Valve Replacement, and Right
Ventricular Outflow Tract Reconstruction. Please see operative
report for surgical details. Following surgery he was
transferred to the CSRU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one he was
started on beta blockers and diuretics and diuresed towards his
pre-op weight. Later on this day he was transferred to the
telemetry floor for further care. On post-op day two his
mediastinal chest tubes were removed and on post-op day three he
pleural chest tubes were removed. Also on post-op day three his
epicardial pacing wires were removed. His medication were
titrated for maximum hemodynamics and he worked with physical
therapy for strength and mobility. He did require aggressive
pulmonary toilet and needed oxygen via nasal cannula for several
days to maintain his oxygen saturation above 93%. This was
slowly weaned and he was discharged home on post-operative day
four with the appropriate meds and follow-up appointments.
Medications on Admission:
Aspirin 325mg qd, Diltiazem 120mg qd, Diovan 80mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10
days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Care Centrix
Discharge Diagnosis:
Pulmonic Stenosis/Suprapulmonic Stenosis of Homograft s/p
Pulmonic Valve Replacement and Right Ventricular Outflow Tract
Reconstruction (RVOT)
PMH: Hypertension, Congenital Aortic Valve Disease s/p AV repair
([**2137**]'s) and [**Doctor Last Name **] procedure ([**2173**])
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 69844**] in [**12-21**] weeks
Dr [**Last Name (STitle) 11250**] in [**1-22**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2185-5-27**]
ICD9 Codes: 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7069
} | Medical Text: Admission Date: [**2115-7-17**] Discharge Date: [**2115-7-22**]
Date of Birth: [**2056-2-1**] Sex: F
Service: PSYCHIATRY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 12693**]
Chief Complaint:
"I'm going to die ..you'll die of old age I just gave you MRSA
because I just shook your hand."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 59 yo cauc. female with reported hx of bipolar
do discharged fom [**Hospital **] Hospital psych unit yeserday brought
to the ED by her husband and twin sister as she continues
delusional.The patient is psychotic, manic and has thoughts that
she and other people are dying and believes she is the last
Catholic alive.
Her husband reports that she was discharged from [**Hospital **]
Hospital
yesterday after a 3 week admission but she continues psychotic,
not sleeping,and arguementative and refusing to take her
medications .He said she is continously hungry , is an insulin
dependent diabetic and last night she ate a huge piece of
cheesecake. This morning he said "she laid down on the kitchen
floor and refused to get up and said " I'm dying."He said that
she has not slept all night and that he has been up with her as
she is a flight risk.He said before her most recent
hospitalization to Norwooed she cut a hole in the screen door,
crawled out and ran and hid under [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].He said she threw her
suiticase in the [**Doctor Last Name 6641**] and continually tried to run away and he
had to watch her 24 hrs a day.
Her husband [**Name (NI) 68655**] that she was referred to a Dr. [**Last Name (STitle) **] in
[**Location (un) 3320**] after she was discharged but was told that she could
not have an appointment with him until she was seen by a
therapist for 2-3 times.
The patient has hx of bipolar do first daignosed and
hospitalized
24 years ago and was admitted to [**Hospital3 15986**] twice and has
been apparently relatively stable unitl this past [**Name (NI) **] and has
reportedly had 2 admisssions to [**Hospital **] Hospital.
Recent stressors are her brother in law her twin sister's
husband
died in [**Name (NI) 404**] and [**Month (only) 958**] is the anniversary of her son's death.
Past Medical History:
* [**Hospital **] Hospital discharged [**2115-7-15**] after a [**2-7**] week
admission where she was admitted from [**Hospital3 3583**] ED
manic
* [**Hospital3 15986**] twice 23 years ago manic and diagnosed with
bipolar do
* no hx of SA or SIB
* [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) **] CNS, @ Southeast Psychiatric [**First Name9 (NamePattern2) 89027**]
[**Location (un) 5110**], MA
* Dr. [**Last Name (STitle) 39602**] in [**Location (un) 3320**] has not seen yet was referred to
him after she was dischzrged from [**Hospital **] Hospital
PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
* PCP [**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5311**] ([**Telephone/Fax (1) 89028**]}
* IDDM hx of insulin pump not connected
* Crohn's Disease
Social History:
alcohol: reported hx of abuse many years ago, sober 9 years
denies hx of w/d sz or balckouts
drugs: denies illicits
tob: denies
caffeine: drinks a pot of coffee a day
SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL
ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL
HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):
The patient was born and grewup in [**Location (un) 6691**],MA. and has an
identical twin sister and a younger brother was from an intact
family and no hx of abuse.Her [**Last Name (un) 89029**] died at age 59 and her
father
has [**Name (NI) 2481**] and lives in a nsg home.
She graduated from [**Hospital **].[**Location (un) 5169**] with a degree in Mathematics
was working until this past [**Month (only) 116**] for an insurance company as a
Customer Survey Representative.
She is married and had 2 children, her dtr is 23 and works @
[**Hospital1 18**] in accounting and her son died at age 20 in a car fire in
[**2106**] while sitting in his car in the driveway of their home.He
was reportedly working with some type of electrical equipment
and
the car caught on fire and he died of smoke inhalation.
Family History:
paternal cousin with psychiatric illness
father and paternal uncle with [**Name (NI) 2481**]
maernal grandfather with mental illness
Physical Exam:
PE:
General: Thin woman in no distress. Frequently getting up out
of
chair during interview, lots of fidgeting.
HEENT: head normocephalic & atraumatic, PERRL, EOMI, no
lymphadenopathy, no thyromegaly
Lungs: Clear to auscultation; no crackles or wheezes.
CV: Regular rate and rhythm; no murmurs/rubs/gallops
Abdomen: Soft, nontender, nondistended
Extremities: No clubbing, edema or cyanosis.
Skin: Warm and dry, no rash or significant lesions.
Neuropsychiatric Examination:
*VS: BP: 155/76 HR: 94 temp: 97.9 resp: 16 O2 sat: 100%
height: 61" weight: 113.6 lbs
Neurological:
*station and gait: gait wnl, but when asked if she is ever
unstable immediatly demonstrated with a self-corrected stumble
*tone and strength: wnl
cranial nerves: PERRL, EOMI, face motor & sensation intact &
symmetric, hearing grossly intact & symmetric to finger rub,
symmetric palate raise, symmetric shoulder shrug, tongue
midline.
abnormal movements: frequent fidgeting
*Appearance & behavior: unkempt hair, dressed in hospital gown
and wearing bright pink socks with black sandals. Nursing had
given her dinner in the exam room because she had a low CBG
[**Location (un) 1131**]; she frequently got up to fidget with the food and ate
very fast and enthusiastically with mouth open. Cooperative,
good eye contact.
*Mood and Affect: "stable" & "a little bit happy"; affect
labile, ranging from tearfulness to happy, occasionally
irritable
*Thought process: tangential, occasionally loose
*Thought Content: delusional content as described in HPI;
denies SI, HI, and hallucinations
*Judgment and Insight: poor
Cognition:
*Attention, *orientation, and executive function: fully
oriented to place, date, time, and season; thought it was
Tuesday
when it is Wednesday.
*Memory: [**3-7**] registration, [**3-7**] short-term
Calculations: did serial 7's starting at 30 down to -6, with
one mistake (23-7=15)
Abstraction: initially interpreted "apple doesn't fall far
from the tree" literally, but able to accurately interpreted
with
the prompt that it is a saying about people. Accurately
interpreted "birds of a feather."
Comparisons: pear & [**Location (un) 2452**] are both fruit
*Speech: rapid, articulate, occasionally bordering on
pressured
Pertinent Results:
[**2115-7-16**] 01:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2115-7-16**] 01:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2115-7-16**] 01:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2115-7-16**] 01:20PM URINE HOURS-RANDOM
[**2115-7-16**] 01:55PM PLT COUNT-271
[**2115-7-16**] 01:55PM NEUTS-78.0* LYMPHS-14.0* MONOS-6.4 EOS-0.6
BASOS-1.0
[**2115-7-16**] 01:55PM WBC-6.5 RBC-3.37* HGB-11.2* HCT-31.1* MCV-92
MCH-33.3* MCHC-36.1* RDW-12.8
[**2115-7-16**] 01:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2115-7-16**] 01:55PM estGFR-Using this
[**2115-7-16**] 01:55PM GLUCOSE-357* UREA N-27* CREAT-0.8 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-25 ANION GAP-16
[**2115-7-17**] 01:00PM GLUCOSE-509* UREA N-14 CREAT-0.7 SODIUM-132*
POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-30 ANION GAP-14
[**2115-7-17**] 01:18PM freeCa-1.17
[**2115-7-17**] 01:18PM GLUCOSE-458* LACTATE-2.2* NA+-131* K+-4.8
CL--90* TCO2-30
[**2115-7-17**] 01:18PM PH-7.38 COMMENTS-GREEN TOP
[**2115-7-17**] 04:21PM freeCa-1.03*
[**2115-7-17**] 04:21PM GLUCOSE-300* LACTATE-3.6* NA+-133* K+-3.6
CL--103 TCO2-23
[**2115-7-17**] 04:21PM PH-7.39
[**2115-7-17**] 05:30PM PLT COUNT-260
[**2115-7-17**] 05:30PM NEUTS-80.6* LYMPHS-14.2* MONOS-4.2 EOS-0.7
BASOS-0.4
[**2115-7-17**] 05:30PM WBC-6.3 RBC-3.20* HGB-10.5* HCT-29.8* MCV-93
MCH-32.8* MCHC-35.1* RDW-12.7
[**2115-7-17**] 05:30PM CALCIUM-8.6 PHOSPHATE-2.5* MAGNESIUM-1.7
[**2115-7-17**] 05:30PM GLUCOSE-228* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-11
[**2115-7-17**] 05:35PM GLUCOSE-217* LACTATE-2.3*
Brief Hospital Course:
#Bipolar: Per her family, Mrs. [**Known lastname 9464**] was successfully treated
with tegretol as an outpatient for 20 years prior to her recent
decompensation. After being admitted to [**Hospital **] Hospital for
mania the patient was transitioned from tegretol to zyprexa and
risperdal, out of concern that tegretol was causing
hyponatremia. While at [**Hospital1 18**] during this hospitalization the
patient was started on lithium for mania. Her level was 0.6 on a
dose of 300mg [**Hospital1 **], so her dose was increased to 300mg TID. She
was also transitioned from zyprexa 10mg daily to ziprasidone
80mg qhs, as this option is a more weight-neutral atypical
antipsychotic. She demonstrated some improvement in her
symptoms, including improvement of her pressured speech and
impulsivity. However she persistently had delusions of death and
traveling through time. She also frequently lay on the floor,
reporting she was either having seizures or dying. In looking
through old records the patient has exhibited this behavior
throughout each of her hospitalizations. She responds well to
2mg PO ativan and re-direction into bed.
#Diabetes: The patient demonstrated very labile blood sugars
throughout this hospitalization. Her sugars were frequently
elevated in the 300s - 400s, however she frequently
over-corrected into the 30s - 50s overnight. [**Last Name (un) **] has been
following the patient and adjusting her insulin, however she
remains difficult to control. Of note the patient has an insulin
pump which she is not currently using. According to her family
her blood sugar was well-controlled prior to her
hospitalizations at [**Location (un) **] when she was started on Zyprexa.
#Autonomic instability: On the day of transfer ([**2115-7-22**]) the
patient had some autonomic instability which was initially
concerning for NMS, as she had received 3 doses of Geodon over
the weekend. She demonstrated tachycardia (128) and muscle
rigidity this morning, with some concern of rising temperature
(99.7 up from 98.5). The patient was given 2mg PO ativan and a 1
liter bolus of normal saline. She had labs sent which
demonstrated a WBC of 12 without bands, and a CK of 85. This
decreased our suspicion for NMS but the patient was placed on
constant observation and we continued frequent vital sign
checks. The patient's vital signs improved to temp 96.3 and HR
91 in the early afternoon. However, she later demonstrated
somnolence and had a fingerstick which showed a blood sugar of
20. The patient was given glucagon but her blood sugar continued
to drop to 18, then 14. A code was called on the patient. The
ICU team came to evaluate the patient and found her to be
hypotensive with blood pressure in the 90s/50s. She was given
D50 for her low blood sugar and her sugar rose to the 200s. The
patient was given another 1L bolus of NS and the decision was
made to transfer her to the ICU for ongoing monitoring, with
likely transfer to the medicine service after acute
stabilization.
#Hypertension: The patient was continued on her outpatient
regimen of metoprolol 50, amlodipine 5 and irbesartan 300mg
daily.
#Alzheimer's: The patient was continued on her Aricept.
According to her husband she has never had formal neuropsych
testing. We will plan to order a neuropsych consult after she
returns to [**Hospital1 **] 4. We will also obtain a head CT at that time,
unless she has a head CT as part of her workup while on
medicine.
#Legal: The patient signed a CV which was accepted by the house
officer on [**Hospital1 **] 4. She remained her voluntarily
#Safety: The patient frequently had to be placed on 5 minute
checks or constant observation for behavioral problems,
including eating other patients' food and lying on the floor
complaining of seizures. She will be on "constant observation"
while on medicine to try to prevent behavioral problems.
Medications on Admission:
* Xanax .5mg qid
* Zyprexa 5mg [**Hospital1 **]
* Aricept 5mg @hs
* Avapro 300mg qd
* Toprol XL 50mg extended release 24hr
* Glucophage 1,000mg [**Hospital1 **]
* Zocor 10mg qd
* Vit D 1000 unit qd
* lantus 100 unit/ML s.c. 24u solutions @ 2100
* Novolog unknown strengthI
* Norvasc 5mg qd
Discharge Medications:
Ziprasidone Hydrochloride 40 mg PO/NG QAM [**7-22**] @ 1550 View
Lithium Carbonate 300 mg PO TID [**7-22**] @ 1550 View
Lorazepam 2 mg PO/NG ONCE Duration: 1 Doses [**7-22**] @ 1043 View
Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose
[**7-20**] @ 0908
Ziprasidone Hydrochloride 80 mg PO/NG HS [**7-18**] @ 1712 View
Avapro *NF* (irbesartan) 300 mg Oral daily Reason for Ordering:
Wish to maintain preadmission medication while hospitalized, as
there is no acceptable substitute drug product available on
formulary. [**7-17**] @ 2122 View
Alprazolam 0.5 mg PO QID:PRN anxiety, agitation [**7-17**] @ 2122
View
Amlodipine 5 mg PO DAILY [**7-17**] @ 2122 View
Donepezil 5 mg PO HS [**7-17**] @ 2122 View
Metoprolol Succinate XL 50 mg PO DAILY [**7-17**] @ 2122 View
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol [**7-17**] @ 2051
View
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol [**7-17**] @ 2051
View
Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO Q4H:PRN acid
reflux [**7-17**] @ 2051 View
Milk of Magnesia 30 ml PO Q8H:PRN constipation [**7-17**] @ 2051
View
Acetaminophen 650 mg PO Q4H:PRN pain, fever [**7-17**] @ 2051 View
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 18**] CC7
Discharge Diagnosis:
II- defer
III - NIDDM, htn
IV - family tensions, acute hospitalizaiton, recent d/c from
psychiatric unit, failure to comply with medications
V-28
Discharge Condition:
Unstable - being discharged to medicine CC7 for stabilization of
blood sugars and blood pressure
Discharge Instructions:
-Please call psychiatry consult service ([**7-/7896**]) to have
psychiatry continue to follow this patient
-Please have [**Last Name (un) **] continue to follow the patient. They are
aware she has been transferred
-Please have patient return to psychiatry when medically stable
Followup Instructions:
No follow up appointments scheduled at this point
ICD9 Codes: 2761, 4589, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7070
} | Medical Text: Admission Date: Discharge Date: [**2161-9-2**]
Date of Birth: [**2161-8-31**] Sex: F
Service: NB
DICTATOR: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NNP, for Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **]
HISTORY: Infant is a full-term, 3890 gram female born, who
was admitted to the Neonatal Intensive Care Unit from Labor
and Delivery for respiratory distress. Infant was born to a
30 year old, gravida 1, para 0 now 1, mother.
PRENATAL SCREENS: O-positive, antibody negative, hepatitis B
surface antigen negative, RPR non-reactive, rubella-immune.
GBS screening negative.
Pregnancy reportedly benign. Mother presented in spontaneous
labor. Maternal fever of 99.5 to 100.3. Rupture of
membranes less than 24 hours prior to delivery. Meconium-
stained amniotic fluid. Spontaneous vaginal delivery.
Apgars were 8 at one minute and 9 at five minutes.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 3890
(greater than 90th percentile), length 50.5 cm (75th
percentile), head circumference 34.5 cm (50-75th percentile).
Resting comfortably on open warmer, pink, oxygen saturations
94 percent on room air. Breathing quietly, however when
agitated infant begins to grunt. Anterior fontanelle soft
and flat, palate intact. Lungs clear and equal bilaterally.
Soft murmur, regular rate and rhythm, femoral pulses +2.
Abdomen soft, positive bowel sounds. Normal female
genitalia. Patent anus. No sacral anomalies. Extremities
pink and well perfused.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Infant
continued to have grunting, flaring, and retractions upon
admission and required nasal cannula flow of 25cc at 100
percent FIO2. Infant transitioned to room air by day of life
1. Infant remains on room air with oxygen saturations
greater than 95 percent and respiratory rates 40 to 50.
Infant has not had any apnea or bradycardia this
hospitalization.
CARDIOVASCULAR: No murmur, hemodynamically stable.
FLUIDS/ELECTROLYTES/NUTRITION: Infant was initially nothing
by mouth, receiving 60 cc/kg per day of D10/W. Glucoses have
ranged from 62 to 92. Enteral feedings were started on day
of life 1. The infant is currently feeding ad lib, breast-
feeding or Similac 20 calories per ounce p.o. The most
recent weight is 3725 grams.
GASTROINTESTINAL: The most recent bilirubin level on day of
life 2 was a total of 10.2 with direct of 0.3. The infant
has not received phototherapy.
HEMATOLOGY: Hematocrit on admission was 53 percent. Infant
has not received any blood transfusions this hospitalization.
The most recent hematocrit on day of life 2 was 49 percent.
INFECTIOUS DISEASE: CBC on admission showed white blood cell
count 5.4, hematocrit 53 percent, platelets 305,000, 22
neutrophils, 5 bands, 5 metas, 2 myelos, 25 nucleated red
blood cells. A repeat CBC and differential on day of life 2
showed a white blood cell count of 31. Hematocrit 49
percent, platelets 323,000, 67 neutrophils, 2 bands. Infant
received a total of 48 hours of ampicillin and gentamicin.
Blood cultures remained negative to date.
NEUROLOGY: Normal neuro exam. Hearing screen
passed bilaterally.
PSYCHOSOCIAL: Parents involved.
CONDITION ON DISCHARGE: Stable on room air.
DISCHARGE DISPOSITION: Home with parents.
PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], phone number [**Telephone/Fax (1) 43116**].
FU to be ararnged for tomorrow.
CARE RECOMMENDATIONS: Feedings at discharge: breast-feeding
or Similac 20 calories per ounce p.o. ad lib.
MEDICATIONS: None.
STATE NEWBORN SCREEN: Sent and pending.
IMMUNIZATIONS: Infant received hepatitis B vaccine on [**2161-9-2**]. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the child's
life, immunization against influenza is recommended for
household contact or care-givers.
FOLLOWUP APPOINTMENTS: Primary pediatrician on [**2161-9-3**].
DISCHARGE DIAGNOSES: Large for gestational age.
Status post respiratory distress, transient tachypnea of the
newborn.
Status post rule out sepsis, ruled out.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 56160**]
MEDQUIST36
D: [**2161-9-2**] 18:27:07
T: [**2161-9-2**] 19:19:41
Job#: [**Job Number **]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7071
} | Medical Text: Admission Date: [**2177-12-15**] Discharge Date: [**2177-12-23**]
Date of Birth: [**2111-12-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CABGx3(LIMA-LAD,SVG-Diag,SVG-OM)[**12-19**]
History of Present Illness:
66 yo M with known CAD who presented to [**Hospital3 **] with chest
pain, ruled in for NSTEMI. Pt was transferred to [**Hospital1 18**] for cath.
Past Medical History:
CAD, s/p MI ??????93 HTN, ^lipid, Mod MR, Spinal stenosis s/p RIH
Social History:
semi retired car salesman
lives with wife
no tobacco
social etoh
Family History:
NC
Physical Exam:
Vitals 52, 189/93, 18
General NAD
Skin unremarkable
Neck Supple Full ROM
Chest CTA bilat
Heart RRR
Abd soft NT ND
Ext warm well perfused
Pertinent Results:
[**2177-12-22**] 06:30AM BLOOD WBC-6.9 RBC-3.08* Hgb-9.5* Hct-27.5*
MCV-89 MCH-30.8 MCHC-34.5 RDW-13.2 Plt Ct-210
[**2177-12-15**] 05:35PM BLOOD WBC-6.2 RBC-4.37* Hgb-13.5* Hct-37.6*
MCV-86 MCH-30.9 MCHC-35.9* RDW-13.3 Plt Ct-220
[**2177-12-22**] 06:30AM BLOOD Plt Ct-210
[**2177-12-22**] 06:30AM BLOOD PT-12.7 INR(PT)-1.1
[**2177-12-15**] 05:35PM BLOOD Plt Ct-220
[**2177-12-15**] 05:35PM BLOOD PT-12.7 PTT-26.9 INR(PT)-1.1
[**2177-12-21**] 04:07AM BLOOD Fibrino-695*#
[**2177-12-23**] 06:10AM BLOOD K-4.5
[**2177-12-22**] 06:30AM BLOOD Glucose-113* UreaN-6 Creat-1.0 Na-140
K-4.4 Cl-105 HCO3-27 AnGap-12
[**2177-12-15**] 05:35PM BLOOD Glucose-138* UreaN-14 Creat-1.0 Na-139
K-3.9 Cl-106 HCO3-23 AnGap-14
[**2177-12-17**] 04:39PM BLOOD ALT-16 AlkPhos-42 TotBili-0.4
[**2177-12-15**] 05:35PM BLOOD AST-26 AlkPhos-41 TotBili-0.8
[**2177-12-16**] 03:20AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2177-12-21**] 04:07AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.3
[**2177-12-17**] 04:39PM BLOOD %HbA1c-5.3
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2177-12-20**] 3:07 PM
CHEST (PORTABLE AP)
Reason: eval for pneumothorax s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with recent CABG s/p chest tube removal
REASON FOR THIS EXAMINATION:
eval for pneumothorax s/p chest tube removal
PORTABLE CHEST.
CLINICAL HISTORY: Status post chest tube removal, please
evaluate for pneumothorax.
FINDINGS: A single portable image of the chest was obtained and
compared to the prior examination dated [**2177-12-19**]. In the interim
since the prior examination, the left chest tube has been
removed. No pneumothorax is visualized. In addition, the
endotracheal tube, NG tube and Swan-Ganz catheter have been
removed. The patient is status post CABG with median sternotomy.
There is a stable left retrocardiac opacity, likely secondary to
underlying atelectasis and a possible small effusion. No new
focal opacities are seen. The right lung is clear. No right
pleural effusions are noted. The cardiac silhouette remains at
the upper limits of normal.
DR. [**First Name (STitle) 2353**] [**Doctor Last Name **]
Approved: SUN [**2177-12-21**] 6:59 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 1955**] [**Hospital1 18**] [**Numeric Identifier 95586**] (Complete)
Done [**2177-12-19**] at 1:19:21 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2111-12-10**]
Age (years): 66 M Hgt (in): 68
BP (mm Hg): / Wgt (lb): 135
HR (bpm): BSA (m2): 1.73 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 410.91, 440.0
Test Information
Date/Time: [**2177-12-19**] at 13:19 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aorta - Abdominal: *5.0 cm <= 2.0 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. 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. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
POST_BYPASS:
Pt removed from cardiopulmonary bypass A paced on phenylephrine.
1. Biventricular function is preserved; LVEF 50-55%.
2. Aortic contours are intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2177-12-22**] 11:58
Cardiology Report ECG Study Date of [**2177-12-19**] 1:41:20 PM
Normal sinus rhythm with left bundle-branch block and frequent
premature atrial contractions. Non-specific ST-T wave
abnormalities.
Left atrial abnormality. Compared to the prior tracing of
[**2177-12-15**]
the frequent premature atrial contractions are new.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 114 144 444/479 67 16 40
Brief Hospital Course:
Underwent cardiac catherization that revealed three vessel
disease. Cardiac surgery was consulted and CABG was planned
after plavix wash out. He remained on a heparin drip however
developed hematuria and his heparin was discontinued. His
hematuria resolved. He was taken to the operating room on [**12-19**]
where he underwent a CABG x 3. See operative report for further
details. He was transferred to the ICU in critical but stable
condition. He was given 48 hours of perioperative vancomycin for
prophylaxis as he was in house preoperatively. He was extubated
later that same day. He was transferred to the floor on POD #2.
He did well postoperatively. He had short burst of atrial
fibrillation controlled with beta blockers. Physical followed
patient during entire post-op course for strength and mobility.
He continued to make steady process and was discharged home with
VNA services on post-op day four.
Medications on Admission:
ASA 325' Folic acid 1' Atenolol 50' Lipitor 40' MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Post op Atrial Fibrillation
NSTEMI
s/p MI ??????93 HTN, ^lipid, Mod MR, Spinal stenosis s/p RIH
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:
Please call to schedule all appointments
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 14069**] in 1 week [**Telephone/Fax (1) 37171**]
Dr. [**Last Name (STitle) **] in [**3-8**] weeks
Completed by:[**2177-12-23**]
ICD9 Codes: 9971, 2724, 4019, 4240, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7072
} | Medical Text: Admission Date: [**2132-7-28**] Discharge Date: [**2132-8-5**]
Date of Birth: [**2079-11-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Mitral valve repair (26 [**Doctor Last Name **] Ring- SN893344,Model 5200),
Ligation left atrial appendage, Coronary artery bypass graft
x1(Saphenous vein graft to obtuse marginal) [**2132-7-30**]
History of Present Illness:
This 52 year old white male was visiting the US from [**Country **]
presented with three days of intermittent chest pain,weakness
and fatigue. An echocardiogram in the ED revealed a partially
flail posterior mitral leaflet with 2+ regurgitation. Cardiac
surgery was consulted for evaluation of surgical correction.
Past Medical History:
Hyperlipidemia
Hypothyroid
s/p thyroid cancer and surgical removal
Social History:
He lives in [**Country **] with his wife, and works as an accountant. He
is visiting his son.
-Tobacco history: quit 30 yrs ago (smoked 1ppd/5 yrs)
-ETOH: 12 drinks/wk
-Illicit drugs: none
Family History:
Mother died at age 62 of CAD, father died of alzheimers. Brother
recently had a stroke.
Physical Exam:
Pulse:108 Resp:16 O2 sat:100/RA
B/P 165/88
Height: Weight:184#
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x- throidectomy scar] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade _3/6 heard across
precordium, loudest at left axilla
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit Right: radiating Left: Radiating
Pertinent Results:
INTRAOP TEE: [**2132-7-30**] PRE-BYPASS: No spontaneous echo contrast is
seen in the body of the left atrium or left atrial appendage.
There is bowing of the interatrial septum suggesting increased
left atrial pressures. The interatrial septum does not appear
aneurysmal. 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 simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. There is partial P2 mitral leaflet flail.
An eccentric, anterior 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). The C-[**Month (only) **] distance is 2.9 cm,
with a [**Doctor Last Name **]/PL ratio of 1.7. There is a trivial/physiologic
pericardial effusion.
POST-BYPASS: The patient is status post mitral valve repair.
There is a well-positioned annuloplasty ring in the mitral
position. No mitral regurgitation or paravalvular leak is seen.
There is no mitral stenosis with a mean gradient of less than 5
mmHg. Biventricular function is unchanged. There is trace aortic
regurgitation. There is no evidence of systolic anterior motion
of the mitral valve or left ventricular outflow tract
obstruction ([**Male First Name (un) **]/LVOTO). The ascending aorta, aortic arch, and
descending thoracic aorta are intact.
CXR: [**2132-8-3**]: Cardiac silhouette is within normal limits. A
valve replacement is seen. There is a small left-sided pleural
effusion. There is some atelectasis at the lung bases, which is
stable since the previous study. No pneumothoraces are seen.
There are no signs for overt pulmonary edema.
[**2132-7-28**] 07:25PM BLOOD WBC-9.5 RBC-4.74 Hgb-14.8 Hct-40.8 MCV-86
MCH-31.2 MCHC-36.3* RDW-13.0 Plt Ct-304
[**2132-8-4**] 07:00AM BLOOD WBC-9.0 RBC-2.89* Hgb-9.0* Hct-25.7*
MCV-89 MCH-31.0 MCHC-34.9 RDW-13.4 Plt Ct-460*
[**2132-7-28**] 07:25PM BLOOD PT-12.6 PTT-23.7 INR(PT)-1.1
[**2132-7-30**] 03:27PM BLOOD PT-15.2* PTT-35.3* INR(PT)-1.3*
[**2132-7-28**] 07:25PM BLOOD Glucose-107* UreaN-18 Creat-1.0 Na-138
K-5.9* Cl-103 HCO3-26 AnGap-15
[**2132-8-4**] 07:00AM BLOOD Glucose-137* UreaN-21* Creat-0.8 Na-137
K-4.3 Cl-99 HCO3-32 AnGap-10
[**2132-7-29**] 07:15AM BLOOD Phos-3.8 Mg-2.2
[**2132-8-2**] 07:15AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 90917**] presented to the ED the day prior to planned surgery
with pain. Enzymes were negative and on [**7-30**] he was taken to the
Operating Room and underwent a Mitral valve repair and Coronary
artery bypass grafting x 1. CARDIOPULMONARY BYPASS TIME:120
minutes. CROSSCLAMP TIME: 93 minutes. He tolerated the procedure
well and was transferred to the CVICU, intubated and sedated in
critical but stable condition. He was weaned from low dose Neo
Synephrine, awoke neurologically intact and was extubated the
night of surgery. All lines and drains were discontinued per
protocol. He was started on Beta blockers/Aspirin/Statin,
diuresed and transferred to the floor on POD #1. Physical
Therapy was consulted to evaluate mobility and strength. Of note
his rhythm was in a first degree AV block/accelerated
junctional, continued on low dose beta blockers (this was
present on day of discharge as well). Stable HCT 24 and was
started on iron. He continued to progress and the remainder of
his hospital course was essentially uneventful. He was cleared
for discharge to home with VNA services on post-op day six with
the appropriate medications and follow-up appointments.
Medications on Admission:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO daily
except fridays.
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO QFRI
(every Friday).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. mupirocin 2 % Ointment Sig: One (1) application Topical twice
a day for 5 days: Please apply to your nose twice daily for 5
days, starting [**2132-7-26**].
8. temazepam 7.5 mg Capsule Sig: One (1) Capsule PO Once, the
night before your surgery for 1 days.
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
Disp:*40 Tablet(s)* Refills:*0*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
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:*2*
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO Q FRIDAY
().
Disp:*5 Tablet(s)* Refills:*2*
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily): take with OJ.
Disp:*30 Tablet(s)* Refills:*2*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Senna-S 8.6-50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
12. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO PO daily
except Fridays.
Disp:*30 Tablet(s)* Refills:*2*
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hotel Recovery
Discharge Diagnosis:
Coronary Artery disease s/p Coronary artery bypass graft x 1
Mitral regurgitation s/p Mitral Valve Repair
Past medical history:
Hyperlipidemia
h/o thyroid cancer s/p thyroidectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right- healing well, no erythema or drainage.
Edema: [**12-16**]+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2132-9-2**] at 2pm in the
[**Hospital Unit Name 91090**] [**Last Name (NamePattern1) **], [**Hospital Unit Name **]
Echocardiogram and CXR prior to office visit - [**2132-8-19**] at 11AM
Phone:[**Telephone/Fax (1) 62**], Clinical center [**Location (un) 470**]
Cardiologist: Dr. [**Last Name (STitle) **] to arrange. Office will contact you
with appointment date and time.
Please call to schedule appointments with: Primary Care doctor
in [**Country **] on return.
**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:[**2132-8-5**]
ICD9 Codes: 4111, 4240, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7073
} | Medical Text: Admission Date: [**2191-10-13**] Discharge Date: [**2191-10-18**]
Date of Birth: [**2124-11-8**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Right-sided weakness and speech difficulties
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC: Code stroke
Called :13:30
Bedside : 13:32
NIHSS : 15
CT / CTA head neck/ perfusion : No bleed. area of hypoperfusion
and thrombus in arotic arch and carotid on left
I was present and reviewed images with radiologist.
tPA: Given . Bolus 8 mg over 1 min started at 14:28 and drip
completed by 15:28
HPI:
Mr. [**Known lastname 16158**] [**Known firstname 16159**] is a 66-year-old right-handed man with a past
medical history significant for HLD, mild DM, and two DVTS, one
in [**2187**] and one in [**2189**], complicated by a pulmonary embolus
currently on coumadin, who presents with acute onset speech
problems and right arm weakness.
Per son, the patient was talking on phone with his brother at
[**Name2 (NI) **], and suddenly had difficulty in speaking. The phone dropped
and he noted sudden onset of weakness involving right upper limb
which rapidly progressed to invlove the lower limb. The son was
concerned and immediately brought him to the ED. The astute ED
team readily called code stroke.
Of note, patient is non compliant with the coumadin and checking
the INR infrequently.
Past Medical History:
- Hyperlipidemia
- IGT
- DVT In [**2187**] which he was on coumadin for a
short period of time, and then another DVT with PE in [**2190-6-10**], and he has been on coumadin since that time.
- Cervcial spondylosis
Social History:
The patient is from [**Country 16160**] and currently lives in [**Hospital1 8**]. He
is a single father of 2 children, ages 16 and 17. He has worked
in engineering, teaching, and customer service (including
driving an airport shuttle) but is now not working/retired. He
reports cigarette use of 1ppd for 2 years but quit many years
ago. He does not drink alcohol and denies recreational drug use.
Family History:
- No h/o DVT, PE, or miscarriages.
- Father died of renal failure at about age 80.
- Mother died from complications of childbirth at age 24
(patient unsure of exact complication).
- Siblings and children reportedly healthy.
Physical Exam:
Admission Exam:
afebrile, 80 regular, 115/90, 16., 100 RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake, alert, Doesnt verbalise. follows few
midline commands and few appendicular commands on left. He is
not
aware of right arm. Other MS exam not possible.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally, Visual fields- blinks to threat on both, somewhat
less on left side. Fundus- no papilledema. Extraocular movements
intact bilaterally, no nystagmus.
Right UMN facial weakness. Palate elevation symmetrical.
Tongue
midline, movements intact
Motor: normal power on left side. He has right UE plegia and
doesnt withdraw even on painful stimuli. He moves right LE
spontanesuly and to pain, although not as much as on the left
side.
Sensation: Intact to touch and pain on left, has loss of
pinprick
on right UE.
Reflexes: 2 plus on both sides, ankles absent.
Toes were downgoing on left and upgoing on right.
Coordination: difficult to assess.
Gait/Romberg: Defd.
=================================================
Exam on discharge:
Mental status: alert, oriented, continues to be aphasic with
productive and receptive components to the deficit, able to name
low but not high-frequency words, able to repeat clearly and
quickly.
