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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7100
} | Medical Text: Admission Date: [**2121-3-19**] Discharge Date: [**2121-4-3**]
Date of Birth: [**2043-6-24**] Sex: M
Service: EMERGENCY
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Respiratory distress.
Major Surgical or Invasive Procedure:
Intubation with mechanical ventilation
Central line placement
Tracheostomy
Placement of Percutaneous Gastrostomy Tube
History of Present Illness:
Mr. [**Known lastname **] is a 77 yo M with PMH of CAD/CABG, DM, CRI, AAA/TAA
repair, multiple CVA, seizure d/o who presented to the ED w/
respiratory distress. Son reports 4 days of lethargy, decreased
POs, 'not walking at all,' and wet, non-productive cough. He
also reports subjective fever the morning of admission. His son
states that his father did not complain of any chest pain,
abdominal pain or dysuria. He has had normal bowel movements. He
lives at home with wife and was seen there today by NP who
referred him to the ED. He denied abdominal
pain/nausea/vomiting/diarrhea/CP/SOB.
On arrival to [**Name (NI) **] pt was tachypneic w/ RR 35, BP 198/122, T 101.2
rectally, sats 70s on RA, 85 on NRB, RLL crackles and rhonchi.
He had a CXR that showed multilobar pneumonia. He was intubated
for respiratory distress with VBG showing 7.28/50/56. Other
significant labs were; BNP 2458, Trop 0.06, Lactate 3.4. His
blood pressure had been in the high 100's systolic and dropped
initially to 90's then to 54/33 after receiving propofol. He
then received 6L NS and peripheral dopa was started. A RIJ
placed and started on central levophed and dopamine per sepsis
protocol (on low dose for both (124/70). He received Levaquin
750mg IV and Ceftriaxone 1gm and was consented for sepsis
research study.
On arrival to floor, ABG was 7.32/45/327 on AC @100% w/ PEEP 10
and FiO2 was decreased to 60. He was started on fentanyl/versed
gtt for sedation, and dopa and levo for BP support.
Past Medical History:
CAD
CABG X 3 VD (70% distal LMCA, 100% PDA/PLV)
HTN
CHF LEVF 50% ([**11-1**])
MR, TR
Anemia (baseline 28.2-33.8)
AFib s/p pacer, D/C cardioversion, on Warfarin
SDH ([**11-1**]): 3 mm L frontoparietal SDH
12 strokes since [**2105**]
DM
CRI (baseline Cr 1.5-1.7)
LLE cellulitis
Surgical History:
AAA repair '[**08**] w/ redo in '[**09**]
TAA repair '95CAD
Social History:
Married, lives in [**Location (un) 538**]. Spanish speaking only . He is
currently retired, was an independent truck driver. Tobacco
remote history, quit over 10 years ago. Alcohol use is rare
Family History:
Non-contributory
Physical Exam:
VS: Temp: 100 BP: 155/83 HR:79 RR:19 O2sat100% on AC FiO2 100,
PEEP 10
GEN: elderly man, lying in bed, intubated
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no jvd
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: sedated
.
on discharge pertinent changes:
NECK: trach collar in place
ABD: PEG in place, wound c/d/i
Pertinent Results:
LABORATORY STUDIES
[**2121-3-19**] BLOOD WBC-10.6 RBC-5.47# Hgb-15.7# Hct-48.6# MCV-89
MCH-28.7 MCHC-32.3 RDW-13.9 Plt Ct-308#
[**2121-3-20**] BLOOD Hct-27.7*
[**2121-4-3**] BLOOD WBC-10.0 RBC-3.71* Hgb-10.5* Hct-32.6* MCV-88
MCH-28.2 MCHC-32.0 RDW-14.8 Plt Ct-524*
[**2121-4-3**] BLOOD Glucose-147* UreaN-14 Creat-1.3* Na-141 K-3.9
Cl-104 HCO3-30 AnGap-11
MICROBIOLOGY
2/2O URINE - NEGATIVE
SPUTUM - NEGATIVE
BLOOD - Coag Neg Staph, Neg
FLU - Negative
Legionella UA Negative
[**Date range (1) 101379**] Sputum growing Yeast
Blood Cx [**3-20**], [**3-22**] Negative
REPORTS AND STUDIES
ECHO [**3-21**]:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular ejection fraction is
normal (LVEF 60-70%); however, the basal segments of the
inferior septum, inferior free wall, and posterior wall are
hypokinetic. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The descending thoracic aorta
is moderately dilated. The aortic valve is not well seen. There
is no aortic valve stenosis. No 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 are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2119-5-6**], the mitral regurgitation appears reduced;
however, this suboptimal study may have underestimated the
mitral regurgitation.
CXR [**2121-4-1**]
In comparison with the study of [**3-31**], there is little overall
change. Tubes remain in place in this patient with median
sternotomy and pacemaker leads. Hazy opacification of the lower
half of the right hemithorax is again seen, consistent with
pleural fluid. Some asymmetric pulmonary edema, worse on the
right, is suggested.
CXR [**2121-4-2**]:
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
single lumen PICC line placement via the right basilic venous
approach. Final internal length is 43 cm, with the tip
positioned in SVC. The line is ready to use.
Brief Hospital Course:
A/P: 77 yo M with PMH of CAD/CABG, DM, CRI, AAA/TAA repair,
multiple CVA who presented initially with RLL pneumonia,
admitted to the MICU intubated [**3-1**] to respiratory distress and
hypotension, extubated briefly, then reintubated secondary to
increased secretions.
.
#) Pneumonia/Respiratory Failure: Upon initial presentation, the
patient had had 4 days of lethargy, and increased cough with
inability to clear sputum. The patient was intubated initially
and started on levofloxacin and ceftriaxone. Flagyl was
additionally added; The patient's vent was titrated according to
ABGs. Ceftriaxone was discontinued on [**3-25**]. The patient was
extubated on [**3-26**], but required reintubation the subsequent day
for respiratory distress, presumed secondary to thick
secretions. A pneumonia was seen on CXR, and the patient was
started on zosyn and vancomycin. The patient had a trach, PEG
and central line placed on [**2-/2042**]. Pressure support was weaned as
tolerated, but he may require more ventilator support for
transport. Zosyn and vancomycin are to be continued for an 8
day course for PNA. Zosyn and vanc are to be given via PICC for
1 more days for 8 days total. PICC lines was placed on [**2118-4-2**]
and is ok for use. Last day of vancomycin and zosyn will be
[**2121-4-4**].
.
#) Hypotension/Sepsis: On initial presentation, pt was
hypertensive to 200s/100s, but BP began to drop after
intubation. IV dopamine and fluids were started, BP increased.
The patient was pan-cultured. The patient's pressors were
weaned and fluid boluses were given as necessary. Resolved.
.
#) Hypernatremia: Initial sodium was 160. The patient did not
appear volume-overloaded on arrival to the medical floor despite
receiving 6 L NS. Most likely cause was thought to be
dehydration from not drinking water. The free water deficit was
calculated and the patient was given free water to bring his
sodium down. His electrolytes were closely monitored. He can
continue to get free water with his tube feeds as needed.
.
#) A-fib/A-flutter: pt has a history of this, controlled on
sotolol and metoprolol. During admission, he went into a-fib
with rvr and a-flutter but this wsa controlled with uptitration
of medications including calcium channel blocker & beta blocker.
- Continue lopressor and diltiazam for control (can titrate up
if needed)
.
#) Renal Failure: Cr 1.8 on admission, elevated BUN/Cr ratio
suggests at least partial pre-renal etiology although pt has
chronic renal insufficiency with baseline Cr of 1.6. Currently,
creatinine stable and at baseline, creatinine 1.3 at discharge.
.
#) Mental Status - Pt still remains largely unarousable despite
being off of sedating medications. Per discussion with family,
his baseline is poor to start.
- continue to hold sedating medications.
.
#.) Anemia-Pt received 1 U PRBC on [**3-31**] for a Hct of 24.9, with
an apppropriate hematocrit elevation. Hematocrit 32.6 at time of
discharge.
.
#) CAD: h/o CAD s/p CABG X 3 VD (70% distal LMCA, 100% PDA/PLV)
- continue ASA, statin
.
#) Pump: last ECHO [**5-4**] = LEVF 50%, no signs of volume overload
at present.
.
#) Hyperlipidemia: continue statin
.
#) DM: Continue glargine 20 U hs and insulin per sliding scale.
.
#) F/E/N: IVF prn. Replete lytes PRN. TF at goal.
.
#) PPx: Bowel regimen, PPI, pneumoboots, heparin SC TID while
nonambulatory.
.
#) Access: PICC
.
#) Code Status: DNR. Patient would like no CPR, no shock, but
vasopressors okay.
.
#) Communication: [**Name (NI) **] [**Name (NI) **] (wife) [**Telephone/Fax (1) 104708**]
Medications on Admission:
Amlodipine 10mg QD
Aspirin 325mg QD
Citalopram 10mg QD
Docusate 200mg [**Hospital1 **]
Glipizide 5mg QD
Keppra 500mg TID
Lipitor 20mg QD
Lisinopril 5mg QD
Metoprolol 100mg QD
Senna 187mg tab QD
Sotalol AF 80mg [**Hospital1 **]
Zyprexa 5mg QD @ 5pm
.
Allergies: Amiodarone (neurotoxicity), Codeine, PCN
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: per
tube.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: per tube.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day): per tube. mL
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): per tube.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
per tube.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: per tube.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5,000
unit injection Injection TID (3 times a day): while
nonambulatory.
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): hold for sbp <100, hr <55
per tube.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
12. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
13. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: humalog insulin sliding scale.* *
Refills:*2*
14. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20)
units Subcutaneous at bedtime.
15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
at 5pm.
16. Citalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
18. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
g Intravenous Q 12H (Every 12 Hours) for 3 doses: To end after
PM dose on [**2121-4-4**].
20. Zosyn 4.5 gram Recon Soln Sig: 4.5 g Intravenous every eight
(8) hours for 1 days: To end after PM dose on [**2121-4-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY
Sepsis
Pneumonia
Atrial Fibrillation
Acute Renal Failure
SECONDARY
Chronic Kidney Disease Stage II
Chronic Diastolic Congestive Heart Failure
Anemia
h/o Subdural Hemorrhage
h/o stroke x12
Diabetes
Dementia
Discharge Condition:
afebrile, normotensive, comfortable on trach mask
Discharge Instructions:
You were admitted to the hospital with respiratory distress and
found to have a pneumonia. You were on the ventilator to assist
with your breathing while you were treated with antibiotics.
Because of your condition, you were not able to be off of the
ventilator initially, and underwent a tracheostomy to help with
secretions and aspiration.
Your medications have changed.
Please review your current medication list.
You are being discharged to a rehab/skilled nursing facility.
If you develop fevers, chills, respiratory difficulty, shortness
of breath, or other concerning symptoms, please return to the
hospital.
Followup Instructions:
Please follow-up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks
of leaving the hospital.
Completed by:[**2121-4-3**]
ICD9 Codes: 0389, 486, 2760, 5849, 5070, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7101
} | Medical Text: Admission Date: [**2104-12-31**] Discharge Date: [**2105-1-6**]
Date of Birth: [**2050-12-10**] Sex: F
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 40865**] is a 56-year-old
woman with a history of coronary artery disease, status post
[**2102**], also longstanding type 1 diabetes, who was in her usual
state of poor health in which she generally just stays in bed
or sits in a chair until two weeks prior to presentation when she
began experiencing chest pain. The patient experienced frequent
episodes of chest pressure up to several times a week lasting up
to 10-15 minutes, but resolving with nitroglycerin.
usual angina, which she describes as a "pressure in the
middle of her chest, at rest". She took one sublingual
nitroglycerin which relieved the pressure. However, the
patient's chest pressure returned 30 minutes later, but was again
relieved with one sublingual nitroglycerin. The discomfort
appeared for a third time, at this time it was a sharp and
sternal chest pain not relieved with nitroglycerin and then
she presented to the [**Hospital1 1474**] Emergency Department.
At no point did she experience any shortness of breath,
nausea, vomiting, diaphoresis, or palpitations. In the
[**Hospital1 1474**] Emergency Department, she was found to have ST
elevations in lead III, [**Street Address(2) 4793**] depression in aVL, 0.[**Street Address(2) 1755**]
depression in V3 and V4. She also had Q waves in V1 and V2
and slight prolonged Q-T interval. At the outside hospital,
she was treated with 50 mg of Lopressor intravenously, and
made pain free with 10 mg of morphine sulfate. She was then
treated with aspirin, Aggrastat, nitroglycerin drip, and Heparin
drip. She remained pain free and was transferred to [**Hospital1 346**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post angioplasty in [**2097**],
myocardial infarction in [**2097**] and [**2102**].
2. Renal insufficiency, baseline creatinine uncertain.
3. Diabetes mellitus type 1 x47 years complicated by
retinopathy, nephropathy, and neuropathy.
4. Depression.
5. Toe amputations of all five digits on the left.
6. Chronic anemia uncertain hematocrit at baseline.
7. Essential tremor.
HOME MEDICATIONS:
1. Lopressor 75 mg [**Hospital1 **].
2. Insulin 10 units of regular q am, 20 units of NPH q am, 24
units of N q pm. She is on a regular sliding scale at
dinner.
3. Lasix 80 mg po q day.
4. Zoloft 50 mg po q day.
5. Lipitor 50 mg po q day.
6. Sublingual nitroglycerin prn.
7. Aspirin 325 mg po q day.
8. Iron sulfate 325 mg po q day.
9. Vitamin C.
ALLERGIES: Bactrim and Biaxin. She becomes nauseous to both
of those drugs.
REVIEW OF SYSTEMS: Of note, the patient spends most of her
time in bed, though will transfer to a chair. She is unable
to walk secondary to weakness and shortness of breath with
minimal exertion.
PHYSICAL EXAMINATION: Upon presentation to the Cardiac
Intensive Care Unit, the patient had the following vital
signs: Her temperature is 97.8, blood pressure 107/55, heart
rate 76 and regular. She is breathing 16. Sating 88% on
room air, 100% on nonrebreather at 10 liters. GENERAL: She
is lying in bed with a nonrebreather. She can speak in full
sentences in no acute distress. She has a resting tremor of
her right foot and left hand. HEENT: She has no vision in
her right eye. Her left eye has decreased vision with
surgical pupils. She is anicteric. Her oropharynx is clear
and dry. NECK: No bruits, no jugular venous distention
appreciated at 45 degrees. CARDIOVASCULAR: Regular, rate,
and rhythm, normal S1, S2, no murmurs, rubs, or gallops.
LUNGS: Respiratory crackles bilaterally to 1/3 up on the
right, 1/2 up on the left. No wheezes or rhonchi. ABDOMEN:
Soft, nontender, and nondistended, positive bowel sounds.
EXTREMITIES: Five toe amputee on the left, no edema. She
had Doppler DP pulses bilaterally and 1+ femoral pulses
bilaterally. NEUROLOGICAL: She is alert and oriented times
three. She is moving all extremities symmetrically despite
the tremor. She has this resting tremor in the right foot
and left hand. She has decreased sensation of both feet to 2
cm above the ankle to light touch.
LABORATORIES ON PRESENTATION: The patient had the following
laboratories at the outside hospital: She had a complete
blood count which had a white blood cell count of 10.1,
hematocrit of 32.2, MCV of 90, and platelets of 248. She had
74% polys, 21% lymphocytes, 3% monocytes. PT 12.2, PTT 20.6,
an INR of 1.0.
Her chemistry is as follows: She had a sodium of 133,
potassium of 5.1, chloride 98, bicarb 22, BUN 51, creatinine
2.0, baseline not certain, and a glucose of 513. Her enzymes
at the outside hospital were as follows: She had a CK of
149, CK MB of 4.7, index of 3.2, and troponin less than 0.3.
She had a chest x-ray which showed bibasilar opacities.
Heart size within normal limits.
Of note, she had cardiac catheterization in [**2103-6-8**] at
[**Hospital3 **], which showed three-vessel disease. She had
diffuse disease in the proximal right coronary artery with a
90% mid right coronary artery lesion and diffuse disease in
the other vessels. She had an echocardiogram in [**6-7**] which
showed an ejection fraction of 45-50%.
Upon arrival here, her laboratories were as follows: She had
a white blood cell count of 11.3, hematocrit of 27.9,
platelets of 241. PT 15.3, PTT 140.9, INR 1.5. Sodium 141,
potassium 4.7, chloride 106, bicarb 22, BUN 51, and
creatinine of 1.7, and glucose was 343, calcium 7.8,
magnesium 2.1, phosphorus 4.3. Her CK had risen to 377. CK
MB to 44. Her index showed 11.7 and troponin increased to
37.8. Her hemoglobin was 7.4. She had a urinalysis which
showed trace blood, negative nitrates, traced glucose,
negative protein, negative ketones, and trace leukocyte
esterase, [**3-11**] red blood cells, and [**6-16**] white blood cells,
many bacteria, and 0-2 epi's. Her urine electrolytes showed
a sodium of 88, creatinine of 49, potassium of 36, and osms
of 410. Of note, she had a peak CK of 1,112, which declined
to 692.
Her electrocardiogram was notable for resolution of the ST
elevation in III the day after admission.
She underwent cardiac catheterization which shows the
following: She had severe three vessel coronary artery
disease, severe left ventricular diastolic dysfunction. Her
left main was diffusely diseased. The left anterior descending
artery was diffusely diseased throughout with 90% lesion at D2.
She had diffusely diseased proximal left circumflex lesion and a
subtotal occlusion of the right coronary artery at the mid vessel
with left to right collaterals.
She in addition, she had a transthoracic echocardiogram during
this admission which demonstrated the following: She had
anterior akinesis with inferobasilar and inferolateral
hypokinesis. Her left ventricular ejection fraction was
likely unchanged from her [**2102**] study which demonstrated an
ejection fraction of 45-50%. Of note, she had a normal TSH
in addition, and she grew Gram-negative rods, Klebsiella
pansensitive from her urine cultures greater than 100,000
colonies.
HOSPITAL COURSE:
1. Cardiovascular: The patient from a pump standpoint, had
severe left ventricular diastolic dysfunction with an
estimated ejection fraction of 45-50%. She remained slightly
fluid overloaded during her hospital stay and was gently
diuresed. This was done carefully given the patient's
tenuous blood sugar control and her tendency to tip into
diabetic ketoacidosis very easily.
Otherwise, her blood pressure remained systolic between
90-130 during her hospital stay. She was started on a beta
blocker and ACE inhibitor, and tolerated both of these
medications well.
From a rhythm standpoint, the patient remained in normal
sinus rhythm following her transfer from Cardiac Intensive
Care Unit to the floor. She had a known artifact on her
Telemetry which mimicked monomorphic V-tach with an essence
of an artifact from her essential tremor. She had no other
arrhythmias.
Coronary artery disease: As mentioned previously, the
patient had a catheterization which showed triple vessel
disease and mid right coronary artery lesion that was complex
in nature and extended for several cm and is deemed not
amenable to stenting due to high risk of reocclusion. The
patient was scheduled for a Persantine thal stress test to
further elucidate the extent of the ischemia. This was
scheduled for [**2105-1-5**].
The plan was if that the ischemia was extensive, that they
would consider placing a stent regardless of the risk of
restenosis. If the ischemia was mild-to-moderate, the plan
was to medically manage the patient with beta blockers, ACE
inhibitors, aspirin, Plavix, and HMG coA reductase inhibitor
until she can be bridged to a drug eluting stent with the much
less likelihood of restenosis.
2. Endocrinology: During her hospital stay, the patient had
blood sugars that were very difficult to control. She
initially had a blood sugar of 513 at the outside hospital
and likely was in diabetic ketoacidosis at that time. She
was initially controlled with an insulin drip, and then
transitioned to subQ insulin. She was initially tried on
doses of Lantus with a Humalog sliding scale tid, however, in
light of this failed to be controlled with blood sugars, and
on the 29th, she was switched back to her outpatient regimen
with 20 units of N in the morning and 24 units of N in the
evening with tid Humalog sliding scale.
She will require close endocrinologic followup, although the
patient states that her insurance will not allow her to go to
[**Last Name (un) **]. This remains an unresolved issue, and the patient
needs to find an endocrinologist closer to home covered by
insurance to manage her sugars better as her hemoglobin A1C
was 7.4 contributing to her cardiovascular disease. In
addition, she is at high risks for persistent diabetic
ketoacidosis. Her TSH was within normal limits.
3. Hematology: Following her admission, the patient had a
slight drop in her hematocrit from 34 to 27, and then to 25.
The patient has known chronic anemia of uncertain etiology
likely secondary to chronic renal insufficiency and iron
deficiency. She showed no evidence of active bleed and had a
small ecchymosis at her catheterization site, however, there
is no evidence that she bled during her hospitalization. She
was transfused 1 unit of packed red blood cells and her
hematocrit rose appropriately, and there was no further
evidence of hematocrit drops or active bleed during her stay.
4. Infectious Disease: The patient was noted to have white
blood cells in her urine and grew greater than 100,000
colonies of Klebsiella that was sensitive to levofloxacin.
She was treated with five day courses of ciprofloxacin and
remained afebrile with a high normal white count during her
hospital stay and no urinary symptoms.
CONDITION ON DISCHARGE: Patient's condition was fair.
DISCHARGE STATUS: Likely to home.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post inferior myocardial
infarction with ST elevation and right coronary artery mid
lesion.
2. Type 1 diabetes with difficult to control blood sugars.
3. Urinary tract infection with Klebsiella.
4. Chronic renal insufficiency.
5. Chronic anemia.
6. Gastroparesis.
7. Postprandial nausea and vomiting.
DISCHARGE MEDICATIONS: The discharge medications will be
completed at discharge summary addendum.
FOLLOW-UP PLAN: Follow-up plans will be completed at
discharge summary addendum.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2105-1-5**] 07:46
T: [**2105-1-9**] 04:52
JOB#: [**Job Number 37961**]
ICD9 Codes: 5990, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7102
} | Medical Text: Admission Date: [**2162-7-5**] Discharge Date: [**2162-7-11**]
Date of Birth: [**2103-3-2**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamides) / Methadone
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
airway observation
s/p RTKA
Major Surgical or Invasive Procedure:
R TKR
History of Present Illness:
This is a 59 yo F with a past medical history significant for
OSA, morbid obesity, COPD and hypogammaglobulinemia who was
admitted today for right total knee replacement. This morning,
she received a dose of IVIG, did well intra and postoperatively,
however, she is admitted to the [**Hospital Unit Name 153**] for observation of her
airway postoperatively given her history of angioedema in [**10-22**].
This was of unclear etiology but thought due to medications and
did not require intubation.
.
In the PACU, her vitals were T 97.6, BP 120/70, HR 50's, RR
10-15 satting in the mid 90's on 2L by NC. On arrival to the
[**Hospital Unit Name 153**], she is on a ketamine gtt, she is alert and communicative
and complains of very mild pain in her right knee.
As indicated above; pt was admitted to orthopaedic surgery for R
TKA. She was admitted one day early for her extensive PMH
including infusion of IVIG.
Past Medical History:
PMH:
Hypogammaglobulinemia and chronic severe urticaria treated with
IVIG
infusions
OSA
Morbid Obesity- BMI of 43
NIDDM
COPD
Autoimmune Hypothyroidism
s/p gastric bypass
prolonged QT interval and possibly with syncopal episodes
migraines
history of angioedema - autoimmune urticaria/angioedema syndrome
GERD
fibromyalgia
Hypercholesterolemia
h/o recurrent pneumonias
DJD back
.
PSH:
s/p TKR on the left
Social History:
no tobacco, etoh, illicits
Family History:
Father died of "blocked arteries. No family history of sudden
death.
Physical Exam:
Vitals: 97.8 134/82 67 23 100%2L NC
General: Obese 59 yo F, alert, NAD
HEENT: EOMI, PERRL, anicteric. OP clear, MM dry, edentulous.
Unable to assess JVP given habitus.
Chest: Distant heart sounds, RRR no m/r/g
Lungs: Small lung volumes, clear to auscultation
anteriorly/laterally
Abd: obese, soft, NT/ND +BS
Ext: no e/c/c, wwp
Skin: warm and dry, no rashes
Neuro: CN II-XII in tact bilaterally, sensation to LT in tact
bilaterally, motor [**4-19**] on upper and LLE, can wiggle toes on RLE.
RLE in CPM.
Ortho Exam:
Wound c/d/[**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 938**]/TA/GS intact
minimal SSD
minimal ecchymosis
Pertinent Results:
[**2162-7-5**] 02:50PM WBC-11.5* RBC-4.33 HGB-12.9 HCT-38.4 MCV-89
MCH-29.8 MCHC-33.6 RDW-13.8
[**2162-7-5**] 02:50PM GLUCOSE-144* UREA N-7 CREAT-0.7 SODIUM-141
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2162-7-7**] 03:25AM 7.1 3.04*# 9.0*# 27.1*# 89 29.8 33.4 13.6
152
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2162-7-7**] 03:25AM 100 6 0.5 140 3.2*1 109* 22 12
[**2162-7-8**] 06:30AM BLOOD WBC-8.2 RBC-3.16* Hgb-9.3* Hct-27.7*
MCV-88 MCH-29.6 MCHC-33.8 RDW-13.5 Plt Ct-152
[**2162-7-7**] 03:25AM BLOOD WBC-7.1 RBC-3.04*# Hgb-9.0*# Hct-27.1*#
MCV-89 MCH-29.8 MCHC-33.4 RDW-13.6 Plt Ct-152
[**2162-7-5**] 02:50PM BLOOD WBC-11.5* RBC-4.33 Hgb-12.9 Hct-38.4
MCV-89 MCH-29.8 MCHC-33.6 RDW-13.8 Plt Ct-236
[**2162-7-5**] 02:50PM BLOOD Neuts-85.5* Lymphs-11.5* Monos-2.6
Eos-0.3 Baso-0.1
[**2162-7-8**] 06:30AM BLOOD Plt Ct-152
[**2162-7-7**] 03:25AM BLOOD Plt Ct-152
[**2162-7-8**] 06:30AM BLOOD Glucose-124* UreaN-8 Creat-0.7 Na-139
K-4.1 Cl-101 HCO3-33* AnGap-9
[**2162-7-7**] 03:25AM BLOOD Glucose-100 UreaN-6 Creat-0.5 Na-140
K-3.2* Cl-109* HCO3-22 AnGap-12
[**2162-7-7**] 03:25AM BLOOD Calcium-6.8* Phos-3.3 Mg-1.4*
[**2162-7-5**] 02:50PM BLOOD Calcium-9.3 Phos-3.9 Mg-1.5*
Brief Hospital Course:
59 y/o F with MMP including hypogammaglobulinemia, prolonged QT
syndrome, OSA and morbid obesity admitted for airway observation
s/p right TKR in light of past h/o angioedema.
.
# Airway mgmt ?????? No s/sx airway compromise, edema post-op;
patient is comfortable with minimal O2 requirement. Stable for
transfer out of ICU.
-cont. outpatient dose of prednisone
.
# s/p right TKR: Pain well controlled
-plan per surgical team ?????? ketamine gtt, dilaudid PCA
.
# prolonged QT ?????? EKG on admission QTc 469, borderline; no
arrhythmias on tele
-repleted K, Mg PRN
.
# COPD: continue albuterol, singulair, prednisone.
.
#. Hypogammaglobulinemia: Received IVIG the morning prior to
surgery. No acute issues.
.
#. NIDDM: Continue metformin, insulin sliding scale. Diabetic
diet.
.
#. Hypothyroidism: continue levothyroxine.
.
#. GERD: omeprazole.
.
#. F/E/N: Diabetic diet. Euvolemic.
ADDENDUM.
The patient was admitted on [**2162-7-5**] for preop optimization and
IVIG infusion and taken to the operating room by Dr.
[**Last Name (STitle) **] where the patient underwent R TKA. The procedure was well
tolerated and there were no complications. Please see the
separately
dictated operative report for details regarding the surgery. The
patient was subsequently transferred to the post-anesthesia care
unit
in stable condition and transferred to the [**Hospital Unit Name 153**] later that day
for observation of her airway given he hx of angioedema and
complicated medical hx.
Overnight, the patient was placed on a PCA for pain control w/
ketamin drip as per the pain service. IV
antibiotics were continued for 24 hours postoperatively as per
routine. Lovenox was started the morning of postop day 1 for DVT
prophylaxis. The patient was placed in a CPM machine with range
of
motion set at 0-45 degrees of flexion up to 90 degrees as
tolerated.
The drain was removed without incident. The patient was weaned
off of
the PCA and ketamin onto oral pain medications. The Foley
catheter was removed
without incident. The surgical dressing was also removed, and
the
surgical incision was found to be clean, dry, and intact without
erythema nor purulent drainage.
During the hospital course the patient was seen daily by
physical
therapy. Labs were checked both post-operatively and throughout
the
hospital course and repleted accordingly. The patient was
tolerating
regular diet and otherwise feeling well. Prior to discharge the
patient was afebrile with stable vital signs. Hematocrit was
stable
and pain was adequately controlled on a PO regimen. The
operative
extremity was neurovascularly intact and the wound was benign.
The
patient was discharged to home with service or rehabilitation in
a
stable condition.
Medications on Admission:
singulair 10
amlodipine 5
propanolol 80
cyclobenzaprine 20 qhs
lunesta 2 qhs
hydroxyzine 25 1-2q4-6prn
darvocet prn
Potassium Chloride 10 meq daily
bumex 1
simvastatin 20
zyrtec prn
prednisone 20
zantac prn
cellcept [**Pager number **]
metformin 500
neurontin 300
levothyroxine 88
rhinoocort prn
prilosec 20
amerge 2.5 prn for headache
proventil
Discharge Medications:
1. Budesonide 32 mcg/Actuation Aerosol Sig: One (1) Nasal prn
().
2. Naratriptan 2.5 mg Tablet Sig: One (1) Tablet PO prn ().
3. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once
a day for 3 weeks.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 2 weeks.
7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Prednisolone Oral
9. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Cyclobenzaprine 10 mg Tablet Sig: Two (2) Tablet PO QHS
(once a day (at bedtime)).
11. Hydroxyzine HCl Oral
12. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for allergy symptoms.
13. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Proventil HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-16**]
Inhalation Q4H (every 4 hours) as needed for for SOB or
wheezing.
15. Darvocet-N 100 Oral
16. Simvastatin Oral
17. Propranolol Oral
18. CellCept Oral
19. Potassium Chloride Oral
20. Metformin Oral
21. Amlodipine Oral
22. Singulair Oral
23. Lunesta Oral
24. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
25. Bumetanide Oral
26. Zantac Maximum Strength Oral
27. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for contipation.
28. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3
hours) as needed for pain.
MEDICATIONS: VERY IMPORTANT - pt has extensive list of
medications and she likes to take her own medications. She is
responsible and knowledgeable about her condition. We gave her
the permission to take her own meds while she is here at the
hospital. From orthopaedic perspective, she should take her
daily dilaudid (4-6mg q3h prn) pain medication prn along with
darvocet (2 tabs) as long as she tolerates both. Dilaudid should
be weaned off as pain improves. She must also take lovenox
injections (40mg SC) x 4 wks for DVT px. Calcium, and vitamin D
supplements were given along with Iron pills (x2 weeks) to
stimulate blood production. While these supplements are
recommended, they are not absolutely necessary. Pt should go
back on all her home medication. At the time of this review, pt
was tolerating all medication as listed on this d/c summary.
Discharge Disposition:
Extended Care
Facility:
Rehab Hospital Of [**Doctor Last Name **]
Discharge Diagnosis:
OA
Discharge Condition:
stable
Discharge Instructions:
should experience: severe pain not relieved by medication,
increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage at the incision
site,
chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new
medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for your pain control. Please
do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain
medication. This medication can cause constipation, so you
should
drink plenty of water daily and take a stool softener as needed
to
prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or
your primary physician.
6. Please keep your wounds clean. You can get the wound wet or
take a
shower starting 5 days after surgery, but no baths or swimming
for at
least 4 weeks. No dressing is needed if wound continued to be
non-draining. Any stitches or staples that need to be removed
will be
taken out at your 2-week follow up appointment, by your PCP or
at
rehab.
7. Please call your surgeons/doctors office to [**Name5 (PTitle) **] or
confirm
your follow-up appointment.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
ANTICOAGULATION: Please take lovenox injections (40mg) once a
day x 4 weeks.
WOUND CARE: Keep your incision clean and dry. Okay to shower
after
POD#5 but do not tub-bath or submerge your incision. Please
place a
dry sterile dressing to the wound each day if there is drainage,
leave
it open to air. Check wound regularly for signs of infection
such as
redness or thick yellow drainage. Staples will be removed by VNA
in 2
weeks. If you are going to rehab, then rehab can remove staples
at 2
weeks.
ACTIVITY: Weight bearing as tolerated to operative leg, and CPM
machine advance as tolerated. No strenuous exercise or heavy
lifting
until follow up appointment, at least.
VNA (after home): Home PT/OT, dressing changes as instructed,
and
wound checks, staple removal in 2 weeks after surgery.
MEDICATIONS: VERY IMPORTANT - pt has extensive list of
medications and she likes to take her own medications. She is
responsible and knowledgeable about her condition. We gave her
the permission to take her own meds while she is here at the
hospital. From orthopaedic perspective, she should take her
daily dilaudid (4-6mg q3h prn) pain medication prn along with
darvocet (2 tabs) as long as she tolerates both. Dilaudid should
be weaned off as pain improves. She must also take lovenox
injections (40mg SC) x 4 wks for DVT px. Calcium, and vitamin D
supplements were given along with Iron pills (x2 weeks) to
stimulate blood production. While these supplements are
recommended, they are not absolutely necessary. Pt should go
back on all her home medication. At the time of this review, pt
was tolerating all medication as listed on this d/c summary.
Physical Therapy:
WBAT.
Treatments Frequency:
should experience: severe pain not relieved by medication,
increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage at the incision
site,
chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new
medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for your pain control. Please
do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain
medication. This medication can cause constipation, so you
should
drink plenty of water daily and take a stool softener as needed
to
prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or
your primary physician.
6. Please keep your wounds clean. You can get the wound wet or
take a
shower starting 5 days after surgery, but no baths or swimming
for at
least 4 weeks. No dressing is needed if wound continued to be
non-draining. Any stitches or staples that need to be removed
will be
taken out at your 2-week follow up appointment, by your PCP or
at
rehab.
7. Please call your surgeons/doctors office to [**Name5 (PTitle) **] or
confirm
your follow-up appointment.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
ANTICOAGULATION: Please take lovenox injections (40mg) once a
day x 4 weeks.
WOUND CARE: Keep your incision clean and dry. Okay to shower
after
POD#5 but do not tub-bath or submerge your incision. Please
place a
dry sterile dressing to the wound each day if there is drainage,
leave
it open to air. Check wound regularly for signs of infection
such as
redness or thick yellow drainage. Staples will be removed by VNA
in 2
weeks. If you are going to rehab, then rehab can remove staples
at 2
weeks.
ACTIVITY: Weight bearing as tolerated to operative leg, and CPM
machine advance as tolerated. No strenuous exercise or heavy
lifting
until follow up appointment, at least.
VNA (after home): Home PT/OT, dressing changes as instructed,
and
wound checks, staple removal in 2 weeks after surgery.
MEDICATIONS: VERY IMPORTANT - pt has extensive list of
medications and she likes to take her own medications. She is
responsible and knowledgeable about her condition. We gave her
the permission to take her own meds while she is here at the
hospital. From orthopaedic perspective, she should take her
daily dilaudid (2-4mg q3h prn) pain medication prn along with
darvocet as long as she tolerates both. Dilaudid should be
weaned off as pain improves. She must also take lovenox
injections (40mg SC) x 4 wks for DVT px. Calcium, and vitamin D
supplements were given along with Iron pills (x2 weeks) to
stimulate blood production. While these supplements are
recommended, they are not absolutely necessary. Pt should go
back on all her home medication. At the time of this review, pt
was tolerating all medication as listed on this d/c summary.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 4599**] [**Last Name (NamePattern1) 9856**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2162-8-6**] 11:40
ICD9 Codes: 496, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7103
} | Medical Text: Admission Date: [**2154-9-9**] Discharge Date: [**2154-9-14**]
Date of Birth: [**2085-7-20**] Sex: M
Service: SURGERY
Allergies:
Ceftriaxone / Cartia Xt / Hydroxyzine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Left infected Charcot foot
Major Surgical or Invasive Procedure:
[**2154-9-10**] Left Below the knee amputation
History of Present Illness:
This 69-year-old gentleman with dialysis dependent renal
failure, longstanding diabetes mellitus, and peripheral
neuropathy, has bilateral Charcot foot deformity. He has had a
Charcot foot reconstruction on the left. This became unstable
again, chronically infected from osteomyelitis and he now has a
flail ankle which is non- salvageable. He was advised to have a
below-the-knee amputation.
Past Medical History:
1. DM2 complicated by retinopathy, nephropathy, neuropathy
2. ESRD (recent baseline Cr 7-7.5). HD M/W/F.
3. HTN
4. Hyperlipidemia
5. Paralyzed right hemidiaphragm s/p MVA [**2135**]
6. OSA on CPAP 11, secondary to #5 per pt
7. h/o syncope, has implanted event recorder x2yrs.
8. Glaucoma
Social History:
Lives at home with wife on [**Hospital3 **]. Owns a construction
company. Denies EtOH/TOB/IVDU.
Family History:
Mom died from DM complications. Has 1 sister and 3 children -
healthy.
Physical Exam:
Afebrile/VSS
Gen: no distress, alert and oriented x 3
HEENT: PERLA, EOMI, anicteric
Neck: no bruits heard
Chest: RRR, lungs clear
Abdomen: soft, nontender, nondistended
Ext: rigth foot warm well perfused, left BKA stump incision
clean and dry, no erythema, there is minimal ecchymoses, minimal
edema
.
Pulses: palpable femorals bilaterally, doppler signals in right
foot
Pertinent Results:
[**2154-9-13**] 08:15AM BLOOD WBC-11.2* RBC-3.99* Hgb-10.2* Hct-32.8*
MCV-82 MCH-25.6* MCHC-31.2 RDW-16.4* Plt Ct-332
[**2154-9-12**] 06:25AM BLOOD WBC-9.6 RBC-4.01* Hgb-10.4* Hct-33.5*
MCV-84 MCH-26.0* MCHC-31.1 RDW-16.4* Plt Ct-311
[**2154-9-9**] 05:30PM BLOOD Neuts-82.0* Lymphs-9.3* Monos-5.8 Eos-2.6
Baso-0.3
[**2154-9-13**] 08:15AM BLOOD Plt Ct-332
[**2154-9-13**] 08:15AM BLOOD Glucose-143* UreaN-51* Creat-7.1*# Na-136
K-4.2 Cl-93* HCO3-33* AnGap-14
[**2154-9-11**] 10:00AM BLOOD CK(CPK)-63
[**2154-9-11**] 03:15AM BLOOD ALT-52* AST-60* AlkPhos-192* TotBili-0.6
[**2154-9-13**] 08:15AM BLOOD Calcium-8.1* Phos-5.6* Mg-2.3
[**2154-9-13**] 08:15AM BLOOD Vanco-21.7*
[**2154-9-11**] 10:10AM BLOOD Type-ART pO2-100 pCO2-57* pH-7.33*
calTCO2-31* Base XS-1 Intubat-NOT INTUBA
[**2154-9-11**] 06:39AM BLOOD O2 Sat-98
[**2154-9-11**] 01:35AM BLOOD freeCa-1.04*
CXR [**2154-9-10**] 6:33 PM
IMPRESSION: Mild dependent pulmonary edema changed in
distribution but not in overall severity since [**9-9**].
Greater opacification in the left lower lobe could be
atelectasis, with likely persistence of at least a small left
pleural effusion. Heart size normal. Mediastinal contours are
unremarkable. ET tube ends at the thoracic inlet. The caliber of
the endotracheal tube may be small, since the diameter, 12 mm,
is less than a half the coronal diameter of the trachea, 26 mm.
Clinical assessment is indicated.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**9-9**] after his normal dialysis
session for preoperative preparation for a left BKA. He
underwent a successful Left BKA on [**2154-9-10**]. While still in the
OR during emergence from anesthesia, he developed profound
bradycardia and lost his blood pressure. Chest compressions
were initiated. After a minute of compressions and a dose of
atropine, his blood pressure returned to 120 systolic.
Postoperatively the patient was kept intubated and transferred
to the cardiovascular intensive care unit where he required
Neosynephrine to maintain his blood pressure. He was quickly
weaned off the Neo and extubated on POD1. His cardiac arrest
was attributed to hypercarbia. The rest of the work up was
normal. He underwent HD on POD1 and tolerated it well. He was
then transferred to the VICU. On the floor, he remained
hemodynamically stable with his pain controlled. He progressed
with physical therapy to improve his strength and mobility. He
continues to make steady progress without any incidents. He was
discharged to a rehabilitation facility in stable condition.
Medications on Admission:
novolog SSI, nephrocap daily, asa 81mg daily, crestor 5mg daily,
norvasc 2.5mg on non-HD days, lasix 80mg Fri/Sat/Sun, cosop 1
gtt ou [**Hospital1 **], alphagan 1 gtt os [**Hospital1 **], renvela 3200mg tid w/ meals,
zoloft 100mg daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
([**Doctor First Name **],FR,SA).
6. Sevelamer Carbonate 800 mg Tablet Sig: Four (4) Tablet PO
EACH MEAL ().
7. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
14. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
15. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): take while not ambulatory and
decreased mobility.
17. Ondansetron 4 mg IV Q8H:PRN nausea
18. Lantus 100 unit/mL Cartridge Sig: Five (5) units
Subcutaneous once a day.
19. Insulin sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-55 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
56-70 mg/dL 0 Units 0 Units 0 Units 0 Units
71-100 mg/dL 7 Units 5 Units 8 Units 0 Units
101-150 mg/dL 8 Units 6 Units 9 Units 0 Units
151-200 mg/dL 9 Units 7 Units 10 Units 0 Units
201-250 mg/dL 10 Units 8 Units 11 Units 0 Units
251-300 mg/dL 11 Units 9 Units 12 Units 2 Units
301-350 mg/dL 12 Units 10 Units 13 Units 4 Units
351-400 mg/dL 13 Units 11 Units 14 Units 5 Units
>401 mg/dL 14 Units 12 Units 15 Units 6 Units
20. Amoxicillin/Clavulanate Sig: One (1) 500mg twice a day
for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
Rehab.hosp. of [**Location (un) **] & Islands-[**Location (un) 6251**]
Discharge Diagnosis:
Left non-healing charcole foot
DM2
ESRD
Hypertension
Hyperlipidemia
Glaucoma
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION
.
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
.
No driving until cleared by your Surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Redness in or drainage from your leg wound(s) .
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 6 weeks.
Do not drive a car unless cleared by your Surgeon.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
Continue taking the antibiotic Augmentin for 1 week.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
.
DIET :
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2154-10-14**] 1:20
ICD9 Codes: 5856, 9971, 4275, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7104
} | Medical Text: Admission Date: [**2171-9-19**] Discharge Date: [**2171-10-22**]
Date of Birth: [**2106-9-24**] Sex: M
CHIEF COMPLAINT: Decreased p.o. intake and refusing to eat.
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
male resident of [**Hospital3 **] Home who has had a history
several week history of refusal to eat, refusal to take
after hydration, the patient was discharged to [**Hospital 48910**]
Hospital inpatient Psychiatry. The patient was recently
discharged from [**Hospital 48910**] Hospital and presented to [**Hospital3 36255**] Home on [**2171-9-16**]. The patient was again
refusing to eat and take medications. The patient also
the patient with poor effort. The patient also complained of
"paralysis." Apparently, the patient lost function of his
MRI revealed white matter changes in the frontal lobe at
[**Hospital 48910**] Hospital. The patient denies fever. Occasional
diffuse abdominal pain. The patient does not recall last
bowel movement. The patient denies headache or chest pain.
The patient complains of being very thirsty.
The patient has a longstanding psychiatry history labeled as
psychotic depression, schizoaffective disorder, with a long
history of resistance and refusal of medical care. He was
referred to [**Hospital1 69**] on [**8-7**]
for refusal to eat or drink and take medications at his
previous nursing home, Sun Bridge [**Location (un) **]. He was
rehydrated and after two days was transferred to [**Hospital 48910**]
Hospital for inpatient psychiatry. They reported that he
began to eat more, and a guardian was obtained. The patient
was found to be incompetent by the courts, and when
guardianship was obtained the patient's son [**First Name8 (NamePattern2) **] [**Name (NI) **]) was
not available at that time.
The patient was then transferred to [**Hospital3 **] Home on
[**9-16**], but since arrival had refused to eat or take
medications. He was only taking sips of fluid. Of note, has
had loss of function of his lower extremities for unclear
reasons. MRI of the head at [**Hospital 48910**] Hospital revealed small
vessel disease and white matter changes predominantly in the
front lobe. There was a question of whether multiple
sclerosis could be involved in this patient, but the patient
refused further workup.
PAST MEDICAL HISTORY:
1. Depression with psychotic features.
2. Questionable parkinsonian feature; it was thought that
perhaps patient's neurodegenerative disease may be related to
antipsychotic medication. The patient did not respond to a
trial of Sinemet.
3. Osteoarthritis.
4. Stage I decubitus ulcer in coccyx.
MEDICATIONS ON ADMISSION: Zyprexa 2.5 mg p.o. q.d.,
Haldol 0.5 mg intramuscularly, zinc sulfate 220 mg p.o. q.d.,
vitamin C 500 mg p.o. q.d., Klonopin 0.25 mg q.8.h.,
multivitamin, Colace. Of note, the patient is refusing to
take all of these medications.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient's guardian is [**Name (NI) **] [**Name (NI) 36260**]
(telephone number [**Telephone/Fax (1) 36257**]). The patient's son is not
the patient's decision maker. The patient's estranged wife ha
s
again reentered the picture.
CODE STATUS: The patient has variably requested to be DNR, bu
t
the guardian is not comfortable with agreeing to a DNR/DNI
status without it being court mandated because of the son
does not agree with the DNR.
The patient also has [**Doctor Last Name 7474**] treatment plan.
PHYSICAL EXAMINATION ON ADMISSION: In general, the patient
is a cachectic elderly man lying in bed with a flat affect.
He was contracted in his lower extremities. Vitals were
temperature of 100, heart rate of 100, blood pressure 120/70,
oxygen saturation 95% on room air. HEENT revealed oropharynx
was very dry. Pupils were equal, round, and reactive to
light and accommodation. Neck was thin. No cervical
lymphadenopathy. Chest was a poor anterior examination,
positive rhonchi anteriorly. Cardiovascular had a regular
rate and rhythm. Normal S1 and S2 and tachycardic. Abdomen
had hypoactive bowel sounds, soft, nontender, and
nondistended, scaphoid. Extremities were extremely
cachectic, early ulcers over heels. Neurologically, the
patient was alert and oriented times three, answered
questions appropriately. Cranial nerves II through XII were
grossly intact, uncooperative with examination. Rigid upper
extremity and lower extremity, would not spontaneously move
upper or lower extremities.
LABORATORY DATA ON ADMISSION: White blood cell count 19.1,
hematocrit 38, platelets 87, MCV 84, 87% neutrophils,
6% lymphocytes, 5% monocytes. INR 1.3, PT 13.9, PTT 25.5.
Sodium 144, potassium 3.7, chloride 103, bicarbonate 24,
BUN 22, creatinine 0.5, glucose 112. Blood cultures times
two were negative. RPR negative. TSH 1.4. Albumin 3.3.
B12 1076, folate 11.8.
RADIOLOGY/IMAGING: X-ray revealed left retrocardiac opacity
suggestive of aspiration pneumonia.
Electrocardiogram revealed Q waves inferiorly, T wave
inversions in II, III, aVF, V3 through V6. ST elevations in
V2 of 2 mm, poor R wave progression.
HOSPITAL COURSE: In summary, this is a 65-year-old male
with psychotic depression and schizoaffective disorder, who
presented with decreased oral intake and aspiration
pneumonia.
1. ASPIRATION PNEUMONIA: The patient was treated with 14
days of intravenous levofloxacin and Flagyl. The patient had
intermittent episodes of desaturations to the 70% and 80%.
These desaturations were thought to be due to aspirations
because they resolved with aggressive suctioning. The
patient is currently on 3 liters of nasal cannula, but most
likely will be weaned down to room air.
2. NUTRITION: The patient has been refusing p.o. intake
since hospitalization. Partial parenteral nutrition was
considered; however, it would not contribute to the patient's
comfort and would only provide at the maximum of 25% of the
patient's daily needs. Since the patient was refusing
laboratory draws, it was also thought unwise to start partial
parenteral nutrition without being able to monitor the
patient for refeeding syndrome. The patient is being
maintained with D-5 normal saline with 40 mEq of [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] at
100 cc per hour. The patient has largely been refusing p.o.
intake but has on occasion taken sips of Boost.
3. PSYCHOTIC DEPRESSION: The patient was evaluated by
Psychiatry on admission. Since he was refusing all
medications it was thought that the patient could be a
candidate for electroconvulsive therapy treatment. The
patient was evaluated by anesthesia who felt that the patient
could not undergo electroconvulsive therapy without being
intubated. It was thought, however, that if the patient was
intubated he may not be able to be weaned off of the
ventilator. Also, since electroconvulsive therapy treatment
requires multiple treatments over several days, it was felt
that intubating the patient for this period of time would be
unsafe. It was then suggested that the patient Zyprexa
dissolvable wafer; however the
patient still refused to take the Zyprexa.
4. NEUROLOGY: It was clear that the patient was suffering
from a neurodegenerative disease, but at this point it
appears that it is end-stage. The patient had refused MRI,
and although the guardian had given approval for a MRI, the
MRI was not able to be performed because the patient's son
had interfered. It was also felt that the patient would have
to be sedated to under MRI, and it was felt that considering
the patient's tenuous pulmonary status that he would not be
able to be sedated safely. Neurology suggested prescribing
Sinemet. The patient has been refusing Sinemet during this
hospitalization. They also suggested a voiding antipsychotic
such as Haldol which may causes exacerbation of the patient's
contracted state. The patient has been refusing further
workup of his neurodegenerative disease.
During this entire hospitalization, the patient has been
refusing the majority of care. The patient is at times
verbally abusive. An court decision regarding DNR/DNI comfort
measures was pursued. The end result was that the patient died
in the hospital, due to inanition and respiratory failure.
DISCHARGE DIAGNOSES:
1. Psychotic depression.
2. Neurodegenerative disease of unclear etiology.
CONDITION AT DISCHARGE: Deceased
DISCHARGE STATUS: deceased
[**Last Name (LF) **],[**First Name3 (LF) 2671**] E. M.D. [**MD Number(1) 2673**]
Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36
D: [**2171-10-8**] 18:44
T: [**2171-10-10**] 19:20
JOB#: [**Job Number 93466**]
1
1
1
R
ICD9 Codes: 5070, 2765, 2761, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7105
} | Medical Text: Admission Date: [**2199-7-4**] Discharge Date: [**2199-7-24**]
Date of Birth: [**2125-4-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
Intubation
PICC line placed on [**7-8**]
History of Present Illness:
This is a 74 y.o. female with diabetic neuropathy and chronic
lower extremity edema who was evaluated and treated in the ER on
[**6-26**] for lower extremity cellulitis. At that time she was
discharged on 2 week regimen of PO Augmentin. She was readmitted
today since her symptoms did not improve on this regimen. She
denies any fevers or chills. She reports ulceration and purulent
drainage from ulcers. She denies any pain but reports that her
sensation is markedly decreased in her lower extremities due to
neuropathy. She denies any nausea, vomitting, diarrhea,
abdominal pain, chest pain or shortness of breath.
Past Medical History:
Chronic atrial fibrillation.
Colon cancer [**2187**] s/p colectomy, treatment with 5-FU, in
remission since.
DM-II x 10 years, has peripheral neuropathy,
microalbuminuria. Most recent Hgb A1c 6.2 in [**10-6**].
HTN
Hyperlipidemia
PVD s/p bilateral fem [**Doctor Last Name **] bypasses
Bilateral cataracts
Obstructive sleep apnea
Urge incontinence
Social History:
Patient is retired and formerly worked at [**Location (un) 8599**]Hospital
in
computers. She has never married and currently lives alone in
senior housing in [**Location (un) 686**]. She has several close friends
that help her with her shopping and getting to appointments.
She has a remote smoking and alcohol history (puffed an
occasional cigarette in social gatherings 50 years ago) denies
any illict drug use.
Family History:
Brother - liver cancer.
Sister - colon cancer.
Physical Exam:
Vitals:BP:160/64 HR:86 RR:20 Tc:98.8 O2Sat:98.8
General:A&O x3, NAD
HEENT:EOMI, Sclera anicteric, MMM, no rhinorrhea or epistaxis,
clear oropharynx.
Neck:Supple, no JVD
Chest: Lungs CTAB, no wheezes, rales or rhonchi
Cardiovascular: RRR, nl S1 and S2, no M/G/R
Abdomen: Soft, NT, ND, +BS, no HSM
Extremities: +1 pitting edema bilaterally. Sensation decreased
bilaterally. Bilateral lower extremity stasis changes and
erythema/warmth overlying anterior legs bilaterally. Ulcerations
present between 1st and 2nd interdigital spaces and on anterior
shin.
Pertinent Results:
[**2199-7-8**] 05:35AM BLOOD WBC-12.8* RBC-3.12* Hgb-8.1* Hct-24.0*
MCV-77* MCH-25.8* MCHC-33.5 RDW-15.4 Plt Ct-276
[**2199-7-9**] 01:00AM BLOOD PT-14.1* PTT-117.7* INR(PT)-1.3*
[**2199-7-8**] 05:35AM BLOOD Glucose-83 UreaN-36* Creat-1.5* Na-139
K-4.1 Cl-102 HCO3-28 AnGap-13
[**2199-7-8**] 05:35AM BLOOD Calcium-8.8 Phos-5.2* Mg-2.3
[**2199-7-7**] 05:35AM BLOOD TSH-2.5
[**2199-7-7**] 05:35AM BLOOD Free T4-1.2
[**2199-7-8**] 05:35AM BLOOD Digoxin-1.2
.
Echo:
The left atrium is mildly dilated. 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 right ventricular cavity is dilated. Right
ventricular systolic function is normal. [Intrinsic right
ventricular systolic function is likely more depressed given
the severity of tricuspid regurgitation.] The aortic valve
leaflets (3) are mildly thickened. 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. Moderate [2+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2198-1-4**]
estimated
pulmonary artery systolic pressure is now higher.
.
CXR [**7-19**]:
1. Increased interstitial markings, nonspecific in appearance.
Differential diagnosis includes CHF or other interstitial
processes. The appearance is likely accentuated by low
inspiratory volumes.
2. Bibasilar atelectasis and small effusions. An early
infiltrate would be difficult to exclude in this setting.
3. There has been some interval clearing of the left base
compared with [**2199-7-17**]. Otherwise, no significant change is
identified.
4. PICC line tip difficult to visualize.
3. ET tube and NG tube removed compared with [**2199-7-17**].
Brief Hospital Course:
74 yo F with DM, HTN, AFib presents with LLE cellulitis,
refractory to oral Abx.
.
#. Respiratory distress/decreased oxygen saturation: Pt noted to
have decreased oxygendation saturations on HD #[**1-5**], dropping
into the 70s while on RA with improvement to the 90s on oxygen.
On HD #6, pt was sent to the ICU for hypoxia and for initiation
of BiPAP with the thought that OSA was contributing to the
hypoxia. During her ICU stay, pt developed worsening hypoxia.
She was initially treated empirically for a PE with a heparin
drip but this was stopped after a VQ scan was low probability.
Due to increasing hypoxia and resp distress, she was intubated.
due to CHF, aspiration pneumonia and OSA. She was diuresed with
a lasix drip, treated with cipro and vancomycin for possible
aspiration pneumonia and she was successfully extubated on HD#14
after eight days. She did well and was sent to the floor. On
the floor, she still required 6L of O2 to maintain sats in the
low 90s. She continued to be diuresed with 80mg of IV lasix [**Hospital1 **]
but when her urine output dropped, Diuril was added to the
lasix, 30 minutes before. Her BP was controlled as below. She
diuresed 1-1.5L per day and her creatinine remained stable at
her baseline of 1.5-1.7. She should continue to be diuresed with
lasix and diuril to maintain goal of 1L negative per day. She
was treated with 14 days of vanc and 10 days of cipro for her
aspiration PNA.
.
# Obstructive Sleep apnea: Pt had been on CPAP 3 years ago but
discontinued due to repeatedly having to take the mask off at
night due to urinary incontinence and repeated trips to the
bathroom. As above, it was thought that OSA was contributing to
her hypoxia but she was not tried on BiPAP while in ICU. We
attempted to try mask on the floor but she did not tolerate. Pt
would benefit from additional sleep study testing as an
outpatient.
.
# Hypertension: Pt's BP was difficult to control in the
hospital. She cannot tolerate beta blockers due to bradycardia.
She was continued on diltiazem, norvasc, lisinopril and
hydralazine. Her hydralazine was discontinued due to poor
outpatient choice for BP control and clonidine patch was
started. Due to bradycardia, her diltiazem was decreased to
60mg qid and clonidine patch increased. She tolerated these
adjustments well and her BP was stable in the 130s/80s.
.
# Afib: Pt is chronically in afib but has refused
anticoagulation. She is very well rate controlled on calcium
channle blocker. Her digoxin was stopped as it was thought that
is was not needed for rate control and is not indicated for her
diastolic heart failure.
.
# Cellulitis: Cellulitis not resolving with outpatient PO
amoxicillin/clavulanate. Pt. is afebrile, hemodynamically
stable, with white count trending upwards. Wound Cx positive for
and treated for Pseudomonas sensitive to Ciprofloxacin.
Bilateral LE US to r/o DVT was negative. She was treated for 10
days with ciprofloxacin. Podiatry followed patient while in
house.
.
#. Acute on chronic renal failure: On admission, creatinine
increased to 1.5 from baseline of 1.3-1.4. This increased to
2.0 and her lasix was held due to thought of volume depletion.
With some fluids and holding renally cleared meds, creatinine
stabilized to 1.5-1.6. This remained stable even with
reinitiation of lasix and ACE. She likely requires a higher
creatinine to maintain euvolemic state.
.
# DM: Pt with some episodes of asymptomatic hypoglycemia while
in house. Her 70/30 was titrated to decrease hypoglycemia.
.
#. Urinary incontinence: Foley was kept in to watch I2 and Os
carefully. Oxybutynin was stopped due to foley and incidence of
orthostatic hypotension.
.
# Diarrhea: cdiff negative. Likely due to antibiotic associated
diarrhea.
.
#. Anemia: Stable at 27-28.
.
# Acccess: PICC placed on [**2199-7-8**]
.
Code status: Full Code
Medications on Admission:
ASPIRIN 81MG daily
COLACE 100MG daily
DIGOXIN 250MCG daily
DITROPAN XL 15MG daily
GLIPIZIDE 2.5 mg daily
LASIX 20 mg daily
LIPITOR 10 mg daily
LISINOPRIL 40MG daily
MULTIVITAMIN daily
NORVASC 10 mg
NOVOLIN 70/30 30u am, 24u pm
NOVOPEN 3
Discharge Medications:
1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Clotrimazole 1 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H PRN ().
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Chlorothiazide 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): give 30 minutes prior to lasix.
11. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every Monday).
12. Diltiazem HCl 240 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO once a day.
13. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Cartridge
Sig: as directed units Subcutaneous twice a day: 20U qam, 15U
qpm.
14. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as
directed units Subcutaneous four times a day: per sliding scale.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
16. Furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection
[**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary Diagnosis:
1. diastolic heart failure
2. aspiration pneumonia
3. Pseudomonas cellulitis
4. Acute on chronic renal failure
5. Obstructive sleep apnea
6. Antibiotic associated diarrhea
7. Anemia of chronic disease
8. Hypertension
Discharge Condition:
Stable, afebrile, tolerating po, satting 100% on 6L
Discharge Instructions:
You were admitted with cellulitis and had several problems with
your breathing due to fluid in the lungs and pneumonia.
Please watch your salt intake and weight yourself every day.
Call your physician if your weight increased by more than 2lbs
in one day.
Please contact your physician or return to the Emergency
Department if you notice fevers > 101.5, chest pain, shortness
of breath, worsening of the leg rash, or any other worrisome
symptoms.
Followup Instructions:
Please follow up with your primary care provider [**Name Initial (PRE) 176**] 1 week.
Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Phone:[**Telephone/Fax (1) 250**]
Completed by:[**2199-7-24**]
ICD9 Codes: 5070, 5849, 3572, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7106
} | Medical Text: Admission Date: [**2161-1-29**] Discharge Date: [**2161-2-7**]
Date of Birth: [**2076-8-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Mitral valve replacement with a [**Street Address(2) 12523**]. [**Hospital 923**] Medical Biocor
Epic tissue valve.
History of Present Illness:
83 year old male with recent dyspnea with exertion and edema
lower extremities that has improved with lasix. Referred for
cardiac catheterization due to mitral regurgitation found on
echocardiogram, in preparation for cardiac
surgery.
Past Medical History:
Hypertension
Hyperlipidemia
Severe mitral regurgitation/prolapse
Atrial fibrillation, on Coumadin; last dose WED [**12-31**]
Diabetes type II
Prostate cancer- elevated PSA (not treated)
Colon polyps s/p polypectomy
Bilateral Inguinal hernia repair
remote trauma to leg involving pitchfork
Social History:
Last Dental Exam: > 1 year
Lives with:alone
Occupation:retired mechanic shop owner
Tobacco:denies
ETOH:denies
Family History:
non contributory
Physical Exam:
Pulse: 78 Resp: 18 O2 sat: 100%
B/P Right: 133/59 Left: 156/80
Height: 6' Weight: 160#
General: no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: systolic ejection murmur
best heart at the left sternal border radiating to both
carotids.
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds + []
Extremities: Warm [x], well-perfused [x]
no Edema; has bilateral varicosities
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 0 Left: 0
Radial Right: 2+ Left: +
Carotid Bruit: left/right: referred cardiac murmur
Pertinent Results:
[**2161-2-7**] 06:40AM BLOOD WBC-6.2 RBC-4.18* Hgb-13.7* Hct-40.1
MCV-96 MCH-32.7* MCHC-34.0 RDW-14.6 Plt Ct-134*
[**2161-2-7**] 06:40AM BLOOD PT-19.1* PTT-38.3* INR(PT)-1.7*
[**2161-1-29**] 04:13PM BLOOD PT-15.5* PTT-28.9 INR(PT)-1.4*
[**2161-2-7**] 06:40AM BLOOD Glucose-98 UreaN-31* Creat-1.0 Na-135
K-4.6 Cl-96 HCO3-31 AnGap-13
[**2161-1-29**] 04:13PM BLOOD Glucose-294* UreaN-33* Creat-1.1 Na-138
K-5.0 Cl-104 HCO3-27 AnGap-12
[**2161-1-29**] 04:13PM BLOOD ALT-17 AST-31 LD(LDH)-224 AlkPhos-112
Amylase-41 TotBili-1.0
Pulse: 78 Resp: 18 O2 sat: 100%
B/P Right: 133/59 Left: 156/80
Height: 6' Weight: 160#
General: no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: systolic ejection murmur
best heart at the left sternal border radiating to both
carotids.