Cranial nerves: pupils symmetric, no field cuts
Sensory: no deficits to light touch, no neglect or extinction
Motor: improved strength to [**4-14**] in lower right extremity. Right
upper extremity had delt [**3-15**], triceps 4-/5, biceps 4-/5, wrist
ext [**3-15**], finger flexors [**12-15**]
Gait: romberg negative, able to walk independently
Pertinent Results:
Admission labs:
[**2191-10-13**] 02:06PM BLOOD WBC-9.5 RBC-5.14 Hgb-15.0 Hct-44.3 MCV-86
MCH-29.2 MCHC-33.9 RDW-14.0 Plt Ct-605*
[**2191-10-13**] 02:06PM BLOOD PT-16.2* PTT-23.2 INR(PT)-1.4*
[**2191-10-13**] 02:05PM BLOOD Creat-1.1
[**2191-10-13**] 02:06PM BLOOD UreaN-13
[**2191-10-14**] 03:35AM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.7 Mg-1.9
Cholest-227*
.
Other pertinent labs:
[**2191-10-14**] 03:35AM BLOOD Glucose-135* UreaN-12 Creat-1.0 Na-143
K-4.6 Cl-109* HCO3-22 AnGap-17
[**2191-10-14**] 03:35AM BLOOD ALT-19 AST-29 AlkPhos-74 TotBili-0.6
[**2191-10-13**] 02:06PM BLOOD cTropnT-<0.01
[**2191-10-14**] 03:35AM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.7 Mg-1.9
Cholest-227*
[**2191-10-14**] 03:35AM BLOOD Triglyc-119 HDL-35 CHOL/HD-6.5
LDLcalc-168*
[**2191-10-14**] 03:35AM BLOOD %HbA1c-6.2* eAG-131*
.
.
Urine:
[**2191-10-13**] 02:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050*
[**2191-10-13**] 02:35PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2191-10-13**] 02:35PM URINE RBC-71* WBC-10* Bacteri-FEW Yeast-NONE
Epi-0
[**2191-10-13**] 02:35PM URINE Mucous-FEW
MIcrobiology:
Time Taken Not Noted Log-In Date/Time: [**2191-10-14**] 1:50 pm
URINE Site: NOT SPECIFIED
[**Doctor Last Name **] TOP HOLD # 63307E [**10-13**] 2:35PM.
**FINAL REPORT [**2191-10-15**]**
URINE CULTURE (Final [**2191-10-15**]): NO GROWTH.
Radiology:
CT HEAD/MRA/BRAIN PERFUSION Study Date of [**2191-10-13**] 2:01 PM
FINDINGS: The non-contrast axial images through the brain
demonstrate a small area of low attenuation on the left parietal
lobe, possibly representing a chronic area of ischemia (image
#19, series #2). There is no evidence of hydrocephalus or
shifting of the normally midline structures. Punctate vascular
calcifications are visualized in the carotid siphons
bilaterally. The orbits, soft tissues, and bone structures are
unremarkable, there is normal pneumatization of the paranasal
sinuses.
CTA OF THE HEAD: There is a vague area of oligemia on the left
parietooccipital region (image 286, series #4), there is no
evidence of mass effect in this region, the 3D reconstructions
demonstrate patency of the major vascular structures in the
circle of [**Location (un) 431**] including the anterior, middle, and posterior
cerebral arteries, the vertebrobasilar system is patent as well
as both posterior inferior cerebellar arteries (image 22, series
557). No
aneurysms are identified.
CTA OF THE NECK: The aortic arch demonstrates filling defects,
possibly
consistent with a pedunculated clot (image #25, 34, series #4),
additionally pulsation artifacts are visualized in the ascending
aorta. There is significant narrowing of the left common carotid
artery below the cervical bifurcation, measuring approximately
25 mm in length (image 11,786, series [**Numeric Identifier 16161**]), this finding
likely represents soft tissue plaque material. The right carotid
artery appears grossly unremarkable as well as the vertebral
artery. The perfusion color maps demonstrate decreased blood
volume and blood flow in the left parietooccipital region with
increased mean transit time, likely
consistent with an area of acute ischemia.
Note is made of mild mucosal thickening identified on the right
maxillary
sinus, likely representing a mucus retention cyst and areas of
low attenuation
noted on the right side of the thyroid gland, correlation with
thyroid
ultrasound is recommended if clinically warranted. The lung
apices are clear,
and the bony structures are grossly normal.
IMPRESSION: Acute ischemic changes are identified in the left
parietooccipital region as described in detail above, with
underlying chronic area of ischemia in the left parietal lobe,
there is no evidence of
hemorrhagic transformation. Extensive filling defect is noted on
the left
common carotid artery as well as in the aortic arch, likely
consistent with
thrombus and soft plaque material. The major arteries in the
circle of [**Location (un) 431**] are apparently patent.
Areas of low attenuation are noted in the right side of the
thyroid gland,
correlation with thyroid ultrasound is recommended for further
characterization.
MR HEAD W/O CONTRAST Study Date of [**2191-10-13**] 9:37 PM
FINDINGS: There is restricted diffusion identified in the left
cerebral
hemisphere in the frontal and parietal cortex and also in the
deep white
matter distribution in the area of watershed territories.
Findings are
indicative of an acute infarct. There is no evidence of blood.
There is
evidence of several areas of low signal on susceptibility images
in the left
parietal region indicative of petechial hemorrhages. There is no
midline
shift or hydrocephalus. The suprasellar and craniocervical
regions are
unremarkable.
IMPRESSION: Acute left cerebral infarcts, predominantly in a
watershed
distribution. Petechial hemorrhages in the left parietal region.
No mass
effect or hydrocephalus.
Portable TTE (Complete) Done [**2191-10-14**] at 10:38:58 AM
Conclusions
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The 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. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: No PFO, ASD or left ventricular thrombus seen.
Normal global and regional biventricular systolic function. Mild
mitral regurgitation.
CT HEAD W/O CONTRAST Study Date of [**2191-10-14**] 4:54 PM
FINDINGS: Again demonstrated is wedge-shaped transcortical left
parieto-occipital hypodensity, compatible with known acute
ischemic watershedinfarct, without CT evidence of frank
hemorrhagic conversion. Petechialhemorrhage in the infarct bed
is better demonstrated on preceding MRI from one day prior.
There is no increased mass effect, new focus of hemorrhage, or
new area of major vascular territorial infarct. Ventricles
remain normal in caliber and patent. There is stable sulcal
effacement in the left parieto-occipital region. Away from the
abnormality, sulcal markings are preserved. Suprasellar and
basilar cisterns are patent.
Paranasal sinuses and mastoid air cells are well aerated.
Vascular
calcifications are seen in the cavernous carotid arteries.
Globes and soft
tissues are within normal limits.
IMPRESSION:
1. Stable-appearing left parieto-occipital for ischemic infarct
with
localized sulcal effacement.
2. No interval increase in mass effect or midline shift.
3. No new focal hemorrhage or new major vascular territorial
infarct.
4. Known petechial hemorrhage within the infarcted region is
better
demonstrated on preceding MRI and not well depicted on CT.
CT TORSO WITH CONTRAST Study Date of [**2191-10-15**] 11:10 AM
IMPRESSION:
1. Similar right thyroid nodule by CT.
2. Multiple subcentimeter hypodensities within the liver are too
small to
characterize but likely represent hepatic cysts.
3. Hypodensity within segment IVB of the liver was partially
visualized on
the CT scan of [**2189-12-24**] and measures up to 32 mm and
appears most
consistent with hepatic cyst.
4. Left upper pole renal cyst.
5. No definite evidence of overt malignancy.
6. Bibasilar atelectasis.
Brief Hospital Course:
66-year-old right-handed man with a past medical history
significant for HLD, mild DM, and two DVTS, one in [**2187**] and one
in [**2189**], complicated by a pulmonary embolus currently on
warfarin but poorly compliant with this (admission INR 1.4) who
presented with acute onset aphasia, and right arm>leg weakness.
Code stroke was called and initial NIHSS was 15. CTP showed
decreased blood volume and blood flow in the left
parietooccipital region in keeping with acute ischemia in
addition to underlying chronic area of ischemia in the left
parietal lobe. CTA showed thrombus in aortic arch as well as
left common carotid. Patient was given tPA and admitted to Neuro
ICU on [**10-13**]. Neurointervention consult was sought but the
decision was made not to proceed, given the risk involved.
He markedly improved with speech much clearer with larger
vocabulary with good right leg power and improvement in right
arm weakness. MRI showed acute left inferior branch of MCA
infarct with with evidence of embolic infarcts predominantly in
a watershed distribution and minimal hemorrhagic conversion with
no mass effect or hydrocephalus. BP was kept >100 with low dose
phenylephrine. Patient was started on IV heparin on [**10-14**]. Echo
showed no PFO, ASD or left ventricular thrombus mild MR [**First Name (Titles) **] [**Last Name (Titles) 16162**]>55%. Patient had abnormal lipid panel with LDL 168 and was
started on atorvastatin 80mg.
Patient was investigated for causes of hypercoagulability with
lupus anticoagulant, anti-cardiolipin, and beta2 glycoprotein.
CT-Torso showed no overt malignancy but did demonstrate a right
thyroid nodule. Patient remained stable and was transferred to
the floor on [**10-15**].
He remained stable with improvement in his aphasia and
improvement in the strength of his upper right extremity.
=
================================================================
.
Transitional issues:
.
1. Stroke: will have outpatient heme-onc appointment for further
stroke workup given that he has had recurrent venous and now
arterial clots with unknown etiology. He will require a more
comprehensive hypercoagulability workup. For the moment, he will
be maintained on his pre-admission INR goal of 2.5-3.5 with
coumadin. HE will be asked to return to coumadin clinic to
continue getting his INR checked.
2. Thyroid: there was an incidental note of a hypodensity on
CT-torso. IT was suggested that he undergo thyroid ultrasound to
further evaluate this finding. Apparntly he has already
undergone FNA but the procedure was supposed to be repeated. It
appears this was lost to followup. We will attempt to make an
appointment for him in followup and tell him to contact the
Endocrinologist.
Medications on Admission:
SIMVASTATIN - 20 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime
WARFARIN - 3 mg Tablet - Take up to 2 Tablet(s) by mouth daily
or
as directed by coumadin clinic
Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
4. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a
day: please continue with these injections until INR is at goal
2.5-3.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital3 **] Medical center because you
had a stroke. You were given a medication to dissolve the blood
clot in your brain called "tPA". You were monitored in the
intensive care unit your blood pressure was controlled during
this time.
You were transfered to the floor and restarted on coumadin. You
should continue taking this medication when leaving the
hospital.
You were seen by physical therapy and they recommended acute
rehabilitation.
You should note the following medication changes:
START:
- lovenox injections (until your INR is therapeutic)
- coumadin (you will continue this medication indefinitely)
STOP:
You should continue to take all your other medications as
prescribed by your physicians.
Followup Instructions:
You will have a follow up with Dr. [**First Name (STitle) **] in his clinic.
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2191-10-26**] at 9:30 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2192-2-13**] at 2:35 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16163**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7074
} | Medical Text: Admission Date: [**2181-10-14**] Discharge Date: [**2181-10-17**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old
female nursing home resident with mild mental retardation who
presented to [**Hospital3 1196**] with a temperature of
103 degrees Fahrenheit per rectum, hypertension, and rigors
in the setting of one week of upper respiratory symptoms
(which included a cough) and malodorous urine in the Foley
catheter.
The patient was found to be hypotensive to 70/48 which was
unresponsive to fluid boluses. The patient was given
moxifloxacin and started on a dopamine drip. The patient was
also given vitamin K for an INR of 7.2 at [**Hospital3 20445**].
She was then transferred to the [**Hospital1 188**] Emergency Department. The patient was admitted to the
Intensive Care Unit for presumed sepsis from a urinary tract
infection versus pneumonia.
A chest x-ray on admission showed a left lower lobe
infiltrate versus atelectasis. An additional of normal
saline was given at [**Hospital1 69**], and
a central line was placed. The patient was started on
Levaquin to treat pneumonia and urinary tract infection.
PAST MEDICAL HISTORY:
1. Congestive heart failure.
2. Atrial fibrillation (on Coumadin).
3. Insulin-dependent diabetes mellitus.
4. Mental retardation.
5. Hypertension.
6. History of zoster.
7. Urinary tract infection.
8. Gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION:
1. Regular insulin sliding-scale.
2. Novolin 40 units subcutaneously in the morning.
3. Coumadin 2.5 mg by mouth once per day.
4. Digoxin 0.125 mg by mouth once per day.
5. Lasix 80 mg by mouth in the morning.
6. Lovastatin 20 mg by mouth once per day.
7. Sublingual nitroglycerin.
8. Zoloft 25 mg by mouth once per day.
9. Iron sulfate 325 mg by mouth three times per day.
10. Zantac 150 mg by mouth at hour of sleep.
ALLERGIES:
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed the patient's sodium was 147, potassium
was 3.6, chloride was 111, bicarbonate was 27, blood urea
nitrogen was 28, creatinine was 1.2, and blood glucose was
87. Her hematocrit was 41.1 and her white blood cell count
was 36.5. Differential revealed 84% polys, 11% bands, 2%
monocytes, and 3% lymphocytes. Urinalysis showed [**Location (un) 2452**]
cloudy urine, large blood, negative nitrites, small leukocyte
esterase, and a few bacteria, greater than 50 red blood
cells, and greater than 50 white blood cells. Serial cardiac
enzymes were followed with a documented troponin leak to 0.26
with flat creatine kinase levels.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram on admission
revealed atrial fibrillation with anterolateral ST
depressions.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. HYPOTENSION ISSUES: The patient was admitted with
hypotension secondary to sepsis from pneumonia versus a
urinary tract infection.
Initially, cardiogenic shock secondary to a myocardial
infarction was considered based on the electrocardiogram
changes on admission. The patient was weaned off dopamine on
the night of admission and continued to maintain normal blood
pressures. Serial enzymes were checked which revealed a
troponin leak of 0.26; possibly related to rate-related
ischemia versus a non-Q-wave myocardial infarction. However,
an echocardiogram revealed an ejection fraction of 55%
without any wall motion abnormalities; which suggested that
this was not a myocardial infarction. The patient was also
noted to have severe pulmonary artery systolic hypertension
on echocardiogram with a pulmonary artery systolic pressure
of 72.
The patient was afebrile by hospital day two. She did not
require intubation for her pneumonia. Her respiratory
examination continued to improve, and the patient was
transferred out of the Medical Intensive Care Unit to the
medicine floor where she was weaned off oxygen. The patient
was continued on Levaquin and was on day [**5-12**] total days on
the day of discharge. Although pulmonary artery hypertension
was noted, the patient was not a candidate at this time for
prostacyclin and appeared stable off of oxygen.
2. ATRIAL FIBRILLATION ISSUES: The patient's rate was
initially high in the Emergency Department which was
controlled on a beta blocker after the patient became
normotensive. The patient was on metoprolol 50 mg by mouth
twice per day on the day of discharge. Her INR was
supratherapeutic on admission. Therefore, vitamin K was
given and Coumadin was held. The patient was restarted on
Coumadin 2 mg by mouth every day on the day prior to
discharge. Her INR was 1.4 on the day of discharge. The
patient should have her INR checked in one to two days
following discharge for adjustment of her Coumadin dose;
especially since the patient is on levofloxacin.
3. HYPERNATREMIA ISSUES: The patient was admitted with a
sodium of 147 which was treated in the Intensive Care Unit
with free water boluses.
The patient became hyponatremic on the General Medicine floor
after she was transferred out of the Intensive Care Unit.
Likely, the hyponatremia was secondary to decreased oral
intake secondary to her decreased thirst in the setting of
illness as the patient was quite ill on admission. Other
possible explanations included partial diabetes insipidus
versus a reset osmolalities which has happened in the past.
Given her urine sodium of 29, urine osmolalities of 391, and
serum osmolalities of 312, the patient was started on D-5-W
free water at a rate of 17 cc per hour for a total of 450 cc
in the first 24 hours to replete free water deficits slowly.
The patient should receive another 400 cc of D-5-W tomorrow
at the same rate. The patient should also be encouraged to
drink fluids.
4. DIABETES MELLITUS ISSUES: The patient was admitted on a
regular insulin sliding-scale and was continued on a regular
insulin sliding-scale in the Intensive Care Unit. However,
the patient was then restarted on NPH on the day of
discharge.
5. HYPERTENSION HISTORY ISSUES: After sepsis resolved on
antibiotics, the patient's blood pressure trended up and the
patient was started on metoprolol.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to nursing home.
MEDICATIONS ON DISCHARGE:
1. NPH 40 units subcutaneously.
2. Insulin sliding-scale.
3. External carotid artery 325 mg by mouth once per day.
4. Ranitidine 150 mg by mouth at hour of sleep.
5. Sertraline 50 mg by mouth once per day.
6. Atorvastatin 20 mg by mouth once per day.
7. Levofloxacin 250 mg by mouth once per day (for five more
days).
8. Digoxin 0.125 mg by mouth once per day.
9. Tylenol 325-mg tablets one to two tablets by mouth
q.4-6h. as needed (for pain).
10. Docusate sodium 100 mg by mouth twice per day as needed
(for constipation).
11. Metoprolol 50 mg by mouth twice per day.
12. Warfarin 2 mg by mouth once per day.
13. Lasix 40 mg by mouth once per day.
14. Sublingual nitroglycerin as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to be
followed by the [**Hospital 2670**] [**Hospital 745**] nursing home.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 3482**]
MEDQUIST36
D: [**2181-10-18**] 18:54
T: [**2181-10-20**] 04:24
JOB#: [**Job Number 20446**]
ICD9 Codes: 0389, 486, 5849, 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7075
} | Medical Text: Admission Date: [**2184-3-29**] Discharge Date: [**2184-3-30**]
Date of Birth: [**2133-8-10**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension, respiratory failure
Major Surgical or Invasive Procedure:
Failed left radial and axillary arterial line placement.
History of Present Illness:
Mr. [**Known lastname 11622**] is a 50 year old gentleman with a PMH significant for
morbid obesity, OSA, and possible EtOH abuse transferred from
OSH with multisystem organ dysfunction, shock, and respiratory
failure. The patient initially presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**3-27**]
for bialteral leg pain of four days in duration. On admission,
he was noted to have a leukocytosis to 14.2 with a 55% bandemia.
He was started on vancomycin, amp/sulbactam, and was admitted
for further management. His OSH hospital course was complicated
by hypotension and respiratory failure requiring intubation and
vasopressor support with levophed, dopamine, and phenylephrine.
A CXR was also, per study report, concerning for mediastinal
adenoapthy. He was evaluated by ID with recommendation of broad
spectrum antibiotics, and hematology-oncology, who felt that his
differential was more sepsis than hematologic malignancy. His
hospital course was also notable for a 34.8% eosinophilia on
[**3-28**] off a WBC of 32.3 which has since resolved. He was noted
to have progressive anuria and refractory acidemia, and so was
transferred to [**Hospital1 18**].
.
On arrival to [**Hospital1 18**], the patient is intubated, sedated, and
unresponsive.
Past Medical History:
Morbid obesity
OSA not on CPAP
Obesity hypoventilation on supplemental O2
EtOH abuse
Lower extremity edema
Chronic macrocytosis
Social History:
Per OSH notes. Pt denies tobacco, EtOH, drugs.
Family History:
Unknown
Physical Exam:
VS: 98.5 109 89/70 AC 550x16, 20, 100% 7.08/43/73
Gen: NAD, morbidly obese
HEENT: ETT in place
CV: Distant heart sounds
Pulm: Distant breath sounds
Abd: Obese.
Ext: 4+ edema, somewhat pitting with signs of severe chronic
stasis dermattis with skin breakdown.
Neuro: Non-responsive. 3->2mm.
Pertinent Results:
[**2184-3-29**] 02:34PM BLOOD WBC-37.8* RBC-3.46* Hgb-12.2* Hct-39.5*
MCV-110* MCH-35.0* MCHC-32.1 RDW-15.6* Plt Ct-145*
[**2184-3-29**] 02:34PM BLOOD Neuts-78* Bands-16* Lymphs-3* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2184-3-29**] 02:34PM BLOOD PT-34.9* PTT-48.2* INR(PT)-3.6*
[**2184-3-29**] 02:34PM BLOOD Glucose-147* UreaN-45* Creat-3.6* Na-124*
K-5.9* Cl-95* HCO3-15* AnGap-20
[**2184-3-29**] 02:34PM BLOOD ALT-3218* AST-9170* LD(LDH)-7940*
CK(CPK)-7854* AlkPhos-389* TotBili-7.3*
[**2184-3-29**] 02:34PM BLOOD CK-MB-291* MB Indx-3.7 cTropnT-1.35*
[**2184-3-29**] 02:34PM BLOOD Albumin-2.2* Calcium-7.5* Phos-9.8*
Mg-2.3
[**2184-3-29**] 08:54PM BLOOD Type-CENTRAL VE Temp-37.1 Rates-30/ Tidal
V-440 PEEP-20 FiO2-100 pO2-44* pCO2-59* pH-7.00* calTCO2-16*
Base XS--18 AADO2-610 REQ O2-100 Intubat-INTUBATED
[**2184-3-29**] 04:22PM BLOOD Type-ART PEEP-20 pO2-73* pCO2-43 pH-7.08*
calTCO2-14* Base XS--17 -ASSIST/CON Intubat-INTUBATED
[**2184-3-29**] 08:54PM BLOOD Lactate-9.9*
[**2184-3-29**] 06:02PM BLOOD Lactate-7.8*
[**2184-3-29**] 04:22PM BLOOD Lactate-8.8*
[**2184-3-29**] 02:58PM BLOOD Lactate-9.2*
[**2184-3-29**] 06:02PM BLOOD O2 Sat-68
[**2184-3-29**] 02:58PM BLOOD O2 Sat-88
CXR: 1. Satisfactory position of the right internal jugular
central venous
catheter and endotracheal tube.
2. Further evaluation of the lungs can be performed with an
upright chest
radiograph, when clinically appropriate.
3. The distal portion of the nasogastric tube is not adequately
visualized onthis radiograph.
Brief Hospital Course:
Mr. [**Known lastname 11622**] is a 50 year old gentleman with a PMH significant for
morbid obesity, OSA, and possible EtOH abuse transferred from
OSH with multisystem organ failure, refractory septic shock, and
respiratory failure.
1. Multisystem organ failure: Patient transferred to [**Hospital1 18**] from
OSH with multisystem organ dysfunction with evidence of shocked
liver, anuric renal failure, elevated cardiac biomarkers, and
persistently elevated lactate >7. He was treated empirically
for sepsis NOS with no source identified with vancomycin and
pip/tazo. He was maxed out on norepinephrine, dopamine,
phenylephrine, and vasopressin, and received 10L IVF during his
initial resuscitation with no improvement in hemodynamics or
organ perfusion. He developed a refractory acidosis with an
maximized minute ventilation, serial 50 meq HCO3 pushes, and a
HCO3 gtt with a pH of [**7-22**].1. Case was discussed with
Nephrology, with the decision that the patient was too
clinically unstable for consideration of CVVHD. Goals of care
were addressed with the patient's next of [**Doctor First Name **], which were his
sister and nephew. As the patient was on maximal life support
with no improvement, the patient was made DNR with no CPR to be
performed. The patient shortly went into pulseless VT and
expired. Family was at the bedside, PCP and attending notified.
2. Respiratory failure: Unclear etiology, although current A-a
gradient of 586 suggests either V/Q mismatch, diffusion, or
shunt. Given degree of obesity, high likelihood of element of
V/Q mismatch from restrictive physiology, as well as additional
element of obesity hypoventilation. CXR with possible RUL
opacity, but poor quality given body habitus, suggests possible
bacterial pneumonia. Given degree of illness would also consider
Influenza. PE a possibility, although given degree of
leukocytosis and bandemia less likely. Given P/F ratio, also
considered ARDS, but CXR difficult to interpret with regard to
bilateral infiltrates. In addition, LTVV was not possible given
that the minute ventilation was maximized in order to improve
acid-base balance given acidosis.
Medications on Admission:
Phenylephrine
Norepinephrine
Dopamine
Acetaminophen prn
Amp/sulbactam
Ciprofloxacin
Clindamycin
Lovenox 40 daily
Hydrocort 100 Q8H
Dilaudid
MOM
[**Name (NI) 80048**] prn
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
Completed by:[**2184-3-30**]
ICD9 Codes: 0389, 5849, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7076
} | Medical Text: Admission Date: [**2178-6-16**] Discharge Date: [**2178-6-29**]
Date of Birth: [**2149-2-26**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Ibuprofen / Codeine
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Exploratory Laparotomy with reivision of Jejunojejunostomy
History of Present Illness:
This is a 29 year old female who presents 1 week status-post a
laparoscopic roux-en-y gastric bypass with severe abdominal pain
after her cat jumped on her abdomen. The pain started acutely
and is [**8-24**], mostly in the left upper quadrant. She has had
some nausea with no emesis. Her last bowel movement was
yesterday. She has felt febrile. Prior to today she has
tolerated her stage 3 gastric bypass diet and had good pain
control
Past Medical History:
Morbid Obesity
Laparoscopic roux-en-y gastric bypass [**2178-6-8**]
hyperlipidemia
GERD
Colonic POlyps
B12 deficiency
[**Doctor Last Name **] Mal Seizures in childhood
Social History:
THe patient smokes half a pack per day and denies alcohol or
recreational
drugs. She lives with her fiance and 2 daughters.
Physical Exam:
ON admission:
101.7, 130, 148/82, 16, 96% room air
Gen: uncomfortable, distressed, alert/awake
CV: sinus tachycardia
Pulm: CTAB
GI: abdomen firm, tenderness to palpation in the left upper
quadrant, incisions c/d/i, no erythema, normoactive bowel sounds
Extr: no edema
Pertinent Results:
[**2178-6-15**] 06:40PM BLOOD WBC-13.9* RBC-4.72# Hgb-13.6# Hct-38.9#
MCV-83 MCH-28.7 MCHC-34.8 RDW-13.3 Plt Ct-416#
[**2178-6-16**] 02:38AM BLOOD WBC-17.5* RBC-4.47 Hgb-12.9 Hct-37.7
MCV-84 MCH-28.9 MCHC-34.2 RDW-13.3 Plt Ct-380
[**2178-6-17**] 03:02AM BLOOD WBC-15.6* RBC-3.37* Hgb-9.6*# Hct-27.8*
MCV-82 MCH-28.5 MCHC-34.6 RDW-13.7 Plt Ct-306
[**2178-6-18**] 03:00AM BLOOD WBC-15.7* RBC-3.38* Hgb-9.7* Hct-28.0*
MCV-83 MCH-28.6 MCHC-34.5 RDW-13.5 Plt Ct-320
[**2178-6-19**] 02:25AM BLOOD WBC-12.2* RBC-3.38* Hgb-9.9* Hct-28.2*
MCV-83 MCH-29.1 MCHC-35.0 RDW-13.4 Plt Ct-368
[**2178-6-20**] 05:08AM BLOOD WBC-14.9* RBC-3.73* Hgb-10.6* Hct-32.7*
MCV-88 MCH-28.5 MCHC-32.5 RDW-13.4 Plt Ct-370
[**2178-6-26**] 04:17AM BLOOD WBC-15.8* RBC-4.07* Hgb-11.6* Hct-33.5*
MCV-82 MCH-28.5 MCHC-34.6 RDW-13.2 Plt Ct-543*
[**2178-6-27**] 03:05PM BLOOD WBC-10.8 RBC-3.72* Hgb-10.3* Hct-30.7*
MCV-83 MCH-27.7 MCHC-33.6 RDW-13.1 Plt Ct-366
[**2178-6-15**] 06:40PM BLOOD Neuts-80* Bands-14* Lymphs-0 Monos-6
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2178-6-16**] 03:15PM BLOOD Neuts-85.6* Bands-0 Lymphs-10.6*
Monos-3.4 Eos-0.2 Baso-0.3
[**2178-6-15**] 06:40PM BLOOD PT-14.3* PTT-34.7 INR(PT)-1.4
[**2178-6-19**] 02:25AM BLOOD PT-14.1* PTT-29.7 INR(PT)-1.3
[**2178-6-15**] 06:40PM BLOOD Glucose-98 UreaN-10 Creat-0.7 Na-135
K-3.5 Cl-99 HCO3-18* AnGap-22*
[**2178-6-16**] 03:15PM BLOOD Glucose-127* UreaN-7 Creat-0.6 Na-136
K-4.3 Cl-105 HCO3-23 AnGap-12
[**2178-6-18**] 03:00AM BLOOD Glucose-120* UreaN-5* Creat-0.4 Na-136
K-3.5 Cl-101 HCO3-28 AnGap-11
[**2178-6-20**] 05:08AM BLOOD Glucose-94 UreaN-8 Creat-0.4 Na-140 K-4.2
Cl-105 HCO3-25 AnGap-14
[**2178-6-26**] 04:17AM BLOOD Glucose-101 UreaN-13 Creat-0.7 Na-135
K-4.1 Cl-101 HCO3-24 AnGap-14
[**2178-6-27**] 03:05PM BLOOD Glucose-91 UreaN-7 Creat-0.4 Na-137 K-4.1
Cl-103 HCO3-23 AnGap-15
[**2178-6-15**] 06:40PM BLOOD ALT-43* AST-30 AlkPhos-97 Amylase-43
TotBili-4.8*
[**2178-6-26**] 04:17AM BLOOD ALT-16 AST-15 AlkPhos-56 Amylase-139*
TotBili-0.2
[**2178-6-15**] 06:40PM BLOOD Lipase-42
[**2178-6-26**] 04:17AM BLOOD Lipase-159*
[**2178-6-15**] 06:40PM BLOOD Albumin-4.1
[**2178-6-16**] 03:15PM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.5*
Mg-1.9
[**2178-6-18**] 03:00AM BLOOD Triglyc-121
[**2178-6-19**] 08:59AM BLOOD Triglyc-96 HDL-20 CHOL/HD-4.8 LDLcalc-56
[**2178-6-15**] 06:42PM BLOOD Lactate-1.6
RADIOLOGY:
[**2177-6-16**] Upper GI study: Conray followed by thin barium was used
for the study. A scout view shows a drain in place over the left
upper abdomen, and surgical staples in place. There is residual
contrast within the patient's colon at the start of the study.
Contrast passes freely through the esophagus into the gastric
pouch. Contrast passes easily through the gastrojejunal
anastomosis without evidence of leak. The gastric pouch is
somewhat dilated, with an air- fluid level inside. The jejunal
loop attached to the stomach is diffusely dilated. Contrast
passes to the region of the jejunojejunal anastomosis, and then
there is complete holdup of contrast at the region of the
jejunojejunal anastomosis. The patient stood for approximately
15 minutes, and there is no further passage of contrast beyond
the level of the jejunojej. An overhead view was taken at the
conclusion of the exam.
IMPRESSION: Complete holdup of contrast at the level of the
jejunojejunal
anastomosis. The findings were discussed and the images were
reviewed with
Dr. [**Last Name (STitle) **].
[**2178-6-22**] Upper GI study: Small amount of contrast passes through
the gastrojejunal anastomosis, and there is non-passage of
contrast beyond a single jejunal loop. There is holdup of
contrast at the left lower quadrant. No evidence of leak.
[**2178-6-26**] CT Abdomen: 1. Moderate left-sided pleural effusion with
reactive atelectasis. Minimal atelectasis at the right lung
base.
2. Appropriate postoperative appearance after gastric bypass. No
evidence of obstruction
3. Two extraluminal fluid collections identified, one anteriorly
within the abdomen and the second deep within the pelvis. These
collections may be postoperative in nature, however, underlying
infection is possible.
4. Small amount of extraluminal fluid and air identified
adjacent to the
distal jejunal-jejunal anastamosis concerning for a leak. This
area may
communicate with the anterior collection described above.
[**2178-6-27**] CT Abdomen: Attempted aspiration of anterior collection.
Given the relatively high attenuation of this area, this may
rather relate to phlegmon. The small amount of material
extracted was sent for Gram stain and culture analysis.
MICRO:
[**6-15**] Blood culture: negative
[**6-26**] Blood Culture: negative
[**6-26**] Urine Culture: negative
[**6-27**] Peritoneal fluid culture: negative
Brief Hospital Course:
This is a 29 year old female who was admitted one week post-op
from a laparoscopic roux-en-y gastric bypass with severe
acute-onset abdominal pain. The patient was taken emergently to
the operating room for repair (please see the operative note of
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for full details). Post-operatively she did
well, with pain controlled with a PCA, and good pulmonary
status. She was started on parenteral nutrition which was
continued until post-op day 11. She was given post-operative
antibiotics; all cultures from her admission were negative. She
had an upper GI evaluation on post-op day 1 which demonstrated
hold-up of contrast at the anastamosis and then post-op day 7
which demonstrated improved flow of contrast through the
anastamosis. She was started on a stage 1 diet on post-op day
11. She had a CT scan on post-op day 12 which demonstrated a
pelvic and anterior fluid collection; the anterior collection
was drained by interventional radiology revealing small amounts
of lysed hematoma but no pus or infection. She was advanced to a
stage 2 and then 3 diet by post-op day 13 which she tolerated
well and her PCA was weened to oral roxicet. She was able to
ambulate on her own and her JP drain was removed on post-op day
14. She was discharged on post-op day 14 with plained follow-up
in the [**Last Name (NamePattern1) **] surgery clinic. Her staples were removed prior
to discharge and her wound remained intact and clean. All
questions were answered to her satisfaction on discharge.
Medications on Admission:
1. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO BID (2
times a day).
Disp:*600 ml* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*250 ML(s)* Refills:*0*
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day
for 6 months.
Disp:*360 Capsule(s)* Refills:*0*
Discharge Medications:
1. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO BID (2
times a day).
Disp:*600 ml* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*250 ML(s)* Refills:*0*
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day
for 6 months.
Disp:*360 Capsule(s)* Refills:*0*
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Leak at Jejunojejunostomy
Discharge Condition:
Tolerating stage 3 diet. Ambulating. Good pain control.
Discharge Instructions:
Take all medications as prescribed. Continue with your stage 3
diet. DO not drive or operate machinery while taking narcotics.
Please call the office with any worsening nausea, fevers to
101.5, or worsening abdominal pain. You should wear an abdominal
binder while in bed. You may shower and ambulate, but no baths
or heavy lifting for 3 weeks. You may continue all the
medications you were taking prior to this admission (i.e. after
your initial surgery) in addition to the medications we have
prescribed for you today.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Where: [**Hospital6 29**] [**Hospital6 **]
SURGERY Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2178-7-1**] 2:00
Provider: [**Name10 (NameIs) **] [**Doctor Last Name 28352**], LDN Where: [**Hospital6 29**] [**Hospital6 **]
SURGERY Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2178-7-1**] 1:30
Completed by:[**2178-6-30**]
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7077
} | Medical Text: Admission Date: [**2173-5-31**] Discharge Date: [**2173-6-18**]
Date of Birth: [**2126-5-6**] Sex: M
Service: [**Company 191**]/MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
male with history of HIV and disseminated TB with a recent
prolonged admission for miliary TB pancreatitis and deep vein
thrombosis. The patient was discharged from his stay on a
four drug TB regimen, HAART including Trizivir and Abacavir
and Coumadin for left iliac deep vein thrombosis, prednisone
20 for a paradoxical reaction. He was re-admitted on this
admission on [**5-31**] for a three day history of fevers to 103
with only other symptoms being nocturia. He has been
compliant on his discharge medications.
PAST MEDICAL HISTORY: As above.
MEDICATIONS ON ADMISSION: INH 300 mg, rifabutin 300 mg,
pyrazinamide 15 mg/kg/day, ethambutol 50 mg/kg/day, Trizivir
1 tablet po b.i.d., Nevirapine 200 mg a day, prednisone 20 mg
a day, Bactrim DS every day and Coumadin 7.5 mg a day.
ALLERGIES: Patient has no known drug allergies.
PHYSICAL EXAMINATION: The patient initially was febrile to
101.3. Heart rate 108. Blood pressure 122/79. Respiratory
rate 22, saturating 100% on room air. In general, he was a
cachectic but well-appearing male in no acute distress.
Head, eyes, ears, nose and throat: Oropharynx was clear.
Mucous membranes were moist. The neck was supple. The heart
was regular, tachycardic with a 2/6 systolic murmur at the
left sternal border. Lungs were clear to auscultation
bilaterally. The abdomen was soft, nontender, nondistended
without hepatosplenomegaly. His extremities showed no
cyanosis, clubbing or edema. Skin showed no rashes. Back:
There was a question of mild left CVA tenderness.
LABORATORIES ON ADMISSION: Showed a white blood cell count
of 5.2, hematocrit 26.4, platelets 219,000. Urinalysis
showed nitrate positive with 3-5 white blood cell and
moderate bacteria. An absolute CD4 count was 57. Admission
laboratories were also notable for a sodium of 130, potassium
4.0, chloride 98, bicarbonate 20, BUN 19, creatinine 1.0,
glucose 88, parathyroid hormone 11, viral culture showed
herpes simplex 1 on his lip confirmed by monoclonal
fluorescent antibody. Culture of a catheter tip showed
coagulase negative Staph. H Pylori antibody was negative.
Cryptococcal antigen was negative. HIV 1 viral load was
2,470. Brucella abortus antibodies were negative. A chest
x-ray had no infiltrates.
The patient received the following tests while a patient:
A chest x-ray which showed no infiltrates.
An MRI of the had which had no lesions.
An MRI of the neck which showed likely lymphadenopathy of the
left neck.
An MRI of the L spine which was negative.
An MRI of the abdomen which was unremarkable when compared to
previous although showed multiple fluids collections.
An ultrasound of the neck which showed probable abscess.
The patient had a colonoscopy which was within normal limits.
An esophagogastroduodenoscopy showed gastritis and
duodenitis.
Renal ultrasound showed diffusely echogenic patterns,
otherwise, normal kidneys.
Patient received multiple sets of blood cultures which were
negative. Fungal blood cultures which were negative.
Macrobacterial isolator cultures which were negative.
Brucella titers which were negative. CMV antigenemia which
was negative.
HOSPITAL COURSE: By system:
1. Infectious Disease: The patient was admitted to the
floor and vitals were monitored. It was felt that his fevers
may be due to Abacavir sensitivity and Abacavir was stopped.
Tenofovir was started at that time. A work-up was done
including multiple cultures and imaging without any source of
fever ever identified. An MRI of the head was negative. An
MRI of the neck was significant for collectional lymph nodes
that may have been there previously. An ultrasound done
several days before discharge was significant for possible
abscess. The Infectious Disease Team opted not to drain at
this time. MRI of the abdomen showed multiple fluid
collections, although, most likely improved or unchanged from
previous CT imaging. An MRI of the L spine was done due to
complaints of back pain which was essentially normal. The
patient was treated for a urinary tract infection with
levofloxacin for three days. Upon discharge, the patient had
been afebrile for 48 hours but a source of infection being
found. The patient was continued on antiretrovirals and TB
regimen while here. Several days prior to his discharge, he
was put on two drug TB regimen and HAART was changed. Please
see discharge medications for HAART regimen. The patient
received aerosolized pentamidine for PCP [**Name Initial (PRE) 1102**].
2. Gastrointestinal: The patient was started on heparin and
discontinued on Coumadin in anticipation of her renal biopsy.
On the evening of starting the heparin, the patient had
several episodes of hematemesis and bright red blood per
rectum. An nasogastric tube was dropped and after several
lavages became clear. The patient then became hypotensive,
received several units of blood and was transferred to the
Intensive Care Unit. While in the Intensive Care Unit,
esophagogastroduodenoscopy which was significant for
gastritis and duodenitis, although, was H. Pylori negative, a
colonoscopy done several days later was essentially normal.
No biopsies of the colon were taken at that time. The
patient's gastrointestinal condition was stable after that
and was given Protonix.
3. Renal: The patient began having an increase in
creatinine with a normal BUN. Creatinine peaked at 1.8.
Renal consult was obtained and biopsy was eventually deferred
since her creatinine went down to 1.2, although, this was
felt most likely to be a drug reaction due to Tenofovir. An
ultrasound was done which showed diffusely echogenic pattern
which would be most consistent with an infiltrative process
or a drug reaction. Bactrim was stopped due to possibly
causing the increased creatinine as was Tenofovir.
4. Hematology: The patient started having a decreasing
white blood cell count on the week prior to admission which
had a nadir of 1.2. Hematology was consulted. They did not
feel bone marrow biopsy was necessary and attributed his
decreasing white blood cell count to drugs, most likely AZT.
AZT was discontinued at that time. Stavudine was started
instead. The patient was started on G-CSF with a good
response.
5. Anemia: The patient was chronically anemic and had a
several unit requirement during his gastrointestinal bleed.
After the bleed, he was hemodynamically stable and had no
more blood requirement.
6. Musculoskeletal: The patient complained of aches and
muscular pains in his legs and back pain. An MRI of the L
spine was negative. CKs were negative.
7. Fluid, electrolytes and nutrition: Hyponatremia: The
patient was chronically hyponatremic and was treated with
fluid restriction and had resolved by the time of his
discharge.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To hotel room arranged through Social
Work.
DISCHARGE MEDICATIONS:
1. Prednisone taper 15 mg times three days, 10 mg times five
days, 5 mg times five days.
2. Coumadin 7.5 mg a day.
3. Lovenox 60 mg b.i.d. subcutaneously.
4. Rifabutin 300 mg a day.
5. Isoniazid 300 mg a day.
6. Peradoxime 50 mg a day.
7. Lamivudine 150 mg twice a day.
8. Nevirapine 200 mg twice a day.
9. Stavudine 30 mg twice a day.
10. Zantac 150 mg b.i.d.
FOLLOW-UP: Patient is to follow-up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
Infectious Disease Clinic on [**6-28**] and at [**Hospital3 **] on [**6-21**] at 1 p.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8859**], M.D. [**MD Number(1) 4728**]
Dictated By:[**Last Name (NamePattern1) 6834**]
MEDQUIST36
D: [**2173-6-23**] 14:31
T: [**2173-6-23**] 14:31
JOB#: [**Job Number 42359**]
ICD9 Codes: 5849, 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7078
} | Medical Text: Admission Date: [**2188-10-1**] Discharge Date: [**2188-10-22**]
Date of Birth: [**2133-11-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Fever, chills
Major Surgical or Invasive Procedure:
Placement of new right tunneled catheter
Transfusion of 2 units of packed red blood cells in total
History of Present Illness:
54 cantonese only speaking male with CAD, HTN, DM, ESRD on HD
was found to be febrile after he had his hemodialysis on DOA. He
complained of chills and fevers since Friday. No n/v/diarrhea.
He did have some back pain for 1-2 days. Does not have any chest
pain, SOB, palpitations, dizziness. His fevers were most likely
from infected tunnelled RIJ. 2 sets of blood cultures were sent
and he was given Vanc 1 gm, Gent 60 mg.
Past Medical History:
HTN
DM
ESRD due to IgA nephropathy/DM
diabetic retinopathy- Blindness
R subclavian Thrombus history of coumadin (seems to have stopped
around [**12-9**])
Anemia of chronic disease
Hyperlipidemia
CAD - Cardiac catheterization from [**2188-2-4**] showed
three-vessel disease with a 30% left main, a diffusely diseased
LAD with 80% mid stenosis, 90% diagonal, 60% second diagonal,
and 90% OM1. No suitable for PCI
Social History:
Cantonese speaking with some English, immigrated to the US 10
yrs ago, currently lives with wife and 3 children, has been
blind for approx 3 years, has not worked recently; No history of
tobacco use, alcohol, or illicit drug use. Wife injects insulin.
Family History:
No DM, CAD, Stroke, HTN, or Renal Disease
Physical Exam:
98.6, 167/97, 79, 22, 94%/RA, FSG 198, Wt 128 lbs
Gen: Comfortable, intermittent hiccups
HEENT: NAD,
Neck: no JVD, tunnel catheter line nontender/ no erythema at
insertion site
Lungs: Lungs clear
Heart: RRR no m/r/g
Abd: +bs, soft, NTND, no palpable masses, no reboud, no guarding
Ext: wwp, no edema
Neuro: AOx3
.
Pertinent Results:
IMAGING:
.
CXRAY [**2188-10-1**]
Cardiomegaly. No evidence of CHF or pneumonia.
Hemodialysis catheter unchanged in position
.
MR L SPINE W/O CONTRAST [**2188-10-3**] 11:21 AM
At L2/3, there is a mild disc bulge, which is not causing canal
or foraminal stenoses.
At L4/5, there is a mild disc bulge eccentric to the left, which
is not causing canal stenosis, but is mildly narrowing the left
subarticular zone. There is no foraminal stenoses.
No paraspinal soft tissue abnormalities are noted.
IMPRESSION: Somewhat limited exam due to lack of gadolinium, but
no evidence of spondylodiscitis or epidural or paraspinal
abscess formation.
Minimal degenerative changes without canal or foraminal
stenoses.
.
CXR [**2188-10-14**]
IMPRESSION: Improvement of pulmonary congestive pattern since
previous examination four days earlier. Also, heart size has
decreased slightly. No evidence of new discrete infectious
pulmonary infiltrates.
.
CT CHEST W CONTRAST [**2188-10-15**]
1. Findings in the right middle lobe and right lower lobe are
consistent with multifocal pneumonia.
2. Mild CHF.
3. Small right pleural effusion and tiny on the left.
4. Small right internal jugular venous thrombus.
5. No evidence of pulmonary infarction.
.
CT HEAD [**2188-10-15**]
IMPRESSION: No intracranial hemorrhages or areas of abnormal
enhancement.
.
TTE ECHO [**2188-10-15**]
- compared with the findings of the prior study (images
reviewed) of [**2188-2-19**], a possible pulmonic valve
vegetation is now seen.
- moderate symmetric LVH
- overall left ventricular systolic function is normal (LVEF
60-70%)
- right ventricular pressure overload
- a small pericardial effusion with no echocardiographic signs
of tamponade
.
KUB [**2188-10-17**] done in context of abdominal pain, N/V
IMPRESSION: No evidence of ileus or obstruction.
.
Repeat CT head [**2188-10-17**]
IMPRESSION: No acute intracranial hemorrhage or mass effect.
.
TEE [**2188-10-20**]
IMPRESSION: Trace aortic regurgitation with normal valve
morphology. Normal pulmonic valve morphology with no evidence of
vegetation or abscess. Mild mitral and tricuspid regurgitation.
.
LABS
CHEM/CBC
[**2188-10-1**] 06:50PM BLOOD WBC-19.0*# RBC-4.04* Hgb-12.6* Hct-36.0*
MCV-89 MCH-31.2 MCHC-35.1* RDW-16.4* Plt Ct-255
[**2188-10-2**] 05:45AM BLOOD WBC-15.7* RBC-3.77* Hgb-11.4* Hct-34.8*
MCV-92 MCH-30.4 MCHC-32.9 RDW-16.4* Plt Ct-294
[**2188-10-10**] 12:00PM BLOOD WBC-6.8 RBC-2.90* Hgb-9.2* Hct-26.8*
MCV-92 MCH-31.6 MCHC-34.2 RDW-17.6* Plt Ct-244
[**2188-10-11**] 09:25AM BLOOD WBC-5.6 RBC-3.01* Hgb-9.4* Hct-27.6*
MCV-92 MCH-31.1 MCHC-33.9 RDW-17.6* Plt Ct-215
[**2188-10-1**] 06:50PM BLOOD Glucose-279* UreaN-11 Creat-3.6*# Na-135
K-6.8* Cl-95* HCO3-30 AnGap-17
[**2188-10-2**] 05:45AM BLOOD Glucose-221* UreaN-18 Creat-4.8*# Na-139
K-3.8 Cl-96 HCO3-33* AnGap-14
[**2188-10-10**] 12:00PM BLOOD Glucose-159* UreaN-31* Creat-4.4*# Na-138
K-3.8 Cl-100 HCO3-28 AnGap-14
[**2188-10-11**] 09:25AM BLOOD Glucose-190* UreaN-14 Creat-3.2*# Na-137
K-3.4 Cl-95* HCO3-33* AnGap-12
.
CARDIAC ENZYMES
[**2188-10-8**] 03:24PM BLOOD CK-MB-NotDone cTropnT-0.29*
[**2188-10-8**] 11:00PM BLOOD CK-MB-NotDone cTropnT-0.29*
[**2188-10-9**] 09:56AM BLOOD CK-MB-NotDone cTropnT-0.36*
.
OTHER LABS
[**2188-10-1**] 06:58PM BLOOD Lactate-1.0 K-5.0
[**2188-10-2**] 02:38AM BLOOD Lactate-0.9 K-3.7
[**2188-10-8**] 03:24PM BLOOD LD(LDH)-274* CK(CPK)-56
[**2188-10-9**] 09:56AM BLOOD CK(CPK)-73
[**2188-10-3**] 05:43AM BLOOD Lipase-21
[**2188-10-4**] 05:50AM BLOOD Lipase-23
[**2188-10-8**] 07:48AM BLOOD Lipase-31
Brief Hospital Course:
Assessment: 54 year old Cantonese-speaking male with DM and ESRD
on HD, and CAD s/p CABG, difficult to control HTN, who had a 3
week hospital course for MSSA septicemia from an infected
hemodialysis catheter, aspiration pneumonia, unstable
angina/demand ischemia with new ST depressions on EKG, and
co-management of other chronic medical issues.
MSSA septicemia from infected HD catheter -
54 year old Cantonese-only speaking male with CAD, HTN, DM and
ESRD on HD presented with fever and chills [**2188-10-1**]. He was found
to have a MSSA RIJ HD catheter infection by cultures on [**10-1**] and
[**10-2**]. He was given Vanc/Gent in the ED. The catheter was removed
and he had a temporary line placed. He was treated for the
infection with vancomycin, dosed with HD, per the renal
attending. The patient had a tunnelled HD catheter placed on
[**2188-10-9**] after dialysis. The patient was continued on vancomycin
on the floor, day# 1= [**2188-10-1**] to finish a 3-week course of
antibiotics the day of discharge. Daily vancomycin levels were
checked and he was dosed at HD ([**Month/Day/Year 766**], Wednesday, Friday) to
keep the vancomycin greater than 15. The patient was kept on
vancomycin for MSSA because the patient did not have good IV
access until an emergent midline was placed on [**2188-10-17**] at which
time the patient needed vancomycin coverage for
aspiration/nosocomial pneumonia. So, throughout the hospital
course, the patient was kept on vancomycin for MSSA instead of
switching to nafcillin. All surveillance blood cultures showed
no growth. The new tunnelled catheter had bleeding around the
site during the 24 hours that the patient was receiving heparin
gtt for possible NSTEMI with new ST depressions. Since then, the
catheter has had some oozing from the site when accessed by
hemodialysis during his sessions but has been controlled with
pressure at the site.
A CT scan of the chest revealed a RIJ thrombus around the site
of the new tunnelled catheter. Per the renal team, there was no
indication to change the catheter and patient will need to have
a follow-up CT scan of his chest in [**3-8**] months to assess this
clot.
Initially, he also complained of back pain in the setting of the
bacteremia and had an MRI and RUQ ultrasound to eval for other
possible source of septicemia, which were negative. The patient
also had a TTE that showed a possible pulmonary valve vegetation
on [**2188-10-14**] but a TEE done 6 days later on [**2188-10-20**] showed no
endocarditis.
The patient was discharged after finishing a 3 week course of
vancomycin per ID team recommendations, at hemodialysis for
septicemia from line infection by [**2188-10-22**], his day of discharge.
Aspiration pneumonia -
During the patient's course in the hospital, he had episodes of
vomiting with likely aspiration. He had both CXR and CT chest on
[**2188-10-15**] which showed areas in the right middle lobe and right
lower lobe consistent with multifocal pneumonia. The patient was
started on IV zosyn and placed on aspiration precautions. By the
day of discharge, the patient completed a 7 day course of zosyn
and was saturating well on room air, without cough or fever for
more than 72 hours.
New ST depressions in lateral leads on EKG [**2188-10-14**] -
On the AM of [**2188-10-14**], patient was found to have unretractable
vomiting, and EKG taken showed new 2-3mm ST depressions in leads
V4-6. His cardiac enzymes were slightly elevated at 0.2-0.4, but
his baseline troponins were also in the 0.2 range. The patient
had no complaints of chest pain, although he was a difficult
historian. Patient was started on a heparin gtt for concern of
NSTEMI, cardiology was consulted but no interventions were
recommended as the patient was with no areas amenable for PCI by
his last cardiac cath, and was not a good surgical candidate. By
his last cardiac cath, the patient had moderate to severe
disease in almost all his coronary arteries. The patient was
maintained on aspirin, plavix, and as the patient had concern of
septic emboli from presumed pulmonary valve endocarditis by TTE
at the time, concern for cerebral hemorrhage given acute change
in mental status, the patient's heparin gtt was discontinued
after 24 hours on [**2188-10-15**]. The patient's daily 12-lead EKGs
continued to have ST depressions, and some new ST elevations in
V3 throughout his hospital stay and no events on telemetry. The
patient was discharged on aspirin, plavix, beta blocker, [**Last Name (un) **],
and statin. He was also started on long acting nitrates with
good response. Cardiology consult team followed him as well and
recommended the above.
HTN/Acute pulmonary edema in the setting of hypertensive urgency
requiring transfer to the MICU on [**2188-10-10**]. Prior to HD, the
patient received, two (Hydralazine 50 mg and amlodipine 10 mg)
out of his five HTN medications. Initial BP 154/104, but HD RN
reported labored breathing and O2 sat 84-87%. Soon after
initiation of therapy his BP increased to 216/100. He was seen
by the renal fellow and medical team and adamantly refused
oxygen. His other oral BP medications were given with minimal
effect. He underwent 2.5 liter ultrafiltration but remained
hypertensive and hypoxic. He was given 10 mg IV Hydralazine X 2
and 10 mg IV Labetalol X 1 with minimal effect. O2 sat remained
85-90% RA. Several discussions via Cantonese interpreter and his
wife were done by the medical team and the patient adamantly
refused oxygen or ABG. BP remained 215/106 and 1 inch nitropaste
placed on patient. The patient was transferred to the MICU for
further management of acute pulmonary edema. 2.5 L
ultrafiltrate removed during HD on date of admission, with addn
2 L removed in CCU. He was transferred back to the floor on
[**2188-10-11**] with no oxygen requirements after removal of 4.5 liters
of fluid by HD. Throughout the rest of his hospital course, the
patient's blood pressure regimen was optimized on discontinuing
hydralazine and starting minoxidil and imdur. He was discharged
on minoxidil and imdur in addition to his home regimen of
maximum doses of metoprolol, amlodipine, and losartan. By
discharge, his blood pressures were ranging 120-140s SBP on this
regimen, with good O2 sat on RA. Blood pressure control was also
maintained by his M,W,F regimen of HD with fluid removal.
Acute on chronic anemia -
The patient had anemia with Hcts below his baseline of 33-34
likely due to chronic kidney disease with acute illness. Given
his acute coronary syndrome with the new ST depressions, the
patient received 2 units of PRBC transfusions during his
hospital stay with his Hct goal to be maintained above 30. He
also receives EPO at hemodialysis.
DM/CKD stage 5 -
The patient was followed by both the renal and [**Last Name (un) **] diabetes
teams during his hospital stay. His fluid status and ESRD were
maintained by hemodialysis three times a week on M,W,F, and his
diabetes was maintained on NPH 70/30 8units QAM, 6units QPM with
a regular insulin sliding scale. He was discharged with follow
up with his dialysis at [**Hospital1 336**] and new appointments were made for
him with Cantonese and Mandarin-speaking providers at [**Last Name (un) **] for
follow up on diabetes control and nutrition (both for diabetes
and diastolic CHF).
Small pericardial effusion found on ECHO - The patient remaied
without signs of HD compromise and no signs of cardiac tamponade
by ECHO. No JVD or hypotension. He will need follow up on this
with his PCP as an outpatient.
Code status -
Initially in the ICU, discussions with an interpreter found the
patient to be DNI but not DNR. Given his many chronic medical
problems and the patient's ongoing wish to go home and leave the
hospital, the palliative care team was consulted to have a
formal code status discussion and also goals of care discussion
with the patient and wife. The result of this discussion with a
Cantonese interpreter was the that patient and wife decided to
continue to pursue resuscitation in the event of a
cardio-pulmonary arrest, and be changed to Full Code status.
This was documented in the chart. The patient was discharged on
[**2188-10-22**] home with close follow up.
Medications on Admission:
- Metoprolol Tartrate 150 TID
- Atorvastatin 40 mg
- Pantoprazole 40 mg
- Amlodipine 10 mg QD
- Calcium Carbonate 500 mg TID
- Lisinopril 40 mg QD
- Sevelamer 800 mg TID
- Aspirin 325 mg QD
- Clonidine 0.3 mg/24 hr QSUN
- Losartan 100 mg QD
- Clopidogrel 75 mg QD
- Hydralazine 50 mg QID
- Insulin NPH 7 units QAM, 7 units QHS
- Folic Acid 1 mg QD
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
10. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
12. Erythromycin 5 mg/g Ointment Sig: 0.5 gm in OS Ophthalmic
QID (4 times a day).
13. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
subcutaneous per insulin sliding scale Injection QACHS.
17. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: One (1) 8 units Subcutaneous QAM, once a morning before
breakfast.
Disp:*qs * Refills:*2*
18. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Six (6) units subcutanous Subcutaneous QPM every night
before dinner.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Final diagnosis
Septicemia secondary to infection in hemodialysis catheter
.
Secondary diagnosis
Aspiration pneumonia
Unstable angina/ Non ST elevation Myocardial infarction
Pulmonary edema
Acute Diastolic congestive heart failure
Hypertensiion, malignant
Chronic kidney disease stage 5; on hemodialysis ([**Date Range 766**],
Wednesday, Friday)
Coronary artery disease, native
Hyperlipidemia
Anemia of chronic disease
Discharge Condition:
Good, good O2 sat on room air, no cough, new HD tunneled
catheter in place.
Discharge Instructions:
You were admitted for fever and chills at hemodialysis and was
found to have a bacterial infection in your bloodstream from an
infection in your dialysis catheter. To treat this, we removed
your infected catheter and are treating you with antibiotics at
hemodialysis treatment. While you were here, you were
transferred to the intensive care unit because you had a very
high blood pressure and had fluid in your lungs leading to
shortness of breath. After you had sessions of hemodialysis to
remove extra fluid, you improved and were transferred back to
the medical floor. We also placed a new hemodialysis catheter.
We made sure that you did not have other sources of the
infection in your spine and abdomen by a MRI of you spine and
ultrasound of your abdomen. However, you were found to have an
infection in your lung, so we started a second antibiotic to
treat this. We were also worried about a possible infection on
your heart valves and were treating you with antibiotics for
this, but the accurate ultrasound of your heart showed there was
no bacteria on your heart valves.
.
During your hospital stay, you were also found to have tracings
on your heart which showed that your heart was not getting
enough blood. The heart doctors were following [**Name5 (PTitle) **], but because
of your other medical problems and the severity of your heart
disease, you are not a good candidate for surgery of placement
of a stent in your heart. For this, we have been treating your
heart disease with medicine and monitoring your heart tracing.
You also received a total of two units of blood transfusion
during your hospital stay for your low blood counts. You were
also found to have a small clot at the end of your current
hemodialysis catheter which you will need to follow up with a
repeat CT scan of your chest in [**3-8**] months. There is no
indication to remove this catheter according to the kidney
doctors. [**First Name (Titles) 357**] [**Last Name (Titles) **] this with your primary care doctor.
.
On discharge from the hospital, you will be finished with a 3
week course of antibiotics for your catheter line infection, and
finished with a 1 week course of antibiotics for your pneumonia.
You will need to continue your hemodialysis on [**Last Name (Titles) 766**],
Wednesday, Friday at [**Hospital1 336**]. We also made the following changes to
your medications:
1. We started a blood pressure medication called minoxidil,
which you should take 2.5mg two times a day
2. We started a blood pressure medication called imdur 30mg
daily for your blood pressure
3. We stopped your hydralazine medication for your blood
pressure. Do not take this medication anymore.
4. We started you on a medication called nephrocaps (B
Complex-Vitamin C-Folic Acid) for your renal disease. Please
take one daily.
5. We adjusted your standing insulin dose to be 8 units of the
NPH insulin before breakfast and 6 units of the NPH at night.
.
Also, it is very important that you eat a low salt diet, less
than 2 grams per day, and restrict your fluid to 1,500ml per
day. You should weigh yourself daily and call your physician if
your weight changes by more than 3 lbs.
.
Please return to the hospital if you experience any fever,
chills, tenderness or pain at your hemodialysis catheter site,
uncontrolled nausea or vomiting, chest pain, shortness of
breath, or swelling in your legs.
Followup Instructions:
You have an appointment with your primary care doctor tomorrow
on [**10-23**] at 1:30pm. Provider: [**Name10 (NameIs) 32199**],[**Name11 (NameIs) 3078**] [**Name Initial (NameIs) **].
[**Telephone/Fax (1) 8236**]. You will need a follow up CT scan of your chest in
[**3-8**] months to follow up on the small blood clot around the tip
of your hemodialysis catheter.
.
You have an appointment with a dietician, [**First Name8 (NamePattern2) 8463**] [**Last Name (NamePattern1) 13260**] to work
on your nutrition. She is a Cantonese speaker. The appointment
is on [**10-30**], at 3pm. Please go to [**Hospital **] clinic on [**Last Name (un) 19749**] on the [**Location (un) **]. If you have any questions, call
[**Doctor First Name **], who is a Cantonese speaker, her telephone number is
[**Telephone/Fax (1) 58905**].
.
You have an appointment at the [**Hospital **] Clinic at [**Last Name (un) **] Diabetes
center on [**12-11**], Thursday afternoon at 4:30pm to follow up
on your diabetes control. The physician is [**Name Initial (PRE) **] mandarin speaker.
Please go to [**Hospital **] clinic on [**Last Name (un) 3911**] on the [**Location (un) **].
If you have any questions, call [**Doctor First Name **], who is a Cantonese
speaker, her telephone number is [**Telephone/Fax (1) 58905**].
.
Continue hemodialysis [**Telephone/Fax (1) 766**], Wednesday, Friday at [**Hospital 58906**]. [**Hospital1 336**] HD center: F ([**Telephone/Fax (1) 58907**]. T ([**Telephone/Fax (1) 58908**]
.
Your other appointments at [**Hospital1 18**] are as follows:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12902**], MD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2188-10-30**] 9:20
Provider: [**Name10 (NameIs) **] PROCEDURE Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2188-10-30**]
10:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2188-12-30**] 9:40
ICD9 Codes: 4280, 5070, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7079
} | Medical Text: Admission Date: [**2107-10-17**] Discharge Date: [**2107-10-21**]
Date of Birth: [**2038-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
fatigue, dark stool
Major Surgical or Invasive Procedure:
EDG
C-scope
Small Bowel Follow thru
History of Present Illness:
69 female h/o NASH, upper GIB in [**2103**] secondary to gastric
ulcers presenting with two days of black stool and fatigue.
.
Patient with recent admission from [**9-15**] - [**9-23**] for klebseilla
urosepsis/pyelo as well as presumed c.dif colitis. Infectious
work-up notable for OSH urine and blood cultures both positive
for
Klebsiella. Patient was started on gentamycin, transitioned to
cefepime -> cipro and discharged on 1st-generation
cephalosporin, cefadroxil. Additionally, patient noted to have
[**5-31**] watery BM/day with associated leukocytosis. Though Cdiff
toxin and PCR returned negative decision made to empirically
treat for colitis with flagyl. Additional issues during that
hospitalization:
1. Anemia. Hct trended down from 31.3 on admission to 26.5 on
HD4 but then remained stable. Iron studies were consistent
w/anemia of chronic disease. Normal B12, folate. No note of
guaiac + stool.
2. ?Cirrhosis. Patient with h/o NASH. Labs significant for
elevated INR, low albumin. Exam with e/o progressive liver
disease: spider angiomas, ascites. HBV and HCV titers were
negative. Pt
reported rare EtOH. Plan to proceed with outpatient biopsy. No
EGD in our system.
.
Patient discharged and returned home. Had been in USOH when
developed painless melena, generalized weakness and orthostasis
x2 days. Reports associated nausea with one episode of vomiting
brown material, Denies abdominal pain, dysphagia, hoarseness,
tenesmus, chest pain, palpitations. Does endorse ~20lb weight
loss over last month in setting of hospitalization; denies
fevers, chills, sweats.
Reports gastric ulcers in past with vomiting of coffee ground
emesis but never black stools. This feels somewhat similiar to
previous episode.
.
In the ED, initial VS 98.2 108 135/44 24 100% RA. Frank melena
on exam. Labs with HCT: 20.1 (25 on [**9-23**]), INR: 1.3. Patient type
and crosses x4u. GI consulted. Patient started on ppt bolus +
ggt. Unable to pass NGT in ED (6 attempts) failure thought
secondary to irregular anatomy. No transfusion as of yet though
received 2L NS. VS prior to transfer: HR 104 128/58 20 100%RA.
Access: 2 18g bilaterally.
.
On arrival to the MICU, patient without complaint though does
cite intermittent nausea as well as slow speech. Denies
abdominal pain.
.
Review of systems:
(+) Per HPI; DOE
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Type 2 Diabetes (insulin-dependent)
Hypertension
NASH
Hypercholesterolemia
Osteoarthritis
Depression
Upper GI Bleed, gastric ulcers [**2103**]
Social History:
Lives alone at home, has worked at [**Location (un) 86**] Financial as a scanner
for past 17 years. No tobacco, alcohol or drug use.
Family History:
Significant for heart disease and diabetes. Mother has afib,
husband died of liver disease
Physical Exam:
On Admission:
General: Alert, oriented, no acute distress, slow speech
HEENT: conjunctival pallor, MMM, oropharynx clear without
exudates or lesion, no subinguinal jaundice
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, soft SEM, rubs, gallops, no
peripheral edema
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: pale, warm, well perfused, 2+ pulses, no clubbing, cyanosis
or edema
Pertinent Results:
ADMISSION LABS
--------------
[**2107-10-16**] 10:35PM BLOOD WBC-10.6 RBC-2.20* Hgb-6.7* Hct-20.1*
MCV-92 MCH-30.6 MCHC-33.4 RDW-18.3* Plt Ct-229
[**2107-10-16**] 10:35PM BLOOD Neuts-64.8 Lymphs-30.5 Monos-3.7 Eos-0.5
Baso-0.4
[**2107-10-16**] 10:35PM BLOOD PT-14.6* PTT-25.1 INR(PT)-1.3*
[**2107-10-16**] 10:35PM BLOOD Ret Aut-5.1*
[**2107-10-16**] 10:35PM BLOOD Glucose-244* UreaN-61* Creat-1.2* Na-139
K-4.5 Cl-108 HCO3-15* AnGap-21*
[**2107-10-16**] 10:35PM BLOOD ALT-28 AST-43* LD(LDH)-204 AlkPhos-86
TotBili-0.4
[**2107-10-16**] 10:35PM BLOOD Albumin-3.5 Calcium-9.9 Phos-4.3 Mg-1.8
[**2107-10-16**] 10:35PM BLOOD Hapto-118
[**2107-10-16**] 10:58PM BLOOD Lactate-4.0*
.
DISCHARGE LABS
--------------
[**2107-10-21**] 06:05AM BLOOD WBC-6.3 RBC-3.56* Hgb-10.6* Hct-31.0*
MCV-87 MCH-29.8 MCHC-34.2 RDW-19.7* Plt Ct-144*
[**2107-10-20**] 06:00AM BLOOD Glucose-150* UreaN-17 Creat-0.9 Na-141
K-3.7 Cl-110* HCO3-21* AnGap-14
[**2107-10-20**] 06:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.7
.
MICROBIOLOGY
------------
[**2107-10-17**] 12:16 pm SEROLOGY/BLOOD Source: Venipuncture.
**FINAL REPORT [**2107-10-19**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2107-10-19**]):
POSITIVE BY EIA.
(Reference Range-Negative).
.
IMAGING
-------
EGD 9/26
Esophagus:
Other No esophageal varices seen.
Stomach: Normal stomach.
Duodenum:
Mucosa: Mild erythema at the junction between the duodenal bulb
and the second portion of the duodenum consistent with
duodenitis.
Other
findings: No source of bleeding identified to explain melena.
Impression: No esophageal varices seen.
Abnormal mucosa in the duodenum
No source of bleeding identified to explain melena.
Otherwise normal EGD to second part of the duodenum
Recommendations: Plan for colonoscopy tomorrow morning. Please
start Moviprep tonight. Advance diet to clears. NPO after
midnight. Stop PPI drip.
.
Colonoscopy: [**10-18**]
Findings:
Other No bleeding source identified to explain anemia and
melena.
Impression: No bleeding source identified to explain anemia and
melena.
Otherwise normal colonoscopy to cecum
Recommendations: Will proceed with inpatient capsule endoscopy.
D/C PPI. Colonoscopy should be repeated given fair preparation.
Therefore, small polyps may have been missed.
.
Capsule endoscopy [**10-19**]:
1. Multiple angioectasias were seen from the mid jejunum to the
distal ileum.
2. No active bleeding sites were seen in the small bowel.
Summary & recommendations
Summary: Multiple angioectasias were seen from the mid jejunum
to
the ileum. No active bleeding sites were seen in the small bowel
at this time.
.
Small bowel enteroscopy [**10-20**]:
The scope was advanced upto mid/distal jejunum
The distal most portion of the small bowel reached was tattood
with [**Country 11150**] ink.
Four to five angioectasias noted in the jejunum.
APC treatment of the angioectasias were performed with success.
(injection, thermal therapy)
A previously administered capsule (Pillcam) was noted in the
colon or distal small bowel by fluoroscopy.
Otherwise normal small bowel enteroscopy to mid jejunum
.
CXR on admission:
FINDINGS: No previous images. The heart is normal in size and
there is no
evidence of vascular congestion, pleural effusion, or acute
focal pneumonia.
Brief Hospital Course:
69 female h/o upper GI bleed in [**2103**] secondary to gastric ulcers
presenting with two days of black stool and fatigue.
.
ACTIVE ISSUES
-------------
# Gastrointestinal bleed. Thought to be related to GI bleed
after report of 2 days of melena. GI was consulted on admission.
Differential diagnosis included bleeding gastric or esophageal
ulcer, [**Doctor First Name **]-[**Doctor Last Name **] tear, variceal bleeding, or malignancy. She
was initially on pantoprazole gtt transitioned to pantoprazole
40mg IV BID, then to PO therapy for H. pylori treatment. She
underwent upper endoscopy and colonoscopy without clear source
of bleed. GI recommended further investigation with a capsule
study to better visualize the small bowel, which showed multiple
angioectasias in the small bowel. In the ICU, she was transfused
6 units pRBC for a HCT of 20.5 with resulting bump to 28, which
then remained stable. Additional anemia work-up including
hemolysis labs, reticulocyte count were within normal limits.
Patient was without further episodes of GI bleeding while
hospitalized. Small bowel enteroscopy was performed and
aforementioned angioectasias were cauterized. Patient was
discharged with stable hematocrit. She does not require
Gastroenterology follow-up, but should return to [**Hospital1 18**] for
repeat imaging if she experiences another GI bleed.
.