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds + []
Extremities: Warm [x], well-perfused [x]
no Edema; has bilateral varicosities
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 0 Left: 0
Radial Right: 2+ Left: +
Carotid Bruit: left/right: referred cardiac murmur
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 89503**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 89504**] (Complete)
Done [**2161-2-2**] at 1:19:08 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: [**2076-8-2**]
Age (years): 84 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for MV Repair vs replacement
ICD-9 Codes: 428.0, 427.31, 424.0, 424.2
Test Information
Date/Time: [**2161-2-2**] at 13:19 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW4-: Machine: U/S 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.2 cm
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast in the
body of the LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Mild
spontaneous echo contrast in the LAA. Depressed LAA emptying
velocity (<0.2m/s) All four pulmonary veins identified and enter
the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Mildly
dilated LV cavity. Normal regional LV systolic function. Mildly
depressed LVEF. [Intrinsic LV systolic function likely depressed
given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Dilated RV cavity. Moderate global RV free wall
hypokinesis.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Simple
atheroma in aortic arch. Focal calcifications in aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Myxomatous mitral valve leaflets. Moderate/severe MVP. Partial
mitral leaflet flail. Moderate mitral annular calcification.
Calcified tips of papillary muscles. No MS. Eccentric MR jet.
Severe (4+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild to
moderate [[**11-23**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
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. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient. Bilateral pleural effusions.
Conclusions
PRE BYPASS The left atrium is dilated. No 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. The left atrial appendage emptying velocity is
depressed (<0.2m/s). The right atrium is dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
mildly dilated. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40-45 %). [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is dilated with
moderate global free wall hypokinesis. There are simple atheroma
in the aortic arch. There are focal calcifications in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. The
mitral valve leaflets are myxomatous. There is bileaflet
prolapse with a flail P2 segment and potentislly some A2 partial
flail. An eccentric, anteriorly directed jet of severe (4+)
mitral regurgitation is seen. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is receiving milrinone and
norepinephrine by infusion. The right ventricle displays normal
systolic function. The left ventricle displays septal dyskinesis
versus severe dysynchronous contraction which is new from the
pre-bypass study. The rest of the LV segments are glbally,
moderately depressed. Overall left ventricular ejection fraction
is approximately 35%. There is a bioprosthesis located in the
mitral position. It appears well seated. The leaflets have
normal motion. There is trace valvular mitral regurgitation. The
maximum gradient through the valve was 6 mmHg with a mean of 2
mmHg at a cardiac output of 3.5 liters/minute. The thoracic
aorta is intact after decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2161-2-2**] 16:09
?????? [**2152**] CareGroup IS. All rights reserved.
Brief Hospital Course:
83 year old with worsening symptoms of heart failure and found
to have severe
mitral regurgitation presenting for mitral valve replacement.
His preoperative work up consisted of dental consult and OMFS
for root extraction. [**2161-2-1**] Mr. [**Known lastname **] was taken to the
operating room and underwent Mitral valve replacement with a [**Street Address(2) 89505**]. [**Hospital 923**] Medical Biocor Epic tissue valve with Dr.[**Last Name (STitle) **].
Please refer to operative note for further surgical details. He
tolerated the procedure well and was transferred to the CVICU in
critical but stable condition. He awoke neurologically intact,
although slow to wake and was extubated on POD#2. He was weaned
off inotropes and pressors and was started on
Beta-blocker/Statin/Aspirin and diuresis. All lines and drains
were discontinued in a timely fashion. Mr.[**Known lastname **] was confused on
POD#2 and narcotics were discontinued. His mental status
improved to baseline. He continued to progress and was
transferred to the step down unit for further monitoring.
Physical Therapy was consulted for evaluation of strength and
mobility. On POD# 4 an unwitnessed slip vs.fall occurred and Mr.
[**Known lastname **] was not able to fully weight bare immediately thereafter.
Orthpeadics was consulted and a CT scan was performed. Per Ortho
Mr.[**Known lastname **] was cleared for discharge with partial weight baring
on his left lower extremity until follow up in [**11-23**] weeks with
Dr.[**First Name (STitle) 4223**] in orthopeadic oncology. On POD# 5 Mr.[**Known lastname **] was
cleared for discharge to [**Hospital 1514**] Health Care Center in Ma. All
follow up appointments were advised.
Medications on Admission:
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
GLYBURIDE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth twice a day
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth daily
SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth daily
WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - 3
Tablet(s) by mouth once a day as directed per coumadin clinic
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth daliy
GLUCOSAMINE SULFATE [GLUCOSAMINE] - (Prescribed by Other
Provider) - Dosage uncertain
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. warfarin 1 mg Tablet Sig: [**Name8 (MD) **] MD Tablet PO DAILY (Daily):
INR goal=>2, indication; Atrial Fibrillation.
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
10. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain, fever.
12. warfarin 3 mg Tablet Sig: One (1) Tablet PO once for 1
doses.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Mitral valve replacement with a [**Street Address(2) 12523**]. [**Hospital 923**] Medical Biocor
Epic tissue valve.
Secondary:
Hypertension
Hyperlipidemia
Severe mitral regurgitation/prolapse
Atrial fibrillation, on Coumadin; last dose WED [**12-31**]
Diabetes type II
Prostate cancer- elevated PSA (not treated)
Colon polyps s/p polypectomy
Bilateral Inguinal hernia repair
remote trauma to leg involving pitchfork
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Groin pain managed with tylenol
Left groin - no erythema or drainage
Right groin - no erythema or drainage
Bilateral Lower extremity with no/trace edema
Discharge Instructions:
Please shower daily including washing puncture sites in groins
with mild soap, no baths or swimming for 1 week until groin
sites are healed.
Please NO lotions, cream, powder, or ointments to puncture sites
in your groins
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month, will be discussed at follow up
appointment
No lifting or pulling more than 10 pounds for 1 week, and then
continue to take it easy for 1 month
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call Integrated Aortic valve clinic in 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) **] #[**Telephone/Fax (1) 170**] on [**2-26**] at 1:15pm
Cardiologist:Dr [**Last Name (STitle) 7526**] on [**3-4**] at 11am.
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] S. # [**Telephone/Fax (1) 28262**] in [**11-23**] weeks
**Please call Integrated Aortic valve clinic in 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
First draw:[**2161-2-8**]
Completed by:[**2161-2-7**]
ICD9 Codes: 4240, 4280, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7107
} | Medical Text: Admission Date: [**2190-10-8**] Discharge Date: [**2190-10-10**]
Date of Birth: [**2123-7-4**] Sex: F
Service: MEDICINE
Allergies:
Paxil / Benadryl / Buspar / Levaquin / Adhesive Tape
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Pericardial effusion s/p SVT ablation
Major Surgical or Invasive Procedure:
electrophysiology study with incomplete ablation
History of Present Illness:
66-year-old lady with history of breast and bladder cancers was
admitted for elective EPS with ablation for SVT. She first
noted palpitations approximately 16 years ago in the setting of
high emotional distress when her son was killed while in the
service. Since then, she has had palpitations in the setting of
chemotherapy, and over the past years has had no more than [**3-2**]
episodes per year. However, on the day of her most recent
cystoscopy on [**3-5**] at [**Hospital1 69**], she
experienced a tachycardia, which was terminated after she
received intravenous Lopressor. The same tachycardia occurred on
[**3-9**] for which she presented to [**Hospital6 17032**]
Emergency Room, where the tachycardia was terminated with
intravenous adenosine. The tracings of the tachycardia were
reviewed by her Electrophysiologist, Dr.[**Last Name (STitle) 1911**], and
thought be a narrow complex tachycardia at 150 beats/minute with
an RP interval of 100-120 msec. However, immediately post
adenosine, there was evidence of sinus rhythm with a fully
pre-excited QRS complex consistent with a left lateral bypass
tract. Since the Emergency Room visit, she has been on low-dose
atenolol without further recurrences of the arrhythmia.
Dr.[**Last Name (STitle) 26676**] recommended EPS with ablation and the patient
was admitted today for the procedure.
.
During the procedure she developed hypotension to SBP of 77 mm
HG. This responded to IVF and dopamine infusion to SBP of 130s.
Patient was mentating appropriately. Focal views of TTE showed
noncircumferential pericardial effusion with mild RA collapse
without RV collapse. Her heparin was reversed with protamine.
PA catheterization showed preserved CO, no equalization of
filling pressures, and preserved Y descent on RA tracing. This
suggested nonhemodynamically significant effusion. Patient was
admitted to CCU with PA catheter for close hemodynamic
monitoring.
.
On arrival patient complained of stable pleuritic chest pain
which she had since the cath lab. She denied any shortness of
breath. No other complaints.
.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
- Total abdominal hysterectomy and salpingoophrectomy [**2164**] r/t
endometriosis
- Left breast cancer diagnosed [**2180**] s/p Left lumpectomy and
radiation therapy
- Papillary bladder cancer diagnosed [**2180**] s/p multiple
resections
and chemotherapy, finished [**2190-4-28**]
- [**2190-3-5**] s/p right ureteral stent, ? transitional cell cancer
of
the right ureteral orifice
- Anxiety
.
Social History:
Lives with: husband
Occupation: retired
ETOH: no
Tobacco: 35 years/ 1ppd, quit in [**2180**]
Contact person upon discharge: Husband and son: [**Telephone/Fax (1) 29176**]
Home Services: NO
.
Family History:
Unremarkable for any cardiac disease
.
Physical Exam:
VS: T=96 BP=103/58 HR=97 RR=17O2 sat= 98% 2LNC
GENERAL: Pleasant lady, in NAD. Lying down flat, Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Unable to assess JVP appropriately given the patient's
position.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB in
anterior lung fields, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis.
PULSES:
Right: DP 2+ Left: DP 2+
.
Pertinent Results:
[**2190-10-10**] 08:50AM BLOOD WBC-14.1* RBC-3.54* Hgb-9.5* Hct-30.5*
MCV-86 MCH-27.0 MCHC-31.3 RDW-14.7 Plt Ct-156
[**2190-10-10**] 08:50AM BLOOD Glucose-120* UreaN-11 Creat-0.8 Na-135
K-4.3 Cl-101 HCO3-26 AnGap-12
[**2190-10-10**] 08:50AM BLOOD Calcium-8.6 Phos-1.6* Mg-2.5
.
ECG: [**2190-10-8**] at 7:23 AM
NSR, rate in 70s, nl axis, early R wave transition in precordial
leads, no acute ST-T changes compared to
.
ECG: [**2190-10-8**] at 11:58 AM
Narrow complex tachycardia, rate in 140s, early R wave
transition. No acute ST-T wave changes.
.
2D-ECHOCARDIOGRAM [**2190-10-8**] Focused Views:
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. There is a small
to moderate sized pericardial effusion primarily around the
right atrium and right ventricle with minimal around the apex
and inferolateral wall. There is mild right ventricular
diastolic collapse.
IMPRESSION: Mild-moderate loculated anterior pericardial
effusion with echocardiographic evidence for increased
pericardial pressure.
.
2D-ECHOCARDIOGRAM [**2190-10-9**]
The left ventricular cavity is unusually small. The inferior and
posterior walls are hypokinetic. The rest of the left ventricle
is hyperdynamic. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is a small
to moderate sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2190-10-8**], the pericardial effusion appears similar
in size.
.
HEMODYNAMICS:
RAP 20, PCWP 17, Arterial oxygen 98%, RV oxygen sat 71%
.
EPS [**2190-10-8**]:
Left lateral ventricular pre-excitation. Retrograde VA block
via BT at 350 msec. Anterograde BT block at 300 msec. Atypical
Induced orthodromic AVRT, CL 400 msec via left lateral BT.
Difficulty crossing AV. Ablations were performed primarily at
the entrent atrial acitivation site during Vpacing. Also slow
pathway ablation were performed to prevent initiation of the
AVRT. Ablation procedure was incomplete given hypotension as
above.
.
CT ABDOMEN/PELVIS [**2190-10-9**]:
1. No retroperitoneal bleed.
2. Mild to moderate sized pericardial effusion with
indeterminate density
measurements suggesting proteinaceous fluid or blood. No obvious
right atrial compression. Recommend echocardiogram
3. Right femoral line with tip located at the cavoatrial
junction.
4. Left lobe hepatic cyst; could consider outpatient ultrasound
for further
characterization.
5. No large hematoma at right femoral entry site.
6. Stranding in mesentery, nonspecific finding.
Brief Hospital Course:
66 y/o lady with history of SVT now with pericardial effusion
s/p attempted EP ablation.
.
# Pericardial Effusion/PUMP: Patient was found to have a 1.4 cm
anterior pericardial effusion after she became hypotensive
during SVT ablation procedure on [**2190-10-8**]. TTE also showed mild
RA collapse without any RV collapse. Emergently, patient
received a right heart cath that was consistent with a
non-hemodynamically signicant effusion w/o tamponade physiology,
so pericardiocentesis was not felt to be indicated. (Cardiac
output was preserved and there was no equalization of filling
pressures.) Swan-ganz was initially left in place to monitor for
development of tamponade physiology. Arterial line was also
placed for blood pressure monitoring. Patient was initially
hypotensive, but her blood pressure was responsive to IV fluid
hydration and dopamine. Her blood pressure remained stable over
the next 24 hours, and a repeat TTE on [**10-9**] did not show
worsening of the pericardial effusion. Chest pain secondary to
the pericardial effusion was well-controlled with Toradol and
patient was discharged on ibuprofen prn for pain.
.
# RHYTHM: Prior to admission, SVT was thought be a narrow
complex tachycardia at 150 beats/minute with an RP interval of
100-120 msec. However, immediately post adenosine, there was
evidence of sinus rhythm with a fully pre-excited QRS complex
consistent with a left lateral bypass tract. In EP lab,
monitors showed left lateral ventricular pre-excitation,
retrograde VA block via BT at 350 msec, anterograde BT block
at 300 msec, and atypical induced orthodromic AVRT, CL 400 msec
via left lateral BT. During the procedure, it was difficult
crossing the AV, and ablations were performed primarily at the
entrent atrial acitivation site during Vpacing. Also slow
pathway ablation was performed to prevent initiation of the
AVRT. The ablation procedure was incomplete given hypotension
as above. Rhythm was monitored on telemetry and showed
predominantly sinus rhythm.
.
# CORONARIES: Patient has no known CAD. Chest pain while
inpatient was pleuritic in nature and attributed to
hemopericardium. ASA was continued.
.
# Extensive groin manipulation: Due to extensive groin
manipulation during cardiac procedures on [**2190-10-8**], patient was
monitored closely for evidence of retroperitoneal bleed. In the
cath lab, heparin was reversed with protamine, post cath checks
were unremarkable, and a CT scan of abdomen and pelvis was
negative for a retroperitoneal bleed. Hemoglobin and hematocrit
remained stable throughout hospital stay.
.
# H/o breast CA and papillary bladder CA: Stable. Patient
advised to continue outpatient follow-up per primary oncologist.
.
FEN: Patient was maintained on cardiac prudent diet.
Electrolytes were repleted as necessary.
.
PROPHYLAXIS: SCD's were used for DVT prophylaxis.
.
CODE: FULL
Medications on Admission:
Atenolol 25mg daily, last dose [**2190-10-3**]
Lunesta 2mg qhs
Alprazolam 0.25mg daily in the am, [**1-29**] tablet at noon, 1 tablet
at night PRN
Simvastatin 30mg daily
MVI daily
Vitamin D daily
Vitamin B12 500mcg daily
Calcium, magnesium daily
Fish oil 1000mg daily
Asa 81mg daily
.
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO once a day.
9. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for pain: please take with food.
10. Lunesta 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Supraventricular tachycardia, AVRT
Pericardial effusion
Secondary Diagnoses:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
- Total abdominal hysterectomy and salpingoophrectomy [**2164**] r/t
endometriosis
- Left breast cancer diagnosed [**2180**] s/p Left lumpectomy and
radiation therapy
- Papillary bladder cancer diagnosed [**2180**] s/p multiple
resections
and chemotherapy, finished [**2190-4-28**]
- [**2190-3-5**] s/p right ureteral stent, ? transitional cell cancer
of
the right ureteral orifice
- Anxiety
Discharge Condition:
stable and improved
Discharge Instructions:
You were admitted to the hospital for a procedure to fix an
abnormal rhythm in your heart. The procedure was unable to be
finished because of concern for build up of fluid around your
heart. Ultrasounds of your heart showed that the fluid around
your heart was not getting worse. You were discharged on
[**2190-10-10**], and will have close follow up with Dr. [**Last Name (STitle) **].
Please follow up in 6 weeks for liver ultrasound to follow up
liver cyst.
No changes were made to your medications.
Please see below for your follow up appointment with Dr.
[**Last Name (STitle) 1911**].
Please call your physician [**Last Name (NamePattern4) **] 911 if you develop chest pain,
shortness of breath, worsening palpitations,
dizziness/lightheadedness, fevers, chills, or any other
concerning medical symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1911**] tomorrow, [**2190-10-11**].
Please call [**Telephone/Fax (1) 11767**]. You have another appointment with Dr.
[**Last Name (STitle) 11649**] on [**2190-10-26**], see below.
[**Last Name (un) 1918**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2190-10-26**] 10:40
ICD9 Codes: 9971, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7108
} | Medical Text: Admission Date: [**2178-4-13**] Discharge Date: [**2178-4-29**]
Service:
HISTORY OF PRESENT ILLNESS: Patient is an unfortunate
80-year-old female with a prior medical history of
hypertension, osteoporosis, prior left carotid stenosis, and
had subsequent left carotid endarterectomy as well as history
of polymyalgia rheumatica, who was involved in a motor
vehicle accident as an unrestrained driver with possible loss
of consciousness.
She was initially seen at an outside facility on [**4-13**],
the date of her accident. She was doing well,
hemodynamically stable, however, she was complaining of
left-sided chest pain. She was diagnosed with multiple left
sided rib fractures and evidence of crepitus. Her
saturations were okay. However, she was quite tachypneic.
She additionally had dropped her systolic blood pressure into
the 90s at the outside facility from an admission blood
pressure in the 130s, and was found to have a hematocrit of
22. She was given 2 units of packed cells, and transferred
here.
Presentation to the Trauma Bay showed her to have extensive
work of breathing requiring subsequent intubation. Initial
trauma survey revealed crepitus in the left chest and
decreased breath sounds necessitating insertion of a left
chest tube. Chest x-ray had confirmed that she had a large
left-sided effusion and multiple rib fractures with no
obvious pneumothorax. Subsequent to this, the patient was
stabilized and received her protocol imaging. Her CT of the
head was otherwise unremarkable. Her CT of the chest
revealed a large left hemothorax with no evidence of
pneumothorax. A large left pulmonary contusion.
Additionally, the scan of the chest revealed a right distal
clavicular fracture and left scapular fracture. Her CT of
the neck was unremarkable. Her CT of the head was negative.
CT of abdomen with intravenous contrast on initial survey
additionally showed no evidence of parenchymal or abdominal
visceral injury. She was admitted to the Trauma Critical
Care Unit for further resuscitation.
Her admission examination was notable for a temperature of
95.3 rectally, heart rate of 107, sinus tachycardia. Her
blood pressure is 104/39, the respiratory rate of 14, and
saturating 100% and vented. She was intubated, however, she
was awake and following commands. She had coarse breath
sounds bilaterally. On the left, she was markedly
diminished. She was tachycardic, but had no murmurs, rubs,
or gallops. Her left chest had some mild crepitus, but there
was no evidence of instability or flail segment. Her abdomen
was soft and nontender. There was no ecchymosis or abrasion.
Her pelvis was stable. The rectal examination had loose
tone, guaiac negative, no masses. Her flanks and back were
otherwise normal without obvious deformity or injury. Her
extremities showed no obvious deformity. There was some
minor cuts and scrapes over the knees and right elbow. She
was able to move all extremities. Her right upper extremity
and left upper extremity were somewhat limited by pain,
however.
Over the ensuing hours of her admission, however, she became
hemodynamically unstable despite being aggressively
resuscitated. The patient was profoundly acidotic and
dropped her hematocrit to 26. Her abdomen became
progressively more distended and had hemodynamic instability
requiring high dose of dopamine and Levophed. Upright chest
x-ray had been repeated showing no evidence of
intraabdominal free air. She had a transthoracic
echocardiogram by the oncall Cardiology fellow that night of
injury revealing a hyperdynamic left ventricular function
with an EF greater than 75%, a normal RV systolic function,
no mitral regurgitation, no evidence of pericardial effusion.
There was spontaneous collapse of the inferior vena cava and
the mechanically ventilated patient, which suggested profound
hypovolemia, and her tachycardia precluded adequate
evaluation of any wall motion abnormalities.
Due to the fact that the patient had initial survey on
abdominal CT showing no evidence of visceral injury and the
rapidly progressing abdominal distention with acidosis and
somewhat collapsed IVC, it was thought that the patient may
in fact be suffering from an abdominal compartment syndrome.
She was thereafter sent to the operating room on the early
morning hours of [**2178-4-14**]. Dr. [**Last Name (STitle) 519**] took her to
the OR, performed a trauma laparotomy. There was no obvious
injury to the viscera. However, after opening the abdomen,
the patient profoundly improved confirming the likely
diagnosis of abdominal compartment syndrome. She only had
100 cc estimated blood loss during this procedure. Received
1200 cc of intravenous fluids and urine output was 700 cc for
the case.
Patient left the operating room intubated, sedated. Over the
ensuing days, the patient progressed into acute respiratory
distress syndrome as defined by her PAO2:FIO2 ratio being
less than 200 with bilateral infiltrates particularly worse
on the left side, where she had a confirmed contusion and
left hemothorax. There was no obvious persistent
pneumothorax, however, as her daily chest x-ray evaluation
confirmed this with a left chest tube being repositioned.
She was given maximal lung protective ventilation strategy
including paralysis, low tidal ventilation, and permissive
hypercapnia and permission hypoxia. Over the ensuing days
she improved. Her tube feed regimen was serially increased.
She had a pulmonary artery catheter that had been placed
during her postoperative course for guidance of her fluid and
electrolyte therapy.
Ultimately, the patient actually somewhat rallied and
improved. We were able to dial back her intravenous fluids,
titrate up her tube feedings to a goal. Ultimately, her ARDS
seemed to improve and she was actually switched from an
assist control setting into a pressure support ventilatory
mode. Her pain control was a [**Last Name **] problem. We had
attempted an epidural twice, were unsuccessful at placement.
She did receive a left-sided rib block several times during
her ICU course to enhance her pain control and to give her an
opportunity to participate in her pulmonary rehab and vent
wean.
We utilized a variety of agents including NSAID therapy with
Vioxx as well as Roxicet elixir to control her
pain. However, there was a significant component of pain and
overall deconditioning that made her ventilatory wean
prolonged. She ultimately necessitated placement of an open
tracheostomy tube, which was performed on [**2178-4-27**] under
the care of Dr. [**Last Name (STitle) **].
Therefore the patient had a speech and swallow evaluation,
and at the time of this discharge summary, the final report
of the speech and swallow evaluation was indeterminate. The
plan was to place a discharge summary addendum with the
results of this were back if she were able to pass her speech
and swallow evaluation, she will be titrated on an oral
regimen and serially advanced accordingly with tube feeds
being cycled at night and dialed back as needed as she took
adequate p.o. intake. However, if she failed her speech and
swallow evaluation, she will likely need a percutaneous
endoscopic gastrostomy tube for feeding access and then a
repeat speech and swallow evaluation as an outpatient can be
performed in a couple of weeks when her aspiration risk was
reduced, and that her mental status has improved.
FOLLOW-UP PLANS BY SYSTEM: Neurologically: She had a
negative head CT and negative CT C spine. No MR films were
done. She wore the collar for more than two weeks. This was
ultimately removed. She was able to interact, although not
at a very robust fashion, but could certainly localize her
gaze to the examiner, able to move her upper extremities with
limited range of motion. Able to make weak grasp with
bilateral upper extremities. Able to wiggle toes and
intermittently move her legs. Therefore, she was following
simple commands. She appeared to have somewhat blunted
affect despite being on a ventilator, the assessment was
whether she may or may not have been suffering from a mild
degree of depression as well as some intermittent waxing and
[**Doctor Last Name 688**] consciousness confirming the likely low grade
delirium. However, this was florid and did not necessitate
antipsychotic regimen or one-to-one sitter or any restraining
mechanism.
Pulmonary wise: The patient was on pressure support
ventilation approximately anywhere from 18 to 20 mmHg being
utilized. She will continue prolong ventilatory wean. Chest
x-ray showed no evidence pneumothorax. She had mild
cephalization and evidence of mild overload, and she had
bilateral effusions left greater than right, but nothing that
seemed to be tapable at this time. She had multiple left
sided rib fractures, left scapular fracture, and right distal
clavicular fracture, and her analgesic regimen will be key to
control so that she can participate in her ventilatory wean
and have adequate strength and analgesia to pull an adequate
tidal volume to allow appropriate weaning as needed. She
will receive standard trach care as needed. She had a #6
Shiley trach tube placed at the time of surgery on
[**2178-4-27**].
Cardiovascular wise: The patient was stable on a
beta-blocker 25 mg p.o. b.i.d. This can be titrated as
needed to control her blood pressure and heart rate. She did
not have any specific parameters, however, it would be nice
to keep her systolic pressures at least under 160 with a
heart rate in the 70-80 range. Her transthoracic
echocardiogram results were stated on the night of admission.
Her baseline cardiac medications included a beta-blocker and
aspirin. Aspirin can be added back as needed on an
outpatient basis in the vent rehab facility.
FEN and GI: Patient had speech and swallow evaluation
pending at the time of this dismissal. If she were to fail
this evaluation, she will get a PEG tube placed, and
continued on Impact with fiber full strength at 60 cc per
hour. This can be cycled serially at night as needed.
Ultimately, she can be reassessed for possible swallowing
function in the rehab setting so that she can ultimately
hopefully be weaned off a tube feeding regimen. She was not
receiving any additional motility agents such as Reglan at
the time of this dismissal note. Her electrolytes were
otherwise stable.
Heme/ID: She had no infectious issues. She had some yeast
that had grown out from a sputum sample at the end of [**Month (only) 958**],
however, she did not have any florid infiltrate on chest
x-ray. Her sputum was somewhat tan colored in nature, but
ultimately it was not felt that she was suffering from a
ventilator-associated pneumonia. At this time, she was not
on any antibiotics. She had a hematocrit of 28.6 and a white
count was 7.8 on [**2178-4-29**] with a normal platelet count of
407.
For Endocrine: She should be on a sliding scale regimen.
She should be placed on a NPH regimen and tighten her sliding
scales for normoglycemia with goal blood sugars of 120-140
can be achieved. This should be continued indefinitely. The
patient almost certainly has some component of insulin
resistance or perhaps undiagnosed type 2 diabetes mellitus.
GU/renal: She had a Foley catheter for urine output
monitoring. She had no significant urinary cultures. Her
creatinine was 0.5 on [**2178-4-29**] with a BUN of 23. She was
making approximately 1-1.5 liters of urine per day.
Tubes, lines, and drains: At the time of this dismissal,
discharge summary, she did have a left subclavian, which was
a triple lumen catheter, which had been in place for 15 days
as well as a left radial A line. Ultimately on dismissal,
she likely will not have her radial arterial line unless
deemed appropriate by the ventilatory rehab facility.
Additionally, she was receiving feedings through a
nasogastric tube pending the speech and swallow evaluation.
She may not end up with a PEG tube, thereby removing that
nasogastric tube accordingly.
Prophylaxis: She should continue on Prevacid 30 mg/NG q.d.
or per PEG as needed if she ends up with a PEG. She can be
on Lovenox 30 mg subq b.i.d. for DVT prophylaxis, Lopressor
25 mg p.o. b.i.d., aspirin 81 mg p.o. q.d., Roxicet elixir as
needed, Vioxx 12.5 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d.,
Dulcolax suppository 10 mg p.o./p.r. one tablet q.d. prn.
Her followup plans will be to see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] in
approximately one month from time of dismissal. Call this
clinic for this follow-up appointment. Additionally, she
should follow up in the Trauma Clinic in approximately 3-4
weeks from time of dismissal if she has been appropriately
weaned from the ventilator. If she is still vent dependent,
then she will stay at the [**Hospital 5442**] Rehab until which time, she
has been weaned from the ventilator and then she may follow
up on a prn basis to the Trauma Clinic.
TREATMENTS AND FREQUENCIES: She will continue on aggressive
enteral feeding regimen her speech and swallow evaluation
will proceed. If her swallowing is poor, then she will
receive a PEG tube for enteral access and feeding, and this
can be reassessed as an outpatient in the ventilatory rehab
setting to see if she can ultimately be started on an oral
regimen. She was not requiring any motility agents at this
time to assist her with her tube feeding tolerance. She
should be on aggressive bowel regimen. Her blood pressure
control is as stated above. She will need aggressive
Physical Therapy. She can be full weightbearing on her lower
extremities as tolerated despite the pelvic fracture as
previously noted. Additionally, she should continue
aggressive Physical Therapy, be out of bed, get a chest
physiotherapy and incentive spirometry, and trach care as
standard fashion.
DISCHARGE DIAGNOSES:
1. Status post motor vehicle crash with multiple injuries
including multiple left-sided rib fractures, left hemothorax,
left sided pulmonary contusion, right distal clavicular
fracture, left scapular fracture, left superior and inferior
pubic rami fracture.
2. Abdominal compartment syndrome resolved.
3. Status post exploratory laparotomy. Negative for any
visceral injury, however, patient was profoundly improved
after her abdomen was opened.
4. Status post acute respiratory distress syndrome now
resolved.
5. Respiratory failure with failure to wean from ventilator.
6. Status post tracheostomy.
OTHER DIAGNOSES:
1. Hypertension.
2. Peripheral vascular disease.
3. Status post left carotid endarterectomy.
4. Osteoporosis.
5. Polymyalgia rheumatica.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 10637**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2178-4-29**] 12:26
T: [**2178-4-29**] 12:50
JOB#: [**Job Number 52915**]
ICD9 Codes: 5180, 2762, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7109
} | Medical Text: Admission Date: [**2153-4-30**] Discharge Date: [**2153-5-8**]
Date of Birth: [**2091-5-14**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Benadryl
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Cardiac angiography
History of Present Illness:
HPI: [**Known firstname **] [**Known lastname **] is a 61-year-old gentleman with history of
HTN, IDDM, hypercholesterolemia, DVT, who was brought to the ED
per EMS
after he developed vomiting and nausea and was off balance
following a headache that he has been having for 6 days.
He initially presented to the Emergency Department on [**2153-4-30**]
for headache and mental status changes. He was intubated for ?
airway protection and admitted to the TSICU, where he was
extubated fairly rapidly. Initial concern was for a CVA, but
head CT and MRI/MRA were unremarkable. While on the floor,
patient had several episodes of hypertensive urgency, with
systolics reaching 220. Cardiology team was consulted, who
recommended labetolol with goal SBPs 150-160, stress results
from [**Hospital1 112**], MRI and 24 hour urine to eval for pheochromocytoma.
.
While in the ICU he was evaluated with MRI/CT/MRA which did not
show any abnormalities. Additionally an LP was done which did
not show any signs of infection though was not sent for viral
PCR (likely suspicion was low). He was empirically treated with
vancomycin, ceftriaxone and acyclovir (vanc, ceftriaxone stopped
[**5-1**], acyclovir stopped [**5-2**]). For BP control the patient was on
Nicardipine, then labetolol and briefly a nitroglycerin drip. He
also was given IVF and showed signs of volume overload and was
diuresed.
Past Medical History:
- HTN
- IDDM
- hypercholesterolemia
- history of DVT in R-leg
- cataract, s/p surgery
- headaches, no migraine headaches per wife
- rosacea
Social History:
Occupation: accountant from [**Month (only) **] to [**Month (only) 547**] (works 7 days a week
during this period; very sedentary)
No illicit drugs, occ alcohol, smoking
Walks without assistance
Married, 2 children.
Family History:
-DM, HTN, breastca mom, no migraine headaches
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Physical Exam:
Blood pressure was 175/82 mm Hg while seated. Pulse was 95
beats/min and regular, respiratory rate was 24 breaths/min. 02
sat 97% 4L t 99.9
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 10 cm, though difficult to assess secondary to obesity.
The carotid waveform was normal. The were no chest wall
deformities, scoliosis or kyphosis. The respirations were not
labored and there were no use of accessory muscles. The lungs
were clear to ascultation bilaterally with normal breath sounds
and no adventitial sounds or rubs.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Skin: erythematous cheeks/nose
Neuro: PERRL, EOMI, CN II-XII intact, strength 5/5 UE, sensation
intact UE, decreased secondary to neuropathy or LE. Alert and
oriented x 3. able to remeber building ([**Hospital Ward Name **]) and do serial 7's
without difficulty
Pertinent Results:
[**2153-4-30**] 03:45PM BLOOD WBC-11.8*# RBC-5.26 Hgb-15.6 Hct-44.9
MCV-86 MCH-29.6 MCHC-34.6 RDW-14.2 Plt Ct-275
[**2153-5-8**] 07:02AM BLOOD WBC-9.0 RBC-4.54* Hgb-12.9* Hct-39.5*
MCV-87 MCH-28.4 MCHC-32.7 RDW-14.4 Plt Ct-327
[**2153-4-30**] 03:45PM BLOOD Neuts-83.6* Lymphs-10.6* Monos-4.4
Eos-1.2 Baso-0.2
[**2153-5-4**] 06:10AM BLOOD Neuts-73.9* Lymphs-14.2* Monos-7.1
Eos-4.3* Baso-0.6
[**2153-5-6**] 07:08AM BLOOD PT-12.7 PTT-71.0* INR(PT)-1.1
[**2153-5-7**] 06:40AM BLOOD PT-12.9 PTT-84.2* INR(PT)-1.1
[**2153-5-1**] 02:20AM BLOOD ESR-15
[**2153-5-1**] 12:59PM BLOOD ESR-22*
[**2153-5-8**] 07:02AM BLOOD UreaN-24* Creat-1.2 K-4.1
[**2153-4-30**] 03:45PM BLOOD Glucose-152* UreaN-19 Creat-1.1 Na-142
K-4.2 Cl-103 HCO3-27 AnGap-16
[**2153-5-2**] 04:20AM BLOOD CK(CPK)-1778*
[**2153-5-2**] 12:11PM BLOOD CK(CPK)-[**2075**]*
[**2153-5-3**] 12:02AM BLOOD CK(CPK)-[**2072**]*
[**2153-5-7**] 06:40AM BLOOD CK(CPK)-136
[**2153-5-1**] 02:20AM BLOOD CK-MB-7 cTropnT-<0.01
[**2153-5-2**] 04:20AM BLOOD CK-MB-23* MB Indx-1.3 cTropnT-0.23*
[**2153-5-2**] 12:11PM BLOOD CK-MB-22* MB Indx-1.1 cTropnT-0.33*
[**2153-5-5**] 06:35AM BLOOD CK-MB-5 cTropnT-0.45*
[**2153-5-6**] 12:35AM BLOOD CK-MB-5 cTropnT-0.38*
[**2153-5-7**] 06:40AM BLOOD CK-MB-4 cTropnT-0.23*
[**2153-4-30**] 03:45PM BLOOD Calcium-9.6 Phos-2.2* Mg-2.0
[**2153-5-8**] 07:02AM BLOOD Calcium-8.8 Mg-2.3
[**2153-5-1**] 02:20AM BLOOD %HbA1c-8.1* [Hgb]-DONE [A1c]-DONE
[**2153-5-1**] 02:20AM BLOOD Triglyc-272* HDL-30 CHOL/HD-5.7
LDLcalc-86
[**2153-5-1**] 02:20AM BLOOD TSH-0.49
[**2153-4-30**] 03:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
.
.
.
.
.
.
................................................................
MRI head on admission:
MRI HEAD WITHOUT CONTRAST: The diffusion-weighted imaging is
unremarkable without evidence of acute infarction. There are
scattered tiny foci of T2/FLAIR hyperintensity within the
subcortical white matter bilaterally, which are non-specific and
likely represent chronic small vessel ischemic changes. The
signal intensity of the brain parenchyma otherwise throughout is
unremarkable. There is no evidence of mass, edema, or shift of
normally midline structures.
MRA OF THE CIRCLE OF [**Location (un) **]: The vertebral arteries, basilar
artery, and right posterior cerebral artery are well identified.
However, there is a sharp cutoff of the P1 segment of the left
posterior cerebral artery which is not clearly delineated on the
source images. However, there is evidence of artifact on the
source images at this level and the apparent cutoff of the
artery may be secondary to artifact. The rest of the major
tributaries of the circle of [**Location (un) 431**] are patent. There is no
evidence of aneurysm or arteriovenous malformation.
IMPRESSION:
1. No evidence of acute intracranial ischemia. No mass lesions
identified.
2. Abrupt cutoff of the left posterior cerebral artery, which
may be secondary to artifact as there is signal drop out on this
level and the source images. However, further evaluation with a
repeat MRA or CT angiogram is recommended to exclude abnormality
involving the left posterior cerebral artery.
.
.
.
.
.
.
.
................................................................
NON-CONTRAST CT OF THE HEAD: No acute intracranial hemorrhage,
shift of normally midline structures, or major vascular
territorial infarct. Periventricular hypoattenuation is
consistent with chronic microvascular ischemic changes.
[**Doctor Last Name **]-white matter differentiation is preserved. The visualized
paranasal sinuses and osseous structures are unremarkable.
IMPRESSION: No acute intracranial process.
.
.
.
.
.
.
.
.
................................................................
MRA head :
FINDINGS: There is fetal origin to the left posterior cerebral
artery. The left posterior cerebral artery also appears to take
a slightly inferior course from its usual location.
There is no evidence of loss of the normal flow signal.
The circle of [**Location (un) 431**] is otherwise normal with no evidence of
aneurysms or stenoses.
IMPRESSION: A fetal left posterior cerebral artery with no
evidence of loss off the normal flow signal.
.
.
.
.
.
.
.
.
................................................................
EEG done while with MS changes:
IMPRESSION: This is a mildly abnormal EEG in the primarily
sleeping
state due to the excessive sleep with a 6 Hz background rhythm.
This
suggests either excessive drowsiness and sleppr or a mild
encephalopathy, which may be seen with infections, toxic
metabolic
abnormalities or medication effect. A repeat EEG with waking
state recorded may better differentiate between sleep and a mild
encephalopathy.
.
.
.
.
.
.
.
.
................................................................
BILATERAL LOWER EXTREMITY ULTRASOUND: Compared to [**2147-5-26**].
Bilateral grayscale and color Doppler ultrasound performed of
the common femoral, superficial femoral, and popliteal veins.
Venous structures demonstrate normal compressibility, flow,
waveforms, and augmentation without intraluminal thrombus.
IMPRESSION: No evidence of DVT.
.
.
.
.
.
.
.
.
................................................................
ECHO:
Conclusions:
The left atrium is mildly dilated. The estimated right atrial
pressure is
0-5mmHg. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
The left ventricular inflow pattern suggests impaired
relaxation. There is a small pericardial effusion posterior to
the atria.
IMPRESSION: Preserved regional/global biventricular systolic
function. Mild mitral regurgitation. Impaired left ventricular
relaxation pattern. Small loculated pericardial effusion.
.
.
.
.
.
.
.
.
................................................................
Cardiac Catherization:
COMMENTS:
1. Selective coronary angiography of this left dominant system
revealed
two vessel disease. The LMCA was free of critical stenoses. The
LAD was
a small vessel with a proximal ulcerated 70% stenosis. The D1
branch was
also small with 80% ostial lesion. The LCx was the dominant
vessel and
free of critical lesions; there was a 40% stenosis at the origin
of the
LPDA. The RCA was a small nondominant and occluded at the
mid-vessel.
2. Non-selective renal angiography revealed bilateral single
renal
arteries without angiographically apparent lesions.
3. Limited resting hemodynamics revealed mildly elevated left
sided
filling pressures with an LVEDP of 15mmHg and moderate systemic
arterial
hypertension with an aortic SBP of 158mmHg.
4. Successful PTCA was performed of the D1 with a 2.0 mm
balloon.
Successful PTCA and stenting was performed of the proximal LAD
with a
2.5 mm Cypher drug eluting stent. Final angiography revealed
10%
residual stenosis in the LAD, 30% residual stenosis in the D1,
no
dissection, and normal flow. (see PTCA comments)
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. No angiographic evidence of renal artery stenosis.
3. Mild left ventricular diastolic dysfunction.
4. Successful PTCA of the D1.
5. Successful PTCA and stenting of the proximal LAD with a drug
eluting
stent.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] M.
[**Last Name (LF) **],[**First Name3 (LF) **]
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Brief Hospital Course:
Patient is a 62 yo man admitted from the ED with severe
hypertension and mental status changes. Patient was transferred
to the ICU and was briefly intubated for airway protectioin.
While in the NeuroICU, the patient was evaluated with MRI,
MRI/A, CT head and LP all of which did not show signs of either
infection or acute change to explain mental status changes.
However, however he did have very elevated blood pressure and
cardiology consultation felt the clinical picture was consistent
with hypertensive encephalopathy. With improved blood pressure
control, mental status cleared and patient was mentating well on
admission to the floor.
.
While on the inpatient floor issues were:
.
# Hypertension- Patient was restarted on his home medications
and then increased as needed to maximize metoprolol, losartan.
HCTZ and amlodipine were added and patient's blood pressure was
eventually improved to normotensive. (Was decreased slowly by
approx 30 mmHg/day). Patient counselled at time of discharge on
necessity of taking all meds and checking blood pressure daily.
.
# NSTEMI/CAD: Initial Troponin leak was thought to be secondary
to cardiac stress given that the patient has had significantly
elevated BPs. However, it continued to rise and eventually
peaked at .45. Given his clinical history of uncontrolled
diabetes and hypertension, it was very concerning for CAD.
Therefore, a cardiac catherization was performed that showed 2
vessel disease and had stenting of the proximal LAD and the
first diagonal artery. Additionally the renal artery
angiography was normal.
.
# Mental status- Was significantly improved from admission.
Mentating well without difficulty. Likely hypertensive
encephalopathy given that patient now improved in the setting of
negative workup otherwise.
.
# Diabetes- Per patient he was on NPH and humalog at home given
only every 12 hours. He was continued on NPH while here and was
also started on a humalog QID sliding scale. Glucose control
improved, but was not optimal. At time of discharge, it became
apparent that the patient had not been tightly following his
glucose level and a VNA was arranged for follow up of his use of
NPH [**Hospital1 **] as well as humalog sliding scale. Further management
will need to be done as an outpatient.
.
Medications on Admission:
- insulin Humulin N 60 [**Hospital1 **], Humalog 30 [**Hospital1 **]?
- lipitor 20 mg
- cozaar 100mg qd
- Zoloft 100 mg QD
- Atenolol 100mg QD
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*0*
4. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Atenolol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Humulin N 100 unit/mL Suspension Sig: Forty (40)
Subcutaneous twice a day: and increase to your home scale
gradually.
10. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: Check your glucose dialy at
breakfast, lunch and dinner and at bedtime and use the sliding
scale.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypertensive Encephalopathy
Coronary artery disease
.
Diabetes
Discharge Condition:
stable
Discharge Instructions:
You were admitted with very severe hypertension and trouble
thinking as a result. You MUST take your medications as
prescribed and stick to a low salt low sugar diet.
.
Please call your doctor or go to the ER if you have any chest
pain, shortness of breath, nausea, vomiting, fever, chills,
headaches, trouble with your vision.
.
Please take all medications as prescribed.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 105190**] and make a follow up appointment in [**2-6**]
weeks. Additionally if you would like to have a PCP in our
system, the number to set up the appointment is [**Telephone/Fax (1) 250**].
.
You also have the following appointments:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Date/Time:[**2153-6-4**] 11:45
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2153-5-29**] 1:20
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7110
} | Medical Text: Admission Date: [**2113-12-27**] Discharge Date: [**2114-1-3**]
Date of Birth: [**2077-5-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
CT scans
History of Present Illness:
36 year old male with a prior hx of 4+ AI and ascending aortic
aneur s/p Bental and St. [**Male First Name (un) 923**] aortic valve replacement [**11-28**] ,
AF (post-op)on amio, HTn, hyper chol, (clean cor on pre-op cath)
presents with subacute SDH and INR 5.9 (now 3.5). He developed
intermittent HA on [**12-21**] in the occipal region radiating down the
R arm. A CT done by his pcp showed [**Name Initial (PRE) **] parietal subdural.
Patient was sent to the ER and admitted no neurosurg. Patient's
coumadin recently was decreased for high INR. Recently started
abx for wound infection.
.
On admission, INR 3.5. Per report INR was 5.9 at osh.
Cardiology consult felt INR likely high dei to recent abx as
well as amiodarone acting as warfarin potentiator. Goal INR is
2.5. Coumadin was held upon admission. CT surgery evaluated.
Patient was followed by CT, bleed appears stable. Felt safe for
transfer to medicine. Did have elevation of INR to 4.8 today,
got additional Vitamin K this afternoon.
Past Medical History:
s/p AVR [**11-4**]
aa repair as above
htn
hyperhol
a fib
Social History:
Married, currently in school at [**Hospital3 12678**]
and works nights at a mental health center. Has 2 children, ages
4 and 23months.
Family History:
Noncontributory
Physical Exam:
97.7, HR 68, 105/36 ( 104-131/36-62), 16 99% RA I/O 2540/3000
LOS in ICU negative 290cc
Gen: Pleasant, laying in bed, a/ox3 NAD
HEENT: Pulils 2-3mm, RRLA, EOMI, OP clear, MMM, neck supple,
face symmetric
CV: S1 mechanical S2, regular
Pulm: CTAb
Chest: wound well healed, no erythema, no warmth, no discharge
Abd: soft, NT/ND, NABS
Ext: no edema noted
Pertinent Results:
CT head [**12-28**]: No acute intracranial hemorrhage. There is a
chronic appearing right cerebral hemispheric subdural hematoma.
Direct comparison with the patient's outside study after it has
been scanned into PACS would enable a meaningful comparison.
[**2113-12-27**] 06:44PM BLOOD WBC-4.6 RBC-4.18* Hgb-12.4* Hct-38.2*
MCV-91 MCH-29.5 MCHC-32.3 RDW-13.1 Plt Ct-294
[**2113-12-27**] 06:44PM BLOOD Neuts-42.4* Lymphs-42.7* Monos-3.6
Eos-10.8* Baso-0.4
[**2113-12-27**] 06:44PM BLOOD Hypochr-1+
[**2113-12-27**] 06:44PM BLOOD Plt Ct-294
[**2113-12-27**] 06:44PM BLOOD PT-23.6* PTT-46.5* INR(PT)-3.5
[**2113-12-27**] 06:44PM BLOOD Glucose-87 UreaN-11 Creat-1.1 Na-140
K-3.8 Cl-105 HCO3-29 AnGap-10
[**2114-1-3**] 06:40AM BLOOD WBC-4.8 RBC-4.21* Hgb-12.3* Hct-37.9*
MCV-90 MCH-29.2 MCHC-32.4 RDW-13.1 Plt Ct-291
[**2114-1-3**] 06:40AM BLOOD Plt Ct-291
[**2114-1-3**] 06:40AM BLOOD PT-20.0* PTT-52.1* INR(PT)-2.5
[**2114-1-3**] 06:40AM BLOOD Glucose-88 UreaN-8 Creat-1.1 Na-144 K-3.7
Cl-106 HCO3-29 AnGap-13
[**2114-1-3**] 06:40AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.9
Brief Hospital Course:
36 y/o man with PMH significant for AVR with mechanical valve
placement on [**2113-11-28**] admitted with a headache in the setting
of supratherapeutic INR. Found to have a subacute R
frontal-parietal SDH. Anticoagulation was reversed but pt became
subtherapeutic so he was started on IV heparin and coumadin.
Goal INR is 2.0-2.5 per neurosurgery and 2.5 to 3.5 per CT
surgery given mechanical valve. At this time, plan to keep it
between 2.5 and 3.0 if possible.
1. [**Name (NI) 44061**] Pt was initially supratherapeutic on
admission. His anticoagulation was reversed but pt then became
subtherapeutic. At that time, he was started on a heparin bridge
with coumadin as his subdural hematoma was stable. He was
continued on this regimen until his INR was 2.5. At that time,
the heparin was discontinued. The pt's INR goal will be between
2.5 and 3.0 given his valve replacement in addition to his
atrial fibrillation. He will follow up with his cardiologist on
[**1-5**] for evaluation of his coags and adjustment of his coumadin
dosage as needed.
2. Subdural hematoma- Pt was initially admitted to and evaluated
by neurosurgery. The subdural hematoma was stable in appearance
throughout the admission with normal neuro function. The pt was
sufferring from a fairly severe headache on admission but this
resolved over the course of the admission. The pt will need
repeat head CT in 2 weeks time which was scheduled prior to his
discharge. He will then follow up with neurosurgery in
outpatient clinic.
3. [**Name (NI) 12329**] Pt with good BP control. He was initially on IV
hydralazine in addition to his oral meds but this was changed to
an oral formulation on [**1-2**] with continued good blood pressure
control. On discharge, pt was continued on his beta blocker,
[**Last Name (un) **], and hydralazine.
4. Atrial fibrillation- Pt was continued on amiodarone
throughout admission. His anticoagulation was managed as above
and his INR was therapeutic on discharge.
5. [**Name (NI) 14983**] Pt was continued famotadine.
6. FEN- Low Na diet. Electrolytes were replaced as needed.
7. Code- Full
Medications on Admission:
Aspirin 81 mg Tablet; Amiodarone HCl 400 mg Tablet Sig: One
(1) Tablet PO once a day for 3 months: continue until after
postop visit with Dr [**Last Name (STitle) **].;Valsartan 80 mg Tablet Sig:
One (1) Tablet PO once a day.; Atenolol 75mg qd;Ibuprofen 600
; Warfarin Sodium
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Valsartan 80 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime:
Take 5 mg on the evening of [**1-3**] and 2.5 mg on the evening of
[**1-4**]. You will have your blood checked on Fri and your dose
should be adjusted as needed at that time. .
Disp:*60 Tablet(s)* Refills:*2*
8. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please have a PT, PTT, and INR checked on Friday [**2114-1-5**].
Your PCP will need to follow up on the results and adjust your
coumadin level as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Stable Subdural Hematoma
Supertheraputic INR
Hypertension
s/p AVR
Discharge Condition:
Stable. INR is in target range 2.5-3
Discharge Instructions:
Follow up with your cardiologist for close follow up of your INR
and coumadin dosing. If you have increased headaches, change in
mental status, feelings of confusion, bleeding, or any falls or
trauma call your doctor or go to the ED.
No lifting greater than 10 pounds or driving for 1 month after
your surgery. You may shower. No bathing or swimming for 1 month
after your surgery.
It is very important that you get your follow up head CT. Please
keep this appointment.
Followup Instructions:
1. Follow up at Dr.[**Name (NI) 44062**] office to have your labs checked on Fri
at your convenience. You will need a PT, PTT, and INR check and
then advice on how to change your coumadin. In addition, you
also have an appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Name (STitle) 766**] [**1-8**] at 4:00.
2. Dr. [**Last Name (STitle) **] (electrophysiology)in 2 months.
3. Please follow up with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 44063**] within one week of discharge. He needs to put in a
referral for the CT of your head that has already been scheduled
so that it is covered by your insurance.
4. You are scheduled for a repeat head CT (to see if bleeding in
brain has changed) on Wed [**1-17**] at 10:30. Please go to the
fourth floor of the [**Hospital Ward Name 23**] Clinical building for this study. Do
not eat or drink for three hours before the study.
5. Please follow up with neurosurgery on Friday [**1-19**] at 10:00.
Their office is located in the [**Last Name (un) 2577**] building [**Hospital Unit Name **].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5849, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7111
} | Medical Text: Admission Date: [**2199-6-27**] Discharge Date: [**2199-7-2**]
Date of Birth: [**2147-3-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
etoh withdrawl
Major Surgical or Invasive Procedure:
sutures in ED
History of Present Illness:
52 yo M with a history of EtOH abuse presented to ED after a
fall onto face day prior to admission. He notes that he had been
clean and sober for 17 months, though "fell off the wagon" and
went into a 3 week drinking "bender". He sat at home on couch
for two days straight with only minimal movement, noting that he
soiled himself to avoid having to get up. He finally did arise
from the couch the evening prior to admission and fell forward
into his TV stand, hitting his left brow and ear. He notes that
his last drink of EtOH was on the evening prior to presentation.
.
Past Medical History:
# Alcohol abuse: Binges, no hx of DTs or seizures
# Depression
# R wrist fracture ([**7-/2196**])
# Acute pancreatitis s/p drinking binge
# Hemorrhoids
Social History:
# Personal: Lives alone, recently divorced
# Professional: Real estate developer for [**Hospital3 **]
communities
# Alcohol: Began drinking in college on weekends. Moderate
social drinking after college. Binge-drinking began in
mid-[**2179**], during a period of high work stress. Longest period
of sobriety lasted 18 months; longest binge lasted three weeks.
Pt had Alcoholics Anonymous sponsor, and had undergone
"self-detox" previously by himself, as well as inpatient alcohol
rehabilitation.
# Tobacco: Social smoking, quit in ~[**2186**].
# Recreational drugs: Experimental marijuana in youth.
Family History:
# M a: Dementia
# F: Prostate CA
# Siblings (1 brother, 1 sister): No known illnesses
Physical Exam:
Physical Exam On Admission:
VS: T afebrile, BP 123/88, P 65, R 18, 98% on RA
GEN: NAD
HEENT: PERRL, oral mucosa slightly dry, oropharynx benign,
multiple facial abrasions and large left brow laceration with
sutures, ecchymotic and tender left ear
NECK: Supple
PULM: CTAB
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS+, soft, NT, ND
EXT: no C/C/E
Skin: shallow sacral ulcerations covered with a dry dressing
NEURO: Oriented x 3, slight resting tremor that attenuates with
distraction, tounge wag present
Pertinent Results:
Labs on Discharge:
CBC WBC-4.4 RBC-3.13* Hgb-10.2* Hct-31.4* MCV-101* MCH-32.7*
MCHC-32.6 RDW-14.3 Plt Ct-281
Coags: BLOOD PT-11.6 PTT-28.8 INR(PT)-1.0
Panel 10 Glucose-103* UreaN-12 Creat-0.7 Na-139 K-4.2 Cl-104
HCO3-25 AnGap-14 Calcium-9.0 Phos-4.6* Mg-2.0
[**2199-6-27**] BLOOD ALT-88* AST-146* CK(CPK)-475* AlkPhos-77
TotBili-1.1
[**2199-6-29**] BLOOD ALT-87* AST-136* CK(CPK)-148 AlkPhos-83
TotBili-0.7
[**2199-6-30**] BLOOD ALT-84* AST-103* AlkPhos-82 TotBili-0.4
[**2199-6-27**] BLOOD calTIBC-204* VitB12-1475* Folate-GREATER TH
Ferritn-611* TRF-157*
Brief Hospital Course:
Pt is 52yo male with hx of alcohol abuse, but sober for 17
months, who went on a 3-week binge. He was brought into the
hospital for head trauma after fall (no acute intracranial or
cervical process), and was subsequently found to have Stage 1
pressure ulcer in buttocks region. Pt was started on Valium
overnight, and received a total (inc standing orders and PRN
CIWA>10) of 120mg. Pt was given thiamine, folate, multivitamin,
and SW consult. Iron panel was also checked, and revealed
Ferritin 611, Fe 46, TIBC 204. B12 and folate wnl. Pt was
transferred to floor when valium needs decreased. Dry dressings
and frequent positional changes for buttock ulcer. He received a
total of 160+mg of Valium during his hospital stay. At the time
of discharge he was not tremulous or anxious, was able to
ambulate well and his ulcer on his buttock region was healing
well.
Medications on Admission:
None
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
6. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for sacral decubitus wound.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Laceration to head
Pressure wounds
ETOH withdrawl
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for withdrawing for alcohol. It was from
drinking too much the last few weeks. You also had sores on
your bottom from sitting in one place too long. You should stop
drinking and seek help as social work has directed. You have
been to treatment programs before and should start going back
again.
As for your wounds, we recommend an antifungal cream for a short
period of time while it heals. If it gets worse, you have
fevers or chills, or other concerns about it, you should seek
medical treatment because you're at a higher risk of infection.
And as for your stitches, you should see a doctor in our
[**Hospital 1944**] clinic to have them removed as outlined below.
Please take a multivitamin, thiamine and folate supplements
after leaving.
Please DO NOT drive for at least 48 hours.
Followup Instructions:
To remove your stitches please go to the following appointment:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2199-7-10**] at 8:30 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please schedule an appointment to follow up with your PCP in the
next week.
ICD9 Codes: 2761, 2875, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7112
} | Medical Text: Admission Date: [**2113-4-5**] Discharge Date: [**2113-4-11**]
Date of Birth: [**2034-4-4**] Sex: F
Service: SURGERY
Allergies:
Ciprofloxacin / Vancomycin / Bactrim Ds
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
FEVER;HYPOTENSION
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 80843**] is a 79 year old female with past medical history of
perforated duodenal ulcer, complicated recovery with several
infections, presents from rehabilitation with fevers, vomiting,
and leukocytosis.
.
Ms. [**Known lastname 80843**] experienced a perforation of her duodenum in
[**12/2112**], which required urgent surgery at an outside hospital.
Her course since that time has been complicated by a number of
infections of fluid collections and indwelling lines, with
several admissions here at [**Hospital1 18**] for sepsis-like physiology. She
has been followed closely by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111**] in the department of
infectious disease, and has continued on linezolid and
fluconazole since her discharge on [**2113-3-24**]. During her last
stay, studies of her duodenum revealed normal passage of
contrast without obstruction or leakage, but she continues to be
limited in her ability to take PO's. She has been followed
closely by Dr. [**Last Name (STitle) 1924**] in surgery as well.
.
She was brought to the emergency room today from rehabilitation
after she experienced fevers, abdominal pain, nausea, as well as
worsening renal function and leukocytosis and diarrhea. She also
reports that she has noted a diffuse red rash over her whole
body that started one or two days prior to admission. She had
been started on Bactrim [**2113-4-4**] for fevers and increasing WBC
(noted to be 18.3 as compared to 12.1 on [**3-29**]). She had had a CT
of her abdomen and pelvis completed as an outpatient on [**4-4**]
that demonstrated a slight increase in right upper abdominal
fluid collection as compared to [**3-19**], as well as persistent
inflammatory stranding adjacent to the duodenum and stable
narrowing of her superior mesenteric vein.
.
Her initial vital signs revealed a temperature of 98.3, blood
pressure of 70/54 right arm and 97/73 in left arm, heart rate of
94, respiratory rate of 18, 97% on 2 liters nasal cannula.
.
She recieved 5 liters of intravenous fluids. ID was contact[**Name (NI) **] in
the emergency room, and recommended linezolid and zosyn which
she received. She also received 50 mg of benadryl for a diffuse
red rash.
She was noted to be guaiac negative. Surgery was consulted and
evaluated the patient in the ED.
Past Medical History:
Duodenal perforation
Intra-abdominal abscess
Staph coag negative sepsis
Iron deficiency anemia
Depression
Diarrhea
Hypertension
Hypercholesterolemia
GERD
Recurrent low back pain s/p disc operation ~ 20 years ago
Social History:
Does not smoke cigarettes. Does drink alcohol. Lives
independently.
Does not smoke cigarettes. Does drink alcohol. Lives
independently.
Family History:
Noncontributory.
Physical Exam:
At discharge: A&Ox3. Appropriate, Listens and responds to
questions appropriately, pleasant
V.S 98.5, 86, 142/72, 18, 99 Ra
Gen: no acute distress
CV: RRR, S1, S2. No murmurs ascultated
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, nontender. G tube also in place, c/d/i
EXT: 2+ pitting edema. 2+ DP pulses BL
Pertinent Results:
[**2113-4-11**] 04:45AM BLOOD WBC-11.4* RBC-2.84* Hgb-8.4* Hct-25.9*
MCV-91 MCH-29.7 MCHC-32.6 RDW-17.5* Plt Ct-401
[**2113-4-5**] 02:00PM BLOOD WBC-15.7*# RBC-3.18* Hgb-9.7* Hct-28.3*
MCV-89 MCH-30.6 MCHC-34.4 RDW-17.6* Plt Ct-502*
[**2113-4-7**] 04:52AM BLOOD Neuts-55.5 Lymphs-18.4 Monos-4.6
Eos-21.1* Baso-0.3
[**2113-4-11**] 04:45AM BLOOD Plt Ct-401
[**2113-4-11**] 04:45AM BLOOD Glucose-126* UreaN-7 Creat-0.7 Na-146*
K-4.2 Cl-112* HCO3-25 AnGap-13
[**2113-4-5**] 02:00PM BLOOD ALT-12 AST-16 AlkPhos-73 TotBili-0.1
[**2113-4-11**] 04:45AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.8
.
BCX negative x 2.
.
UCX negative.
.
STUDIES
[**4-5**] CT Abd/Pelvis: Limited evaluation without contrast. No free
air. No apparent change in size of upper abdominal fluid
collection with adjacent inflammatory change since [**4-4**]. No new
collection.
Micro:
[**2113-3-18**] Blood VRE
[**2113-2-8**] Fluid MRSA, [**Female First Name (un) 564**]
Brief Hospital Course:
The patient was brought to the emergency room from
rehabilitation after she experienced fevers, abdominal pain,
nausea, as well as worsening renal function and leukocytosis and
diarrhea. She also reports that she has noted a diffuse red rash
over her whole body that started one or two days prior to
admission. She had been started on Bactrim [**2113-4-4**] for fevers
and increasing WBC (noted to be 18.3 as compared to 12.1 on
[**3-29**]). She had had a CT of her abdomen and pelvis completed as
an outpatient on [**4-4**] that demonstrated a slight increase in
right upper abdominal fluid collection as compared to [**3-19**], as
well as persistent inflammatory stranding adjacent to the
duodenum and stable narrowing of her superior mesenteric vein.
.
Her initial vital signs revealed a temperature of 98.3, blood
pressure of 70/54 right arm and 97/73 in left arm, heart rate of
94, respiratory rate of 18, 97% on 2 liters nasal cannula.
.
She recieved 5 liters of intravenous fluids. ID was contact[**Name (NI) **] in
the emergency room, and recommended linezolid and zosyn which
she received. She also received 50 mg of benadryl for a diffuse
red rash.
She was noted to be guaiac negative. Surgery was consulted and
evaluated the patient in the ED.