# Helicobacter pylori infection: patient was noted to have
positive H. pylori testing, and was started on omeprazole,
clarithromycin and amoxicillin for planned 14-day course, which
she will continue as an outpatient.
.
# Toxic-metabolic encephalopathy. Per patient as well as
daughter; patient more mentally slow in the days preceding
admission. Patient denied any focal complaints however felt as
if her speech was slurred. She had a non-focal neurologic exam.
Kidney and liver function was only mildly abnormal, then
improved. Patient was without asterixis. TSH was within normal
limits. After acute treatment of anemia, patient's confusion
resolved.
.
# Dyspnea. Likely related to anemia. No focal consolidation or
signs of volume overload on exam or chest X-ray. Patient was
transfused with improvement in symptoms.
.
# Acute kidney injury. Mild elevation in creatinine to 1.2 on
admission. Likely pre-renal in etiology in setting of GI
bleed/hypovolemia. Patient received 2 liters of normal saline in
the ED as well as 6 units PRBCs in the ICU with improvement of
creatinine to 1.0.
.
CHRONIC ISSUES
---------------
# Diabetes mellitus type II. Poorly controlled with Last A1c in
[**2107**]: 10.6. PO diabetic regimen was held while NPO and she was
maintained on an insulin sliding scale
.
# Hyperlipidemia. Continued home rosuvastatin.
# Depression. Continued fluoxetine
.
TRANSITION OF CARE
------------------
# Follow-up: patient has scheduled follow-up with her PCP. [**Name10 (NameIs) **]
does not require Gastroenterology follow-up, but should return
to [**Hospital1 18**] for repeat imaging if she experiences another GI bleed.
There are no pending studies at the time of discharge.
# Code status: Full (discussed with patient)
.
# Contact: [**Name (NI) **] [**Name (NI) **], daughter [**Telephone/Fax (1) 91707**]
Medications on Admission:
1. fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
2. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
3. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
6. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Apidra 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous four times a day.
Discharge Medications:
1. fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
2. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
3. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
6. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day) for 13
days.
Disp:*26 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 13 days.
Disp:*52 Tablet(s)* Refills:*0*
9. amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 13 days.
Disp:*104 Capsule(s)* Refills:*0*
10. Apidra 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous four times a day.
11. insulin syringes (disposable) 1 mL Syringe Sig: One (1)
syringe Miscellaneous as needed.
Disp:*100 syringes* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Gastrointestinal bleeding, likely from small bowel angioectasias
acute blood loss anemia
Helicobacter pylori infection
acute renal failure, prerenal
Secondary diagnosis:
metabolic encephalopathy
Diabetes mellitus type II, uncontrolled
Hypertension
Hyperlipidemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 18**]. You came for
further evaluation of bloody bowel movements. Further tests
showed that you likely bled from your small intestine, from
blood vessel malformations called angioectasias. A colonoscopy,
EGD, capsule endoscopy and small bowel enteroscopy was performed
to identify these areas. It was also found that you have an
infection with Helicobacter pylori, for which you are being
treated. It is important that you continue your medications and
follow-up with the appointments listed below.
The following changes have been made to your medications:
We ADDED omeprazole, clarithromycin and amoxicillin to treat an
infection in your stomach called H. pylori. Please take these
medications for the full course outlined.
Followup Instructions:
PCP [**Name Initial (PRE) 648**]: Wednesday, [**10-26**] at 11:30am
With:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14839**],MD
Location: [**Hospital1 **] HEALTHCARE - UPPER FALLS
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 14512**]
Phone: [**Telephone/Fax (1) 3393**]
Department: LIVER CENTER
When: TUESDAY [**2107-10-25**] at 10:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2107-11-10**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11307**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5849, 2762, 2851, 4019, 2720, 311, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7080
} | Medical Text: Admission Date: [**2123-2-16**] Discharge Date: [**2123-2-22**]
Date of Birth: [**2059-5-4**] Sex: M
Service:
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This 62 year-old diabetic male
with a history of atypical chest pain and dyspnea on exertion
referred for cardiac catheterization after a positive stress
test. Cardiac catheterization showed ejection fraction of
60%, 60% left main disease, 80% left circumflex, 70% RCA.
The patient remained in house after his cardiac
catheterization and was taken to the operating room on
[**2123-2-16**] with Dr. [**Last Name (Prefixes) **].
PAST MEDICAL HISTORY:
1. Noninsulin dependent diabetes mellitus.
2. History of prostate cancer status post prostatectomy 10
years ago.
3. Asbestosis.
4. Hypertension.
5. A 30 to 40 pack year smoking history, quit in the 70s.
6. Status post biopsy of a right anterior tibial lesion with
a follow up bone scan and CT scan of the abdomen and pelvis
to rule out metastasis from prostate cancer. Results are
unknown.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Imdur 30 milligrams po q day.
2. Lipitor 20 milligrams po q day.
3. Glucotrol 5 milligrams po q day.
4. Tiazac 360 milligrams po q day.
5. Diovan 80 milligrams po q day.
6. Aspirin 325 milligrams po q day.
LABORATORY DATA: White blood cell count 7.5, hematocrit
46.2, platelet count 184,000, sodium 140, potassium 4.5,
chloride 106, bicarb 26, BUN 19, creatinine 1.2. Blood sugar
150.
HO[**Last Name (STitle) **] COURSE: The patient was taken to the operating room
on [**2123-2-17**] with Dr. [**Last Name (Prefixes) **] for CABG times three. In the
operating room it was difficult to place a Foley catheter
preoperatively. Urology was consulted. Flexible cystoscopy
showed a bladder neck stricture. A wire was placed and the
stricture was dilated. A Foley catheter was inserted. The
patient underwent CABG times three, LIMA to diagonal,
saphenous vein graft to RCA, saphenous vein graft to OM. The
patient was transferred to the Intensive Care Unit in stable
condition. The patient was weaned and extubated from
mechanical ventilation on postoperative day one. The patient
remained in the Intensive Care Unit requiring Neo-Synephrine
infusion to maintain adequate blood pressure.
The patient was transferred out of the Intensive Care Unit on
postoperative day two. The patient's chest tubes were
removed on postoperative day two. Post chest tube removal
chest x-ray demonstrated a small left apical pneumothorax
from which the patient was asymptomatic. The patient was
transferred to the floor and began ambulating with Physical
Therapy.
The patient's temporary pacing wires were removed on
postoperative day three.
The patient's Foley catheter was removed on postoperative day
five. The patient is to void prior to discharge otherwise
Foley catheter will be re-inserted.
Repeat chest x-ray on [**2123-2-21**] demonstrated a continued small
left apical pneumothorax unchanged from previous chest x-ray
of [**2123-2-18**]. It is felt that the size and stability of the
pneumothorax did not require any intervention. The patient
was cleared for discharge on [**2123-2-22**] to rehabilitation
facility as it was felt that the patient would need continued
physical therapy and short term rehabilitation.
CONDITION AT DISCHARGE: Tmax 100.4 F, T current 99.1 F.
Pulse 94, sinus rhythm. Blood pressure 122/52. Oxygen
saturation 94% on two liters nasal cannula. The patient's
weight on [**2123-2-22**] is 105 kilograms. The patient was 99
kilograms preoperative. White blood cell count 9.9,
hematocrit 26.9, platelet count 233,000, sodium 140,
potassium 4.3, chloride 100, bicarbonate 31, BUN 19,
creatinine 0.9, blood sugar 169. The patient is alert and
oriented times 3, neurologically grossly intact.
Cardiovascular - regular rate and rhythm. No audible rub or
murmur. Extremities are warm and well perfused. Respiratory
- breath sounds are decreased bilaterally with crackles at
the left base. GI - abdomen is obese, soft, positive bowel
sounds, nontender, nondistended, positive bowel movement.
Extremities - right lower extremity incision is clean, dry
and intact. The patient has Dermabond over the incision.
Sternal incision - Steri Strips are intact, no erythema or
drainage is noted. There is scant amount of serosanguinous
drainage from the medial chest tube site with no erythema
noted.
DISCHARGE MEDICATIONS:
1. Lopressor 50 milligrams po bid.
2. Lasix 20 milligrams po bid times 10 days.
3. KCL 20 milliequivalents po bid times 10 days.
4. Colace 100 milligrams po bid.
5. Ranitidine 150 milligrams po bid.
6. Enteric coated aspirin 325 milligrams po q day.
7. Lipitor 20 milligrams po q HS.
8. Glucotrol 5 milligrams po q day.
9. Ibuprofen 400 milligrams po q four to six hours prn.
10. Oxycodone 5/325 one to two tablets q four to six hours
prn.
11. Dulcolax suppository one po q day prn.
12. Regular sliding scale insulin for blood sugar of 150 to
200 give three units subcutaneous; for blood sugar 201 to 250
give five units subcutaneous; blood sugar 251 to 300 give
seven units subcutaneous; blood sugar 301 to 350 give 9 units
subcutaneous.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post CABG.
2. Noninsulin dependent diabetes mellitus.
3. History of prostate cancer status post prostatectomy ten
years.
4. Bladder neck stricture, status post dilation.
5. History of asbestosis.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient is to be discharged to a
rehabilitation facility in stable condition. The patient is
to follow up with Dr. [**Last Name (STitle) 8952**] in three to four weeks. The
patient is to follow up with Dr. [**Last Name (Prefixes) **] in three to four
weeks. The patient is to follow up with Dr. [**Last Name (STitle) **] upon
discharge from rehabilitation.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2123-2-22**] 09:26
T: [**2123-2-22**] 09:44
JOB#: [**Job Number 38407**]
ICD9 Codes: 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7081
} | Medical Text: Admission Date: [**2126-1-31**] Discharge Date: [**2126-2-1**]
Date of Birth: [**2055-10-11**] Sex: M
Service: Neurosurery
HISTORY OF PRESENT ILLNESS: This 70-year-old male was found
down while plugging in a new telephone. EMS were called by
his companion. The patient was unresponsive, pulseless,
epinephrine was given x3 along with atropine. Pulse returned
in rate of 40s to 50s. Blood pressure was 70 palpable. The
patient was intubated at scene and was down for 5 to 10
minutes.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: Hemorrhoidectomy.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient smoked 1 to 2 packs per day.
PHYSICAL EXAMINATION Pulse was 116, blood pressure 140/80,
he was intubated. The patient was unresponsive, pupils were
2 to 4 trace reactive, minimal rotation of right upper
extremity, to painful stimulation no withdraw in bilateral
lower extremities.
Hematocrit was 44, white count 16, platelets 193, coags 13.3,
26.3 and 1.2. Sodium 144, potassium 3.1, chloride 106,
bicarb 23, BUN 16, creatinine 1.3 and glucose 344. Head CT
showed a large subarachnoid bleed including blood in the
fissures around the pons, mid brain and minimal blood in the
ventricles, no obvious focus of interparenchymal blood. CT
of the head showed a 7 mm anterior cerebral aneurysm.
The patient was admitted to the neurosurgery service, started
on nimodipine 60 mg q4 hours and Nipride drip to keep his
blood pressure less than 130. He was loaded with Dilantin 1
gram and then 100 mg t.i.d., started on Zantac 150 mg,
ventriculostomy catheter was placed for ICP measurement and
drainage, it was placed at 20 cm above the tragus. Ancef was
given 1 gram for prophylaxis of the vent drain. The patient
was placed in the ICU with q1 hour neuro checks.
The next morning, [**2-1**], the patient's pupils were 2 and
reactive, trace movement in the upper extremities to painful
stimuli, bilateral lower extremities had no movement, no
corneal reflexes bilaterally, positive gag reflex. The drain
was placed down to 15 mm of water. Dr. [**Last Name (STitle) 1132**] saw the patient
later in the day and discussed with the patient's family and
his companion that the patient had suffered a grave
neurologic injury. He had a grade 5 subarachnoid hemorrhage
and did not improve at all with ventriculostomy drain. He
had a very poor chance for recovery. After discussion the family
decided to make the patient comfort measures only. He was
extubated and started on a morphine drip. He died peacefully
at 22:30 hours.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2126-2-1**] 22:50
T: [**2126-2-6**] 08:05
JOB#: [**Job Number 53463**]
ICD9 Codes: 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7082
} | Medical Text: Admission Date: [**2101-7-17**] Discharge Date: [**2101-7-26**]
Date of Birth: [**2030-2-22**] Sex: M
Service: MEDICINE
Allergies:
Lyrica / Ambien
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a 71 yo man with h/o IPF, followed by Dr. [**Last Name (STitle) **],
who presents with one week history of worsening SOB. Per the
patient and his family, his symptoms began last Tuesday when he
developed a sore lesion on the right side of his buttock. He
was seen by his PCP, [**Name10 (NameIs) 1023**] started him on Cefalexin for possible
bacterial infection. Shortly thereafter, as he was unable to
take deep breaths secondary to the pain from this lesion, he
began to experience increased shortness of breath and a
non-productive cough. Over the past few days, he has had
increased dizziness and his O2 sats dropped to the low 70s and
high 60s (baseline in the 80s on 2L O2 at home). Yesterday, he
had a low-grade fever of 100.2 and an episode of fecal
incontinence. Per the patient, he has also been experiencing a
"tingling" sensation in his legs for the past three days, and he
had an associated mechanical fall last night while walking to
the kitchen. Given concerns over these events, the patient's
wife and daughter brought him to the [**Name (NI) **] this morning.
.
Of note, the patient was diagnosed with IPF in [**2100-12-26**].
He had biopsies performed at [**Hospital1 2177**] and is currently followed by
Dr. [**Last Name (STitle) **]. Per the patient, he has had a significant clinical
decline since this time and was most recently hospitalized at
[**Hospital3 3583**] in [**2101-1-23**] for PNA.
.
In the ED, his VS were T 98.2, P 109, BP 118/65, R 20, O2 87% on
3L. He was had 3 word dyspnea and was placed on 4L, and his O2
sat increased to 91-92%. CXR showed new area of opacity in LUL,
so he was started on Ceftriaxone and Levofloxacin for CAP.
.
On the floor, the patient continues to complain of increased SOB
and tingling in his legs. He admits to increased lower back and
abdominal pain, as well as difficulty swallowing for the past
three days. Finally, he states that he has had increased
urinary retension over the past week.
Past Medical History:
Idiopathic Pulmonary Fibrosis (FVC 1.6, FEV1 1.53, FEV1/FVC 96%,
DLCO 42% pred)
Trigeminal Neuralgia
Hyperlipidemia
h/o Duodenal Ulcer
h/o Rheumatic fever
Borderline DM2
Appendectomy
Tonsillectomy
Lumbar spinal fusion in [**10-2**]
Social History:
He was previously a welder and he designed [**Holiday **] ornaments
with his wife. [**Name (NI) **] currently lives with his wife in [**Name (NI) 8072**],
MA. He never smoked, though he was exposed to significant
second hand smoke as a child. No drugs, occ EtOH.
Family History:
The patient's sister and mother died from lung disease (unclear
history). No h/o CAD.
Physical Exam:
Vitals: T: 98.4, BP: 118/70 P: 104 R: 29 O2: 90% on 4L
General: Three-word dyspnea, AAOx3, in obvious respiratory
distress. HEENT: PERRL, EOMI, oropharynx clear, dry mucous
membranes
Neck: Supple, JVP not elevated, no LAD, clear use of accessory
muscles
Lungs: Diffuse crackles over all lung fields
CV: Tachycardic, sinus rhythm. Normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: +BS, soft, diffusely tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: Foley in place
Ext: 3/5 strength in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]. warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema
Skin: erythematous ulcerated rash in the S2-S3 dermatomal
distribution
Pertinent Results:
ADMISSION LABS:
.
[**2101-7-17**] 01:20PM BLOOD WBC-12.4* RBC-4.26* Hgb-13.5* Hct-40.0
MCV-94 MCH-31.6 MCHC-33.6 RDW-14.2 Plt Ct-230
[**2101-7-17**] 01:20PM BLOOD Neuts-89.2* Lymphs-8.0* Monos-1.9*
Eos-0.6 Baso-0.2
[**2101-7-17**] 01:20PM BLOOD Plt Ct-230
[**2101-7-17**] 05:03PM BLOOD PT-13.5* PTT-23.2 INR(PT)-1.2*
[**2101-7-17**] 01:20PM BLOOD Glucose-135* UreaN-31* Creat-0.8 Na-137
K-4.0 Cl-98 HCO3-26 AnGap-17
[**2101-7-17**] 05:03PM BLOOD Calcium-8.7 Phos-2.9 Mg-2.5
[**2101-7-17**] 06:10PM BLOOD Type-ART pO2-60* pCO2-36 pH-7.51*
calTCO2-30 Base XS-5 Intubat-NOT INTUBA Comment-O2 DELIVER
[**2101-7-17**] 01:28PM BLOOD Lactate-1.6
.
.
PERTINENT LABS/STUDIES:
Hct: 40.0 -> 35.4
WBC: 12.4 -> 10.5 -> 14.6
BNP: 163
.
Micro:
CSF: 93 WBC (4 PMNs, 38 L, 51 Monos), TProtein: 98, Glucose 122
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final [**2101-7-19**]):
POSITIVE FOR VARICELLA-ZOSTER VIRUS.
Viral antigen identified by immunofluorescence.
REPORTED BY PHONE TO P.KIZHA ON [**2101-7-19**] AT 11:15 CC7D.
.
Pending labs:
[**Doctor First Name **]
ANCA
Anti-GBM
BAL Cultures
CSF Cultures
CXR ([**7-17**]): Worsening interstitial opacities, more confluent in
the LUL.
Although these changes may be related to worsening nterstitial
lung disease, a superimposed pneumonia in the left upper lobe
cannot be excluded.
CT Chest ([**7-17**]): 1. No evidence of central, lobar or segmental
pulmonary embolism or acute aortic syndrome. 2. Moderately
progressive worsening of pulmonary fibrosis without focal
consolidations.
MRI L-Spine ([**7-18**]): 1. Enhancement of the cauda equina extending
from L3 to L5 consistent with arachnoiditis. 2. No evidence of
cauda equina or spinal cord compression.
Brief Hospital Course:
The patient is a 71 yo man with IPF, who presents with a
one-week history of worsening hypoxia and found to have zoster
of S2-S3 and lumbar arachnoiditis (likely [**12-27**] VZV) causing
weakness in hip flexion bilaterally.
.
#. Ideopathic Pulmonary Fibrosis: The patient has a h/o IPF,
which was diagnosed 6 months ago. He was seen by pulmonary as
an inpatient who felt his shortness of breath to likely be an
IPF exaxerbation, but also considered superimposed PNA or viral
infection. He has had increasing hypoxia over the past week,
with recent ABG of 7.51/36/60/30. He is currently taking
Prednisone, Acetylcystine, and Azathioprine and his prednisone
was increased to 60 mg [**Hospital1 **], but will be tapered down to 40 mg
daily over a 3 week course. CXR showed new LUL infiltrate for
which he was started on ceftriaxone and levofloxacin, later
narrowed to levofloxacin. He has significant desats on even
mild exertion to the mid to high 70s. During his time in the
hospital, his O2 sats improved. Upon admission, he desatted to
the low 70's when he stood up. Now, he can take 10 steps before
having to rest, and his sats stay in the low 80s. His new O2
requirement is, however, higher than before. He reports using
2L at rest and 3L with activity, and now it appears he needs
4-5L at rest. He will still be continued on his Mucomyst,
Azathioprine, and Prednisone, and Bactrim for PCP [**Name Initial (PRE) 1102**].
He finished his course of Levo in the hospital, and will require
2 more week of Acyclovir PO after being discharged. His current
respiratory status is much improved from admission and likely
represents his new baseline.
.
# Zoster: The patient developed an ulcerated lesion in his
coccyx several days before presenting to the hospital. It
developed into an expanding rash in the S2,S3 dermatomal
distribution early in his hospital stay. He was seen by Derm
and ID who swabbed the rash and determined it to be Zoster. He
was started on a 10 day course of IV Acyclovir, the last day of
which is [**7-29**]. The rash is only minimally painful now and much
improved from the first few days after it developed when the
patient described [**9-3**] pain.
.
# Arachnoiditis - Likely cause for fecal incontinence and BLE
weakness. CSF labs are consistent with viral etiology as there
was an elevated WBC with a predominance of lymphocyte with
elevated protein and normal glucose; varicella PCR came back
positive, HSV PCR pending. Varicella zoster is likely etiology
given the patient's current active dermatologic manifestation
and presence of immunosuppression. He was initially on
ceftriaxone, ampicillin but bacterial cultures were negative. He
was started on a 10 day course of IV Acyclovir, the last day of
which is [**7-29**]. He BLE weakness has improved and he feels more
steady walking than he did before admission, however, he does
not have full strength. He also has more sensation in BLE than
before. He still does not have control of his bowels and
reports daily episode of fecal incontinence, but reports having
a much better sense of when he's about to go than before and
feels like this is continually improving.
.
# Code: DNR/DNI, discussed with palliative care. The patient
understands that if a situation were to occur that required
intubation, given his underlying lung disease, there is a very
small chance that he would ever be extubated. With this
knowledge the patient and his family agree that he would be
better off as DNR/DNI. This was discussed at length with the
medical team and palliative care team present.
Medications on Admission:
Acetylcysteine 600 mg TID
Alendronate 70 mg qweek
Azathioprine 25 mg daily
Lorazepam 0.5 mg qhs prn
Percocet 1-2 tablets q4-6h prn for pain
Pantoprazole 40 mg daily
Prednisone 40 mg daily
Simvastatin 80 mg daily
Calcium 600 mg daily
Colace 100 mg [**Hospital1 **]
Multivitamin
Omega-3 Fatty Acids 1000 mg daily
Bactrim 400 mg-800 mg M/W/F
Cephalexin 500 mg qid
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation. Tablet(s)
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Six Hundred
(600) mg Miscellaneous TID (3 times a day).
5. Azathioprine 50 mg Tablet Sig: 0.5 Tablet PO once a day.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
15. Prednisone Taper
Please take prednisone according to this schedule:
[**7-26**] - [**7-31**]: take 60 mg in the AM, 60 mg in the PM
[**7-31**] - [**8-4**]: take 60 mg in the AM, 40 mg in the PM
[**8-5**] - [**8-9**]: take 40 mg in the AM, 40 mg in the PM
[**8-10**] - [**8-14**]: take 40 mg in the AM, 20 mg in the PM
[**8-15**] and onwards: take 40 mg one time daily
16. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day): Please give prednisone according to attached taper
schedule.
17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
18. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO Q6H (every
6 hours) as needed for pain, SOB.
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
20. Acyclovir Sodium 500 mg Recon Soln Sig: Seven Hundred (700)
mg Intravenous Q8H (every 8 hours) for 4 days: Please continue
IV acyclovir q8hrs until [**2101-7-29**].
21. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO 5 times/day
for 12 days: Please give from [**7-30**] - [**8-10**] .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
Idiopathic Pulmonary Fibrosis Exacerbation
VZV encephalitis
.
Secondary Diagnosis:
Type II Diabetes
Trigeminal Neuralgia s/p gamma knife therapy
Hyperlipidemia
h/o Duodenal Ulcer
h/o Rheumatic fever
s/p Appendectomy
s/p Tonsillectomy
s/p Lumbar spinal fusion in [**10-1**]
Discharge Condition:
Good, afebrile, saturating well on 5 L of O2
Discharge Instructions:
You were seen at the [**Hospital1 69**] on
[**2101-7-17**] because you were found to have worsening shortness of
breath, a painful rash on your bottom, and weakness in your
legs. This was worrisome for an infection in your lungs or
worsening of your IPF and for reactivation of the virus that
causes chicken pox.
While you were here, we put in an intravenous line into your arm
so that we could give you fluids and medicines. We gave you an
antiviral medication called Acyclovir to treat the viral
infection and an antibiotic called Levofloxacin for your
potential pneumonia. We also did a number of lab tests to give
us a better idea of what was going on. We gave you your normal
home medications while you were here.
We found that you had reactivation of your varicella, or chicken
pox, infection (aka shingles) that was causing the rash on your
left buttock. This was also affecting your spinal cord, which
caused your leg weakness and fecal incontinence. We also found
that your O2 sats were low because of either an infection in
your lungs or worsening of your IPF or most likely both.
The medications we gave you improved your rash and leg weakness
and your O2 sats increased as well.
While you were here, we increased your dose of Prednisone. We
are now in the process of lowering the dose to your normal home
dose of 40mg PO Daily. We are also continuing you on the
acyclovir that we started in the hospital. Please continue to
take it as prescribed.
Please take prednisone according to this schedule:
[**7-26**] - [**7-31**]: take 60 mg in the AM, 60 mg in the PM
[**7-31**] - [**8-4**]: take 60 mg in the AM, 40 mg in the PM
[**8-5**] - [**8-9**]: take 40 mg in the AM, 40 mg in the PM
[**8-10**] - [**8-14**]: take 40 mg in the AM, 20 mg in the PM
[**8-15**] and onwards: take 40 mg one time daily
Please continue the acyclovir according to this schedule:
Until [**7-29**] - acyclovir 700 mg IV every 8 hours
[**7-29**] - [**8-10**] - acyclovir 800 mg PO 5 times a day
If you experience the following symptoms: increased shortness of
breath, fever/chills, new cough, chest pain, worsening leg
weakness, fecal or urinary incontinence, or any other worrisome
symptoms, please contact your PCP or go to the Emergency
Department.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB
Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2101-8-15**] 11:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2101-8-15**] 11:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. (Pulmonary)
Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2101-8-15**] 12:00
Please make an appointment to see your PCP [**Last Name (NamePattern4) **] [**2-28**] weeks.
ICD9 Codes: 486, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7083
} | Medical Text: Admission Date: [**2170-2-19**] Discharge Date: [**2170-2-21**]
Date of Birth: [**2103-9-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Atorvastatin
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain and shortness of breath
Major Surgical or Invasive Procedure:
Cardiac cath ([**2170-2-20**])
History of Present Illness:
In brief, this patient is a 66-year-old male with past medical
history of DMII, hypertension, hyperlipidema, significant CAD
s/p CABGx2 most recently in [**2165**] who presented to [**Hospital 5279**]
Hospital with complaints of significant chest pressure and
dyspnea. The day of presentation he was extremely short of
breath and complained of [**6-15**] nonradiating chest pressure over
his left chest wall associated with nausea and dyspnea. In the
ED, he was noted to be in severe respiratory distress and was
found to have acute CHF as well as ST depression on his EKG and
required CPAP and an ICU course briefly with low dose dopamine
for support. He was diagnosed with NSTEMI given elevated cardiac
biomarkers (trop I 1.45). He also required a nitro and lasix gtt
initially. Cardiac cath revealed complex anatomy and three
vessel native CAD with subtotal occlusion SVG-Diag. He was
transferred to [**Hospital1 18**] for evaluation by cardiac surgery and
interventional cardiology. He underwent c. cath at [**Hospital1 18**] and is
s/p DES in the SVG to Diagonal.
On the floor, he denies any complaints or concerns.
14-point review of systems negative and reviewed with patient.
Past Medical History:
Past Medical History:
Diabetes Mellitus
Hypertension
Hypercholesterolemia
Carotid artery disease
Systolic heart failure
Anemia
Past Surgical History:
CABG [**2159**] and [**2165**]
Right Carotid endarterectomy
Tonsillectomy
Social History:
Race:caucasian
Lives with: alone
Occupation: works in dietary department at nursing home
Tobacco: none
ETOH: none
Family History:
coronary disease of both parents
Physical Exam:
VS: T 97.9 BP 106/54 P 82 RR 18 pOx 96 RA Weight 162 (dry
weight)
Gen: NAD, lying in bed
HEENT: Normocephalic, anicteric, OP benign, MMM
CV: RRR, no M/R/G; JVP above clavicle; 2+ radial, PT, DP pulses
bilateral. Femoral pulses 2+ bilat with no bruit. No hematoma
Pulm: CTAB anteriorly
Abd: Soft, non-tender, non-distended, +BS, no organomegaly or
masses appreciated
Ext: Warm and well perfused, no edema
Neuro: AAOx3
Psych: Pleasant, cooperative
Pertinent Results:
I. Labs
A. Admission
[**2170-2-19**] 01:06PM BLOOD WBC-6.6 RBC-3.82* Hgb-10.9* Hct-31.4*
MCV-82 MCH-28.6 MCHC-34.7 RDW-13.6 Plt Ct-369
[**2170-2-19**] 01:06PM BLOOD PT-14.1* PTT-35.6* INR(PT)-1.2*
[**2170-2-19**] 01:06PM BLOOD Glucose-158* UreaN-36* Creat-1.3* Na-136
K-4.4 Cl-104 HCO3-20* AnGap-16
[**2170-2-19**] 01:06PM BLOOD ALT-20 AST-21 CK(CPK)-68 AlkPhos-82
Amylase-47 TotBili-0.7
[**2170-2-20**] 04:05PM BLOOD CK-MB-3 cTropnT-0.76*
[**2170-2-19**] 01:06PM BLOOD CK-MB-4 cTropnT-1.06*
[**2170-2-19**] 01:06PM BLOOD Albumin-3.9 Calcium-8.4 Phos-2.8 Mg-1.6
[**2170-2-19**] 01:06PM BLOOD %HbA1c-6.9* eAG-151*
B. Discharge
[**2170-2-21**] 06:45AM BLOOD WBC-4.9 RBC-3.86* Hgb-10.9* Hct-32.9*
MCV-85 MCH-28.3 MCHC-33.2 RDW-13.4 Plt Ct-325
[**2170-2-21**] 06:45AM BLOOD PT-14.3* PTT-25.7 INR(PT)-1.2*
[**2170-2-21**] 06:45AM BLOOD Glucose-138* UreaN-18 Creat-1.0 Na-138
K-4.2 Cl-103 HCO3-25 AnGap-14
[**2170-2-21**] 06:45AM BLOOD TotProt-6.2* Albumin-3.8 Globuln-2.4
Calcium-8.9 Phos-2.3* Mg-1.9
II. Cardiology
A. EKG
Cardiology Report ECG Study Date of [**2170-2-19**] 1:26:48 PM
Sinus rhythm. Intraventricular conduction delay. ST-T wave
abnormalities. No previous tracing available for comparison.
Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 142 114 402/445 69 35 -168
B. Cardiac cath - final report not available at time of
discharge
III. Radiology
A. Carotid US ([**2170-2-19**])
Final Report
REASON: Preop for CABG.
FINDINGS: Duplex evaluation was performed of both carotid
arteries. The left carotid artery is occluded. On the right,
velocities are 103, 94, 22 in the ICA, CCA, ECA respectively.
This is consistent with no stenosis.
On the left, velocities are 63, 93 in the CCA, ECA respectively.
There is
antegrade flow in both vertebral arteries.
IMPRESSION: On the right, there is no evidence of stenosis. In
the internal carotid artery on the left appears to be a chronic
ICA occlusion. Clinical correlation is warranted.
Brief Hospital Course:
66-year-old male with past medical history of DMII,
hypertension, hyperlipidema, significant CAD s/p CABGx2 most
recently in [**2165**] who presented to [**Hospital 5279**] Hospital with NSTEMI,
underwent c. cath showing severe three vessel disease and
complex coronary anatomy and transferred to [**Hospital1 18**] for further
evaluation. Cardiac surgery deferred CABG with intervetional
cardiology performing c. cath, s/p DES in the SVG to Diagonal.
# NSTEMI with severe native CAD s/p PTCA
Patient presented to [**Hospital 5279**] Hospital with 1-week history of
progressive dyspnea and [**6-15**] non-radiating chest left chest
pressure with nausea. On presentation, he was found to be in
pulmonary edema with hospital course complicated by hypotension
and NIPPV. See [**Hospital 5279**] Hospital records for hospital course and
cardiac cath report. His Troponin I peaked at 1.45 with no
CK-MB. EKG showed ST depression (unknown leads) with the
impression of NSTEMI. He underwent c. cath showing complex
anatomy and three vessel native CAD with subtotal occlusion of
SVG-Diag. He was transferred to [**Hospital1 18**] for further evaluation by
cardiac surgery and interventional cardiology in setting of
complex coronary anatomy. It was deemed for him to undergo
cardiac cath with subsequent DES to SVG-Diag with no apparent
complications. An ECHO was performed at [**Hospital 5279**] Hospital with
report requested but not sent at time of discharge.
He was started on plavix for at least 1 year and should remain
on ASA indefinitely. Given his history of myalgias with
atorvastatin therapy but the desire for stronger lipid lowering
therapy after his recent event, pravastatin 80 mg was changed to
crestor 20 mg. He should be monitored carefully.
Physical therapy evaluated the patient before discharge, and
given the intense nature of his work in the dietary department
at a nursing home, it was recommended for him to remain out of
work for 4-6 weeks. He should be cleared for return to work by
his cardiologist.
.
# Hypertension
He was continued on amlodipine, lisinopril.
.
# Chronic systolic heart failure (last EF 35 %)
The patient had pulmonary edema and fluid overload at [**Hospital 5279**]
Hospital and was diuresed with a lasix infusion. On arrival to
[**Hospital1 18**], he appeared euvolemic and at his dry weight of 162 lbs.
He did not complain of dyspnea on exertion. He had no oxygen
requirement. He was continued on beta blocker and ACE inhibitor
at discharge.
.
# Diabetes (last A1c 6.9)
He was continued on glucotrol 10 mg PO qAM and 5 mg qPM,
metformin
.
# Hyperlipidemia
He was discharged on crestor 20 mg PO qD.
.
Discharge summary faxed to:
- Jennnifer Wise ([**Telephone/Fax (1) 89852**])
- Dr. [**Last Name (STitle) 89853**] ([**Telephone/Fax (1) 76739**])
Medications on Admission:
ASA 325 mg PO qD
Ferrous sulfate 325 mg PO qD
Glucotrol 10 mg PO qAM and 5 mg qPM
pravastatin 40 mg PO qD
amlodipine 5 mg PO qD
naproxen 500 mg PO qD
Lisinopril 40 mg PO qD
metoprolol succinate 25 mg PO qD
metformin 850 mg PO qD
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. ferrous sulfate 325 mg (65 mg Iron) Capsule, Extended Release
Sig: One (1) Capsule, Extended Release PO once a day.
3. glipizide 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
4. glipizide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. naproxen 500 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
9. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
10. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: coronary artery disease
Secondary diagnosis: hypertension, hyperlipidemia, chronic
systolic heart failure (last EF 35 %)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital1 18**] for a cardiac cath. You had a
stent placed in one of your vessels.
Medication changes:
Discontinue pravastatin
START crestor for cholesterol, which is more potent. It is
important to follow-up closely with your doctor given previous
muscle aches with atorvastatin.
START Plavix. Take this medication daily. Do NOT STOP unless you
talk to your cardiologist.
Please call your doctor if you gain more than 3 lbs.
Followup Instructions:
Name: WISE,[**Doctor Last Name **] R.
Location: [**Hospital 89854**] MEDICAL GROUP
Address: [**Apartment Address(1) 89855**], [**Location (un) **],[**Numeric Identifier 89856**]
Phone: [**Telephone/Fax (1) 74697**]
Appt: Wednesday, [**2170-2-28**]:45am
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] CARDIOLOGY CONSULTANTS
Address: 1 ELLITOT WAY [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 85099**]
Phone: [**Telephone/Fax (1) 66607**]
Appt: Wednesday, [**3-7**] at 10:20am
ICD9 Codes: 4019, 2720, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7084
} | Medical Text: Admission Date: [**2183-3-17**] Discharge Date: [**2183-3-20**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Attending Info 8238**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo F h/o alzheimers dementia, COPD, bipolar disorder who
presents from her [**Female First Name (un) **]-psych facility with fever, tachycardia,
tachypneic to the mid-20s. For the past few days has been
somnolent at her facility, and was recently diagnosed with a
UTI, and started nitrofurantoin. In speaking with her case
manager, she has been feeling unwell for several days with
stomach distension, increased leg swelling and redness of which
lasix was started recently. Due to fever, tachycardia and cough
this morning, the patient was transferred to [**Hospital1 18**] for further
management.