.
Upon arrival to the [**Hospital Unit Name 153**], she is no distress and has no
complaints. Her BP is 110/70, with heart rate in the 70's.
.
IMAGING:
[**2113-4-5**]
CT Abdomen and Pelvis without contrast
Limited evaluation without contrast. No free air. No apparent
change in size of upper abdominal fluid collection with adjacent
inflammatory change since yesterday. No new collection.
.
[**2113-4-5**]
Chest x-ray
The lungs are of low volume. There is stable appearance to the
scattered tiny calcific densities, which may be related to a
prior granulomatous infection.
There is subtle added density at the left costophrenic angle
suggestive of infective change. Cardiomediastinal silhouette is
stable. Right lung is clear.
.
CONCLUSION:
Subtle added density at the left lung base, may represent
infective change. Please ensure followup to clearance.
.
#) Fevers, leukocytosis: Sources of potential infection include
abdominal fluid collection, pneumonia (given appearance of CXR,
though no cough or sputum reported), or urinary source given
urine analysis. Most likely is abdominal in setting of abdominal
discomfort and emesis, however after discussion with surgery
team, this has been an ongoing unexplained problem for her
(inability to take good PO's), and the fluid collection is not
significantly changed from prior scans.
Also possible is drug reaction in setting of rash and elevated
eosinophils, though leukocytosis and hypotension are more
consistent with infection as etiology. She has no RUQ tenderness
to suggest cholecysitis, with benign LFT's. No significant
findings on CT, but c. difficile infection is possibility given
diarrhea and leukocytosis.
Relatively recent echocardiogram from [**2113-3-22**] was without
vegetations, and she has no stigma of endocarditis, but this is
also a possible source of recurrent infections.
- Per ID team who was contact[**Name (NI) **] in [**Name (NI) **], [**First Name3 (LF) **] continue linezolid,
zosyn, and fluconazole. The referral sheet indicated that she
completed fluconazole on [**4-2**] and Zyrox 600 mg on [**2113-4-2**] as
well.
.
#) Hypotension: Suspect secondary to sepsis in setting of
fevers, leukocytosis. Other possible (and likely) contributing
etiology is volume depletion in setting of poor PO intake while
at rehabilitation and concurrent administration of usual blood
pressure medications. Given diffuse red rash after initiation of
Bactrim and history of similiar rash with ciprofloxacin,
allergic reaction (not anaphylactoid) is another possibility.
Her hypotension has responded well to IVF while in the ED. BP on
prior admission was systolic of 110's.
- IVF boluses for goal MAP >55, will need to consider placement
of central line should she continue to require boluses beyond
those given in ED, also would then be able to measure CVP
.
#) Acute renal failure: Baseline creatinine is 0.9-1.1. Suspect
pre-renal etiology in setting of concurrently elevated BUN,
fevers, and emesis contributing to significant insensible
losses. Component of ATN is also possible given hypotension and
continued administration of anti-hypertensives. Urine output has
picked up to over 50cc/hour with IVF resuscitation.
- Hydration, follow up trend
- Urine electrolytes, urine sediment
- Should his renal function not improve, will consider renal
ultrasound or additional work-up
.
#) Rash: Patient noted diffuse erythema yesterday, at which time
she was also started on Bactrim for increasing leukocytosis. She
has a history of a similar rash which was ultimately felt to
likely be secondary to mediations (ciprofloxacin) in the setting
of eosinophila. She again today has a marked eosinophila, and
given temporal association to new medication, this is highest on
the differential. No mucosal involvement noted, no pruritis or
new peeling or blistering.
- Patient received benadryl 50 mg once in the [**Last Name (LF) **], [**First Name3 (LF) **] continue
to treat should she be symptomatic, though this would make
mental status more difficult to assess.
.
#) Eosinophila: As noted above in discussion of rash.
- Will follow trend, also check stool O&P - negative
.
#) Anemia: Patient's HCT today on admission is 28, which is up
from her baseline prior to discharge (25-27), likely
representing some degree of hemoconcentration. No history of
bleeding. Guaiac negative in ED. Has history of iron deficiency.
- Monitor trend, guaiac stools.
.
#) Duodenal performation: Patient has had difficulty with PO's
since her surgery and complicated recovery. During last stay she
had studies demonstrating patent duodenum without obstruction,
but she may need further intervention to improve ability to take
PO's and assist with chronic nausea and vomiting.
.
#) Mental status: Unknown baseline at this time, though she is
on remeron as outpatient. She is currently oriented, though has
poor recall of recent events. Per surgery team, this is close to
her baseline.
- Continue to monitor, obtain further information from family in
AM.
- Resume remeron once taking PO's.
.
#)ID was consulted and they recommended Daptomycin 450 mg IV
Q24H fir a total of 4 weeks. laboratory monitoring required:
-weekly CBC/diff, BUN/Cr, LFT, CK
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**]
.
#) Psych agrees pt depressed, but do not recommend SSRI while on
Linezolid, nor Remeron, and to check TSH (3.9)
.
The patient was transfered to [**Hospital Ward Name **] 5. She was placed on
telemetry secondary to prior sepsis. She was made NPO and tube
feeds were administered via GJ tube at a goal rate of 40, which
she tolerated well. A PICC line was placed for long term ABX per
ID. The patient has a history of chronic loose stools, she was
started on imodium 2 mg [**Hospital1 **] PRN with good effect.
.
Physical therapy also worked with patient and [**Hospital 80844**] rehab.
Please see physical therapy note.
.
The patient will follow up with ID on [**2113-4-14**] and Dr. [**Last Name (STitle) 1924**] in 2
weeks.
Medications on Admission:
Vancomycin 750mg IV daily, Flucanazole 200mg daily, Lisinopril
10mg twice daily, Metoprolol 12.5 mg twice daily, Remeron 15mg
nightly, Prevacid 30mg twice daily, Tylenol, Senna, Maalox,
Lactulose PRN, Prochlorperazine 10mg q6h PRN nausea, dulcolax PR
PRN, Benadryl cream, Dorzolamide-timolol 2-0.5% drps twice daily
both eyes,
Florastor II cabs twice daily, MVI, combivent, insulin
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed.
2. Dorzolamide-Timolol 2-0.5 % Drops [**Last Name (STitle) **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for pruritus.
4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
5. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
6. Daptomycin 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 4 weeks: last dose
[**2113-5-5**].
7. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
8. Sodium Chloride 0.9 % 0.9 % Syringe [**Month/Day/Year **]: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
9. Prevacid 30 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. Florastor 250 mg Capsule [**Month/Day/Year **]: Two (2) Capsule PO twice a
day.
11. Insulin
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL [**1-13**] amp D50 [**1-13**] amp D50 [**1-13**] amp D50 [**1-13**] amp D50
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 2 Units
161-200 mg/dL 4 Units 4 Units 4 Units 4 Units
201-240 mg/dL 6 Units 6 Units 6 Units 6 Units
241-280 mg/dL 8 Units 8 Units 8 Units 8 Units
12. Prochlorperazine Maleate 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO
every six (6) hours as needed for nausea.
13. Loperamide 2 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2 times
a day) as needed for loose stool.
14. Mirtazapine 15 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QHS PRN.
Discharge Disposition:
Extended Care
Facility:
life care center of [**Location (un) **]
Discharge Diagnosis:
Primary:
FEVER
HYPOTENSION
leukocytosis
Acute renal failure
Anemia
Duodenal performation
.
Secondary:
Duodenal perforation and repair [**12/2112**]
- Intra-abdominal abscess
- Staph coagase negative sepsis
- Iron deficiency anemia
- Depression
- Diarrhea
- Hypertension
- Hypercholesterolemia
- GERD
- Recurrent low back pain s/p disc operation ~ 20 years ago
Discharge Condition:
Stable.
Tolerating tube feeds at goal rate. Please cycle and encourage
PO intake during day.
Pain well controlled.
Discharge Instructions:
Rehab:
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 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.
.
GJ Tube:
-Please continue to assess GJ tube site for s/s of infection
-Please change dressing QD and PRN
-Please cycle tube feeds: Peptamen 1.5 Full strength;
Goal rate: 40 ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 30 ml water q8h
.
Please check weekly labs CBC/Diff/BUN/Cr/AST/ALT/CK and fax to
Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 432**].
.
Please continue with Daptomycin 450 mg IV Q24H until [**5-5**].
Followup Instructions:
1. Please call Dr.[**Name (NI) 12822**] office, [**Telephone/Fax (1) 7508**], to make a
follow up appointment in 2 weeks.
.
Scheduled Appointments :
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2113-4-14**] 10:30
Completed by:[**2113-4-11**]
ICD9 Codes: 0389, 2930, 2720, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7113
} | Medical Text: Admission Date: [**2189-1-29**] Discharge Date: [**2189-2-2**]
Date of Birth: [**2116-1-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Lipitor / Codeine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
superficial sternal wound infection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 67738**] is a 73 year old woman who [**Known lastname 1834**] a coronary
artery bypass grafting times four and mitral valve repair on
[**2189-1-14**]. She subsequently was discharged to a rehab facility.
Once home, her visiting nurse described her sternal wound to be
erythematous with foul smelling eschar. She was admitted to
[**Hospital1 69**] for debridement and
intravenous antibiotics.
Past Medical History:
s/p CABG x4/MVr (on [**2189-1-14**])
Coronary artery disease with unstable angina
chronic systolic heart failure
mitral regurgitatiuon
obesity
insulin dependent diabetes mellitus
s/p coronary angioplasty
pulmonary hypertension
hypertension
peripheral vascular disease-s/p stenting lower extremities
s/p cholecystectomy
s/p appendectomy
s/p psoas abcess
gastritis
Social History:
Heavy smoker up to 2 PPD for 50 years, quit in [**10-25**]. Denies
etOH or IVDU. Pt is a retired x-ray technician. She lives with
her husband and two grandchildren in [**Name (NI) 67740**], She is the
caregiver for her sister with [**Name (NI) 309**] body dementia and her husband
as well as her two grandchildren.
Family History:
No family history of CAD or premature death, DM, HTN, HLD.
Mother with PD. Sister with [**Name (NI) 309**] body dementia. Sister with lung
CA.
Physical Exam:
At admission Ms. [**Known lastname 67738**] was noted to be in no acute distress.
She was hemodynamically stable and afebrile. Her lungs were
clear to auscultation bilaterally and her heart was of regular
rate and rhythm. Her abdomen was soft, non-tender, and
non-distended. Her mediastinal incision was intact at the
superior pole, but inferiorly a 3 cm long by 2 cm wide area of
eschar.
Pertinent Results:
[**2189-1-30**] 04:19PM BLOOD WBC-10.2 RBC-3.77* Hgb-11.2* Hct-34.2*
MCV-91 MCH-29.7 MCHC-32.7 RDW-13.5 Plt Ct-495*#
[**2189-2-2**] 05:59AM BLOOD WBC-10.4
[**2189-1-30**] 04:19PM BLOOD Glucose-338* UreaN-40* Creat-1.5* Na-133
K-6.0* Cl-94* HCO3-31 AnGap-14
[**2189-2-2**] 05:59AM BLOOD UreaN-31* Creat-1.1
[**2189-1-29**] 6:22 pm SWAB Source: mediastinum.
GRAM STAIN (Final [**2189-1-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final [**2189-2-1**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
Brief Hospital Course:
Ms. [**Known lastname 67738**] was admitted and her wound cultured. She was placed
on Vancomycin and her wound was debrided. Superficial eschar
was removed and vascularized healthy tissue was discovered just
below it. No pus was expressed. A peripherally inserted central
catheter was placed for access. She remained afebrile with a
normal white blood cell count. Her wound on discharge was
superficial without erythema or drainage. Her sternum was stable
with no [**Doctor Last Name **] or click. Wound swab culture from [**1-29**] showed mixed
bacteria. As per Dr.[**Last Name (STitle) **], Vanco and Cipro was
discontinued and Ms.[**Known lastname 67738**] was placed on oral antibiotic course:
Keflex 500 mg every 6 hours x ten days. A visiting nurse has
been arranged for wound checks at home and Ms.[**Known lastname 67738**] has been
instructed on dressing changes as well so that the wound can be
dressd twice daily. She was advised to call with any signs or
symptoms of worsening infection, and to follow up with
Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **] for wound visit in 1 week.
Medications on Admission:
plavix 75mg
omeprazole 20mg [**Hospital1 **]
Insulin NPH 36 units in the morning and evening
Insulin Lispro 4 units in the morning and evening
atrovent
xenopex
[**Hospital1 21177**] 10mg
metolazone 5mg [**Hospital1 **]
colace
zocor 40mg
aspirin 81mg
percocet
amiodarone 400mg
lopressor 75mg
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, 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. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*180 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Rosuvastatin 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. [**Hospital1 **] 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-21**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 * Refills:*0*
10. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): x 10 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
superficial sternal wound infection
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
No creams, lotions, powders, or ointments to incisions
**Wound dressing changes, wet to dry, twice daily
Followup Instructions:
See Dr. [**Last Name (STitle) **] in 1week
Call for appointment [**Telephone/Fax (1) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2189-2-2**]
ICD9 Codes: 4280, 4019, 4240, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7114
} | Medical Text: Admission Date: [**2188-4-8**] Discharge Date:
Date of Birth: [**2130-3-24**] Sex: F
Service:
NOTE: This is an interim Discharge Summary through today
([**2188-4-18**]), and there will be a further Discharge
Summary required.
CHIEF COMPLAINT: This is a 58-year-old Caucasian female who
presents with hypoxia, and mental status changes, and
hypercapnia.
HISTORY OF PRESENT ILLNESS: This is a 58-year-old female
with a history of morbid obesity, obstructive sleep apnea,
and chronic obstructive pulmonary disease who presents with
hypoxia, per [**Hospital6 407**]. The patient had
been found by [**Hospital6 407**] on the morning of
admission confused, with shortness of breath, and an oxygen
saturation of 79% on room air. The patient initially
reported a sore throat, tightness, and chest pain which was
not reported by the patient on presentation to the Emergency
Department.
Ms. [**Known lastname **] had recently been admitted to [**Hospital1 346**] a few days before with a workup for
subacute renal failure. At that time, it was decided that
Ms. [**Known lastname 34727**] renal failure was likely secondary to
hypovolemia. She was given intravenous fluids, and her usual
dose of 80 mg p.o. of Lasix b.i.d. was held. The patient's
creatinine peaked around 4.1, and at discharge was 2.9.
Currently, the patient is disoriented, awake, and alert. She
has no complaints of chest pain, nausea, vomiting,
diaphoresis, sore throat or shortness of breath. In the
Emergency Department, she was given Levaquin 500 mg p.o.
q.d., Lasix 40 mg intravenously times one, Solu-Medrol 120 mg
times one, albuterol nebulizers, bicarbonate, D-50, and
intravenous insulin. This was in response to a white blood
cell count of 8.4, potassium of 6.1, and a blood urea
nitrogen of 54, and creatinine of 2.6.
PAST MEDICAL HISTORY:
1. Morbid obesity, weight of greater than 400 pounds.
2. Obstructive sleep apnea.
3. Cor pulmonale; echocardiogram in [**2188-1-12**] showed
an ejection fraction of greater than 50%. There was also
right atrial and ventricular dilatation, and severe global
right ventricular hypokinesis. There was also abnormal right
ventricular wall motion abnormalities. There was 4+
tricuspid regurgitation. Dobutamine MIBI on [**2187-3-30**] showed no defects.
4. Osteoarthritis/rheumatoid arthritis.
5. Hypertension.
6. Peptic ulcer disease.
7. Chronic obstructive pulmonary disease. The patient has a
72-pack-year smoking history, but no pulmonary function tests
in the record. There is a history of intubation in the past,
and she requires home oxygen of 2 liters to 3 liters. Her
baseline bicarbonate was noted to be 48 to 50.
8. Renal insufficiency with a creatinine of 0.7 up until
[**2187-9-12**], and since then has been 2 to 4.
ALLERGIES: DEMEROL and CASHEWS.
MEDICATIONS ON ADMISSION: Medications at home include
Flovent 4 puffs b.i.d., Combivent 2 puffs q.i.d.,
albuterol 2 puffs q.i.d., Vioxx 25 mg p.o. q.d.,
trazodone 100 mg p.o. q.d., Prozac 20 mg p.o. q.d.,
Plaquenil 200 mg p.o. q.d., Protonix 40 mg p.o. q.d.,
Detrol 2 mg p.o. b.i.d., glucosamine 100 mg p.o. q.d.,
Neurontin 300 mg p.o. q.d., Norvasc 2.5 mg p.o. q.d.,
digoxin 0.125 mg p.o. q.d., Lasix 20 mg p.o. q.d., and
K-Dur 20 mg p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed a temperature of 98, pulse of 100,
blood pressure of 164/90, respiratory rate of 20, satting 96%
on 50% face mask. In general, she was a very morbidly obese
Caucasian female in moderate respiratory distress. Skin was
pink. On neck examination unable to assess. On
cardiovascular examination difficult to hear heart sounds.
Second heart sound and second heart sound, tachycardic.
Lungs were clear to auscultation anteriorly and laterally.
The abdomen was obese, nontender and nondistended, positive
bowel sounds. Extremities revealed some breakdown of the
skin at the ankles. Pretibial edema was present.
Neurologically, cranial nerves II through XII were intact
bilaterally. Moved all four extremities and followed
commands. Thought that the year was 200; had no response to
date. She noted location was the hospital, but not that it
was [**Hospital1 69**]. Otherwise, there
were no focal neurologic deficits.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission with a complete blood count that showed a white
blood cell count of 8.4, hematocrit of 31.2, platelets of 187
(with 78% neutrophils, 1% basophils, 12% lymphocytes,
3% monocytes, and 5% eosinophils). Chem-7 revealed the
following: Sodium of 143, potassium of 6.1, chloride of 105,
bicarbonate of 30, blood urea nitrogen of 64, creatinine
of 2.6, blood sugar of 95. Digoxin level of 2.3. Urinalysis
showed the following: Specific gravity of 1.025, large
blood, 30 protein, moderate leukocyte esterase, negative
nitrites, 6 to 10 white blood cells, many bacteria. Lactate
of 1.1, A-gradient of 15.5. Arterial blood gas on 50% face
mask was the following: pH of 7.18, PCO2 of 88, PO2 of 231.
Urine culture from [**2188-4-4**] showed Klebsiella
sensitive only to imipenem with 10,000 colony-forming units.
Urine culture from [**4-8**] was pending. Sputum from
[**3-29**] showed methicillin-resistant Staphylococcus
aureus in rare colonies.
RADIOLOGY/IMAGING: Chest x-ray was limited, but no definite
congestive heart failure or pneumonia.
Electrocardiogram showed low voltages, rate of 110, with
atrial abnormalities, far right axis deviation. No acute
ST-T wave changes. No sign of Q waves. This was compared to
an electrocardiogram from [**2188-3-23**].
CT of the abdomen and pelvis in [**3-15**] showed moderate
ascites. She underwent paracentesis on [**2188-3-25**]
which showed no spontaneous bacterial peritonitis by white
blood cells or culture.
Hospital course prior to being transferred to the [**Hospital1 **]
Service, Ms. [**Known lastname **] was admitted to the Medical Intensive
Care Unit Service for further management of her respiratory
distress.
She was placed on BiPAP and did not tolerate this well
overnight. However, she maintained her oxygenation and was
switched to nasal cannula during the day on the following
morning. It was uncertain in the beginning as to whether her
respiratory distress was secondary to congestive heart
failure versus pneumonia/chronic obstructive pulmonary
disease. Chest x-ray, lack of fever, and lack of
leukocytosis suggested that there was not an infectious
component. Thus, Solu-Medrol was discontinued at this time
as well as Levaquin for pneumonia. She was diuresed in the
intervening days with good response. Since then she has been
able to maintain herself off of BiPAP and only on 3 liters to
4 liters nasal cannula.
During her Medical Intensive Care Unit stay, Mr. [**Known lastname **]
also converted to new atrial flutter with transient
hypotension. At that time DC cardioversion was considered,
but Ms. [**Known lastname 34727**] blood pressure improved. She was also
tried on ibutilide drip without affect. She was
anticoagulated initially with heparin and then converted to
Coumadin and started on amiodarone while in the unit.
MEDICATIONS ON TRANSFER:
1. Flovent 4 puffs inhaled b.i.d.
2. Albuterol and Atrovent nebulizers q.6h.
3. Imipenem 500 mg q.6h. intravenously.
4. Protonix 40 mg p.o. q.d.
5. Lasix 40 mg p.o. b.i.d.
6. Amiodarone 400 mg p.o. t.i.d.
7. Heparin drip.
8. Combivent 2 puffs q.4-6h.
PERTINENT LABORATORY DATA ON TRANSFER: Complete blood count
showed a white blood cell count of 6.5, hematocrit of 28.7,
platelets of 171. Chem-7 showed the following: Sodium
of 142, potassium of 5.2, chloride of 103, bicarbonate of 30,
blood urea nitrogen of 67, creatinine of 2.7, blood sugar
of 110. Calcium of 8.3, phosphate of 5.8, magnesium of 1.9.
Urine culture from [**4-9**] did eventually grow out
100,000 Klebsiella pneumoniae which was sensitive only to
imipenem. Nasal swab from [**2188-3-25**], showed positive
methicillin-resistant Staphylococcus aureus.
PHYSICAL EXAMINATION ON TRANSFER: Temperature of 96.3, pulse
of 89 (in atrial flutter), blood pressure of 104/62,
respiratory rate of 27, satting 88% to 97% on 4 liters nasal
cannula. In general, this was an extremely obese Caucasian
female lying in bed, in no acute distress. Nasal cannula was
in place. Head, eyes, ears, nose, and throat revealed pupils
were equal, round, and reactive to light. Extraocular
movements were intact. Poor attention span. The oropharynx
was clear. Poor dentition. Cardiovascular examination
showed a regular rate, irregularly rhythm. No murmurs, rubs
or gallops could be assessed. Lungs revealed poor
inspiratory effort, otherwise clear. The abdomen revealed
normal active bowel sounds, nontender, and nondistended. No
masses could be palpated. An extremely obese abdomen.
Extremities were clean, dry, and intact. There was brawny
induration with 3+ pitting edema up to her lower thighs.
Neurologically, alert and oriented times three. Able to move
all four extremities against gravity and pressure. Light
touch was intact bilaterally; grossly nonfocal.
HOSPITAL COURSE: (After being transferred to the [**Hospital1 **]
Medicine team)
1. CARDIOVASCULAR: (a) Arrhythmia: Ms. [**Known lastname **] was
noted to be in new atrial fibrillation/atrial flutter but was
not considered a candidate for electrocardioversion. She had
been attempted previously for chemical cardioversion with
ibutilide drip without success. She was started on
amiodarone on [**2188-4-11**] and also anticoagulated with a
heparin drip with Coumadin. The goal at that time was for an
INR of greater than 2. Digoxin was discontinued secondary to
its effect on both amiodarone and Coumadin.
Thyroid-stimulating hormone and liver function tests were
recently checked and were within normal limits with the
exception of a subclinical hypothyroidism. Ms. [**Known lastname 34727**]
INR did finally reach a therapeutic range but had to be
reversed with vitamin K secondary to need for new line
placement.
(b) Coronary artery disease: Ms. [**Known lastname **] was ruled out
for myocardial infarction during her Medical Intensive Care
Unit course. Electrocardiograms were followed every few
days.
(c) Congestive heart failure: Ms. [**Known lastname **] has known
right-sided heart failure secondary to extreme obesity,
chronic obstructive pulmonary disease, and obstructive sleep
apnea. Cardiology was consulted who recommended holding off
on Swan-Ganz catheter and suggested possible right heart
catheterization at a later time.
2. RESPIRATORY: Ms. [**Known lastname 34727**] respiratory distress
responded well to diuresis with Lasix up to 80 mg
intravenously b.i.d. At the time of transfer from the
Medical Intensive Care Unit, this had been changed to p.o.
Lasix at 40 mg p.o. b.i.d. Strict ins-and-outs were
requested, and oxygen was weaned as tolerated. Ms. [**Known lastname **]
continued to refuse BiPAP as well as nebulizers while on the
Medicine floor.
3. RENAL: Ms. [**Known lastname **] was known to have recent acute
renal failure with chronic renal insufficiency, likely
secondary to hypovolemia. In the intervening days after
being transferred from the Medical Intensive Care Unit, her
creatinine and blood urea nitrogen continued to rise; likely
secondary to prerenal picture including hypovolemia and
possible congestive heart failure. Renal was consulted.
Urine electrolytes had been obtained prior to a Renal
consultation which showed a urea of 26, which likely
indicated prerenal state. Urinalysis was also obtained which
showed many bloody/brown casts. However, Renal was consulted
and thought that only granular casts could be visualized on
the urinalysis. FENa was repeated and found to be 0.17%,
likely indicating prerenal.
Ms. [**Known lastname **] is not a candidate for dialysis at this time
secondary to her preload dependence and poor blood pressure.
However, they believed that she was a candidate for
continuous venovenous hemofiltration to help remove
approximately 120 pounds of fluid. She will require
placement of a hemodialysis catheter and transfer to the
Medical Intensive Care Unit for hemodynamic monitoring and
continuous venovenous hemofiltration.
In light of her renal failure, all medications are now
renally dosed, and all nephrotoxins have been discontinued.
4. FLUIDS/ELECTROLYTES/NUTRITION: Ms. [**Known lastname **] had been on
a regular diet except for nuts. However, in the intervening
days she began to have decreased oral intake. Albumin was
checked and was found to be 3.4. Intravenous fluids had been
avoided at this time secondary to whole body anasarca.
Ms. [**Known lastname **] was treated for hyperkalemia on admission with
a potassium of 6.1. Potassium was carefully monitored over
the next few days. On [**2188-4-17**], potassium was found to
be 5.5, and she was given Kayexalate 30 g with good affect.
5. HEMATOLOGY: Ms. [**Known lastname 34727**] hematocrit on admission
was 30.2, and trended down to 28.7. This was likely
secondary to chronic renal insufficiency and poor Epogen
production. Transfusion parameters were for a hematocrit of
less than 27.
6. INFECTIOUS DISEASE: Ms. [**Known lastname **] has had a chronic
indwelling Foley for greater than two years. Cultures from
[**2188-4-4**] and [**2188-4-9**] showed two strains of
Klebsiella which were imipenem sensitive. She was treated
with seven days of imipenem which was discontinued on
[**2188-4-15**]. Foley was changed on [**2188-4-11**]. She
continued on methicillin-resistant Staphylococcus aureus and
contact precautions.
7. LINES: Ms. [**Known lastname **] has a left subclavian line which
was placed in the unit on admission on [**2188-4-8**].
This will be changed when transferred to the Medical
Intensive Care Unit on [**2188-4-21**].
8. DISPOSITION: Ms. [**Known lastname **] is do not resuscitate but
NOT do not intubate. She will be transferred at this time to
the Medical Intensive Care Unit for further monitoring and
continuous venovenous hemofiltration/hemodialysis.
Ms. [**Known lastname **] understands that continuous venovenous
hemofiltration does have risks involved including possible
renal failure, heart failure, and other kinds of morbidities.
She is willing to take these risks including possibly
requiring hemodialysis for the rest of her life.
As stated before, this is an interim Discharge Summary. A
discharge addendum will be needed later.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 8073**]
MEDQUIST36
D: [**2188-4-18**] 14:05
T: [**2188-4-18**] 17:58
JOB#: [**Job Number 34728**]
ICD9 Codes: 4280, 4168, 5849, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7115
} | Medical Text: Admission Date: [**2143-6-18**] Discharge Date: [**2143-6-26**]
Date of Birth: [**2067-3-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB and chest pain
Major Surgical or Invasive Procedure:
CABGx4 (LIMA>LAD, SVG>Diag, SVG>Ramus, SVG>OM) [**2143-6-21**]
History of Present Illness:
76 yo M who fell and fractured hip, had ORIF at [**Hospital3 **]
[**2143-6-9**]. He developed chest pain on POD #2, had +ETT and
cardiac cath which showed multivessel CAD. He was transferred
for surgery.
Past Medical History:
PMH: CAD, HTN, DM, BPH, peripheral neuropathy, L [**Doctor Last Name **] DVT
PSH: Rt hip ORIF, Spinal [**Doctor First Name **] x2(15yrs ago)
Social History:
retired mechanic
quit tobacco 20 years ago
denies etoh
Family History:
mother died of ischemic heart disease at age 42
Physical Exam:
HR 63 RR 18 BP 136/76 98% on 2L
NAD, pain free
muliple scratched on arms/legs
Lungs CTAB
Heart RRR no M/R/G
Abdomen benign
Extrem warm, no edema
Neuro non-focal but poor historian, forgetful
Pertinent Results:
[**2143-6-25**] 05:35AM BLOOD Hct-28.9*
[**2143-6-24**] 01:40AM BLOOD WBC-13.5* RBC-3.42* Hgb-10.1* Hct-29.3*
MCV-86 MCH-29.6 MCHC-34.5 RDW-14.6 Plt Ct-295
[**2143-6-25**] 05:35AM BLOOD PT-14.1* INR(PT)-1.2*
[**2143-6-25**] 05:35AM BLOOD K-4.4
[**2143-6-24**] 01:40AM BLOOD Glucose-182* UreaN-22* Creat-0.8 Na-132*
K-4.3 Cl-98 HCO3-28 AnGap-10
PORTABLE CHEST, [**2143-6-23**].
COMPARISON: [**2143-6-21**].
INDICATION: Tube removal.
Various indwelling devices have been removed, with no evidence
of
pneumothorax. Cardiomediastinal contours are within normal
limits for
postoperative status. Patchy and linear areas of atelectasis are
present in
both lung bases, slightly worse in the interval, and there are
also very small
bilateral pleural effusions. Calcified pleural plaques are
present consistent
with prior asbestos exposure.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 78541**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78542**] (Complete)
Done [**2143-6-21**] at 12:59:43 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: [**2067-3-27**]
Age (years): 76 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: cabg
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2143-6-21**] at 12:59 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW-1: Machine: aw2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild
(1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
(1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage. Right ventricular chamber size and free wall motion
are normal.
LV systolic fxn is good, with an EF of 50 - 55%.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are moderately thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
An epi-aortic scan was done to aid placement of aortic cannula
and cross-clamp.
Post-CPB:
Preserved biventricular systolic fxn. AI and MR remain 1+. Aorta
intact.
Brief Hospital Course:
He was admitted to cardiac surgery. He continued on heparin and
nitroglycerine drips and he remained chest pain free. He was
taken to the operating room on [**6-21**] where he underwent a CABG x
4. He was transferred to the ICU in stable condition. He was
extubated post op. He was transferred to the floor on POD #2. He
was started on coumadin for his recent hip surgery. Chest tubes
and wires were pulled without incident. Foley was reinserted for
urinary retention and he was restarted on his flomax and
proscar. Foley was again removed on [**6-25**] and he voided
successfully. He was ready for discharge to rehab on POD #5. His
right leg remains ecchymotic secondary to recent trauma. He will
need lovenox until his INR is 2.0 or greater, he has received 3
doses of 5 mg of coumadin so far.
Medications on Admission:
Novalin, Procrit, Proscar 5', Flomax 0.4', Colace 100", Pepcid
20', MOM
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. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous with breakfast.
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous with dinner.
9. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale units Subcutaneous four times a day.
10. Lovenox 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous twice a day: please check inr daily, when 2.0 or
greater discontinue lovenox.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily):
Check INR daily, continue lovenox until INR >= 2. Has received 3
doses of 5 mg.
Discharge Disposition:
Extended Care
Facility:
Berkeley Retirement Home
Discharge Diagnosis:
CAD s/p CABG
PMH: CAD, HTN, DM, BPH, peripheral neuropathy, L [**Doctor Last Name **] DVT
PSH: Rt hip ORIF, Spinal [**Doctor First Name **] x2(15yrs ago)
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
CT scan in 3 months to follow-up left upper lobe lung nodule.
Dr. [**Last Name (STitle) 28745**] 2 weeks
Dr. [**First Name (STitle) 3646**] 2 weeks
Dr. [**Last Name (STitle) 914**] 4 weeks
Completed by:[**2143-6-26**]
ICD9 Codes: 4111, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7116
} | Medical Text: Admission Date: [**2177-4-14**] Discharge Date: [**2177-4-18**]
Date of Birth: [**2098-11-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Hypoxia
Posterior hip dislocation
Major Surgical or Invasive Procedure:
Reduction of left posterior hip dislocation
PICC line insertion
History of Present Illness:
78M with hx of CABG in [**2168**], CAD, DM hx of hip frequent
dislocation of artificial L hip, tripped over rug in apartment
and fell, no Head strike or LOc. He felt hip [**Doctor Last Name **] out. In the ED,
initial VS were:97.3 108 144/75 16, no O2 sat recorded, 3L
NC(recorded).However resident noted patient to be tachypneic at
35 hypoxic to 50. Patient did note several hours of shortness of
breath today upon further questioning. CXR showed R pulmonary
edema vs infiltrate, placed on NRB, then sats to mid90s-100. A
CT scan was negative for PE, but did show right sided pneumonia,
possible aspiration. Patient noted to have elevated lactate 4.4.
WBC 2.8 with N:59.5 L:33.2 M:5.4 E:0.9 Bas:1.0.
Vanc/Zosyn/Levoflox given. Trop of 0.05. EKG: sinus 92 NA, IV
conduction delay ST depression I and aVL.
.
In ED, Ortho consulted and patient had procedural sedation with
with fent (100)/versed (4) hip successfully reduced in ED.
Reversed sedation with flumazenil (0.2)/narcan (2), Got 2L IV
fluids for the lactate.
.
On arrival to the MICU, patient's VS. 97.7/ 81/112/69/13 100%
NRB. On recheck 91% on RA. 97% on 2L. patient denied any Chest
pain/SOB. Feels very well and is surprised to be admitted.
Past Medical History:
Coronary artery disease status post CABG, [**2168**]
Diabetes recently stopped glyburide and metformin per his doctor
[**First Name (Titles) **]
[**Last Name (Titles) 6093**], muscle weakness, NOS
spinal stenosis, lumbar
MITRAL INSUF/AORT STENOS
PVD, NOS
HL
Social History:
Social History: Lives by himself. Has a home care nurse [**First Name (Titles) **] [**Last Name (Titles) 6094**]s every 2 weeks. Uses a walker or cane and scooter when out
of apartment. No smoking, no alcohol, no rec drugs. has a Niece
[**Name (NI) **] [**Name (NI) **] who lives in [**Hospital1 1474**] [**Telephone/Fax (1) 6095**] (cell)
[**Telephone/Fax (1) 6096**] (work) is HCP according to patient.
Family History:
Family History: Father with MI in 50s. Brother with MI in 50s.
No history of cancer
Physical Exam:
Vitals: 97.7/ 81/112/69/13 100% NRB
General: Alert, oriented x3, no acute distress, NRB in place
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, holosystolic murmur
radiates to both axilla and carotids, rubs, gallops
Lungs:rales in bilateral lung bases R>L., no wheezes, occasional
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred. Left leg in knee immobilizer
Pertinent Results:
ADMISSION
[**2177-4-14**] 09:45AM BLOOD WBC-2.8* RBC-3.81* Hgb-10.3* Hct-35.3*
MCV-93 MCH-27.2# MCHC-29.3*# RDW-14.1 Plt Ct-144*
[**2177-4-15**] 07:36AM BLOOD Hct-28.4*
[**2177-4-15**] 12:05PM BLOOD Hct-29.7*
[**2177-4-14**] 09:45AM BLOOD PT-10.4 PTT-25.9 INR(PT)-1.0
[**2177-4-15**] 04:24AM BLOOD Plt Ct-100*
[**2177-4-14**] 09:45AM BLOOD Neuts-59.5 Lymphs-33.2 Monos-5.4 Eos-0.9
Baso-1.0
[**2177-4-15**] 04:24AM BLOOD Ret Aut-2.4
[**2177-4-14**] 09:45AM BLOOD Glucose-322* UreaN-23* Creat-0.6 Na-139
K-4.0 Cl-98 HCO3-29 AnGap-16
[**2177-4-15**] 04:24AM BLOOD Glucose-113* UreaN-14 Creat-0.4* Na-138
K-4.0 Cl-104 HCO3-30 AnGap-8
[**2177-4-14**] 09:45AM BLOOD CK(CPK)-216
[**2177-4-14**] 03:57PM BLOOD ALT-29 AST-46* LD(LDH)-225 CK(CPK)-482*
AlkPhos-51 TotBili-0.3
[**2177-4-14**] 08:54PM BLOOD CK(CPK)-516*
[**2177-4-15**] 04:24AM BLOOD LD(LDH)-214 CK(CPK)-395* TotBili-0.3
[**2177-4-15**] 12:05PM BLOOD CK(CPK)-379*
[**2177-4-14**] 09:45AM BLOOD CK-MB-8
[**2177-4-14**] 09:45AM BLOOD cTropnT-0.05*
[**2177-4-14**] 03:57PM BLOOD CK-MB-15* MB Indx-3.1 cTropnT-0.34*
[**2177-4-14**] 08:54PM BLOOD CK-MB-15* MB Indx-2.9 cTropnT-0.37*
[**2177-4-15**] 04:24AM BLOOD CK-MB-11* MB Indx-2.8 cTropnT-0.25*
[**2177-4-15**] 12:05PM BLOOD CK-MB-10 MB Indx-2.6 cTropnT-0.19*
[**2177-4-15**] 04:24AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0
[**2177-4-15**] 04:24AM BLOOD Hapto-48
[**2177-4-14**] 04:18PM BLOOD Type-[**Last Name (un) **] pH-7.29* Comment-GREEN TOP
[**2177-4-14**] 04:18PM BLOOD Lactate-0.9
[**2177-4-14**] 09:56AM BLOOD Lactate-4.4*
[**2177-4-14**] 04:18PM BLOOD freeCa-1.02*
[**2177-4-14**] 11:45AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029
[**2177-4-14**] 11:45AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2177-4-14**] 11:45AM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
[**2177-4-14**] 11:45AM URINE CastHy-1*
[**2177-4-14**] 11:45AM URINE Mucous-RARE
DISCHARGE
[**2177-4-18**] 06:15AM BLOOD WBC-1.9* RBC-3.33* Hgb-8.9* Hct-29.1*
MCV-87 MCH-26.8* MCHC-30.6* RDW-13.9 Plt Ct-125*
[**2177-4-17**] 06:05AM BLOOD Neuts-58.9 Lymphs-29.5 Monos-9.1 Eos-2.2
Baso-0.4
[**2177-4-18**] 06:15AM BLOOD ESR-15
[**2177-4-18**] 06:15AM BLOOD Glucose-126* UreaN-11 Creat-0.5 Na-141
K-3.6 Cl-99 HCO3-33* AnGap-13
[**2177-4-17**] 06:05AM BLOOD ALT-23 AST-28 LD(LDH)-225 AlkPhos-63
TotBili-0.3
[**2177-4-18**] 06:15AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.3
[**2177-4-18**] 06:15AM BLOOD CRP-5.8*
MICRO
Blood Culture, Routine (Preliminary):
SENSITIVITIES REQUESTED BY DR.[**Last Name (STitle) **] ([**Numeric Identifier 6097**]) ON [**2177-4-18**].
VIRIDANS STREPTOCOCCI. OF TWO COLONIAL MORPHOLOGIES.
Isolated from only one set in the previous five days.
Anaerobic Bottle Gram Stain (Final [**2177-4-15**]):
Reported to and read back by DR. [**Last Name (STitle) **]. ROSE ON [**2177-4-15**] AT
0145.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
-[**Date range (1) 6098**] blood cxs are no growth to date
CHEST (PORTABLE AP) Study Date of [**2177-4-14**] 9:47 AM
IMPRESSION: Increased hazy opacity in the right lung,
predominantly in the right greater than left base, which could
represent asymmetric edema versus aspiration or infection. No
pneumothorax. No laboratory data is available at the time of
interpretation, which should be correlated as well as with
clinical presentation.
HIP UNILAT MIN 2 VIEWS LEFT PORT Study Date of [**2177-4-14**] 10:13 AM
IMPRESSION: Findings consistent with posterior dislocation of
the prosthetic femoral head from the acetabular cup.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2177-4-14**]
11:04 AM
IMPRESSION:
1. Bilateral lower lobe consolidations, likely reflecting
pneumonia and/or aspiration, worse on the right.
2. Right upper lobe and left apical ground-glass opacities, with
neighboring smooth septal wall thickening, likely reflecting
combination of inflammation/infection and mild edema.
3. No pulmonary embolus detected to the subsegmental levels. No
acute
dissection.
4. Mildly prominent left para-aortic lymph node/
Portable TTE (Complete) Done [**2177-4-15**] at 9:53:07 AM
Conclusions
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is probably normal (LVEF~55%).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The ascending aorta is mildly dilated.
The aortic valve leaflets are severely thickened/deformed. There
is moderate to severe aortic valve stenosis (valve area
~1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests impaired
relaxation. There is no pericardial effusion.
CHEST (PORTABLE AP) Study Date of [**2177-4-15**] 7:59 AM
FINDINGS: As compared to the previous radiograph, there is
marked improvement of the pre-existing right parenchymal
opacity. On the left, there is unchanged evidence of moderate
retrocardiac atelectasis, potentially combined to a minimal left
pleural effusion. Unchanged status post CABG with stable size of
the cardiac silhouette and stable sternal wires.
PELVIS AP [**4-15**] There is some relocation of the left total hip
arthroplasty. There is some asymmetric positioning of the
femoral head suggestive of polyethylene liner wear with the
femoral head positioned slightly more superolaterally within the
center. No periprosthetic fractures are seen. Vascular
calcifications are present.
Brief Hospital Course:
78M with hx of CAD s/p CABG, L THA with Left hip dislocation s/p
reduction, here with hypoxia in setting of likely
pneumonia/aspiration.
.
ACTIVE ISSUES
.
#Aspiration Pneumonia with Strep Viridans Bacteremia. Patient
presented with dyspnea, elevated lactate, hypoxia, and CXR/CT
with evidence of pneumonia vs aspiration pneumonitis. Patient
initially received vancomycin, levofloxacin, and ceftriaxone for
likely community-acquired v aspiration PNA. He was initially
admitted to the MICU as he required a non-rebreather but he was
quickly transitioned to nasal cannula and sent to the floor. He
continued to improve clinically, remaining afebrile and without
leukocytosis or an oxygen requirement. One of 4 blood cultures
was postive for gram positive cocci, so vancomycin was also
started. When the blood culture speciated to Streptococcus
viridans, vancomycin was discontinued and he was kept on
ceftriaxone and levofloxacin. TEE could not be performed to rule
out endocarditis due to his tenuous aortic valve but as patient
appeared clinically well and had a very low-grade bacteremia
(only one positive culture out of many bottles), CRP/ESR were
low and TTE was negative for vegetations, there was a low
suspicion for endocarditis so ID recommended he be treated for
two weeks of IV antibiotics for his bacteremia until [**4-28**].
Patient was discharged on oral levofloxacin as well to cover for
atypical organisms.
.
#Elevated Troponin. Presented with troponin of 0.05 that peaked
at 0.37. Cardiology was consulted who felt this was due to
demand ischemia in the setting of his fall. Patient was without
chest pain throughout his stay. EKG showed no acute changes only
borderline ST depressions in I and aVL. He was placed on ASA,
metoprolol 12.5mg [**Hospital1 **], and continued on his statin. Cardiology
agreed with plan, and recommended considering an ACE-I, however
his outpatient cardiologist did not want to start it. Patient
remained chest pain free with stable EKGs throughout his stay.
.
#Left hip dislocation. Patient with total hip arthroplasty of
left hip many years ago and has had multiple dislocations in
past, this presentation is similar to his previous. It was
reduced successfully in the ED. Patient was initially placed in
a lower lumbar to hip brace by orthopedics with restrictions on
movement that were gradually loosened. At the time of discharge
they recommended keeping him in the brace when out of bed only
and with a maximum of 70 degrees hip flexion. At night, he
should wear an abduction pillow. They recommended he continue in
these braces until his hip can be evaluated for surgical repair.
.
CHRONIC ISSUES
.
#Aortic Stenosis: TTE on this admission showed severe AS (valve
area 1.0cm2) with otherwise preserved EF.
.
#DM. Maintained on insulin sliding scale in house.
Diet-controlled.
.
#HTN. Continued lasix 20mg daily, switched atenolol 12.5mg daily
to metop 12.5 [**Hospital1 **].
.
#HL. Continued rosuvastatin 5mg daily
.
#GERD. Continued omeprazole 20mg daily.
.
# Melanoma: Followed at VA. Was scheduled for biopsy this week
which he missed due to this hospitalization. He is to follow-up
with dermatology next week here at [**Hospital1 18**] for an urgent
appointment.
.
TRANSITIONAL ISSUES
- Given his severe aortic stenosis, patient will likely require
cardiac evaluation to determine whether he is a candidate for
hip surgery
- Patient will need follow-up for his melanoma. We have arranged
an appointment for him at [**Hospital1 18**] for next week for biopsy.
- Patient will require repeat blood cultures two weeks after he
has completed his antibiotic course to make sure his infection
has cleared
Medications on Admission:
Lasix 20mg qday
multivitamin qday
omeprazole 20mg qday
atenolol 12.5mg qday
Calcarb 600 With Vitamin D 1tab qday
lactulose 10g/15mL 1tblespoon as needed for constipation
Ecotrin 81mg qday
tylenol 650 qday
rosuvastatin 5mg qday
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days.
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. lactulose 10 gram/15 mL Solution Sig: One (1) PO once a day
as needed for constipation.
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) unit Intravenous Q24H (every 24 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
PRIMARY
Hip dislocation
Aspiration Pneumonia
Demand ischemia
.
SECONDARY
HTN
HL
Aortic stenosis
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 6099**],
You were admitted to [**Hospital1 18**] because you fell, dislocated your
hip, and were found to have trouble breathing. Your hip was put
back into place by our orthopedic surgeons who felt you should
wear a brace to help keep your joint in place. You will likely
require surgery to repair this hip. We have scheduled
appointments with an orthopedic surgeon to evaluate your hip.
You will need to talk to your cardiologist to determine whether
you are a good candidate for surgery given your narrow aortic
valve.
Your shortness of breath was thought to be due to some
accidental swallowing of your stomach contents during your fall.
We treated you with antibiotics and your breathing improved
quickly. However, some bacteria was found in your blood, likely
coming from this infection in your lungs. As a result you will
need to be on intravenous antibiotics to make sure that all the
bacteria in your blood is gone.
For the lesions on your nose, we have arranged for the [**Hospital1 18**]
dermatologists to see you next week to determine whether it is
melanoma. Please bring your records from the VA with you to this
appointment.
The following medications were changed during this
hospitalization:
START ceftriaxone intravenously for a total of two weeks to end
on [**4-28**]
START levofloxacin until [**4-20**]
STOP atenolol and START metoprolol 12.5mg twice a day
.
Please continue your other medications as previously prescribed
Followup Instructions:
The doctor at rehab will follow-up this hospitalization. They
will schedule you for an appointment with your PCP upon
discharge.
Department: ORTHOPEDICS
When: THURSDAY [**2177-4-24**] at 11:10 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2177-4-24**] at 11:30 AM
With: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DERMATOLOGY
When: THURSDAY [**2177-4-24**] at 2:00 PM
With: [**Name6 (MD) 1037**] [**Name8 (MD) 5647**], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please bring your dermatologic records from the VA to this
appointment if possible.
ICD9 Codes: 5070, 7907, 4019, 4241, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7117
} | Medical Text: Admission Date: [**2168-3-2**] Discharge Date: [**2168-3-16**]
Date of Birth: [**2091-9-21**] Sex: F
Service: PLASTIC
Allergies:
Bactrim / ciprofloxacin / Codeine / Penicillins / Thiazides /
sulfa
Attending:[**First Name3 (LF) 36263**]
Chief Complaint:
Right hand pain, swelling s/p fall with fever, ? of necrotizing
fasciitis.
Major Surgical or Invasive Procedure:
[**2168-3-2**]
Incision and debridement and carpal tunnel release right hand
and forearm.
.
[**2168-3-3**]
Debridement of skin, subcutaneous tissue, tendons of right upper
extremity (measuring 25 x 15 cm).
.
[**2168-3-6**]
Irrigation and debridement of skin, subcutaneous tissue, fascia.
.
[**2168-3-8**]
1. Irrigation and debridement of skin, subcutaneous tissue, and
fascia.
2. Neurorrhaphy of the lateral antebrachial cutaneous nerve.
.
[**2168-3-10**]
Placement of 'Integra' dressing to right hand wound defect and
application of wound VAC dressing.
History of Present Illness:
76 year old female transferred from [**Hospital3 26615**] for ?
necrotizing fasciitis to her Right hand sustained from fall this
weekend. Pt denies any other pain, complaints at this time. Of
note, prior to transfer her temp was 104.2, she was subsequently
given 1 gram vancomycin, clindamycin 900mg, gentamycin 120mg IV
at OSH. On presentation to [**Hospital1 18**] ED her temp was 99. However,
she did trigger in the room (low BP). She is a poor historian.
Lives alone in [**Hospital3 4634**] and is seen 3x per week by VNA
for BLE wounds (vasculopathy) and at the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] wound
clinic.
Past Medical History:
Hypothyroidism
Depresion
Skin ulcers
vasculopath
double bypass
previous blood clots
Known MRSA cellulitis to RLE
Social History:
Lives alone in [**Hospital3 4634**] and VNA comes three times per
week to treat BLE ulcers. Uses walker and ambulates about her
unit. Does not drive. Her brother lives in the south and is 84
years old. She has no family nearby. Does not smoke or drink.
Physical Exam:
99.2 94 114/92 18 93% 4L
Appearance: complaining of R hand pain, AAOx3
VASCULAR R Radial Pulse: dopplerable
R hand red, hot, swollen with ascending cellulitis and areas of
ischemia. Notable blistering, areas of fibro-eschar along
anatomical snuff box, fluid filled bulla up volar forearm
NEUROLOGICAL:
Sensation: [x] Intact - painful to touch [] Absent
INTEGUMENT:
Ulceration(s): [] Full thickness [x] Partial thickness
[] Pre/Post-ulcerative [] Absent
Pertinent Results:
[**2168-3-2**] 09:00PM URINE MUCOUS-OCC
[**2168-3-2**] 09:00PM URINE AMORPH-MOD
[**2168-3-2**] 09:00PM URINE HYALINE-10*
[**2168-3-2**] 09:00PM URINE RBC-0 WBC-26* BACTERIA-FEW YEAST-NONE
EPI-3
[**2168-3-2**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN->600
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-LG
[**2168-3-2**] 09:00PM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019
[**2168-3-2**] 09:00PM PLT SMR-NORMAL PLT COUNT-220
[**2168-3-2**] 09:00PM NEUTS-67 BANDS-10* LYMPHS-19 MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2168-3-2**] 09:00PM WBC-3.0* RBC-3.58* HGB-11.0* HCT-33.9* MCV-95
MCH-30.7 MCHC-32.4 RDW-13.7
[**2168-3-2**] 09:00PM CALCIUM-8.3* PHOSPHATE-1.7* MAGNESIUM-1.5*
[**2168-3-2**] 09:00PM estGFR-Using this
[**2168-3-2**] 09:00PM GLUCOSE-134* UREA N-39* CREAT-1.9* SODIUM-134
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-21* ANION GAP-14
[**2168-3-2**] 09:21PM LACTATE-2.4*
[**2168-3-2**] 09:40PM PT-19.9* PTT-25.1 INR(PT)-1.9*
.
MICROBIOLOGY:
[**2168-3-2**] 9:00 pm BLOOD CULTURE #1.
**FINAL REPORT [**2168-3-8**]**
Blood Culture, Routine (Final [**2168-3-8**]): NO GROWTH.
.
[**2168-3-2**] 10:40 pm BLOOD CULTURE
**FINAL REPORT [**2168-3-8**]**
Blood Culture, Routine (Final [**2168-3-8**]): NO GROWTH.
.
[**2168-3-2**] 11:35 pm SWAB Site: HAND RIGHT.
GRAM STAIN (Final [**2168-3-3**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 39755**] ON [**2168-3-3**] AT
0105.
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
WOUND CULTURE (Final [**2168-3-5**]):
BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH.
ANAEROBIC CULTURE (Final [**2168-3-7**]): NO ANAEROBES ISOLATED.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2168-3-3**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
.
[**2168-3-3**] 2:36 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2168-3-4**]**
MRSA SCREEN (Final [**2168-3-4**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
.
RADIOLOGY:
Cardiovascular Report ECG Study Date of [**2168-3-2**] 10:43:28 PM
Sinus rhythm. Inferior wall myocardial infarction of
indeterminate age.
Possible anterior wall myocardial infarction of indeterminate
age. Diffuse
non-diagnostic repolarization abnormalities. No previous tracing
available for comparison.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2168-3-2**] 9:13
PM
IMPRESSION:Lung volumes with vascular crowding.
.
Radiology Report HAND, AP & LAT. VIEWS RIGHT PORT Study Date of
[**2168-3-2**] 9:48 PM
FINDINGS: There are severe degenerative changes at the DIP and
PIP joints and at the CMC and triscaphe joint of the right hand.
No evidence of fractures, foreign bodies or soft tissue gas.
There is prominent soft tissue swelling, most pronounced at the
dorsum of the hand.
.
Brief Hospital Course:
On presentation to [**Hospital1 18**] ED on [**2168-3-2**], patient's temp was 99.
She became hypotensive and confused shortly after arrival. She
was placed on levophed and a central line was placed. Blood
cultures were obtained and sent. She arrived with foley
catheter in place for chronic retention. A urinalysis was sent
and showed few bacteria, 26k WBC with hyaline casts. Her right
hand was erythematous, swollen and hot with obvious areas of
blistering and ischemia. She had received vancomycin,
gentamicin, clindamycin IV at an OSH. Due to her overall
clinical picture, there was a high suspicion for necrotizing
fasciitis and patient was taken to the OR for emergent
exploration of the right hand. She underwent incision and
debridement and carpal tunnel release right hand and forearm.
Cultures were obtained and sent in the OR. The patient was kept
intubated and transferred to the ICU post surgery.
.
Upon admission to the ICU, a second pressor was added
(Norepinephrine) for persistent hypotension and she was given a
dose of azithromycin and ceftriaxone intravenously. Overnight,
she was commenced on meropenem, clindamycin and linezolid IV and
Infectious Disease was consulted in the morning. Her
postoperative course was notable for increasing pressor
requirement and hemodynamic lability. As a result, she was
emergently taken back to the operating room on [**2168-3-3**] for a
repeat I&D.
.
Once back in ICU, the patient was maintained on contact
precautions for a reported history of MRSA and follow up MRSA
nasal swab confirmed this. ID recommended discontinuing
meropenem and linezolid and maintaining the patient on
ceftriaxone and clindamycin. Right hand/forearm debrided areas
were treated with TID dressing changes of wet to dry and right
forearm/hand maintained in a splint. A wound care consult was
requested for care of chronic left lower extremity ulcers and
wounds were treated daily, per their recommendations.
Electrolytes were repleated PRN and a NG tube was inserted for
purposes of medication administration. Patient was commenced on
heparin subcutaneous for DVT prophylaxis and her foley catheter
was changed.
.
Patient was able to wean off of pressors within 24-hours post
ICU arrival. She was successfully extubated on [**2168-3-4**] and she
was started on regular diet. Her temporary central access was
discontinued and a left arm PICC line was placed on [**2168-3-5**] and
she was transferred to the floor in stable condition. By this
time her OR wound cultures from [**2168-3-2**] confirmed 'Beta group A
streptococcus' and she continued on her course of ceftriaxone
and clindamycin IV per ID recommendations. Her blood cultures
from [**2168-3-2**] remained negative. Electrolytes were repleted PRN.
Patient was noted to have a significant drop in hematocrit from
29.7 on [**2168-3-4**] to 23.8 on [**2168-3-5**] and was treated with 2 units of
PRBCs with lasix given in between units. Hematocrit corrected
to 29.5.
.
On [**2168-3-6**], patient was taken back to the OR for further
debridment of right hand and forearm wounds which she tolerated
well. She remained stable and afebrile. On [**2168-3-8**] patient went
back to OR for further debridement with wound VAC placement to
right arm/hand wounds which she tolerated well. Patient
developed a left upper extremity thrombophlebitis just above
PICC line which was treated with warm compresses and ibuprofen,
as needed.
.
On [**2168-3-9**], Clindamycin was discontinued per ID recommendations.
On the eve of [**2168-3-9**], patient's urinary output had a significant
drop to <20cc an hour. She was given a liter of NS with an
improved urine output and she was placed back on maintenance IV
fluids. On the morning of [**2168-3-10**], patient spiked a fever to
101.2 and was somewhat somnolent. Patient was pancultured,
stool for C.diff was sent due to reported 'loose stools' and
labs were reviewed and essentially benign. We attempted to
remove the right hand/forearm wound VAC dressing at bedside to
examine the wound for possible source of fever and patient
immediately responded to this stimulus and began protesting. As
patient had returned to her baseline mental state within an hour
she was again returned to the OR. There she underwent
irrigation and debridement of skin and subcutaneous tissue of
the right forearm with application of Integra skin substitute
followed by wound VAC application. Patient tolerated the
procedure well. All results from [**3-10**] panculture returned
negative for infection and patient remained afebrile.
.
Vac dressing was changed prior to discharge to rehab facility
(dressing change on [**2168-3-15**]) and patient has a follow up
appointment in Hand Clinic in 1 week to remove Vac dressing and
evaluate status of Integra. At the time of discharge on [**2168-3-16**],
the patient was doing well, afebrile with stable vital signs,
and tolerating a regular diet.
Medications on Admission:
Librium 20 TID to QID
Synthroid 25 mcg'
Neurontin 300 QAM
ASA EC 81'
Celexa 200'
Vit D 1000 IU'
Procardia XL 30'
Celebrex 200'
Hyoscamine 1mg TID to QID
Culturelle 1 cap"
Discharge Medications:
1. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen.
2. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours): D/C [**3-24**] (14 days post last surgery).
3. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain: For LUE pain from thrombophlebitis
.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
6. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
10. chlordiazepoxide HCl 5 mg Capsule Sig: Four (4) Capsule PO
QID (4 times a day).
11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
17. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
18. sliding scale
Regular insulin sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Necrotizing fasciitis of right hand/forearm
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. Prior to admission she lived independently (with
VNA visits) and ambulated her apartment with a walker.
Discharge Instructions:
Personal Care:
1. You will have a wound VAC dressing with a wound vac machine
in place for discharge. This VAC dressing will remain in place
and not be changed as it is applying pressure to your recently
placed Integra dressing.
2. While VAC is in place, please clean around the VAC site and
monitor for air leaks of the VAC
3. You may continue to wash up daily using a basin and soapy
water.
4. No baths/showers until after directed by your surgeon.
5. LLE wound care as ordered.
6. Foley care as ordered.
.
Activity:
1. Avoid strenous activity with wound vac in place.
2. Do not lift anything heavy with right hand/arm.
.
Medications:
1. Take medications as directed on your medication sheet.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness around the surgical site, or
unusual drainage in the collection container.
2. Fever greater than 101.5 oF
3. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness,swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Hand Clinic: ([**Telephone/Fax (1) 2007**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) 1385**]
Please follow up in the Hand Clinic on Tuesday, [**2168-3-22**] at
9:30AM. The clinic is open from 8-12pm most Tuesdays. The
clinic is located on the [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) 1385**], Orthopedics.
.
Please bring a VAC sponge kit with you for dressing change in
the clinic.
Completed by:[**2168-3-16**]
ICD9 Codes: 486, 0389, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7118
} | Medical Text: Admission Date: [**2170-1-15**] Discharge Date: [**2170-1-19**]
Date of Birth: [**2091-10-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2170-1-15**] Coronary artery bypass graft x 4 (left internal mammary
artery to left anterior descending, saphenous vein graft to
diagonal, saphenous vein graft to obtuse marginal, saphenous
vein graft to posterior descending artery)
History of Present Illness:
This 78 year old Spanish speaking male has a cardiac history
that includes RCA stent, inferior STEMI with in-stent restenosis
of RCA, s/p BMS pRCA. He reports right sided back pain that
radiates to his chest which occurs with walking short distances.
The pain resolves with rest and does not occur unrelated to
activity. He reports he has been taking Oxycodone three times
daily for this chest pain. He states this is the only medication
that helps him. He was recently seen by Dr. [**Last Name (STitle) 171**] and referred
for a stress test which was positive and was referred for
cardiac catheterization. He was found to have multivessel
disease upon cardiac catetherization and is now being referred
to cardiac surgery for revascularization.
Past Medical History:
s/p inferior Myocardial infarction restenosis of the RCA
s/p bare metal stent of pRCA [**2160**] RCA stent
Hypertension
Hyperlipidemia
Chronic Chest Pain
Hypothyroidism
noninsulin dependent diabetes mellitus
h/o Prostate cancer- s/p radiation treatment [**2164**]
Social History:
Race:Hispanic
Last Dental Exam:2 months agp
Lives with:Alone, children live out of state
Contact:[**Name (NI) **] [**Name (NI) 67533**] (friend) Phone #[**Telephone/Fax (1) 67534**]
Occupation:Retired
Cigarettes: Smoked no [] yes [x] Hx: [**11-20**] ppd x 15 years quit >40
years ago
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**12-26**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Son had open heart surgery
recently in [**State 108**]; age 54
Physical Exam:
Pulse:58 Resp:12 O2 sat:100/RA
B/P Right:169/77 Left:169/73
Height:5'6" Weight:150 lbs
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] No Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral 2 Right: 2 Left:
DP 2 Right: 2 Left:
PT 2 Right: 2 Left:
Radial 2 Right: 2 Left:
Carotid Bruit Yes Right: No Left:
Pertinent Results:
[**2170-1-15**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results at time of
surgery.
POST-BYPASS: The patient is in sinus rhythm. Biventricular
function is unchanged. Mitral regurgitation is unchanged. The
aorta is intact post-decannulation.
.
[**2170-1-17**] 04:55AM BLOOD WBC-11.5* RBC-3.03* Hgb-10.2* Hct-28.1*
MCV-93 MCH-33.6* MCHC-36.1* RDW-13.3 Plt Ct-113*
[**2170-1-17**] 04:55AM BLOOD Glucose-110* UreaN-13 Creat-1.1 Na-129*
K-4.2 Cl-94* HCO3-27 AnGap-12
[**2170-1-15**] 02:01PM BLOOD UreaN-14 Creat-0.9 Na-138 K-4.0 Cl-109*
HCO3-20* AnGap-13
[**2170-1-19**] 06:10AM BLOOD WBC-7.2 RBC-3.21* Hgb-10.5* Hct-30.4*
MCV-95 MCH-32.6* MCHC-34.5 RDW-12.7 Plt Ct-179#
[**2170-1-19**] 06:10AM BLOOD Glucose-108* UreaN-17 Na-133 K-4.2 Cl-96
HCO3-32 AnGap-9
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit and on [**1-15**] was brought directly
to the Operating Room where he underwent coronary artery bypass
grafts x 4. Please see operative note for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours he was weaned
from sedation, awoke neurologically intact and extubated.
On post-op day one he was started on beta-blockers and diuretics
and gently diuresed towards his pre-op weight. Later on this day
he was transferred to the step-down floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol.
H edid experience some postoperative nausea and vomiting at POD
3. however, after moving his bowels this resolved and he felt
well. Physical Therapy worked with him for strength and
mobility. He was ready for transfer to a rehabilitation
facility for further recovery prior to return home. He was
discharged to [**First Name4 (NamePattern1) 730**] [**Last Name (NamePattern1) 731**] Rehab on [**1-19**].,
Medications on Admission:
Simvastatin 20mg (was instructed to stop and start Lipitor
[**10-30**]- he is still currently taking simvasatin and no Lipitor)
ATORVASTATIN (Not Taking as Prescribed) 80 mg Daily
PLAVIX 75 mg Daily pt reports he does not take this consistently
LISINOPRIL 40 mg daily
METOPROLOL SUCCINATE 25 mg Daily
OXYCODONE-ACETAMINOPHEN 5 mg/325 mg Tablet- takes 1 tablet 3 x
day for chest pain
RANITIDINE HCL 150 mg daily
SIMVASTATIN 20 mg daily
ASPIRIN 325 mg Daily
MILK OF MAGNESIA Dosage uncertain
Discharge Medications:
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] - [**Location 8391**]
Discharge Diagnosis:
Coronary artery disease
s/p Corornary artery bypass graft x 4
s/p inferior Myocardial infarction
s/p bare metal stent of pRCA [**2160**] RCA stent
Hypertension
Hyperlipidemia
Chronic Chest Pain
Hypothyroidism
noninsulin dependent diabetes mellitus
h/o Prostate cancer (s/p radiation treatment [**2164**])
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait with assistance
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema- trace
Discharge Instructions:
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) **] ([**Telephone/Fax (1) 170**]) on [**2170-2-14**] at 1:45pm
Cardiologist: Dr. [**Last Name (STitle) 171**] on [**2170-2-7**] at 10am
Please call to schedule appointments with:
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 14918**]) in [**2-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2170-1-19**]
ICD9 Codes: 412, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7119
} | Medical Text: Admission Date: [**2109-9-24**] Discharge Date: [**2109-10-17**]
Date of Birth: [**2030-1-16**] Sex: F
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Acute perineal resection
History of Present Illness:
79F with biopsy proven stage III T3N1 rectal cancer who
recently finished XRT on [**2109-9-7**] presents with 2 weeks of
nonspecific abdominal pain. The patient is a very poor
historian, but per the daughter, she has had a very poor
appetite
with decreased PO intake over the past few days. She had been
urged to be evaluated but has refused until today. She states
that she has been having bowel movements but cannot remember
when
the last one was. She denies fever, chills, nausea, and emesis.
Past Medical History:
Dementia-presumed, undergoing w/u with Dr. [**Last Name (STitle) **]
h/o ETOH abuse-pt denies
Newly diagnosed rectal cancer
Chronic intermittent diarrhea/fecal incontinence, being w/u
urinary urge incontinence
Anxiety/depression
Cataracts, awaiting surgery
Chronic multifactorial debility [**12-31**] arthritis, loss of function
RUE after fall, back pain, balance issues-mostly wheelchair, but
is able to ambulate
Smoker
s/p L ankle surgery
s/p ovarian cyst removal
s/p Appy
Social History:
Married. h/o ETOH abuse per family though pt denies, none
recently as poor access to ETOH. Also h/o 50pack year, still occ
smokes but unable to quantify. no illicits. Poor mobility,
mostly wheelchair bound, but is able to walk if needed.
Dependent on some ADLs and all IADLs.
Family History:
no family h/o GI malignancy, dementia, DM
Physical Exam:
98.4, 82, 99/53, 18, 95% on room air
Gen: no distress, alert, appears demented, poor historian
HEENT: PERLA, EOMI, mucus membranes dry
Neck: supple
Chest: RRR, lungs clear
Abd: soft, nondistended, diffusely tender to palpation, no
rebound or guarding noted
Rectal: patient refused
Ext: trace edema, feet warm
.
At Discharge:
Vitals:98.1, 91, 167/89, 18, 97% on 2L
GEN: NAD, A/Ox3
CV: RRR, no m/r/g
RESP: Coarse with bilateral rhonchi at bases, no SOB.
ABD: soft, ND, appropriately TTP, +BS
Incision: small abdomen OTA with dermabond, CDI. Old JP site,
scant serous drainage. Intact with DSD. Perineal incision OTA
with sutures, serosanguinous drainage. No exudate or purulent
drainage noted. Surrounding skin with improved maceration and
erythema.
Ostomy: stoma dark red and viable, protruding out with blood
clot at skin margin. Profusing well. Liquid brown effluence,
+gas
Coccyx: Stage II ulcer
Extrem: LUE edema, CSM's intact. Mild pedal edema bilaterally.
+pulses, brisk cap refill.
Pertinent Results:
Micro/Imaging:
[**2109-10-16**] PICC line inserted in RUE via Interventional radiology
[**2109-10-15**] RUE and B/L LE U/S negative
[**2109-10-14**] LUE U/S occlusive thrombus of L subclv, axillary,
brachialis, and basilic
[**2109-10-10**] URINE URINE CULTURE-FINAL {YEAST}
[**2109-10-6**] CXR no opacities. unchanged bibasilar atelctasis and
pl. effusions
[**2109-10-6**] CTchest mod b/l pl eff. loc eff on R. focal opacities
RU+[**Doctor Last Name **] ?inf vs. atelec
[**2109-10-3**] Cdif neg
[**2109-10-1**] Bcx NGTD
[**2109-9-30**] CXR worsening opacity, ?central obstruction, b/l
effusions
[**2109-9-30**] CT chest collapse of RML, known COPD, ?adrenal met b/l
pl effusions
[**2109-9-30**] Ucx no growth UA:sm leuks, neg nit no bact
[**2109-9-30**] Bcx no growth
[**2109-9-28**] Cdiff neg
[**2109-9-27**] CXR RLL infiltrate
[**2109-9-24**] Ucx neg UA: mod leuks, neg nit, rare bact
[**2109-9-24**] Stool cx Neg
[**2109-9-24**] Bcx NGTD
[**2109-9-24**] CT rectal ca w/o mets, patent graft, pulmonary nodule,
?r asp PNA, DJD
[**2109-9-24**] 10:40AM BLOOD WBC-7.4 RBC-4.21 Hgb-12.5 Hct-38.1 MCV-90
MCH-29.6 MCHC-32.8 RDW-14.8 Plt Ct-298
[**2109-9-25**] 03:44AM BLOOD WBC-7.5 RBC-3.93* Hgb-12.0 Hct-36.1
MCV-92 MCH-30.6 MCHC-33.3 RDW-14.2 Plt Ct-291
[**2109-9-30**] 06:50AM BLOOD WBC-15.9* RBC-4.01* Hgb-12.0 Hct-37.4
MCV-93 MCH-30.0 MCHC-32.2 RDW-14.7 Plt Ct-584*
[**2109-10-10**] 01:30AM BLOOD WBC-26.0*# RBC-3.15* Hgb-9.4* Hct-29.4*
MCV-93 MCH-29.7 MCHC-31.9 RDW-15.5 Plt Ct-75*
[**2109-10-11**] 03:30AM BLOOD WBC-13.8* RBC-2.27*# Hgb-6.7*# Hct-21.5*#
MCV-95 MCH-29.5 MCHC-31.0 RDW-16.1* Plt Ct-65*
[**2109-10-14**] 06:10AM BLOOD WBC-14.8* RBC-3.38* Hgb-10.2* Hct-30.5*
MCV-90 MCH-30.3 MCHC-33.6 RDW-15.7* Plt Ct-28*
[**2109-10-15**] 05:55AM BLOOD WBC-12.3* RBC-3.47* Hgb-10.4* Hct-31.8*
MCV-92 MCH-29.9 MCHC-32.5 RDW-15.4 Plt Ct-41*
[**2109-10-16**] 05:25AM BLOOD WBC-12.4* RBC-3.27* Hgb-9.9* Hct-30.0*
MCV-92 MCH-30.2 MCHC-33.0 RDW-15.3 Plt Ct-52*
[**2109-10-15**] 05:55AM BLOOD PT-28.3* PTT-71.3* INR(PT)-2.8*
[**2109-10-11**] 10:30PM BLOOD PT-16.4* PTT-31.5 INR(PT)-1.5*
[**2109-9-27**] 07:45AM BLOOD PT-12.4 PTT-26.9 INR(PT)-1.0
[**2109-9-24**] 10:40AM BLOOD PT-11.6 PTT-28.0 INR(PT)-1.0
[**2109-10-11**] 10:36AM BLOOD Fibrino-176
[**2109-10-10**] 01:30PM BLOOD Fibrino-270
[**2109-10-11**] 10:36AM BLOOD FDP-0-10
[**2109-9-30**] 03:20PM BLOOD ESR-0
[**2109-10-15**] 05:55AM BLOOD Glucose-81 UreaN-17 Creat-0.9 Na-141
K-4.2 Cl-99 HCO3-31 AnGap-15
[**2109-10-14**] 06:10AM BLOOD Glucose-79 UreaN-15 Creat-0.9 Na-141
K-3.4 Cl-98 HCO3-34* AnGap-12
[**2109-10-13**] 05:54AM BLOOD Glucose-84 UreaN-12 Creat-0.7 Na-141
K-3.9 Cl-102 HCO3-31 AnGap-12
[**2109-10-12**] 12:49PM BLOOD Glucose-103 UreaN-12 Creat-0.7 Na-142
K-3.4 Cl-102 HCO3-31 AnGap-12
[**2109-10-11**] 03:30AM BLOOD Glucose-80 UreaN-13 Creat-0.8 Na-141
K-4.0 Cl-106 HCO3-25 AnGap-14
[**2109-9-29**] 05:00AM BLOOD Glucose-145* UreaN-11 Creat-0.9 Na-141
K-3.6 Cl-105 HCO3-24 AnGap-16
[**2109-9-27**] 07:45AM BLOOD Glucose-116* UreaN-8 Creat-0.4 Na-142
K-4.1 Cl-107 HCO3-30 AnGap-9
[**2109-9-25**] 03:44AM BLOOD Glucose-88 UreaN-9 Creat-0.4 Na-139 K-3.6
Cl-102 HCO3-22 AnGap-19
[**2109-9-24**] 10:40AM BLOOD Glucose-116* UreaN-12 Creat-0.4 Na-138
K-3.8 Cl-101 HCO3-28 AnGap-13
[**2109-9-29**] 05:00AM BLOOD CK(CPK)-28
[**2109-9-24**] 10:40AM BLOOD ALT-25 AST-19 AlkPhos-54 TotBili-0.6
[**2109-9-29**] 05:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2109-9-24**] 10:40AM BLOOD Lipase-10
[**2109-10-15**] 05:55AM BLOOD Calcium-7.6* Phos-3.0 Mg-2.4
[**2109-10-14**] 06:10AM BLOOD Calcium-7.4* Phos-3.6 Mg-1.7
[**2109-10-13**] 05:54AM BLOOD Calcium-7.6* Phos-3.4 Mg-2.2
[**2109-10-11**] 10:36AM BLOOD Albumin-2.7*
[**2109-9-24**] 10:40AM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.6 Mg-1.5*
[**2109-9-25**] 03:44AM BLOOD Albumin-2.9* Calcium-8.3* Phos-3.6
Mg-1.4* Iron-18*
[**2109-9-27**] 07:45AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1
[**2109-9-25**] 03:44AM BLOOD calTIBC-194* Ferritn-128 TRF-149*
[**2109-9-25**] 03:44AM BLOOD Triglyc-109
Brief Hospital Course:
[**Hospital Unit Name 153**] Course
79 yo female with mild dementia, recent HAP, pleural effusions
with stage III rectal cancer now s/p perineal resection
(including sigmoidectomy, protectomy, resection of portion of
colon) with uncomplicated operative course who was admitted to
[**Hospital Unit Name 153**] on [**2109-10-10**] for monitoring post-operatively. Onb
admission, the patient was noted to marked leukocytosis, which
was believed to be post-operative change. However, given recent
history of HAP, the patient was pan-cultured. No antibiotics
were initiated and WBC count trended down by ICU Day #2. The
patient was given IV Morphine PRN for pain control. Nausea was
controlled with IV Zofran PRN. The patient was noted to have
significant drop in Hct from 29.4 to 20.0 on ICU day #2. She
was transfused with 2 units of pRBCs with appropriate response.
The patient also had significant thombocytopenia. Because of a
concern for HIT due to long-term exposure to Heparin in this
patient, Heparin was discontinued and the patient was switched
to pneumoboots for DVT Prophylaxis. HIT Antibody Panel was
sent and was positive. Serotonin Release Assay was sent out.
The patient was also noted to have increasing INR to 1.8,
without a significant change in PTT. This was believed to be
due to a poor nutritional status in this patient, although DIC
was considered as well. DIC labs were not conclusive. The
patient also received 2 units FFP, Platelets. Albumin and
prealbumin were sent out to assess nutritional status. COPD:
The patient received albuterol/ipratropium nebs for her COPD.
Anxiety/Depression: The patient was seen by Palliative colult
team for help with anxiety/depression. The patient was called
out to surgery service for further management.
.
Patient was admitted to the general surgery service for better
control of her abdominal pain and management of her nutrition
prior to her scheduled surgery. She was kept NPO and given IVF.
Her pain was well controlled with Tylenol and Morphine as
needed. Geriatics was consulted for assistance with medical
management prior to surgery. They made recommendations for
prevention of delirium, management of her COPD and pain.
.
She was scheduled for surgery on [**9-27**], for which she prepared
with a bowel prep on the preceding day. Anesthesia was
concerned about the patient's respiratory status. CXR in the
holding area revealed an acute infilrate consistent with
hospital-acquired pneumonia on top of her known severe COPD.
The decision was made to delay surgery. She was started on a 5
day course of IV vancomycin and zosyn and returned to a regular
diet. She continued to have multiple bowel movements after the
bowel prep and was given several boluses (totaling 2L) for
hypotension to SBPs of 60s. Her creatinine rose from 0.4 to 1.5
in this setting. Her FeNa was 2.1 and therefore her renal
failure was thought to be from intrinisic renal failure, likely
acute tubular necrosis. Geriatrics continued to follow her.
.
A repeat CXR on [**9-30**] showed persistent atelectasis with concern
for central obstruction. A chest CT was recommended and
preformed the same day. The CT revealed RML consolidation as
well as known COPD and the question of an adrenal metastasis.
Following this information, she was transferred to the medicine
service for further management of her renal and pulmonary
issues. Although the patient was not an optimal surgical
candidate, surgery was thought to be delayed until another time
rather than cancelled.
.
.
During her medical admission, the patient did not demonstrate
any subjective shortness of breath or chest pain. Her exam was
remarkable for decreased lung sounds bilaterally, a heart murmur
and right shoulder mass that have both been present for years.
Her labs were remarkable for elevated renal function findings
and leukocytosis. Over the next few days, the patient also
complained of bilateral arm swelling and pain. The course of
each issue progressed as follows:
?????? Lung infiltrates. The patient hardly complained of shortness
of breath or other subjective respiratory distress. Over her
stay, her oxygen saturation improved while on oxygen flow and
peaked to 95-96% on 1-L, up to 99% after nebulizers. She never
dipped below the 90s on room air. Her lung exam improved over
several days, with increasingly louder respiratory sounds. One
chest x-ray was suggestive of a loculated lesion that was then
reassessed with a chest CT. It was decided that this did not
merit any draining given her overall positive picture.
?????? COPD. The patient suffers from COPD which continued to benefit
from her nebulizer regimen. She was maintained on ipratropium
bromide (Q6H) and albuterol 0.083% Q6H.
?????? Renal function. The patient's creatinine decreased and
stabilized within the range of 0.7-0.8. Her GFR continued to be
impaired at 43 (nml for age group is 75), but it was similarly
stable. Strict I/Os were difficult to maintain due to her
baseline incontinence.
?????? Leukocytosis. The patient's WBC count was initially elevated
(around 12) and then started to fall within normal levels (<10).
No source of infection was identified; she was C. Diff
negative. The only significant correlate of this laboratory
finding is her recovering pneumonia and loculated infiltrate
sequelae.
?????? Bilateral upper extremity swelling. The patient also
complained of acute swelling of both of her arms. On exam, it
was noted that the left arm appeared larger than the right, with
some possible dependent edema on her abdomen. It was found that
her albumin levels were below the normal range of variation
(2.4). A nutrition consult was placed to improve her dietary
input. Nutrition is currently following.
?????? Hypocalcemia/hypomagnesemia. On the second-to-last day before
surgery, she patient was found to be hypomagnesemic and
hypocalcemic. She received a magnesium citrate bowel prep the
day before surgery.
?????? R shoulder mass - most likely a seroma. The patient reports
it has been present for years. We monitored the mass and it did
not change size or consistency.
?????? Diarrhea. The patient has baseline diarrhea given her rectal
cancer. She was C. Diff negative and therefore was placed on
her home regimen of loperamide. This alleviated her symptoms.
?????? Pain control. Over her stay, the patient complained of vague
abdominal, R ankle/knee, L-thigh, back pain, bilateral arm pain,
and R-shoulder pain. She did not consistently focus on any
specific spot on a day-to-day basis. Her pain medication
regimen was limited to acetaminophen, lidocaine patches and
tramadol.
?????? Heart murmur. The patient has a chronic systolic heart murmur
heard best in L sternal border, ([**3-4**]), mild thrill). The
location was suggestive of a right-heart process, which could be
as benign as flow murmur to more insidious etiologies like
pulmonic valve stenosis or tricuspid insufficiency. Her EKG
from [**10-1**] normal and a subsequent echocardiogram did not show
any concerning abnormalities (R/L atria nml; mild L ventricle
hypertrophy; aortic and mitral valve leaflets mildly thickened;
no Ao. valve stenosis; no mitral regurg. Moderate pulmonary
artery systolic hypertension; no pericardial effusion).
?????? Depression. The patient has endorsed suicidal ideation
without active plans. Denies homicidal ideation. She is not on
any antidepressants. Social work following.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
................................................................
General Surgery:
Operative course uncomplicated. Admitted to Stone 5 for post-op
care. Pain controlled with PCA, quickly weaned due to cognitive
status, and age. Patient continued to be followed by Geriatrics,
Palliative Care, and Social Work post-op. Recommendations were
instituted as needed.
.
Respiratory status stabilized post-op. Oxygen weaned. Continued
with nebulizers and aggressive Chest PT. Completed full
anitbiotic regimen for treatment of Pre-op pneumonia.
.
Upper extremity edema decreased as patient diuresed post-op. LUE
remained edematous. U/S negative on [**10-10**]. Edema persisted.
Patient also noted to have drop in platelets. Noted to be HIT
positive. All heparin agents discontinued. Platelets monitored
daily. Hematology/Oncology consulted. Patient started on an
Argatroban drip. LUE re-scaned -extensive DVT noted. All other
extremities underwent ultrasound, all negative. Heme/Onco
advised continuing argatroban drip untile platelets above
100,000 for at least 48hours, then convert to PO Coumadin.
Patient will require about 6 months of treatment. This will be
monitored by patient's PCP once discharged back home from Rehab.
.
Abdominal incision intact with staples, CDI. Diet advanced
gradually from sips to regular food as ostomy function and
abdominal distention improved. IV fluid discontinued. Foley
removed. Voided without issue. Medications switched to oral.
Pain well controlled with oral Ultram. Activity returned to
baseline. Continued to work with Physical Therapy. Patient
deconditioned, and requires extensive Physical and Pulmonary
REHAB.
Medications on Admission:
tylenol, nystatin powder, imodium, potassium supplement, vitamin
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24 () as needed for
pain.
2. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain for 2 weeks: Hold for somnolence, RR<12.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Two (2) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
4. Ipratropium Bromide 0.02 % Solution Sig: Two (2) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain: Do not exceed 4000mg in
24hrs.
6. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 1 weeks.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for fungal infection: apply under
breasts & perineal area
.
8. Argatroban 100 mg/mL Solution Sig: 0.5-2 mcg/kg/min
Intravenous INFUSION (continuous infusion): Refer to attached
protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
stage III T3N1 rectal cancer completed XRT [**2109-9-7**]
pre-op treatment of pneumonia
post-op DVT-LUE
post-op stage II ulcer of coccyx
Positive for heparin induced thrombocytopenia
Discharge Condition:
Alert & oriented x3
Tolerating a regular diet with supplements
Pain well controlled with oral Ultram and Tylenol
Discharge Instructions:
REHAB Instruction:
Please call the 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:
1.Abdomen: open to air with Dermabond, clean & intact
2.Old JP drain site: Apply dry gauze dressing until serous
drainage stops. Change at least twice a day & as needed.
3.Perineal: open to air with sutures,
-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.
4. Ostomy-stoma protruding, dark red in color with clotted blood
at skin level. Functioning well. No concerns for ischemia.
Continue to monitor. Call Dr.[**Name (NI) 3377**] office with any concerns.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, CALL Dr[**Doctor Last Name **] office.
.
Anticoagulation:
-Continue Argatroban drip [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Hospital3 66399**] protocol and adhere
to modifications per Hematology/Oncolgy specialists (see
enclosed note & Instruction section).
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) 1120**] [**Telephone/Fax (1) 160**] [**2109-11-6**] 1:30pm
in Multidisciplinary [**Hospital 7819**] Clinic.
.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 49562**], MD Phone:[**Telephone/Fax (1) 19886**]
Date/Time:[**2109-11-6**] 1:30
.
3. Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2109-11-6**] 1:30
.
4. Please follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],
[**Telephone/Fax (1) 719**] once you are discharged from REHAB for long-term
management of anticoagulation.
Completed by:[**2109-10-16**]
ICD9 Codes: 5845, 486, 5119, 2930, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7120
} | Medical Text: Admission Date: [**2150-10-5**] Discharge Date: [**2150-10-11**]
Date of Birth: [**2131-8-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
GSW to Right posterior chest
Major Surgical or Invasive Procedure:
right chest tube placement
Repair Right hemidiaphragm
Endoscopy
Exploratory laparatomy
History of Present Illness:
19M s/p GSW to R flank, sustaining grade 3 liver laceration, R
lung contusion and hemothorax, presumed diaphragmatic injury.
Bullet fragments with RML and in esophoazygous recess. No
pneumomediastinum to indicate esophageal injury and no extrav
from azygous.
Past Medical History:
PMH: childhood asthma
Social History:
Lives at home with mother
Family History:
non contributory
Physical Exam:
On the day of discharge:
97.5 68 130/78 16 100% 2L NC
General: NAD, A and O x3
Pulm: Lungs clear to auscultation bilaterally
Cards: Regular rate and rhythm, + pericardial rub
Abdomen: soft non-tender, non-distended
Extremities: no clubbing, cyanosis or edema
Neuro: Equal strength and sensation bilaterally. L pupil 6->4. R
pupil 5->3
Pertinent Results:
[**2150-10-5**] 05:33AM PT-14.6* PTT-28.6 INR(PT)-1.3*
[**2150-10-5**] 05:33AM WBC-21.6* RBC-3.67* HGB-11.8* HCT-34.6*
MCV-94 MCH-32.3* MCHC-34.2 RDW-12.7
[**2150-10-5**] 05:33AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-10-5**] 05:37AM HGB-13.1* calcHCT-39 O2 SAT-78 CARBOXYHB-2
MET HGB-0
[**2150-10-5**] 10:50AM GLUCOSE-155* UREA N-13 CREAT-0.9 SODIUM-141
POTASSIUM-4.8 CHLORIDE-109* TOTAL CO2-25 ANION GAP-12
[**2150-10-5**] 11:54PM HCT-31.3*
Ct head [**10-5**]: No acute intracranial pathology.
Ct spine [**10-5**]: No fracture or malalignment. an extramedullary
hematoma
[**10-7**] Esophagram: No evidence of esophageal perforation.
Massively distended stomach filled with air.
CXR [**10-7**]: With the chest tube on waterseal, there is evidence of
a minimal lateral pneumothorax. The width of the pleural gap 2
to 3 mm. no tension.
Ct spine: stable epidural hematoma C3-C6
CT head [**10-7**]: Normal head CT without evidence for hemorrhage or
infarction.
[**10-8**] cxr: no change in ptx.
[**10-9**] echo: Small to moderate circumferential pericardial
effusion most prominent anterior to the right ventricle (1.5cm)
and <1cm elsewhere. No definite evidence of hemodynamic
compromise.
If clinically indicated, serial evaluation is suggested.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the trauma surgery ICU after
suffering a gunshot wound to the Right posterior chest. He had a
chest tube placed in an outside hospital prior to his transfer
to [**Hospital1 **]. On HD 1 the patient was taken to the OR for repair of a
posterior diaphragmatic injury, esophagoscopy, and Right chest
tube placement. He tolerated the procedure very well and was
taken to the TSICU to recover. On HD 1, it was also discovered
that the patient had a possible epidural hematoma of unknown
etiology. On HD 3 the patient had a barium swallow which showed
no acute esophageal injury. In addition, his hard collar was
removed and replaced with a soft collar. The chest tube was
removed on HD 3 and a f/u CXR showed a small apical
pneumothorax. After removing the chest tube, the patient
continued to improve and f/u CXR showed resolution of his PTX
over the ensuing days. On HD 7 the patient was ambulating,
tolerating a regular diet, and his pain was well controlled on
an oral regimen. As a result it was felt that it would be
appropriate to discharge him home with neurosurgery and trauma
f/u.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 * Refills:*0*
2. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*40 Capsule(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
S/p right posterior chest gunshot wound
Right liver laceration
Right diaphragmatic injury
Cervical Cord epidural hematoma
Discharge Condition:
hemodynamically stable, voiding without difficulty, pain
controlled on an oral regimen, ambulating, tolerating normal
diet.
Discharge Instructions:
Please return to the Emergency room for evaluation if you
experience:
fever>101.5, increasing shortness of breath, increasing chest
pain or abdominal pain, uncontrollable nausea/vomiting, you have
redness or increasing drainage from one of your surgical
incisions, or other symptoms that are concerning to you.
Surgical incision care: You may shower as you normally have in
the past. if you have drainage at your abdominal incision or
Chest tube site, you may put a clean dry gauze bandage over it.
Do not swim or take a bath for 4 weeks.
Neck: Continue to wear the soft collar until your followup with
Dr. [**Last Name (STitle) 548**].
Medication: Take all medications as ordered. while taking
narcotics for pain, do not operate heavy machinery or consume
alcohol.
Followup Instructions:
Trauma: Please call Dr.[**Name (NI) 1863**] office on Monday at [**Telephone/Fax (1) 79670**] for a followup appointment in [**2-11**] weeks.
Neurosurgery: Please call Dr.[**Name (NI) 2845**] office on Monday at ([**Telephone/Fax (1) 18865**] for a followup appointment in 6 wks. Prior to this
appointment you will need to get a non-contrast CT of your
C-spine (the scheduler will help you arrange this).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2151-2-17**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7121
} | Medical Text: Admission Date: [**2190-8-4**] Discharge Date: [**2190-8-10**]
Date of Birth: [**2143-6-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Attending Info 8238**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
47 yo M with a hx of EtOH abuse who presented to [**Hospital1 **] [**Location (un) 620**]
today after 2 generalized seizures. Per report the patient
stopped drinking abruptly yesterday, and had a seizure the
morning of presentation for about 2 minutes. Prior to
presenting to [**Hospital1 **] [**Location (un) 620**] he had another 20 minute seizure.
Patient reportedly drinks 5 shots and 4 beers daily. Patient
was complaining of nausea, mild epigastric pain, and emesis 2
days prior to presentation. Labs at [**Location (un) 620**] were concerning for
cholecystits with wbc of 10, initial lactate 4.3 (repeat after
3L NS 2.3), TBili 6.6, DBili 4.4, and RUQ U/S concerning for
acute cholecystitis. The patient was transferred to [**Hospital1 18**] for
possible ERCP and further management of EtOH withdrawal. Prior
to transfer he received 20 mg IV diazepam, 3L IVF, IV Zosyn and
potassium.
In the ED initial VS were T99 HR99 BP137/95 RR20 satting 96% on
RA.
Labs showed ALT 54, AST 160, Tbili 6.1, with normal alk phos and
lipase. Serum tox screen was negative. Metabolic panel showed
evidence of hypokalemia at 2.6, as well as hypocalcemia of 7.6,
hypomagnesemia of 1.3, and phosphate of 1.5. CBC showed a
macrocytic anemia with a HCT of 34.1 and thrombocytopenia of 88.
WBC was 7.9 with 80.2% PMNs without bandemia. Lactate and
urine tox screen were normal. UA showed moderate blood,
bilirubin, and trace ketones without evidence of infection. EKG
did not show any acute ischemic changes. Surgery was consulted
who suggested to continue Zosyn and to defer CCY as patient is
having withdrawal seizures. ERCP was also consulted who will
follow along. Repleted with IV potassium and magnesium prior to
transfer. Prior to admission patient received 2 mg lorazepam.
VS prior to admission were HR 91, BP [**Numeric Identifier 112365**], RR 24, Sat 97%.
On arrival to the MICU, pt was alert, oriented, and in no acute
distress. Vitals: P: 93, BP: 135/89, R: 27, O2: 94% on 2L NC.
Past Medical History:
ETOH abuse, psoriasis, HTN (has not been taking
anti-hypertensives for years)
Medications HOME:
none
Allergies: NKDA
Social History:
Positive for Alcohol and Smoking
Family History:
no panc or GI CA hx
Physical Exam:
On admission:
Vitals: P: 93, BP: 135/89, R: 27, O2: 94% on 2L NC
Constitutional: ill appearing, tremulous
HEENT: significant scleral icterus, mucosa dry
Chest: diffuse wheezing, no distress
Cardiovascular: regular tachycardia
Abdominal: hepatomegaly with question ascites, non-tender
GU/Flank: few bruises noted
Extr/Back/Skin: venous incompetence with several bruises and
plaques c/w psoriasis
Neuro: Pt A+O times 3, CN II-XII intact, no asterixis
On discharge:
98.8, P 84, BP 149/94 (today range 120-140/80-100s), 16, 98RA
Gen- alert well appearing
Psych- nl affect/mood, pleasant
Skin- no pallor
CV- RRR no m/g
Lung- CTAB without wheeze
Abd- soft, NT/ND
Pertinent Results:
[**2190-8-4**] 12:10AM BLOOD WBC-7.9 RBC-3.37* Hgb-11.7* Hct-34.1*
MCV-101* MCH-34.7* MCHC-34.2 RDW-14.1 Plt Ct-88*
[**2190-8-10**] 07:15AM BLOOD WBC-7.3 RBC-3.56* Hgb-12.4* Hct-37.5*
MCV-105* MCH-34.9* MCHC-33.2 RDW-13.5 Plt Ct-286
[**2190-8-4**] 08:11AM BLOOD PT-13.5* PTT-33.1 INR(PT)-1.3*
[**2190-8-6**] 04:49AM BLOOD PT-14.6* PTT-29.3 INR(PT)-1.4*
[**2190-8-4**] 12:10AM BLOOD Glucose-90 UreaN-9 Creat-0.6 Na-139
K-2.6* Cl-102 HCO3-26 AnGap-14
[**2190-8-10**] 07:15AM BLOOD Glucose-105* UreaN-2* Creat-0.6 Na-137
K-4.0 Cl-105 HCO3-25 AnGap-11
[**2190-8-4**] 12:10AM BLOOD ALT-54* AST-160* AlkPhos-96 TotBili-6.1*
[**2190-8-9**] 05:45AM BLOOD ALT-63* AST-98* AlkPhos-132* TotBili-2.6*
[**2190-8-4**] 12:10AM BLOOD Lipase-53
[**2190-8-4**] 12:10AM BLOOD Albumin-3.4* Calcium-7.6* Phos-1.5*
Mg-1.3*
[**2190-8-10**] 07:15AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7
[**2190-8-4**] 08:11AM BLOOD VitB12-1238*
[**2190-8-10**] 07:15AM BLOOD Folate-12.3
[**2190-8-4**] 08:11AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2190-8-4**] 12:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2190-8-4**] 08:11AM BLOOD HCV Ab-NEGATIVE
Utox negative
Liver US [**8-4**]
1. Asymmetric focal thickening of the gallbladder wall which
may relate to underlying liver disease; however, cholecystitis
cannot be excluded. A HIDA scan is recommended for further
characterization of the gallbladder.
2. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
HIDA [**8-4**]
IMPRESSION: 1. Normal filling of the gallbladder with normal
transit to the GI tract. 2. Mild persistent blood pool is
suggestive of hepatic dysfunction, and compatible with abnormal
LFTs.
CT abd [**8-4**]
1. Free intraperitoneal air likely represents perforation from
a duodenal ulcer; recommend endoscopy.
2. Evidence of diffuse hepatosteatosis with apparent areas of a
nodular
hepatic contour and early recanalization of the paraumbilical
vein. Overall findings are suspicious for cirrhosis and early
portal hypertension. Recommend correlation with liver function
tests and nonemergent liver biopsy. Gallbladder wall edema may
be secondary to hepatic dysfunction.
3. Subtle, peripheral wedge-shaped areas of hypodensity within
both kidneys raise the possibility of small
ischemic/inflammatory abnormalities which may be seen in the
setting of certain medications, vasculitis or disseminated
infection.
4. Gallbladder abnormality seen on US is not seen on CT and
therefore very unlikely to be a mass.
5. Compression deformity of L1 vertebral body is of
indeterminate chronicity.
Brief Hospital Course:
47yoM with hx alcoholism, untreated HTN admitted for alcohol
withdrawal, duodenal perforation, and new diagnosis cirrhosis.
# Alcohol- admitted for withdrawal, initially to ICU. Managed
on IV ativan. Psychiatry consulted. Recommended Ativan taper
which patient finished uneventfully on [**2190-8-9**].
He appears motivated to achieve sobriety immediately. He met
with social work. The patient is afraid that more alcohol will
cause serious illness again. He is scared of temptation, and of
having lack of structure in his day. He plans to attend AA
meetings, and states his girlfriend has already removed all
alcohol from his residence.
# Duodenal perforation- seen on CT abdomen with evidence of free
air. Probably from a perforated ulcer in setting of alcohol and
NSAID use. H pylori serology negative. Surgery was consulted,
patient did not require any operative intervention. Endoscopy
also not done given danger of further worsening things. Was
treated with antibiotics. Recommend continuing cipro/flagyl for
total 10 days, started [**2190-8-4**], end date [**2190-8-13**]. He was also
placed on IV PPI drip transitioned to oral twice daily PPI. He
should continue this and have an EGD in ~8 wks to document
healing.
# Liver disease- transaminitis and hyperbilirubinemia along with
thrombocytopenia. Possibly component of alcoholi hepatitis.
Imaging was negative for acute cholecystitis (equivocal US but
negative HIDA). His LFTs downtrended on their own; however, CT
abdomen indicated cirrhosis which is a new diagnosis for the
patient. Most likely due to alcohol. An MRCP was considered to
look for other causes, but it was then decided this is not an
urgent study and the LFTs were more attributable to
cirrhosis/alcohol. He will follow up with liver clinic for
ongoing management. The EGD recommended above should also assess
for presence of varices.
# Macrocytosis- probably due to alcohol and/or cirrhosis. B12
and folate normal.
# HTN- reported hx of untreated elevated BP. Was elevated here
intermittently but not to point of starting inpatient
management. No BP meds.
# Psoriasis- treated in house with topical steroid.
Transitional Issues
=======================
[ ] Antibiotics (Cipro + Flagyl) through [**2190-8-13**]
[ ] Recommend repeat EGD in ~8 weeks for ulcer eval and variceal
screening
Medications on Admission:
ibuprofen
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
end date [**2190-8-13**]
RX *Cipro 500 mg 1 tablet(s) by mouth twice a day Disp #*6
Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 3 Days
RX *Flagyl 500 mg 1 tablet(s) by mouth three times a day Disp
#*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal and alcoholism
Perforated duodenal ulcer
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for alcohol withdrawal. You
were found to have a small tear in the intestinal lining,
possibly from an ulcer. You were also found to have findings
concerning for likely liver cirrhosis. I recommend you stop
drinking alcohol, and take your new medications as prescribed.
Followup Instructions:
Department: LIVER CENTER
When: THURSDAY [**2190-8-19**] at 8:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 112366**], MD
Specialty: Primary Care
When Tuesday [**8-24**] at 11:15am
Location: [**Hospital **] MEDICAL ASSOCIATES-[**Location (un) **]
Address: [**Location (un) 11898**], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 8506**]
ICD9 Codes: 5715, 2768, 2875, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7122
} | Medical Text: Admission Date: [**2101-12-26**] Discharge Date: [**2102-1-2**]
Date of Birth: [**2027-2-7**] 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:
[**2101-12-26**] - CABGx4 (left internal mammary->Left anterior
descending artery, Saphenous vein graft(SVG)->Posterior
descending artery, SVG->Obtuse marginal artery, SVG->Ramus
artery).
History of Present Illness:
74-year-old gentleman with a history of exertional chest
tightness and
abnormal stress test. He was recently hospitalized and
underwent cardiac catheterization which revealed severe disease
of the left anterior descending artery. His obtuse circumflex
and right coronary arteries had mild luminal irregularities.
Past Medical History:
Dyslipidemia
Diabetes
Eczema
Hx of herpes zoster
Resection of adenomatous colon polyps
Remote hernia repair
Tonsillectomy
Basal cell carcinoma of the face, s/p Mohs procedure
Social History:
Retired chemistry profesor. Lives with wife in [**Name (NI) 5087**]. Never
smoked. Social alcohol use.
Family History:
Denies
Physical Exam:
Blood pressure 136/80, heart rate 69, and weight is 189 pounds.
The patient is a reasonably fit-appearing man in no acute
distress. He is well-developed and well-groomed, oriented to
person, place, and time. He describes his symptoms eloquently.
Mood and affect are appropriate. Pupils are equal. There is no
icterus. There is mild arcus senilis bilaterally. Funduscopic
exam reveals sharp optic disks without evidence of chronic
hypertensive vascular disease. Neck is supple without
lymphadenopathy, JVD, or thyromegaly. No chest wall deformity.
His lungs are clear to auscultation bilaterally with normal
respiratory effort. No abdominal aortic, femoral, or carotid
bruits. Cardiac PMI is in the fifth ICS at MCL without a heave
or palpable gallop. Normal S1, normally split S2, no S3, S4,
rub, or click. There was no murmur. Pulses are 2+ and
symmetric in carotid, radial, femoral, PT, and DP arteries.
There was no
HSM, abdominal mass, or tenderness. Extremities have no
cyanosis, clubbing, or edema. Some spider varicosities below
knee. Inspection and palpation of skin and subcutaneous tissue
showed no stasis dermatitis, ulcers, or xanthomas. The gait and
muscle tone are grossly normal.
Pertinent Results:
[**2101-12-26**] ECHO
Pre Bypass: No mass/thrombus is seen in the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen.
Post Bypass: Patient is in sinus rhythmon phenylepherine gtt.
Perserved biventricular function, LVEF >55%. MR remains mild.
Aortic contour intact. Remaining exam is unchanged. All findings
discussed with surgeons at the time of the exam.
[**2101-12-31**] 07:05AM BLOOD WBC-4.3 RBC-2.72* Hgb-8.8* Hct-25.0*
MCV-92 MCH-32.1* MCHC-35.0 RDW-13.5 Plt Ct-208
[**2102-1-1**] 08:55AM BLOOD UreaN-20 Creat-0.9 K-4.2
Brief Hospital Course:
Mr. [**Known lastname 24110**] was admitted to the [**Hospital1 18**] on [**2101-12-26**] for surgical
management of his coronary artery disease. He was taken directly
to the operating room where he underwent coronary artery bypass
grafting to four vessels. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next several hours, he awoke neurologically
intact and was extubated. Beta blockade, a statin and aspirn
were resumed. On postoperative day one, he was transferred to
the step down unit for further recovery. Mr. [**Known lastname 24110**] was gently
diuresed towards his preoperative weight. The physical therapy
service was consulted for assistance with his postoperative
strength and mobility. Mr. [**Known lastname 24110**] failed to void after removal
of his foley and thus had a new foley catheter reinserted.
Urology was called and they stated he should go home with a
foley and leg bag, follow up in urology clinic in 2 weeks. On
the morning of POD 6 he experienced a brief episode of
asymptomatic rapid atrial fibrillation that resolved with IV
amiodarone bolus. He was maintained on oral amiodarone
thereafter. On the day of discharge, the patient was found to
have a urinary tract infection and was started on bactrim. The
patient was discharged in good condition to home on POD 7, with
VNA services.
Medications on Admission:
metformin 500', Zocor 20', ASA 81', Torpol xl 50',
Preservision', Betamethasone 0.005% prn, NTG sl prn
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day for 2
weeks.
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x5 days then
400mg Qd x 5 days then 200mg QD.
Disp:*60 Tablet(s)* Refills:*1*
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
14. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
CAD
Dyslipidemia
Diabetes mellitus
H/O shingles
Eczema
Basal cell skin cancer
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 171**] in [**1-17**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 5717**] in [**1-18**] weeks. [**Telephone/Fax (1) 250**]
Please follow-up with [**Hospital 159**] Clinic in 2 weeks ([**Telephone/Fax (1) 772**]
Completed by:[**2102-1-2**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7123
} | Medical Text: Admission Date: [**2146-5-8**] Discharge Date: [**2146-5-13**]
Date of Birth: [**2091-8-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Recurrent altered mental status
.
Major Surgical or Invasive Procedure:
Paracentesis
.
History of Present Illness:
54 year old man with history of ETOh induced cirrhosis with
complications of esophageal varices, refractory ascites s/p TIPS
and subsequent closure p/w altered mental status. Of note the
patient was just discharged from [**Hospital1 18**] on [**2146-5-1**] for an
admission for hepatic encephalopaty at which time he was found
to have a UTI and he completed 7 days of antibiotics. He had his
lactulose regimen titrated up during the admission. He had an
outpatient liver u/s on [**5-6**] but the read is still pending. On
the afternoon of the 24th his wife noted him to be less
interactive and more somnolent. He was at home and leaned down
onto floor from his recliner and did not get up. He had a small
abrasion on his head. She gave him an additional dose of
lactulose. However his somnolence persisted and she had him
brought to [**Hospital3 3583**]. His vitals there were unremarkable
and he was breathing comfortably on room air. He received an
additional 20 gm of lactulose prior to transfer to [**Hospital1 18**].
.
In the ED his initial vital signs were afebrile 110/79 90 19
97%RA. He received an additional dose of lactulose PO. A head CT
was unremarkable for hemorrhage. He was transfered to the floor.
.
Past Medical History:
1. EtOH induced cirrhosis with portal HTN and esophageal
varices, refractory ascites. h/o encephalopathy. previously not
candidate for txp due to obesity, but lost 40 lbs and put on
list in [**10-21**].
2. s/p TIPS [**2137**] with frequent revisions, [**8-4**] and TIPS redo
[**2145-11-19**], now s/p closure [**4-21**]
3. CKD with baseline Cr 1.6
4. DM2
5. s/p ccy for porcelain gallbladder in [**10/2145**]
6. neuroendocrine tumor in stomach
7. obesity
8. OSA on BiPAP at home c/b mild pulmonary hypertension
9. Squamous cell skin ca on left shoulder
10. s/p rhinoplasty after broken nose
11. s/p surgery for R cheek infection
12. s/p TIPS closure due to frequent encephalopathy [**4-/2146**]
.
Social History:
Married to wife [**Name (NI) **] and living in [**Name (NI) 3320**]. 16 py h/o smoking,
quit 27 years ago. H/O alcohol abuse, quit 10 yrs ago. Remote
marijuana/cocaine use in the 60s-70s, no IVDU. Umemployed at
present. He previously worked as the Director of food & beverage
services on a cruisline in the Hawaiian islands.
.
Family History:
# Mother, d 56: CVA
# Father, d 84: Alzheimer's
# Sister: DM2, seizures
# Brother, older: [**Name2 (NI) 3495**] disease
# Brother, younger: [**Name2 (NI) **] known disease
.
Physical Exam:
VS: 97.5 94 129/93 15 97%2L
GEN: minimally arousable to voice or noxious stimuli.
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, mild
icteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: [**Last Name (un) 25359**] open ccy scar, pendulous, NT, distended with ascites,
+ BS, no HSM. marked scrotal edema (inguinal hernia with ascites
tracking down). non-visible urethral meatus.
EXT: warm, dry, +2 distal pulses BL, no femoral bruits
NEURO: awake. arousable to voice and noxious stimuli, not
following commands, CN II-XII grossly intact, withdrawals all 4
ext symmetrically. No sensory deficits to light touch
appreciated. +asterixis
.
Pertinent Results:
CT head [**5-8**]: There is no hemorrhage, hydrocephalus, shift of
normally midline structures, or evidence of major vascular
territorial infarct. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. Hyperdensities are seen within the periventricular
and subcortical white matter consistent with chronic
microvascular ischemic disease. The visualized paranasal sinuses
and mastoid air cells remain normally aerated. The surrounding
soft tissue and osseous structures are within normal limits.
.
CXR [**5-8**] Portable radiograph of the lower lung and upper abdomen
is demonstrated. The NG tube tip is in the stomach. The TIPS
catheter is demonstrated in expected unchanged location. The
limited evaluation of the upper abdomen is unremarkable. The
evaluation of the lung bases demonstrates left pleural effusion
and left lower lobe atelectasis.
.
RUQ US w/doppler [**5-9**]: Complete occlusion of the TIPS catheter
compatible with recent TIPS closure procedure performed on [**4-14**], 08, no change from [**2146-4-27**].
.
Brief Hospital Course:
54 year old man with history of alcoholic cirrhosis complicated
by refractory ascites s/p TIPS c/b recurrent hepatic
encephalopathy with TIPS closure, who presented to ICU from OSH
for somnolence, now mental status improved with lactulose but
still not at baseline.
.
# Recurrent hepatic encephalopathy: The patient presented with
sudden decline in mental status and an unwitnessed fall at home.
He was somnolent when he arrived from OSH so was admitted to ICU
and improved with lactulose per NGT. Mental status slowly
improved back to baseline. We will also evaluate whether the
TIPS is still closed. No indication of infection - diagnostic
para negative for SBP, UCx negative, CXR without evidence of
infection. He was continued on lactulose and rifamixin. RUQ
[**Month (only) 950**] with doppler confirmed TIPS is closed.
.
# Etoh cirrhosis: He is awaiting liver [**Month (only) **]. MELD on
admission was 20. Patient has had issues with recurrent hepatice
encephalopathy so TIPS was closed on [**2146-4-16**]. Patient also with
h/o esophageal varices but Hct stable and no evidence of bleed.
Lactulose and rifamixin were continued as above. Nadolol and
diuretics were held initially and then re-started prior to
discharge at his pre-admission doses.
.
# s/p unwitnessed fall: Patient has abrasions on forehead and
knees bilaterally when he was encephalopathic prior to
admission. CT head negative. Wounds all looked superficial and
there was no evidence for more serious injury.
.
# s/p UTI: Patient finished 7 day course of amoxicillin for
enterococcal UTI on [**2146-5-5**]. Patient had difficult foley
placement by urology in ICU so started on a course of CTX but
this was discontinued after 2 days as there was no evidence for
UTI. Foley was discontinued when his mental status cleared.
.
#) Pancytopenia: This is chronic and likely [**1-15**] liver disease.
He is known to be guaiac positive, presumed to be from his
neuroendocrine tumor in his stomach. Hct at last discharge on
[**5-6**] was 30.2, currently 27-28.
.
#) DM2: DM regimen at home is NPH 75 units qAM, 70. His regimen
was decreased in the ICU as patient was NPO. Once he started
eating, his NPH regimen was titrated up to his home doses. He
was also covered with a humalog insulin sliding scale.
.
#) Neuroendocrine tumor: Patient has known 1.5cm mass in gastric
cardia from [**12/2145**], not much increase in change from last EGDs
in [**2144**]. Pathology consistent with carcinoid tumor. No evidence
of flushing, increased urination. Patient can follow up as
outpatient for further workup of carcinoid syndrome
.
#) Code status: FULL, confirmed with wife and patient at time of
admission.
.
Medications on Admission:
Pantoprazole 40 mg Q24H
Magnesium Oxide 400 mg [**Hospital1 **]
Spironolactone 100 mg [**Hospital1 **]
Furosemide 100 mg DAILY
Rifaximin 400 mg TID
Nadolol 10 mg DAILY
Lactulose 10 gram/15 mL Syrup Sig: One [**Age over 90 **]y (120)
ML PO QAM (once a day (in the morning)).
Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QNOON.
Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO QPM
(once a day (in the evening)).
Insulin NPH 75U QAM;70U QPM
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Furosemide 20 mg Tablet Sig: Five (5) Tablet PO once a day.
3. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO once a day.
7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Seventy
Five (75) units Subcutaneous qAM.
8. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Seventy
(70) units Subcutaneous qPM.
9. Glucerna Shake Liquid Sig: One (1) bottle PO twice a day.
Disp:*60 bottles* Refills:*2*
.
Discharge Disposition:
Home With Service
Facility:
[**Age over 90 269**] Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Final diagnosis:
Hepatic encephalopathy
.
Secondary diagnosis:
EtOH-induced cirrhosis
CKD with baseline Cr 1.2-1.5
DM 2
Neuroendocrine tumor in stomach with chronic low grade GIB
.
Discharge Condition:
Stable
.
Discharge Instructions:
You were admitted for confusion and an unwitnessed fall at home
due to your hepatic encephalopathy. Initially you were in the
intensive care unit as you were very sleepy and required a
nasogastric tube for lactulose. You improved with lactulose and
were transferred to the medical floor. You had a paracentesis on
the day of discharge for increasing ascites with 5L removed.
.
Please continue all your home medications and keep all scheduled
follow-up appointments.
.
Please call your physician or return to the emergency room if
you have any increased confusion, decreased bowel movements
despite increased lactulose, fever, chills, pain on urination,
or any other new or worrisome symptoms.
.
Followup Instructions:
Provider [**Name9 (PRE) **],[**Name9 (PRE) 8754**] DERMATOLOGY GEN-[**Doctor First Name 8754**] (NHB)
Date/Time:[**2146-5-11**] 10:00
.
Provider [**Name9 (PRE) 1382**] [**Name9 (PRE) 1383**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2146-5-20**] 10:00
.
Provider PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2146-7-19**] 11:10
.
ICD9 Codes: 5849, 5990, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7124
} | Medical Text: Admission Date: [**2159-2-1**] Discharge Date: [**2159-2-4**]
Date of Birth: [**2097-8-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Small Bowel Obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 year-old male with a history of a renal transplant on [**2137**]
that has now failed, and also a history of multiple abdominal
operations. He has a long history of small bowel obstructions
and was recently hospitalized last week with an episode of small
bowel obstruction. He reports last night had a similar episode
of pain and presented to clinic. He denies nausea, vomiting,
fevers, chills, chest pain, and shortness-of-breath. He was
evaluated by Dr. [**First Name (STitle) **] in the clinic and was sent to the
emergency room for further evaluation for a possible small bowel
obstruction.
Currently, he continues to have pain that has improved. He
continues to have no nausea, vomiting, fevers, chills, chest
pain, or shortness-of-breath. He continues to have high output
from his ostomy with copious amounts of gas. He empties the
ostomy approximately 7-8 times per day.
Past Medical History:
ESRD on HD (secondary to post-streptococcal
glomerulonephritis, Renal transplant '[**37**] failed, transplant
nephrectomy in [**2143**]), Hyperparathyroidism, Hypertension, Atrial
fibrillation (started on warfarin [**Date range (1) 101024**]), CAD, Diastolic CHF
with remote history of systolic CHF MSSA, Endocarditis w/ Aortic
and Mitral valve involvement, Repeated episodes of pneumonia,
VRE
septic arthritis, L wrist MSSA infective arthritis, Right hip
fracture s/p Right hip hemiarthroplasty, [**2157-1-11**], Right
Prosthetic Hip infection s/p explantation [**2-18**], Ischemic
colitis/ileitis s/p subtotal colectomy and terminal ileal
resection, followed by ileocolonic anastomosis with diverting
loop ileostomy and gastrostomy tube placement [**2156**]
PAST SURGICAL HISTORY:
[**2158-11-7**]: Aortic valve replacement(21 mm ON-X, Mitral valve
replacement 25/33 On-X Conform-X mechanical valve)
[**2158-10-5**]: Right heart catheterization
[**2158-10-3**]: Paracentesis
[**2158-7-13**]: Fistulogram, 6-mm balloon angioplasty of
juxta-anastomotic segment
[**2157-6-16**]: Washout and drainage right hip wound infection.
[**2157-6-14**]: Revision left radiocephalic arteriovenous fistula,
endarterectomy radial artery.
[**2157-2-22**]: Evacuation drainage of right hip deep hematoma-abscess.
[**2157-2-18**]: Removal right hip hemiarthroplasty.
[**2157-2-3**]: Irrigation, debridement and evacuation of hematoma of
right septic hemiarthroplasty.
[**2157-1-26**]: Right hip revision of hemi arthroplasty due to
dislocation.
[**2157-1-15**]: Exploratory laparotomy, gastrostomy tube, ileocolonic
anastomosis and diverting loop ileostomy.
[**2157-1-14**]: Exploratory laparoscopy, subtotal colectomy.
[**2157-1-13**]: Exploratory laparotomy, Subtotal colectomy, Resection
of terminal ileum, Temporary abdominal closure.
[**2157-1-11**]: Right hip hemiarthroplasty.
[**2156-12-10**]: Left wrist incision and drainage.
[**2156-2-17**]: Right ring finger closed reduction percutaneous pinning
for mallet finger. Left index and long ring finger PIP joint
manipulation under anesthesia.
[**2155-12-16**]: Left carpal tunnel release and left index, long and
ring finger trigger releases
Social History:
Owner of a clothing store in [**Location (un) 4398**]. No current tobacco and
alcohol h/o intermittent tobacco use in the past (~3
pack-years). Denies illicit drug use. HIV negative [**2156-12-27**]
Family History:
Positive for cancer (father-prostate), [**Name (NI) 2481**] (mother).
Father deceased. Brother has fibromyalgia. Daughter in good
health
Physical Exam:
Gen: NAD
HEENT: MMM no lesions
CV: RRR no MRG
RESP: CTAB no WRR
ABD: soft, NT ND. Ostomy w stool and gas. G tube with drainage
bag, thin gastric contents present.
Ext: No LE edema
Pertinent Results:
[**2159-2-3**] 06:50AM BLOOD WBC-3.5* RBC-3.96* Hgb-11.9* Hct-36.7*
MCV-93 MCH-30.1 MCHC-32.4 RDW-19.6* Plt Ct-75*
[**2159-2-3**] 06:50AM BLOOD Glucose-65* UreaN-14 Creat-3.1* Na-138
K-4.2 Cl-96 HCO3-33* AnGap-13
[**2159-2-3**] 06:50AM BLOOD Calcium-9.4 Phos-4.4 Mg-1.7
[**2159-2-3**] 01:35PM BLOOD CK-MB-4 cTropnT-0.47*
[**2159-2-3**] 06:50AM BLOOD CK-MB-4 cTropnT-0.48*
[**2159-2-2**] 07:15PM BLOOD CK-MB-5 cTropnT-0.43*
[**2159-2-2**] 02:00PM BLOOD cTropnT-0.41*
[**2159-2-2**] 04:00AM BLOOD CK-MB-5 cTropnT-0.31*
[**2159-2-1**] 08:15PM BLOOD CK-MB-4 cTropnT-0.28*
KUB [**2-1**]:
FINDINGS: Dilated small bowel in the lower abdomen measuring up
to 4.3 cm in diameter containing air-fluid levels on the upright
view. Findings concerning for small-bowel obstruction.
Brief Hospital Course:
Pt was admitted from ED in good condition with the diagnosis of
small bowel obstruction. He was given hemodialysis for an
elevated potassium. His small bowel obstruction was treated
conservatively with IV hydration, PPI's, and nothing by mouth.
On HD2, the patient's ostomy began to put out stool and gas. He
was advanced to a clear, then regular diet on HD3. By HD 4 the
patient was comfortable eating a regular diet, having stool and
gas from his ostomy, without abdominal pain or distention. He
was then deemed safe for discharge home. Of note, the patient
had a set of troponins that were drawn in the ED for the symptom
of epigastric pain. An EKG was normal, and the pt was
hemodynamically stable. Thus his troponin elevation was thought
to be due to his renal failure and not from cardiac ischemia. He
was restarted kept on coumadin throughout his hospitalization
and made sure his INR levels were therapeutic by his discharge,
as he came with subtherapeutic levels. He was discharged on
[**2-4**] with an INR of 3.0 and will closely follow-up his levels
with the coumadin clinic from the labs drawn at [**Month/Year (2) 2286**].
Medications on Admission:
atorvastatin 10mg daily, B complex-vitamin C-folic acid 1,
cinacalcet 60, ciprofloxacin 500mg daily, epoetin alfa
injection,
pantoprazole 40mg daily, warfarin 2mg daily, aspirin 81 daily
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Cipro 500 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 once a day.
4. Coumadin 2 mg Tablet Sig: please take according to levels
Tablet PO once a day.
5. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Alert and Oriented to all spheres, ambulating and voiding
without difficulty
Discharge Instructions:
You were admitted to the hospital with a small bowel
obstruction. Your obstruction was relieved on hospital day 2,
and you were then able to eat regular food without any problems.
Make sure to monitor for symptoms of nausea, vomiting, or
abdominal pain while eating. Keep track of your daily ostomy
output, and whether or not you have gas and stool in the bag.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please call and make an appointment with Dr. [**First Name (STitle) **] in 2 weeks
[**Telephone/Fax (1) 673**]
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2159-2-15**] 3:40
Please follow the coumadin levels and follow up with the
coumadin clinic for dose tomorrow.
Completed by:[**2159-2-6**]
ICD9 Codes: 4280, 2767, 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7125
} | Medical Text: Admission Date: [**2157-9-28**] Discharge Date: [**2157-9-30**]
Date of Birth: [**2102-11-12**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Incarcerated hernia
Major Surgical or Invasive Procedure:
[**2157-9-28**] Left Inguinal hernia repair w/ mesh
History of Present Illness:
Pt is a 54 M w/ h/o L inguinal hernia repair by Dr. [**Last Name (STitle) **] in
[**2151**]. He noticed a bulge in his left groin approximately 5 days,
and has been having worsening nausea/vomiting for the last ~24
hrs, with approximately 11 episodes of emesis yesterday. His
pain has been stable. He did have a subjective fever last night.
Past Medical History:
CAD s/p 3V CABG to LAD, OM1, PDA.
HTN, controlled on meds
Dyslipidemia
Social History:
No tobacco hx, very rare EtOH use, no IVDU. Pt is a MSM, lives
with a steady male partner, currently sexually active, does not
use protection, no hx of STDs in himself or partner. Employed in
clothing design firm.
Family History:
Extensive family hx of CAD.
F died of MI [**92**], Uncle died of MI [**83**]. GF died of MI.
Physical Exam:
Physical Exam upon admission:
Vitals:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft. Minimally distended. Nontender. No guarding/Rebound.
Palpable L inguinal Hernia
Ext: No LE edema, LE warm and well perfused
Physical Exam upon discharge:
VS: 98.2, 119/57, 78, 16, 99/RA
GEN: Resting in chair, NAD
HEENT:No scleral icterus, mucus membranes moist
CARDIAC: Normal S1, S2. RRR. No MRG
PULM: Lungs CTAB
ABDOMEN: obese, soft/nontender/mildly distended
EXT: + pedal pulses. No CCE.
NEURO: AAOx4
Skin: Left groin incision OTA, steri strips intact.
Pertinent Results:
Imaging:
[**2157-9-28**] Radiology CT ABD & PELVIS WITH CO
Left inguinal hernia containing sigmoid colon and causing large
bowel
obstruction. Minimal surrounding inflammation. No bowel wall
enhancement abnormalities to suggest ischemia, though trace
fluid is identified within the abdomen. No free air.
[**2157-9-29**] 08:25AM BLOOD WBC-9.1 RBC-4.72 Hgb-14.9# Hct-41.3#
MCV-88 MCH-31.5 MCHC-36.0* RDW-13.0 Plt Ct-173
[**2157-9-28**] 12:50PM BLOOD WBC-10.9# RBC-6.02 Hgb-18.7* Hct-51.8
MCV-86 MCH-31.1 MCHC-36.1* RDW-13.2 Plt Ct-245#
[**2157-9-28**] 12:50PM BLOOD Neuts-82.9* Lymphs-11.5* Monos-5.1
Eos-0.1 Baso-0.3
[**2157-9-29**] 08:25AM BLOOD Glucose-103* UreaN-18 Creat-0.9 Na-136
K-3.9 Cl-103 HCO3-25 AnGap-12
[**2157-9-28**] 12:50PM BLOOD Glucose-118* UreaN-19 Creat-1.1 Na-132*
K-3.6 Cl-95* HCO3-24 AnGap-17
[**2157-9-28**] 12:50PM BLOOD ALT-49* AST-31 AlkPhos-54 TotBili-1.3
[**2157-9-29**] 08:25AM BLOOD Calcium-8.1* Phos-3.9 Mg-2.0
[**2157-9-28**] 12:50PM BLOOD Albumin-5.3*
[**2157-9-28**] 12:58PM BLOOD Lactate-2.5*
Brief Hospital Course:
The patient is with h/o L inguinal hernia repair by Dr. [**Last Name (STitle) **]
in [**2151**]. He noticed a bulge in his left groin approximately 5
days, and has been having worsening nausea/vomiting for the last
several hours. He was admitted to the Acute Care Service after a
CT Scan revealed "Left inguinal hernia containing sigmoid colon
and causing large bowel obstruction. Minimal surrounding
inflammation."
On [**2157-9-28**], the patient was taken to the operating room for
repair of his incarcerated recurrent left inguinal hernia with
mesh. Please see operative report for details of this procedure.
He tolerated the procedure well and was extubated upon
completion. He was subsequently taken to the PACU for recovery.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and he remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. His diet was advanced on the morning of
[**2157-9-29**] to regular, which he tolerated without abdominal pain,
nausea, or vomiting. He was voiding adequate amounts of urine
without difficulty. He was encouraged to mobilize out of bed and
ambulate as tolerated, which he was able to do independently.
His pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed. His left groin
incision was open to air with steri strips that were
clean/dry/intact. On [**2157-9-30**], he was discharged home with
scheduled follow up in [**Hospital 2536**] clinic.