.
In the ED, initial VS were: 101.2 96 117/60 18 98% 2L nc. c/o
sob. BLE new swelling/erythematous and excoriations c/f
cellulitis. Labs notable for Cr 1.7 (baseline around 1.0),
lactate of 5.1 which improved to 2.0 with 3 liters NS. CT scan
of abdomen showed no acute process. CXR: can't rule out PNA.
Received 1 gram of tylenol, Vancomycin and zosyn. Access: 2
PIVs. VS prior to transfer 101.8 122 117/68 20 96% 2L
.
On arrival to the MICU, the patient states she is comfortable
without pain or shortness of breath. She states she is in a
hospital, but is not clear why she is here. She states she came
from home.
.
Review of systems: unable to obtain accurate review
Past Medical History:
Per the records, and health care proxy:
Breast cancer, s/p mastectomy
Alzheimer's dementia
Bipolar Disorder
Orthostatic Hypotension and Syncope
COPD
Osteoporosis
Hyperlipidemia
Bifascicular block
Borderline Diabetes
Social History:
Previously sociology professor [**First Name (Titles) **] [**Last Name (Titles) 3278**], retired. Never married.
No current tobacco. Occasional alcohol. Resident ot [**Last Name (un) 35689**]
House in JP, due to recent aggressive behaviour, she was
sectioned and staying at [**Hospital 1191**] Hospital
Family History:
NC
Physical Exam:
Vitals: T:99.8 BP: P:107 R: 23 O2: 97%
General: Alert, oriented to person, no acute distress
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
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: moving all extremeties
DISCHARGE EXAM:
Skin- bilateral medial shins/calves have an erythematous rash
with multiple vesicles/papules/pustules overlying. Some
underlying edema. No sloughing of skin, no tenderness, no
drainage. No rash on other parts of body. No mucosal rash.
Pertinent Results:
Admission Labs:
[**2183-3-17**] 12:50PM BLOOD WBC-8.7# RBC-3.15* Hgb-10.4* Hct-31.8*
MCV-101* MCH-33.1* MCHC-32.8 RDW-12.8 Plt Ct-194
[**2183-3-17**] 12:50PM BLOOD Neuts-78.9* Lymphs-14.3* Monos-2.8
Eos-3.9 Baso-0.2
[**2183-3-17**] 12:50PM BLOOD Glucose-114* UreaN-25* Creat-1.7* Na-137
K-4.8 Cl-101 HCO3-24 AnGap-17
[**2183-3-17**] 12:50PM BLOOD ALT-15 AST-19 LD(LDH)-226 AlkPhos-57
TotBili-0.3
[**2183-3-18**] 12:42AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1
[**2183-3-18**] 12:42AM BLOOD VitB12-498 Folate-GREATER TH
[**2183-3-17**] 11:55PM BLOOD Type-ART pO2-89 pCO2-46* pH-7.41
calTCO2-30 Base XS-3 Intubat-NOT INTUBA
[**2183-3-17**] 01:47PM BLOOD Lactate-5.1*
[**2183-3-17**] 11:55PM BLOOD Lactate-0.8
[**2183-3-17**] 11:55PM BLOOD freeCa-1.14
[**2183-3-20**] 08:00AM BLOOD WBC-4.7 RBC-2.74* Hgb-9.1* Hct-27.7*
MCV-101* MCH-33.1* MCHC-32.7 RDW-12.5 Plt Ct-197
[**2183-3-19**] 10:45AM BLOOD Neuts-70.8* Lymphs-16.6* Monos-4.9
Eos-7.2* Baso-0.4
[**2183-3-20**] 08:00AM BLOOD Plt Ct-197
[**2183-3-20**] 08:00AM BLOOD Glucose-112* UreaN-21* Creat-1.3* Na-145
K-4.9 Cl-114* HCO3-22 AnGap-14
[**2183-3-20**] 08:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.3
Diagnostics:
CXR [**2183-3-17**]: IMPRESSION: Interstitial prominence which could
reflect edema or atypical infection. Correlate clinically
CXR [**2183-3-18**]: FINDINGS: As compared to the previous radiograph,
the patient has made a lesser inspiratory effort. As a
consequence, the lung volumes have decreased. Borderline size of
the cardiac silhouette. No overt pulmonary edema. No evidence of
pneumonia or pleural effusions. Retrocardiac atelectasis. No
pneumothorax.
CT abd/pelv [**2183-3-17**]: IMPRESSION:
1. No acute intra-abdominal or pelvic process.
2. Incompletely characterized 15 x 11 mm splenic hypodensity. In
the absence of a history of malignancy, incidental splenic
lesions are typically benign.
3. Pancreatic calcifications, some may be vascular, but raising
concern for chronic pancreatitis. No CT evidence of acute
pancreatitis.
Brief Hospital Course:
89 yo F h/o alzheimers dementia, COPD, Bipolar d/o presenting
with fever, tachycardia, and an elevated lactate.
.
Sepsis: With fever, tachycardia and elevated lactate and
possible PNA and cellulitis consistent with sepsis. Patient was
started on vancomycin and cefepime. She was switched to
bactrim/doxycycline PO. Her blood pressure was low on night of
admission and received a total of 8 liters of IVFs over
approximately 16 hours. Her blood pressure then normalized after
this intervention. Patient was called out of the MICU within 24
hours of admission. On arrival to the medicine floor, patient's
antibiotics were switched to augmentin/bactrim for cellulitis
and azithromycin for questionable atypical pneumonia. Knowing
that patient had recent urinary tract infection, urine culture
results were obtained form [**Doctor First Name 1191**] which showed sensitivity to
nitrofurantoin, which patient had been treated with prior to
admission. AVSS throughout stay on medicine floor.
Her rash was not classic for cellulitis given the
vesiculo-pustular appearance and symmetry; it appeared more like
a contact dermatitis, although without known exposure. We
unroofed a vesicle and sent for HSV/VZV DFA which is pending at
time of discharge. Also would consider medium potency topical
steroid cream.
Patient will be continued on augmentin/bactrim x 5 more days and
azithromycin x 3 more days.
.
Goals of Care: ICU attending held discussion with HCP regarding
goals of care and it was decided that patient would not benefit
from escalation of care. This included NO central line or
pressors. Patient would likely benefit from DNH (do not
hospitalize) order.
.
[**Last Name (un) **]: Elevated at 1.7 from baseline near 1.0. After IVFs, patient
CR decreased to 1.5 and stabilized at 1.3. PO fluid intake was
encouraged throughout the hospital stay.
.
COPD: Currently not on any inhalers, however has been in the
past, ordered combivent nebs prn. Did not require any PRNs
while in house.
.
Dementia: Reportedly due to alzheimers and with recent
aggressive behavior. Continued donepezil 10 mg daily. Patient
did not require PRN medications and remained calm and oriented
throughout her stay on the medicine floor
.
Bipolar d/o: Recent medication adjustment at [**Hospital 1191**] Hospital.
Continued [**Hospital3 4107**] regimen of Seroquel 12.5 prn,
citalopram 20 mg daily, Divalproex and gabapentin as well.
Patient did not require any PRN medications for agitation while
on the medicine floor
.
Anemia: Stable. No transfusions in the MICU. Remained stable on
emdicine floor
.
Splenic hypodensity: CT scan showed splenic hypondensity, given
history of malignancy, could be followed up with further
evaluation although may not be compatible w/ goals of care.
.
Code: DNR/DNI
.
Transitional issues - HSV/VZV DFA pending at time of discharge;
topical steroid cream not yet started
Medications on Admission:
Medications: Per [**Doctor First Name 1191**] [**Month (only) 16**]
Citalopram 20 mg Once Daily
docusate sodium 100 mg at bedtime
donepezil 10 mg qhs
MVI
Omeprazole 20 mg daily
Simvastatin 20 mg daily
Gabapentin 100 mg TID
Divalproex 125 mg [**Hospital1 **] (0900 and 1400)
Divalproex 250 mg qhs
Nitrofurantoin 100 mg [**Hospital1 **]
Saliva Substitute 2 mL QID after meals and HS
Fluocinolone acetonide [**Hospital1 **]
Acetaminophen 650 daily
Maalox q4H prn
MgOH daily prn
Quetiapine 12.5 mg q6h PRN and 25 mg q6H prn
Albuterol prn
bisacodyl 10 mg PRN
Lasix 60 mg daily
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. divalproex 125 mg Capsule, Sprinkle Sig: One (1) Capsule,
Sprinkle PO BID (2 times a day).
7. divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO HS (at bedtime).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
10. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
12. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] of [**Location (un) 55**]
Discharge Diagnosis:
Cellulitis
pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 1655**],
You were admitted to the hospital with fevers and confusion
concerning for a serious infection. You were admitted to the
intensive care unit and stabilized and then observed on the
floor. Your fever was likely caused by a skin infection on your
legs. You were started on two antibiotics for this, augmentin
and bactrim, and will need to take both two times per day for an
additional 5 days. A chest x-ray was concerning for a
developing pneumonia and you were started on a separate
antibiotic for this. You will need to take this antibiotic,
azithromycin, one time daily for another 3 days total.
We have made the following changes to your medications:
# ADD: augmentin [**Hospital1 **] for 5 days
# ADD: bactrim [**Hospital1 **] for 5 days
# ADD: azithromyicin daily for 3 days
Please continue all of your other medications as prescribed
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 1 week
Completed by:[**2183-3-20**]
ICD9 Codes: 0389, 486, 5849, 5859, 2859, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7085
} | Medical Text: Admission Date: [**2155-8-14**] Discharge Date: [**2155-8-17**]
Date of Birth: [**2112-9-15**] Sex: M
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: Patient is a 42-year-old white
male with past medical history significant for alcoholic
cirrhosis, chronic pancreatitis resulting in pancreatic
insufficiency, and insulin dependent-diabetes mellitus,
chronic renal failure with baseline creatinine of 4.0,
chronic thrombocytopenia, who has a recent admission to the
[**Hospital1 69**], who presented on
[**2155-8-13**] with acute onset fatigue, worsening dyspnea on
exertion, increased lower extremity edema, and decreased
urine output x3 days.
The patient was recently admitted at [**Hospital1 190**] from the period of [**2155-7-12**] to [**2155-7-16**] for
refractory lower extremity edema x2 weeks. This admission
was also associated with a 25 pound weight gain with
increased abdominal girth and exertional shortness of breath,
and fatigue. He was discharged home with decreased edema on
Lasix dose of 80 mg po bid, hydrochlorothiazide qod, along
with levofloxacin for urinary tract infection. He now
returns reporting return of the fatigue, exertional dyspnea
on exertion, lower extremity edema for the past few days, and
decreased urine output.
On presentation, he denied any chest pain, fevers, abdominal
pain, cramps, or cough. He reports baseline diarrhea which
is not changed. He denied bright red blood per rectum,
melena, nausea, vomiting, hematemesis. His last alcohol
intake was 24 hours prior to this admission.
Laboratories on admission were significant for a
BUN-creatinine ratio of 58/8.6, a troponin-T of -.42 with a
CK of 64, and a hematocrit on admission of 28 that dropped to
23.6 12 hours later. Electrocardiogram was unchanged.
Rectal examination showed heme-negative stool. Urine
electrolytes were not consistent with a prerenal etiology of
acute or on chronic renal failure, but of note, he had been
getting Lasix at home. On examination, he was euvolemic.
PAST MEDICAL HISTORY:
1. Chronic alcoholic pancreatitis complicated by pseudocyst
in 10/99, resulted in pancreatic insufficiency and insulin
dependent-diabetes mellitus.
2. Insulin dependent-diabetes mellitus with nephropathy and
neuropathy: Insulin dependent x3 years. He had episodes of
diabetic ketoacidosis with an Intensive Care Unit admission
in 08/[**2154**].
3. Chronic renal failure with baseline creatinine of 4.0.
4. History of alcohol abuse, resulting in cirrhosis.
5. Hypertension.
6. Obstructive-sleep apnea on BiPAP at home.
7. History of bilateral nephrolithiasis, complicated by
development of pyelonephritis and urosepsis.
8. Anemia secondary to renal failure.
9. History of thrombocytopenia secondary to Haldol.
10. History of multiple perirectal abscesses, status post
multiple incision and drainage procedures.
11. History of ARDS in 10/99 with tracheostomy for six weeks;
developed ARDS during pancreatitis episode. Complicated by
Pseudomonas pneumonia, pancreatic necrosis, Clostridium
difficile colitis, line sepsis, left lower extremity DVT,
Haldol induced thrombocytopenia.
12. History of left lower extremity DVT.
13. History of Clostridium difficile colitis.
14. History of right vocal cord paralysis.
15. Gastritis.
16. History of diabetic foot ulcers.
MEDICATIONS PRIOR TO ADMISSION:
1. Insulin-sliding scale.
2. Calcium carbonate 500 mg po tid with meals.
3. Nephrocaps one cap po q day.
4. Protonix.
5. Epogen 5,000 units subQ 2x/week administered on Tuesdays
and Fridays.
6. Folic acid 1 mg po q day.
7. Pancrease three caps po tid with meals.
8. Sodium bicarbonate 1300 mg po tid.
9. NPH 10 units q am.
10. Hydrochlorothiazide 12.5 mg qod.
11. Lasix 80 mg po bid.
ALLERGIES: The patient reports allergies to Haldol resulting
in thrombocytopenia.
SOCIAL HISTORY: Former real estate [**Doctor Last Name 360**], current
unemployed. Lives alone. Smokes 1-1.5 packs per day x20
years. Currently admits to five drinks of alcohol per week.
Denies any IV drug use or any recreational drug use.
Divorced with no children.
PHYSICAL EXAM UPON ADMISSION: Vital signs: Temperature of
96.3, blood pressure 116/70, heart rate 96, respiratory rate
12, oxygen saturation 100% on 2 liters face mask. General
appearance: Supine, well-developed white male in no apparent
distress, disheveled, peeling skin. HEENT: Normocephalic,
atraumatic. Skin on face scaly, pupils are equal, round, and
reactive to light and accommodation. Extraocular eye
movements intact. Eyes and sclerae icteric. Oropharynx
clear. Pulmonary examination: Bibasilar rales, occasional
expiratory wheeze. Coronary examination: Regular, rate, and
rhythm, no murmur. Abdominal examination: Positive bowel
sounds, nontender, distended, positive fluid wave, liver and
spleen not palpable. Extremities: [**1-23**]+ edema to knee
bilaterally. Neurologic: Cranial nerves II through XII
intact, moves all four extremities, no asterixis noted.
PERTINENT LABORATORIES AND OTHER STUDIES: Complete blood
cell count showed white blood cell count 12.1 with
differential of 71.6% neutrophils, 16.5% lymphocytes, 5.5%
monocytes, 1.2% eosinophils, 0.6% basophils. Hematocrit is
28.1, platelets 89. Serum chemistries showed sodium 138,
potassium 3.5, chloride 101, bicarbonate 13, BUN 56,
creatinine 8.6 (creatinine was 3.9 on [**7-23**]), glucose 304.
ALT 23, AST 30, amylase 25, ALT 254, LDH 218, total bilirubin
0.9, albumin 1.8, total protein 6.4, lipase 5. Coagulation
profile showed a PT of 14.5, PTT 45.1, INR 1.4. Alcohol
level was 35.
Chest x-ray showed small bilateral pleural effusions. Left
lower lobe atelectasis.
Urinalysis showed specific gravity of 1.010, large blood,
negative nitrate. Positive trace protein. Moderate
leukocytes, [**12-11**] red blood cells, and greater than 50 white
blood cells, 0 epithelial cells, and no bacteria.
Renal ultrasound showed no evidence of hydronephrosis. A
large simple right kidney cyst was noted. It is not
significantly changed from prior studies.
SUMMARY OF HOSPITAL COURSE:
1. Acute renal failure: Patient is a 42-year-old male with a
history of alcoholic cirrhosis, chronic renal failure,
diabetes with nephropathy, status post recent admission for
worsening renal failure, and urinary tract infection, now
presents with a [**3-25**] day history of exertional dyspnea,
fatigue, poor urine output consistent with fluid overload
secondary to acute on chronic renal failure.
The etiology of his acute on chronic renal failure is
unclear. It is probably not prerenal given that he appeared
euvolemic on exam, and now that although his diuretic doses
had recently been increased, he was not losing any fluid
wave. The plan was to initially hold off on any IV fluids
and diuretics. Initially, it was felt that the patient did
not have any indication for acute hemodialysis. Indications
for hemodialysis were to include intractable dyspnea,
uncontrolled uremic symptoms like nausea or encephalopathy,
or hyperkalemia.
Renal consultation service team was [**Name (NI) 653**], and they
agreed with the plan to not aggressively diurese the patient
initially unless his respiratory status declined. However,
his respiratory status remained stable, and on hospital day
#2, he reported an inability to make urine. That evening the
patient was given trial of diuretics. Specifically, he was
given Lasix 100 mg IV, and also he was given metolazone 10 mg
po. This also failed to result in any urine production.
The patient's BUN and creatinine continued to increase. He
continued to complain of shortness of breath, but not to the
point that it limited activity. He continued to remain alert
and oriented, and without any signs of uremic encephalopathy.
He was to undergo Permacath placement on [**2155-8-18**], and was to
receive hemodialysis also on that day. The metabolic
abnormalities associated with his uremia included calcium
carbonate 500 mg po tid, Nephrocaps one cap po q day, Epogen
5,000 units subQ 2x/week on Tuesdays and Fridays, Amphojel,
and calcitriol.
2. Dyspnea: The patient was only slightly dyspneic likely to
compensate for the underlying metabolic acidosis secondary to
his uremia. Initially, the plan was to diurese the patient
or dialyze him if he became severely dyspneic and had chest
x-ray evidence of fulminant failure. However, the patient's
respiratory status remained stable and his level of dyspnea
was felt not to warrant acute intervention.
Instead he was managed symptomatically with albuterol
inhalers and oxygen therapy. Initially, it felt that some
component of his dyspnea might be due to his abdominal
ascites collection. Therefore on hospital day #2, he
underwent a paracentesis with drainage of 2 liters of acidic
fluid. This resulted in some resolution of his dyspnea.
Finally, the patient was to continue his BiPAP machine that
he brought from home for treatment of his obstructive-sleep
apnea.
3. Elevated troponin: Upon admission, the patient had an
elevated troponin value. It was felt that very possibly he
had an acute coronary event a few days prior to admission
leading to renal hypoperfusion, which might explain his acute
renal decompensation. However, it felt that based on his
comorbidities, that there was no role for Heparin or emergent
catheterization at his initial presentation. An aspirin was
held given patient's history of thrombocytopenia and uremia.
He was not given a beta blocker given that his clinical
status was tenuous and there was a question of unstable
hematocrit values.
Cardiac echocardiogram was obtained, which demonstrated a
hyperdynamic ejection fraction greater than 75% and mild left
ventricular hypertrophy.
4. Diabetes: Initially patient came in on NPH 10 units q am.
However, it is felt that initially his fingerstick blood
glucose values were running low. Therefore, his NPH was
changed to 5 units q am and he was covered additionally with
regular insulin-sliding scale.
5. Cirrhosis: Upon admission, the patient had large volume
ascites. He had a diagnostic tap on his previous admission
in [**2155-6-22**] with no evidence of spontaneous bacterial
peritonitis. He underwent a therapeutic paracentesis on the
afternoon of [**2155-8-15**] with removal of 2 liters of acidic
fluid. At the time of this dictation, culture results on
that fluid were still pending.
6. Anemia: On the day of admission, patient had a drop in
hematocrit from 28 to 23.6 in 12 hours. He was therefore
transfused 1 unit packed red blood cells. His stool was
checked for occult blood and was heme negative. He was given
his regular outpatient dose of Epogen 5,000 units subQ on
[**2155-8-15**]. He was additionally to receive Epogen during his
dialysis sessions.
7. Dermatological: Patient had a two week history of
erythematous, excoriated rash on his legs, back, face, and
arms. Throughout the course of his hospital stay, the rash
became more erythematous and excoriated. Therefore
Dermatology was consulted. Per their recommendations,
multiple topical ointments and moisturizing regimens were
added to the patient's previous medication list. In
addition, wound consult was obtained secondary to patient's
history of diabetic foot ulcers.
After initiation of this dermatological regimen, the patient
experienced mild improvement in his skin rash and
excoriation.
8. History of alcohol abuse: Patient was placed on Ativan
and CIWA scale monitoring for alcohol withdrawal symptoms.
The remainder of the hospital course, discharge status,
condition, medications, and followup plans will be dictated
as a separate addendum to this report.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2155-8-17**] 17:57
T: [**2155-8-28**] 08:27
JOB#: [**Job Number 9133**]
cc:[**Name8 (MD) 9134**]
ICD9 Codes: 5849, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7086
} | Medical Text: Admission Date: [**2183-3-24**] Discharge Date: [**2183-3-28**]
Date of Birth: [**2124-11-17**] Sex: M
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
Pneumonia, sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 55406**] is a 58M with asplenia, anxiety/depression, s/p
[**Country **] dissection and L hemiparesis, who presents with 2-3 days
worsening productive cough, fever, and fatiuge. The patient was
in his usual state of health until the weekend when he noted
chest congestion, increasing productive cough, SOB and fatigue.
He denies any [**Last Name (LF) **], [**First Name3 (LF) **], sinus congestion, overt CP, n/v/d, rash,
or dysuria. He was so fatigued he tripped on his cat and fell,
without LOC. On sunday, he spiked a fever to 102. He denies sick
contacts or recent travel. He received his flu shot this year.
.
In the ED, VS T 103, HR 70, BP 108/52, RR 18, 95%NRB, 80s on RA.
The patient subsequently became tachy to 120s with BP 80s-90s.
Given 6L NS without improvement. RIJ was placed and started on
Levophed 0.06mcg/kg/min. ? PNA so given Levaquin but had
reaction. Changed to CTX/Azithro, and Vanco.
Past Medical History:
1. Asplenia secondary to trauma incurred during Vietman, [**2144**],
pneumococcal vaccine given in [**2176**]. Does not remember if he
received H flu or meningococcus.
2. PTSD
3. ADHD
4. Depression/Anxiety
5. h/o Alcohol abuse
6. Migraine
7. Status post C5-C6 laminectomy and fusion several years ago by
[**Doctor Last Name 1327**]
8. Diverticulitis, now status post partial colectomy
9. Multiple sharpnel injuries while in Vietmam, [**2142**] - NO MRI!!
10. Scrtoal Hematoma s/p R radical orchiectomy [**3-7**] with phantom
pain syndrome
11. Traumatic [**Country **] dissection with L hemiparesis [**11/2180**]
Social History:
Married. 2 biologic and 1 adopted child. Works as a real estate
broker. Quit smoking a few years ago, former 1ppd. History of
alcohol abuse but no EtOH for 4 yrs. No drug use.
Family History:
adopted
Physical Exam:
VS: T 98.8, 132/70, HR 104, RR 22, 97% NRB
Gen: Awake and alert but fatigued, talking in full sent over
mask
HEENT: EOMI, PERRL, anicteric sclera, MMM
Neck: supple, RIJ line intact, no LAD
Heart: Tachy ,regular, nl S1 S2 no m/r/g
Lungs: Coarse crackles heard bilat at bases
Abd: soft NT/ND +BS no rebound or guarding
Ext: warm well perfused,
Skin: R arm with scattered wheal, no bruising or ecchymoses
Neuro: CN II-XII intact, [**5-5**] strengh on R, [**3-5**] in L upper ext,
[**1-4**] in L lower ext, decreased sensation on L, preserved on R
Pertinent Results:
[**2183-3-24**] 09:50AM BLOOD WBC-7.9 RBC-4.68 Hgb-13.6* Hct-40.5
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.2 Plt Ct-366
[**2183-3-27**] 05:50AM BLOOD WBC-16.0* RBC-4.39* Hgb-12.8* Hct-37.6*
MCV-86 MCH-29.2 MCHC-34.2 RDW-13.1 Plt Ct-426
[**2183-3-28**] 05:40AM BLOOD WBC-9.0 RBC-4.61 Hgb-13.4* Hct-39.6*
MCV-86 MCH-29.1 MCHC-33.9 RDW-13.4 Plt Ct-535*
[**2183-3-24**] 09:50AM BLOOD Glucose-159* UreaN-39* Creat-2.6*# Na-138
K-4.8 Cl-101 HCO3-23 AnGap-19
[**2183-3-28**] 05:40AM BLOOD Glucose-104 UreaN-9 Creat-0.8 Na-141
K-4.0 Cl-107 HCO3-23 AnGap-15
[**2183-3-24**] 03:42PM BLOOD Type-ART pO2-181* pCO2-47* pH-7.28*
calTCO2-23 Base XS--4
[**2183-3-24**] 08:35PM BLOOD Type-ART pO2-52* pCO2-44 pH-7.32*
calTCO2-24 Base XS--3 Intubat-NOT INTUBA
CXR ([**3-27**]): FINDINGS: AP and lateral chest views were obtained
with patient in sitting upright position. The heart size is
normal, and no pulmonary vascular congestion is present. Again
demonstrated is a parenchymal density in the left lower lobe
posterior segment, similar in appearance as described on the
next preceding AP single chest view of [**3-26**]. Additional new
findings consist of some small fluffy poorly identified
parenchymal abnormalities suspected in the lateral portion of
the right upper lobe as well as in the mid left lung field. As
the technical differences of the two studies to be appreciated,
the latter findings are somewhat insecure. Considering, however,
the patient's sepsis status, a followup chest examination with
short interval is recommended.
IMPRESSION: Persistent left lower lobe pneumonic infiltrate,
suspicion for new small disseminated pulmonary parenchymal
densities. Follow up recommended.
Chest CT ([**3-27**]): IMPRESSION:
1. Ground-glass opacities as well as centrilobular nodules in
the lower lobes, these findings are all consistent with
multifocal atypical infection.
2. Small bilateral pleural effusions.
3. Mediastinal lymphadenopathy as described above may be
reactive.
Followup imaging after treatment is recommended to ensure
resolution of these findings.
Brief Hospital Course:
Sepsis. : On admission, patients symptoms consistent with
sepsis, with hypotension, fever, and tachycardia. His pressures
were supported with levophed, and patient was admitted to the
MICU. The etiology of the patient's infection was attributed to
likely pneumonia, given hypoxia, cough, and concerning chest XR.
He was initially started on vanc/levo, but due to drug induced
hives reaction, patient was switched to vanc/CTX/azithromycin.
Sputum culture grew out MSSA, and patient was switched to
nafcillin then diclocicilian on discharge. Patients chest XR
showed developing disseminated pulmonary parencymal densities.
A chest CT was obtained, which showed ground glass opacitieis in
RUL and LML c/w multifocal atypical infection. Given the
patients complaints of shortness of breath and URI type symptoms
in the 2-3 weeks prior to presentation, i is felt that the
patient had an atypical pneumonia then developed a secondary
superinfection with a staph pneumonia. The patient was
afebrile, had a resolving WBC count, and normal vital signs
prior to discharge. He was sent home on a twenty-one day course
of diclox as well as azythromycin to complete a 7 day course for
atypical pneumona. The patient will follow up with his PCP [**Last Name (NamePattern4) **]
[**1-1**] weeks. Follow up chest XR should be optained to evaluate
for resultuion of disseminated pumonary parencymal densities'
resolution.
.
ARF: The patient with a baseline Cr of 1, which was elevated to
2.6 on admission. The patient's renal function resolved after
IVF resuscitation.
.
Asplenia: Underwent splenectomy in [**2144**] due to injury in
[**Country **]. Has not had severe infection in the past. Our records
indicate recent pneumo vax, flu shot, but no evidence of H. flu
or meningoccal vaccine. On follow up with is his PCP, [**Name10 (NameIs) **]
patient should receivie these vaccinations for encapsulated
organisms. Additionally, we would recommend consideration of
providing patient with prophylatic antibiotic to take of
immediate health care in not accessible.
.
s/p CVA: Occurred due to traumatic [**Country **] dissection s/p tPA. Had
subsequent anuerysm thought healing related change. Has L
hemiparesis as result. Not on anticoagulation anymore, hypercoag
work up neg
- Monitor clinically
.
Depresion/Anxiety: Continued outpatient Buproprion,
Nortriptyline.
.
Pain syndrome: Diagnosed with a phantom pain syndrome in the
setting of his orchiectomy. Has been seen by pain. Continued
patients neuronti, oxycodone, nortiptyline, and MS contin.
.
HTN: Patient admitted with hypotension, and anti-hypertensives
were held. Upon resolution, his outpatient BP meds were
restarted to good effect.
Medications on Admission:
Amlodipine 2.5 mg Daily
Bupropion 200 mg qAM, 100mg qPM
Disulfiram 250 mg Daily
Gabapentin 600 mg qAM, 600mg qPM, 1200mg qHS
Ibuprofen 800 mg TID:PRN
Lisinopril 40 mg Daily
Methylphenidate 20 mg [**Hospital1 **]
Morphine [MS Contin] 30 mg [**Hospital1 **]
Nortriptyline 25-50 mg qHS:PRN
Oxycodone 5-10 mg q4-6 PRN
Aspirin 325 mg Daily
Discharge Medications:
1. Nortriptyline 25 mg Capsule Sig: [**1-1**] Capsules PO HS (at
bedtime) as needed.
2. Disulfiram 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
4. Methylphenidate 20 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
5. Bupropion 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
6. Bupropion 100 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
10. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 17 days.
[**Month/Day (2) **]:*68 Capsule(s)* Refills:*0*
14. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days: start morning of [**3-29**].
[**Date Range **]:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Dx:
Sepsis
Staphalococcous Pneumonia
Atypical Pneumonia
Secondary Dx:
Acute Renal Failure
Hyptertension
Asplenia
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after admission
for sepsis. The etilogy of your infection is believed to be due
to a bacterial pneumonia. You were started on antibiotics, and
should ocmplete the course as an outpatient.
If you develop fevers, worsening shortness of breath,
cough, or any other concerning symptoms, you should call your
PCP. [**Name10 (NameIs) **] should follow up with you PCP at the below listed time
for follow.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] to schedule a follow up
appointment in the next 1-2 weeks.
ICD9 Codes: 0389, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7087
} | Medical Text: Admission Date: [**2134-6-11**] Discharge Date: [**2134-6-25**]
Date of Birth: [**2134-6-11**] Sex: M
Service: NB
HISTORY: [**First Name8 (NamePattern2) **] [**Known lastname 73589**], boy 1 admitted to NICU due to
preterm infant. Gestational age is 35 1/7 weeks. Birth weight
was 1735 gm. This infant was a triplet.
MATERNAL HISTORY: A 40 year-old gravida 1, para 0, 3 now
with an EDC of [**2134-7-17**]. History of spontaneous
abortion at 6 weeks. This pregnancy was IVF conception.
PAST MEDICAL HISTORY:
1. Asthma, treated with Albuterol and Fluticasone.
2. Gastroesophageal reflux, treated with Protonix.
3. Anemia (evaluated in [**2134-4-23**]) consistent with iron
deficiency plus dilutional due to volume expansion in
pregnancy. A maternal methylmalonic level was done on
[**2134-5-21**]. The results were 203 (normal range is 87
to 318). Rationale for obtaining this test is not known;
but may be related to anemia complications.
4. Question history of thalassemia. No further history.
5. Past history of depression not requiring medications.
MEDICAL RECORD NOTE: On [**2130-8-23**], mother was positive
for hepatitis B and hepatitis A but negative for hepatitis D.
Maternal records indicate all tests always normal in past and
during this pregnancy. Pregnancy records during this
pregnancy document hepatitis B negative and no comment
regarding hepatitis A.
PRENATAL LABS: Blood type O+, ABA negative, hepatitis B
negative, Rubella immune, RPR nonreactive.
FAMILY HISTORY: Negative for thalassemia, negative for other
disorders, Italian background.
This pregnancy was notable for dichorionic tri amniotic
triplets. Triplets one and two shared same placenta (and they
were both smaller than triplet three); triplet three had its
own placenta (and was the largest of the three). Of note
triplet one noted to have a two vessel umbilical vessel. No
fetal anomalies noted on fetal ultrasound. Due to the concern
growth of triplet one and two with estimated fetal weight of
triplet one of 1835 gm, which is less than the 10th
percentile and triplet two was 1717 gm, less than 10th
percentile, C section was performed. No maternal ID risk
factors at the time of delivery. Triplet boy had Apgar's of 8
and 9. Infant admitted to NICU for a late preterm infant
care. Infant also had, as noted, two vessel cord in delivery
room. The baby was admitted initially for evaluation of cardiac
status and for thermoregulation concerns.
PHYSICAL EXAMINATION AT DISCHARGE: Current weight is [**2076**]
gm, still less than 10th percentile. Head circumference 31.0
cm, less than 10th percentile. Length 43 cm, still less than
10th percentile. Respiratory efforts in room air. Breath
sounds are clear. CV: Pink Tetralogy of Fallot. Loud
audible murmur. Grade [**1-26**]. Pulse is palpable 2+/4. Infant
pink and well perfused. Head, ears, eyes, nose, and throat:
Anterior fontanel is open and soft. Abdomen: Positive bowel
sounds, no hepatosplenomegaly. Neuro: Active on exam with
good tone. Infant with two vessel cord.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant has been in room air since birth
without distress and without apnea of prematurity.
2. Cardiac: The infant is diagnosed as pink Tetralogy of
Fallot with an echocardiogram on [**2134-6-16**]. Our
report summary states Tetralogy of Fallot, large anterior
malalignment ventriculoseptal defect with bidirectional
flow, moderate secundum atrial septal defect with
bidirectional flow, mild subvalvar and valvar pulmonary
stenosis, hypoplastic main pulmonary artery, good sized
branch pulmonary arteries, qualitatively good
biventricular function, distal left anterior descending
coronary artery not well seen, and a small muscular
ventricular septal defect not completely excluded. The
infant also had a chest x-ray on [**2134-6-13**] which was
consistent with a boot-shaped heart. EKG on [**2134-6-13**]
was nonspecific T wave changes. Infant has been
hemodynamically stable throughout infant. The infant will
be followed by [**Hospital1 **] Cardiology one week after
discharge. Heart rates have been 130 to 140, regular rate
and rhythm, with a blood pressure of 64/40 with a mean of
48. O2 saturation checks have been >95%. Parents were given
teaching on what to watch for for "Tet spells" and will contact
their cardiologist with any further questions.
3. Fluids, electrolytes and nutrition: Weight once again is
[**2076**] gm, less than 10th percentile. Head circumference is
31 cm, around 10th percentile. Length was 43 cm, which
was less than 10th percentile. The infant has been all
p.o. feeds since birth, full caloric feeds reached on day
of life 9 of EnfaCare 26 with corn oil. Renal ultrasound
was also performed due to two vessel cord on [**2134-6-17**] which was on day of life seven, which was read as
normal with small amount of intraperitoneal fluid which
was read as benign, and kidneys were normal.
4. GI: Maximum bilirubin on day of life five with 11.3/0.3,
which was treated with photo therapy.
Photo therapy was discontinued on day of life six with a
bilirubin of 7.7/0.3 and a rebound bilirubin of 6.9/0.3
performed on day of life 8. LFTs were also performed on day
of life eight, per a cardiology request: ALT of 7, AST of 25,
and an alk phos of 321.
1. Hematology: Infant has not received blood transfusion.
The patient's blood type was not done.