Medications on Admission:
Metoprolol Tartrate 25 mg PO BID
Lisinopril 5 mg PO DAILY
Atorvastatin 20 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO BID
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
3. Lisinopril 5 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated Inguinal Hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital complaining of nausea and abdominal
pain. A CT scan revealed an left inguinal incracerated hernia .
You were taken to the operating room for hernia repair. Your
bowel function has returned and you have resumed a regular diet.
Please follow up in [**Hospital 2536**] clinic at the appointment scheduled for
you below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Hospital 5059**] at your next visit.
Don't lift more than 20-25 lbs for 4-6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Location: [**Hospital1 **] [**Location (un) **]
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
Appt: [**10-5**] at 12:20pm
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2157-10-13**] at 3:00 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2157-9-30**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7126
} | Medical Text: Admission Date: [**2125-10-14**] Discharge Date: [**2125-10-31**]
Date of Birth: [**2063-4-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
[**2125-10-14**] emergency CABG x3 with IABP (SVG to LAD, SVG to OM, SVG
to PDA)
Emergent left heart catheterization and coronary angiogram,
placement of IABP [**10-14**]
History of Present Illness:
This 62 year old white male presented to ER with severe angina,
shortness of breath, tingling down his left arm, and a new LBBB.
He had a prior infarction with PTCA in [**2108**]. Acute coronary
syndrome with shock was diagnosed and therefore, he went
urgently to the catheterization lab.
In the lab he developed acute respiratory distress requiring
intubation. Critical left main, LAD and circumflex disease were
found as well as occlusive RCA disease. An IABP was placed for
cardiogenic shock and a decision was made to proceed with
emergent coronary revascularization for myocardial salvage.
Past Medical History:
Myocardial infarction in [**2108**]
coronary angioplasty [**2102**]
Social History:
lives with brother
no tobacco or recreational drugs
occasional ETOH
Family History:
unknown
Physical Exam:
Awake, alert and oriented. 2/4 strength left arm, 3/4 strength
left leg. Full ROM sensation seems intact. There is some
neglect of left side, unsteady gait when looks up while walking.
Mild right facial weakness. Gag and swallowing intact.
lungs- clear
cor- SR 60-60
exts- without edema
wounds- clean and dry. Stable sternum
Pertinent Results:
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No spontaneous echo contrast or thrombus is seen in
the body of the right atrium or the right atrial appendage.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe
regional left ventricular systolic dysfunction with complete
akinesis of anteroseptal and anterior walls along with moderate
depression of the entire lateral wall. The inferior and
inferolateral walls are severely hypokinetic as well.. No masses
or thrombi are seen in the left ventricle and the apex was not
well visualized.. Overall left ventricular systolic function is
severely depressed (LVEF= 10 to 15 %).
RV has mild global free wall hypokinesis.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
There is no pericardial effusion.
IABP was initially 6cm below the Left SCA and was repositioned
to 2cm below the Left SCA.
Dr. [**Last Name (STitle) **] was notified in person of the results on Mr.[**Known lastname 80487**]
immediately after anesthesia induction and TEEexam..
POST-BYPASS: Patient is on infusions milrinone, levophed and
epinephrine and IABP
Preserved RV systolic function.
Mild improvement in septal wall motion abnormalities. LVEF 25%.
Mild to Moderate MR (This was not seen in the preoperative or
prebypass period)
Intact thoracic aorta.
Trivial TR.
IABP is positoned well,
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician
[**2125-10-29**] 05:25AM BLOOD Hct-35.1*
[**2125-10-28**] 06:15AM BLOOD WBC-6.0 RBC-3.64* Hgb-11.4* Hct-33.6*
MCV-92 MCH-31.3 MCHC-33.9 RDW-13.8 Plt Ct-332
[**2125-10-14**] 02:40AM BLOOD WBC-15.1* RBC-4.55* Hgb-14.5 Hct-41.2
MCV-91 MCH-31.9 MCHC-35.2* RDW-13.1 Plt Ct-287
[**2125-10-29**] 05:25AM BLOOD PT-24.3* INR(PT)-2.4*
[**2125-10-28**] 06:15AM BLOOD Glucose-112* UreaN-10 Creat-1.1 Na-139
K-3.9 Cl-106 HCO3-23 AnGap-14
[**2125-10-14**] 02:40AM BLOOD Glucose-242* UreaN-13 Creat-1.2 Na-139
K-4.0 Cl-101 HCO3-21* AnGap-21*
[**2125-10-25**] 02:48AM BLOOD ALT-26 AST-18 LD(LDH)-312* AlkPhos-100
Amylase-45 TotBili-0.4
[**2125-10-18**] 07:31PM BLOOD ALT-68* AST-69* LD(LDH)-636* AlkPhos-214*
Amylase-35 TotBili-1.0
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2125-10-24**] SCHED
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 80488**]
Reason: r/o bleed into CVA
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with
REASON FOR THIS EXAMINATION:
r/o bleed into CVA
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: AJy WED [**2125-10-24**] 12:12 PM
PFI: Right frontal lobe hypodensities consistent with evolution
of known
infarct. No evidence for hemorrhage, significant edema, or mass
effect.
Final Report
HISTORY: 62-year-old male with recent CVA. Evaluate for
hemorrhagic
conversion.
COMPARISON: CTA of the head from [**2125-10-21**] and MRI of the brain
from
[**2125-10-22**].
TECHNIQUE: Contiguous axial images were obtained through the
brain without
the administration of IV contrast.
FINDINGS: There has been interval development of multiple
partially confluent
hypodense foci in the right frontal lobe, in territory
consistent with known
recent CVA. This is consistent with expected evolution of
ischemic infarct.
There is no evidence for hemorrhage, significant edema, mass
effect, shift of
midline structures, or effacement of cisterns. The osseous
structures remain
unremarkable without suspicious lytic or sclerotic lesions.
Visualized
paranasal sinuses and mastoid air cells remain clear.
IMPRESSION:
1. New right frontal lobe subcortical hypodensities, consistent
with expected
evolution of ischemic infarction.
2. No evidence for hemorrhage, significant edema, or mass
effect.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: WED [**2125-10-24**] 1:23 PM
Imaging Lab
Cardiology Report ECG Study Date of [**2125-10-26**] 5:29:56 AM
Sinus rhythm. First degree A-V block. Long QTc interval. Poor R
wave
progression. Possible anterior myocardial infarction, age
undetermined.
Clinical correlation is suggested. Non-specific intraventricular
conduction
delay. Anterior T wave changes suggest myocardial ischemia. Low
QRS voltage
in the limb leads. Compared to the previous tracing of [**2125-10-15**]
the
ventricular rate is slower. The P-R interval is longer.
Anterolateral
T wave changes are more pronounced.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Brief Hospital Course:
Mr. [**Known lastname 80487**] presented to the ED with an acute MI on [**10-14**], with
cardiogenic shock and was taken to the cath lab where
angiography revealed an 80% LM lesion and an occluded RCA. An
IABP was placed in the cath lab where he was intubated due to
respiratory distress and CHF. He received Plavix, Integrilin
and Heparin and then was transferred to the OR emergently in
cardiogenic shock for revascularization. His EF was noted to be
10-15% by echo in the OR with a large area of infarct. He
weaned form bypass on epinephrine, levophed, milrinone, insulin,
and propofol drips. He had a significant amount of ventricular
ectopy post operatively and electrolytes were repleted.He
received amiodarone as well. He subsequently remained stable
postoperativley.Thge epinephrine then the Levophed were slowly
weaned, keeping his MAP>65mmHg. The IABP was weaned to 1:2 and
removed on POD 2. The amiodarone and Milrinone were continued
and extubation occurred on POD 2. The Milrinone was weaned and
discontinued as an ACEI was begun, and he remained stable.
He was then transferred to the step down floor on POD 3. The
chest tubes and wires were removed. He was seen in consultation
by the physical therapist. He was noted to have bursts of atrial
tachycardia and therefore was seen by electrophysiology who
recommended continuation of the amiodarone and a repeat
echocardiogram in a month. Due to PAF and the low LVEF he was
anticoagulated with Coumadin.
On the evening of POD 7 ([**10-21**]) he was noted to have an unsteady
gait and felt exhausted. There was left sided weakness of the
leg/arm with neglect. The stroke team was notified and an
emergent CTA demonstrated occlusion of the right internal
carotid extending to the right MCA with distal
collateralization. No intervention was indicated beyond the
ongoing anticoagulation and he was transferred to the ICU for
monitoring.
Carotid ultrasound on [**10-22**] confirmed no flow through the right
internal carotid artery. There was no stenosis of the left
internal carotid. Head CT/CTA on [**10-22**] demonstrated a right ICA
occlusion with good collaterals and distal flow. He transiently
required neosynephrine for BP support to maintain cerebral
perfusion and all negative inotropes were discontinued.
He remained stable from a cardiac standpoint throughout the
remainder of his hospitalization.Physical therapy continued to
work with the patient in the ICU and after his return to the
floor.
Family meeting with PT/OT cleared him for discharge to home with
sister-in-law on [**2125-10-31**].
Medications on Admission:
ASA 81 mg daily
Discharge Disposition:
Home with Service
Discharge Diagnosis:
coronary artery disease
s/p emergency coronary artery bypass grafting
acute myocardial infarction with shock
s/p remote coronary angioplasty
postoperative stroke
occlusion of right carotid artery
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotion, creams, or powders on any incision
no driving for one month and until off all narcotics
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5
report any redness or drainage of incisions
take all medications as directed
Followup Instructions:
see Dr. [**Last Name (STitle) 8079**] in [**1-24**] weeks
see Dr. [**Last Name (STitle) 911**] in [**2-25**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2125-10-31**]
ICD9 Codes: 5185, 4271, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7127
} | Medical Text: Admission Date: [**2190-7-21**] Discharge Date: [**2190-8-5**]
Date of Birth: [**2113-11-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Abdominal Pain/ Nausea and Vomiting
Major Surgical or Invasive Procedure:
[**7-21**]- Cholangioscopy for CBD stone
[**7-30**]- Cholangioscopy with Bx specimens
History of Present Illness:
76yo woman with h/o dementia, s/p Billroth II and
cholecystectomy, admitted for cholangioscopy and attempted
biliary lithotripsy by IR [**2190-7-21**], transferred to MICU for
hypotension. The patient was initially seen at [**Hospital 794**] Hospital
three weeks ago after c/o several weeks of abdominal pain and
nausea/vomiting. MRCP at that time showed a common biliary duct
stone and dilated ducts, but ERCP failed to remove the stone. A
temporary drain was placed and she was treated with Unasyn. The
drain goes through the right biliary tree, into the common
biliary duct, and ends in the duodenum. There is a stone in the
cystic duct and stenosis of the common biliary duct. She was
admitted to [**Hospital1 18**] [**Date range (1) 67837**]/06 and seen by the ERCP service, who
deferred further treatment to IR. IR attempted stone retrieval
but was unsuccessful. There was a 1cm mass seen near a biliary
enteric anastomosis thought to be stenosis. She underwent MRCP
and MRI. Her external drain was capped and she was changed to po
levoflox for a 14 day course. She was discharged from [**Hospital1 18**] on
[**7-10**] with plans for possible future lithotripsy.
.
She was readmitted [**2190-7-21**] and underwent cholangioscopy with
attempted biliary lithotripsy by IR that was again unsuccessful.
IR is attempting to delineate CBD stone vs. mass. Today,
[**2190-7-22**], she was found hypotensive with SBP 60s, HR 70s. Tmax
was 99.6 axillary at noon. 2L NS was bolused, and she was
transferred to the MICU for further management. She c/o
abdominal pain today. She does c/o nausea. She denies headache,
dizziness, chest pain, or SOB. Pt does report that she
sometimes has mild CP
Past Medical History:
Dementia
billroth II
Social History:
lives with son, [**Name (NI) **] EtOH, no tobacco
Family History:
NC
Physical Exam:
PE- Gen: NAD
CV: RRR no m/r/g
Resp: CTAB
Abd: soft, NT/ND c/o mild abdominal pain to palpation
diffusely, no rebound or guarding
Ext: no bruising or pitting edema, 2+ pulses Bilaterally x 4
Neuro: A&O x 1 (person only), demented w/o focal signs
Pertinent Results:
[**2190-7-21**] 10:13PM BLOOD WBC-8.0 RBC-3.67* Hgb-10.1*# Hct-28.9*#
MCV-79* MCH-27.4 MCHC-34.9 RDW-15.4 Plt Ct-222
[**2190-7-31**] 03:41AM BLOOD WBC-6.9 RBC-3.50* Hgb-9.5* Hct-28.2*
MCV-81* MCH-27.3 MCHC-33.8 RDW-16.3* Plt Ct-231
[**2190-7-21**] 10:13PM BLOOD PT-14.7* PTT-29.0 INR(PT)-1.3*
[**2190-7-31**] 06:05PM BLOOD PT-15.2* PTT-30.9 INR(PT)-1.4*
[**2190-7-21**] 10:13PM BLOOD Glucose-134* UreaN-9 Creat-0.5 Na-138
K-3.2* Cl-103 HCO3-28 AnGap-10
[**2190-8-2**] 06:28AM BLOOD Glucose-74 UreaN-11 Creat-2.0* Na-141
K-3.5 Cl-115* HCO3-18* AnGap-12
[**2190-7-21**] 10:13PM BLOOD ALT-14 AST-25 LD(LDH)-151 AlkPhos-73
TotBili-0.5
[**2190-7-30**] 03:50PM BLOOD ALT-33 AST-42* AlkPhos-66 TotBili-0.5
[**2190-7-21**] 10:13PM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.6
Mg-1.5*
[**2190-7-31**] 06:05PM BLOOD Mg-1.8
[**2190-7-29**] 01:23PM BLOOD calTIBC-212* VitB12-661 Folate-9.6
Hapto-116 Ferritn-35 TRF-163*
Brief Hospital Course:
After Cholangioscopy, patient transferred from floor to MICU
HD#2 for hypotension which resolved with fluids. Not septic, Hct
stable, no adrenal insuff. Moved back to floor HD#3 once stable.
Patient again became hypotensive HD#5 and was transferred back
to the MICU. Patient again responded to fluids. Unclear what
cause of hypotension, but possibly from infection trending
toward Sepsis. She remained stable in the MICU on ABX and was
returned to the floor on HD#6 on Vanco and Zosyn for question of
Biliary Sepsis. Biliary drain remained in place from procedure
on. Once returning to the floor, patient maintained stable BP's
and remained afebrile. She completed a 10 day course of
Vancomycin and Zosyn at which time Abx were discontinued. She
remained afebrile at discharge.
Per IR, apparently patient has a cystic duct remnant with a
stone that is not the source of obstruction. Her obstruction
was caused by a mass vs. stricture distal to the stone which is
causing obstruction. On HD#9 she again underwent cholangioscopy
with stenting and Biopsy taken from stricture/mass to help
deliniate. Pathology displayed inconclusive specimens. IR
discussion on HD#15 drain drain was capped and they would like
patient to follow-up next week for reevaluation. At follow-up
it is likely that drain could be D/C completely.
On HD# 10 Patient was found to have ARF with Cr 0.9-->1.9-->2.5.
Renal was consulted and patient was believed to have ATN from a
prerenal source of dehydration. Pt responded to IVF and her RF
resolved. Urine Cx continued to be negative. Pt was found to
have VRE and had to be placed on Contact Precautions.
Pt was also chronically anemic during her hospitalization. Iron
studies revealed some evidence of mixed iron deficiency and
anemia of chronic disease. She was started on Ferrous Gluconate
and her HCT was stable at D/C.
Pt initially returned to the floor with low albumin and poor PO
intake. She was given Boost supplementation, but was found to
not be taking appropriate nutrition. On HD#14 nutrition felt
that Tube Feeds would increase Patient's nutritional status. On
discussion with the patient's son/Health Care Proxy, feeding
tube was not something they wanted to pursue at this time. Pt's
family feels that she will take more PO once she is in her home
environment. They agree to keep up with her intake and continue
supplementation with boost puddings. Pt's nutiritional status
will be monitored by family and followed up with her PCP [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 46**].
Pt was initially screened for rehabilitation vs. skilled nursing
facilities. Her disposition was altered after discussion with
her son who felt the patient would be bettere served at home
with close supervision and VNA. He has changed around his work
schedule to accomodate this care and has arranged with his
brother to do the same. Pt was D/C home in stable condition and
will F/U with her PCP and Interventional Radiology
Medications on Admission:
Protonix 40mg qday
Hydromorphone 2 mg q2h prn
Levofloxacin 500 qday
Remeron 15 mg qhs
Trazodone 50 mg qhs
Risperdal 0.5 mg qam, 1mg qpm
Discharge Medications:
1. Risperidone 0.25 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
2. Risperidone 1 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
7. Megestrol 40 mg/mL Suspension Sig: Eight Hundred (800) mg PO
DAILY (Daily).
Disp:*QS one month* Refills:*2*
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
Bayada VNA
Discharge Diagnosis:
Primary:
1. Cholangitis and Sepsis.
2. Acute Renal Failure.
3. Cystic Duct Remnant with Retained Stone.
4. Common Bile Duct Stricture NOS.
5. Malnutrition - Moderate
6. Iron Deficiency Anemia.
7. VRE Colonization.
Secondary:
1. Dementia.
2. S/P Bilroth II Roux-en-Y.
3. S/P Cholecystectomy.
Discharge Condition:
Good
Discharge Instructions:
You have been admitted to the hospital for Biliary Obstruction
with superimposed infection. You should call your doctor or
return to the hospital if you experience any of the following:
Fever > 101
Severe Abdominal Pain
Nausea and Vomiting
Constipation or Diarrhea
Bloody Stools
Chest Pain
Shortness of Breath
Followup Instructions:
Please follow-up with your primary care doctor Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 46**]
in [**12-28**] weeks. Please call [**Telephone/Fax (1) 67838**] and schedule an
appointment.
Please follow-up with Interventional Radiology in one week. You
should call the office of Dr. [**Last Name (STitle) 4686**] ([**Telephone/Fax (1) 44617**] on Monday
to schedule an appointment.
Completed by:[**2190-8-5**]
ICD9 Codes: 5849, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7128
} | Medical Text: Admission Date: [**2131-3-31**] Discharge Date: [**2131-4-1**]
Date of Birth: [**2073-9-26**] Sex: M
Service: CSU
DEATH SUMMARY:
ADMISSION DIAGNOSES:
1. Acute myocardial infarction.
2. Diabetes mellitus type 2.
3. History of asbestosis.
DISCHARGE DIAGNOSES:
1. Acute myocardial infarction.
2. Diabetes mellitus type 2.
3. History of asbestosis.
4. Cardiac arrest.
5. Ventricular fibrillation.
6. Status post insertion of right ventricular assist device.
7. Status post insertion of left ventricular assist device.
8. Status post placement on extracorporeal membrane
oxygenation system.
9. Status post placement on continuous [**Last Name (un) **]-[**Last Name (un) **]
hemodialysis.
10. Blood loss anemia.
11. Pulmonary edema/respiratory failure.
12. Multiple organ system failure.
AD[**Last Name (STitle) **]N HISTORY AND PHYSICAL: Mr. [**Known lastname **] is a 57 year old
gentleman with a history of type 2 diabetes mellitus and
asbestosis who was diagnosed with an acute myocardial
infarction at [**Hospital3 **] Hospital on [**2131-3-29**]. He was
diagnosed after initially having about a one week history of
intermittent fatigue and malaise, with one episode of chest
pain and dyspnea. When he arrived to [**Hospital **] [**Hospital **] hospital,
he was found to have elevated cardiac enzymes and EKG changes
consistent with an inferior wall myocardial infarction. He
was taken urgently to the cardiac catheterization laboratory,
where he was found to have a thrombotic lesion of
approximately 99 percent of the right coronary artery.
Stenting was attempted, with placement of several stents,
but, again, there was not good restoration of blood flow or
return of good cardiac function. It was therefore felt that
the patient would need a ventricular assist device for any
chance at survival, and he was therefore emergently life-
flighted to the [**Hospital1 69**] after a
consultation with Dr. [**First Name (STitle) **] Dr. [**Last Name (Prefixes) **] of Cardiac
Surgery. He arrived to the [**Hospital1 188**] on [**2131-3-31**] at approximately 2 p.m. and was
taken directly from the helipad to the operating room.
On arrival to the operating room, the patient was extremely
pale and cool. He was noted on his telemetry strip to be in
cardiac arrest and had in fact possibly had some episodes of
possible cardiac arrest en route. He had been on large doses
of epinephrine, bicarbonate, isoproterenol and dobutamine,
with an aortic balloon pump in place. As noted, his cardiac
rhythm was irregular. His lungs were coarse. His abdomen was
distended, and his right lower extremity was quite cool and
pale. Upon arrival to the operating room, the patient was
placed on cardiopulmonary bypass within four minutes, and
operation was undertaken.
HOSPITAL COURSE: Due to the patient's cardiogenic shock, he
underwent placement of right and left ventricular assist
devices, along with closure of a patent foramen ovale. His
femoral arteries were actually repaired bilaterally by the
vascular surgery service (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]) secondary to
bilateral lower extremity ischemia which was evident on
initial examination. The cardiopulmonary bypass time was 180
minutes. There was no cross clamp time. The patient was
transferred to the intensive care unit on Levophed,
vasopressin and insulin. Upon arrival in the CSRU, as noted,
the patient was quite hypoxic, and he was placed on ECMO
oxygenation circuit. During placement of the cannulas, it was
noted that the patient may have had some increased degree of
vascular insufficiency in his leg, as cannula placement was
quite difficult. The vascular surgery service was again
consulted, and they emergently re-explored the right groin
and repaired his femoral artery, which was bleeding. Even
after placement on the ECMO circuit, we had significant
difficulty oxygenating the patient secondary to massive
amounts of pulmonary edema, which manifested as copious
frothy liquid emanating from the endotracheal tube. We
evacuated approximately 3 to 4 liters of liquid from the
endotracheal tube. In an effort to reduce the patient's
volume overload, we placed him on continuous [**Last Name (un) **]-[**Last Name (un) **]
hemodialysis after consultation with the nephrology service.
None of these efforts allowed us to improve his oxygenation
status. His ventricular assist device continued to maintain
an adequate cardiac output, but there was growing concern of
cerebral hypoxia in the setting of his diminished oxygen
saturation. We continued our efforts, along with massive
blood product transfusion, up until 0300 on [**2131-4-1**].
Notably, we attempted using IV steroids to improve his
pulmonary status, but this did not improve this situation at
all. As there was no improvement in his clinical status at
this time, after discussion with the family and the attending
surgeon, it was felt that resuscitative efforts should be
withdrawn. He was pronounced dead on [**2131-4-1**] at 0300.
The family was present. The patient's daughters were present
at the time of expiration. The patient's primary care
physician was [**Name (NI) 653**], and a message was left with the
answering service. The patient's spouse was [**Name (NI) 653**]
directly.
RELEVANT LAB VALUES: The patient was quite acidotic
throughout the course of his hospitalization, with pH's which
has dropped to as low as 6.85, with a maximum of no more than
7.20. This was a combination of a respiratory and a metabolic
acidosis, which we attempted to correct with manipulation of
his ventilator and the ECMO circuit, along with the
administration of bicarbonate, with little success. His
hematocrit ranged between the 20-30's, and he had required
massive amounts of blood transfusion. He was quite
coagulopathic, with INR above 2, requiring multiple
transfusions of fresh frozen plasma.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2131-4-1**] 03:54:04
T: [**2131-4-1**] 05:15:06
Job#: [**Job Number 60626**]
ICD9 Codes: 4280, 5185, 4275, 2851, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7129
} | Medical Text: Admission Date: [**2139-2-1**] Discharge Date: [**2139-2-26**]
Date of Birth: [**2074-5-16**] Sex: M
Service: MEDICINE
Allergies:
Roxicet
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Fevers, fatigue
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] implantation [**2139-2-13**] DDD [**Company 1543**]
Electrophysiology study [**2139-2-5**]
History of Present Illness:
Mr. [**Known lastname 93612**] is a 64 yo man with history of bicuspid AV s/p [**Known lastname 1291**]
and MSSA endocarditis and repeat [**Known lastname 1291**], AFib on coumadin and
amiodaron, bronchiectasis and GIB who presented to [**Hospital1 18**]
complaining of fatigue and fevers. He was recently admitted to
[**Hospital1 18**] with a GIB in [**12/2138**] which resolved. He was in his usual
state of health until about two days ago when he began feeling
subjective fevers and weakness. Today he decided to call EMS
because he could not walk more than 10 steps. In the ED, he was
found to be febrile, to have a leukocytosis and hypotensive with
a pulse in the 30's. EKG showed a sinus rate of 140 and 1:3
block. Levaquin, gentamycin and [**Year (4 digits) **] were given. a RIJ was
placed despite an INR of >4.
.
On arrival to the CCU he was febrile, hypotensive, and
bradycardic. Tele showed complete heart block. EP was consulted
and a transvenous pacing wire was placed at the bedside with
fluoroscopic guidance.
Past Medical History:
1. Bicuspid AV-s/p [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1291**] in 92, MSSA endocarditis and
abscess- s/p redo in 5/00
2. Afib on amiodarone
3. Bronchomalecia and Bronchiectesis
4. Gastritis
5. CABG times 3- [**2132**] ([**2136**], LVEF>55%)
6. hypercholesterolemia
7. HTN
8. Diverticulosis and Lymphoid aggregates on Colonoscopy in [**2135**]
9. impotence
10. hernisted disc
11. STROKE ([**2137**]) ax
12. thoracic aneurysm
Social History:
Divorced, 2 sons, [**Name (NI) **] ETOH (per pt) but + h/o drinking 1 gallon
of wine daily in [**2133**] that pt always denied, no current tobacco,
4ppd times 30 years and quit in 92, no IVDU, divorced, can do
all ADLS. At baseline he walks a quarter of a mile every day.
He will get short of breath on walking quickly [**2-28**] blocks.
Family History:
NC per patient
Pertinent Results:
[**2139-2-1**] 08:07PM PT-52.3* PTT-66.0* INR(PT)-6.2*
[**2139-2-1**] 01:48PM GLUCOSE-102 UREA N-15 CREAT-1.0 SODIUM-139
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-23 ANION GAP-11
[**2139-1-31**] 06:30PM WBC-23.0*# RBC-3.83* HGB-11.3* HCT-33.2*
MCV-87 MCH-29.5 MCHC-34.0 RDW-15.2
[**2139-2-1**] 06:27AM GLUCOSE-92 UREA N-19 CREAT-1.4* SODIUM-141
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-21* ANION GAP-13
RENAL U.S. [**2139-2-20**] 1:08 PM
IMPRESSION: No masses, stones, or hydronephrosis present within
the kidneys.
CHEST (PORTABLE AP) [**2139-2-15**] 5:16 PM
IMPRESSION: No significant interval change.
ECG Study Date of [**2139-2-14**] 10:41:52 AM
Regular ventricular pacing
[**Date Range **] rhythm - no further analysis
Since previous tracing, ventricular paced rhythm present
UNILAT UP EXT VEINS US RIGHT PORT [**2139-2-12**] 12:59 PM
IMPRESSION:
1) No evidence of deep venous thrombosis in the right upper
extremity.
2) Large hetergenous round area within the right axilla, likely
a hematoma. Right axillary vein was not visualized.
ECHO Study Date of [**2139-2-2**]
Conclusions:
There are complex (>4mm) atheroma in the descending thoracic
aorta. A well-seated bileaflet aortic valve prosthesis is
present. The aortic prosthesis discs appear to move normally.
There is a small 3mm fluttering echodensity is seen on the LVOT
side of the valve consistent with vegetation/thrombus. No aortic
valve abscess is seen. Mild (1+) aortic regurgitation is seen.
Mild to moderate ([**1-27**]+) mitral regurgitation is seen.
IMPRESSION: Small echodensity on the aortic valve disc
consistent with a
vegetation (or thrombus) as described above. Mild aortic
regurgitation.
Moderately dilated aortic arch and proximal descending aorta.
CT ABDOMEN W/CONTRAST [**2139-2-2**] 2:06 PM
IMPRESSION:
1. No evidence of abscess, as clinically questioned.
2. Gallstone.
3. Bilateral renal cysts.
4. Mild dependent atelectasis.
CT HEAD W/O CONTRAST [**2139-2-1**] 10:06 AM
IMPRESSION: No evidence of acute intracranial hemorrhage. No CT
evidence of brain ischemia.
Brief Hospital Course:
A/P: 64M w/ CAD s/p CABG, [**Year/Month/Day 1291**], MSSA endocarditis, repeat [**Year/Month/Day 1291**] and
bentall procedure, who presented with bradycardia, hypotension
and fever/leukocytosis. Found to have a likely vegetation on his
AV by TEE with CHB s/p PM on [**2139-2-13**].
.
#)AV node dysfuction, complete heart block evolved back to type
2, then type 1 heart block. Pt required a temporary wire early
in hospital course. Pt had EPS [**2-5**] which showed H-V interval in
the 80's (prolonged) and on faster rhythm he went in 2:1 block.
Had permanent [**Month/Year (2) 4448**] on [**2139-2-13**], heparin restarted. Also on
coumadin.
- in nsr on [**2-17**], intermittently v paced
- Interrogated by EP on [**2-20**].
- Outpatient follow up.
- Beta-blocker restarted without difficulty. In NSR on
discharge.
#) Hematoma right arm
- The patient developed a spontaneous hematoma on heparin on
[**2139-2-11**]. He was evaluated by vascular who recommended arm
elevation and ACE wrap. His Hct dropped from 31 to 26 but has
remained stable at 26.
- An ultrasound was obtained on [**2-12**] which showed no clot.
- Given his high risk of stroke with an [**Month/Year (2) 1291**], the heparin was
restarted around [**2-28**] pm on [**2-12**].
- Improved on [**2139-2-13**] and resolved by the time of discharge.
.
#) AF: The patient had been on Amiodarone- this was DC'd on [**2-10**]
as he developed 2nd degree AV block on tele but restarted on
[**2139-2-14**] without event post [**Date Range 4448**]. He was discharged on
coumadin.
#) HTN:
. His HCTZ and beta-blocker were restarted. ACE was held with
acute renal failure.
.
#) ARF
- Cr rose to 1.4 from 1.1 which was felt to be most likely from
gentamycin toxicity.
- His FENA was <1 with rare eos on UA. He was given IVF with no
improvement of his kidney function.
- We continue to hold his ACE.
- Renal ultrasound on [**2139-2-20**] showed no acute abnormalities.
- A Cr of 1.4 was deemed to be his new baseline.
.
#) Culture negative endocarditis: ID evaluated him inhouse and
subsequently signed off. Vegetation seen on TEE.
-The plan is for 6 weeks of Cefepime, Vanco, and initially 2 wks
gentamycin.
- No rifampin per ID given multiple drug interactions.
- Had acute rise in Cr on [**2-9**], therefore DC'd gentamycin and he
did not receive this for the remainder of his stay.
- His vanco was dosed by level, trough <15 with results as an
outpatient to be faxed to his ID specialist per their request.
- Prior to DC, his level had been greater than 15 and was held
two days prior to DC with permission to be restarted at 750 mg
IV QD as an outpatient.
-PICC placed on Tuesday in RUE.
.
#) CAD
- Restarted ASA 81 mg on [**2-10**]. Resarted BB. Held ACE with ARF.
Zetia, statin.
.
#) h/o GI bleed: The patient has known angioectasia and had GI
bleed without multiple diverticula as well. Was to have outpt
appointment with [**Doctor Last Name 519**] in surgery but missed it because of
hospitalization. This was rescheduled prior to DC.
- GI had seen the patient on [**2-4**] and felt no need for scope
this admission. -
- On [**2-9**], the patient noted black appearing stool (started iron
day before). Guaiac negative, hemo stable. Hct stable and
required no transfusions for this reason.
- This was not an active issue for the remainder of his stay.
.
#) Mechanical AV valve: Required prolong hospitalization for
heparin/coumadin bridge pre and post procedure. He required up
to 10 mg of coumadin in-house to get a therapeutic INR, goal
2.5-3.5.
- He formerly took 5 and 7.5 mg of coumadin at home.
- He will have his INR checked in 2 days and have the results
faxed to the coumadin clinic to adjust his coumadin dose
accordingly.
- Although coumadin 10 mg was required to achieve a therapeutic
INR, he will be discharged on coumadin 7.5 mg.
.
#) Anemia
- Concerning drop from 30->26 on [**2-13**] to 22 on [**2139-2-15**]. Guaiac
negative. The hct drop was felt to be secondary to his right arm
hematoma.
- He was transfused 2 units from [**2-15**] to [**2138-2-16**]. His Hct
remained stable thereafter and he required no further
transfusions.
.
#) Code status: full code.
.
#) dispo: Home with VNA.
Medications on Admission:
amiodarone 200mg daily, dicloxacillin 25omg q8, HCTZ 25mg daily,
lipitor 80mg, lisinopril 5mg daily, metoprolol XL 12.5mg daily,
MVI, protonix, coumadin 2.5mg daily, zetia 10mg daily
Discharge Medications:
1. Cefepime 2 g Recon Soln Sig: One (1) Intravenous twice a day
for 3 weeks.
Disp:*56 * Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. 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*
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Disp:*30 ML(s)* Refills:*3*
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for 5 days.
Disp:*50 ML(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
14. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*2 * Refills:*1*
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Outpatient Lab Work
INR check 2 days after discharge with results faxed to PCP.
Vanco trough checked 2 days after discharge with results faxed
to PCP. [**Name10 (NameIs) **] should continue for trough <15.
18. Sodium Chloride 0.9 % Parenteral Solution Sig: One (1)
3 cc Intravenous once a day.
Disp:*30 * Refills:*3*
19. [**Name10 (NameIs) **] 500 mg Recon Soln Sig: 1.5 Intravenous once a
day for 3 weeks: 750 mg IV QD. hold for trough >15.
Disp:*30 * Refills:*3*
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
21. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Culture negative endocarditis
Complete heart block with [**Hospital 4448**] implantation
Paroxysmal atrial fibrillation
Gentamicin-induced renal insufficiency
Discharge Condition:
stable
Discharge Instructions:
Please continue your antibiotics [**Hospital **] and Cefepime for a
total of 6 weeks (last dose [**3-15**]).
Please fax [**Month (only) **] troughs to Dr. [**First Name (STitle) **], your infectious
disease specialist, weekly. Her fax is [**Telephone/Fax (1) 1419**].
The [**Telephone/Fax (1) 4448**] RN will call you at home [**2139-3-12**] to check PM (see
below).
Followup Instructions:
Please follow up with the infection specialist - Provider:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6400**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2139-3-12**] 9:00
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2139-3-12**]
11:30
You have an appointment with your cardiologist, Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**],
on [**6-8**] at 2:00pm. His office is located on the [**Location (un) 436**] of
the [**Hospital Ward Name 23**] building. Please call ([**Telephone/Fax (1) 24798**] should you have
any questions.
You have an appointment with your electrophysiologist, Dr. [**Last Name (STitle) **]
[**Name (STitle) 26676**], on ***. His office is located on the [**Location (un) 436**] of
the [**Hospital Ward Name 23**] building. Please call ([**Telephone/Fax (1) 12468**] should you have
any questions.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Phone:[**Telephone/Fax (1) 34552**] Date/Time:[**2139-4-6**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**]
Date/Time:[**2139-3-9**] 8:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2139-3-5**] 2:30
ICD9 Codes: 5849, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7130
} | Medical Text: Admission Date: [**2130-3-30**] Discharge Date: [**2130-4-2**]
Date of Birth: [**2100-4-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Cephalexin / Penicillins
Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
Headaches
Major Surgical or Invasive Procedure:
[**2130-3-30**]: suboccipital craniotomy and C1 laminectomy for chiari
decompression
History of Present Illness:
This is a 29 year old male with occipital tussive headaches,
dizziness and UE/LLE paresthesias. MRI imaging revealed a Chiari
Malformation and he opted to procede for a decompression.
Past Medical History:
Asthma, Genital Herpes, Eczema, ADHD, allergic rhinitis,
anxiety, asthma, LBP, prediabetes, PTSD
Social History:
He is a truck driver. He has two children. He has smokes [**11-28**] ppd
since age 8. He denies ETOH use.
Family History:
NC
Physical Exam:
No apparent distress
Alert and oriented x3
CN's intact
PERRL
CTAB
RRR
Normal bulk and tone
5/5 strength and sensation intact in all 4 extremities
Ambulating on own
No pronator drift
Wound clean, dry and intact. No signs of infection.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] on [**3-30**] and was taken to the OR
with Dr. [**Last Name (STitle) **] for a suboccipital craniotomy and C1
laminectomy for decompression of a chiari malformtaion. He was
extubated post-op and was taken to the SICU for close
management. Post-op CT head showed good decompression. He
remained stable in the SICU. His pain was initially controlled
with a combination of IV and PO medications with a transition to
only PO medications. He was able to void and ambulate
independently. He progressed well and was transferred to the
regular hospital floor on [**4-1**]. On the floor he remained stable,
with stable vital signs, and was deemed ready for discharge on
[**4-2**]. He was given the appropriate prescriptions and instructions
for follow-up care.
Medications on Admission:
Valtrex, Cetirizine, Albuterol, Clobetasol, Fluticasone
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm: do not drive, drink alcohol or
operate machinery/appliances while taking this medication.
Disp:*40 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: do not drive, drink alcohol or operate
machinery/appliances while taking this medication.
Disp:*60 Tablet(s)* Refills:*0*
5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
6. cetirizine 10 mg Tablet Sig: One (1) Tablet PO QD ().
7. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed for
sob/wheeze.
8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): resume
home med.
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day: resume home med.
10. Valtrex 500 mg Tablet Sig: One (1) Tablet PO once a day:
resume home med.
Discharge Disposition:
Home
Discharge Diagnosis:
Chiari malformation
Discharge Condition:
Stable
alert and oriented
ambulating independently
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**6-6**] days(from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast at that
time.
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7131
} | Medical Text: Admission Date: [**2135-12-2**] Discharge Date: [**2135-12-11**]
Date of Birth: [**2076-8-3**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Zestril / adhesive tape
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest pain, melena, lightheadedness
Major Surgical or Invasive Procedure:
[**12-5**] Colonoscopy
[**12-5**] Upper Endoscopy
[**12-9**] Small capsule study
History of Present Illness:
This is a 59 year old male with multiple cardiac co-morbidities
including CAD (s/p CABG abd multiple caths with PCIs), chronic
angina on methadone for pain control, mechanical aortic valve on
coumadin, who presents chest pain after 3 days of dark stools,
weakness and lightheadedness. He had an INR elevated to 4.9 on
[**11-29**] and held the dose. The next day he [**Last Name (un) 4996**] noticing dark
stools and gradually became lightheaded and weak over the next 2
days. He also felt nauseous and had poor po intake. He denies
abdominal pain. He denies any increase in his stools frequency
or change in consistency. He has been having one well formed BM
per day. He denies NSAID or steroid use. He has baseline chronic
angina which he rates as [**1-27**] pain. This morning he began to
have worsening chest pain, greater than baseline which began as
a [**4-26**] pain and increased up to [**7-27**]. His current chest pain is
associated with left arm pain as is his baseline chest pain. He
called his PCP and was referred to the ED given the dark stools
and chest pain he was sent to ED for evaluation.
.
In the ED, initial vs were: 6 T 98.0 P 75 BP 121/63 RR 18 O2 sat
100%. Labs were significant for hematocrit 19.1, INR 2.3,
troponin <0.01. Melena was seen on rectal exam. EKG shows LBBB
uchanged from prior. NG lavage showed flecks of blood but was
otherwise non-bloody. Patient was given pantoprazole 80 mg bolus
+ drip, 2 units blood. For his pain he was given morphine,
dilaudid 1 mg iv. His most recent vitals prior to transfer
were: T: 99.3, P: 68, RR 12, 100/62.
.
On the floor, patient was initially complaining of [**7-27**] chest
pain which improved to [**5-27**] after morphine 8 mg iv.
Past Medical History:
1. CAD RISK FACTORS: known CAD, HTN, dyslipidemia,
2. CARDIAC HISTORY:
-CABG: [**2119**] (LIMA to LAD) due to CCATH showing total occlusion
of the RCA and circumflex arteries and an 80% left main
stenosis.
-CCATH/PCI: [**2121**], [**2123**], [**2126**] - PTCA and DES x2 of the LMCA
bifurcation (LAD and ramus), [**2126**], [**2127**], [**2128**], [**2128**], [**2129**] - [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]/Lcx, [**2130**], [**2130**] - [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], [**2130**] - [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22594**] anastomotic site
of LIMA to LAD, [**2130**], [**2131**]
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-s/p St. [**Male First Name (un) 1525**] Aortic Valve Replacement [**2130**] - on coumadin
-"intractable angina" on methadone
-hypertension
-dyslipidemia
-h/o defibrillation in [**2121**]
-nephrolithiasis
-s/p lap cholecystectomy in [**2129**]
-dCHF
-Horner's syndrome - mild
Social History:
Married. on disability [**1-19**] chest pain. Quit tobacco in [**2119**] (25
pack-year history), no EtOH, never IVDA
Family History:
Brother died of MI at age 51. Father died of MI at age 72.
sister died of uterine cancer at 58. His mother also had 'heart
issues'.
Physical Exam:
Vitals: T: 99.1 BP: 122/35 P: 71 R: 16 O2: 98% on 3L NC
General: overweight, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: minimal bibasilar crackles, otherwise clear to
auscultation bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1, mechanical S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
On discharge:
VSS, satting 97-100% on RA, afebrile
No change in physical exam except crackles gone.
No signs of volume overload.
Pertinent Results:
[**2135-12-2**] 03:18PM BLOOD WBC-5.6 RBC-2.53* Hgb-6.9* Hct-20.7*
MCV-82 MCH-27.2 MCHC-33.3 RDW-15.8* Plt Ct-153
[**2135-12-2**] 10:30PM BLOOD WBC-6.4 RBC-2.81* Hgb-8.0* Hct-23.0*
MCV-82 MCH-28.5 MCHC-34.9 RDW-15.8* Plt Ct-158
[**2135-12-3**] 03:21AM BLOOD WBC-4.7 RBC-2.91* Hgb-8.2* Hct-24.0*
MCV-82 MCH-28.2 MCHC-34.3 RDW-15.8* Plt Ct-153
[**2135-12-3**] 08:25AM BLOOD WBC-5.2 RBC-3.43* Hgb-9.4* Hct-28.5*
MCV-83 MCH-27.4 MCHC-33.0 RDW-15.9* Plt Ct-168
[**2135-12-4**] 03:49AM BLOOD WBC-4.2 RBC-3.07* Hgb-8.4* Hct-25.1*
MCV-82 MCH-27.4 MCHC-33.7 RDW-15.8* Plt Ct-151
[**2135-12-4**] 12:07PM BLOOD WBC-5.7 RBC-3.36* Hgb-9.3* Hct-28.3*
MCV-84 MCH-27.6 MCHC-32.7 RDW-15.4 Plt Ct-164
[**2135-12-2**] 10:10AM BLOOD Neuts-79.0* Lymphs-13.9* Monos-5.6
Eos-1.2 Baso-0.5
[**2135-12-2**] 10:10AM BLOOD PT-24.5* PTT-40.4* INR(PT)-2.3*
[**2135-12-2**] 03:18PM BLOOD PT-24.8* PTT-38.1* INR(PT)-2.4*
[**2135-12-3**] 03:21AM BLOOD PT-23.6* PTT-40.9* INR(PT)-2.3*
[**2135-12-4**] 03:49AM BLOOD PT-23.0* PTT-38.8* INR(PT)-2.2*
[**2135-12-2**] 10:10AM BLOOD Glucose-125* UreaN-29* Creat-1.2 Na-136
K-3.8 Cl-99 HCO3-26 AnGap-15
[**2135-12-2**] 03:18PM BLOOD Glucose-88 UreaN-24* Creat-1.1 Na-139
K-3.5 Cl-107 HCO3-26 AnGap-10
[**2135-12-3**] 03:21AM BLOOD Glucose-92 UreaN-22* Creat-1.2 Na-138
K-3.6 Cl-107 HCO3-25 AnGap-10
[**2135-12-4**] 03:49AM BLOOD Glucose-91 UreaN-21* Creat-1.3* Na-137
K-3.8 Cl-103 HCO3-26 AnGap-12
[**2135-12-4**] 03:49AM BLOOD ALT-15 AST-29 CK(CPK)-197 AlkPhos-59
TotBili-2.1*
Cardiac enzymes:
[**2135-12-2**] 03:18PM BLOOD CK-MB-4 cTropnT-<0.01
[**2135-12-2**] 10:30PM BLOOD CK-MB-4 cTropnT-<0.01
[**2135-12-3**] 03:21AM BLOOD CK-MB-3 cTropnT-<0.01
[**2135-12-4**] 03:49AM BLOOD CK-MB-4 cTropnT-<0.01
Anemia workup:
[**2135-12-2**] 10:10AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-2+ Stipple-1+
Ellipto-1+
[**2135-12-2**] 10:10AM BLOOD Hapto-48
[**2135-12-2**] 03:18PM BLOOD calTIBC-398 Ferritn-15* TRF-306 Iron-32*
[**2135-12-7**] 07:20AM BLOOD Hapto-60
[**2135-12-2**] 10:10AM BLOOD LD(LDH)-222
[**2135-12-4**] 03:49AM BLOOD ALT-15 AST-29 CK(CPK)-197 AlkPhos-59
TotBili-2.1*
[**2135-12-6**] 07:20AM BLOOD ALT-21 AST-42* AlkPhos-69 TotBili-2.8*
DirBili-0.3 IndBili-2.5
[**2135-12-6**] 01:00PM BLOOD Ret Man-6.4*
[**2135-12-7**] 07:20AM BLOOD LD(LDH)-318* TotBili-3.1* DirBili-0.3
IndBili-2.8
[**2135-12-7**] 07:20AM BLOOD LD(LDH)-318* TotBili-3.1* DirBili-0.3
IndBili-2.8
Discharge Labs:
[**2135-12-11**] 06:22AM BLOOD WBC-4.3 RBC-3.79* Hgb-10.2* Hct-30.6*
MCV-81* MCH-26.8* MCHC-33.3 RDW-15.2 Plt Ct-175
[**2135-12-11**] 06:22AM BLOOD Neuts-65.5 Lymphs-21.2 Monos-8.1 Eos-4.4*
Baso-0.8
[**2135-12-10**] 07:20AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-OCCASIONAL
Tear Dr[**Last Name (STitle) **]1+
[**2135-12-11**] 06:22AM BLOOD PT-28.4* INR(PT)-2.7*
[**2135-12-11**] 06:22AM BLOOD Glucose-84 UreaN-20 Creat-1.2 Na-137
K-3.6 Cl-100 HCO3-28 AnGap-13
[**2135-12-7**] 10:07AM URINE Hemosid-NEGATIVE
Microbiology:
Urine culture x2= negative
Blood culture x4= negative
Studies:
CXRay [**12-7**]: IMPRESSION: Left lung consolidation, compatible
with pneumonia.
CXray [**12-8**]: IMPRESSION: Left lower lobe pneumonia.
Colonoscopy [**12-5**]:
Impression: Normal colonoscopy to cecum
Recommendations: Recommend capsule endoscopy for further
evaluation of melena. Colonoscopy in 5 years
Upper endoscopy [**12-5**]:
Impression: Small hiatal hernia
Erythema and erosion in the fundus
Erythema in the antrum
Otherwise normal EGD to third part of the duodenum
Recommendations: Will proceed to colonoscopy for evaluation of
melena.
Continue PPI.
Small capsule study:
1. Sub-optimal bowel prep with a moderate amount of food debris
in the stomach and segments of the jejunum.
2. Erythema in the stomach (gastritis).
3. A few petechiae in the proximal jejunum .
4. Two angioectasias in the proximal jejunum.
5. No active bleeding site found.
SUMMARY & RECOMMENDATIONS:
Summary: Sub-optimal bowel prep with a moderate amount of food
debris in the stomach and jejunum. Mild gastritis with two
angioectasias in the proximal jejunum. No active bleeding site
found.
Recommendations: Follow up with the PCP (Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**]) and
consider a small bowel enteroscopy.
Brief Hospital Course:
Mr. [**Known lastname **] is a 59 year-old man with a PMH of CAD (s/p CABG and
multiple PCIs) on aspirin, aortic valve replacement on coumadin,
dCHF who presents with chest pain, lightheadedness and melena
found to have HCT of 19.1 transferred to MICU for GI bleed. Pt
was in stable condition so transferred to cardiology service
where he underwent EGD, colonoscopy, and small capsule study
without evidence of active bleed. Pt subsequently had fevers
[**2047-12-7**] to 102 and evidence on CXray of LLL pna. Pt
defervesced on antibiotics.
.
# GI Bleed/Anemia: Pt had lightheadedness, chest pain, melanotic
stools, and a HCT of 19 on [**12-2**] admission with ED noting heme
positive stool. Pt had a supratherapeutic INR to 4.9 on
[**2135-11-29**]. He received 2 units of packed red blood cells in the
ED and another 2 units in the MICU on [**2135-12-2**] before his
transfer to cardiology service. EGD, colonoscopy, and small
capsule study were negative for active bleeding source although
small capsule study did reveal two angioectasias in the jejunum.
Hypothetically, in the setting of an elevated INR while on
aspirin and plavix, the patient may have bled from this site
which resolved at the time of study. GI bleed likely resulted in
iron deficiency anemia as the patient's labs were mostly
consistent with this--a microcytic anemia with low ferritin, low
iron, low % transferrin saturation, hypochromatic cells with the
presence of ovalocytes. Although he was iron deficient, his
marrow showed appropriate response with a retic index of 2.65%.
Accordingly the patient was started on 325 mg FeSO4 [**Hospital1 **] which
will need to be taken for greater than 2 years in order to
replete the patient's iron stores. The patient can take TID if
the constipating effects aren't limiting as patient does have
history of constipation and is already taking opiates. Also of
note, the patient had a mildly elevated indirect bilirubin,
although it is unclear what the cause of this is--however, it
was only found after transfusion as was the presence of
schistocytes; thus there may have been some low level
intravascular hemolysis present post-RBC transfusion. Notably,
the patient's LDH and haptoglobin were normal on admission,
making it extremely unlikely the patient was undergoing any sort
of hemolysis at presentation. Furthermore, urine hemoglobin and
hemosiderin were negative further aruging against intravascular
hemolysis. Coombs test was negative strongly arguing against
extravascular hemolysis. Pt was maintained and will remain on
[**Hospital1 **] PPI for now, the duration of which can be determined by GI.
Plavix was stopped since patient's last stent was placed in [**2130**]
and risk of bleeding while also on coumadin and aspirin
outweighs benefit of preventing stent thrombosis in someone with
a stent placed four years ago. Dr. [**Last Name (STitle) **] was in agreement with
this. Pt will be followed by GI as outpatient with potential
small bowel enteroscopy.
.
# Pneumonia - Patient became febrile to 102 degrees on [**12-8**] and
continued to spike on [**12-9**] with cxrays x2 demonstrating LLL
pneumonia. The pt had no cough, adventitious sounds on physical
exam, or elevated white count and his only symptom was fever.
He otherwise felt extremely well. However, because blood and
urine cultures were negative and cxray was suggestive of pna,
the patient was initially started on HAP with vancomycin and
cefepime before transitioning to PO levofloxacin, which he was
discharged on after he was afebrile on this for >24 hours. He
will complete a week long course of abx.
.
#Aortic Valve replacement: Pt had a mechanical aortic valve
replacement in [**2130**]. Coumadin was held while pt had GI bleed and
was restarted after EGD/Colonscopy and stabilization of HCT.
The pt was bridged with heparin. Target INR is 2.0-3.0
.
#Angina/ CAD: Patient has extensive cardiac history including
prior CABG and multiple PCIs, aortic valve repair, last
intervention in [**2130**] who now has chronic angina. The acute
exacerbation of his angina on presentation was likely related to
demand from anemia in the setting of his GI bleed. The patient
ruled out for ACS. His chest pain diminished with an increased
HCT. He remained on his "angina protocol" which is listed in OMR
under problem list without issue. This consists of methadone,
imdur, lorazepam prn, morphine prn. The patient otherwise
maintained his home methadone, imdur, metoprolol, aspirin, and
atorvastatin. Plavix was stopped since the patient's last stent
was in [**2130**], his reocclusions with stents have been from
restenosis (neointimal) and not actual thrombotic
(platelet-driven) events, his CAD is stable, and the risk of
bleeding is too great for the benefit offered by plavix in this
setting.
.
# Chronic dCHF: Pt was mildly volume overloaded in the MICU and
was restarted on his home diuretics with good effect. He was
euvolemic on the floor. The pt will continue with his home
diuresis regimen, consisting of torsemide [**Hospital1 **], spironolactone,
and metolazone prn, as well as his other heart failure/blood
pressure meds including metoprolol, amlodipine, and
spironolactone.
.
# Hypertension: Pt was normotensive throughout his hospital
course. He was maintained on his home regimen as stated above.
He did have wide pulse pressures likely [**1-19**] to anemia.
.
# Dyslipidemia: He was continued on atorvastatin.
.
# Elevated indirect bili: Likely from low-level hemolysis,
possibly intravascular given presence of schistiocytes post
transfusion. Gilberts is another possibility although this
wouldn't cause the presence of schistiocytes and would be
unusual in someone with CAD.
.
# Mildly elevated AST: Only occurred x1. Can monitor for
resolution.
.
# Code: Full (discussed with patient)
.
Transitional: Monitor hematocrit. Follow up with GI for
possible push enteroscopy. Treat [**Doctor First Name **]. Make sure fevers resolve
after pna treatment. Monitor pts INR as pt seems to have GI
bleeding tendency when INR is supratherapeutic. Trend
bilirubin. Monitor for resolution of elevated AST.
Medications on Admission:
Nitroglycerin 0.4 mg Sublingual Tab Sublingual prn
Toprol XL 50 mg 24 hr Tab [**Hospital1 **]
Aspirin 81 mg Tab Oral daily
Folic acid 1 mg Tab daily
Celexa 15 mg Tab daily
Lipitor 80 mg Tab Daily
Ativan 1 mg Tab Oral 1 - 2 Tablet(s) Twice daily prn
Coumadin as directed
Imdur 120 mg 24 hr Tab daily
Amlodipine 6.25mg daily
Plavix 75 mg Tab Oral daily
Xanax 0.25 mg Tab Oral TID
Methadone 15 mg Tab Oral TID
torsemide 20 mg Tab Oral [**Hospital1 **] (twice weekly two pills in am)
Miralax 17 gram
Aldactone 25 mg Tab Oral daily
Metolazone 2.5 mg Tab Oral daily
Klor-Con M20 20 mEq Tab Oral daily
Soma 250 mg Tab Oral TID
Fluocinonide 0.05 % Topical Cream Topical [**Hospital1 **] prn
Vicodin
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days.
[**Hospital1 **]:*6 Tablet(s)* Refills:*0*
2. Outpatient [**Hospital1 **] Work
Please have your INR drawn on Monday [**12-12**]
Please have your INR and HCT drawn on Wednesday [**12-14**]
Please have these results faxed to Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] at
[**Telephone/Fax (1) 18702**]
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
[**Telephone/Fax (1) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: can take up to 3
tabs in 15 minutes.
5. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO twice a day.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ativan 1 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for anxiety.
11. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM: Do not take a 10 mg dose while you are on levfloxacin
unless directed by Dr. [**Last Name (STitle) **].
12. Imdur 120 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
13. amlodipine 2.5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
14. methadone 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
15. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Miralax 17 gram Powder in Packet Sig: One (1) PO once a
day.
17. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
18. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
19. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed: take 1 tab 1/2 hour before torsemide.
20. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended
Release Sig: One (1) Capsule, Extended Release PO twice a day.
21. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back pain.
22. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: GI bleed, Pneumonia, Iron deficiency anemia, Acute on
chronic diastolic CHF
Secondary: CAD, [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] aortic valve
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted for chest pain accompanied by black stools, weakness,
and lightheadedness. Your HCT was 19 on admission and you were
found to have a Gastrointestinal bleed. You were transfused a
total of 5 units of PRBC with good response.
A colonoscopy, upper endoscopy and small capsule study were
conducted which revealed abnormal blood vessel dilations in the
proximal jejunum but no sites of active bleeding.
You developed fevers as high as 102 which resolved with
antibiotics. The only source that we have found is a chest x
ray concerning for left sided pneumonia. You will need to
continue treatment with levofloxacin for 6 more days.
Because you started levofloxacin, you need to closely monitor
your INR as this drug can increase the effects of coumadin.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The following changes were made to your medications:
Started levofloxacin for pneumonia
Started pantoprazole for GI bleed
Started iron pills for anemia
Stopped plavix
Your Celexa was increased to 30mg daily
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2135-12-20**] at 4:00 PM
With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2135-12-19**]
ICD9 Codes: 486, 4111, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7132
} | Medical Text: Admission Date: [**2115-6-18**] Discharge Date: [**2115-6-26**]
Date of Birth: [**2060-7-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Demerol / Oxycontin / Morphine Sulfate / Darvocet-N 100
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Recurrent right pleural effusion
Major Surgical or Invasive Procedure:
[**2115-6-20**] Right pleural effusion drainage with pigtail placement
and talc pleurodesis
History of Present Illness:
[**Known lastname 34440**] is a 54 year-old woman whp is s/p R VATS
decortication, mechanical pleurodesis, and doxycycline chemical
pleurodesis for recurrent effusion/trapped lung on [**2115-6-7**]. The
pathology was benign. I suspect the etiology of the effusion
was cardiac (valvular) + previous chest radiation. Unfortunately
she developed recurrent dry cough, chest pain, SOB 3 days ago.
She has some wheezing. She denies fevers, chills, or sweats.
Past Medical History:
ALLERGIES: demorol, morphine, oxycontin (all cause dizziness,
nausea, vomiting)
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, Hypertension
Other Past History:
- CHF diastolic : baseline BNP in 300s
- Aortic stenosis
- Mitral regurgitation
- Pulmonary hypertension
- DM2: on insulin since [**2112**]
- Recurrent pleural effusions: Since [**2113**], s/p multiple
thoracenteses. Pleurex cath inserted in [**3-/2115**] for drainage at
home; averages 550cc every other day. Exudative but negative for
infection and malignancy with negative bx from [**4-14**] thorascopy.
- H/o Hodgkin's lymphoma: Dx [**2078**]. S/p thymectomy, splenectomy.
S/p mantle, abdominal, and pelvis XRT.
- H/o breast cancer: T1cNo ER+/PR+ invasive ductal carcinoma in
left breast, s/p left mastectomy and chemo. On anastrozole.
- H/o Hurtle cell thyroid nodule: s/p total thyroidectomy at [**Hospital1 2177**]
followed by radioactive iodine.
- Pericarditis and pleuritis: In [**2094**], s/p pleurocentesis and
pericardiocentesis, rx'ed with abx
- LUE tremor
- S/p mutiple surgeries for basal cell carcinoma
- Chronic leukocytosis/Thrombocytocis for past 2 years: JAK2 and
MPLW 515 mutations drawn by her hematologist still pending
- S/p TAHBSO for fibroids
Social History:
Pt lives with her husband and works as community developer for
city of [**Hospital1 1474**] and a youth organizer in her church. Social
history is significant for the absence of current tobacco use.
There is no history of alcohol abuse. Drinks only occasionally.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father died in 80s, had COPD and AFib. Mother
living in 80s, has DM2. 10 siblings including an older brother
s/p prosthetic valve replacement. Has 2 children including 35yo
son with diverticulitis and 33yo daughter with Tetralogy of
Fallot s/p 3 surgeries at CHB and s/p ICD placement.
Physical Exam:
96.5 73 136/70 22 94RA
WNWD NAD AAx3
Decreased BS R to halfway up chest
RRR
soft NT ND
no LE edema
Pertinent Results:
Labs on Admission:
[**2115-6-18**] 12:46PM BLOOD WBC-8.3 RBC-5.82* Hgb-9.8* Hct-34.8*
MCV-60* MCH-16.9* MCHC-28.3* RDW-18.4* Plt Ct-728*
[**2115-6-18**] 12:46PM BLOOD PT-27.3* PTT-29.6 INR(PT)-2.7*
[**2115-6-18**] 12:46PM BLOOD Glucose-104 UreaN-14 Creat-0.6 Na-137
K-4.6 Cl-102 HCO3-26 AnGap-14
[**2115-6-18**] 12:46PM BLOOD Calcium-8.4 Phos-4.2 Mg-2.0
Labs prior to expiration:
[**2115-6-25**] 09:09PM BLOOD WBC-21.6*# RBC-5.65* Hgb-9.6* Hct-34.9*
MCV-62* MCH-16.9* MCHC-27.4* RDW-19.9* Plt Ct-475*
[**2115-6-25**] 01:17AM BLOOD PT-18.3* PTT-29.1 INR(PT)-1.7*
[**2115-6-24**] 02:35PM BLOOD Fibrino-778*
[**2115-6-25**] 09:09PM BLOOD Glucose-108* UreaN-40* Creat-2.2* Na-136
K-6.2* Cl-93* HCO3-13* AnGap-36*
[**2115-6-25**] 02:30PM BLOOD ALT-29 AST-66* CK(CPK)-10* AlkPhos-77
TotBili-0.7
[**2115-6-25**] 09:09PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2115-6-25**] 02:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2115-6-23**] 02:10PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2115-6-22**] 07:59PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2115-6-25**] 09:09PM BLOOD Calcium-9.1 Phos-8.8*# Mg-2.5
[**2115-6-26**] 01:58AM BLOOD Type-ART pO2-244* pCO2-36 pH-7.48*
calTCO2-28 Base XS-4
[**2115-6-26**] 12:43AM BLOOD Type-ART pO2-88 pCO2-40 pH-7.18*
calTCO2-16* Base XS--12
[**2115-6-25**] 11:12PM BLOOD Type-ART pO2-101 pCO2-43 pH-7.17*
calTCO2-17* Base XS--12
[**2115-6-25**] 09:25PM BLOOD Type-ART pO2-175* pCO2-41 pH-7.09*
calTCO2-13* Base XS--17
[**2115-6-26**] 12:43AM BLOOD Lactate-14.8* K-5.1
[**2115-6-25**] 11:12PM BLOOD Lactate-17.4* K-5.0
[**2115-6-25**] 09:25PM BLOOD Lactate-14.8*
Imaging:
CHEST (PORTABLE AP) Study Date of [**2115-6-25**] 8:26 PM:
Small multiloculated right pleural effusion has increased over
the course of the day, not as large as it was on [**6-23**]. Tiny
volume of pleural air at the base of the right lung is stable.
Basal and apical pleural tube are unchanged in their respective
positions. There is appreciably greater congestion and possibly
mild edema in the right lung now than earlier in the day.
Moderate-to-severe cardiomegaly is stable. Minimal left
perihilar edema has also developed. Tip of the new Swan-Ganz
catheter projects over the bifurcation of the pulmonary
arteries. ET tube in standard placement, transvenous right
atrial and right ventricular pacer leads unchanged in standard
placements as well.