2. Infectious disease: Infant did not have risk factors for
infection. Infection did not receive infectious
evaluation.
3. Neurology: The infant does not meet criteria for head
ultrasound.
4. Audiology: Hearing screen was performed with auditory
brain stem responses. Result: Passed.
5. Ophthalmology: The infant does not meet criteria for eye
exam.
6. Thermoregulation - the baby required assistance with isolette
but has demonstrated good control over the past several days in a
crib.
7. Psychosocial: B.i.d. MC social worker involved with
family. The contact social worker can be reached at [**Telephone/Fax (1) 73590**].
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 73591**], MD. The phone
number is [**Telephone/Fax (1) 40499**]. Follow up is scheduled in 2 days.
DISCHARGE PLAN AND RECOMMENDATIONS: Feeds at discharge: Ad
lib feeds of EnfaCare 26 calorie with corn oil made with
EnfaCare 24, which is concentrated and 2 cal/ounce of corn
oil. Discharge weight 2035gm.
Cardiology follow up:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73592**], pager [**Telephone/Fax (1) 53567**] ID # 6155.
Appointment - Friday [**2134-7-2**] at 3PM in Cardiology Clinic
MEDICATIONS: Ferrous sulfate which comes in a bottle of 25
mg/1ml. The infant is receiving 0.2 ml daily which is 5 mg
daily which comes out to be 2.6 mg/kg/dose, iron and vitamin
D supplementation:
1. Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age.
2. All infants feed predominantly breast milk should receive
vitamin D supplementation at 200 international units (may
be provided as a multivitamin preparation) until 12
months corrected age.
CAR SEAT POSITION SCREEN: The infant had passed.
NEWBORN SCREEN: Newborn screening has been performed per
protocol. First one sent on day of life three and read as
blank. Repeat sent on day of life 14, [**2134-6-25**]. Results
are pending.
Immunizations received: Infant has received hepatitis B vaccine
on day of life nine, which was [**2134-6-20**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered for [**Month (only) **]
through [**Month (only) 958**] for infants who meet of the following four
criterias:
2. Infants born at less than 32 weeks.
3. Born between 32 and 35 weeks with two of the following:
Day care during RC season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school
age siblings.
4. Chronic lung disease.
5. Hemodynamically significant congenital heart disease.
6. Influenza immunization is recommended annually in the
fall for all infants once they reach six months of age.
For this age (and for the first 24 months of the child's
life) immunization against influenza is recommended for
household contacts and at home care givers.
7. This infant has not received rotavirus vaccine. The
American Academy of Pediatrics recommends an initial
vaccination of preterm infants at/or following discharge
from the hospitals that are clinically stable and at
least six weeks or fewer than twelve weeks of age. Follow-
up appointment scheduled and recommended. Follow-up
appointment with Dr. [**Last Name (STitle) **] 48 hours after discharge,
[**Hospital1 **] cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73593**] one week after
discharge, and as of note, parents have been informed
regarding Tetralogy of Fallot type cells by cardiologist.
DISCHARGE DIAGNOSIS:
1. Late preterm infant triplet #1.
2. Two vessel umbilical cord.
3. Tetralogy of Fallot.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern1) 73594**]
MEDQUIST36
D: [**2134-6-25**] 03:31:07
T: [**2134-6-25**] 09:15:08
Job#: [**Job Number 73595**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7088
} | Medical Text: Admission Date: [**2194-1-20**] Discharge Date: [**2194-1-28**]
Date of Birth: [**2109-7-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
aortic stenosis
Major Surgical or Invasive Procedure:
[**2194-1-21**]
TAVI-Aortic Valve Replacement via Right Thoracotomy ([**Company 1543**]
29 mm porcine CoreValve)
History of Present Illness:
Mr. [**Known lastname 36776**] is an 84 year old man with severe symptomatic aortic
stenosis a history of coronary bypass grafting in [**2185**] at the
[**Hospital1 18**] (LIMA to LAD, SVG-PDA,SVG-OMB),atrial fibrillation, severe
obstructive lung disease, peripheral vascular disease, carotid
artery disease, post-polio
syndrome, pulmonary hypertension.
He was seen approximately 6 months ago for aortic valve
treatment options. He was determined to be of prohibitively
extreme risk for surgical aortic valve replacement due to
frailty. He was undergoing evaluation for TAVI with incidental
findings of a pulmonary nodule. Workup included a repeat CT scan
of the chest which showed improvement of the nodule consistent
with resolving a infectious process.
He returned for Corevalve procedure via direct aortic approach.
He continues to be symptomatic with the ability ambulate bed to
bathroom before being limited by shortness of breath.
NYHA Class: III
Past Medical History:
aortic stenosis
s/p coronary artery bypass
noninsulin dependent diabetes mellitus
hyperlipidemia
s/p carotid stent
s/p carotid endarterectomies
h/o bladder cancer with neurogenic bladder
s/p pacemaker implant
chronic atrial fibrillation
post polio syndrome
Social History:
He lives with a caretaker and was a former venture capitalist.
He is a former smoker.
Family History:
- HTN, heart disease, stroke
- Mother died at 99 of old age
- Father died at 52 of an MI
- 1 sister with CHF
- 1 sister deceased from cancer (unknown type)
- Brother has ?stomach cancer
- 2 sisters are healthy
Physical Exam:
Pulse:77
B/P: 163/72
Resp: 20
O2 Sat: 976
Temp:98.4
Height: 68 inches Weight: 145lbs
General: frail, elderly male in wheelchair
Skin: color pale, turgor fair, warm and dry. Stage II
excoriation
left buttock.
HEENT: normocephalic, anicteric, oropharynx moist.
Neck:supple, trachea midline, bilat bruits vs referred murmer
Chest: mild kyphosis, well healed surgical scar, LS decreased
bases.
Heart: murmer throughout
Abdomen: soft, nontender, nondistended, hyperactive bowel
sounds,
last BM today. Foley insitu on arrival, clear yellow urine.
Extremities: 1+ lower extremity edema, prosthetic shoes, leg
lengths unequal, calves mild atrophy. Left foot deformity. No
femoral bruits.
Neuro: HOH, pleasant, vague at times, generalized weakness,
unsteady gait.
Pulses: weakly palpable peripheral pulses.
Pertinent Results:
[**2194-1-25**] 04:05AM BLOOD WBC-9.8 RBC-3.83* Hgb-10.4* Hct-32.1*
MCV-84 MCH-27.1 MCHC-32.4 RDW-15.4 Plt Ct-226
[**2194-1-26**] 05:15AM BLOOD PT-21.0* INR(PT)-2.0*
[**2194-1-26**] 05:15AM BLOOD UreaN-28* Creat-1.3* Na-142 K-4.2 Cl-102
[**2194-1-21**] 08:05PM BLOOD CK(CPK)-387*
[**2194-1-20**] 12:40PM BLOOD ALT-21 AST-20 CK(CPK)-75 AlkPhos-75
TotBili-0.3
[**2194-1-25**] 04:05AM BLOOD proBNP-4948*
[**2194-1-25**] 04:05AM BLOOD Mg-2.1
[**2194-1-20**] 12:40PM BLOOD %HbA1c-6.9* eAG-151*
TTE [**2194-1-25**]: The left atrium is elongated. 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%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. An aortic
CoreValve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet motion and
transvalvular gradients. Mild (1+) perivalvular aortic
regurgitation is seen. The mitral leaflets are mildly thickened.
Mild to moderate ([**1-13**]+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Well seated CoreValve aortic prosthesis with normal
gradient Mild perivalvular aortic regurgitation. Mild symmetric
left ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild-moderate mitral
regurgtiation. Pulmonary artery hypertension.
Compared with the prior study (images reviewed) of [**2194-1-23**],
the severity of aortic regurgitation has increased/more
apparent. The severity of mitral regurgitation, tricuspid
regurgitation, and estimated PA systolic pressure are now
reduced.
CLINICAL IMPLICATIONS:
Based on [**2189**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2194-1-25**] 13:52
[**2194-1-25**] 04:05AM BLOOD WBC-9.8 RBC-3.83* Hgb-10.4* Hct-32.1*
MCV-84 MCH-27.1 MCHC-32.4 RDW-15.4 Plt Ct-226
[**2194-1-27**] 06:20AM BLOOD PT-27.2* INR(PT)-2.6*
[**2194-1-26**] 05:15AM BLOOD PT-21.0* INR(PT)-2.0*
[**2194-1-25**] 04:05AM BLOOD PT-18.3* INR(PT)-1.7*
[**2194-1-24**] 05:47AM BLOOD PT-15.6* INR(PT)-1.5*
[**2194-1-23**] 04:01AM BLOOD PT-13.4* INR(PT)-1.2*
[**2194-1-28**] 04:55AM BLOOD PT-25.7* INR(PT)-2.5*
Brief Hospital Course:
H e was admitted [**1-20**] and completed pre-op work up. He underwent
TAVI// CoreValve via mini right thoracotomy with Dr.[**Last Name (STitle) 914**] on
[**1-21**]. He was transferred to the CVICU in stable condition and
extubated later that day. He transferred to the floor on POD #1
to begin increasing his activity level.
The chest tubes were removed per protocol. He remains with his
chronic indwelling Foley. Coumadin was restarted for chronic
atrial fibrillation and Plavix was given and discontinued when
the INR reached 2. Beta blockade and ACE inhibitors were given.
he was diuresed towards his preoperative weight and edema had
essentially cleared by discharge. He continued to make good
progress and was cleared for discharge to [**Hospital **] Rehab on
[**2194-1-28**], POD 7. The atrial pacer lead was found to have a high
impedance on evaluation [**1-28**], having been normal on [**1-25**]. The
Electrophysiology Service felt this could be evaluated by his
primary cardiologist after rehab discharge.
He was walking with assistance and a walker at discharge and
Lisinopril and Lopressor were titrated to good blood pressure
control.
Medications on Admission:
BUMETANIDE - (Prescribed by Other Provider) - 1 mg Tablet -
Tablet(s) by mouth twice a day take 3 tablets in the am and 2
tablets in the afternoon
DIGOXIN - 125 mcg Tablet - one Tablet(s) by mouth every other
day
FINASTERIDE - (Prescribed by Other Provider) - 5 mg Tablet -
Tablet(s) by mouth once a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 0.5 (One half) Tablet(s) by mouth twice daily
NITROFURANTOIN MACROCRYSTAL - 100 mg Capsule - one Capsule(s) by
mouth daily
PAROXETINE HCL - 20 mg Tablet - one Tablet(s) by mouth in the
evening
PRAVASTATIN - 40 mg Tablet - one Tablet(s) by mouth daily
PREDNISONE - (Prescribed by Other Provider) - 5 mg Tablet - 1.5
Tablet(s) by mouth daily
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg
Capsule
- Capsule(s) by mouth twice a day
SITAGLIPTIN [JANUVIA] - (Prescribed by Other Provider) - 100 mg
Tablet - 1 Tablet(s) by mouth once a day
[**Month/Year (2) **] - 0.4 mg Capsule, Ext Release 24 hr - 2 Capsule(s) by
mouth daily
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - one capsule orally daily
WARFARIN - 3 mg Tablet - one Tablet(s) by mouth daily - last
dose
[**2194-1-13**]
Medications - OTC
ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg Tablet
-
1 Tablet(s) by mouth twice a day
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - one Tablet(s)
by
mouth daily
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Tablet - two Tablet(s)
by mouth daily
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - one Capsule(s) by
mouth daily
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
iron) Tablet - Tablet(s) by mouth once a day
NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Prescribed by Other
Provider) - 100 unit/mL Suspension - 15 units twice a day
VITAMIN E - 1,000 unit Capsule - one Capsule(s) by mouth daily
--------------- --------------- --------------- ---------------
Allergies: Penicillin - anaphylaxis
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-13**]
Puffs Inhalation Q6H (every 6 hours) as needed for bronchospasm.
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. furosemide 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
17. warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
INR 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Severe Aortic stenosis
s/p Core Valve insertion
coronary artery disease
Asthma
noninsulin dependent diabetes mellitus
s/p right carotid stent
parosxymal atrial fibrillation
s/p dual chamber pacemaker ([**Company 1543**])
h/o stroke
Hypertension
Dyslipidemia
chronic obstructive pulminary disease
peripheral vascular disease
Post-polio syndrome with atrophy bilateral legs Pulmonary
hypertension
gastrointestinal reflux disease
h/o Bladder cancer - indwelling foley
Psoriasis
urinary tract infection
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
mini Right thoracotomy - healing well, no erythema or drainage
Edema:trace lower extremeties
Alert and oriented x3, nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
mini Right thoracotomy - healing well, no erythema or drainage
Edema:trace lower extremeties
Alert and oriented x3, nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
mini Right thoracotomy - healing well, no erythema or drainage
Edema:trace lower extremeties
Alert and oriented x3, nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
mini Right thoracotomy - healing well, no erythema or drainage
Edema:trace lower extremeties
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Drs. [**Name5 (PTitle) 914**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2194-2-24**]
@ 12:00,[**Hospital Ward Name **] 2A
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2194-2-24**] 10:00
ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2194-2-24**] 9:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**4-17**] weeks [**Telephone/Fax (1) 36783**]
**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 Afib
Goal INR 2.0-3.0
First draw day after discharge
****Coumadin follow up to be arranged prior to discharge from
rehab
Completed by:[**2194-1-28**]
ICD9 Codes: 4241, 4168, 2930, 5990, 4280, 4439, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7089
} | Medical Text: Admission Date: [**2148-6-22**] Discharge Date: [**2148-7-8**]
Date of Birth: [**2091-9-29**] Sex: F
Service: MEDICAL ICU/OMED
HISTORY OF PRESENT ILLNESS: This is a 56-year-old Italian
female with past medical history significant for CLL status
post allo BMT in [**2148-2-10**], who was admitted to [**Hospital1 1444**] secondary to a several day
history of fevers. The patient initially presented to
Hematology/[**Hospital **] Clinic on [**6-18**] with a temperature of
101.9. At that time, her left PICC line was D/C'd and blood
cultures sent. She was treated with a dose of Vancomycin,
ceftriaxone, and given IV hydration. The patient has also
had a two week history of a frontal headache and as a result,
a head CT was attained in outpatient clinic, which revealed
findings of a sinusitis.
At that time, the patient's outpatient prednisone dose was
increased from 15 q.d. to 20 b.i.d. She refused admission,
but agreed to return to clinic the very next day still
febrile. She was treated again with a gram of Vancomycin and
ceftriaxone. She was also given IV Solu-Medrol and IV
hydration yet again. This continued for another day again
the same drill. She finally agreed to admission and
presented to the ED on the 12th with continued fevers and
chills along with a two day history of nausea, vomiting, and
diarrhea. In the Emergency Department, the patient was given
100 mg of Solu-Medrol as well as Levaquin, Flagyl, and
Vancomycin.
PAST MEDICAL HISTORY:
1. CLL status post allo BMT in [**2148-2-10**].
2. Questionable graft-versus-host disease.
3. History of CMV viremia x3.
ALLERGIES: No known allergies.
MEDICATIONS ON ADMISSION:
1. CellCept [**Pager number **] b.i.d.
2. Magnesium oxide.
3. Prednisone 20 b.i.d.
4. Bactrim double strength q Monday, Wednesday, Friday.
5. Diflucan 200 q.d.
6. Protonix 40 q.d.
7. Ativan 1 b.i.d.
8. Colace 100 b.i.d. prn.
SOCIAL HISTORY: The patient lives with her husband and
daughters. She denies any alcohol, tobacco, or drug use.
PHYSICAL EXAM ON ADMISSION: Temperature 101.7, blood
pressure 92/50, pulse 130, sating 98% on 2 liters and 97% on
room air with a respiratory rate of 17. In general, the
patient appeared fatigued, but was in no acute distress.
Mucous membranes were dry. Oropharynx was clear. Her skin
revealed a perioral, nasolabial, and chin erythematous rash
with white scaly patches. Cardiac examination revealed a
tachycardic S1, S2, but regular and no murmurs, rubs, or
gallops. Lungs were clear bilaterally. Abdomen was benign.
Left Hickman site was without erythema or pus. Extremities
were without any edema. She did have 1-2 cm erythematous
round well demarcated macules on her arms, buttocks, and legs
as well as her trunk that all partially blanched and were
nontender.
LABORATORIES ON ADMISSION: Notable for a white count of 7.4
with 10 polys, 7 bands, 59 lymphocytes, 16 monocytes, and 12
atypicals. Absolute granulocyte count was 7,840. Sodium was
131, bicarb 16, anion gap of 15, creatinine was 1.3, INR 2.5.
AST 132, ALT 303, LDH 384, alkaline phosphatase 106, total
bilirubin 1.7, lipase 117, amylase 312, albumin 3.9, TSH 2.
Urinalysis showed [**2-14**] granular hyaline casts, 250 glucose,
trace protein, few bacteria. CMV viral load was negative.
Urine, blood, and tip cultures initially remained negative.
Chest x-ray revealed a questionable retrocardiac density.
KUB showed no obstruction. EKG showed sinus tachycardia at
146 with T-wave inversions in I and L as well as left atrial
enlargement and left ventricular hypertrophy.
BRIEF HOSPITAL COURSE: The patient had a long and protracted
course on the Bone Marrow Transplant service most marked by
grade 4 graft-versus-host disease, with involvement of the GI
tract and the skin that did not respond to steroids.
She developed progressive multiorgan failure. On she was
transferred to the Fenard ICU on
[**7-6**] in multiorgan failure.
She developed acute oliguric renal failure. . Her grade 4 graft-
versus-host disease of the GI tract and the skin continued to
progress despite high doses of Solu-Medrol, CellCept, Remicade,
and cyclosporin. Her LFTs continued to rise with a peak total
bilirubin of 19.9 on transfer to the MICU. She also
continued to have unrelenting diarrhea.
She developed microangiopathic changes and DIC with an INR that
continued to rise eventually reaching 1.7 with schistocytes on
her smear, a low fibrinogen and a LDH of 1,922. As a result, a
question of TTP vs HUS arose. She also developed paroxysmal
atrial fibrillation with intermittent rapid ventricular
response. As a result, she was given both IV metoprolol and
diltiazem in the form of a drip to keep her heart rate
controlled.
In addition, her mental status began to decline. This was
thought to be multifactorial in etiology in part due to
uremic/hepatic encephalopathy, questionable TTP, and drug
induced as the patient had been receiving high doses of
benzodiazepines and narcotics in the setting of hepatic and
renal function.
Once she was transferred to the Medical ICU, it was decided
to discontinue all mind-altering medications. As she was
given fluid boluses in last effort to improve her urinary
output but without effect. She became persistently more hypoxic
with agonal breathing at times. Her white count also continued
to rise on a daily basis with no clear etiology as all cultures
continue to remain negative. She, however, remained on broad-
spectrum antibiotics, antifungals, and antivirals.
Towards the end of her hospital course, however, the
patient's chest x-ray did reveal multiple nodules bilaterally
very concerning for fungal infection. In light of her
worsening clinical condition. On [**7-8**] because of
progressive declining clinical condition the family requested a
DNR/DNI order. It was decided to continue
the current level of care including all medications and
laboratory draws, but there was to be no escalation of
treatment (i.e., no intubation, hemodialysis, or pressors).
The patient later that afternoon became
persistently more hypotensive and bradycardic likely
secondary to her progressively increasing acidemia from her
renal failure. As a result, she passed away at 4:15 p.m. on
[**2148-7-8**] with her entire family present in the room.
The request for autopsy was denied.
DISCHARGE DIAGNOSES:
1. Stage IV graft-versus-host disease.
2. Multiorgan failure.
DISCHARGE CONDITION: Demised.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 10997**]
Dictated By:[**First Name (STitle) 47744**]
MEDQUIST36
D: [**2148-9-2**] 21:20
T: [**2148-9-6**] 11:10
JOB#: [**Job Number 47745**]
ICD9 Codes: 2765, 5789, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7090
} | Medical Text: Admission Date: [**2181-6-2**] Discharge Date: [**2181-6-8**]
Date of Birth: [**2103-5-21**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p fall from standing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 70820**] is a 78F who was home alone, bent over to pick up
mail on the floor & fell forwards. She slid face first into a
[**Country **] cabinet, breaking the cabinet itself. She was brought to
[**Hospital6 4287**] by ambulance and transfered to [**Hospital1 18**] when CT
scans revealed a possible LeForte Type I facial fracture. She
was admitted to the Trauma Surgery service and CT scans of the
head, C-Spine & sinuses/maxilla were redone.
Past Medical History:
Arthritis, Bursitis, Type 2 Diabetes Mellitus, hx tongue cancer,
hx ovarian & breast cancer, chronic pain, EtOH use
Social History:
Pt lives at home with her husband & his 26 yr-old grandson. They
are well supported by their 2 children.
Family History:
Daughter - breast ca
Multiple maternal relatives with cancer
Physical Exam:
A and O, appears uncomfortable, groaning, unable to speak
clearly
secondary to extensive soft tissue swelling of face
VS HR 78 143/91 20 92
B/L massive facial swelling w/ecchymoses of forehead,
periorbital
area, b/l zygomas, maxilla, and around her mouth and left neck
Eyes: b/l periorbital ecchymoses and swelling, including in fat
pat; but PERRL, EOMi
Nose: R nare packed with rhinorocket, L nare edematous with
active but slow oozing
Mouth: philtrum s/p lac repair; tongue intact, intraorbital
swelling, gross blood on hard and soft palate, unable to
visualize uvula, ecchymosis most on left buccal mucosa,
edentulous; palate grossly intact
Neck, slight swelling and ecchymoses on anterior triangle
RRR no m/r/g
CTAB anteriorly
soft NT/ND, but obese abdomen, midline abd incision,
well-healed,
right vertical incision in RLQ
no c/c/e
Pertinent Results:
[**2181-6-2**] 07:20PM BLOOD WBC-9.0 RBC-3.51* Hgb-11.0* Hct-33.2*
MCV-95 MCH-31.3 MCHC-33.2 RDW-14.1 Plt Ct-227
[**2181-6-2**] 07:20PM BLOOD Glucose-204* UreaN-24* Creat-0.7 Na-138
K-4.5 Cl-100 HCO3-29 AnGap-14
[**2181-6-2**] 07:20PM BLOOD Neuts-83.5* Lymphs-11.6* Monos-3.7
Eos-0.9 Baso-0.4
[**2181-6-2**] 07:20PM BLOOD PT-13.7* PTT-22.5 INR(PT)-1.2*
[**2181-6-3**] 02:06AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9
[**2181-6-2**] 09:25PM BLOOD Glucose-200* Lactate-2.7* Na-140 K-4.1
Cl-94* calHCO3-33*
[**2181-6-6**] 06:40AM BLOOD WBC-6.9 RBC-3.46* Hgb-11.0* Hct-31.9*
MCV-92 MCH-31.9 MCHC-34.6 RDW-14.5 Plt Ct-341
[**2181-6-6**] 06:40AM BLOOD Glucose-175* UreaN-12 Creat-0.7 Na-137
K-3.3 Cl-101 HCO3-26 AnGap-13
[**2181-6-6**] 06:40AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.0
.
IMAGING:
[**6-2**] CXR: Given the elevated hemidiaphragm and resultant volume
loss, the
opacity at the medial right lung base is presumed atelectasis,
although an
early developing pneumonia is difficult to entirely exclude.
Correlate
clinically.
[**6-2**] CT HEAD: Facial swelling and fractures as seen on
maxillofacial CT. There is soft tissue contusion in the frontal
region. Otherwise, no evidence of intracranial hemorrhage or
skull fracture is seen.
[**6-3**] CT C-SPINE: Patchy osteopenia limits evaluation somewhat.
However, no
evidence for acute fracture is seen. Maxillofacial fractures are
as seen on CT maxillofacial bones.
[**6-3**] CT SINUS/MAXILLA: Extensive soft tissue swelling and
subcutaneous gas. Fracture does extend through the walls of
bilateral maxillary sinuses and the nasal septum. Blood and
fluid opacify both maxillary sinuses and partially opacify the
remainder of the paranasal sinuses. Fractures also extend
through the lateral plate and spine of the left sphenoid bone
and right pterygoid plate.
Brief Hospital Course:
Ms [**Known lastname 70820**] was transfered from an OSH for multiple facial
fractures s/p fall from standing. She was evaluated in our ED
and was admitted to the TSICU for airway observation given the
extent of epistaxis reported at [**Hospital3 **] and for monitoring of
her airway given her extensive facial swelling. She was made
NPO and given IVF and IV medications for pain control. She was
noted to have some memory impairment, which her daughter
reported had been progressive for some time. Overnight she was
unable to verbalize her pain levels and was agitated &
hypertensive. It was felt, given conversations with the family,
that she may in fact have been withdrawing from EtOH vs
benzodiazipines. She was started on Ativan per CIWA protocol.
On HD2 she was evaluated by Ophthalmology, who noted no EOM
entrapment & did note periorbital contusions & hematoma. Plastic
Surgery consultation was obtained and her injuries were
determined to be non-operative. A soft diet and sinus
precautions were recommended. Speech & Swallow initial
evaluation was deferred for confusion & oral edema, pt was kept
NPO and continued on CIWA scale. Geriatrics was also consulted
On HD3 the pt was again evaluated by Speech & Swallow who noted
overt oral/lingual edema and immediate reflexive coughing on
thin liquids consistent with aspiration.
On HD4 she had a desat event to the 80s, moist saline was given
& she coughed up large old blood clot, after which her sats
improved to the high 90s. She was transfered to the floor in
stable condition
On HD5 Speech & Swallow again noted oral/lingual edema that pt
c/o "raw pain" in her mouth with presentation of PO. She was
unable to transition any PO anteriorly to posteriorly within her
oral cavity, [**2-19**] edema and she did not trigger a swallow the
evaluation. She therefore remained NPO.
On HD6 the pts swelling had resolved enough for her to tolerate
a soft diet with nectar thickened liquids. She was started back
on her home medications.
HD7 the pt was discharged to rehab in stable condition with
instruction for follow up in both Opthalmology & Plastic Surgery
clinics. She was also instructed to follow up with her PCP
regarding this admission and her family's concerns regarding her
steadiness at home and her progressive memory difficulties.
Medications on Admission:
lorazepam 2mg PO daily, fludrocortisone 0.1mg PO daily,
glipizide ER 5mg PO daily, levothyroxine 112mcg PO daily,
meloxicam 15mg PO daily, gabapentin 600mg PO twice daily,
imipramine 100mg PO daily, percocet 5-325 tabs TID prn pain,
detrol LA 4mg PO daily, asa 81mg PO daily, omeprazole 20mg PO
twice daily (NOTE: per [**Hospital3 **] report pt taking metoprolol
25', but pts husband confirms this was dc'ed a few months ago)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
2. Saliva Substitution Combo No.2 Solution Sig: Thirty (30)
ML Mucous membrane QID (4 times a day) as needed for dry mouth.
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-19**] Sprays Nasal
QID (4 times a day) as needed for dry mucous membranes.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
5. Glipizide 5 mg Tablet Extended Rel 24 hr (2) Sig: One (1)
Tablet Extended Rel 24 hr (2) PO DAILY (Daily).
6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Meloxicam 7.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
9. Imipramine HCl 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
10. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
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. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): [**Month (only) 116**] increase dose at rehab prn.
14. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mL PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Primary Diagnosis: s/p fall from standing. Injuries:
-severe epistaxis, controlled at OSH w/rhinorocket &
Afrin-soaked cotton ball.
-5cm lac across philtrum, sutured at OSH
-multiple sinus fxs
-orbital floor fxs
Secondary Diagnoses: DM2, HTN, arthritis, chronic pain, hx
multiple cancers (tongue, breast, ovarian), EtOH use, distant
narcotic pain reliever dependence
Discharge Condition:
Stable.
Pain well controlled.
Discharge Instructions:
Given your facial injuries, we recommend that you follow a soft
mechanical diet. Please adhere to this diet until you have been
seen in follow up by Plastic Surgery.
.
Please maintain Sinus/Nasal Precautions: Keep the head of your
bed elevated at all times, please do not use straws, you may
wipe--but not blow--your nose, try to sneeze with your mouth
open. Continue to use the saline nasal spray to prevent dryness
or cracking in your nostrils, both of which can cause epistaxis.
Followup Instructions:
Please call ([**Telephone/Fax (1) 5120**] to make a follow up appointment with
the [**Hospital 8183**] clinic in one week.
.
A follow up appointment has been made for you in the Plastic
Surgery Clinic at 2:30 pm on [**2181-6-22**]. Please call ([**Telephone/Fax (1) 25891**] if you need to change this appointment.
.
Please follow up with your PCP as soon as possible about this
admission and about your family's concerns regarding your
steadiness at home and your progressive memory difficulties.
Completed by:[**2181-6-8**]
ICD9 Codes: 5070, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7091
} | Medical Text: Admission Date: [**2111-7-9**] Discharge Date: [**2111-7-20**]
Date of Birth: [**2049-11-28**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 60-year-old male with
a history of diabetes mellitus who was admitted for cardiac
catheterization. The patient has been having exertional
substernal chest pain and short of breath for months and on
the morning prior to admission experienced an episode of
chest tightness while leaving the parking lot to have his
stress test done. The ETT which was done showed ST segment
depression in 2, 3 and AVF and V2 through V5 after 5 minutes
and 49 seconds. The patient also had substernal chest
discomfort and short of breath which persisted resulting in
him being rushed to the [**Hospital3 **] emergency department.
On electrocardiogram there was resolution of the ST segment
abnormalities. He received nitropaste which relieved his
symptoms. CKMB at that hospital was 3.7, troponin were flat
and he was transferred to [**Hospital1 188**].
PAST MEDICAL HISTORY:
1. Diabetes mellitus Type 2.
2. Hypertension.
3. Hypothyroidism.
4. Status post right radical nephrectomy in [**2103**].
5. Arthritis.
MEDICATIONS:
1. Atenolol 50 mg q day.
2. Hydrochloraquin 200 mg twice a day.
3. Naproxen 37.5 mg twice a day
4. Glyburide 2.5 mg q day.
5. Accupril 10 mg q day.
6. Synthroid.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He stopped tobacco in [**2090**] and has
occasional cigars. Drinks one beer per day.
PHYSICAL EXAMINATION: The patient's vital signs were
temperature 97.5, heart rate 65, blood pressure 127/67,
respiratory rate 20. O2 sat 96% on two liters. Skin was
warm, dry and icteric. Head, eyes, ears, nose and throat;
Normocephalic, atraumatic. The pupils are equal round and
reactive to light. Extraocular movements intact. Positive
cataracts. Neck supple,no bruits. Lungs: Clear to
auscultation bilaterally. Cardiovascular; S1 and S2 regular
rate and rhythm with a harsh systolic ejection murmur
radiating to the carotids. Abdomen obese, bowel sounds
present, soft, nontender, nondistended. Extremities: No
edema. Bilateral palpable dorsalis pedis and posterior
tibial pulses, no groin bruits. Neurological: Cranial
nerves II to XII grossly intact. Rectal: External
hemorrhoids, normal tone, guaiac negative.
On admission the patient's white blood count was 12.4,
hemoglobin 12.1, hematocrit 34.7. platelet count 247.
Prothrombin time 12.5, PTT 25.6, INR 1.0. Urinalysis was
negative for nitrates, positive for 100 protein, sodium 142,
potassium 4.9, chloride 108, CO2 19, BUN 41, creatinine 1.7,
glucose 88. CK was 66.
Echocardiogram by bedside done at [**Hospital3 **] showed
aortic stenosis, peak gradient greater than 25 mm of mercury.
EF of approximately 50% with borderline Left ventricular
hypertrophy.
Chest x-ray done here was negative.
HOSPITAL COURSE: The patient was admitted to the medical
service on [**2111-7-9**] with a diagnosis of unstable angina. He
was treated with aspirin, Lopressor, nitropaste. Continued
on his Ace inhibitor. The patient underwent cardiac
catheterization the next day which showed no aortic valve
gradient and on coronary angiography a right dominant system
LMCA of 50% distal, Left anterior descending mild, left
circumflex 99% proximal, right coronary artery 50% proximal
and 50% distal stenosis. Based on the above results it was
decided that coronary artery bypass graft would be necessary
and the patient preoperative workup was completed. He was
additionally started on Heparin. On [**2111-7-14**] the patient was
taken to the operating room where he underwent three vessel
coronary artery bypass grafting with the following grafts:
left internal mammary artery to left anterior descending,
vein to OM, vein to right coronary artery under general
anesthesia. The patient tolerated the procedure well, there
were no intraoperative complications and he was transferred
to the Cardiac Recovery Unit in normal sinus rhythm intubated
on Propofol and Neo drip.
The patient was able to be extubated the evening of the
operation and from a respiratory standpoint remained stable
throughout the rest of his postoperative course. The patient
remained in Intensive Care Unit through the next day while he
was being weaned off his Neo drip. He was further transfused
two units of packed red blood cells for a hematocrit of 22
with repeat hematocrit 26. His urine was also borderline
improving with Lasix however, his creatinine had elevated to
2.3 from 1.7 causing his Lasix to be stopped. This
hematocrit also decreased to 23.5 for which he received
another unit of packed red blood cells. On postoperative day
two the patient was transferred to the regular floor after
having had his chest tubes removed. He was closely
monitored and on postoperative day #3 was found to have some
minimal drainage from his sternotomy [**Date Range **], apparently old
serosanguinous fluid. Sternum was stable with no clicks.
There was no erythema or induration noted.
He was empirically started on Ancef and the chest x-ray was
obtained which was negative for sternal dehiscence. His
[**Date Range **] continued to be monitored. On postoperative day four
the patient spiked a temperature to 103, his urine culture
found to be positive for E. coli. He was started on
Ciprofloxacin. He was also started on Vancomycin. His white
blood cell count was elevated to 18 and decreased the next
day to 16 and it was felt clinically that his Vancomycin
could be discontinued. With respect to his sternal [**Date Range **] the
drainage eventually decreased and he was felt to be stable
for discharge home on postoperative day 6. He had been
afebrile, his white count decreased to 13.3 and he was
discharged on Ciprofloxacin for his urinary tract infection.
Of note on postop day #3 the patient's BUN and creatinine
normalized to 30 and 1.8, his creatinine further decreased to
baseline of 1.6 where it stabilized.
CONDITION ON DISCHARGE: The patient is stable for discharge
home due to the fact that he is ambulated to a level V
remains afebrile, tolerating a regular diet.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSIS:
1. Status post three vessel coronary artery bypass graft.
2. Coronary artery disease.
3. Urinary tract infection on Ciprofloxacin.
4. Status post left nephrectomy with transient increase in
BUN and creatinine stabilized to baseline.
5. Diabetes mellitus Type 2.
6. Hypertension.
7. Hypothyroidism.
8. Arthritis.
DISCHARGE MEDICATIONS:
1. Ciprofloxacin 500 mg p.o. b.i.d. times one week.
2. Lopressor 75 mg p.o. q 12 hours
3. Colace 100 mg p.o. twice a day.
4. Zantac 150 mg p.o. twice a day.
5. Aspirin 81 mg p.o. q day.
6. Synthroid 25 mcg q day.
7. Glyburide 5 mg q day.
8. Percocet one to two p.o. q 4 to 6 hours p.r.n.
9. Tylenol 650 mg p.o. q 4 to 6 hours p.r.n.
DISCHARGE INSTRUCTIONS: The patient is discharged to home
with visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] care. He is to follow-up with
Dr. [**Last Name (STitle) 35025**] in three to four weeks and to follow-up with his
primary care physician in one to two weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2111-7-20**] 20:33
T: [**2111-7-20**] 21:44
JOB#: [**Job Number 35026**]
ICD9 Codes: 4111, 5990, 496, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7092
} | Medical Text: Admission Date: [**2178-1-20**] Discharge Date: [**2178-2-3**]
Date of Birth: [**2122-3-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Transfer from OSH with hypercarbic respiratory failure and acute
transaminitis
Major Surgical or Invasive Procedure:
intubated [**1-20**] and extubated [**1-25**]
History of Present Illness:
This is a 55 year old woman with a history of depression, hip
replacement, EtOH abuse, who presented to an OSH ED with CP,
SOB, and nausea. Patient is currently intubated and sedated, so
history is obtained form OSH records and her children. Per
patient's son and daughter, she was not feeling well for the
last several days. She had complained of dizziness,
lightheadedness, and nausea. She also may have fainted and had a
fall 2 days prior to admission. For the last day, she has had
shortness of breath and chest heaviness. The family do not
believe that she had fevers, chills, or cough. They are not
certain of any other symptoms. She went to an OSH ED because of
the SOB and chest heaviness.