RUQ U/S:
Normal son[**Name (NI) 493**] appearance of the kidneys bilaterally.
Prominent fluid-containing structure with internal debris in the
left upper quadrant may represent gastric contents versus
pleural effusion with heterogeneous internal debris,
incompletely evaluated. Further imaging can be performed if
indicated.
TTE [**2115-6-25**]:
The left atrium is mildly dilated. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
with borderline normal free wall function. There is abnormal
septal motion/position. The aortic valve is abnormal. The aortic
valve is not well seen. Moderate (2+) aortic regurgitation is
seen. Mild to moderate ([**2-8**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
CT CHEST W/CONTRAST Study Date of [**2115-6-21**] 4:18 PM
1. Persistent large multiloculated right pleural effusion. New
loculated
hydropneumothoraces are likely related to pleural catheter
placement.
2. New high attenuation along diaphragmatic pleural region,
probably
representing talc deposition given history of interval talc
treatment.
3. Improving left lower lobe opacity which may be due to
resolving area of
infection or inflammation.
4. Septal thickening, probably reflecting hydrostatic edema, but
attention to this area on followup CT may be helpful to exclude
lymphangitic
carcinomatosis
Brief Hospital Course:
Mrs. [**Known lastname 34440**] was a very pleasant 54 year-old female who
unfortunately was readmitted for recurrent right pleural
effusion following a right VATS decortication,
mechanical/doxycycline pleurodesis . Her chest CT showed an
increase of the right-sided pleural effusion, partially
divided/organized in two major compartments. Her coumadin was
held on admission.
.
On [**6-20**]/009 she underwent placement of a pigtail catheter and
talc pleurodesis by IR. She received 2u FFP periprocedure.
Pigtail was inserted without complications, 1350cc of straw
colored fluid was drained. Post-procedure CXRs showed continued
right pleural effusion. Her WBC was elevated, which we
attributed to the talc pleurodesis, as she was otherwise w/o
signs or symptoms of infection. It quickly became evident that
the pigtail placed was too small in diameter for adequate
drainage of this multiloculated effusion and that she would need
a repeat R VATS decortication with placement of a pleurx
catheter.
.
On [**2115-6-22**] patient developed tachycardia with rates to the 150s
and a drop in SBPs to 90-80s. The rhythm initially appeared to
be sustained Vtach. However, on closer inspection of her rhythm
strip and in consultation with cardiology, it was determined
that she actually had afib RVR with aberrancy. She was
immediately transferred to the unit and given IV lopressor. She
later spontaneously converted to sinus rhythm without any
further intervention. It also became quickly apparent to us
that she was particularly preload dependent given her severe AS,
which manifested as a prominent drop in SBPs with HRs >120s.
Her urine output remained adequate before and after these
episodes of afib. She was afebrile. Her electrolytes were
closely monitored and repleted PRN. She remained in the unit
until [**2115-6-24**] when she underwent a repeat R VATS decortication
with placement of a pleurx catheter. Please see Dr. [**Name (NI) 5794**] operative note for details. She tolerated the
procedure well and was transferred back to the SICU extubated.
.
In the early am of [**2115-6-25**] she again was in and out of afib with
RVR. Her SBP was 70-80s requiring neosynephrine. She was given
an amiodarone loading dose and then drip. She was also given 2
500 NS boluses for soft pressures. She never lost consciousness
and had a strong peripheral pulse during these episodes. She
also was found to have hyperkalemia, for which she received
insulin, bicarb, and kayexylate. Repeat K 2 hours following
treatment was 4.9. Her Cr was stable. Her urine output for
most of the morning was adequate at ~25cc per hour. However,
she suddenly became oliguric with outputs ~5cc/hr by 5:00am that
morning. There was some debate at that point whether she was
vol depleted or overloaded. Urine electrolytes were sent which
showed a FENA of 3%, not c/w a prerenal state. Her creatinine
bumped to 1.7. Ultimately it was decided that we should attempt
diuresis, and she was given 10mg lasix. She did not respond,
and became anuric. She again was intermittently in afib with
RVR on an amio drip. Serial ABGs were obtained which showed a
severe metabolic acidosis most likely caused by renal failure
with a pH of 7.21, CO2 42 and HCO3 18. Subsequent ABGs showed
worsening acidosis. Lactate was 13.8 and later trended upward
to a max of 17. At this point, it became obvious that she was
deteriorating fast and the etiology of this decline was unclear.
Of note, her clinical exam was stable. She did not have
abdominal pain or surgical abdomen and her chest tubes were
adequately draining sersang fluid.
.
Renal and cardiology consults were immediately obtained. Renal
thought she might have urosepsis given the presence of WBC
casts. Again, she remained afebrile. She did have
leukocytosis, although this temporally was consistent with her
recent talc/doxy pleurodesis. A urinalysis taken on [**6-22**] showed
6-10 WBCs with mod bacteria, but was believed to be contaminated
given the presence of [**7-17**] epi cells. Urine culture from that
time eventually was negative. Urinalysis from [**2115-6-23**] was also
negative for infection. Thus, there was few sxns and signs of
urosepsis and was generally felt to be an unlikely cause of her
sudden deterioration. Regardless, we immediately empirically
started her on vanc/zosyn at that time.
.
Cardiology recommended stating a dilt drip and another amio load
followed by drip for her continued intermittent afib with AVR.
They were unsure if her metabolic acidosis and rising lactate
was consistent with cardiogenic shock or sepsis physiology. We
needed a swanz catheter. A TTE showed elevated PCWP with a
preserved EF>55%. The aortic valve was not well visualized.
There was moderate TR and mild MR.
.
On the evening of [**6-25**] patient was emergently intubated for
worsening ABGs. A swanz catheter was inserted. Post swan CXR
showed appropriate line placement without new PTX. The
following plan for the evening was placed - obtain hemodynamic
data, start CVVH to correct the metabolic acidosis, and cont
vanc/zosyn. Her abdominal exam was stable. Serial ABGs were
closely monitored. Bicarb was given for severe metabolic
acidosis, which began to improve after CVVH was started.
Hemodynamics were remarkable for a SVO2 60s, SVR >1300 (while on
3 of neo), PA pressures 60s/30s, wedge 28, mixed venous O2 50s,
CO 2.4, fick CI 1.5. Cardiology believed the thermodilution was
inaccurate given her severe valvular pathology and calculated
the CI to be 2.3 (corrected for hemoglobin). They ultimately
did not feel she was in cardiogenic shock and instead attributed
the decline to peripheral vasodilation despite the high SVR and
low SVO2. Thus, we still did not have an adequate explanation
for the rising lactate and ARF. We contemplated the idea that
she had thromboembolic acute mesenteric ischemia in the setting
of intermittent afib, but ultimately felt this was extremely
unlikely given the fact that she did not have abdominal pain or
tenderness on exam. Again, urosepsis seemed an unlikely cause.
Ultimately, we did not understand the exact cause of acute
decline, but were actively managing here metabolic acidosis and
renal failure by CVVH and bicarb drip. CVVH was started at 0000
[**2115-6-26**]. She was relatively rate controlled for most of the
evening with HR in the 110s, and SBP by aline in the 100-110s
(neo of 3). Her Hct was stable in the low 30s.
.
At approximately 1:45am, patient suddenly went into PEA arrest.
She was without a pulse and unresponsive. ACLS protocol was
immediately instituted. She was given CPR with approximately 6
rounds of epi/atropine. Multiple rds of CaCl and bicarb were
given. At approximately 10 minutes into the code, she regained
a pulse with a SBP to the 50s. However, this was temporary and
then became asystolic. Bedside ultrasound was negative for a
pericardial effusion. She did intermittently regain a rhythm,
at times vfib, and was shocked as appropriate. But she never
regained a sustainable rhythm and ultimately the code was called
at 2:19am. Medical examiner declined the case and the death
certificate was signed.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): until INR 2.0 .
6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO once a day.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed to maintain INR 2.0-3.0 for L DVT.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Regular Insulin Sliding Scale
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expried
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2115-7-1**]
ICD9 Codes: 5119, 5849, 9971, 4271, 2762, 4275, 4280, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7133
} | Medical Text: Admission Date: [**2120-10-24**] Discharge Date: [**2120-10-24**]
Date of Birth: [**2120-10-24**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 3228**] is a newborn 37
week infant admitted to the NICU with respiratory distress
and dysmorphic features.
Infant was born at 5:54 a.m. this morning as the 2035 gram
product of a 37 and [**2-19**] week gestation pregnancy to a 31 year-
old G1 P0 to 1 mother with [**Name (NI) 37516**] [**2120-11-12**]. Prenatal labs
including blood type O positive, antibody negative, RPR
nonreactive, hep B surface antigen negative, rubella immune,
GBS negative. Triple screen was not performed. Pregnancy was
notable for normal 19 week ultrasound, a mildly elevated
blood pressure with normal biophysical profile and upper
normal AFI 2 weeks ago. Yesterday she was noted to have
markedly elevated blood pressures as well as IUGR and
elevated AFI. Because of these findings mother was admitted
for labor and was induced.
Antepartum course notable for vacuum assisted delivery with
prolonged pushing. No fever was noted and spontaneous rupture
of membrane occurred 5 hours prior to delivery. No antepartum
antibiotics were administered. The infant was born vaginally
with slightly meconium stained amniotic fluid. He was
intubated with no meconium found below the cord. He was then
stimulated with good response with Apgars of 7 and 8,
increased work of breathing and increased secretions were
noted and he was brought to the NICU.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2035, which is the
50th percentile. Head circumference 31 cm, which is the 10th
percentile. Length of 43.5 cm, which is also the 10th
percentile. Temperature 98.6. respiratory rate 40 to 50.
Heart rate 150. Blood pressure 81/47 with a mean blood
pressure of 54. O2 sat 99 to 100% on room air. In general, he
is a small infant with mildly increase work of breathing, reduced
activity. HEENT exam revealed molding with a caput. Fontanelles
were soft and flat. Ears were posteriorly rotated and low. small
palpebral fissures, small chin. He did have a positive red
reflex. Pupils were equal and round and reactive to light. Nares
were patent and palat was intact. Left side of the face was noted
to have decrease movement or tone. Neck was supple with no
lesions. Chest noted to have mild retractions, coarse, well
aerated. Cardiac regular rate and rhythm. No murmur. Abdomen
was soft with a 3 vessel cord. No masses. No
hepatosplenomegaly and quiet bowel sounds. GU exam revealed a
male with small genitalia. No testes palpable. Small scrotum
and a patent anus. Extremities including hips and back were
normal. Initially hypotonic, now improving.
HOSPITAL COURSE:
1. Respiratory. Patient was noted to have increased work of
breathing and therefore by 2.5 hours of life was
intubated and placed on conventional mechanical
ventilation. First blood gas 7.34/36/196 and weaned from 18/5
x 20 to 16/5 x 18. Repeat 7.44/33 and rate decreased to 15.
2. Cardiovascular. Patient has remained hemodynamically
stable throughout his initial hospital course.
3. FEN/GI. Patient was noted to have copious amount of
secretions after delivery that in concert with the
polyhydramnios noted by the obstetrician prompted
placement of an NG tube. Xrau showed an NG tube
coiling in the esophagus. Of note, a small amount of air
was observed most likely in the stomach--midline and above the
diaphragm ??c/w hiatal hernia. Thus, fistula is possible.
4. CBC and blood culture were obtained, results of which are
pending at this time. Patient has not been started on
antibiotics. WBC=16.2, crit=42.6%, 48P4B36L2 metas, plt=312.
5. Neuro, patient is noted to have a left sided facial
weakness as well as some hypotonia on exam.
6. Genetices: as stated above in physical examination, the
patient does have some dysmorphic features including low
set ears, hypotonia, left sided facial weakness as well
as hypogonadism. Will meed to have further evaulation for
possible CHARGE syndrome and requires genetics consultation.
CONDITION ON DISCHARGE: Critical
DISCHARGE DISPOSITION: [**Hospital3 1810**] NICU 7 North.
NAME OF PRIMARY CARE PEDIATRICIAN: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63290**], MD [**First Name (Titles) **]
[**Last Name (Titles) 1426**] Pediatrics.
CARE/RECOMMENDATIONS: Feeds, the patient is currently NPO on
IV fluids at 80 cc per kilo per day.
DISCHARGE DIAGNOSES:
1. Esophageal atresia with possible fistula
2. Possible hiatal hernia vs diaphragmatic hernia.
3. Respiratory distress due to multiple secretions, resolving
4. r/o syndrome.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) 58671**]
MEDQUIST36
D: [**2120-10-24**] 08:09:41
T: [**2120-10-24**] 08:50:53
Job#: [**Job Number 63291**]
ICD9 Codes: 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7134
} | Medical Text: Admission Date: [**2168-4-9**] Discharge Date: [**2168-4-13**]
Date of Birth: [**2115-7-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 293**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD and banding of 5 varices
History of Present Illness:
52 year old man with h/o cirrhosis, etiology unknown, who
presented to [**Hospital3 417**] Hospital on [**2168-4-9**] with an upper GI
bleed from esophageal varices. He reports eating some acidic
salad dressing on Friday, then developed burning abdominal pain
and bloating afterwards. That evening, he then vomited ~800cc of
blood and was taken to the hospital. One prior episode in [**1-7**],
again assoc w/ acidic food.
.
At [**Hospital3 417**] Hospital, he was hemodynamically stable with
HR 103 and BP 134/75. An NGT had approximately 800 ml of bloody
output. His initial HCT was 37 but dropped to 32 on repeat check
and he was given 1 unit PRBC. He was started on IV fluids and
octreotide 100 mcg per hour. GI was consulted for urgent
endoscopy which showed grade 4 esphageal varices without active
bleeding. There was also pooling of blood in the fundus, but no
other source of bleeding was noted. Given the severity of the
varices, the pt was transferred to [**Hospital1 18**] for consideration for
TIPS procedure.
.
MICU course was notable for: Pt was maintained on octreotide
gtt. He was given levofloxacin for ppx as well as PPI [**Hospital1 **]. A R
IJ was placed for access. He did not have any bleeding
overnight. BP . Hct trended down to 26, 1 u PRBCs given. EGD
performed on [**4-11**] and showed varices in the distal esophagus as
well as erythema and congestion in the stomach body/fundus. 5
bands were placed. He was monitored in the MICU for the
remainder of the day and was then tx out of the ICU for further
monitoring/workup of his cirrhosis on the floor.
Past Medical History:
Liver cirrhosis of unclear etiology
Previous GI bleed with varices identified in [**1-/2167**]
Social History:
Originally from [**Country 2045**], moved in [**2142**]'s. Unmarried, has
girlfriend. [**Name (NI) 1403**] in water resources. No tobacco or IVDU. Drinks
minimally, usually only when he goes to [**Country 2045**] (drinks the
home-made rum). Does not drink EtOH here. Has had 5 sexual
partners in his life, usually uses a condom for protection. Has
never been told that he has hepatitis, HIV, or any other blood
borne disease. No h/o transfusions or surgeries (though has
undergone several attempted circumscisions in last several yrs).
Family History:
Mother died of asthma at 65, Father alive and well, no health
concerns (age 72). No h/o CAD or MI.
Physical Exam:
VS: 98.8/98.9m BP 134/44 (92-150/38-60) P 71, 60-70 R19, 97-100
% 2L NC, I/O=-875 cc, -2.4 L LOS
Gen: No apparent distress. Conversational, well appearing man.
HEENT: sclera mildly icteric.
Neck: no JVD
Resp: crackles bilateral bases, clear with cough
CV: RRR nl s1s2 no MGR
Abd: soft, NT, obese, with normoactive bowel sounds and no
hepatospenomegaly. Dull to percussion on flanks.
Ext: no edema
Neuro: A+Ox3, no asterixis. CN 2-12 intact. Strength 5/5 UE and
LE.
Skin: Dark without telangiectasias.
Pertinent Results:
LABS on admission:
WBC 4.0, Hct 28.0, MCV 89, Plt 81*
(DIFF: Neuts-59.5 Bands-0 Lymphs-28.0 Monos-10.1 Eos-1.7
Baso-0.7)
PT 18.0*, PTT 29.9, INR(PT) 1.7*
Na 141, K 4.0, Cl 108, HCO3 25, BUN 18, Cr 0.9, Glu 114
ALT 84, AST 106, LDH 197, AlkPhos 65, TBili 2.4
Albumin 3.3*, Calcium 7.8*, Phos 2.1*, Mg 1.8
calTIBC 296, Ferritin 82, TRF 228, TSH 0.30
.
Urinalysis:
[**2168-4-10**] 01:32AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
.
LABS during hospitalization:
[**2168-4-10**] ALPHA-1-ANTITRYPSIN-130 (within normal range)
[**2168-4-10**] freeCa-1.11*
[**2168-4-10**] HCV Ab-NEGATIVE
[**2168-4-10**] IgG-1223
[**2168-4-10**] AFP-2.8
[**2168-4-10**] [**Doctor First Name **]-POSITIVE Titer-1:40
[**2168-4-10**] AMA-NEGATIVE
[**2168-4-10**] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE
[**2168-4-11**] HAV Ab-POSITIVE
[**2168-4-12**] IgM HBc-NEGATIVE
[**2168-4-12**] IgM HBc-NEGATIVE
[**2168-4-12**] Smooth-NEGATIVE
[**2168-4-12**] HIV Ab-NEGATIVE
[**2168-4-12**] HEPATITIS Be ANTIBODY-REACTIVE
[**2168-4-12**] HEPATITIS Be ANTIGEN-NONREACTIVE
[**2168-4-13**] HEPATITIS B VIRUS GENOTYPE-PND
.
LABS on discharge:
WBC 4.1, Hct 30.9*, MCV 88, Plt 88*
PT 15.2*, PTT 26.0, INR(PT) 1.4*
Na 137, K 3.7, Cl 102, HCO3 27, BUN 13, Cr 1.2, Glu 104
ALT 115*, AST 111*, LDH 215, AlkPhos 64, TotBili 1.8*
Calcium 8.2*, Phos 3.3, Mg 1.8
Cholest 163, Triglyc 74, HDL 45, CHOL/HDL 3.6, LDLcalc 103
.
MICRO:
[**2168-4-9**] - blood cx neg
[**2168-4-10**] - urine cx neg
[**2168-4-13**] - catheter tip cx neg
[**2168-4-13**] - hep C viral load NEG
.
IMAGING:
RUQ US [**4-10**]:
1. Heterogeneous-appearing liver consistent with cirrhosis.
2. Main portal vein, hepatic arteries, and hepatic veins appear
patent with normal direction of flow. No drainable amount of
ascites seen.
.
CXR [**4-10**]: The cardiomediastinal contours are unchanged. Lung
volumes are low, but the lungs are clear. No effusion. There is
no PTX.
.
EGD [**4-11**]: Varices at the mid to distal esophagus (ligation)
Erythema and congestion in the stomach body and fundus
compatible with portal HTN gastropathy
Normal mucosa in the duodenum
There was a malfunction of the first set of banding equipment
and the plastic tip along with unapplied bands fell off the
endoscope into the stomach.
Otherwise normal EGD to second part of the duodenum
.
Brief Hospital Course:
52 year old man with history of cirrhosis of unclear [**Name2 (NI) 25100**]
presents with GI bleed from grade 4 varices.
.
# UPPER GI BLEED - Mr. [**Name14 (STitle) 66577**] was found to have grade IV
esophageal varices at OSH, w/ a question of large gastric
varices as well. He was started on an octreotide gtt and
tranferred to [**Hospital1 18**] for TIPS evaluation. On EGD here, he was
found to have grade 3 varices and portal HTN gastropathy. He
underwent banding to 5 esophageal varices on [**2168-4-11**] and has
been stable since. He was monitored in the ICU for 24 hours. His
Hct remained stable and he was transferred to the floor. He was
continued on nadolol and protonix for his varices. He was also
treated with levofloxacin for SBP prophylaxis, for a total of 7
days, to be completed as an outpatient. His diet was slowly
advanced and by discharge, he was tolerating a soft diet without
any complaints.
.
# CIRRHOSIS - Mr. [**Last Name (Titles) 66578**] laboratory evaluation revealed a
pattern most consistent with cirrhosis, with elevated LFT's and
compromised synthetic function. Imaging was also consistent with
cirrhosis. However, his cirrhosis is of unclear etiology. From
his history, he denies EtOH use, exposure to hepatitis B or
hepatitis C. He also denies IVDU or tattoos. Hepatology/GI was
consulted and recommended a laboratory workup which revealed
that Mr. [**Name14 (STitle) 66577**] was hepB core Ab positive, likely representing
a chronic hep B infection. He was given an appointment for
outpatient follow-up in the Liver Clinic. He was continued on
nadolol and protonix and completed a 7 day course of
levofloxacin as an outpatient.
.
# PANCYTOPENIA - He was noted to be pancytopenic while
hospitalized, with a decreased WBC, RBC and platelet count.
Platelets could be low due to sequestration in spleen, but did
not feel his spleen on exam. Hct likely low as well due to his
GI bleeding. Most likely etiology was felt to be viral, likely
his hepatitis. HIV was negative.
.
# PPX - Pneumoboots were given for DVT prophylaxis. He was given
a PPI [**Hospital1 **] for his varices. No bowel regimen was needed.
.
# FEN - He was kept NPO, then advanced to clears, and finally to
a soft diet. No IVF were needed after his transfusions. His
electrolytes were checked daily and were repleted to keep K >4
and Mg >2.
.
# ACCESS - He had a R IJ, as well as peripheral IVs.
.
# CODE - FULL
.
# DISPO - To home, with follow-up in Liver Clinic.
Medications on Admission:
Pantoprazole
Nadolol (? compliant)
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. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Esophageal varices
Esophageal variceal bleed
Duodenal ulcer
.
Secondary diagnosis:
Cirrhosis of unknown etiology
Discharge Condition:
Afebrile. BP 140/80, HR 60, RR 20, 98% on RA
Discharge Instructions:
Please call your PCP or go to the nearest ER if you develop any
of the following symptoms: fever, chills, shortness of breath,
chest pain, difficulty swallowing, nausea, vomiting, vomiting
blood, bloody stools, dark or tarry stools, or any other
worrisome symptoms.
.
Please take all your medications as prescribed. Please follow a
soft, low residue diet for another 2 days. After that you may
resume a normal diet.
.
Please keep all your follow-up appointments.
Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 2405**], as scheduled.
.
Please follow-up with the Liver Clinic (Dr. [**Last Name (STitle) **] on [**2168-5-3**] at
11:30am. Please call [**Telephone/Fax (1) 2422**] if you have any questions or
need to reschedule your appointments. Their office is located in
the [**Hospital Unit Name **], at [**Last Name (NamePattern1) **]., [**Location (un) **]. Please call
their office upon discharge to update your demographic
information in the computer.
ICD9 Codes: 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7135
} | Medical Text: Admission Date: [**2150-5-23**] Discharge Date: [**2150-6-10**]
Date of Birth: [**2082-2-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Fever, altered mental status, and RLQ pain at rehab facility.
Major Surgical or Invasive Procedure:
[**2150-6-1**] nephrostogram with dilatation
[**2150-6-8**] nephrostogram
History of Present Illness:
Pt. is a 68 year-old male who presented to the ED with the
aforementioned complaints. His potassium level in the ED was
found to be 7.4 and his serum creatinine was 5.4 from a normal
baseline. The patient was emergently dialyzed, and an
obstruction was suspected. Prior to admission, the patient
underwent cadaveric renal transplant in [**12-27**] that was
complicated by proximal resection of the patient's ureter. A
nephrostomy tube was placed in the donor ureter shortly after
surgery and was removed on [**2150-5-21**].
Past Medical History:
DM2 x32 years
DM-associated retinopathy, nephropathy, and neuropathy.
CAD
ESRD
HTN
hypercholesterolemia
PVD
PSH:
s/p R ORIF hip [**2150-2-13**]
CRT [**2150-1-15**]
evac hematoma [**2150-1-16**]
nephrostomy tube [**2150-2-6**] for urinoma
CABG [**2143**]
Right fem-distal bypass
s/p R BKA
LUE AV fistula
Social History:
SOCIAL HISTORY: Significant for distant use of tobacco. He quit
in [**2143**]. No history of alcohol use or IV drug abuse. His wife
died of bone cancer. He has 6 children, all adults with an
eldest son with a history of diabetes. He has supportive family
in the area. He currently lives alone.
Family History:
Noncontributary
Physical Exam:
V/S: 98.9/P55/R20/BP137/53
Gen - cachectic male in NAD
Skin - L heel decubitus ulcer with eschar, no rashes
HEENT - NC/AT, EOMI, PERRL bilat., MMM, no palpable LAD
Cardiac - RRR, palpable thrill from L brachial AV fistula
Lungs - CTA bilat.
[**Last Name (un) **] - bowel sounds present, soft, NT, ND, no organomegaly
P.Vasc - 1/4 L d.p. and p.t. pulses, [**12-26**] palp. UE pulses bilat.,
no edema, no audible bruits
Musc/Skel - s/p R BKA, full active and passive ROM at L lower
extremity and upper extremities bilat.
Neuro - Gen - A&Ox3, appropriate speech and affect
CN - II-XII intact
Reflexex - 1+ at patella bilat., 1+ at brachiorad and
bicipital bilat.
Sensory - intact to light touch and temp at UE bilat, LE
bilat
Motor - 5/5 strength throughout
Cerebellar - + intention tremor
Gait - not assessed - pt. is s/p R BKA and without
prosthetic.
Pertinent Results:
[**2150-6-9**] 06:05AM BLOOD WBC-4.9 RBC-3.27* Hgb-9.0* Hct-28.1*
MCV-86 MCH-27.7 MCHC-32.2 RDW-15.6* Plt Ct-341
[**2150-6-9**] 06:05AM BLOOD WBC-4.9 RBC-3.27* Hgb-9.0* Hct-28.1*
MCV-86 MCH-27.7 MCHC-32.2 RDW-15.6* Plt Ct-341
[**2150-6-9**] 06:05AM BLOOD Glucose-97 UreaN-31* Creat-1.5* Na-139
K-5.8* Cl-111* HCO3-21* AnGap-13
[**2150-6-6**] 06:17AM BLOOD Glucose-71 UreaN-27* Creat-1.3* Na-140
K-4.9 Cl-110* HCO3-22 AnGap-13
[**2150-6-9**] 06:05AM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.4* Mg-1.6
[**2150-6-9**] 06:05AM BLOOD FK506-7.4
Brief Hospital Course:
Pt. was dialysed emergently upon arrival. His nephrostomy tube
reopened and allowed to drain. Pt's creatinine gradually
decreased to baseline levels over the course of admission with
hydration. Pt's blood glucose levels were initially high, but
were brought under good control with the help of the [**Last Name (un) **]
center. At the time of discharge, pt's blood glucose levels were
116-130.
[**5-29**]: Nutrition consult recommends Boost supplements
[**5-30**]: TSH, folate, B12 normal, urine output via foley catheter
and nephrostomy tube increased, creatinine continues to decrease
[**6-1**]: Nephrostogram with stomal dilation, tube still open and
draining well
[**6-2**]: Nephrostomy tube closed for trial, foley catheter draining
hematuria with clots. Foley removed.
[**6-3**]: Pt. refused replacement of foley,urethral clots stopped.
[**6-4**]: Urethral clots reappear,hematuria via nephro bag.
[**6-7**]: Pt. started Zoloft, tolerated well. Pt. began eating well.
[**6-8**]: Pt's Boost changed to Nepro supplements due to elevated
potassium levels, kayexalate given for asymptomatic
hyperkalemia.
[**6-8**]: Nephrostogram --> no vasovesicular fistula present.
[**6-9**]: Acute renal failure resolved, foley catheter draining more
that neprhostomy tube; pt. tolerates nephrostomy tube capping.
Pt. eating well. Pt.'s blood glucose levels in good control.
Medications on Admission:
tacrolimus 6 mg po bid
amlodipine 5 mg po qd
metoprolol 25mg po tid
fluoxetine 20 mg po qd
mycophenolate mofetil 1000mg po bid
valgancyclovir 450mg po qd
paantoprazole 40mg po qd
isosorbide dinitrate 60mg po qd
colace 100mg po bid
bactrim ss i po qd
CaCO3 100 mg po qid
nystatin 5 ml po qid
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): apply to scrotum then apply aloe vesta.
8. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times
a day).
9. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 20304**] Rehabilitation & Nursing Center - [**Location (un) 2498**]
Discharge Diagnosis:
hematoma/urinoma s/p cadaver kidney transplant complicated by
nephrostomy tube
DM type II
hypertension
depression
peripheral vascular disease.
Discharge Condition:
stable
Discharge Instructions:
call if fevers, chills, nausea, vomiting, inability to take
medications, inability to urinate, decreased urine output from
nephrostomy tube or if nephrostomy tube urine becomes more
bloody.
Change Nephrostomy tube dressing every day.
Labs once a week for cbc, chem 7, calcium, phosphorus, ast,
t.bili, albumin, urinalysis and trough prograf level. Fax
results to [**Hospital1 18**] [**Telephone/Fax (1) 697**]
Followup Instructions:
call [**Hospital1 18**] for follow up appointment in [**11-23**] weeks [**Telephone/Fax (1) 673**]
Completed by:[**2150-6-9**]
ICD9 Codes: 0389, 5990, 5849, 2767, 4439, 311, 4019, 3572, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7136
} | Medical Text: Admission Date: [**2182-5-24**] Discharge Date: [**2182-6-3**]
Date of Birth: [**2115-12-3**] Sex: F
Service: MEDICINE
Allergies:
Motrin
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Hand pain
Major Surgical or Invasive Procedure:
I+D of the left hand
History of Present Illness:
66 y/o with ESRD on HD M/W/F, CAD, PVD, DM, HTN presents with
worsening pain and swelling left 3rd digit for 2-3 weeks. Pt had
L UE AV fistula banded for vascular steal symptoms on [**2182-5-9**] by
Dr. [**First Name (STitle) **]. Prior the operation the pt describes her had as
black. Pt says the pain and swelling the the digits started
within a few days of the operation. No F/C/S. The syptoms were
progressively worsening of the last week. She went to see Dr.
[**Last Name (STitle) **] (? transplant) today in clinic. There she had diminished
L radial pulse with strong doppler signal. Ulnar pulse also has
a strong doppler signal. There is good cap refill and was sent
in to the ED for eval of possible infection.
.
In the ED, initial VS: T97.7, 61, 179/49, 18, 100%RA. Initial
exam felt consistent with paronychia. I+D attempted without pus
by ED resident. Hand was consulted and did a 2nd attempt of I+D
was performed. Pt received ampicillin-Sulbactam and Vanco 1gm in
the ED. No pus produced. Packed by hand team who argeed with
treatment of vanco and unasyn (per ED). X ray performed and read
as Soft tissue defect at the nail bad and osteomyelitis of the
distal phalanx of
the left 4th digit. Per ED report hand is less impressed with
the idea of osteomyletis. Hand will continue to follow. Pt
remained HD stable in ED. PIV in place. VS prior to transfer
98.5, 65, 180/64, 16, 100% RA.
.
ON arrival the pt complaints of severe left finger pain and her
dressing has quickly soaked through. BP 201/60, but denies CP,
HA, change in vision.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
PER [**Last Name (STitle) **]:
PVD - s/p left SFA stent placement [**6-15**]
CAD - 3VD per cath [**2179**], s/p stent to RCA in [**2177**]
DM - on insulin, last A1C 8.9% in [**3-/2181**]
ESRD - HD-M/W/F @ [**Location (un) **] (Dr. [**First Name (STitle) **]
HTN
hyperlipidemia
hyperparathyroidism
s/p hysterectomy
h/o colonic polyps
s/p phacoemulsification with posterior chamber lens implant left
eye [**2181-6-14**].
Anemia
Paroxysmal atrial fibrillation.
Social History:
Lives in [**Location 2268**] with daughter on [**Location (un) 448**] of her house, no
history of tobacco, alcohol, drugs.
Family History:
Diabetes, hypertension in several family members
Physical Exam:
VS: T96.9, BP 201/60, 65, 22, 98%
GENERAL: elderly appears AA female in moderate painful distress.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: no JVD,
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e. Left 3rd digit with 1cm incision
along radial aspect with wick exposed, ongoing bleeding. good
cap refill in BL hands. Swelling of finger largely confined to
distal to DIP. very TTP on the finger pad. Given pain flexsion
PIP, DIP limited. No swelling appreicated proximal to PIP. no
erythema. Radial and ulnar only appreciated by doppler. LUE
fistula with good thrill.
SKIN: dark nail changes in BL U and L ext which pt says is new
since operation. No obvious splinter hemrhorages. muliple dark
macules on palms / soles which appear chronic and nonblanching
(therefore unlikely to be [**Last Name (un) **] lesions.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
and senstion grossly intact throughout.
Pertinent Results:
[**2182-5-24**] 04:33PM LACTATE-1.7 K+-5.3
[**2182-5-24**] 04:25PM GLUCOSE-237* UREA N-33* CREAT-5.2*#
SODIUM-133 POTASSIUM-7.8* CHLORIDE-95* TOTAL CO2-31 ANION GAP-15
[**2182-5-24**] 04:25PM CALCIUM-9.3 PHOSPHATE-3.8 MAGNESIUM-2.1
[**2182-5-24**] 04:25PM WBC-3.6* RBC-3.58* HGB-11.4* HCT-35.1* MCV-98
MCH-31.9 MCHC-32.5 RDW-16.1*
[**2182-5-24**] 04:25PM NEUTS-57.0 LYMPHS-29.5 MONOS-9.8 EOS-3.0
BASOS-0.8
[**2182-5-24**] 04:25PM [**Name (NI) 8255**] TO PTT-UNABLE TO INR(PT)-UNABLE
TO
[**2182-5-24**] 04:25PM PLT COUNT-107*
MICROBIOLOGY: blood cult pending
.
STUDIES:
X-ray left finger: Soft tissue defect at the nail bad and
osteomyelitis of the distal phalanx of
the left 4th digit.
.
ECG: [**2182-5-24**] 2251: NSR at 65, NANI. old TWF in lateral [**Location (un) 18187**]. No
st changes. poor R wave progression.
.
MRI BRAIN:
Multiple areas of high signal in subcortical and periventricular
distribution
are redemonstrated on FLAIR imaging, compatible with small
vessel ischemic
disease. Mild prominence of sulci and ventricles is again noted,
suggestive
of global atrophy. There is no evidence of acute infarction. On
T2-weighted
images, there is high signal intensity involving the left pons,
compatible
with remote infarction.
MRA BRAIN:
There is severe stenosis involving bilateral posterior cerebral
arteries.
Severe stenosis of the right distal M1 and M2 segments of the
right middle
cerebral artery are demonstrated. The left MCA is minimally
narrowed. A
supraclinoid segment of the left internal carotid artery appears
markedly
narrowed. These multiple foci of stenosis were not visualized on
most recent
CTA of [**2182-5-27**].
IMPRESSION:
1. Multiple severe stenoses involving posterior and anterior
circulation, as
detailed above. These findings appear new from [**2182-5-27**] CTA
exam and are
concerning for vasculitis or vasospasm due to meningitis.
2. Small vessel ischemic disease.
3. Old left pontine infarction.
CTA HEAD [**2182-5-30**]:
Preliminary Report !! WET READ !!
1. C-Head:1. no large acute major territorial infarction,
intracranial
hemorrhage or mass. Stable hyperdensity likely calcification in
left frontal
lobe (2,24) unchanged in size and appearance since [**2182-5-27**]. 4
2. CTA of the head: Reformats are pending . Within this
limitation:
a) Stable appearance of bilateral proximal cavernous ICA with
e/o stenoses due
to calcified atheromatous plaque with normal caliber and
contrast enhancement
distal to these segments.
b) Calcified atheromatous plaque involving the intracranial
vertebral arteries
is noted with small area of focal stenosis of the right
vertebral artery.
c) Remaining vessels show no definite flow limiting stenosis, or
aneurysm >
3mm.
Brief Hospital Course:
# Finger infection: Concerned initially for deep tissue
infection, however I+D without pus x 2 in the ED. On admission
the x-ray wet read osteomyelitis was a possiblility. Hand
surgery was consulting on the patient and the patient was placed
on vancomycin and ceftazidime with HD. The antibiotitcs were
started on [**2182-5-24**] and will finish on [**2182-7-5**]. Blood cultures
eventually grew multiple strains of bacteria including CONS and
GNRs with high levels of resistence. ID was consulted and
recommended vanc/meropenem for at least a 6 week course but they
will tailor the antibiotics to her clinical status. She will
need weekly safety labs while on the antibiotics. These will
include cbc, chem 7 and lfts. These will be faxed to the [**Hospital 4898**]
clinic at [**Hospital1 18**]. A PICC line was placed on [**2182-6-2**] for meropenem
dosing. Hand surgery recommended [**Hospital1 **] dressing changes and [**Hospital1 **]
soaks in betadyne/saline solution (a 1:1 ratio). They will
follow up with the patient on the Tuesday after her discharge in
hand clinic. If her appointment needs to be rescheduled the
number is: [**Telephone/Fax (1) 3009**]. It is very important that she follow up
with them as she may need an amputation of the finger if the
infection does not clear up with antibiotics. Her pain was
controlled with tylenol RTC. She was unable to tolerate
oxycodone or morphine as they made her sleepy.
# HTN: BP 201/60 in the setting of pain on admission. Chronic
hypertensive on multiple agents. EKG without ischemic changes.
Pt without chest pain, HA, vision changes, or abd pain
suggestive of hypertensive emergency. Blood pressures were
well-controlled after pain controlled on her home regimen.
.
# Toxic metabolic encephalopathy: Pt had acute altered mental
status while on the medicine floors. Pt was aphasic with right
sided weakness. CODE stroke was called, and pt had urgent CT
head that demonstrated no ICH. She was transferred to the MICU
for closer monitoring. Pt was evaluated by neuro, who thought
most likely toxic metabolic given fevers. Given fevers,
meningitis was considered; however, unable to perform LP given
body habitus. MRI head was done which showed was concerning for
possible MCA territory infarction but could also have been
artifact that was not seen on the prior CTA Head. She underwent
a repeat head CT which revealed no changes from the prior one.
She was started on ASA 325mg daily per neuro recs. Her EEG
revealed epileptiform waves on the right side consistent with
seizures. Neurology recommended starting keppra. She remained
stable and was transferred to the medical floor. On discharge
she was alert and oriented X 3.
# DM: continued home doses of NPH and HISS
# CAD/PVD: continued statin, BB, imdur, ASA 81mg
# ESRD on HD MWF: continued her regular dialysis sessions here
and continued renal caps and calcium accetate.
# Anemia: Patient's hematocrit down-trended while hospitalized.
Her hematocrit at discharge was 26.5.
# thrombocytopenia: at baseline. Defer to outpatient providers
for followup.
# CODE: confirmed full with pt.
# CONTACT: [**First Name8 (NamePattern2) 1258**] [**Last Name (NamePattern1) 3234**], daughter, HCP, [**Telephone/Fax (1) 102079**],
[**Telephone/Fax (1) 102080**]
# Transitions of care:
- Patient will need weekly labs drawn in HD and faxed to the
[**Hospital 4898**] clinic to ensure she does not have toxicity from the
vancomycin
- Patient will need to follow up with hand clinic to ascertain
whether she needs an amputation 7-10days after discharge
- Patient has a PICC line in place (placed [**2182-6-2**]) which will
need to be taken out when antibiotic course is completed
Medications on Admission:
MEDICATIONS per [**Name (NI) **], pt unable to confirm except for insulin:
amlodipine 10mg PO daily
Renal caps 1 PO daily
calcium acetate 667 mg PO evenings w/ meals
clonidine 0.1mg PO BID
furosemide 20mg PO BID
gabapentin 300mg PO qhs
hydrocodone-acetaminophen 5/500mg [**2-10**] tab q4-6 hr prn pain
imdur 30mg PO daily
lidocaine 5% patch to lower back
lisinopril 40mg PO daily
metoprolol tartrate 200mg PO BID
simvastatin 80mg PO daily
acetaminophen 1000mg PO q6h prn
ASA 81mg Po daily
Carbamide peroxide 6.5% drops 2 drops daily prn earwax
colace 100mg Po daily
regular insulin 4 U qam and 2 units evening
NPH 20 units qam, 10 u qpm
senna PO daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
9. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. metoprolol tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day).
11. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. insulin lispro 100 unit/mL Solution Sig: Four (4) units
Subcutaneous QAM.
15. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous QAM.
16. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous QPM.
17. insulin lispro 100 unit/mL Solution Sig: Two (2) units
Subcutaneous at bedtime.
18. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
Disp:*30 Tablet(s)* Refills:*2*
19. Vancomycin 1000 mg IV HD PROTOCOL
20. Carbamoxide Ear Drops 6.5 % Drops Sig: 1-2 drops Otic once a
day as needed for ear wax.
21. Outpatient Lab Work
Please check weekly CBC, LFTs, Chem 7 and fax to [**Hospital 4898**] [**Hospital **] clinic.
22. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
24. Meropenem 500 mg IV Q24H
please give AFTER HD on HD days
25. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Osteomyelitis of left finger
DM2
ESRD on HD
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. You were admitted to the hospital with an infection
of your hand. You had IV antibiotics (vancomycin, ceftazadine)
to treat this. You were seen by the plastic surgeons who cleaned
out your hand infection and recommend dressing changes and soaks
(in a solution of betadyne and saline) twice a day. They want to
see you within one week of discharge to see whether the
infection is healing or whether you might need the tip of your
finger removed. You should continue the antibiotics for 6 weeks
with last dose on [**2182-7-5**].
You also had an event during which your brain did not seem to be
functioning as well as it usually does. You had a ct scan and
MRI of your head which did not reveal a stroke or mass or
infection. You had an EEG which showed a seizure. The
neurologists recommended starting an anti seizure medication
called Keppra. You should continue this and follow up with the
neurologists as an outpatient. You should also continue to take
a full dose aspirin to prevent strokes. It was also thought that
your pain medications may have contributed to this episode and
these were discontinued. You should continue to take tylenol for
your pain.
Medication Changes:
START: Vancomycin with HD for at least 6 weeks
START: Meropenem IV for at least 6 weeks
START: Acetominophen 1gm by mouth TID
START: Keppra
It was a pleasure taking part in your care.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2182-6-27**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2182-6-27**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2182-6-4**] at 8:00 AM
With: HAND CLINIC [**Telephone/Fax (1) 3009**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2182-6-4**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please follow-up with Hand Surgery Clinic, the office number is
[**Telephone/Fax (1) 3009**] 7-10 days following discharge.
ICD9 Codes: 5856, 2760, 2875, 4439, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7137
} | Medical Text: Admission Date: [**2119-10-20**] Discharge Date: [**2119-10-25**]
Date of Birth: [**2044-8-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
Right leg weakness
Major Surgical or Invasive Procedure:
- OPERATIONS:
1. Fusion T2-T8.
2. Extra cavitary decompression T5.
3. Laminectomies T4, t6
4. Instrumentation T2-8.
5. Cage placement at T5.
6. Autograft.
History of Present Illness:
This is a 75 year old male with a history of metastatic renal
cell carcinoma with metastasis to multiple ribs and lungs with
associated pleural effusions s/p Genentech study drug who
presents with right leg weakness, urinary retention, and
constipation over the past several days. Ordinarily, Mr
[**Known lastname 82579**] is able to ambulate with a walker without difficulty at
home - he prepares meals for himself at his home he shares with
his wife. Over the past few days, due to increasing weakness in
his right leg, he has had difficulty with walking. He has also
been constipated over this same time period, his last bowel
movement 5 days ago. His PO intake has been diminished over the
last several months, although he takes considerable fluids. He
has also described urinary retention over the past three months.
Otherwise, he denies any other extremity weakness, with no
numbness or tingling. Back pain is minimal at rest, although
coughing does make it worse. He recently had a pleurex catheter
in place for pleural effusion during last admission.
An MRI was performed on day of admission which reveals multiple
spinal mets with significant collapse of the T5 vertebral body
with epidural extension and marked canal narrowing with cord
impingement at this level. The other areas of metastases are
not associated with cord compression. For the MRI, the patient
was intubated for claustrophobia and anxiety treatment - he was
immediately extubated thereafter without need for supplemental
O2.
Neurosurgery saw the patient and plan on taking the patient to
the OR assuming that this plan is acceptable per the Oncology
team, based on their overall treatment plan.
At time of transfer to floor, the patient was comfortable with
no pain, but continued symptoms as described above.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-- On [**2117-7-22**], MRI revealed a 3.2 cm solid exophytic lesion
arising from the lower pole of left kidney suspicious for clear
cell renal cell carcinoma and a 1.6 cm solid lesion in the
anterior left pole of the left kidney and a 2.4 cm lesion in the
mid pole of the right kidney, both of which concerning for tumor
cell carcinoma, papillary type. He was referred to Dr. [**Last Name (STitle) 3748**]
on
[**2117-4-13**]. Given its small size, he was recommended to have
followup imaging ([**2117-7-22**] MRI at [**Hospital1 18**] compared to CT without
contrast from [**2117-4-2**]).
-- On [**2118-1-13**], he underwent repeat MRI, which showed no
significant change and bilaterally no masses.
-- On [**2118-9-28**], he underwent repeat MRI, which revealed
significant interval increase in the lower pole of the left
kidney obstructing mass, now measuring 4.9 x 3 cm from 3.1 x 2.7
cm and development of nodules in the perinephric fat, consistent
with extrarenal spread suspicious for clear cell renal cell
carcinoma, and there were also two other lesions that were
minimally increased in size. On [**2118-11-15**], he underwent
laparoscopic left radical nephrectomy, which revealed a 4.6 cm
clear cell carcinoma and a 2.8 cm papillary renal cell
carcinoma,
grade 3 tumors with tumor extension into the perinephric tissue
(T3a N0), 0/11. Of note, the clear cell renal cell carcinoma
shows no areas of signaling, no definitive sarcomatoid
differentiation.
Renal cell carcinoma is diffusely positive CA9, negative for CK7
and patchy positivity for P504s. The papillary renal cell
carcinoma is again diffusely positive for CK7 and P504s and
focally positive for CA9. Packs two shows focal weak staining
for both tumors with no after lymphovascular invasion as
identified on CT31 staining.
-- on [**2118-11-16**] Splenectomy showed vascular congestion with
subcapsular hematoma.
-- On [**2118-1-29**], the lesion in the pole of the right kidney most
consistent with papillary renal cell carcinoma is unchanged, and
fluid collection consistent with pseudocyst of one of the
pancreas is noted.
-- On [**2118-4-13**], he underwent partial right nephrectomy of the
2.6 cm papillary renal cell carcinoma, grade 2 (T1a Nx) with the
size of the tumor measured as a solid part 2.6 cm, adjacent cyst
continued minimal tumor. Specimen one in the belt of the cyst
adjacent to the tumor, right margin with papillary carcinoma
cauterized.
--On [**2119-4-15**], post-nephrectomy period complicated by fever and
treated for pneumonia. He was noted to have a low O2 and
underwent a chest x-ray, which noted a 5 cm elliptical opacity
in
the left upper hemi collapse with apparent adjacent local
destruction, new since [**18**]/[**2118**].
--On [**2119-4-17**], CT abdomen and pelvis revealed a 5.1 x 2.2 soft
tissue density lesion with destruction of the third posterior
lateral rib, fluid collection in the right partial nephrectomy
bed with a seroma. Coronary and aortic valve calcifications,
enlarged pulmonary artery, right lower lobe consolidation
concerning for pneumonia. A 7-mm right lung nodule, nonspecific
left upper lobe ground-glass opacity.
--On [**2119-10-1**] admitted for pleural effusion which was tapped by
IP. Interval need of supplemental O2. He was stopped on his
experimental therapy.
Past Medical History:
PMH: HTN, bilateral renal masses, HLD
PSH: splenectomy [**2118**], lap left radical nephrectomy [**2118**], R CEA
([**Doctor Last Name **]) [**2116**], hernia repair x 2
Social History:
He is a senior project coordinator for the Department of Mental
Health, specializes in [**Doctor First Name **] networks. He has a 50-pack-year
smoking history, continues to smoke one pack per day, occasional
alcohol, no drug use. He drinks rare alcohol. He is retired but
still works two days a week.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM ON DISCHARGE:
Vitals - T: 97.6 BP: 118/52 HR: 65 RR: 18 02 sat: 96% 2L NC
GENERAL: NAD, tired appearing
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
BACK: Dressing c/d/i with drain in place
ABDOMEN: nondistended, [**Month (only) **] BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength 5/5 biceps and triceps
bilaterally, left hip flexors, plantar and dorsiflexion; 4- R
dorsiflexion, 4+ R hip flexors
Pertinent Results:
MR [**Name13 (STitle) 1093**] [**10-20**]: There are multiple vertebral body metastases
demonstrated. These are identified at T1, T2, T4, T5, and
sacrum. The largest of these lesions is at T5 where there is
collapse of the vertebral body, to a considerably greater extent
than present on the [**9-26**] CT scan. There is extensive
soft tissue extending from the posterior vertebral body into the
spinal canal producing severe spinal cord compression at T5.
Tumor extends into the canal from the T2 body and just touches
the left anterior surface of the spinal cord. Tumor also
extends into the canal from the T4 body, again touching the
anterior surface of the cord. There is no evidence of cord or
cauda equina compromise at the other metastatic levels.
At the level of most severe spinal compression, there is
hyperintensity in the spinal cord on the long TR images,
presumably edema related to severe compression.
The metastases enhance after contrast administration. No
intradural tumor is identified.
Again noted are multiple other metastases in the chest wall,
incompletely
evaluated on this examination. Also again seen are bilateral
pleural
effusions, greater on the left than right.
CONCLUSION: Multiple spinal vertebral metastases with collapse
of the T5 vertebral body and a soft tissue extending into the
canal at this level producing severe spinal cord compression.
Soft tissue extends into the canal at T2 and T4 contacting the
spinal cord but not producing cord compression.
Brief Hospital Course:
Mr. [**Name13 (STitle) 54864**] is a 75M with metastatic renal cell carcinoma with
known malignant right sided pleural effusion s/p recent drainage
who presented with several days of right sided leg weakness,
urinary retention for several weeks/months and constipation,
with radiographic evidence of cord compression at the level of
T5 as above.
1) Cord compression - Upon admission, Mr. [**First Name (Titles) 82581**] [**Last Name (Titles) 23156**]
clinical signs of cord compression, including right leg
paralysis and radiographic evidence of T8 cord invasion. He
underwent operative intervention on [**2119-10-22**] with decompression
at the level of the T5 lesion, fusion T2-T8, laminectomies at T4
and T6, instrumentation T2-8, cage placement at T5, and
autografting. Please see the operative report for complete
details. Following this procedure, his strength improved. He was
placed on a post-operative steroid taper, starting at
dexamethasone 6mg IV q6hrs to be tapered down by 1mg q6hrs every
other day. This regimen was converted to PO on the day of
discharge. He was discharged taking 4mg PO q6hrs. His next
adjustment was to be a decrease to 3mg PO q6hrs, to be initiated
48 hours after discharge.
2) Pleural Effusion - Patient was recently discharged after
drainage of a recurrent malignant right pleural effusion and
placement of Pleurx catheter. Admission CXR demonstrated a
stable/slightly decreased effusion. He was saturating well on
room air at time of discharge. This collection was drained every
other day per his regular scheduled.
3) Hyponatremia - Stable sodium at 132 upon admission.
Previously attributed to SIADH. Stable throughout this
hospitalization; sodium equal to 133 on day of discharge.
4) Hypercalcemia - Calcium at admission 10.4. Previous
admissions with suspicion of etiology secondary to combination
of bony metastases and paraneoplastic hypercalcemia, though no
definitive work-up for PTHrP performed. Managed well via
intravenous fluids. Corrected calcium equal to 9.1 on day of
discharge.
4) Leukocytosis - Patient with persistent leukocytosis of
several years - attributed on previous admissions to be
secondary to his renal cell carcinoma. Relatively stable
througout admission, though did exhibit increase in WBC count
status-post initiation of dexamethasone therapy. WBC count equal
to 21.4 on day of discharge, comparable to previous values.
Expected to trend downwards with tapering of steroids as above.
5) Thrombocytosis - Patient's thrombocytosis attributed to
previous splenectomy/hyposplenism.
6) Metastatic renal cell carcinoma - Had been receiving Genetech
study drug, but discontinued on recent admission secondary to
dyspnea and progressive disease. Mr. [**Name13 (STitle) 54864**] is to follow-up as
an outpatient for re-evaluation and initiation of chemotherapy.
CHRONIC ISSUES:
7) Hyperlipidemia - continued simvastatin.
8) Hypertension - continued metoprolol.
==========================================
TRANSITIONAL ISSUES:
- Mr. [**Known lastname 82579**] remained full code throughout his
hospitalization.
- His HCP is [**Name (NI) 2411**] [**Name (NI) 44263**] (girlfriend of many years):
[**Telephone/Fax (1) 82582**], Cell phone: [**Telephone/Fax (1) 82583**]
- He will require outpatient follow-up with [**First Name8 (NamePattern2) 20062**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
NP [**Telephone/Fax (1) 63699**] after discharge.
- He has an appointment with Dr. [**Last Name (STitle) **] (neurosurgery) on
TUESDAY [**2119-10-31**] at 9:30 AM
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Tartrate 25 mg PO BID
4. Senna 1 TAB PO BID:PRN constipation
5. Simvastatin 10 mg PO DAILY
6. Tamsulosin 0.4 mg PO BID
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
Breakthrough pain. Hold for RR < 12.
8. Bisacodyl 10 mg PO DAILY
9. Morphine SR (MS Contin) 30 mg PO Q8H
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Polyethylene Glycol 17 g PO DAILY constipation
3. Tamsulosin 0.4 mg PO BID
4. Simvastatin 10 mg PO DAILY
5. Dexamethasone 4 mg PO Q6H Duration: 48 Hours
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Pantoprazole 40 mg PO Q24H
8. Metoprolol Tartrate 25 mg PO BID
9. Morphine SR (MS Contin) 30 mg PO Q8H
RX *morphine 30 mg 1 tablet(s) by mouth q8hrs Disp #*52 Tablet
Refills:*0
10. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
Breakthrough pain. Hold for RR < 12.
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q4hrs
Disp #*80 Tablet Refills:*0
11. Senna 1 TAB PO BID:PRN constipation
12. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
PRIMARY:
- metastatic renal cell carcinoma
SECONDARY:
- T5 cord compression
- hypercalcemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 54864**],
Thank you for choosing [**Hospital1 18**] for your medical care. You were
admitted to the hospital for compression of your spinal cord
caused by a metastatic lesion from your renal cancer. You
underwent surgery to relieve this compression. You did well.
Upon discharge, please keep all of your scheduled appointments
with your doctors. Please take all medications as prescribed.
Refrain from driving while taking pain medication.
Please return to the hospital or call Dr.[**Name (NI) 9034**] office at
[**Telephone/Fax (1) 3231**] if you experience any of the following: fever,
chills, night sweats, loss of conciousness, chest pain, trouble
breathing, opening of your incision, foul smelling or pus-like
discharge from your wound, worsening back pain, increasing
weakness, or any other symptoms that concern you.
Spine Surgery recommendations per Dr. [**Last Name (STitle) 14354**] [**Name (STitle) **]:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? Dressing may be removed on Day 2 after surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any medications such as Aspirin unless directed by
your doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We 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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
You will have a follow-up appointment in approximately 2 weeks
with Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) 17265**] to discuss chemotherapy
options. They will call you with an appointment. Please call
[**First Name8 (NamePattern2) 20062**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 63699**] if you have not heard from
them within approximately one week.
Neurosurgery Follow-up:
Wound check w/ Nurse [**Month (only) **]
Date: Tuesday, [**2119-10-31**]
Time: 9:30am
Location: [**Hospital Ward Name 517**], [**Hospital Unit Name **] ([**Hospital Unit Name 12193**])
[**Last Name (NamePattern1) 439**], [**Location (un) 86**], [**Numeric Identifier 718**]
T-Spine CT scan **NPO 3 hrs prior to scan**
Date: Tuesday, [**2120-1-30**]
Time: 1:30pm
Location: [**Hospital Ward Name 517**], Clinical Center ([**Location (un) 470**])
[**Hospital1 7768**], [**Location (un) 86**], [**Numeric Identifier 718**]
[**First Name8 (NamePattern2) **] [**Doctor Last Name **], M.D, PhD
Date: Tuesday, [**2120-1-30**]
Time: 2:30pm
Location: [**Hospital Ward Name 517**], [**Hospital Unit Name **] ([**Hospital Unit Name 12193**])
[**Last Name (NamePattern1) 439**], [**Location (un) 86**], [**Numeric Identifier 718**]
If you know that you will not be able to keep your appointment,
please give us a call and we will be happy to re-schedule your
appointment for you. Please call [**Telephone/Fax (1) 3231**].
Department: NEUROLOGY
When: MONDAY [**2119-10-30**] at 11:00 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
Department: NEUROSURGERY
When: TUESDAY [**2119-10-31**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 82584**], NP [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5859, 3051, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7138
} | Medical Text: Admission Date: [**2100-7-21**] Discharge Date: [**2100-7-22**]
Date of Birth: [**2038-3-30**] Sex: M
Service: MEDICINE
Allergies:
Latex / Verapamil
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
elective ablation for A-fib
Major Surgical or Invasive Procedure:
s/p elective blation for A-fib
s/p pericardiocentesis
History of Present Illness:
62 year old man has a history of paroxysmal atrial fibrillation
that dates back to his 20's. He has undergone about 7
cardioversions and has been trialed on several antiarrythmics
including Sotalol and Flecainide. In late [**2097**] the patient began
to experience increasing episodes of AF and underwent pulmonary
vein isolation/flutter ablation on [**2099-4-1**]. Following the
ablation he gradually weaned off of Flecainide. In [**Month (only) 1096**] of
[**2098**] he had a prolonged episode of rapid palpitations that
required cardioversion. Following this he has had almost monthly
episodes of rapid palpitations that he has treated with am
"Flecainide cocktail", described as 300mg every four hours until
resolution of symptoms. His most recent episode in [**2100-6-6**]
required admission to [**Hospital3 **] for repeat cardioversion.
He has not had further palpitations since then and is referred
for left atrial tachycardia ablation.
.
Prior to admission the patient reported feeling well except for
an occasional sensation of skipped beat. He had intermittent LE
edema which he treated with compression stockings and as needed
lasix. When he is in the arrhythmia for a prolonged period, he
is aware of palpitations and a feeling of being run down.
.
He presented on the morning of admission to the CCU for elective
ablation for A-fib complicated by pericardial effusion. MAPs
fell into the 40s. A drain was placed and 500cc were drained.
His MAPs rose into the 80-90s and he was brought to the CCU for
treatment and monitoring.
.
On arrival to the CCU, patient was intubated with normal
pressures.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes (pre), + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
PAF s/p multiple cardioversions, s/p ablation [**3-/2099**], s/p
ablation [**7-/2100**]
Sleep apnea (does not use machine)
Elevated PSA, three prior biopsies negative
[**2083**] Cholecystectomy
? Asthma, frequent bronchitis
Microscopic Hematuria- cystoscopy negative per patient report
Hx of Extended-spectrum beta-lactamase (ESBL)
Social History:
-Tobacco history: Never
-ETOH: one beer 1-2 times per month
-Illicit drugs: Denies
Married with two children. Works as an electrical engineer.
Family History:
His grandfather also had atrial fibrillation. He has two
daughters, one of whom is 29, has had paroxysmal atrial
fibrillation for the past five years.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=98.3 BP=124/73 HR=99 RR=17 O2 sat= 98%
GENERAL: WDWN male, intubated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. Pericardial drain in place.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2100-7-21**] 07:00AM BLOOD WBC-8.1 RBC-4.90 Hgb-15.3 Hct-45.3 MCV-93
MCH-31.3 MCHC-33.8 RDW-13.0 Plt Ct-193
[**2100-7-21**] 07:00AM BLOOD PT-23.0* INR(PT)-2.2*
[**2100-7-21**] 07:00AM BLOOD Glucose-167* UreaN-16 Creat-0.8 Na-142
K-3.8 Cl-106 HCO3-26 AnGap-14
[**2100-7-21**] 04:20PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8
.
Discharged labs:
[**2100-7-22**] 05:20AM BLOOD WBC-11.4* RBC-4.30* Hgb-13.2* Hct-40.4
MCV-94 MCH-30.8 MCHC-32.8 RDW-12.9 Plt Ct-201
[**2100-7-22**] 05:20AM BLOOD PT-21.1* PTT-32.2 INR(PT)-2.0*
[**2100-7-22**] 05:20AM BLOOD Glucose-154* UreaN-13 Creat-0.8 Na-140
K-3.7 Cl-107 HCO3-25 AnGap-12
[**2100-7-22**] 05:20AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.0
.
[**2100-7-21**] TTE:
There is a small-moderate pericardial effusion visualized along
the LV apex and right ventricle. Tamponade physiology cannot be
excluded based on the initial pre-pericardiocenthesis. Following
aspiration of 400 cc of fluid, the amount of pericardial
effusion appears small without echocardiographic signs of
tamponade. After removal of an additional 100 cc of fluid, the
pericardial effusion appears trivial. Based on limited views,
global left ventricular systolic function is normal (LVEF >
55%).
.
[**2100-7-22**]: TTE
There is a trivial/physiologic pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
There are no echocardiographic signs of tamponade.
.
IMPRESSION: Focused study. Trivial pericardial effusion without
echocardiographic evidence of tamponade.
.
Compared with the prior study (images reviewed) of [**2100-7-21**],
the findings are similar (when compared to the
post-pericardiocentesis images performed at the end of the
study).
Brief Hospital Course:
62 yo male with PAF, HTN, and HLD who presented for elective
ablation for A-fib complicated by pericardial effusion.
#Pericardial Effusion: Patient's ablation procedure was
complicated with ablation through left atriam with resulting
pericardial effusion. In the cath lab, patient's MAPs fell into
the 40s during the procedure. He was placed on neo and
pericardiocentsis was perfromed with drainage of 500cc of bloody
fluid. Subsequently his MAPs rose into the 80-90s and neo was
discontinued. He was transfered to CCU for further monitoring
overnight. Per report patient ablation was not totally completed
at the time of pericardial effusions. Overnight in the CCU
patient's blood pressure reamined stable. He reported
improvement in his pleuritic chest pain. Overnight patient had
about 125ml of serosangrounes fluid in the drain with no blood
or clot therefore the drain was removed and sterile dressing
applied. He had repeat echo in the morning which did not show
any further reaccumulation of pericardial fluid. Patient was
discahrged on colchicine 0.6mg for one month to help with pain
and prevent pericarditis.
#Recurrent atrial fibrillation: He underwent a left atrial
ablation for recurrent PAF. The procedure was complicated as
above. His INR remained 2.0 and his Coumadin was continued as an
outpatient with an INR check on [**2100-7-26**] at his [**Hospital 197**] clinic.
He was continued on Metoprolol 25 mg twice daily as prescribed.
he was also started on Aspirin 325 mg daily for 1 month post
ablation. Prilosec 40 mg daily for 1 month.
#HLD: continued home atrovastatin
EMERGENCY CONTACT: [**Name (NI) 8513**] (wife) [**Telephone/Fax (1) 90267**] (cell)
#Transitional issues:
- Started patient one month of aspirin. Continued Coumadin
daily, INR goal [**1-8**]. PT/INR at [**Hospital3 3765**] on [**2100-7-26**].
- Patient will follow up with Dr. [**Last Name (STitle) **] on thursday [**8-26**], [**2099**] at 2:40pm
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Magnesium Oxide 500 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Flecainide Acetate 300 mg PO Q4H:PRN while in AF
4. Warfarin 6-8 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. Furosemide 20 mg PO DAILY:PRN LE edema
7. Multivitamins 1 TAB PO DAILY
8. Calcium Carbonate 600 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY:PRN while taking lasix
Duration: 24 Hours
Hold for K > 5.0
10. Tamsulosin 0.8 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY Duration: 1 Months
2. Atorvastatin 10 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
Hold HR<55, SBP<100
4. Omeprazole 40 mg PO DAILY Duration: 1 Months
5. Tamsulosin 0.8 mg PO DAILY
6. Warfarin 6 mg PO DAILY
as directed
7. Potassium Chloride 20 mEq PO DAILY:PRN while taking lasix
Duration: 24 Hours
Hold for K > 5.0
8. Calcium Carbonate 600 mg PO DAILY
9. Furosemide 20 mg PO DAILY:PRN LE edema
10. Magnesium Oxide 500 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Colchicine 0.6 mg PO DAILY Duration: 30 Days
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: pericardial effusion
Secondary: atrial fibrilation
Discharge Condition:
Hospital course; Mr. [**Name14 (STitle) 90268**] was admitted to the hospital
following an elective ablation for recurrent symptomatic atrial
fibrillation. It was complicated by a collection of fluid around
your heart. The fluid was drained and you did well. A follow up
echo did not show any further accumulation of fluid.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 90269**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admittted to the hospital following an
ablation to treat atrial fibrillation. The procedure was
complicated by a collection of fluid around your heart. The
fluid was drained and you did well.
We made the following changes to your medications:
- Please take Prilosec (omeprazole) daily for 1 month to
decrease stomach acid.
- Please take aspirin daily for 1 month to decrease
inflammation.
- Please take colchicine daily for 1 month to prevent
inflammation around the heart. This medicine may cause nausea
and diarrhea.
Followup Instructions:
Please have your INR checked at your clinic at [**Hospital1 **] on
Monday.
Department: CARDIOLOGY [**Location (un) **]
When: THURSDAY [**2100-8-26**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1536**]
Building: [**Apartment Address(1) 71186**]
([**Location (un) 1514**],MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Completed by:[**2100-7-23**]
ICD9 Codes: 9971, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7139
} | Medical Text: Admission Date: [**2188-12-24**] Discharge Date: [**2188-12-30**]
Date of Birth: [**2137-10-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Acute Coronary Syndrome with V-Fib Arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization with placement of Bare Metal Stents to
the Right Coronary Artery - [**2188-12-24**]
History of Present Illness:
**History obtained from medical record/pt's wife
51-year-old man with a past medical history of hypertension and
hyperlipidemia who was brought by EMS to the ED at [**Hospital1 **] on
the evening prior to admission with VFib arrest. He complained
of feeling "poorly" all day on the day prior to admission, with
back pain, nausea, and profound weakness (though he did go
towork). He took tylenol with codeine for back pain and Tums
for symptoms of indigestion. He went to bed at midnight. As
soon as his wife shut the lights off, she felt him shaking,
turned on the lights and he was "having a seizure" and did not
respond to her. 911 was called; EMS arrived within 5 minutes.
Found the patient nonresponsive. Placed AED-->V-Fib arrest-->
defibrillated him x 1. He developed sinus brady, transient Afib
and then sinus tach. Lidocaine gtt started. SBP low at 80,
dopamine gtt started. Unable to intubate, bagged him
successfully. Given narcan due to pinpoint pupils with no
response. He was transported to [**Hospital1 **].
.
OSH COURSE: GCS on arrival to ED= 5. He was intubated, NGT and
foley placed. Head CT negative for bleed, chest CT negative for
PE. His cardiac enzymes were positive (trop 712, CPK 466, MBI
6.5, ALT 271, ALT 195, ABG: 7.37/36/231). Initial EKG with Afib
at 98, Lateral ST depressions, inferior Q waves; then converted
to sinus rhythm 117, lateral ST depression, inferior Q waves.
BP increased to 210/140, dopamine and lidocaine discontinued.
Given NS 1.5L, ASA 325, Plavix 300, heparin and integrillin
gtts, metoprolol 5 mg IV, Ativan 2 mg.
Admitted to OSH ICU overnight. Cardiac cath performed on the day
of transfer; found to have 100% occluded RCA with collaterals,
Left Main: 20% at ostium, LAD: clean, D1 50% ostial stenosis,
LCx: 30% stenosis. V gram: EF 40%, inferior wall hypo/akinesis,
normal mitral valve, normal aortic root. Started on integrillin,
transferred to [**Hospital1 18**] for revascularization. Vitals at OSH: HR in
60's afebrile, SBP 9o's.
.
Past Medical History:
Hypertension
hyperlipidemia
remote h/o tobacco use
.
Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension
Social History:
Social history is significant for the absence of current tobacco
use; he is a former smoker (stopped in [**2161**], has 15 pk yr hx).
There is no history of alcohol abuse, currently drinks less than
1 glass of wine/day. Exercises regularly.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother died of MI at 63, also had DM,
depression. Father: died at 70 COPD, ETOH. He has 1 sister and
4 brothers, one had CABG in 50s. Works as architect, married x
25 years, has 2 sons.
Physical Exam:
VS: T 101 , BP 98/55, HR 82, RR 22, O2 100%
VENT: AC 500x18, 40% O2, PEEP= 5.
Gen: WDWN middle aged male, intubated/sedated. NGT in place,
draining coffee grounds.
NEURO: Sedated/nonresponsive. +gag, +corneal reflexes,
withdraws RUE, RLE, LLE in response to pain, babinski upgoing
b/l.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple
CV: PMI located in 5th intercostal space, midclavicular line.
heart sounds distant, RR, normal S1, S2. No S4, no S3. No
murmur.
Chest: No chest wall deformities, scoliosis or kyphosis. No
crackles, wheeze, rhonchi on anterior exam.
Abd: Obese, soft, ND, No HSM or tenderness. No abdominial
bruits. NGT with guaic + drainage.
Ext: No c/c/e. No femoral bruits. R fem arterial sheath in
place
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+
PT, dopperalble DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP,
1+ PT
Pertinent Results:
EKG demonstrated NSR at 79, nl axis, nl intervals, Q's in
2,3,avF, TWI 3, avF, 1 PVC.
.
TELEMETRY demonstrated: NSR at 85
.
[**2188-12-24**] 02:28PM WBC-7.4 RBC-3.60* HGB-11.7* HCT-32.7* MCV-91
MCH-32.7* MCHC-36.0* RDW-12.6
[**2188-12-24**] 02:28PM NEUTS-86.5* BANDS-0 LYMPHS-8.6* MONOS-4.2
EOS-0.5 BASOS-0.2
[**2188-12-24**] 02:28PM CK-MB-97* cTropnT-5.19*
[**2188-12-24**] 02:28PM GLUCOSE-159* UREA N-28* CREAT-1.1 SODIUM-140
POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-17* ANION GAP-16
[**2188-12-24**] 03:55PM CK-MB-88* MB INDX-5.2 cTropnT-5.91*
.
Cath: [**12-24**]
1. Limited coronary angiography demonstrated single (1) vessel
coronary
artery disease. The right coronary artery demonstrated a
totally
occluded proximal RCA with a large thrombus burden. The left
system was
not engaged - outside hospital angiography demonstrated no
severe
stenosis with the distal left supplying collaterals to the
right.
2. Successful thrombectomy, PTCA and stenting of the proximal -
mid RCA
with a Vision (3x28mm) bare metal stent postdilated with a 4.0
mm
balloon in the proximal portion of the stent. Final angiography
demonstrated no angiographically apparent dissection, no
residual
stenosis and TIMI III flow (see PTCA comments).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Acute inferior myocardial infarction, managed by
thrombectomy, PTCA
and stenting of the proximal-mid RCA with a bare metal stent.
.
TTE [**12-25**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with inferior
akinesis and basal inferolateral hypokinesis. The remaining
segments contract normally (LVEF = 45%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD.
Brief Hospital Course:
ASSESSMENT AND PLAN
Pt. is a 51y.o. M with a PMH of HTN and hyperlipidemia
transferred from OSH after VFib arrest and diagnostic cath
demonstrated TO of RCA.
.
# CAD/Ischemia: Pt presented with late sx of ischemia after
suffering Vfib arrest at home. Per records EMS defibrillated
w/in 5minutes of call. Diagnostic cath at OSH demonstrated no
stenosis of LAD, 50% ostial D1, mild stenosis of mid LCx and
prox occlusion of RCA. LVgram EF 40%. Pt underwent PCI upon
transfer with BMS to RCA. Pt HD stable. Peak CK 1700. Patient
was maintained on aspirin, plavix, metoprolol, high-dose statin,
and lisinopril 10mg daily, and was discharged on these
medications.
.
# Pump: LV gram as OSH demonstrated EF of 40%. ECHO showed EF of
45% with akinesis of inferior wall and no RV involvement.
Patient to be continued on metoprolol and lisinopril as an
outpatient, and should also have an echocardiogram done within 2
months time to assess his heart function.
.
# Rhythm: Pt currently NSR. History of Vfib arrest, most likely
secondary to ischemic event. His QT-interval have been monitored
on morning ECGs and are not concerning. He was monitored on
telemetry while hospitalized and did not have any further
arrhythmias.
.
# Altered Mental Status - Pt was bagged in the field by EMS and
intubated on arrival at OSH. Per records, the Pt was
resuscitated quickly following arrest. Unclear length of time
the patient was anoxic. Per report CT head negative for evidence
of CVA. Patient has been improving since extubation. Per
behavioral neurology consult, this is likely anoxic brain
injury, and will improve with time, no need for MRI at this
time. Will need outpatient rehabilitation. Psychiatry was
consulted to see patient for agitation, confusion, and paranoia,
and suggested using Haldol and redirection rather than
antipsychotics or sedatives. His mental status has since greatly
improved, and his short term memory continues to improve as
well. He is being discharged on Haldol 1mg at bedtime as needed,
given this improvement. He will need further
neuro-rehabilitation.
.
# PNA - Patient has been febrile since admission. PA and lateral
CXR with RUL opacity, and sputum culture positive for heavy
growth of MSSA. Blood cultures NGTD and patient will need to
finish a 10-day course of Doxycycline. Etiology unclear but
etiologies include aspiration during myocardial infarction, or
introduction of organisms during intubation. He will complete
his course of antibiotics on [**2189-1-6**].
.
# GI bleed - On admission, pt with coffee ground emesis on NG
tube suctioning - heme positive. No evidence of active bleeding
with NG lavage. Bleed most likely related to trauma of NG tube
placement with anticoagulation. Hematocrit has remained stable
with no further evidence of bleed. Patient was maintained and
discharged on a PPI.
.
# Elevated LFTs - At OSH AST 271, ALT 197. Elevation most likely
related to MI, continued to improve during hospitalization.
.
Medications on Admission:
MEDICATIONS AT HOME: (per OSH records)
Lisinopril 40 daily
Atenolol 25 daily
.
MEDICATIONS on Transfer:
Lipitor 80
Heparin gtt
Integrillin gtt
Propofol gtt
Aspirin 325
Plavix 300 mg then 75 daily
Protonix 40
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 7 days.
Disp:*15 Capsule(s)* Refills:*0*
8. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Primary Diagnoses:
1. Myocardial infarction with Vfib arrest
2. MSSA pneumonia
3. Anoxic brain injury
.
Secondary Diagnoses:
Hypertension
hyperlipidemia
remote h/o tobacco use
Discharge Condition:
Afebrile, stable vital signs, tolerating POs, ambulating without
assistance, mental status improving.
Discharge Instructions:
You were admitted to the hospital as you had a heart attack and
an abnormal heart rhythm called ventricular fibrillation. You
were defibrillated, or shocked, by the EMTs in the ambulance,
and were brought to [**Hospital1 18**]. You had a cardiac catheterization
and with removal of a clot and subsequent placement of a bare
metal stent in your right coronary artery. Given the amount of
time that elapsed from the beginning of your symptoms you may
have suffered some anoxic brain injury. You were agitated
initially, and you were seen by Psychiatry and Behavioral
Neurology, who recommended a medication at bedtime called
Haldol, which you should continue to take at night as needed.
You continued to improve greatly, but you will need further
rehabilitation after discharge.
.
1. Please take all medication as prescribed.
2. Please make all medical appointments.
3. Please return to the Emergency Room immediately if you have
any concerning symptoms.
Followup Instructions:
You should follow-up with your Primary Care Provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 24298**], on Tuesday, [**1-6**], at 2:30pm. Phone: [**Telephone/Fax (1) 35985**]
.
You should follow-up with your cardiologist within 2 weeks
following discharge. If you do not have one and would like to
be followed at [**Hospital1 69**], please call
the Dept of Cardiology at [**Telephone/Fax (1) 62**] to schedule an
appointment.
.
You should also follow-up with Behavioral Neurology, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], on Thursday, [**1-22**], at 9:30am, on [**Hospital Ward Name 77198**], at the [**Hospital Ward Name 860**] [**Doctor Last Name **] [**Apartment Address(1) 16806**]. Phone: [**Telephone/Fax (1) 1690**]
.
ICD9 Codes: 486, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7140
} | Medical Text: Admission Date: [**2123-6-4**] Discharge Date: [**2123-6-7**]
Date of Birth: [**2052-2-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
hypoxia, fever/cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
71 y/o female with PMH significant for for severe diastolic
dysfunction, atrial fib, severe PVD with chronic LE ulcers, and
CAD admitted through the ED with hypoxia. Pt had a recent
admission to the MICU [**Date range (1) 32718**]/5 for septic shock (presumed [**3-10**]
LE ulcers). She was in her normal state of health until this
morning when she appeared very lethargic when trying to get out
of bed. Her oxygen saturation was found to be 60% on room air at
[**Hospital1 100**] Senior Life. Pt was sent to the [**Hospital1 18**] ED where her sat
was 85 to 100% on a NRB with a ABG of 7.30/63/161. She was
started on CPAP of 10 which she tolerated well for approximately
20 minutes. However, she then became hypotensive to 78/40 so
CPAP was discontinued and she was put back on a nonrebreather.
After a 500 cc bolus, pt's SBP increased to around 90. Her Sats
came up to 94-100% on 4L NC. Pt states she has had productive
cough x 5 days. Otherwise ROS neg for f/c, HA, stiff neck, abd
pain, d/c/n/v.
.
In ED, received vanco, levofloxacin, flagyl, solumedrol 50mg,
tylenol
.
Past Medical History:
1. CHF diastolic dysfunction (EF 65% 1/05 MIBI normal)
DRY WEIGHT 194 lbs
2. DM 2 on insulin
3. Atrial Fibrillation
4. Anemia
5. CAD s/p PTCA x 3 (RCA '[**09**], LCx '[**10**], RCA '[**13**])
6. Pulmonary HTN
7. Hypercholesterolemia
8. COPD/[**Year (2 digits) 105496**] on home O2 (sometimes on home O2)
9. Thyroid CA s/p resection/now hypothryoid
10. Myoclonic tremors
11. H/O PE
12. OSA on CPAP (started last admission)
13. Depression/Anxiety
14. h/o MRSA/VRE. ICU admit x 2 for MRSA aortic valve
endocarditis and pseudomonal sepsis (secondary to wound
infection), status post intubation x 2.
15. S/p laproscopic cholecystectomy
[**34**]. s/p right throcoscopy and decortication. Right lung bx.
17. s/p right hip ORIF
18. s/p right ankle ORIF
Social History:
SH:
Pt lives at [**Hospital1 100**] Senior Life. She is divorced and has three
children. She quit smoking in [**2104**] but has a history of 1 PPD
for 15 years. No ETOH or drugs.
Family History:
FH:
[**Name (NI) 1094**] father died at age 47 from a MI. Her mother died of colon
CA. Pt has a brother with DM.
Physical Exam:
PE:
103.8 --->101.7 w/o meds 88 107/52 18 98% 2L NC
Genl- well appearing, conversant, NAD
HEENT- anicteric, sclera/op clear, dry mm
Neck- jvd difficult to appreciate, supple
Cardiac- irregular no m
Lungs: crackles halfway up on R and [**2-8**] way up on L
Abdomen- +bs, soft, nt
Extremities- chronic LE ulcers b/l, chronic venous stasis
changes
Neuro- alert and oriented, moving all extremities
Pertinent Results:
[**2123-6-4**] 11:45AM LACTATE-1.6
[**2123-6-4**] 11:18AM K+-4.8
[**2123-6-4**] 11:15AM URINE HOURS-RANDOM
[**2123-6-4**] 11:15AM URINE GR HOLD-HOLD
[**2123-6-4**] 11:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2123-6-4**] 11:15AM URINE RBC-0-2 WBC-[**4-10**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2123-6-4**] 09:16AM TYPE-ART RATES-/30 O2-100 PO2-161* PCO2-53*
PH-7.30* TOTAL CO2-27 BASE XS-0 AADO2-506 REQ O2-84
INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2123-6-4**] 09:16AM HGB-11.4* calcHCT-34
[**2123-6-4**] 09:05AM CK(CPK)-122
[**2123-6-4**] 09:05AM CALCIUM-8.7 PHOSPHATE-4.8* MAGNESIUM-1.9
[**2123-6-4**] 09:05AM CK-MB-2
[**2123-6-4**] 09:05AM WBC-22.0*# RBC-4.44 HGB-12.0 HCT-38.3 MCV-86
MCH-27.1 MCHC-31.4 RDW-30.5*
[**2123-6-4**] 09:05AM NEUTS-86* BANDS-6* LYMPHS-3* MONOS-2 EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2123-6-4**] 09:05AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2123-6-4**] 09:05AM PLT COUNT-331#
[**2123-6-4**] 09:05AM PT-13.4 PTT-31.9 INR(PT)-1.1
ECG- Narrow complex tachycardia at 134 beats per minute. No
clear ST-T wave changes.
.
CXR (WET READ)- Cardiomegaly. Question of mild edema.
Brief Hospital Course:
71f w/ extensive PMHx, including recent admit [**Date range (1) 32718**]/5 for
septic shock (presumed [**3-10**] LE ulcers) who presents from Rehab
with hypoxia, fever, leukocytosis and transient hypotension.
1. Hypoxia:
This was most likley secondary to bronchitis/mucous plugging.
Her hypoxia resolved with bringing up a mucous plug, and her
oxygen saturation remained appropriate with minimal supplemental
oxygen. She was weaned from 2L nc to room air.
Her chest film on admission revealed stable chronic interstitial
lung disease, with no evidence of acute PNA or CHF. h/o [**Month/Day (2) 105496**],
ILD. transient hypoxia over hours. Pt's sat already up to 99% on
2L NC.
.
2. Fever/leukocytosis: possible sources include LE ulcers, and
pulmonary. UA neg. She recently completed 2week course of
vanco/ceftaz/flagyl for her ulcers. Over course of hospital
stay, trimmed abx down to just levo/vancomycin for presumed
bronchitis since she has a hx of MRSA. She got a PICC line
placed on [**6-7**] and will complete a 10 day course of Vanc/Levo for
prsumed bronchitis vs bacterial pneumonia.
She was seen by [**Month/Day (2) **] while in house, and continued her
routine dressing changes and wound care. There was no evidence
of wound infection at this time.
.
3. Hypotension - Overall, this was transient, and likely
secondary to decreased preload in the context of positive
pressure ventilation. Thereafter, she remained normotensive,
and required no further hemodynamic support. There was no
evidence of sepsis, and her [**Last Name (un) 104**] stim test showed no evidence of
adrenal insufficiency.
.
5. DM - She was continued on glargine and RISS
.
6. Pain - She was continued on fentanyl patch, prn oxcodone, and
gabapentin.
.
7. Asymmetric leg swelling: She has a hx of severe PVD and
chronic venous stasis. LENI was negative for DVT. Asymmetric
leg edema is likely from her chronic venous change.
.
8. Access - She got a PICC line placed in the right arm on [**6-7**].
.
9. PPx - PPI, hep SC
.
10. Code status - FULL CODE
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
3. Atrovent 18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
8. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Methylphenidate HCl 10 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
11. Methylphenidate HCl 5 mg Tablet Sig: One (1) Tablet PO
NOONTIME ().
12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
13. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
16. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
17. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
18. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
19. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
21. Vancomycin HCl 1000 mg IV Q12H
22. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): day#1 was [**6-5**] for first full day of abx;
continue for 10d course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
1. Hypoxia - resolved
2. fever, bronchitis/pneumonia
3. hypotension - resolved
4. atrial fibrillation
5. h/o CAD
6. DM 2
7. hypothyroidism
8. COPD/[**Location (un) 105496**], pulmonary htn
9. anxiety/depression
10. h/o MRSA and VRE
11. chronic lower extremity [**Location (un) 1106**] disease/ulcerations
Discharge Condition:
good
Discharge Instructions:
Weights at NH to monitor fluid status
2 gm sodium diet
Continue antibiotics and regular medications.
Follow up with [**Hospital1 100**] SeniorLife primary physician
Completed by:[**2123-6-7**]
ICD9 Codes: 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7141
} | Medical Text: Admission Date: [**2144-12-17**] Discharge Date: [**2144-12-22**]
Date of Birth: [**2099-2-28**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Dilantin
Attending:[**First Name3 (LF) 19817**]
Chief Complaint:
transfer from CHB after status epilepticus
Major Surgical or Invasive Procedure:
extubation
History of Present Illness:
Per admitting resident:
54 year old woman with history of seizure disorder, smoker,
who presents intubated after having been on and off seizures for
30 min. She is a patient of Dr. [**Last Name (STitle) 2442**], has partial complex
seizures. She was having increased seizure frequency when she
was
last seen in clinic by Dr. [**Last Name (STitle) 2442**] in [**5-23**], one every other
day. "Almost all are staring spells with
oral automatisms and touching her lips. She is not aware of the
start of them and may not be aware of the entire seizure or not
for the reports of her children and coworkers"; her boyfriend
says that she rarely has GTC seizures, last one was 2 months
ago.
She has been on lamictal 900mg; stopped keppra on [**12-22**] due to
side effects. Of note, her first seizure occurred at age
16 and led to a fall and head injury.
She works at the [**Hospital1 **] at the neurology department and was
seen to have R sided twitching that evolved to GTC seizures,
intermittently, for a period of 30 min. She received 15
diastat;
was intubated in [**Hospital1 **] ER; sedated on versed and received a
total of 8mg ativan. Her WBC was 20; had a temperature 38.9 C
and
she was given 2mg ceftriaxone. An LP was performed with 0 WBC 1
RBC (unknown protein and glucose values right now). She was
loaded with 1g dilantin. A head CT was read as negative at
[**Hospital1 **] and she was transferred here. On arrival here she had
T 98.9 BP 103/60 P 93 RR 19 Sat 100, intubated. She received 1g
of vancomycin. She was found to have a UTI. She had no jerks and
eyes were midline.
Past Medical History:
-epilepsy (as above)
-asthma
-eating disorder
-fibroids
Social History:
lives with 2 daughters, smokes 5 cigarettes per day as per
previous notes, works at [**Hospital1 **] neurology department as a
secretary; no history of alcohol abuse
Family History:
paternal uncle with seizures, sister with ESRD on HD, HTN,
and "SA" (?substance abuse)
Physical Exam:
Exam on admission:
T 98.9 BP 103/60 P 93 RR 19 Sat 100; intubated
Gen: Lying in bed, intubated
HEENT: NC/AT, moist oral mucosa
Neck: supple
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: intubated,on versed, grimaces to noxious stimuli
Cranial Nerves:
Pupils equally round and slugshly reactive, 3 mm bilaterally.
Normal Doll's, corneal and gag reflexes.
Motor:
She moves all extremities symmetrically and spontaneously
Sensation: She retracts all extremities symmetrically to noxious
stimuli
Reflexes: B T Br Pa Pl
Right 2 1 1 1 1
Left 2 1 1 1 1
Toes were downgoing bilaterally.
Coordination: not able to perform
Gait: not able to perform
Romberg: not able to perform
Exam at time of discharge:
Pertinent Results:
Labs on admission:
[**2144-12-17**] 10:52AM BLOOD WBC-30.5* RBC-3.93* Hgb-12.3 Hct-35.6*
MCV-91 MCH-31.4 MCHC-34.6 RDW-12.6 Plt Ct-298
[**2144-12-18**] 02:12AM BLOOD WBC-18.5* RBC-3.45* Hgb-10.4* Hct-32.1*
MCV-93 MCH-30.3 MCHC-32.6 RDW-13.3 Plt Ct-254
[**2144-12-18**] 02:12AM BLOOD Neuts-88.0* Lymphs-8.1* Monos-3.7 Eos-0.1
Baso-0.1
[**2144-12-17**] 10:52AM BLOOD PT-14.2* PTT-21.5* INR(PT)-1.2*
[**2144-12-18**] 02:12AM BLOOD Glucose-92 UreaN-8 Creat-0.7 Na-144 K-3.3
Cl-114* HCO3-23 AnGap-10
[**2144-12-17**] 10:52AM BLOOD ALT-38 AST-26 LD(LDH)-257* CK(CPK)-122
AlkPhos-74 TotBili-0.4
[**2144-12-17**] 10:52AM BLOOD Albumin-4.5 Calcium-9.5 Phos-2.6* Mg-2.0
[**2144-12-17**] 10:52AM BLOOD cTropnT-<0.01
[**2144-12-17**] 10:52AM BLOOD Lipase-11
[**2144-12-17**] 03:35PM BLOOD TSH-0.99
[**2144-12-17**] 03:35PM BLOOD Phenyto-18.7
Toxicology:
[**2144-12-17**] 10:52AM BLOOD ASA-4 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Urine studies:
[**2144-12-17**] 10:52AM URINE RBC-0-2 WBC-[**6-24**]* Bacteri-MOD Yeast-NONE
Epi-[**6-24**]
[**2144-12-17**] 10:52AM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2144-12-17**] 03:34PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Imaging:
CT head: Prelim - no acute intracranial process
CXR - no pulmonary pathology
CT abd/pelvis;
1. Abnormal perfusion of the left kidney with areas of decreased
enhancement
within the cortex. These findings are worrisome for an acute
pyelonephritis.
Please clinically correlate.
2. Low attenuating lesion within segment II of the liver,
indeterminate in
etiology, this may represent an atypical hemangioma. Further
workup is
recommended, and can commence with an ultrasound.
3. Enlarged uterus with multiple fibroids. There is also
enlargement of the
right ovary. Therefore, an ultrasound of the pelvis may be
warranted for
further evaluation and to ensure stability.
Liver ultrasound;
IMPRESSION: Nonspecific subcentimeter hypoechoic lesion within
the left
hepatic lobe, corresponding to CT abnormality. Findings not
characterizable
as hemangioma and MR may be performed to further assess as
clinically
indicated.
Urine culture; yeast
Brief Hospital Course:
45 year old woman with history of seizure disorder (complex
partial seizures and occasional GTC) who was transferred from
CHB after a seizure cluster (30 mins) in setting of 38.9C, WBC
of 20K. On trasfer, she was intubated and her LP and CT head
were reportedly negative. Patient was loaded with Dilantin at
CHB with subsequent level of 18. She was admitted to Neuro ICU
for further treatment and monitoring.
NEURO: Suspected status epilepticus. Infectious evaluation was
as below. Routine EEG did not show epileptiform activity. She
was extubated and restarted on Lamictal 600mg [**Hospital1 **] (dosing
reported by patient). Dilantin was discontinued, she was
temporarily bridged with ativan 1mg IV Q8H while she was not
able to take PO. After extubation, patient appeared
encephalopathic, with impaired attention, intrusion saccades and
lateral gaze nystagmus without focal features. It was felt that
worsening of her seizure frequency was most likely due to either
an infectious process, medication non-adherence or non-epileptic
seizures (an event was witnessed while in ICU: report of a
gaseous odor, staring for 10 seconds, bilateral arm shaking that
was suppressible by examiner (total duration of 30 seconds) and
no post-ictal confusion). The patient was transferred to the
floor and refused further EEG monitoring during the
hospitalization because she was very angry her hair was cut at
time of presentation when leads were initially placed. She was
maintained on the lamictal 600 [**Hospital1 **] but voiced concern over her
dosing multiple times. The patient initially stated she was
taking this dose at home, however there were several conflicting
reports as to her actual dose she was taking. [**Location (un) 535**] was
[**Location (un) 653**] and she had been receiving lamictal 100 mg tabs,
directed to take 5 tabs [**Hospital1 **], and given 300 tabs per month. This
was last filled [**2144-10-1**]. When this was discussed with the
patient, she stated that she was taking 500 mg [**Hospital1 **], but still
had pills left from her last refill (which appeared to be
inconsistent with the number of pills dispensed at that time).
The last note from the patient's epileptologist, Dr. [**Last Name (STitle) 2442**],
reported a plan to take lamictal 900 mg daily. Given the
conflicting reports, it was decided to discharge the patient on
this dose. She had an episode [**12-21**] in which she vomited and
then became unresponsive with tonic posturing, eyes open and
midline with occasional frequent blinking, and was unresponsive
to noxious stimuli. The episode lasted approximately five
minutes and resolved after 1 mg ativan. She had no further
episodes and neurological examination at time of discharge was
nonfocal with fluent speech, EOMI with no nystagmus, and steady
gait.
ID: Temperature at CHB of 38.9C max, WBC of 30K. She had a
history of chills and malaise 2 days prior to her event. No
cough, no subjective fever, no diarhea, but had LLQ tenderness.
BCx have showed no growth to date. UA was contaminated and
repeat UA showed mild leukocyte count with elevated RBCs, which
were treated as a UTI with ceftriaxone started. This was
changed to PO bactrim on day 5. A urine culture only grew out
yeast, which was presumed to be a contaminate. A CT
abdomen/pelvis was concerning for acute pyleonephritis and she
was continued on a 7-day antibiotic course for this. Her
leukocytosis has trended down and has been afebrile for the past
4 days prior to discharge. A respiratory culture was negative.
PULM: Patient was extubated on HD 1 w/o complications. CXR did
not show evidence of PNA.
GI: Patient was complaining LLQ pain x 1 week, which was
attributed to pyleonepritis as above and had resolved with
antibiotic treatment. Also, on CT abd/pelvis, a subcentimeter
liver lesion was noted and ultrasound was performed for further
evaluation which was also non-diagnostic. The patient's PCP was
[**Name (NI) 653**] regarding this finding, which can be followed up as an
outpatient.
F/E/N: During the hospitalization there was also some concern by
the primary team of weight loss since her last admission and
anorexia, and it is advised that the patient continued to be
evaluated for this by her PCP.
Medications on Admission:
-lamictal 600mg [**Hospital1 **]
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Lamotrigine 100 mg Tablet Sig: Four (4) Tablet PO QAM (once a
day (in the morning)).
3. Lamotrigine 100 mg Tablet Sig: Five (5) Tablet PO QPM (once a
day (in the evening)).
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure disorder
Pyelonephritis
Discharge Condition:
Fluent speech, attentive. EOMI, no nystagmus. No asterixis.
Full strength throughout, steady gait.
Discharge Instructions:
You were admitted to [**Hospital1 18**] from [**Hospital3 1810**] after you
were found to have a suspected seizure. At [**Hospital3 **]
you underwent a lumbar puncture (negative) and a CAT scan of
your head(negative), were intubated and were transferred to our
hospital. You were found to have an infection in your kidney
and treated with antibiotics. You were also found to have a
small lesion in your liver on the CAT scan and ultrasound.
Please follow this up with your PCP. [**Name10 (NameIs) 357**] continue your
medications as prescribed, avoid driving or any other activities
(such as unsupervised swimming) that may put you or others in
danger should you have recurrent events.
Followup Instructions:
Please follow with the following appointments:
NEUROLOGY:[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 3506**]
Date/Time:[**2145-2-9**] 9:30
PRIMARY CARE: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. Date/Time:[**2145-1-12**] 5:20
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7142
} | Medical Text: Admission Date: [**2101-11-30**] Discharge Date: [**2101-12-6**]
Date of Birth: [**2023-6-28**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
gentleman with a past medical history of syringomyelia with
residual left hemi-diaphragmatic paralysis and chronic
obstructive pulmonary disease on home oxygen. He presents
from an outside hospital after two days of worsening
shortness of breath. By report, the patient had stopped his
Lasix two weeks prior to admission to the outside hospital
and had begun home oxygen around the clock instead of at
night only.
On admission to the outside hospital, he was found to have a
collapse of the left lung, initially thought secondary to
mucus plugging, since he did improve with suctioning at that
time. On [**2101-11-17**], the patient was diagnosed with a right
lower lobe pneumonia at the outside hospital and started
empirically on Vancomycin and Zosyn. The patient was
transferred to the Intensive Care Unit there for respiratory
failure on [**2101-11-21**] and intubated at that time. Bronchoscopy
was performed on [**11-22**] which found a mass in the left medial
basilar lobe, with intrinsic compression of other bronchi.
Biopsy done on that lesion came back as collagen, with a
question of possible chondroma or bronchial cartilage. The
patient was transferred to our hospital for a possible
endobronchial intervention by Dr. [**Last Name (STitle) **].
On receiving the patient from the outside hospital, he was
alert and responsive to voice. He was in restraints but
denied any pain or discomfort. He was resting comfortably on
the vent.
PAST MEDICAL HISTORY: Other past medical history of peptic
ulcer disease, complicated by gastrointestinal bleeds. He
has no known drug allergies.
MEDICATIONS ON TRANSFER:
Zosyn 3.375 grams q. 8 hours, day 15.
Prevacid 30 mg p.o. q. day.
Theophylline 50 mg p.o. four times a day.
Albuterol.
Reglan.
Celexa 20 mg p.o. q. day.
Timolol eye drops.
Xalatan eye drops.
Dulcolax.
Milk of Magnesia prn.
SOCIAL HISTORY: Lives at home with his wife.
PHYSICAL EXAMINATION: On admission, the patient was
afebrile; blood pressure 101/65; heart rate of 65;
respirations of 20; saturating 93% on the vent. In general,
he was alert and appeared comfortable. He had dry oral
membranes. His neck was supple. Cardiovascular examination
noted a normal S1 and S2, with no murmurs. His lungs were
clear on the right. He had decreased breath sounds at the
left base. Abdomen had positive bowel sounds, was soft and
nontender. Extremities: Warm and without edema. Left upper
extremity was somewhat atrophic with 1/5 strength.
LABORATORY DATA: White count was 9.9; hematocrit was 29.8;
platelets were 392. Sodium was 139; potassium was 4.1;
chloride 100; bicarbonate was 35; BUN was 9; creatinine .6;
glucose 115. Liver function tests were all within normal
limits. Calcium, magnesium and phosphorus were all normal.
Chest x-ray showed complete white-out of the left lung.
Electrocardiogram showed sinus rhythm with frequent premature
atrial contractions. Rate was 65. He had a left axis
deviation and early R wave progression but no acute ST or T
wave changes.
HOSPITAL COURSE: 78 year old gentleman with left
hemi-diaphragmatic paralysis secondary to syringomyelia and
chronic obstructive pulmonary disease, transferred from an
outside hospital for further work-up and management of
possible endobronchial lesion and left lung collapse.
On hospital day number three, a rigid bronchoscopy was
performed in the operating room which showed a distal lesion
with granulation; question of a possible foreign body. An
attempt at biopsy was aborted secondary to heavy bleeding.
A rigid bronchoscopy was repeated on hospital day number five
and a successful biopsy of the lesion was obtained and sent
to pathology for further review. In terms of the patient's
questionable pneumonia status, the patient had received 15
days of Zosyn at the outside hospital and it was felt that
the patient did not currently have a pneumonia; thus, the
Zosyn was discontinued on admission to our hospital.
In terms of his chronic obstructive pulmonary disease, the
patient was on a vent and got nebs and inhalers as needed. In
terms of his hematologic status, the patient received two
units of packed red blood cells on hospital day number six,
after he had dropped his hematocrit. This was after the
second bronchoscopy and he dropped his hematocrit to 20. His
hematocrit following the two units increased to 35. He
remained stable.
In terms of his cardiovascular status, he had no known heart
dysfunction and that remained stable.
DISCHARGE CONDITION: The patient had a tracheostomy
performed on hospital day number six, along with a second
rigid bronchoscopy. The patient was weaned off the
ventilator for approximately two hours on hospital day number
seven. He tolerated that well. The patient was placed back
onto the ventilator, secondary to some desaturations into the
high 80's, however, his respiratory rate remained at around
20.
DISCHARGE STATUS: Back to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] Hospital.
DISCHARGE DIAGNOSES:
Left endobronchial lesion, not otherwise specified.
Left upper lobe collapse.
Chronic obstructive pulmonary disease.
Anemia.
DISCHARGE MEDICATIONS:
Acetaminophen 650 mg p.o. q. four to six hours as needed.
Albuterol neb, one neb q. six hours as needed.
Albuterol inhaler, two to four puffs every six hours as
needed.
Celexa 20 mg p.o. q. day.
Docusate 100 mg p.o. twice a day.
Ipratropium bromide four puffs inhaled four times a day as
needed.
Lantonoprost eye drops.
Lansoprazole oral solution, 30 mg p.o. q. day.
Lorazepam .5 to 2 mg p.o. every six hours prn.
Oxycodone 5 mg p.o. q. six hours prn.
Senna one tablet p.o. twice a day prn.
Theophylline 100 mg p.o. q. 8 hours.
Heparin 5000 units subcutaneous q. 8 hours.
Timolol eye drops.
Ipratropium bromide nebs, one neb q. six hours.
FOLLOW-UP PLANS: The patient should follow-up with his
primary care physician following his discharge from [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 805**] Hospital.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
MEDQUIST36
D: [**2101-12-6**] 04:07
T: [**2101-12-6**] 17:41
JOB#: [**Job Number 53448**]
ICD9 Codes: 5180, 496, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7143
} | Medical Text: Admission Date: [**2184-6-1**] Discharge Date: [**2184-6-12**]
Date of Birth: [**2120-9-13**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Right shoulder infection
Major Surgical or Invasive Procedure:
Arthroscopy and drainage of right shoulder
Intubation
PICC placement
History of Present Illness:
Mr. [**Known lastname **] is a 63 year old man who was transfered from [**Hospital **] for surgical evaluation of his right shoulder. Per
records, he had visited [**Hospital3 **] 2 times within the last
2 weeks for right shoulder pain after a fall which was without
fracture. He was sent with pain medications and outpatient f/u.
He had an MRI which was unrevealing (per [**Location (un) **] records). On
[**5-28**] he was admitted to [**Hospital3 7569**] for increased weakness,
fevers, and right shoulder pain.
In [**Location (un) **] ED he was noted to have WBC of 16.7 with 54 neuts and
34 bands. He denied N/V, chest pain, SOB, abd pain, headache, or
syncope. CXR showed no pneumonia. Right shoulder was reportedly
swollen and erythematous. U/S showed a fluid collection under
the deltoid and ortho was consulted. They deferred surgery given
his persistent hyponatremia.
He continued to spike fevers, developed ARF with BUN/Cr of
51/2.6 (baseline 1.0). He became hypotensive and required
levaphed. LFTs remained stable and RUQ U/S was negative. Since
it was felt that he needed surgical drainage of his shoulder, he
was transfered to [**Hospital1 18**]. He had 2 peripheral IVs, and was
recieving levaphed through them.
He arrived on the floor, on max dose of levaphed through his
peripheral IV, but was noted to have a pressure of 170s/100s.
Levaphed was weaned off entirely and the patient remained
stable.
Review of sytems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, or abdominal pain. No recent change
in bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
HTN
Right adrenalectomy
MVA 20 yrs ago with multiple injuries.
Significant ETOH abuse in past, but per wife, he now drinks only
2 days/wk
Social History:
Works as a computer analysist. Lives with wife.
T - 20 pack year history
A - Former drinker, but now only drinks socially on
Fridays/Saturdays per wife
D - Denies illicit drug use, no IVDU
Family History:
NC
Physical Exam:
Vitals: T: 96.5 BP: 118 P: 108/64 R: 24 O2: 97% on NC of 2L
General: Alert, orientedx x 1, 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: Tachy, reg rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: surgical incision scar, soft, non-tender, moderately
distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
edema.
R shoulder. Very painful with movement
Skin: diffuse erythematous rash over trunk/chest and arms.
Pertinent Results:
Labs on admission:
[**2184-6-1**] 02:44AM BLOOD WBC-15.9* RBC-3.26* Hgb-9.2* Hct-28.9*
MCV-89 MCH-28.3 MCHC-31.9 RDW-16.2* Plt Ct-293
[**2184-6-1**] 02:44AM BLOOD Neuts-76* Bands-7* Lymphs-5* Monos-4
Eos-4 Baso-1 Atyps-0 Metas-2* Myelos-1*
[**2184-6-1**] 02:44AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2184-6-1**] 02:44AM BLOOD PT-14.5* PTT-24.5 INR(PT)-1.3*
[**2184-6-1**] 02:44AM BLOOD Glucose-96 UreaN-52* Creat-2.3* Na-131*
K-4.9 Cl-100 HCO3-19* AnGap-17
[**2184-6-1**] 02:44AM BLOOD Albumin-2.3* Calcium-8.0* Phos-4.0 Mg-2.5
[**2184-6-1**] 02:44AM BLOOD ALT-82* AST-93* LD(LDH)-320* AlkPhos-94
TotBili-1.0
[**2184-6-2**] 02:51AM BLOOD Lipase-31
[**2184-6-2**] 04:52PM BLOOD Lactate-1.1
[**2184-6-1**] 02:44AM BLOOD Cortsol-14.4
[**2184-6-1**] 05:53AM BLOOD Cortsol-28.5*
[**2184-6-1**] ECG: Baseline artifact. Atrial fibrillation or probable
atrial flutter with predominantly 2:1 block. The baseline is
difficult in terms of making differentiation between atrial
flutter and atrial fibrillation and possible ST-T wave
abnormalities. There certainly is an RSR' pattern in lead V1.
Clinical correlation is suggested.
[**2184-6-2**] CT head: There is no hemorrhage, edema, mass effect, or
CT
evidence of acute large vascular territorial infarction. The
[**Doctor Last Name 352**]-white
matter differentiation is preserved. The ventricles and sulci
are normal in size and configuration. There is no shift of
midline structures. The basilar cisterns are preserved. There
are no abnormal extra-axial fluid collections. Osseous
structures demonstrate no fracture. There is minimal mucosal
thickening with small mucus-retention cysts in the right
maxillary sinus. The mastoid air cells are normally-pneumatized
and clear. There are punctate calcifications in the vertex scalp
soft tissues, of uncertain significance.
[**2184-6-2**]: CT Abdomen:
1. No evidence of obstruction or volvulus.
2. Small bilateral pleural effusions and bibasilar atelectasis,
new since
outside hospital CT of [**2184-5-28**].
[**2184-6-4**]: MRI Shoulder:
1. Complex, enhancing joint effusion with associated loculated
collections in the subacromial-subdeltoid bursa and the
subscapularis recess. Findings are consistent with an
inflammatory and/or infectious arthritis.
2. Full-thickness supraspinatus and infraspinatus tendon tears
with tendon
retraction.
3. No definite osteomyelitis.
Echocardiogram [**2184-6-5**]:
The left atrium is dilated. The right atrium is dilated. There
is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with probably mild inferior septal hypokinesis.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
[**2184-6-5**]: MRI/MRA of the head:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation. Distal left vertebral
artery ends in posterior- inferior cerebellar artery, a normal
variation.
[**2184-6-8**]: CXR - IMPRESSION: Satisfactory position of the
left-sided PICC line with the tip in the lower SVC. Interval
improvement in degree of atelectasis in the left lower lobe.
Mild cardiomegaly with no overt evidence of pulmonary edema.
Brief Hospital Course:
Mr. [**Known lastname **] is a 63 year old male with a history of ETOH abuse and
hypertension transferred from an OSH for septic shock with
concern for septic right shoulder.
# Septic shock/Septic Shoulder/HAP: The patient was transferred
from OSH on levophed but hypertensive on arrival. Levophed
weaned off without difficulty. R shoulder suspected source but
cell count from initial joint tap by Ortho not clearly septic
appearing with WBC only 18,000 in setting of traumatic tap with
negative culture. Given agitation, patient required intubation
for MRI shoulder. While awaiting that study, lung bases on CT
showed pneumonia, presumed HAP. Levofloxacin was discontinued
but patient continued on vanc/zosyn, which was later changed to
vanc/meropenem given concern for drug rash. Pt subsequently had
MRI shoulder which showed a complex joint effusion with
loculated collections in the subacromial-subdeltoid bursa and
the subscapularis recess. R shoulder was re-tapped, this time
with 101,500 WBC although still culture negative. Pt underwent
wash-out of septic right shoulder on [**2184-6-5**] requiring extensive
debridement and notable for finding of rotator cuff tear;
intraarticular and subacromial subdeltoid bursal drains left in
place. He underwent joint washout which was uneventful. He
completed a course of vancomycin/meropenem for hospital acquired
pneumonia and will need to complete a 4 week course of
antibiotics for septic shoulder (culture data negative but frank
pus in the joint). His vancomycin trough was low at 11.8 on
[**6-11**] and so his dose was increased to 1.5 grams Q12H. His last
dose of antibiotics should be [**2184-7-9**] unless otherwise decided
by his orthopedist. He should follow-up with orthopedics 2
weeks following discharge for suture removal and further
discussion regarding his antibiotic course. Pain was managed
via Dilaudid IV in house, patient transitioned to PO on
discharge.
# Altered Mental Status: Prior to admission, the patient was
last mentally cleared approximately [**5-25**] while at OSH, prior to
initiation of dilaudid and flexeril. Concern for head trauma
given prior fall, but head CT without acute process. Lyme and
erhlichia serologies negative. Did have history of heavy EtOH,
but now only drinking 2 of 7 nights per week according to wife.
[**Name (NI) **] history of illicit drug use prior. Likely secondary to
polypharmacy given OSH dilaudid and short course of stress dose
steroids for question of adrenal insufficiency. Agitation not
responsive to escalating doses of haldol (received 100mg in one
day) although some improvement with ativan (despite being out of
time frame for EtOH withdrawal). Required intubation for studies
on [**2184-6-2**] and controlled on propofol, which was later changed to
fentanyl/versed secondary to hypertriglyeridemia. Extubated on
[**2184-6-5**]. Patient was also given thiamine, folate, and a MVI.
The patient's mental status gradually improved in the unit and
the patient felt he was at his baseline the day prior to
discharge. Oxazepam and neurontin were also held due to concern
for AMS. These medications were not restarted as the patient
appeared to be doing well without them.
# Tachycardia: Atrial flutter vs. atrial fib alternating with
sinus rhythm with PACs. TTE with biatrial enlargement with mild
regional left ventricular systolic dysfunction (EF 45-50%) with
probable mild inferior septal hypokinesis. On HCTZ/bisprolol at
home. On [**2184-6-8**] required diltiazem drip and high dose
metoprolol for rate control and subsequently spontaneously
converted to sinus rhythm. He was placed back onto metoprolol
for blood pressure and rate control. Also started on heparin
drip as a bridge to coumadin. Patient was discharge on home
Bisoprolol 20mg daily.
# Transaminitis: No pain on palpation and RUQ U/S from OSH
without evidence of cholecystitis. Lyme and ehrlichia serologies
negative. [**Month (only) 116**] have been secondary to EtOH use. Improved on
discharge.
# Hypertension: On HCTZ/bisprolol 10/6.25 [**Hospital1 **], clonidine 0.6 mg
QSun, and Avapro 300 mg daily as outpatient. Clonidine was
initially held given mental status. He was restarted on a beta
blocker in the unit initially for rate control, then uptitrated
in setting of hypertension. Losartan was started as avapro is
not on formulary.
The patient was noted to be markedly hypertensive on transfer to
the medical floor. HCTZ and clonidine patches were restarted on
[**6-11**]. On discharge the patient was transitioned to home
Bisoprolol 20mg daily and Avapro 300mg daily.
# Rash: Concern for drug rash secondary to penicillins although
no documented history of drug allergies. Zosyn changed to
meropenem with improvement.
# Anemia: Stable. Hematocrit was serially monitored.
# S/p adrenalectomy: Initially presented with shock,
hyponatremia, and hyperkalemia. [**Last Name (un) **] stim was normal so stress
dose steroids were discontinued.
# Acute renal failure: Cr down to 1.0 from peak of 3.1 at OSH on
[**2184-5-30**] with improved UOP. FENa 0.8 suggested prerenal etiology.
Cr trended back down to normal over hospital course.
# Constipation: KUB concerning for cecal volvulus but not seen
on CT abdomen. Started on aggressive bowel regimen with good
subsequent stool output.
# Hyponatremia: Na 131 on admission, thought secondary to
dehydration. Corrected without intervention.
Medications on Admission:
Medications Home:
ASA 325 daily
HCTZ/Bisprolol 10/6.25 [**Hospital1 **]
Clonidine 0.6 mg QSun
Avapro 300 mg daily
Prilosec 20 mg daily
Oxazepam Q 6hr prn anxiety
Ambien 5 mg HS
Neurontin
Paroxitine 20mg daily
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
10. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
11. Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch
Weekly Transdermal QFRI.
12. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) 3 mL flush
Injection Q8H (every 8 hours) as needed for line flush.
13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. Heparin, Porcine (PF) 1,000 unit/mL Solution Sig: as
directed Injection continuous IV infusion: based on
weight-based heparin dosing plan.
17. Vancomycin 750 mg Recon Soln Sig: Two (2) Intravenous every
twelve (12) hours for 4 weeks: Needs trough checked on morning
of [**6-13**] with goal range of 15-20. .
18. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
19. Bisoprolol Fumarate 10 mg Tablet Sig: Two (2) Tablet PO once
a day.
20. Dilaudid 2 mg Tablet Sig: [**12-30**] (two-three) Tablets PO q3h as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Primary Diagnoses:
Septic arthritis (right shoulder)
Atrial fibrillation
Hospital Acquired Pneumonia
Altered mental status
Secondary Diagnoses:
Hypertension
Anemia
Acute renal failure
Discharge Condition:
Vital signs stable. Symptoms improved.
Discharge Instructions:
You were transferred to [**Hospital1 18**] from an outside hospital. You
were found to have pneumonia, and you completed a course of
antibiotics for the pneumonia. You also had an infection in your
right shoulder, which was drained and washed out by the
orthopedic surgeons. You will need to continue taking
intravenous antibiotics for 4 weeks.
.
You were also found to have atrial fibrillation, which is an
abnormal rhythm of the heart. You were started on Coumadin,
which is a blood thinner, since atrial fibrillation increases
your risk of having clots. You should follow-up with a
cardiologist as an outpatient to assess the need for life-long
anticoagulation.
.
The following changes were made to your medications:
1. Restart your Avapro and Bisoprolol. You were continued on
hydrochlorothiazide.
2. You were started on the blood thinning medication coumadin.
You will need to have frequent INR checks until you are stable
on this mediation. You will need to continue the heparin drip
until your INR has become therapeutic.
3. Your oxazepam and neurontin were stopped. You seemed to do
okay without these medications. Please talk with your PCP to
determine if they are necessary.
.
Please call your physician or return to the hospital if you
develop high fevers, worsening shoulder pain, chest pain,
shortness of breath, or other concerning symptoms.
Followup Instructions:
Please follow-up at your primary care office on Friday [**6-18**] @
9am.
[**0-0-**]
Please ask your primary care physician to refer you to a
cardiologist to discuss how long you should be on
anticoagulation. Also discuss with them the need to restart your
oxazepam and neurontin
Please call [**Telephone/Fax (1) 1228**] to schedule a follow-up appointment
with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to have the sutures in your shoulder removed
and to follow-up after your shoulder surgery.
ICD9 Codes: 0389, 5849, 486, 2761, 5180, 5119, 2767, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7144
} | Medical Text: Admission Date: [**2125-4-4**] Discharge Date: [**2125-5-29**]
Date of Birth: [**2070-4-5**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
1) Bedside incision and drainage, right hand [**2125-4-4**]
2) Operative incision and drainage, right hand [**2125-4-12**]
3) Arthroscopic wash out, bilateral shoulders [**2125-5-11**]
4) Percutaneous pigtail drainage of mid thoracic paravertebral
abscess under radiographic guidance [**2125-4-18**]
5) Left PICC, placed [**2125-4-30**], repositioned [**2125-5-18**]
History of Present Illness:
54 F with Crohn's disease on prednisode and Remicade, receiving
TPN through a PICC, admitted to an outside hospital on [**4-3**]
with two weeks of right hand swelling, fevers, and chills. At
the OSH emergency department, she was ill-appearing,
hypotensive, and afebrile, with a leukocytosis to 22 with 15%
bandemia and 70% polys; her creatinine was 1.7. She was
admitted to the MICU at the OSH where she was given stress dose
steroids, empiric vancomycin and levofloxacin, 4L IVF, and blood
cultures drawn. An ultrasound guided drainage of the right hand
was performed, expressing a small amount of pus that was sent
for gram stain and culture; Gram stain showed 2+ gram positive
cocci. Four of four blood cultures grew gram positive cocci, as
well. She subsequently developed respiratory distress overnight
with an arterial blood gas of 7.2/14.5/95 and was intubated.
Chest X-ray at the OSH was consistent with ARDS vs volume
overload. An MRI of the right hand showed no definite fluid
collection.
.
An attempt at a right subclavian central catheter prior to
transport failed, and a right femoral line was placed instead.
She received versed and vecuronium and was transported to [**Hospital1 18**]
by [**Location (un) 7622**].
Past Medical History:
Crohn's, longstanding on remicade, 5mg prednisone
short bowel syndrome
TPN through PICC
Rheumatoid arthritis
Social History:
Lives at home with husband
[**Name (NI) **] EtOH, IVDA.
Family History:
non-contributory
Physical Exam:
100.9 130 104/53 31 100% on AC500X22 w/PEEP 8 and FIO2 1
Intubated, sedated
MMD, PERRL
RLL crackles, DTP
Tachy, I/VI HSM @ apex; site of multiple R subclav attempts
evident but clean
soft, nt, nd, +BS
WWP X 4; R hand swollen; R fem line c/d/i; multiple stick sites
evident
Not responding to commands, pain
Pertinent Results:
Admission laboratories:
[**2125-4-4**] 02:13PM BLOOD WBC-26.7* RBC-3.78* Hgb-11.0* Hct-32.8*
MCV-87 MCH-29.1 MCHC-33.5 RDW-15.2 Plt Ct-235
[**2125-4-4**] 02:13PM BLOOD Neuts-90.3* Bands-0 Lymphs-7.5*
Monos-1.7* Eos-0.1 Baso-0.4
.
[**2125-4-4**] 02:13PM BLOOD Glucose-151* UreaN-37* Creat-0.9 Na-143
K-3.6 Cl-116* HCO3-15* AnGap-16
[**2125-4-4**] 02:13PM BLOOD Albumin-2.2* Calcium-7.6* Phos-6.5*
Mg-1.6
.
[**2125-4-4**] 02:13PM BLOOD PT-14.0* PTT-42.1* INR(PT)-1.2*
[**2125-4-4**] 02:13PM BLOOD Fibrino-576* D-Dimer-8768*
.
[**2125-4-4**] 02:13PM BLOOD ALT-25 AST-55* LD(LDH)-257* CK(CPK)-175*
AlkPhos-276* TotBili-3.7*
.
[**2125-4-4**] 04:43PM BLOOD Type-ART Temp-38.3 pO2-75* pCO2-42
pH-7.06* calHCO3-13* Base XS--18 Intubat-INTUBATED
.
Discharge laboratories:
[**2125-5-28**] 05:00AM BLOOD WBC-8.5 RBC-3.26* Hgb-9.0* Hct-27.8*
MCV-85 MCH-27.8 MCHC-32.5 RDW-17.9* Plt Ct-521*
.
[**2125-5-29**] 05:17AM BLOOD Glucose-105 UreaN-26* Creat-0.7 Na-136
K-4.2 Cl-104 HCO3-23 AnGap-13
[**2125-5-29**] 05:17AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9
.
Other relevant laboratories:
[**2125-4-17**] 03:53AM BLOOD ESR-135*
[**2125-4-16**] 03:02AM BLOOD CRP-149.6*
.
[**2125-5-4**] 05:44AM BLOOD Cortsol-20.4*
.
Relevant Studies:
CHEST - PORTABLE AP ([**2125-4-16**]): Poorly defined nodular opacities
in right upper and left mid lung zones, concerning for septic
emboli or fungal infection.
.
CT CHEST W/CONTRAST ([**2125-4-16**]): The heart and great vessels are
unremarkable. A single right axillary lymph node measures 1 cm.
There are no other pathologically enlarged mediastinal lymph
nodes. The airways are patent bilaterally. There is a small
right pleural effusion with associated atelectatis. Lung windows
revea severe emphysematous changes. There are multiple
bilateral, scattered varying- sized rounded and irregular
non-cavitating focal pulmonary opacities, predominantly with a
peripheral location. In the left posterior paraspinal
musculature just deep to the trapezius muscle extending
inferiorly from the C1 level , there is a rim enhancing
multiloculated fluid collection concerning for abscess. In the
region of the lower thoracic spine there is an apparent
encapsulated prevertebral fluid collection adjacent to the right
pleural effusion, and with low but slightly higher [**Doctor Last Name **] density
than the free pleual effusion. No gas is present within this
effusion but The vertebral bodies at this level (probable T8.9
and 10) demonstrate a mixed sclerotic/ lytic pattern and
findings are concerning for osteomyelitis.
.
MR [**Name13 (STitle) **] T-SPINE W &W/O CONTRAST ([**2125-4-17**]): There are signs
of extensive osseous abnormality of the mid thoracic spine with
a prevertebral collection associated with bone and interspace
abnormality. This is most suspicious for infection and abscess
formation. There is also an adjacent pleural effusion, and
extension of an infectious process into this space should be
considered. An area suspicious for large abscess collection is
also identified in the subcutaneous musculature of the posterior
back extending from roughly C7, 8 cm inferiorly into the
thoracic region, to about T5. Abnormality at the C1-2 junction
is also identified and though this could represent degenerative
change, but infection cannot be excluded in this location.
.
TEE ([**2125-4-17**]): No spontaneous echo contrast is seen in the body
of the left atrium or right atrium. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function appears preserved (LVEF>55%), however transgastic views
were not obtained. Right ventricular systolic function also
appears preserved. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. No mitral valve abscess is seen.
Trivial mitral regurgitation is seen. There is no abscess of the
tricuspid valve. No vegetation/mass is seen on the pulmonic
valve.
.
CT OF THE CHEST WITH IV CONTRAST ([**2125-5-22**]): Pulmonary arteries
appear well opacified and there is no evidence of acute
pulmonary embolism. Heart and great vessels appear unremarkable.
Again seen are several mediastinal lymph nodes, however, none
appear to meet CT criteria for pathological enlargement. There
is no evidence of pathologically enlarged hilar or axillary
lymphadenopathy. There has been interval improvement of
previously seen small right-sided pleural effusion. Again seen
are diffuse emphysematous bullous changes bilaterally. Three
poorly-defined peripheral opacities are present in the right
lung. The opacity seen on series 3, image 39, does not appear
significantly changed from prior study. New linear/nodular
opacities seen on series 2, image 34, possibly represents
atelectasis. Also seen is a smaller irregular peripheral
opacity, best seen on series 3, image 55. Peripheral opacity in
the left lung (series 3, image 49) appears improved compared to
prior study. Again seen is a paraspinal abscess collection
anterior to the mid thoracic region. Small amount of fluid is
again seen, decreased compared to [**4-16**]. Compared to [**4-28**], the
fluid collection is likely not significantly changed to slightly
larger in size. Soft tissue inflammation is also seen in this
area. Again seen is destruction of the T7 through T9 vertebral
bodies.
.
CT OF THE ABDOMEN WITH IV CONTRAST ([**2125-5-22**]): The liver,
pancreas, spleen, adrenal glands, and kidneys appear unchanged.
The bile duct measures 9 mm, not changed from prior study. There
is no evidence of free fluid or free air within the abdomen.
Scattered mesenteric lymph nodes again seen, however, none
appear to meet CT criteria for pathologic enlargement.
.
CT OF THE PELVIS WITH IV CONTRAST ([**2125-5-22**]): The rectum and
sigmoid appear unremarkable. Small amount of air is noted within
the bladder, correlate with recent catheterization. Small area
of enhancement again noted within the left psoas muscle,
previously described as abscess, not significantly changed from
prior study.
.
BONE WINDOWS ([**2125-5-22**]): Again seen is destruction of the T7
through T9 vertebral bodies. Degenerative changes also again
noted within the spine, most notably at the L5 level.
.
Microbiology:
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- 1 I
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
Brief Hospital Course:
1) Sepsis/disseminated infection: Patient was transferred from
OSH for sepsis thought secondary to a hand infection. An initial
incision and drainage of the right hand abscess had been
performed at the OSH. Here, she was started on vancomycin with
gentamycin at synergistic dosing for gram positive cocci on
outside hospital cultures. She was aggressively resuscitated
with IV fluids, with Levophed for additional pressure support.
She received a course of Xigris and stress dose steroids. When
cultures showed MSSA on HD #2, vancomycin was changed to
nafcillin. Gentamycin was stopped after 5 days of synergistic
dosing. She was weaned off of pressor support by HD #4 and
remained hemodynamically stable thereafter, although she
remained intubated on mechanical ventilation to facilitate
operative debridement of her right hand osteomyelitis.
.
Although she subsequently remained hemodynamically stable, she
continued to be febrile. There was concern for line infection.
Her chronic PICC for home TPN was removed at the outside
hospital. Left and right internal jugular central catheters
placed since admission were removed, as well as her arterial
line. A new left subclavian catheter was placed. However, she
continued to remain febrile.
.
A transesophageal echocardiogram was performed, which showed no
evidence of endocarditis. A chest X-ray showed pulmonary
nodules, prompting a follow up CT of the chest. This showed
nodular opacities consistent with septic emboli. In addition, it
showed two fluid collections, one involving the vertebral bodies
of T8-T10, and another in the left paraspinal muscles extending
inferiorly from C7. A CT of the abdomen and pelvis showed a left
iliopsoas abscess.
.