.
On arrival at the OSH ED, HR was 82, BP 130/80. O2 sat was noted
to be 81% on 4L nc and she was placed on NRB. SL NTG was given
due to pt c/o chest heaviness. A dose of lovenox was also given.
The patient's son called in to say that the patient had been
taking multiple meds for hip and back pain, including darvocet,
percocet, and vicodin, as well as ativan and EtOH. For this
reason, narcan was given. It does not appear that there was any
improvement in her respiratory status. Flumazenil was also
given, with no improvement. ABG was done: 7.094/90.9/73. The
patient was intubated (etomidate and succinylcholine given). NGT
was inserted. Ativan was given for agitation with no effect,
versed was given with better effect. Propofol was then started.
Repeat ABG was 7.41/35/171 on vent settings AC at 550x18, PEEP
5, FiO2 100%. Mucomyst 14g was given via NGT. She was noted to
have about 350cc blood from NGT, then later vomited bloody brown
material around NGT. 2U FFP were started as the patient was
ready to be transferred. Protonix 80mg IV and a dose of Zosyn
were also given (for T 101). By report, blood cultures were
drawn.
.
The patient was then transferred to [**Hospital1 18**] for ICU level care.
Past Medical History:
HTN
s/p hip replacement in [**8-13**]
chronic back pain
depression
EtOH abuse
Social History:
Lives with youngest daughter, currently in a hotel while
apartment is being renovated. Not working, on disability. Quit
smoking 7yrs ago. Smoked 1/2ppd for 7 yrs. Drinks 1 pint of
vodka. No IVDU.
Family History:
Father had MI and peripheral nueropathy
Physical Exam:
VS: 99.5, 57, 174/72, 19, 100% (on AC Vt 550, RR 18, PEEP 5,
FiO2 100%)
Gen: intubated and sedated
HEENT: ETT in place
Neck: unable to assess JVP
Lungs: coarse breath sounds b/l
Heart: bradycardic, regular, no m/r/g
Abd: hypoactive BS, soft, obese, NT/ND
Extrem: warm, dry, no edema
Pertinent Results:
[**2178-1-20**] 01:30AM BLOOD WBC-9.0 RBC-3.38* Hgb-11.4* Hct-32.4*
MCV-96 MCH-33.8* MCHC-35.3* RDW-16.1* Plt Ct-97*
[**2178-1-26**] 03:57AM BLOOD WBC-6.2 RBC-2.95* Hgb-9.8* Hct-28.4*
MCV-96 MCH-33.1* MCHC-34.5 RDW-14.8 Plt Ct-113*
[**2178-1-20**] 01:30AM BLOOD PT-17.4* PTT-32.8 INR(PT)-1.6*
[**2178-1-26**] 03:57AM BLOOD Glucose-73 UreaN-39* Creat-5.8*# Na-142
K-3.7 Cl-99 HCO3-21*
[**2178-1-20**] 01:30AM BLOOD Glucose-122* UreaN-25* Creat-1.4* Na-140
K-3.2* Cl-101 HCO3-24 AnGap-18
[**2178-1-26**] 03:57AM BLOOD ALT-415* AST-47* LD(LDH)-308*
AlkPhos-132* Amylase-316* TotBili-1.6*
[**2178-1-20**] 01:30AM BLOOD ALT-5935* AST-[**Numeric Identifier 27680**]* LD(LDH)-[**Numeric Identifier 2494**]*
CK(CPK)-213* AlkPhos-80 Amylase-215* TotBili-1.0
[**2178-1-26**] 03:57AM BLOOD Lipase-484*
[**2178-1-21**] 04:08PM BLOOD Lipase-671*
[**2178-1-20**] 01:30AM BLOOD Lipase-192*
[**2178-1-20**] 01:30AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-4144*
[**2178-1-26**] 03:57AM BLOOD Albumin-3.0* Calcium-9.4 Phos-9.1*#
Mg-2.6
[**2178-1-20**] 04:08PM BLOOD Hapto-68
[**2178-1-20**] 01:30AM BLOOD calTIBC-338 Ferritn-GREATER TH TRF-260
[**2178-1-23**] 12:18PM BLOOD Acetone-NEGATIVE
[**2178-1-20**] 01:30AM BLOOD TSH-0.99
[**2178-1-20**] 01:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2178-1-23**] 04:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2178-1-20**] 01:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2178-1-20**] 01:30AM BLOOD HCV Ab-NEGATIVE
[**2178-1-20**] 03:46AM BLOOD Type-ART Temp-37.5 Rates-18/ Tidal V-550
PEEP-5 FiO2-100 pO2-456* pCO2-31* pH-7.54* calTCO2-27 Base XS-5
AADO2-251 REQ O2-48 -ASSIST/CON Intubat-INTUBATED
[**2178-1-25**] 10:55AM BLOOD Type-ART Temp-37.2 pO2-125* pCO2-47*
pH-7.34* calTCO2-26 Base XS-0 Intubat-INTUBATED
[**2178-1-20**] 03:46AM BLOOD Lactate-2.0
[**2178-1-21**] 12:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2178-1-21**] 12:50PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-TR Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2178-1-21**] 12:50PM URINE RBC-[**5-17**]* WBC-[**2-9**] Bacteri-FEW Yeast-FEW
Epi-0-2
[**2178-1-21**] 12:50PM URINE Hours-RANDOM Creat-42 Na-53
[**2178-1-21**] 12:50PM URINE Osmolal-315
[**2178-1-20**] 05:58AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
Bcx [**1-20**]: no growth
Ucx [**1-20**]: no growth
.
[**2178-1-24**] 3:44 pm SPUTUM
GRAM STAIN (Final [**2178-1-24**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
MODERATE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
STAPH AUREUS COAG +. HEAVY GROWTH.
.
Head CT [**1-20**]: Normal head CT
.
Abd u/s [**1-20**]:IMPRESSION:
1. No biliary ductal dilatation or focal liver mass.
2. Normal liver Doppler.
.
CXR [**1-20**]:
Heart size is top normal. Pulmonary mediastinal vasculature is
distended. Ascending thoracic aorta may be significantly
enlarged. Nasogastric tube ends in the stomach. ET tube in
standard placement. No pneumothorax or pleural effusion. No
evidence of pneumonia.
.
Renal ultrasound [**1-21**]:
No obstructing stones or hydronephrosis.
Brief Hospital Course:
This is a 55 year old woman with a history of depression, EtOH
abuse, back pain, s/p hip replacement, HTN, who presents with
hypercarbic respiratory failure and acute transaminitis.
.
# Respiratory failure: Initially hypercarbic respiratory failure
and had significant AG metabolic acidosis which resolved with
HD. Etiology of resp failure likely [**1-9**] to medications.
?hypoventilation vs dead-space. CNS process ruled out with
normal head CT. CXR not impressive for pna or chf. Blood and
urine cultures negative. Serum tox repeat negative X2, urine
positive for benzos and opiates-likely from ativan and darvon.
Echo [**2178-1-20**]: Preserved regional/global biventricular systolic
function. Moderate tricuspid regurgitation. Mild aortic
regurgitation. Mild mitral regurgitation. BNP elevated at
4,000, however CXR not impressive for volume overload, although
heart size appears enlarged. Extubation on [**1-25**], now doing well
with no O2 requirments, no chest pain, and no SOB. At time of
discharge, patient's respiratory status resolved to her baseline
prior to admission without symptoms of dyspnea and without O2
requirement.
.
# Acute hepatitis/liver failure: Transaminases initially rose to
ALT 6,000s and AST 16,000s. Likely due to toxicity from darvon.
Received Nac 14g at OSH and continued her until [**2178-1-23**]. On
admission, received activated charcoal and banana bag. Synthetic
function preserved (INR peaked at 1.6 and improved to 1.1,
albumin 3.9). Hepatitis panel negative. Abdominal U/S
w/dopplers unremarkable. Hemolysis labs negative. Liver
function improved to normal LFTs by time of discharge.
.
# Acid/base: Had significant AG metabolic acidosis (33)which
improved with HD. Likely [**1-9**] to her renal failure and cell death
from liver failure or toxin. Renal U/S neg. Has now had HD X 5
(as of [**2178-1-30**]). U/A on [**1-21**] had 30 protein and 15 ketones. On
discharge her AG metabolic acidosis had resolved.
.
# ARF: Cr 1.4 on admission, baseline unknown. Peaked at 7.9
during hospital course. Renally dosed meds and nephrotoxins were
avoided. Renal U/S negative for hydronephrosis. Renal failure
was thought most likely secondary to ATN. Hemodialysis was
initiated while inpatient with first session on [**2178-2-4**] and will
follow up with HD as outpatient as well. She has been
instructed on renal diet and will adhere to this as an
outpatient.
.
# GI bleed: Noted to have bloody NGT drainage and bloody brown
emesis at OSH. Not clear if guaiac was checked from NGT. There
was no further evidence of bleeding during her hospital stay.
She remained guaiac negative from below.
.
# Anemia: Baseline hematocrit during this hospitalization has
been in the low 30s. In OSH was 42 and had UGIB as above at OSH.
Retic count 2.8. Iron studies revealed iron 43, TIBC 306,
Ferritin 305. Ferrous sulfate was initiated at 325 mg PO TID for
iron deficiency anemia. She had drop in hct to 27s, with repeat
checks stable and without a source of bleeding including GI.
She will need hct monitoring as an outpatient to ensure
stability.
.
# Sinus bradycardia: Was found to be bradycardic upon transfer,
but BP stable. Pt is on BB at home, but based on pill count did
not appear to have overdosed. Head CT negative for intracranial
process. TTE unremarkable. Her beta blocker was held during her
stay and its reinitiation should be reevaluated in follow up.
.
# Peripheral neuropathy: She now has increased sensation in feet
although it remains difficult to walk. Normally takes darvon
for pain. She was started on neurontin 100 [**Hospital1 **] which can be
titrated up as appropriate in outpatient setting.
.
# EtOH use/abuse: Per patient's children, has at least [**1-10**]
drinks per day. Did not show signs of withdrawal during her
hospital stay. Given her acute hepatitis, she was instructed to
avoid EtOH. She will likely need social work and or substance
abuse counseling as outpatient as well.
.
# Pancreatitis: Amylase/lipase elevated on admission and had
normalized by time of discharge.
.
# Hypertension: Her beta blocker was held due to bradycardia as
above, and [**Last Name (un) **] was held in the setting of renal failure. She was
started on amlodipine for HTN which she tolerated well, on which
she will be discharged.
.
# Depression: Her home meds of wellbutrin and effexor were held
given her renal and hepatic failure. If continued improvement,
PCP may opt to reinitiate as an outpatient. Even with their
discontinuation, her mood has remained stable here.
Medications on Admission:
lasix 40mg Qd
toprol 50mg QD
wellbutrin 100mg Qd
effexor 37.5g TID
darvon 65mg TID
Diovan
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
For High Blood Pressure.
Disp:*60 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. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*0*
4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed: for constipation.
Disp:*30 Suppository(s)* Refills:*0*
7. Neomycin-Polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops,
Suspension Sig: Five (5) Drop Otic TID (3 times a day) for 8
days.
Disp:*QS ML* Refills:*0*
8. Outpatient Lab Work
Please check hematocrit at next hemodialysis session on Thursday
[**2178-2-4**]. Please phone result to patient's primary care doctor,
DR. [**Last Name (STitle) 72460**] [**Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) 72461**]
Discharge Disposition:
Home With Service
Facility:
VNA of the [**Location (un) 1121**]
Discharge Diagnosis:
Primary
Hypercarbic respiratory failure
Hepatitis
Acute renal failure
.
Secondary
Hypertension
Peripheral Neuropathy
Chronic back pain
Depression
EtOH abuse
Discharge Condition:
Stable with no oxygen requirements, recovered liver function,
and on hemodialysis for renal failure.
Discharge Instructions:
You were admitted to the hospital for respiratory and liver
failure with subsequent renal failure. Please return to the
emergency room or call your doctor if you experience any of the
following symptoms: fever > 101.5, intractable nausea/vomiting,
dizziness or light-headedness, diarrhea, bleeding, rashes,
swelling, increasing redness/pain at your dialysis catheter
site, or any other concerning symptoms.
.
Please take all medications as prescribed. You should avoid all
alcholic beverages and avoid tylenol currently as your liver is
recovering from significant damage.
.
Please also adhere to the renal diet as outlined during your
hospital stay.
.
Please follow up as scheduled for hemodialysis on Thursday
[**2178-02-04**], where you will be followed by a nephrologist
.
Please follow-up with hepatology Dr. [**Last Name (STitle) 10924**] [**Name (STitle) **] [**Location (un) **] at 8:30 am on [**2-19**].
.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 72462**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], Post
Office Square, [**Location (un) 16848**], Phone: ([**Telephone/Fax (1) 72463**] on Monday, [**2-7**] at 10:45am.
Followup Instructions:
Please follow up as scheduled for hemodialysis on Thursday
[**2178-02-04**], where you will be followed by a nephrologist
.
Please follow-up with the Liver clinic, Dr. [**Last Name (STitle) 10924**] [**Name (STitle) **]
[**Location (un) **] at 8:30 am on [**2-19**].
.
Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 72462**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], Post Office Square,
[**Location (un) 16848**], Phone: ([**Telephone/Fax (1) 72463**] on Monday, [**2-7**] at
10:45am.
ICD9 Codes: 5789, 2762, 2760, 5849, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7093
} | Medical Text: Admission Date: [**2164-6-18**] Discharge Date: [**2164-6-24**]
Service: CARDIOTHORACIC
HOSPITAL COURSE: Mr. [**Known lastname 1352**] is an 80 year-old man
transferred from [**Hospital3 **] the morning of [**2164-6-18**] with
unstable angina. He had nonspecific electrocardiogram
changes with a troponin of 0.54. He was treated with
heparin, Aggrastat and nitropaste. He also received aspirin
and Lopressor prior to transfer. On arrival he had a cardiac
catheterization, which demonstrated multivessel disease. On
[**2164-6-19**] he underwent coronary artery bypass grafting times
four including a left internal mammary coronary artery to
left anterior descending coronary artery bypass.
Cardiopulmonary bypass time was 82 minutes, cross clamp time
was 15 minutes. The patient had an uncomplicated course and
was taking a cardiac diet on postop day number one and
rapidly progressed with physical therapy. The patient was
discharged home on [**2164-6-24**] in good condition.
PAST MEDICAL HISTORY: Gastroesophageal reflux disease,
status post appendectomy, status post cholecystectomy, status
post hyperlipidemia now corrected with diet, status post
prostatectomy for prostate cancer in [**2148**], status post
arthroscopic knee surgery [**2164-5-12**], status post fall, [**7-12**]
with rib fractures and pneumothorax.
ALLERGIES: Dye, shellfish.
MEDICATIONS AT DISCHARGE: Lopressor 12.5 mg po b.i.d., Lasix
20 mg po q day, potassium chloride 20 milliequivalents po q
day, Colace 100 mg po b.i.d., Zantac 150 mg po b.i.d.,
Halcion 2.5 mg po q.h.s., Percocet one to two tabs po q 6
hours prn, Milk of Magnesia prn.
PHYSICAL EXAMINATION: Temperature 37.0, heart rate 70, blood
pressure 120/70, respirations 14. Neurological intact. No
focal deficits. Chest clear to auscultation bilaterally.
Cardiovascular, regular rate and rhythm. Normal S1 and S2.
Abdomen soft, nontender, nondistended. No masses, no
ascites. Extremities no peripheral edema. Palpable dorsalis
pedis pulses bilaterally.
LABORATORY: Laboratories at the time of discharge, white
blood cell count 11, hematocrit 25, platelets 155, sodium
132, potassium 4.2, chloride 95, CO2 28, BUN 12, creatinine
0.6, glucose 101, calcium 8, magnesium 2.0.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home. The patient should follow up with
Dr. [**Last Name (STitle) 70**] in two weeks.
DISCHARGE DIAGNOSES:
Status post coronary artery bypass graft times four.
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 11232**]
MEDQUIST36
D: [**2164-6-24**] 12:51
T: [**2164-6-27**] 07:10
JOB#: [**Job Number **]
ICD9 Codes: 2761, 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7094
} | Medical Text: Admission Date: [**2197-10-31**] Discharge Date: [**2197-11-11**]
Date of Birth: [**2125-8-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
gastric adenocarcinoma
Major Surgical or Invasive Procedure:
s/p subtotal gastrectomy, D2 lymphadenectomy, CBD exploration,
and choledochojejunostomy
History of Present Illness:
The patient is a 72 yo M, who initially presented w/ obstructing
choledocholithiasis [**8-30**] (CBD 2.0 cm), s/p ERCP + stent on
[**2197-9-11**] performed by [**Doctor First Name **] [**Doctor Last Name **]. During the procedure, the
patient was incidentally found to have a large antral ulcerated
tumor on ERCP. Biopsy was consistent with gastric (antral)
adenocarinoma. He is now presenting to [**Hospital Unit Name 153**] for post-operative
monitoring and management after undergoing subtotal gastrectomy,
D2 lymphadenectomy, CBD exploration, and choledochojejunostomy.
Found densely adherent abdomen with difficult lysis of
adhesions. Gastric adenocardinoma in antrum, distal margin
negative on frozen section. Distal stomach, gallbladder, CBD
stones sent to pathology. The case ~12 hours. EBL 2700. Received
6000 Crystalloid, 1000 Albumin, 3 units pRBCs. UOP 500. Abx
Cefazolin 2g x4?, Flagyl. Initially got Metoprolol, later
required Neo briefly.
.
On arrival to [**Name (NI) 153**], pt. on AC 600/14/5/40%, satting 93%.
Sedation with Fentanyl 75, Midaz 2. No pressor requirement. Pt.
was agitated, Fentanyl increased to 100.
Past Medical History:
choledocholithiasis s/p ERCP + stent [**2197-9-11**], COPD, varicose
veins, ventral hernia repair in [**2191**]
Social History:
Born in [**Country 6257**]. Worked as a cleaning person in a factory, but
who is now retired. Long smoking history, 1 ppd recently. He
apparently is a former alcoholic, but after counseling 10 years
ago, his alcohol intake is much reduced. Current EtOH
consumptions unclear. 3 children who are all well.
Family History:
"stomach cancer" in his mother who died at age [**Age over 90 **]. His father
had laryngeal cancer
Physical Exam:
GENERAL: intubated sedated
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= 8cm
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM, several incisions with
clean dressings, one JP drain
EXTREMITIES: No edema, 2+ dorsalis pedis/ posterior tibial
pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: occ opens eyes and follows commands
Pertinent Results:
[**2197-10-31**] 07:27PM TYPE-ART RATES-/11 TIDAL VOL-640 O2-50
PO2-225* PCO2-46* PH-7.41 TOTAL CO2-30 BASE XS-4
INTUBATED-INTUBATED VENT-CONTROLLED
[**2197-10-31**] 07:27PM GLUCOSE-143* LACTATE-1.6 NA+-136 K+-4.4
CL--101
CXR [**2197-11-2**]: As compared to the previous examination, the
patient has been extubated. The nasogastric tube is in unchanged
position. The lung volumes have slightly decreased. The
pre-existing bilateral pleural effusions are slightly more
extensive than on the previous examination. Also slightly more
extensive are the pre-existing bilateral areas of atelectasis.
Unchanged evidence of mild pulmonary edema. No newly occurred
focal parenchymal opacities suggesting pneumonia. Unchanged
moderate cardiomegaly.
Brief Hospital Course:
72 year old male with s/p subtotal gastrectomy, D2
lymphadenectomy, CBD exploration, and choledochojejunostomy for
gastric antral CA.
[**11-1**] pt admitted to the [**Hospital Ward Name **] ICU post op. He was kept
intubated, NPO/ IVF, PPI [**Hospital1 **], EBL was 2700 intraop given 3 untis
of pRBC, 1 L of albumin. Epidural in place for pain control.
[**11-2**] Extubated , good urine ouput. Hct stable 28.9. Slight
hyppotension to 80s systolic wiht response to decresing the
epidural and 2 L of IVF bolus.
[**11-3**] Trophic tube feeds started. Jp drain removed. Transferred
out of the [**Hospital Unit Name 153**].
[**11-4**] Started on [**Last Name (LF) 84754**], [**First Name3 (LF) **] with norm gas pattern. Epidural
dcd. Cefoxitan started for ? PNA on CXR.
[**11-5**] High NGT output 1600 cc - TF at 30 cc / hr. PCa for pain
control.
[**11-6**] Febrile to 102.5 - pancultured. Nutrition consult.
[**11-7**] Tf at 60cc , sterted on cefoxitan. Dulcolax given.
Physical therapy consulted.
[**11-8**] NGT removed. Diarrhea. C diff checked. Foley removed. Tf
decreased to [**2-22**] stregth with improvement in diarrhea. UGIB
with low gastric emptying.
[**Date range (1) 84755**] Fluids dcd. started on sips to clears.
[**11-11**]: Advanced to regular diet, pain well controlled,
ambulating. Dcd home with VNA, HHA and PT.
Medications on Admission:
Protonix 40 mg [**Hospital1 **]
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
Disp:*qs 1* Refills:*0*
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
1. Gastric adenocarcinoma.
2. Common bile duct obstruction with cholelithiasis and
choledocholithiasis
Discharge Condition:
VSS, toleratins a regular diet with supplements, pain well
controlled with po pain medications, ambulating without
assistance
Discharge Instructions:
General:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your 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:
Please call ([**Telephone/Fax (1) 5323**] to schedule follow up with Dr. [**Last Name (STitle) 519**]
for early next week - please call monday [**2197-11-13**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2197-11-11**]
ICD9 Codes: 5185, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7095
} | Medical Text: Admission Date: [**2160-1-22**] Discharge Date: [**2160-1-30**]
Date of Birth: [**2112-11-21**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 47 year old
gentleman, with a history of HIV, hypertension,
cardiomyopathy, alcohol abuse, fatty liver, with frequent
admissions for early alcohol withdraw, characterized by
tremulousness and sinus tachycardia. He frequently leaves
the hospital against medical advice. He was admitted to the
SICU on [**2160-1-22**] after an episode of binge drinking,
complicated by loss of consciousness and falling. The patient
had a picture consistent with rhabdomyolysis on admission
with CK peaking at 3577 and lactic acidosis with bicarbonate
of 10 and molar gap of 30, secondary to dehydration and
alcohol use. The patient's blood alcohol level on admission
was 417. The patient had an admission CAT scan of his head
which was negative.
The patient was initially put on CIWA scale. Initially, he
was empirically treated with Vancomycin and Ceftriaxone.
Antibiotics were stopped and there was no evidence of sepsis.
The patient had a CAT scan of the abdomen and chest, which
was only sufficient for fatty liver. On admission, the
patient was tachycardia to 130's with sinus tachycardia
secondary to early alcohol withdraw. The patient was started
on Ativan drip and electrolytes were aggressively repleted.
During the SICU stay, the patient had an episode of paranoid
agitation. Psychiatry was consulted and on [**2160-1-24**], the
patient was given Haldol and standing Valium. The patient
was seen by psychiatry again and was shown to have the
capacity to make his own medical incisions and leave against
medical advice if he so wished.
Over the course of the Intensive Care Unit stay, the
patient's lactate, CK trended down. The patient had a
transient episode of thrombocytopenia, secondary to liver
dysfunction in a setting of alcohol use. The patient's
weights were trending back up. The patient was
hemodynamically stable and tolerating regular diet. The
patient declined inpatient psychiatric admission.
PAST MEDICAL HISTORY:
1. HIV, diagnosed in [**2135**]. The patient is a presumed non
progressor.
2. Hypertension.
3. Cardiomyopathy, presumed secondary to alcohol use.
Ejection fraction of 30% on [**6-14**].
4. History of rheumatic heart disease.
5. Generalized anxiety disorder.
6. Macrocytic anemia.
7. Status post cholecystectomy.
8. Fatty liver [**11-14**].
9. Alcoholism.
10. Frequent admissions for early signs of alcohol withdraw.
ALLERGIES: No known drug allergies.
MEDICATIONS AS AN OUTPATIENT:
Risperidone 1 mg p.o. q. day.
Effexor XR 150 mg p.o. q. day.
Propanolol 80 mg p.o. twice a day.
Klonopin 1 mg p.o. three times a day.
Zestril 10 mg p.o. q. day.
Hydrochlorothiazide 25 mg p.o. q. day.
Multi-vitamin one q. day.
Thiamine 100 mg p.o. q. day.
Folate 1 mg p.o. q. day.
Protonic 40 mg p.o. q. day.
MEDICATIONS ON TRANSFER FROM THE INTENSIVE CARE UNIT:
[**Unit Number **]. Trazodone 50 mg p.o. q h.s.
2. Risperidone 10 mg p.o. q. day.
3. Effexor XR 150 mg p.o. q. day.
4. Nicotine patch.
5. Propanolol 40 mg p.o. q. day.
6. Protonic 40 mg p.o. q. day.
7. Klonopin 1 mg p.o. three times a day.
8. Valium 5 mg intravenous every one to two hours prn for
CIWA scale.
9. Tylenol prn.
10. Percocet one to two tablets p.o. every four to six hours
prn.
11. Haldol prn.
12. Imodium 2 mg p.o. four times a day prn.
SOCIAL HISTORY: Lives in [**Hospital3 **] for HIV patient's.
Positive alcohol use since a young age. Frequent history of
binge drinking. Tobacco 70 pack year smoking history.
PHYSICAL EXAMINATION: T maximum of 100; T current of 98.0
pulse 95 to 113; blood pressure 94 to 150 over 59 to 96; 99%
on room air. General: Comfortable in bed, in no apparent
distress. HEAD, EYES, EARS, NOSE AND THROAT: Moist mucous
membranes. Cranial nerves intact. Neck: No
lymphadenopathy. Pulmonary: Clear to auscultation
bilaterally. Cardiovascular: Regular rate and rhythm,
normal S1 and S2, no murmurs, rubs or gallops. Abdomen:
Positive bowel sounds, soft, nontender, nondistended.
Extremities: No cyanosis, clubbing or edema. Right groin
hematoma which is stable. No asterixis. Mild intention
trauma. Neurologically intact. No focal signs.
LABORATORY DATA: On admission to the hospital on [**2160-1-22**],
white count was 6.5; hematocrit of 39.2; platelets 140; MCV
49. Chemistry 10 revealed a sodium of 137; potassium of 4.1;
chloride of 90; bicarbonate 20; BUN 8; creatinine 0.8;
glucose 138. Anion gap of 27. CK 35, 77. Troponin less
than .01. Amylase 160; lipase 43; ALT 199; AST 496; alkaline
phosphatase 235. Total bilirubin of 0.8. INR of 1.0.
Calcium 8.4. Phosphorus of 5.3. Magnesium of 1.5. Serum
osmolarity 385. Alcohol level 417. Otherwise, serum
toxicology screen was negative.
Abdominal CT revealed no intraperitoneal or pelvic visceral
injury. Positive fatty infiltration of liver with
hepatomegaly. Chest x-ray revealed no infiltrates, effusions
or congestive heart failure.
Electrocardiogram revealed narrow complex tachycardia; no ST
T wave changes.
Arterial blood gases 7.33, 27, 88. Urine toxicology positive
for benzos.
Laboratory on transfer from Surgical Intensive Care Unit on
[**2160-1-27**] revealed white count of 5.8; hematocrit of 30.3;
platelets 130. INR of 1.5. Sodium of 135; potassium of 4.6;
chloride of 102; bicarbonate 26; BUN 6; creatinine 0.6;
glucose 86. Calcium 8.6. Phosphorus of 4.2. Magnesium of
1.8. ALT 65; AST 76; LDH 279. Alkaline phosphatase 164.
Total bilirubin of 0.8. Amylase of 117. Lipase 85. Albumin
3.2.
HOSPITAL COURSE: 1. Alcohol withdraw. As mentioned above,
the patient was intermittently on Ativan drip. The patient
did not go into delirium tremens and was hemodynamically
stable after Intensive Care Unit course. On transfer to
general medical floor, the patient's CIWA was between 0 and
1. The patient has not required any further Valium. Issues
around alcohol cessation were discussed extensively with the
patient. The patient states that he strongly opposes
alcoholic anonymous meetings; however, he is agreeable to
join Smart Program and will follow through as an outpatient.
The patient was continued on multi-vitamin, folate, thiamine
and B-12. He was able to ambulate with physical therapy.
The patient refused inpatient physical therapy during this
admission.
2. Lactic acidosis, secondary to alcohol use/dehydration.
This resolved with aggressive fluid resuscitation. The
patient was able to take regular p.o. on the day of
discharge.
3. Rhabdomyolysis. The patient's CK's were trending down.
The patient's renal function remained intact.
4. Alcoholic hepatitis. The patient's liver function tests
were monitored and the patient's transaminase trended down to
patient's baseline levels. The patient has known fatty liver
secondary to alcoholic hepatitis. The patient was once again
instructed on dangers of constantly using alcohol. He was
explained about the problems with liver and pancreas
dysfunction.
5. Diarrhea. The patient's stool studies were sent and were
negative. The patient was empirically started on Pancrease
three times a day before meals with resolution of diarrhea.
Therefore, his diarrhea was presumed to be secondary to
pancreatic insufficiency due to chronic alcoholic
pancreatitis.
6. Thrombocytopenia. Secondary to liver disease. Platelets
were at baseline. On discharge, there was no evidence of
bleeding. The patient had negative heparin dependent
antibodies that were sent in the Intensive Care Unit.
7. Cardiomyopathy: Presumed secondary to alcohol use. The
patient was started on Lisinopril and Propanolol that was
increased to the outpatient dose of 80 mg twice a day. The
patient's Hydrochlorothiazide is to be started as an
outpatient since the patient's systolic blood pressure was
between 100 and 120 on the day of discharge.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES;
1. Alcoholism.
2. Alcohol withdraw.
3. Lactic acidosis.
4. Rhabdomyolysis.
5. Thrombocytopenia.
6. Diarrhea secondary to pancreatic insufficiency.
7. Chronic pancreatitis.
8. Cardiomyopathy.
DISCHARGE MEDICATIONS:
The following changes to the outpatient medications were
made:
1. The patient is to take Pancrease one capsule p.o. three
times a day with meals for pancreatic insufficiency.
2. The patient is to take Lisinopril 10 mg p.o. q. day.
3. The patient was instructed not to take
Hydrochlorothiazide until seen as an outpatient by Dr.
[**First Name (STitle) 4702**].
FOLLOW-UP PLANS:
1. The patient is to follow-up with Dr. [**First Name (STitle) 4702**] within the
next week after discharge.
2. The patient is to attend SMART recovery meetings.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4704**], M.D. [**MD Number(1) 4705**]
Dictated By:[**Name8 (MD) 4937**]
MEDQUIST36
D: [**2160-1-30**] 10:54
T: [**2160-1-30**] 12:01
JOB#: [**Job Number 33915**]
ICD9 Codes: 2765, 2762, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7096
} | Medical Text: Admission Date: [**2182-6-22**] Discharge Date: [**2182-6-26**]
Date of Birth: [**2110-2-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 72 year old
male with a past medical history significant for
gastrointestinal bleed, status post gastrectomy and +/-
Billroth II procedure, who was admitted to the Medical
Intensive Care Unit initially after two days of melena.
The patient was previously taking Aspirin, however, he knew
to stop this medication once the patient started to notice
that he had several episodes of melanotic stools. The
patient was last admitted to [**Hospital6 1708**] in
[**2182-1-29**], where an esophagogastroduodenoscopy showed
questionable scar rupture or Dieulafoy's lesion causing the
patient's gastrointestinal bleed.
During this admission to [**Hospital1 188**], the patient had an esophagogastroduodenoscopy which
showed no active bleeding ulcers and they recommended
increasing the patient's dose of Protonix. In the Intensive
Care Unit, the patient required a total of four units of
packed red blood cells.
The patient's hematocrit on admission was 26.4 and
subsequently went up to 33.4 after the four units. The
patient remained hemodynamically stable throughout the brief
Intensive Care Unit stay and did not require any pressors.
The patient was not hypotensive at any point, nor did he
require intravenous fluid boluses.
However, on hospital day two, the patient's hematocrit
continued to fall, eventually down to 26.0. However, on
recheck, it was 29.1. There was no evidence of any acute
bleeding going on and it was felt that the patient would
continue to have some mild melanotic stools given the history
of gastrointestinal bleed.
The patient also spiked a temperature to 101.2 during the
Intensive Care Unit stay. Urinalysis, chest x-ray and blood
cultures were done. The urinalysis was negative and blood
cultures were negative. Chest x-ray showed patchy opacities
in both the right mid and left lung zones.
Since there was no prior chest x-ray for comparison, it was
not known if these were new or old, however, it was felt that
there was no need for any antibiotics at this time. The
patient defervesced on his own without any intervention. It
was the feeling of the Intensive Care Unit team that the
fever may just have been from postprocedure.
The patient was transferred to the floor in stable condition
for further management of his upper gastrointestinal bleed.
PAST MEDICAL HISTORY:
1. History of gastrointestinal bleed times two, status post
Billroth II gastrectomy in [**Male First Name (un) 1056**] forty years ago.
2. History of Dieulafoy's lesion.
3. Noninsulin dependent diabetes mellitus, followed at
[**Last Name (un) **] by Dr. [**Last Name (STitle) **].
4. Hypertension.
5. History of heart murmur.
6. Stress test at [**Hospital6 1708**] in [**2180-3-29**], showed no perfusion defects.
7. History of BCG vaccine and positive PPD in the past.
ALLERGIES: Codeine.
MEDICATIONS ON ADMISSION:
1. Glyburide 5 mg p.o. b.i.d.
2. Atenolol 50 mg p.o. q.d.
3. Zocor 20 mg p.o. q.d.
4. Aspirin which had been held.
5. Prevacid 30 mg p.o. b.i.d.
6. Metformin 500 mg p.o. b.i.d.
7. Sublingual Nitroglycerin 0.4 mg p.r.n. chest pain.
MEDICATIONS ON TRANSFER:
1. Regular insulin sliding scale.
2. Protonix 40 mg p.o. b.i.d.
3. Metoprolol 25 mg p.o. b.i.d.
4. Sucralfate one gram q.i.d.
FAMILY HISTORY: The patient's mother had a history of
diabetes mellitus as well as congestive heart failure.
Father died in a motor vehicle accident.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] has
been in the United States for thirty years, was originally
fro [**Male First Name (un) 1056**]. He socially drinks alcohol and denies
tobacco use. He works as a hospital inspector.
PHYSICAL EXAMINATION: Vital signs on admission revealed
temperature 98.9, blood pressure 140/90, pulse 110, oxygen
saturation 100% in room air, respiratory rate 20. In
general, the patient was an elderly Hispanic male in no
apparent distress. Head, eyes, ears, nose and throat -
mucous membranes moist. The oropharynx was clear. There was
no jugular venous distention. No lymphadenopathy. The neck
was supple. There were no bruits. The chest was clear to
auscultation bilaterally, no wheezes or crackles were
appreciated. Good air entry. The heart revealed regular
rate and rhythm, II/VI systolic murmur at the apex radiating
to the axilla, no rubs or gallops were appreciated. The
abdomen was soft, nontender, nondistended, positive bowel
sounds. Extremities showed 1+ edema bilaterally and 2+
pulses bilaterally. No clubbing or cyanosis.
Neurologically, the patient was awake, alert and oriented
times three.
LABORATORY DATA: On admission, white blood cell count 8.0,
hematocrit 29.1, platelets 147,000, MCV 85. Sodium 140,
potassium 2.7, chloride 105, bicarbonate 28, blood urea
nitrogen 18, creatinine 0.6, calcium 7.7, magnesium 1.5,
phosphorus 3.2. Blood cultures times two was negative.
Urinalysis was positive for ketone, otherwise no leukocytes,
negative for nitrites.
HOSPITAL COURSE:
1. Gastrointestinal - The patient remained hemodynamically
stable. He was transfused an additional two units of packed
red blood cells with an appropriate bump in his hematocrit to
32.6 prior to discharge. The patient continued to have
episodes of melena.
The gastroenterology service thought that the patient would
continue to have episodes of melena given his history of
upper gastrointestinal bleed for approximately one week. The
patient's Protonix was continued at 40 mg p.o. b.i.d.
The patient was subsequently restarted on his Atenolol given
the fact that the patient's blood pressure had remained
stable and the patient was not hypotensive at any point. The
patient tolerated p.o. diet well without any nausea or
vomiting.
2. Endocrine - The patient had a history of diabetes
mellitus. Initially, the patient was just on regular insulin
sliding scale, however, once the patient tolerated clears as
well as regular p.o. diet, he was restarted on his usual oral
hypoglycemics that he was on as an outpatient and tolerated
those just fine.
3. Pulmonary - Given the patient's patchy pulmonary
opacities in the left mid lung and right base, a chest CT was
done. Chest CT showed nonspecific ground glass opacities in
the left upper lobe in the perihilar region. The
differential included early or resolving infectious process,
asymmetric pulmonary edema, pulmonary hemorrhage or
aspiration event. Multiple calcified mediastinal and hilar
lymph nodes. Calcified pulmonary granulomas and splenic and
hepatic granulomas likely representing previous granulomatous
infection and enlargement of the pulmonary artery suggestive
of pulmonary hypertension. Small foreign body in the right
upper lobe.
Given these findings on chest CT, it was felt that another
PPD should be planted. PPD was planted in the right forearm
and was checked two days after placement. Since the patient
was eventually readmitted after discharge, PPD was found to
be 3.0 centimeters positive for induration.
After discussion with infectious disease service, it was felt
that given the patient's history of positive PPD in the past
and lack of current symptoms including fever, chills,
hemoptysis, that no treatment would be warranted given his
advanced age and increased risk from INH toxicity. However,
the patient should have a follow-up chest CT in a few months
to follow-up those lesions.
4. Infectious disease - The patient was not given any
antibiotics, did not have any more fevers. Blood cultures
were negative. The patient had a RPR drawn at some point
which was negative. The patient's white count remained
stable.
The patient was discharged to home with follow-up with
follow-up at [**Company 191**] for [**Location (un) 1131**] of his PPD , however, the
patient was readmitted. Apparently the patient has a primary
care physician at [**Hospital1 **] and is
followed by Dr. [**Last Name (STitle) 30281**] at [**Last Name (un) **]. He is looking for a new
primary care physician. [**Name10 (NameIs) **] will be decided after
discharge.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed.
2. Noninsulin dependent diabetes mellitus.
3. Hypertension.
4. History of heart murmur.
5. Negative stress test.
6. History of PPD positive.
7. Chest CT with calcified granulomas.
DISCHARGE STATUS: Stable.
MEDICATIONS ON DISCHARGE:
1. Glyburide 5 mg p.o. b.i.d.
2. Atenolol 50 mg p.o. q.d.
3. Zocor 20 mg p.o. q.d.
4. Protonix 40 mg p.o. b.i.d.
5. Metformin 500 mg p.o. b.i.d.
6. Captopril 12.5 mg p.o. t.i.d.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 11283**]
Dictated By:[**Name8 (MD) 9784**]
MEDQUIST36
D: [**2182-6-28**] 16:38
T: [**2182-6-29**] 18:31
JOB#: [**Job Number 30282**]
ICD9 Codes: 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7097
} | Medical Text: Admission Date: [**2149-11-28**] Discharge Date: [**2149-12-9**]
Date of Birth: [**2076-12-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
s/p Coronary Artery Bypass Graft x3 (Left internal mammary
artery > Left anterior descending, saphenous vein graft > RAMUS,
saphenous vein graft > obtuse marginal) and mitral valve
replacement with 27mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] bicor tissue valve [**2149-12-1**]
History of Present Illness:
72 year old male with increasing shortness of breath at rest and
exertional chest pain increasing over the last 3-4 days.
Admitted to OSH and underwent cardiac catherization that
revealed CAD. Transferred to [**Hospital1 18**] for surgical evaluation
Past Medical History:
Hypertropic obstructive cardiomyopathy
Coronary artery disease
mitral regurgitation
Social History:
owner of food company
Tobacco denies
ETOH 1 drink/week
Lives with spouse
Family History:
Father CAD deceased age 77
Brother CAD deceased age 75
Physical Exam:
Vitals 69, 18, RT B/P 104/45
Skin unremarkable
Neck Full ROM, supple
HEENT unremarkable
Chest CTA bilat
Heart RRR SEM [**3-18**] at LSB > apex
Abd soft, NT ND
Ext warm well perfused no edema
Pertinent Results:
[**2149-12-8**] 06:10AM BLOOD WBC-9.1 RBC-3.38* Hgb-9.6* Hct-28.9*
MCV-85 MCH-28.4 MCHC-33.3 RDW-16.0* Plt Ct-331#
[**2149-12-9**] 06:15AM BLOOD PT-27.0* INR(PT)-2.7*
[**2149-12-8**] 06:10AM BLOOD PT-21.5* INR(PT)-2.0*
[**2149-12-9**] 06:15AM BLOOD UreaN-32* Creat-1.6* K-4.9
[**2149-12-8**] 06:10AM BLOOD UreaN-33* Creat-1.8* K-4.7
[**2149-12-7**] 06:30AM BLOOD Glucose-123* UreaN-30* Creat-1.5* Na-135
K-4.4 Cl-96 HCO3-30 AnGap-13
RADIOLOGY Final Report
CHEST (PA & LAT) [**2149-12-7**] 11:40 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
72 year old man s/p cABG and MVR
REASON FOR THIS EXAMINATION:
evaluate effusion
STUDY: PA and lateral chest. [**2149-12-7**].
HISTORY: 72-year-old man status post CABG with mitral valve
replacement. Evaluate effusion.
FINDINGS: Comparison is made to previous study from [**2149-12-5**].
The right-sided venous catheter has been removed. There is
improvement of the pulmonary edema since the previous study.
There remains a left-sided pleural effusion and left
retrocardiac opacity. Atelectasis within the right mid lung zone
is again seen. Median sternotomy wires are seen. There is
air-filled colon interposed between the diaphragm and the liver.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75407**] (Complete)
Done [**2149-12-1**] at 1:27:23 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2076-12-16**]
Age (years): 72 M Hgt (in): 67
BP (mm Hg): 140/60 Wgt (lb): 200
HR (bpm): 70 BSA (m2): 2.02 m2
Indication: Intraoperative TEE for MVR/CABG
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2149-12-1**] at 13:27 Interpret MD: [**Name6 (MD) 3892**]
[**Name8 (MD) 3893**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW3-: Machine: 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Peak Resting LVOT gradient: 5 mm Hg <= 10 mm
Hg
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Mitral Valve - Mean Gradient: 3 mm Hg
Findings
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Severe symmetric LVH. Mildly dilated LV cavity.
Overall normal LVEF (>55%). [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Partial mitral leaflet flail. Severe mitral annular
calcification. Severe thickening of mitral valve chordae. [**Male First Name (un) **] of
mitral valve leaflets. Calcified tips of papillary muscles.
Eccentric MR jet. Severe (4+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
1. The left atrium is dilated. No atrial septal defect is seen
by 2D or color Doppler.
2. There is moderate to severe symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF>55%). [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.]
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic regurgitation is seen.
6. The mitral valve leaflets are severely thickened. There is
posterior leaflet flail. There is severe mitral annular
calcification. There is severe thickening of the mitral valve
chordae. There is systolic anterior motion of the mitral valve
leaflets. An eccentric, anteriorly and posteriorly directed jet
of Severe (4+) mitral regurgitation is seen. There is systolic
reversal as noted by pulse wave doppler of both sided pulmonary
veins.
7. Pt has a hypertrophied septum measuring 1.9 cm to 2.2cm. Peak
velocity across the LVOT is 2.4cm/s.
8. The tricuspid valve leaflets are mildly thickened.
POST-BYPASS:
1. Biventricular function is maintained, LVEF >50%.
2. A bioprosthetic prosthetic valve is noted in the mitral
position. The valve is well seated; there is good leaflet
excursion and there is no paravalvular leak or mitral
regurgitations. Peak gradient across the valve is 11mmHg, mean
gradient is 5mmHg, MVA is 1.7cm2.
3. There is no change in the velocity across the LVOTat rest and
measures 2.4 cm/s.
4. 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) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2149-12-3**] 10:02
Brief Hospital Course:
Transferred in from outside hospital for surgical evaluation.
He underwent preoperative workup and plavix washout. On [**12-1**]
he went to the operating room and underwent coronary artery
bypass gradt and mitral valve replacement. Please see operative
report for further details. He was transferred to the CVICU on
neo, epi, and propofol. In the first 24 hours he awoke
neurologically intact and was extubated. He was started on
amiodarone for ventricular ectopy and continued for atrial
fibrillation. He continued to require vasoactive medications
for blood pressure management and were weaned off post operative
day 3. He continued to improve and was transferred to the floor
post operative day 4. He continued to progress slowly and had a
gout flare in the L knee and ankle. He was treated with
colchicine, was seen by rheumatology. He had a slight increase
in his creat which imporved with a decrease in his lasix. He
was discharged home in stable condition on POD #8.
Medications on Admission:
[**Doctor First Name **]
ASA
Diovan 80/12.5
Flonase
Prilosec
Toprol 100
Vytorin
Discharge Medications:
1. 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*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg daily x 7 days then 200mg daily until discontinued
by Dr. [**Last Name (STitle) 5017**].
Disp:*37 Tablet(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO DAILY (Daily) for 2 weeks.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
9. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
10. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day): to tape burns on left leg.
Disp:*QS 1 month* Refills:*0*
11. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home with Service
Facility:
TBA
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Mitral Regurgitation s/p MVR
Hypertrophic obstructive cardiomyopathy
Unstable Angina
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 [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 5017**] in [**1-14**] weeks ([**Telephone/Fax (1) 5424**]) please call for
appointment
Please follow up with outpatient dentist for evaluation of
implant lower left side
Wound check [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3633**])
[**Hospital 2225**] clinic(Dr. [**Last Name (STitle) 12434**], Ermana or Raychandhur) in 3 weeks
- [**Telephone/Fax (1) 2226**]
Completed by:[**2149-12-9**]
ICD9 Codes: 9971, 4111, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7098
} | Medical Text: Admission Date: [**2122-8-24**] Discharge Date: [**2122-9-8**]
Date of Birth: [**2057-10-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
1. Cardiac catheterization
2. Swan ganz catheter placement
History of Present Illness:
Pt is a 64 year old spanish speaking male from [**Male First Name (un) 1056**] with
history of DM, AF and CHF in the past who presented to [**Hospital1 **] on
[**8-22**] with CP, dyspnea and palpitations. Over the past month
patient had reported several times to local hospitals in [**Country **]
[**Country **]. Pt had several complaints including chest pain, SOB,
fatigue, hernia pain. However he was never admitted there and
sent home with unknown meds. Family was unhappy with care so
took patient out of hospital and brought back to Mass. He
arrived to Mass on [**2122-8-18**]. He was then admitted to [**Hospital1 2519**] on [**2122-8-21**]. There he was found to be in heart failure
and afib. Reportedly he was on Coumadin prior to admission
which he stopped on his own 1 month ago d/t ecchymosis. BNP was
2900 on admission. He was treated with Lasix and diuresed.
There he had an 18 beat run of VT with multiple pauses, up to 4
seconds long. Lidocaine was started and VT did not recur. Echo
done today shows global hk, 3+ MR, EF 30%. Ruled out for an MI.
Received Lovenox 80mg at 8am today. Aspirin 325mg given this
am. Not on Plavix.
.
Pt has a heavy alcohol history drinking about 1 liter vodka per
day for 30 years. Last drink was reportedly 2-3 weeks. ago. No
history of withdrawals or seizures.
.
In the cath lab, he was noted to have R dominant system, with
normal coronaries. Right heart cath with swan placement showed
PCWP 32, with significant elevated V wave at 52. His PAP 60/30
(38).
.
On floor, patient denied any pain. He did complain of slight
SOB, worse with laying down. Denied cough, fevers/chills,
abdominal pain, nausea/vomitting. +BMs (loose).
Past Medical History:
Past Medical Hx:
- A.fib
- CHF
- HTN
- DM2
- Arthritis
- R inguinal hernia
- EtOH Abuse
Social History:
Social Hx: Lives in [**Location 8880**] [**Country **]. Works as construction worker.
[**Country 3992**] vet. Heavy alcohol use 1 liter vodka per day for 30+
years. No tobacco, illicit drug use(denies cocaine, heroin,
IVDU). Last drink was 2-3 weeks ago per family, but definitely
has not had any drinks since [**8-18**] when he arrived in US.
Family History:
Mother and father with heart disease, DM. Brothers with CAD,
heart disease, details unclear.
Physical Exam:
VS: afebrile, BP 145/97, HR 91, RR 23, 02
Gen: Awake, alert, lying in bed. NAD. Appears stated age
Heent: EOMI, PERRL, anicteric sclera, MMM, throat w/o lesions
Neck: supple, no LAD, difficult to assess for JVD
Chest: CTA anterior/lateral, no wheezes or crackles, equal
expansion
CVS: no hyperdnamic impulses appreciated. [**1-19**] syst murmur,
difficult to appreciate, at LLSB
Abd: soft but contracting musculature, NT/ND, no hepatomegaly,
+BS
Ext: warm, well perfused, no edema, no clubbing/cyanosis, 1+
peripheral pulses
Groin: Left groin well dressed, no oozing, no hematoma
Neuro: AO x 3. No focal deficits appreciated
Pertinent Results:
Labs at OSH: Labs at OSH [**8-24**]: na 140, k 4.4, bun 26, creat 1.1,
Cl 96,
dig level 0.6, wbc 6.5, hct37.3, plt 219, INR 1.42, Ca 8.2, Trop
I 0.03
.
OSH Imaging: ECHO: EF 30%
.
[**8-25**] TTE MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.0 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *5.7 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.8 cm
Left Ventricle - Fractional Shortening: *0.16 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 25% (nl >=55%)
Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aorta - Arch: *3.1 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - E Wave Deceleration Time: 111 msec
TR Gradient (+ RA = PASP): *31 to 35 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 0.7 m/sec (nl <= 1.0 m/s)
INTERPRETATION: LEFT ATRIUM: Moderate LA enlargement. RIGHT
ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT
VENTRICLE: Mildly dilated LV cavity. Severe global LV
hypokinesis. Severely depressed LVEF. RIGHT VENTRICLE: Mildly
dilated RV cavity. Severe global RV free wall hypokinesis.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root. AORTIC VALVE: Mildly thickened aortic valve
leaflets (3). Mild (1+) AR. MITRAL VALVE: Mildly thickened
mitral valve leaflets. Mild mitral annular calcification. Mild
thickening of mitral valve chordae. Moderate to severe (3+) MR.
Eccentric MR jet.
TRICUSPID VALVE: Moderate to severe [3+] TR. Mild PA systolic
hypertension. PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is moderately dilated. The right atrium is
moderately
dilated. 2. The left ventricular cavity is mildly dilated.
There is severe global left ventricular hypokinesis. Overall
left ventricular systolic function is severely depressed. 3.
The right ventricular cavity is mildly dilated. There is severe
global right ventricular free wall hypokinesis. 4. The aortic
valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. 5. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is
seen.
6. Moderate to severe [3+] tricuspid regurgitation is seen.
There is mild
pulmonary artery systolic hypertension.
.
Labs on Admission:
[**2122-8-24**] 11:40PM HGB-12.3* calcHCT-37 O2 SAT-70
[**2122-8-24**] 09:59PM TYPE-ART PO2-88 PCO2-47* PH-7.44 TOTAL
CO2-33* BASE XS-6
[**2122-8-24**] 09:59PM LACTATE-1.7
[**2122-8-24**] 09:59PM O2 SAT-96
[**2122-8-24**] 09:59PM freeCa-1.19
[**2122-8-24**] 09:47PM GLUCOSE-82 UREA N-23* CREAT-1.0 SODIUM-137
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-30 ANION GAP-14
[**2122-8-24**] 09:47PM ALT(SGPT)-20 AST(SGOT)-21 LD(LDH)-166 ALK
PHOS-95 TOT BILI-1.0
[**2122-8-24**] 09:47PM ALT(SGPT)-20 AST(SGOT)-21 LD(LDH)-166 ALK
PHOS-95 TOT BILI-1.0
[**2122-8-24**] 09:47PM ALBUMIN-3.7 CALCIUM-9.0 PHOSPHATE-2.9
MAGNESIUM-1.5*
[**2122-8-24**] 09:47PM %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE
[**2122-8-24**] 09:47PM TSH-2.7
[**2122-8-24**] 09:47PM WBC-6.1 RBC-4.27* HGB-12.7* [**Month/Day/Year **]-38.3* MCV-90
MCH-29.8 MCHC-33.2 RDW-17.8*
[**2122-8-24**] 09:47PM PLT COUNT-204
[**2122-8-24**] 09:47PM PT-13.5* PTT-30.8 INR(PT)-1.2*
.
Imaging:
[**2122-8-24**]: Cath:
1. Coronary angiography in this right dominant system did not
demonstrated angiographically apparent coronary artery disease.
.
[**2122-8-25**]: ECHO:
Conclusions:
1. The left atrium is moderately dilated. The right atrium is
moderately
dilated.
2. The left ventricular cavity is mildly dilated. There is
severe global left ventricular hypokinesis. Overall left
ventricular systolic function is severely depressed.
3. The right ventricular cavity is mildly dilated. There is
severe global
right ventricular free wall hypokinesis.
4. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Moderate to
severe (3+) mitral regurgitation is seen.
6. Moderate to severe [3+] tricuspid regurgitation is seen.
There is mild
pulmonary artery systolic hypertension.
.
[**2122-8-27**]: Left femoral Ultrasound:
In the left groin, the left common femoral artery and left
common femoral vein are identified. A vessel is seen to extend
from the artery superiorly to a vascular structure which
demonstrates aliasing. This measures 3.3 cm in maximum
transverse x 2 cm in maximum AP x 3.3 cm in sagittal dimension.
Some thrombus is seen in this lesion. The appearances are
consistent with a pseudoaneurysm of the left groin.
.
IMPRESSION:
.
Pseudoaneurysm of left groin.
.
ART DUP EXT LO UNI;F/U [**2122-8-28**] 8:39 AM
.
Reason: extent of pseudoaneurysm--Dr. [**Last Name (STitle) 68680**] to eval for [**First Name9 (NamePattern2) 10260**]
[**Last Name (un) **]
.
[**Hospital 93**] MEDICAL CONDITION:
64 year old man with CHF, cardiomyopathy, afib, s/p cardiac cath
from left groin, now with pulsatile mass at left groin site
REASON FOR THIS EXAMINATION:
extent of pseudoaneurysm--Dr. [**Last Name (STitle) 68680**] to eval for [**Last Name (STitle) 10260**] thrombin
injection
HISTORY: Follow up for a femoral pseudoaneurysm.
.
FINDINGS: Duplex and color Doppler demonstrate interval,
complete thrombosis of the left common femoral artery
pseudoaneurysm.
.
CHEST (PORTABLE AP) [**2122-8-28**] 7:08 AM
.
FINDINGS: There has been slight interval improvement in the
previously noted pulmonary vascular congestion. The Swan-Ganz
catheter remains in place with the distal tip within the left
interlobar artery. Slight decreased in persistent right pleural
effusion with adjacent relaxation atelectasis is noted. No focal
consolidation noted to suggest pneumonia. An atherosclerotic
aorta and enlarged cardiac silhouette are again evident.
Degenerative change is noted throughout thoracic spine.
.
IMPRESSION: Slight interval decrease in right pleural effusion
and improved pulmonary vascular congestion. Swan-Ganz placement
as above. No repositioning indicated.
.
FEMORAL VASCULAR US LEFT [**2122-8-29**] 9:05 AM
LEFT GROIN ULTRASOUND AND DOPPLER: Again seen is the thrombosed
pseudoaneurysm in the left groin, measuring approximately 19 x
31 mm in greatest axial dimension, similar to the previous exam.
The neck of the pseudoaneurysm is still visible.
.
Doppler evaluation of the neck shows that there is still a
pulsatile flow within it. However, no definite pulsatile flow is
seen around or in the pseudoaneurysm itself.
.
IMPRESSION: Thrombosed pseudoaneurysm. Pseudoaneurysm neck still
open. Compression to close the neck is advised.
.
FEMORAL VASCULAR US LEFT [**2122-8-31**] 10:10 AM
FINDINGS: [**Doctor Last Name **]-scale and color Doppler ultrasound examination of
the left groin again demonstrates a pseudoaneurysm measuring 2.2
x 2.8 cm (which allowing for differences in measurement
technique is relatively unchanged in size from the prior study
where it measured 19 x 31 mm). However, on today's exam, there
is pulsatile flow demonstrated on Doppler within the
pseudoaneurysm, as well as flow within it's neck.
.
IMPRESSION: Unchanged size of pseudoaneurysm. However, on
today's exam, there is redemonstration of flow both within the
pseudoaneurysm as well as within its neck.
.
FEMORAL VASCULAR US LEFT [**2122-9-1**] 10:29 AM
FINDINGS: Grayscale and color Doppler ultrasound examination of
the left groin demonstrates a thrombosed pseudoaneurysm as seen
on the prior study. However, on today's exam, no flow is seen
within the pseudoaneurysm. No neck is visible or identifiable.
.
IMPRESSION: Thrombosed pseudoaneurysm. No flow is seen within
the pseudoaneurysm. No neck is identified.
.
ECG Study Date of [**2122-9-1**] 3:28:38 PM
Normal sinus rhythm with occasional ventricular premature beats.
Voltage
criteria for left ventricular hypertrophy with secondary ST-T
wave
abnormalities. Compared to the previous tracing of [**2122-8-25**]
atrial fibrillation is no longer present.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 156 102 [**Telephone/Fax (2) 68681**] 17 107
.
ECHO Study Date of [**2122-9-1**]
Conclusions:
Mild spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. Mild
spontaneous echo contrast is present in the left atrial
appendage. Mild spontaneous echo contrast is seen in the body of
the right atrium. The left ventricular cavity is dilated.
Overall left ventricular systolic function is severely
depressed. The right ventricular cavity is mildly dilated. There
is moderate global right ventricular free wall hypokinesis.
There are comple (>4mm) 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. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Moderate to
severe (3+) mitral regurgitation is seen. Quantitative
evaluation of mitral regurgitation demonstrates a regurgitant
volume 44 ml/beat with an effective regurgitant orifice ([**Last Name (un) **])
area of 0.34 cm2. Moderate [2+] tricuspid regurgitation is seen.
There is no pericardial effusion.
.
IMPRESSION: No intracardiac thrombus seen. Severe global left
ventricular
systolic dysfunction. Moderate-to-severe mitral regurgitation.
Moderate
tricuspid regurgitation.
.
FEMORAL VASCULAR US LEFT [**2122-9-3**] 9:21 AM
FINDINGS: Grayscale and color Doppler ultrasound examination of
the left groin again demonstrates a predominantly thrombosed
pseudoaneurysm. However, on today's exam, the neck is widely
patent. There is flow also seen within portions of this complex
pseudoaneurysm on today's exam.
.
IMPRESSION: Pseudoaneurysm with flow demonstrated in it's
periphery as well as a widely patent neck.
.
ECG Study Date of [**2122-9-3**] 3:14:52 PM
Sinus rhythm. Occasional ventricular ectopy. Left ventricular
hypertrophy with ST-T wave changes. Compared to the previous
tracing of [**2122-9-1**] no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 198 98 436/442.85 66 15 100
.
CHEST (PA & LAT) [**2122-9-7**] 4:58 PM
PA AND LATERAL CHEST X-RAY: There has been interval removal of a
Swan-Ganz catheter. The cardiac silhouette is enlarged, but
stable. Mediastinal and hilar contours are normal. There are
intramural aortic calcifications. No pneumothorax is seen. A
tiny right pleural effusion is decreased from prior exam. The
left lung is clear. The surrounding soft tissues are stable.
.
IMPRESSION:
1. Interval decrease in size of small right pleural effusion.
2. Cardiomegaly.
.
CHEST (PORTABLE AP) [**2122-9-8**] 10:54 AM
FINDINGS: There is again noted cardiac silhouette enlargement as
well as enlargement of the appendix. The aorta is calcified. The
size of the heart is unchanged, when compared to prior study.
There is again noted a small right pleural effusion. The left
lung is clear. Pleural effusions are unchanged when compared to
the prior study. There is no evidence of pneumothorax or focal
consolidations.
.
IMPRESSION:
1. Stable right pleural effusion.
2. Cardiomegaly.
Brief Hospital Course:
Cardiac:
Pump/CHF: TTE showed EF 25% with global hypokinesis and 3+MR.
There was no significant CAD therefore his disease was likely
non-ischemic cardiomyopathy. Differential included alcohol
induced cardiomyopathy, tachycardic induced cardiomyopathy, and
idiopathic. Thyroid studies were normal. His hemodynamics were
initially decent coming from the cath lab. However, his Sv02
fell to 53, then 45, with a low CI (1.6) and high SVR. These
numbers were not thought to be entirely accurate. He was
started on high dose lisinopril for afterload, which was changed
to captopril for titration. He was also given Lasix 40IV with
an initial good response, being negative 1L. We also started
him on dobutamine to improve inotropy. His hemodynamics
improved significantly (CI 3.18, SVR 800s, Sv02 74). His
dobutamine was then titrated off. We continued his statin. His
Swan was taken out on [**8-29**] with final readings of CI 2.07, SVR
1500. His captopril was switched to Lisinopril 40mg [**Hospital1 **], and he
was also started on Valsartan 80mg. He remained on Metoprolol
and was started on low dose lasix, autodiruesing well. Digoxin
was also started without loading. EP was consulted and
recommended TEE and cardioversion with maintenance on
amiodarone, while holding ICD placement to assess function in
sinus rhythm. He remained asymptomatic throughout admission.
.
Rhythm: The patient was in afib, with mild tachycardia. His
blood pressure was stable. It was unclear how long he had been
in this rhythm. However, it was likely for several months as he
had been on coumadin at some point in time. He also had NSVT at
the outside hospital, for which he was started on a lidocaine
drip. His electrolytes were repleted accordingly, and per EP
recs his lidocaine was stopped in the CCU. To control his afib,
he was maintained on his metoprolol. He was also anticoagulated
on heparin to prevent thrombus, which was stopped for 72hrs and
intermittently thereafter for groin pseudoaneursym management.
TEE and successful cardioversion was performed on [**2122-9-1**]. He
was started on Amiodarone and his digoxin was stopped. He
remained in sinus rhythm after cardioversion.
.
CAD: His cath did not show any disease. Moreover, his lipid
panel looked excellent, with an LDL of 50 and an HDL of 42. We
continued his aspirin and zocor.
.
Valves: Per TTE, the patient had 3+MR. [**Name13 (STitle) **] on dobutamine, his
hemodynamics and exam improved. He was afterloaded with an
ACEI/[**Last Name (un) **] and he tolerated this well. Cardiothoracic surgery was
consulted and thought he might be a good candidate for MVR in
the future. However, they recommended TEE to better assess his
mitral valve. Additionally, they advised holding on any surgery
until he was off alcohol for 3 months. TEE was performed on
[**9-1**] and showed [**1-16**]+ MR with normal leaflets. No immediate
surgical plans were made, although he is to follow up with
cardiac surgery for further assessment.
.
Left Groin Pseudoaneurysm: 48hr post cath, the left groin was
noted to be firm and pulsatile. No bruits or thrills were
appreciated. He had good distal pulses and warm extremities.
An ultrasound was performed which showed a 3.3-2-3.3cm
pseudoaneurysm. Vascular surgery successfully compressed the
aneurysm, confirmed by thrombosus by ultrasound. However,
repeat ultrasound on [**8-31**] showed return of flow. The heparin
drip was witheld and the pseudoaneurysm was re-compressed. Once
again, repeat ultrasound demonstrated complete thrombosus. He
had another ultrasound on [**9-3**] which showed some flow within
complex pseudoaneurysm.
.
Anticoagulation: The patient was maintained on heparin
throughout admission with a PTT goal of 40-50. He was started
on warfarin 3mg PO qHS on [**2122-9-1**]. INR did not increase
appropriately and dose was increased to 5mg. He will be followed
by the [**Hospital 191**] [**Hospital3 **] as an outpatient for dosing of
his warfarin and INR checks.
.
Diabetes Mellitus: His HgbA1C was 6.3. He was kept on an
insulin sliding scale with good result.
.
Alcohol Abuse: The patient was put on CIWA protocol, as well as
standing ativan. He initially had confusion which improved over
the course of 24hrs. He remained stable and did not require
significant amounts of ativan. Socail work was also consulted.
This issue remained stable throughout admission and the patient
was given counceling on the importance of abstinence from
alcohol, especially given his current condition.
.
UTI: A urinalysis was performed on [**9-2**], which showed trace
leukocyte esterase, 6-10 WBCs, moderate bacteria. He was
asymptomatic. His foley was D/C'd and he was started on
Ciprofloxacin 500mg PO BID for 7 days (day 1 = [**9-2**]).
.
Hematuria: Patient had persistent moderate hematuria, though he
was not complaining of urinary symptoms such as frequency, pain,
or urgency. He has not had a prostate exam and will need f/u by
PCP. [**Name10 (NameIs) **] remained stable at discharge.
.
Code: The patient was full code during admission.
Medications on Admission:
ASA 325 PO qDay
MVI
Digoxin 0.125 (held at [**Hospital1 **])
Lisinopril 20 qDay
Zocor 10 qAM
Folate 1 mg PO qDay
Metoprolol 50mg PO BID (held at [**Hospital1 **])
[**Name (NI) **]
MOM
Lidocaine gtt (1mg/hr)
Tylenol
Protonix 40mg qDay
Sertraline 50mg qDay
Isosorbide Mononitrate 30mg PO qDay
Lovenox q12
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please take in the morning.
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed: pain.
10. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 6 days: last dose on [**9-14**], then switch to only one
time per day.
Disp:*12 Tablet(s)* Refills:*0*
11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks: Start [**9-15**], switch to lower dose on [**9-28**].
Disp:*14 Tablet(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
start on [**9-29**].
Disp:*30 Tablet(s)* Refills:*2*
13. Coumadin 2 mg Tablet Sig: 2.5 Tablets PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Congestive Heart Failure
.
Secondary Diagnosis:
1. Idiopathic cardiomyopathy
2. Mitral regurgitation
3. Type 2 Diabetes Mellitus
Discharge Condition:
Afebrile, hemodynamically stable.
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow up appointments, especially with the [**Hospital 3052**] for INR check sicne you are on coumadin. Please avoid
contact sports/heavy lifting as you are on blood thinning
medication. Please return to the hospital with chest pain,
shortness of breath, or any other symtoms that concern you.
Followup Instructions:
Provider: [**Name10 (NameIs) 191**],[**Name11 (NameIs) **] [**Name12 (NameIs) 191**] MEDICAL UNIT Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2122-9-10**] 8:15, located on [**Location (un) **] [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Building, South Reception
.
Provider: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2122-9-10**] 10:50
.
Provider: [**Name10 (NameIs) 62718**] [**Last Name (NamePattern4) 62719**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2122-9-18**] 10:00AM, [**Hospital Ward Name 23**] [**Hospital **] [**Hospital **] Central Suite at [**Hospital1 18**]
.
Provider: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2122-9-30**]
1:30, [**Hospital Ward Name 23**] [**Hospital **] [**Hospital3 **] Central Suite at
[**Hospital1 18**]
.
Please follow up with Dr. [**Last Name (STitle) 914**] of Cardiac Surgery on
Wednesday, [**10-21**], at 2:00 PM in the [**Hospital Unit Name **], [**Location (un) **]
- [**Telephone/Fax (1) 170**]
.
You have a follow up appt with Heart Failure Clinic with Dr.
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**10-5**] at 10AM in [**Hospital Ward Name 23**] 7, Cardiac Servies
[**Telephone/Fax (1) 3512**] .
.
You have a follow up ultrasound on [**9-22**] at 1:00pm in
[**Hospital Unit Name **] [**Location (un) 470**]. Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-9-22**] 1:00
ICD9 Codes: 4280, 4254, 4240, 5990, 4271, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7099
} | Medical Text: Admission Date: [**2151-7-20**] Discharge Date: [**2151-7-24**]
Date of Birth: [**2103-11-11**] Sex: M
Service: SURGERY
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
47 M presents after possible assault in jail and reported
seizure. Intubated at OSH for airway protection. It is not
clear if seizure was secondary to assault or EtOH withdrawl.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 47yo M transf'd from OSH s/p unknown trauma. Per EMS,
pt
was arrested on Saturday [**2151-7-16**] for DUI. Possible MVC
associated w/ arrest, but pt was not taken to hospital. Pt was
withdrawing in jail and was found having a seizure. There is a
vague report he may have been assaulted while in jail, but this
has not been confirmed. He was brought to the OSH, intubated
and
transf'd to [**Hospital1 18**].
Physical Exam:
VS 98.2 128/74 116 20 98% RA
pupils equal
RRR
Chest chear
Abdomen soft
Pertinent Results:
[**2151-7-20**] 07:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
Patient was noted to be tremorous when propofol was turned down.
It was thought that he likely had alcohol withdrawal seizures.
He was weaned from the ventilator and extubated. He has a
subdural hematoma, and a C-5 facet fracture. He was seen by
physical therapy who thought he was deconditioned and week. He
was transferred to the floor where magnesium and potassium were
repleted. On [**2151-7-23**] he was discharged.
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic withdrawal syndrome
seizure disorder
C-5 facet fracture
Subdural hematoma
Discharge Condition:
Stable
Discharge Instructions:
You had some bleeding in your head (called a subdural hematoma).
CT scans show that the bleeding has stabilized.
You should take Dilantin for a total of 7 days, to be completed
[**2151-7-28**]. Because of your bleeding, you are at increased risk of
seizures. The Dilantin will help to prevent these.
No driving for 6 months.
Call your doctor's office or come to the Emergency Room if you
have:
* fevers above 101.5F
* nausea, vomiting that doesn't stop
* headaches or changes in your vision
* blackouts
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 548**] in 4 weeks. You will have
another CT scan of your head on this visit. Please call
[**Telephone/Fax (1) 2992**] to have this arranged.
ICD9 Codes: 2762 |
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