The orthopaedic spine team was consulted, and an MRI of the
spine was obtained for further delineation of these lesions. The
MRI confirmed osteomyelitis of the T9 vertebra, and showed a
fluid collection abutting the spine in addition to a fluid
collection subcutaneously on the back. The orthopaedic spine
service recommended a conservative approach with CT guided
drainage of the paraspinal fluid collection. The infectious
diseases team agreed with a strategy of attempting to treat each
locus of infection discretely and attempt drainage. However at
this point, the infection appeared fairly disseminated and there
was some concern that the infection would be difficult to
eradicate. The pulmonary nodules were felt to not be accessible
by bronchoscopy, and not large enough for percutaneous drainage.
The left iliopsoas abscess was likewise felt not to be amenable
to drainage. These concerns were shared with the patient and the
family. The patient underwent successful CT guided drainage of
the superficial abscess on the back, in addition to the
paraspinal fluid collection (with a pigtail catheter left in
place for drainage).
.
She was called out to the floor where she continued to be
febrile. Plans were made for CT guided drainage of the
parascapular abscess. However, the scan showed no drainable
fluid in the parascapular region. The T8-T10 paraspinal fluid
collection was persistent, but slightly improved. Incidentally,
however, it showed bilateral shoulder effusion. Orthopaedics
performed a joint aspirate, which returned grossly cloudy fluid,
with 41k WBCs and a negative gram stain. She was taken to the
operating room for bilateral shoulder washouts, which she
tolerated well.
.
She subsequently defervesced, and was afebrile x 1 week prior to
discharge. She was discharged with plans for an indefinite
course of nafcillin.
.
2. Pain control: She was initially placed on a morphine PCA for
pain control, but had difficulty operating the PCA. She was
changed to a fentanyl patch with IV Dilaudid boluses for
breakthrough. IV Dilaudid was transitioned to PO Dilaudid prior
to discharge. On discharge, her pain was well controlled on 25
mcg/hr fentanyl patch with 8mg PO Dilaudid Q2h for breakthrough
pain.
.
3. Respiratory failure: The patient had developed respiratory
failure at the OSH and arrived on mechanical ventilation. This
was thought secondary to non-cardiogenic pulmonary edema in the
setting of sepsis. Her ventilator settings were weaned, and she
was clinically ready for extubation several days after
admission. However, she remained intubated for an additional [**12-11**]
days because of planned hand surgery by plastic surgery. She was
extubated successfully on the following day, although her
respiratory status remained tenuous. She was reintubated on [**4-17**]
for a TEE and again successfully extubated on [**4-17**] after the TEE.
Her respiratory status was stable through the remainder of her
course on the floor.
.
4. Crohns: She was given a short course of stress dose steroids
on arrival, as described above, and subsequently put on 4mg IV
Solu-Medrol QD. She was transitioned back to her home regimen of
prednisone 5 mg PO QD prior to discharge. She was maintained on
TPN throughout her hospitalization for short gut syndrome. It
was initially run by continuous infusion, but was transitioned
to a cycled regimen over 12 hours prior to discharge. Her Crohns
was otherwise stable, without any complaints of abdominal pain.
5. Cardiac: She had a mild troponin T leak ~ 0.7, with a peak
CK-MB of 95. This was felt to be demand related in the setting
of sepsis. An initial TTE showed a depressed EF. However, this
recovered on subsequent TEEs.
.
6. Anemia: Patient had a stable anemia with iron studies
consistent with chronic inflammation.
.
7. Tachycardia: Patient was noted to be persistently tachycardic
during hospitalization. This was confirmed to be sinus by ECG,
and thought most likely multifactorial from anxiety, pain, and
her hypermetabolic state from infection. In addition to
treatment of her underlying infection and pain control described
above, she was given anxiolytics as needed. CT was negative for
PE.
.
8. Acidosis/hyperkalemia: The patient was noted to have a
metabolic acidosis on admission. This corrected spontaneously
over the subsequent several days. However, as the acidosis
resolved, she developed a significant hypokalemia, with
potassium levels down to 2.4. There were no ECG changes.
Potassium was repleted aggressively over the following several
days, with subsequent resolution.
.
Prophylaxis: She received heparin in her TPN for DVT
prophylaxis.
.
Code status was confirmed to be full.
Medications on Admission:
remicaide
prednisone 5 mg
Discharge Medications:
1. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) gram
Intravenous Q4H (every 4 hours).
Disp:*2 week supply* Refills:*2*
2. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch Transdermal
Q72H (every 72 hours).
Disp:*10 Patch(s)* Refills:*0*
3. Hydromorphone 8 mg Tablet Sig: One (1) Tablet PO Q2-4h as
needed.
Disp:*100 Tablet(s)* Refills:*0*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
MSSA Sepsis
Septic pulmonary emboli
Left ileopsoas abscess
T9 paraspinal abscess with T7-9 vertebral osteomyelitis
- s/p percutaneous pigtail drain
Parascapular abscess
Right hand abscess
- s/p open irrigation and debridement
Crohns Disease
Discharge Condition:
Stable
Afebrile
Discharge Instructions:
1) Continue your medications as prescribed
- You were started on an antibiotic called naficillin for
multiple infections in your body. You need to continue this
until you have back surgery, and likely for 6 weeks afterwards.
2) Follow up as directed below.
3) Call if any of your wounds looks worse, has worsened redness
or pain, discharge, if you have chest pain, difficulty
breathing, nausea, fevers, chills, or any other concerns.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] (orthopaedics) for your shoulders on
[**2125-6-7**] at 10:00am
- Call [**Telephone/Fax (1) 1228**] if you have questions or need to
reschedule.
Follow up with Dr [**Last Name (STitle) **] (orthopaedic spine) [**2125-7-5**] at
11:00am
- His coordinator will try to get you an earlier appointment.
If possible, they will contact you at home.
- Call [**Telephone/Fax (1) 1228**] if you have questions or need to
reschedule.
Follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (ID) on [**2125-6-15**] at 9:00am.
- Call [**Telephone/Fax (1) 457**] if you have questions or need to
reschedule.
Follow up with Dr [**Last Name (STitle) 5385**] in Plastic Surgery Hand Clinic on
[**2125-6-5**] at 9am.
- Call [**Telephone/Fax (1) 5343**] if you have questions or need to
reschedule.
You asked to transfer your primary care here to the [**Hospital1 18**], and
were scheduled for an appointment with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Hospital 191**]
clinic Atrium Suite on [**2125-6-26**] at 1:30pm
- You need to call your insurance company to change your listed
PCP.
[**Name Initial (NameIs) **] After you change your PCP, [**Name10 (NameIs) 138**] the clinic at [**Telephone/Fax (1) 250**] to
request referrals for the specialists listed above. You will
need these referrals before you see any of the specialists.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2125-5-30**]
ICD9 Codes: 5185, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7145
} | Medical Text: Admission Date: [**2138-3-3**] Discharge Date: [**2138-3-17**]
Date of Birth: [**2085-6-26**] Sex: M
Service: PODIATRY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3529**]
Chief Complaint:
Right foot infection
Major Surgical or Invasive Procedure:
[**2138-3-4**] Right foot I&D
[**2138-3-6**] Right foot I&D
[**2138-3-11**] Right foot I&D, skin graft, wound vac placement
History of Present Illness:
Mr. [**Known lastname **] is a very pleasant 52 year old man with a PMH
significant for DMII, HTN, HCol, who presents to his PCP today
with [**Name Initial (PRE) **] swollen R foot, subsequently referred to the ED.
He had not seen his PCP in two years, but came in to his PCP
this AM because his right foot was hot, red, warm, and painful.
He has had pain in this foot for the past three weeks; he
attributes the onset to the self-removal of a callus on the ball
of his foot. He had noted the development of some neuropathy in
his bilateral lower extremities staring a year ago. There was
purulent discharge from his wound.
In the ED, initial VS were 99.6 120 158/83 18 96%. Labs were
notable for U/A with 100 Protein, 1000 Glucose, 150 Ketones.
Electrolytes are notable for Na 129, Cl 90, Bicarb 21, Glucose
326, and AG 18. Labs notable for WBC count 20.5, microcytic
36.5, without bandemia. The patient was given Vancomycin 1g,
Metronidazole 500 mg IV, and Ciprofloxacin 400 mg IV. Foot films
showed a tib/fib WNL, a R ankel that showed normal soft tissues,
with retro- and plantar calcaneal spurs, and a R foot with no
signs of osteomyelitis, fracture, or significant degenerative
joint disease. Podiatric surgery evaluated him, and debrieded
the wound x 2. Per podiatry notes, this lesion did not probe to
bone.
Per PCP records, last A1c% was 8.9 in [**2134**]. Baseline labs are
notable for HDL 40, LDL 83, microalb 3.4 (elevated), Cr 0.77.
On arrival to the MICU, he is AAOx3, but tachcyardic to the
110s.
Past Medical History:
DM Type II
Hypertension
Hypercholesterolemia
.
PSH:
Appendectomy
Social History:
Works as an aide in a group home. He lives with his parents. He
had a 26 pack year history, and has been sober from alochol for
the past 28 years. States he has felt "depressed" and had
stopped taking his medications for x1 year.
Family History:
Father Diabetes - Type II
Mother [**Name (NI) 3730**] - [**Name (NI) **]; Hyperlipidemia
Physical Exam:
General: AAOx3
HEENT: Dry MM
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses on the L, R foot is heaviliy
bandaged, edema on the R foot to the mid-calf, warm
.
d/c fitals
Gen: NAD, AAOx3
CV: RRR
Pulm: [**Street Address(1) **]
Abd: soft, NT
UE: improved phlebitis to previous PIV sites, pulses palpable,
no chords
LE: b/l LE pulses palpable, RLE dressing CDI to thigh & foot
Pertinent Results:
LABORATORY RESULTS
[**2138-3-3**] 08:26PM LACTATE-1.1
[**2138-3-3**] 08:00PM GLUCOSE-249* UREA N-16 CREAT-0.8 SODIUM-129*
POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-23 ANION GAP-15
[**2138-3-3**] 08:00PM CK(CPK)-26* AMYLASE-42
[**2138-3-3**] 08:00PM LIPASE-38
[**2138-3-3**] 08:00PM CK-MB-1 cTropnT-<0.01
[**2138-3-3**] 08:00PM CALCIUM-8.4 PHOSPHATE-2.7 MAGNESIUM-2.0
IRON-14*
[**2138-3-3**] 08:00PM %HbA1c-13.3* eAG-335*
[**2138-3-3**] 08:00PM WBC-18.0* RBC-3.73* HGB-10.8* HCT-29.9*
MCV-80* MCH-28.9 MCHC-36.0* RDW-12.2
[**2138-3-3**] 08:00PM PLT COUNT-339
RADIOLOGY
[**2138-3-3**]:
Foot/ankle/tib-fib Xrays:
IMPRESSION: No signs of osteomyelitis, fracture, or significant
degenerative joint disease.
[**2138-3-3**]:
CXR: Cardiac silhouette is within normal limits and there is no
evidence of vascular congestion, pleural effusion, or acute
focal pneumonia.
[**2138-3-3**] Cardiovascular ECG: Sinus tachycardia. No previous
tracing available for comparison.
[**2138-3-4**] Radiology CHEST (PA & LAT): Slight increase in
pulmonary and mediastinal vascular engorgement suggests
borderline cardiac decompensation, although the heart is normal
size and there is no pulmonary edema. There may be a tiny volume
of pleural fluid in each
side of the chest. Peribronchial opacification in the left lower
lobe is
probably atelectasis.
[**2138-3-5**] Radiology MR FOOT W&W/O CONTRAST: 1. Plantar ulcer
status post debridement one day prior with likely at least in
part postoperative edema and enhancement in the subcutaneous
tissues and plantar muscle compartments. Diabetic myositis and
or infection can have similar appearance. 2. No evidence of
osteomyelitis. 3. No abscess or drainable fluid.
[**2138-3-6**] Cardiovascular ECHO: No vegetations or
clinically-significant regurgitant valvular disease seen
(adequate-quality study). Normal global and regional
biventricular systolic function. In presence of high clinical
suspicion, absence of vegetations on transthoracic
echocardiogram does not exclude endocarditis.
MICROBIOLOGY
[**2138-3-3**] FOOT CULTURE: WOUND CULTURE (Final
[**2138-3-6**]):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. MODERATE
GROWTH.
[**2138-3-4**] SWAB: GRAM STAIN (Final [**2138-3-4**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND IN SHORT
CHAINS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2138-3-6**]):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
[**2138-3-6**] SWAB: GRAM STAIN (Final [**2138-3-6**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
WOUND CULTURE (Final [**2138-3-9**]):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
ANAEROBIC CULTURE (Preliminary):
ANAEROBIC GRAM NEGATIVE ROD(S). RARE GROWTH.
BLOOD CULTURES
[**2138-3-3**] BLOOD CULTURE: Blood Culture, Routine (Final
[**2138-3-9**]):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. FINAL
SENSITIVITIES.
Sensitivity testing performed by Sensititre.
SENSITIVE TO CLINDAMYCIN MIC <= 0.12 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (MILLERI)
GROUP
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final [**2138-3-4**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 3:10 PM ON
[**2138-3-4**].
GRAM POSITIVE COCCI IN CHAINS.
[**2138-3-3**] BLOOD CULTURE: Blood Culture, Routine (Final
[**2138-3-7**]):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
342-0390S
[**2138-3-3**].
FUSOBACTERIUM SPECIES. BETA LACTAMASE NEGATIVE.
Anaerobic Bottle Gram Stain (Final [**2138-3-4**]):
Reported to and read back by [**First Name4 (NamePattern1) 674**] [**Last Name (NamePattern1) **] PACU OVERRIDE
LOCATION @ 12:42
PM ON [**2138-3-4**].
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2138-3-4**]):
GRAM POSITIVE COCCI IN CHAINS.
BLOOD CULTURES from [**Date range (1) 91825**] are still pending
.
[**2138-3-17**] 06:43AM BLOOD WBC-8.6 RBC-3.77* Hgb-10.3* Hct-32.4*
MCV-86 MCH-27.2 MCHC-31.7 RDW-13.0 Plt Ct-599*
[**2138-3-10**] 07:12AM BLOOD Neuts-77* Bands-0 Lymphs-16* Monos-5
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2138-3-17**] 06:43AM BLOOD Glucose-92 UreaN-16 Creat-1.1 Na-137
K-4.5 Cl-101 HCO3-30 AnGap-11
[**2138-3-17**] 06:43AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.8
[**2138-3-17**] 06:43AM BLOOD Vanco-9.9*
.
Brief Hospital Course:
Mr. [**Known lastname **] is a very pleasant 52 year old man with a PMH
significant for DMII, HTN, Hyperlipidemia, who presents to his
PCP today with severe right leg cellulitis and a septic picture.
On [**2138-3-4**], he was brought to the operating room; please see the
operative report for full details. He tolerated the procedure
well and was transferred to the PACU with vitals stable and
vascular status intact. On admission he was admitted to the
MICU but following the procedure and with stabilization of the
pt overnight, the pt was transferred to the podiatry service.
2/2 blood cultures from [**2138-3-3**] grew back GNR and wcx showed
preliminary GPB. An ID consult was placed and recommended an
echo as well as daily blood cultures.
The pt continued to have low grade fevers as well as an elevated
wbc. There was no decrease in erythema to his foot with
malodor, tenderness, and purulent bleeding. The pt was brought
back to the operating room on [**2138-3-6**] for a further I&D; please
see the operative report for full details.
A rash to his PIV and perineal region was noted over the weekend
which ID thought may be due to a drug reaction or to a fungal
infection. Topical antifungals did not improve the affected
sites and changing antibiotics did not aid the area as well. ID
recommended a dermatology consult at this point.
Dermatology recommended miconazole 2% cream [**Hospital1 **] to affected
groing area, Triamcinolone 0.1% ointment to wrist & back [**Hospital1 **],
sarna lotion and benadryl for symptomatic relief.
On the floors, daily wet to dry dressings were changed during
evaluation of the RLE. He remained afebrile at this time and
was able to tolerate po nutrition. Physical therapy evaluated
the pt and stated the pt would be best served at a
rehabilitation facility.
The pt was brought back to the operating [**2138-3-11**] for a
right foot debridement, skin graft, and wound vac placement;
please see the operative report for full details.
The wound vac remained on while the pt was in-house with a wound
vac change on the 5th day. The STSG was healing well to the
plantar aspect of his foot, and all sutures remained intact with
nice closure of wound edges. His thigh STSG donor site was
notable to be heeling well, and was changed every second day
with a non-adherent bandage. His wbc slowly began to trend
downward. He remained hemodynamically stable.
On discharge, his VSS and neurovascular status was intact to his
RLE. He was discharged to rehab with strict NWB to RLE,
non-adherent dry dressing changes to affected areas qdaily, and
followup with Dr. [**First Name (STitle) 3209**], Dermatology and ID.
# Sepsis: He met [**3-2**] SIRS criteria with fevers, tachycardia,
elevated WBC count, and an infectious source on the form of a
diabetic foot ulcer and resultant cellulitis. He was placed on
broad spectrum antibiotics and cultures will need to be
followed.
.
# Hyperglycemia/DM: Likely secondary to acute infection. Does
not appear to have DKA/HONK given modestly elevated BS, normal
lactate, and AG of around 18. Insulin drip was started in the
ICU but quickly weaned off to insulin sliding scale. Upon
transfer to the floor he remained on ISS which normalized his
BS.
.
# ?Osteomyelitis: Per Podiatry wound does not probe to bone, but
ESR and CRP are markedly elevated. Continue broad spectrum
antibioitcs coverage with vanc/cipro/flagyl pending tissue
culture. Consider MRI lower extremity to assess for any
enhancement suggestive of osteomyelitis.
.
# Anemia: HCT was 36.5 with mild microcytosis. Iron studies
consistent with anemia of chronic inflammation.
.
# Hyponatremia: Corrected sodium is 133 on admission. He was
likely volume deplete in the setting of infection.
.
# Anion Gap Acidosis: Likely in the setting of elevated blood
sugars and lactate. Resolved after IVF resuscitation and brief
stint on an insulin drip in the ICU.
.
# Depression: Patient endorses having difficulty with his home
medication regimen and may have some underlying depression
making coping difficult. Therefore, a Social Work consult was
placed.
.
# Communication: Patient, HCP/brother is [**Name (NI) **] [**Name (NI) **]
.
# Code Status: Full Code
Medications on Admission:
(per PCP [**Name Initial (PRE) 626**]; he has not filled nor taken any of these in the
past year):
Sildenafil 100 mg PRN
Lisinopril 5 mg Daily
Glyburide 10 mg Daily
Simvastatin 40 mg QHS
Omeprazole 20 mg Daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxycodone 5 mg Capsule Sig: [**12-30**] Capsules PO every 4-6 hours
as needed for pain: Do not drive or drink alcohol while taking
this medication. .
Disp:*40 Capsule(s)* Refills:*0*
6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Continue until [**4-1**] per ID.
Disp:*30 Tablet(s)* Refills:*2*
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Continue until [**4-1**] per ID.
Disp:*90 Tablet(s)* Refills:*2*
8. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
twice a day: Until [**4-1**] per ID - total of 1.5.g [**Hospital1 **].
Disp:*qs qs* Refills:*2*
9. vancomycin 500 mg Recon Soln Sig: One (1) Intravenous twice
a day: until [**4-1**] per ID recs - total of 1.5g [**Hospital1 **].
Disp:*qs qs* Refills:*2*
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
14. heparin, porcine (PF) 10 unit/mL Syringe Sig: Three (3) ML
Intravenous PRN (as needed) as needed for line flush.
15. diphenhydramine HCl 50 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed for itching.
16. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): Apply to hands and wrist for 5 more
days (until [**3-22**]) & to back for 7 more days (until [**3-24**]).
17. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Apply to all other areas of body where rash
persists.
18. INSULIN
please resume your previous Insulin regimen
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Right foot infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were discharged with new medications. Please take as
directed. You may resume your normal home medications unless
otherwise directed.
You are to remain NONWEIGHT BEARING to your RIGHT FOOT at all
times in a surgical shoe. Physical therapy will continue to work
with you on your strength & balance.
Nurses will perform all your dressing changes. Keep your
dressings clean, dry, and intact. Avoid getting your dressings
wet.
You may resume your normal home diet.
If you develop any of the symptoms listed below or anything else
concerning, please see your PCP or go to your nearest emergency
room.
Please keep all follow up appointments.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2138-3-25**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2138-3-25**] 1:15
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2138-4-1**]
9:00
[**First Name8 (NamePattern2) 3210**] [**Last Name (NamePattern1) **] DPM 48-137
Completed by:[**2138-3-18**]
ICD9 Codes: 2761, 3572, 311, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7146
} | Medical Text: Admission Date: [**2106-10-27**] Discharge Date: [**2106-11-8**]
Date of Birth: [**2033-5-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest/back pain
Major Surgical or Invasive Procedure:
CTA Torso/Neck/Head
History of Present Illness:
73 y/o male who presented to ED after multiple episodes of dull
pain which started between shoulder blades radiating to front of
chest with abdominal nausea. Rated most severe pain [**1-8**] lasting
5-10 minutes. Admitted to re-check type b aorta dissection via
CT.
Past Medical History:
Type B aortic dissection.
Coronary Artery Disease s/p Coronary Artery Bypass Graft 10 yrs.
ago
Hypertension
Hypercholesterolemia
Rheumatoid arthritis
Melanoma
Social History:
Lives with wife.
Cigs: none
ETOH: none
Family History:
DM
Physical Exam:
Elderly [**Male First Name (un) 4746**] in NAD
HEENT: NC/AT, PERLA, EOMI, poor dentition
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+ bilat.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl s1, s2
Abd: +BS, soft, nontender without masses or hepatosplenomegaly
Ext: without C/C/E
Neuro: nonfocal, A&O x 3. MAE
Discharge
Gen NAD
Neuro: a/ox3 nonfocal
Pulm CTAB
Card: RRR no murmur/rub/gallop
Abd: soft, NT, ND +BS
Ext warm well perfused pulses +2
Pertinent Results:
[**2106-11-8**] 06:20AM BLOOD WBC-9.6 RBC-3.76* Hgb-11.4* Hct-31.9*
MCV-85 MCH-30.3 MCHC-35.7* RDW-13.4 Plt Ct-311
[**2106-10-26**] 07:20AM BLOOD WBC-11.2* RBC-4.34* Hgb-13.3* Hct-37.5*
MCV-86 MCH-30.5 MCHC-35.4* RDW-13.9 Plt Ct-160
[**2106-10-27**] 10:30AM BLOOD Neuts-81.9* Lymphs-10.4* Monos-5.8
Eos-1.8 Baso-0.1
[**2106-11-8**] 06:20AM BLOOD Plt Ct-311
[**2106-11-8**] 06:20AM BLOOD PT-13.5* PTT-30.4 INR(PT)-1.2*
[**2106-10-27**] 10:30AM BLOOD PT-12.8 PTT-26.2 INR(PT)-1.1
[**2106-10-26**] 07:20AM BLOOD Plt Ct-160
[**2106-11-8**] 06:20AM BLOOD Glucose-106* UreaN-18 Creat-1.1 Na-139
K-4.8 Cl-101 HCO3-27 AnGap-16
[**2106-10-26**] 07:20AM BLOOD Glucose-124* UreaN-16 Creat-1.1 Na-139
K-4.5 Cl-100 HCO3-30 AnGap-14
[**2106-10-28**] 06:35AM BLOOD ALT-11 AST-12 CK(CPK)-26* AlkPhos-115
TotBili-0.6
[**2106-10-27**] 07:29PM BLOOD ALT-15 AST-20 LD(LDH)-310* CK(CPK)-59
AlkPhos-132* Amylase-35 TotBili-0.6
[**2106-10-28**] 06:35AM BLOOD cTropnT-<0.01
[**2106-10-27**] 07:29PM BLOOD Lipase-18
[**2106-11-4**] 06:15AM BLOOD Mg-2.4
[**2106-10-28**] 06:35AM BLOOD Triglyc-105 HDL-47 CHOL/HD-2.9 LDLcalc-66
CTA chest [**10-27**]
IMPRESSION:
1. Aortic dissection involving the descending thoracic aorta
([**Location (un) 11916**] B, deBakey III). No extension to involve the ascending
aorta is evident.
2. History of prior CABG corroborated.
3. There is severe emphysema with a persistent left pleural
effusion.
4. There is cholelithiasis without evidence of cholecystitis.
[**11-2**] Echo
Left Atrium - Long Axis Dimension: *4.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.3 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.2 cm
Left Ventricle - Fractional Shortening: 0.32 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aorta - Ascending: *4.3 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.13
Mitral Valve - E Wave Deceleration Time: 133 msec
TR Gradient (+ RA = PASP): *27 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Normal regional LV systolic function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Moderately dilated ascending
aorta.
Descending aorta intimal flap/aortic dissection.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral
annular
calcification.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size
and systolic function (LVEF>55%). Regional left ventricular wall
motion is
normal. Right ventricular chamber size and free wall motion are
normal. The
ascending aorta is moderately dilated. While no clear dissection
flap is seen,
color Doppler imaging suggests a proximal descending aortic
dissection,
originating just distal to the origin of the left subclavian
artery. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are
structurally normal. There is no mitral valve prolapse. There is
mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Symmetric LVH with preserved global and regional
biventricular
systolic function. Moderately dilated ascending aorta.
Descending aortic
dissection.
[**11-2**] Stress Thallium
IMPRESSION: 1. Normal myocardial perfusion. 2. Normal LV cavity
size and
function.
[**11-4**] CTA head/neck
IMPRESSION:
1. Irregularity and narrowing along the V4 segment of the left
vertebral artery.
2. Mild/moderate right internal carotid artery stenosis at the
origin.
3. Atherosclerosis of bilateral carotids, most prominently at
the bulbs and cavernous portions.
4. Emphysema.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 8389**] was admitted for CT to
evaluate aorta. His blood pressure was closely managed and
cardiology was consulted. CT revealed no change in his Type B
Dissection of his Aorta from prior study. Cardiac enzymes were
followed with no increase suggestive of cardiac event. He was
further evaluated for endovascular stent and underwent
preoperative workup. He was transferred to the floor and pain
resolved. At this time declined surgery and was discharged home
a follow up CTA in 5 weeks and to call if pain returns.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
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:*0*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for back pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Type B aortic dissection.
Coronary Artery Disease s/p Coronary Artery Bypass Graft 10 yrs.
ago
Hypertension
Hypercholesterolemia
Rheumatoid arthritis
Melanoma
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Call if pain reoccurs.
Followup Instructions:
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 6 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-12-14**] 9am - do not eat
or drink anything 3 hours before. please go to [**Hospital Ward Name **] 4 at
[**Hospital1 18**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] in [**1-1**] weeks please call for appointment
Completed by:[**2106-11-9**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7147
} | Medical Text: Admission Date: [**2126-5-25**] Discharge Date: [**2126-6-2**]
Date of Birth: [**2070-7-15**] Sex: M
Service: CME
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: This is a 55-year-old male with
longstanding diabetes, CAD status post CABG on [**2126-3-6**], and
peripheral vascular disease who presented after 2 days of
nausea/vomiting with notable coffee-ground emesis on the
morning of admission. He has had 2 days of epigastric pain
and 2 days prior to admission was informed by PCP to start on
PO vancomycin for positive C. difficile. The patient
reported nausea immediately following initiation of
vancomycin, which progressed to vomiting. He had 2 days of
sharp, constant, abdominal pain and diarrhea, which was
improving. No blood per rectum or black/tarry stools. The
patient also complained of chest pain/left arm pain x 2-3
months, tender to palpation and worse with movement. He also
has shortness of breath associated with the pain though
different from prior angina. In ED, the patient was
hypertensive with right arm 218/147, left 240/98, tachycardia
to 103. EKG showed no T-wave inversions in V2 to V4 and lead
I compared to that of [**2126-3-19**]. He was treated with
sublingual nitroglycerin, IV Lopressor, and labetalol as well
as morphine with response of decreasing chest pain and blood
pressure. He was noted to vomit coffee-grounds and was NG
lavaged clear with 600 cc. He was given IV Protonix at that
time.
PAST MEDICAL HISTORY: Hypertension.
Left lower lobe collapse.
Hypercholesterolemia.
Insulin-dependent diabetes.
CHF with EF of 30-35 percent on [**2126-2-27**].
Chronic renal insufficiency, baseline creatinine 1.5-1.9.
CAD status post CABG x 4 in [**2-28**] with LIMA to LAD, SVG to
RCA to PDA, SVG to OM1.
PVD/claudication.
Tracheomalacia.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg a day.
2. Lipitor 20 mg p.o. q.d.
3. Amitriptyline 25 mg q.h.s.
4. Lopressor 75 mg p.o. b.i.d.
5. Lasix 40 mg p.o. b.i.d.
6. Protonix 40 mg p.o. q.d.
7. Pletal 100 mg p.o. b.i.d.
8. Glargine 20 units q.a.m.
9. Atacand 16 mg p.o. q.d.
ALLERGIES: CEFEPIME, WHICH GIVES FLUSHING AND TACHYCARDIA.
SOCIAL HISTORY: A 20-pack-year tobacco history. No ETOH.
No IVDU. Spanish-speaking from [**Country 7192**]. Lives with
brother's family. Not married. No kids.
FAMILY HISTORY: Father with CAD.
PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Afebrile,
heart rate 90s, blood pressure 122/60, respirations 17,
oxygen saturation 100 percent on 5 liters, decreasing to 97
percent on room air. GENERAL: Hispanic male, appearing
older than stated age, resting, in no acute distress. HEENT:
PERLA and EOMI. Moist mucous membranes. Clear oropharynx
with poor dentition. NECK: Supple, bilateral carotid
bruits. JVP about 8 cm at 45 degrees. CARDIOVASCULAR:
Regular rate and rhythm. Normal S1, S2. Early systolic
murmur over right upper sternal border and left upper sternal
border radiating to carotids bilaterally. LUNGS: Clear to
auscultation bilaterally. No egophony. Slight decreased
breath sounds to left lower lung. ABDOMEN: Normoactive
bowel sounds, soft, nondistended, tender in midepigastrium
without rebound or guarding, audible bruit, midline abdomen
with well-healed surgical scar. EXTREMITIES: Faint PT
pulses bilaterally, but good flow with Doppler. Chronic
venous stasis changes bilaterally. Sensation to touch and
position intact bilaterally. No palpable cords or edema.
RECTAL: Guaiac negative. NEURO: Cranial nerves II-XII
grossly intact.
LABORATORY DATA: Significant on admission for white count
12.4, hematocrit 35.1, and platelets 549. BUN 25, creatinine
1.5, CK 138, MB 6, troponin 0.04. Next set, CK 103 with MB
of 4 and troponin of 0.02.
RADIOGRAPHIC STUDIES: Chest x-ray, elevation of left
hemidiaphragm, blunting of the right and left CPAs, no
pulmonary vascular condition, no pneumothorax, persistent
bibasilar atelectasis. MRA showing atherosclerotic changes
of infrarenal abdominal aorta without evidence of aneurysmal
dilatation. High-grade stenosis of right proximal common
iliac and diffuse disease of left common iliac, severe
disease of left superficial femoral artery. Bilateral
disease of anterior tibial arteries.
HOSPITAL COURSE: GI bleed: The patient had EGD on [**2126-5-26**],
showing nonbleeding [**Doctor First Name **]-[**Doctor Last Name **] tear from vomiting in the
gastric cardia. EGD also showed mild esophagitis and
multiple erosions possibly consistent with NSAID-associated
gastropathy and gastritis. The patient was started on
Protonix b.i.d. with no further rebleeding from this tear.
His hematocrit has remained stable, so he did require a few
blood transfusions. He was guaiac negative later during
admission. He also was treated with Carafate 4 times a day
and was instructed to follow all pills with soft bread. Per
GI fellow, he will need IV PPI b.i.d. x 8 weeks followed by
PPI q.d.
Clostridium difficile colitis: Because of abdominal upsets
on oral vancomycin, he was switched to oral Flagyl to
complete a 14-day course. Although, he experienced continued
dyspepsia, he tolerated this medication well with no further
nausea/vomiting. His diarrhea also had resolved by hospital
discharge.
CAD: The patient was status post CABG and ruled out for MI
earlier on initial presentation. He experienced 1 further
episode of chest pain for which he received 4 sublingual
nitroglycerin with decrease in the pain. He had no EKG
changes at that time, and repeat enzymes were sent, which
were negative. He will be continued on aspirin, beta-
blocker, and statin with re-adding of his ACE inhibitor as an
outpatient once his creatinine is fully stable. His
hematocrit was kept greater than 30 during admission.
Hypertension: For extremely elevated blood pressure, the
patient was started on nitroglycerin gtt and once this was
weaned off, started on hydralazine and Isordil. His
hydralazine was gradually weaned off during admission. The
patient required increasing doses of his beta-blocker during
admission with occasional persistent hypertension to systolic
of 150s-160s. His ACE inhibitor was not restarted during
admission secondary to chronic renal insufficiency issues,
but should be restarted on discharge.
CHF: The patient had an EF of 30-35 percent. Initially,
gentle fluids were given with holding of Lasix secondary to
renal failure, but Lasix was re-added at home dose later in
admission. Because he developed crackles later in admission,
he was also given 2 doses of IV Lasix with good response of
urine output.
Acute renal failure: After admission, creatinine noted to
bump up to the mid-2 range. He was gently hydrated with
holding of his Lasix, and creatinine decreased to baseline by
discharge. His ACE inhibitor was held during admission.
Right hand cellulitis: The patient was noted to have
increase in white count with erythema, tenderness, and warmth
on the dorsum of his right forearm, where his former IV site
had been. Given that patient was diabetic, he was started on
Augmentin for a 7-day course.
Peripheral vascular disease: The patient has chronic
claudication and was to be scheduled for outpatient bypass
procedure by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]. Given that he was already
an inpatient, the patient was taken to lab for bilateral
iliac stent placement prior to discharge, which he tolerated
well. He will need to return in the next 3 weeks for full
bypass procedure once his renal issues are resolved.
IDDM: The patient continued on Lantus and RISS.
Urinary retention: The patient was noted to have urinary
retention late during admission without administration of
narcotics or other medications causing this. He was started
on Flomax.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Hypertensive emergency.
Diabetes mellitus, insulin-dependent.
Clostridium difficile colitis.
Coronary artery disease.
Status post coronary artery bypass surgery.
Peripheral vascular disease status post bilateral iliac
stent.
Urinary retention.
DISCHARGE MEDICATIONS:
1. Sucralfate 1 tablet p.o. q.i.d.
2. Pantoprazole 40 mg p.o. b.i.d.
3. Isosorbide dinitrate 40 mg p.o. t.i.d.
4. Simethicone p.r.n.
5. Atorvastatin 20 mg p.o. q.d.
6. Amlodipine 10 mg p.o. q.d.
7. Aspirin 81 mg by p.o. q.d.
8. Metoprolol 100 mg p.o. t.i.d.
9. Plavix 75 mg by p.o. q.d.
10. Furosemide 40 mg p.o. b.i.d.
11. Glargine 20 units subcutaneous q.h.s.
12. Tamsulosin 0.4 mg p.o. q.h.s.
13. Amoxicillin/clavulanate 500 mg/125 mg p.o. q.12
hours x 6 additional days.
14. Ibuprofen as needed.
FOLLOW-UP PLANS: The patient will call PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], who
was also in-patient attending, for follow-up appointment in
the next 2-3 weeks and will also arrange to have full
vascular surgery with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] in the next 3
weeks.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **]
Dictated By:[**Last Name (NamePattern1) 7193**]
MEDQUIST36
D: [**2126-6-3**] 11:21:45
T: [**2126-6-4**] 02:34:32
Job#: [**Job Number 7194**]
ICD9 Codes: 4280, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7148
} | Medical Text: Admission Date: [**2136-9-20**] Discharge Date: [**2136-9-26**]
Date of Birth: [**2099-9-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Tetracyclines / Succinylcholine / Clozaril /
Calcium Channel Blocking Agents-Benzothiazepines /
Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Infected transhepatic catheter
Clotted right brachial-to-right atrial arteriovenous graft.
Major Surgical or Invasive Procedure:
[**2136-9-21**]: Angioplasty and stent of right brachial artery-to-
right atrium arteriovenous graft.
History of Present Illness:
Patient was seen in clinic for evaluation of Right arm dialysis
graft and was noted to be febrile and ill-appearing. The
transhepatic catheter that was being used for hemodialysis was
noted to have copious amounts of pus at the insertion site. Due
to fever and septic appearance she was admitted through the ER
to the SICU for catheter removal and medical management
Past Medical History:
PAST MEDICAL HISTORY:
1. ESRD due to IgA nephropathy
2. Schizoaffective disorder
3. Depression
4. Anemia
5. GERD
6. Cardiomyopathy
7. Hypothyroidism
8. GI bleed
9. Coagulase negative staph infection
10. RLE DVT
11. Seizures x 2 [**8-11**]
PAST SURGICAL HISTORY:
s/p L upper & lower AV fistula - failed
s/p R AV fisula basilic v transposition - failed
s/p R forearm AV graft - failed
s/p PD catheter '[**27**] - failed
central venous stenosis - R brachiocephalic v.
occlusion of inominate v.
s/p R arm brachial->axilla AV graft ([**2133-10-9**])
s/p thrombectomy & angioplasty of outflow stenosis ([**2133-10-11**])
s/p thrombectomy ([**2133-10-23**])
s/p thrombectomy and revision of R arm AV graft ([**2133-11-12**])
s/p thrombectomy of R arm AV graft ([**2133-11-16**], [**2133-12-15**])
s/p excision of infected R arm AV graft ([**2133-12-25**])
[**2136-8-2**] right brachial artery to right atrium graft
[**2136-8-3**] rue graft thrombectomy
7/-/07 Trache
[**2136-8-13**] RUE exploration -seroma
[**2136-8-31**] UTI, pseudomonas
[**2136-9-8**] replacement of transhepatic hemodialysis catheter
Social History:
Currently a patient at [**Hospital6 **], unemployed, no
tobacco, alcohol, or recreational drug use. Estranged from
mother [**Name (NI) **] ([**Telephone/Fax (1) 32972**])
Family History:
Non-contributory.
Physical Exam:
VS: 102.2-104, 115, 80/48, 22, 100% 12L trach,mask
Gen: Shaking, awake but appears sleepy
Card: Sinus tach, regular
Lungs: CTA, on trach mask
Abd: Soft, ND, NT, pus at insertion site of catheter
Pertinent Results:
On Admission: [**2136-9-20**]
WBC-10.3# RBC-2.66* Hgb-8.7* Hct-26.4* MCV-99* MCH-32.6*
MCHC-32.8 RDW-17.2* Plt Ct-275
PT-17.5* PTT-31.5 INR(PT)-1.6*
Glucose-116* UreaN-40* Creat-5.0* Na-143 K-4.8 Cl-104 HCO3-25
AnGap-19
ALT-14 AST-20 AlkPhos-137* Amylase-86 TotBili-0.3
TotProt-7.0 Calcium-8.5 Phos-4.2 Mg-1.9
On Discharge: [**2136-9-26**]
WBC-4.7 RBC-2.41* Hgb-7.6* Hct-23.4* MCV-97 MCH-31.4 MCHC-32.3
RDW-16.8* Plt Ct-199
PT-25.6* INR(PT)-2.6*
Glucose-82 UreaN-38* Creat-5.1*# Na-142 K-3.5 Cl-102 HCO3-29
AnGap-15
Calcium-8.4 Phos-3.7 Mg-1.7
Brief Hospital Course:
Patient admitted to the SICU due to the severity of the fever
and infected transhepatic catheter that had copious pus at the
insertion site. The catheter was removed. Cultures of Blood,
urine and sputum were ordered. Blood cultures grew Coag+ Staph,
(MRSA) as well as the catheter tip. She was started on Vanco and
Gentamycin on admission, the gentamycin was withdrawn once
culture data received.
She underwent thrombectomy and stent placement to the dialysis
graft on [**2136-9-21**] with Drs [**Last Name (STitle) 816**] and [**Name5 (PTitle) 32976**].
Initial arteriographic images revealed occlusion and thrombus
near the anastomosis with no blood flow to the heart. After a
successful balloon dilation of the graft and advancing of the
wire into the right atrium, there was evidence of blood flow and
the area of the anastomosis of the right atrium was discovered.
There was
successful deployment of self-expandable stent in the graft
followed by another deployment of a stent from the prior stent
into the right atrium. The post-stenting images reveal
excellent patency of the graft and flow immediately through
the graft into the right atrium and into the right ventricle.
She was placed on a heparin drip, and was then converted back to
Coumadin which she will be discharged on.
She was dialyzed using the Right graft with 350 blood flows.
She was dialyzed again on [**9-24**] and [**9-26**]. On [**9-26**] she received 1
unit pRBCs for hct of 23.4%
Of note the patient remains on the trach with O2 via trach mask.
Laryngoscopy done on [**9-18**] just prior to this admission shows
mild collapse medially of left arytenoid and omega shaped
epiglottis. Patnet airway. Their recommendation is that
respiratory therapy can try plugging the trach during the day
and see how she tolerates. They recommend follow-up in 3 months
with [**First Name4 (NamePattern1) 9317**] [**Last Name (NamePattern1) **] MD ([**Telephone/Fax (1) 32977**]) Please see attached report
from ENT.
Patient should continue to receive Vanco at hemodialysis and
then PO Flagyl for 2 weeks following Vanco completion.
Follow PT/INR per facility protocol, Coumadin is for thrombus
management
Of note, a cardiac echo was performed on [**9-25**]: there was no
evidence of vegetations, EF > 55%
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Ropinirole 1 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)).
5. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
6. Fluphenazine HCl 1 mg Tablet Sig: Five (5) Tablet PO LUNCH
(Lunch).
7. Mirtazapine 15 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime).
8. Clonazepam 0.5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for sbp <100 and HR <55.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
14. Fluphenazine HCl 1 mg Tablet Sig: Five (5) Tablet PO
BREAKFAST (Breakfast).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed: Sarna for pruritus.
17. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
18. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain / fever.
2. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Midodrine 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Through [**11-7**].
6. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
7. Ropinirole 1 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)).
8. Fluphenazine HCl 10 mg Tablet Sig: 0.5 Tablet PO Q AM WITH
BREAKFAST ().
9. Fluphenazine HCl 10 mg Tablet Sig: 0.5 Tablet PO Q LUNCH ().
10. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
11. Clonazepam 0.5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Mirtazapine 15 mg Tablet Sig: 2.5 Tablets PO HS (at
bedtime).
16. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
Check PT/INR per facility protocol.
17. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol): Give throughSept 19.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**]
Discharge Diagnosis:
Infected transhepatic dialysis catheter/removed
Thrombectomy Right arm dialysis graft
Discharge Condition:
Fair
Discharge Instructions:
Continue hemodialysis schedule T-Th-S
Use Right AVG dialysis graft for hemodialysis. Check bruit and
thrill daily. Please call [**Telephone/Fax (1) 673**] if unable to appreciate
bruit/thrill
No constrictive clothing, blood pressures, blood draws or IV's
to Right arm
Continue medications as directed
Vanco for one additional month at hemodialysis
Flagyl for 6 weeks
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2136-10-4**] 9:50
[**First Name4 (NamePattern1) 9317**] [**Last Name (NamePattern1) **] MD: 3 month follow-up ([**Telephone/Fax (1) 32977**])
Completed by:[**2136-9-26**]
ICD9 Codes: 0389, 4254, 5856, 2449, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7149
} | Medical Text: Admission Date: [**2130-8-13**] Discharge Date: [**2130-8-14**]
Date of Birth: [**2083-4-1**] Sex: M
Service: MEDICINE
Allergies:
Haldol / Navane / Morphine
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
requesting detox
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
47 yo male with PMH significant for borderline personality
disorder,
alcohol abuse, schizo-affective disorder, and IDDM who presented
to the ED intoxicated after being brought in by EMS requesting
detox. The pt reports that he is unable to recall the exact
details of how EMS care was initiated.
In the ED, initial vitals were 98.0, 105, 20, 138/88 and 94% RA.
The pt was failry combative and required several doses of Ativan
and Haldol for sedation. A serum EtOH level was found to be 291.
The pt complained on nausea and was reported to have
approximately 500 cc of bright red hematemasis; he was then
given Zofran for nausea. A right subclavian line was placed as
the pt has difficult access. Lab testing was remarkable for an
elevated serum blood sugar and AG acidosis.
The pt report that he had been in his usual state of health
until the end of last week. Approximately four days PTA the pt
stepped off a curb when he slipped and fell, injuring his left
foot (denies hitting his head). The following day he stopped
taking his insulin, which he reports he does intermittently. He
denies significant NSAID use.
At present, the pt reports he is comfortable but thirsty. He
denies pain, fever, chills or persistent nausea. No CP,
palpitations or diaphoresis. No cough, but the pt does report
his breathing has felt "shallow" a few times in the last several
days; he noted this while at rest. No abd pain. The pt reports
he has noted some BRB streaking his stools over the last few
days which is new for him; he denies melena or blood mixed
within the stool. MSK complaints only as above. Denies weakness,
change in sensation or balance.
Past Medical History:
*recent diagnosis of hepatitis B
*History of alcohol and substance abuse
*Borderline personality disorder
*IDDM since [**2111**] with a history of diabetic ketoacidosis in the
past
*Prior suicidal behavior
*Schizo-affective disorder
*History of depression and paranoia
*Questionable history of seizure disorder, no seizures in 25
years
*History of microcytic anemia
Social History:
The patient is divorced with one child. He is currently homeless
but lives in the [**Location (un) 86**] area. Positive history of alcoholism,
reports drinking approximately one quart of whisky daily.
History of IV drug use. Currently smoking 2 ppd; has smoked (at
lower level) for 15 years. He is currently not working; former
printer.
Family History:
Remarkable for DM. No bleeding diathesis or early CAD.
Physical Exam:
Gen: Chronically ill appearing adult male, no acute distress.
HEENT: PERRL, EOMI. Dry MM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD. No tenderness with
palpation.
Chest: CTAB anterior and posterior.
Cor: Normal S1, S2. Mildly tachycardic, regular rhythm. No
murmurs appreciated.
Abdomen: Soft, non-tender and non-distended. +BS, no HSM.
Extremity: Warm, without edema. Tenderness and swelling noted at
left foot. 2+ DP pulses bilat.
Neuro: Alert; initially oriented to self only. CN 2-12 intact.
Motor strength intact in all extremities. Sensation intact
grossly. Cerebellar function intact. Gait not assessed.
Pertinent Results:
[**2130-8-12**] 09:40PM WBC-10.0 RBC-3.99* HGB-11.0* HCT-32.7* MCV-82
MCH-27.6 MCHC-33.8 RDW-14.7
[**2130-8-12**] 09:40PM NEUTS-85.1* LYMPHS-11.5* MONOS-2.4 EOS-0.7
BASOS-0.2
[**2130-8-12**] 09:40PM GLUCOSE-403* UREA N-9 CREAT-0.9 SODIUM-139
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-19* ANION GAP-28*
.
Admission CXR:
Bibasilar atelectasis. No free air under the diaphragms or
evidence of pneumomediastinum. Mild gaseous distention of
colonic loops of bowel in the left upper quadrant.
Brief Hospital Course:
47 yo male with borderline personality disorder, alcohol abuse,
schizo-affective disorder and IDDM admitted with DKA and and an
episode of hematemesis.
#DKA: Pt reports not taking his insulin; this, in conjunction
with EtOH intake, appears to be the cause of his DKA. Currently
no evidence of infection or myocardial ischemia. Found to have
elevated serum glucose, glucose and ketones in urine and AG
acidosis. Clinical picture is c/w DKA; HONK also in differential
although less likely.
-continue insulin gtt with hourly FBSB until controlled and AG
closed
-q4 hour lytes with aggressive repletion of Mg and K
-continue aggressive fluid repletion
#Hematemesis: Pt with episode of hematemasis in ED. HCT appears
approximately five points below prior baseline; pt currently HD
stable. No prior h/o GI bleeding or varicies. Pt is not
coagulopathic.
-PPI gtt
-GI aware; probable EGD in AM
-serial HCTs
-type and cross
-central access; attempt to also place PIV
-hold home ASA for now
#Elevated LFTs: Pt with elevated LFTs at admission, greater than
in past. Denies abd sxs. Recent dx as above of hepatitis B. Ddx
would include EtOH abuse, stone disease, NASH.
-consider U/S
-trend LFTs
#Foot injury: Pt is s/p fall in which he injured foot. Will
check x-ray.
#EtOH abuse: Pt reports drinking one quart of alcohol daily.
-continue home thiamine, folate and MVI
-CIWA protocol
#left foot injury: Pt is s/p fall. Will check x-ray to eval for
fracture.
#question history of seizures: Continue Depakote once able to
clarify dose.
#Psych: Pt currently reports treatment with Celexa and
thorazine, however doses unclear. [**Name2 (NI) **] to clarify these in AM.
Would consider psych consult once improved. SW consult now.
#Anemia: Normocytic with normal RDW. Difficult to interpret in
setting of possible acute GI bleeding. Will need additional
workup once stable.
#HTN: Hold antihypertensives in setting of possible GIB.
#Hyperlipidemia: Would consider continuation of statin once dose
can be clarified.
#FEN: NS for volume repletion as above. Aggressive electrolyte
repletion. NPO for now.
#Code: Full
#Prophy: Pneumoboots given possible bleeding. PPI infusion for
hematemasis as above.
On the morning after admission the patient was adamant to leave
the hospital. He was able to clearly state the risks of this
choice including death. Pysch had seen him the night prior and
felt he did have capacity. He signed AMA paperwork and left the
hospital with instructions for follow up
Medications on Admission:
ASA 81 mg daily
Lantus 25 units QHS
Humalog insulin SS with meals
Depakote (dose unknown)
Celexa (dose unknown)
thorazine (dose unknown)
antihypertensive (unknown)
lipid lowering med ([**Last Name (un) 5487**])
multivitamin
folate
thiamine
Discharge Medications:
left ama
Discharge Disposition:
Home
Discharge Diagnosis:
UGIB
DKA
Discharge Condition:
left ama
Discharge Instructions:
left ama - told to return to this or any hospital if he was
willing to reconsider his decision or felt more ill
Followup Instructions:
left ama
ICD9 Codes: 5789, 3051, 2859, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7150
} | Medical Text: Admission Date: [**2194-2-26**] Discharge Date: [**2194-4-8**]
Date of Birth: [**2115-9-30**] Sex: M
Service: MEDICINE
Allergies:
Cytarabine
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78 yo Cantonese speaking male started noticing dizziness about 5
days ago. He felt a room spinning sensation with both standing
up and change in head position. He did not have any tinnitus,
hearing loss, ear pain or drainage, headache, visual changes,
focal neurological changes. He denies fevers, chills,
congestion, cough. He took a chinese herbal tea called "small
box tea" day before yesterday and then went to see his PCP
[**Name Initial (PRE) 1262**]. His PCP drew some labs and he was found to have
neutropenia and anemia and pt was asked to see PCP again today.
Over the last 2 days, his dizziness had been improving and
currently he does not have any dizziness anymore.
Other than the herbal tea, he denies ingesting any other
over the counter or herbal medications. He does not get
medications from anyone other that his PCP and has been on the
same medications for years
Other than recent dizziness he has not fallen ill in the
last few months, he does not have any sick contacts and has not
had any foreign travel. He denies easy bruising or bleeding
He denies chest pain, shortness of breath, cough,
nausea/vomiting/diarrhea, deneis urinary symptoms
ROS:
-Constitutional: [x]WNL []Weight loss []Fatigue/Malaise []Fever
[]Chills/Rigors []Nightweats []Anorexia
-Eyes: [x]WNL []Blurry Vision []Diplopia []Loss of Vision
[]Photophobia
-ENT: [x]WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: [x]WNL []Chest pain []Palpitations []LE edema
[]Orthopnea/PND []DOE
-Respiratory: [x]WNL []SOB []Pleuritic pain []Hemoptysis []Cough
-Gastrointestinal: [x]WNL []Nausea []Vomiting []Abdominal pain
[]Abdominal Swelling []Diarrhea []Constipation []Hematemesis
[]Hematochezia []Melena
-Heme/Lymph: [x]WNL []Bleeding []Bruising []Lymphadenopathy
-GU: [x]WNL []Incontinence/Retention []Dysuria []Hematuria
[]DIscharge []Menorrhagia
-Skin: [x]WNL []Rash []Pruritus
-Endocrine: [x]WNL []Change in skin/hair []Loss of energy
[]Heat/Cold intolerance
-Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain
-Neurological: [x] WNL []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache
-Psychiatric: [x]WNL []Depression []Suicidal Ideation
-Allergy/Immunological: [x] WNL []Seasonal Allergies
.
Past Medical History:
1. Diabetes Mellitus
Social History:
Lives with wife. Married for 30+ years. Denies smoking, alcohol
or drug use history ever. Denies hx of blood transfusion. Does
not have intercourse with anyone other than wife.
Family History:
No one in family has hx of cancer/blood disorders
Physical Exam:
Physical Exam:
Appearance: NAD
Vitals: T:98.4 BP:103/64 HR:93 RR: 16 O2:99 % RA
Eyes: EOMI, PERRL, conjunctiva clear, anicteric,
ENT: Moist
Neck: No JVD, no LAD
Cardiovascular: RRR, nl S1/S2, no m/r/g
Respiratory: CTA bilaterally, comfortable, no wheezing, no
ronchi, no rales
Gastrointestinal: soft, non-tender, non-distended, normal bowel
sounds
Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint
swelling, no edema in the bilateral extremities
Neurological: Alert and oriented x3, fluent speech, no pronator
drift, no asterixis, sensation WNL, CNII-XII intact
Integument: warm, no rash, no ulcer
Psychiatric: appropriate, pleasant
Hematological/Lymphatic: No cervical, supraclavicular, axillary,
or inguinal lymphadenopathy
GU: no CVAT
Pertinent Results:
[**2194-2-26**] 10:50AM WBC-0.9* RBC-2.78* HGB-9.6* HCT-27.1* MCV-97
MCH-34.7* MCHC-35.6* RDW-15.6*
[**2194-2-26**] 10:50AM NEUTS-10* BANDS-0 LYMPHS-80* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2194-2-26**] 10:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2194-2-25**] 09:33AM UREA N-16 CREAT-0.7 SODIUM-133 POTASSIUM-4.3
CHLORIDE-97 TOTAL CO2-27 ANION GAP-13
[**2194-2-25**] 09:33AM TSH-0.90
Brief Hospital Course:
AP: 78 yo Chinese male w PMHx of T2DM presents with 4-5 day hx
of dizziness which is now resolved and found to have neutropenia
and anemia and AML.
#. Leukemia: Patient presented with neutropenia and anemia.
Found to have AML. Started on 7+3. Course complicated by
stridor and ICU stay (see below). Patient recovered and
continued his chemo course without complication. His counts
dropped as expected and he developed severe abdominal pain and
fevers (discussed below). Eventually his counts recovered and
he did well. He was noted to have some atypical cells in his
peripheral smear. He never had a day 14 BM biopsy because of
his clinical deterioration during that time. He will follow up
with Dr. [**Last Name (STitle) 410**] and they can discuss future treatments.
.
#. T2DM: Holding outpatient oral regemin and treating with
lantus at night and sliding scale. Patient had increased
inslulin requirements while on steroids. Then he had pretty
well controlled diabetes until the week prior to discharge when
he started having pretty severe hyperglycemia. [**Last Name (un) **] was
consulted and his lantus and sldiding scale were changed. He
was not on insulin prior to admission, and so he needed insulin
teaching and was hooked into the [**Hospital **] clinic as an outpatient.
He and his wife and children were doing well with insulin
teaching.
.
# Febrile neutropenia / Fungemia - while patient was having
fevers during his nadir, he had a positive blood cutlure growing
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**]. ID was consulted and the patient had an echo
and eye exam, both of which were normal. He was started on
micafungin and stopped having fevers. Eventually when he had
elevated LFTs, we switched his micafungin to anidlofungin per ID
recs. During this time, he was having severe abdominal pain, so
with worries for hepatosleno candidemia, we did an MRI that did
not show any involvement. His abdominal pain improved, but he
contined to have elevated LFTs despite switching antifungals.
He also was hyperglycemic and tachycardic which would lead more
to continued infection. We thought he should have an extended
course of the anidlofungin and was discharged home on it with ID
follow up prior to the end of his course.
.
# Elevated LFTs - after having fungemia, he had elevated LFTs
which were thought to likely be due to med effect v.
hepatospleno candidemia. His MRI was negative, but he continued
to have clinical signs of infection (although never spiked
another fever once on antifungals). Liver was consulted, and
his LFTs started trending down so it was decided that a biopsy
was not needed. By time of discharge, they continued to be
trending downward. Will follow up as outpatient.
.
# Abdominal pain - while patient was in his nadir of his counts,
he developed severe abdominal pain, which caused him to stop
eating. He was placed on TPN because of his poor PO intake. He
had two CT scans that did not show any bowel infection or
typhlitis. It did show severe constipation. He was treated for
his constipation and his symptoms improved. When his counts
recovered, he no longer had abdominal pain and was eating very
very well by the time of discharge.
.
# Enterococcus UTI: Diagnosed from urine culture in the ED and
treated with cefepime. Patient was spiking fevers after that
which were attributed to Leukemia but as he was neutropenic he
was continued on a course of Vancomycin and cefepime for
neutropenic fevers until his count recovers. He had second
fevers while on vanco/cefepime and found to have fungemia (as
discussed above).
.
# Stridor/respiratory distress: The patient was started on
chemotherapy on [**3-6**]. He was given cytarabine and idarubicin.
After his first dose, he developed acute respiratory distress,
with tachypnea and audible stridor. He was presumed to have an
anaphylactic reaction to his chemotherapy, and was given
solumedrol 125mg IV X1, Benadryl 25mg IV X1, inhaled racemic
epinephrine, and epinephrine .3mg IM X1. His respiratory
distress did not subside, and he was transferred to the [**Hospital Unit Name 153**]
emergently for intubation. Anesthesia intubated the patient
without complications, and did not observe swollen or edemetous
trachea or vocal cords. His vitals at this time were Temp 103.0,
BP 180/100, HR 160. He was transported to the ICU and intubated
for airway protection. It could not be determined if he
actually had a reaction to the chemo or a transfusion reaction.
He was restarted on the chemo while getting IV steroids. He was
premedicated for all blood products. His blood was sent for a
transfusion reaction but none could be identified. He had no
other respiratory symptoms except one day of wheezing which was
likely due to fluid overload and disappeared after being
diuresed.
# Gluteal Hematoma: Patient had a traumatic bone marrow biopsy
complicated by a gluteal hematoma. This eventually extended
down his thigh and was likely the cause of a hematocrit drop.
There was no evidence of compartment syndrome and he was
transfused. He improved with supportive care. By time of
discharge, the bruising and discoloration was gone and he had no
pain.
Medications on Admission:
1. Doxazosin 2mg QHS
2. Aspirin 325mg QD
3. Metformin 1000mg [**Hospital1 **]
4. Glipizide 10mg [**Hospital1 **]
5. Lisinopril 10mg QD
Discharge Medications:
1. Doxazosin 4 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*15 Tablet(s)* Refills:*2*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: take
for constipation.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Anidulafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous daily () for 11 days.
Disp:*11 Recon Soln(s)* Refills:*0*
5. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection twice
a day for 30 days.
Disp:*60 syringes* Refills:*0*
6. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lantus 100 unit/mL Solution Sig: 16 u in AM, 30 u in PM units
Subcutaneous qAM and qPM.
Disp:*10 ml* Refills:*2*
8. Insulin Syringes (Disposable) 1 mL Syringe Sig: One (1)
syringe Miscellaneous twice a day.
Disp:*120 syringes* Refills:*2*
9. Ultra Thin Lancets Misc Sig: One (1) lancet Miscellaneous
four times a day.
Disp:*120 lancets* Refills:*2*
10. Blood Glucose Test Strip Sig: One (1) strip In [**Last Name (un) 5153**]
four times a day.
Disp:*120 strips* Refills:*2*
11. Insulin Regular Human 100 unit/mL Solution Sig: as directed
by sliding scale unit Injection four times a day.
Disp:*10 ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Final Diagnosis:
1. Neutropenia/Anemia
2. AML
3. Diabetes
4. Fungemia
5. Hepatospleno candidasis
Discharge Condition:
stable, walking around with walker, feeling well
Discharge Instructions:
You were admited because your primary care doctor found some of
your blood levels to be low. You were worked up and found to
have leukemia. You started chemotherapy. Right when you
started you had a bad reaction to either some blood or the
chemo. It required you to go to the intensive care unit and be
intubated. You were extubated and restarted your chemotherapy
without any issues. You were given medications to prevent
another reaction with blood.
.
While your white count was low, you got an infection with
[**Female First Name (un) **] (a type of yeast/fungus). You were very sick and had a
lot of abdominal pain during this time, too. We treated you
with antibiotics. You will need to continue receiving the
anti-fungal at home through your PICC line, with the help of a
home nurse.
.
We also did several CT and MRI scans to look at your abdomen.
We think your pain was mostly from constipation. You should
continue to make sure you are having bowel movements at home and
call or take stool softeners if you have not had one in over 2
days. You also likely had the fungus infection in your liver.
We followed your liver function tests in your blood and they
have started going towards normal. You will need to continue
getting IV antibiotics for the next two weeks.
.
Please return to the hospital for any fevers, chills, redness or
pain around your PICC line, chest pain, shortness of breath,
abdominal pain, worsening diarrhea, constipation or any other
concerns. Please follow up as listed below.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 410**] on Thursday [**4-10**] at 11:00 am in
[**Hospital Ward Name 23**] 7 to discuss the future AML treatment.
Please follow up with Dr. [**Last Name (STitle) 724**] in infectious disease next Tues
[**4-15**] at 2pm in [**Hospital Ward Name 23**] 7 (where you see Dr. [**Last Name (STitle) 410**] to determine
whether or not you will need to continue your antibiotics.
Please follow up at [**Last Name (un) **] in the Asian [**Hospital 982**] Clinic with
[**First Name8 (NamePattern2) 8463**] [**Last Name (NamePattern1) 13260**] on [**5-13**] at 1:30 pm. [**Last Name (un) **] will be contacting you
if there is a cancellation for you to see them earlier.
Please make sure to call your opthamologist and make a follow up
appointment at some point in the near future. They will help
you set up this appointment when you see the diabetes doctor [**First Name8 (NamePattern2) **] [**Last Name (un) 4372**].
Please follow up with your primary care doctor Dr. [**First Name (STitle) **] [**Name (STitle) **] at
phone number [**Telephone/Fax (1) 8236**]. Call to make an appointment for
sometime in the next month.
Completed by:[**2194-4-17**]
ICD9 Codes: 5185, 5990, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7151
} | Medical Text: Admission Date: [**2115-6-24**] Discharge Date: [**2115-6-29**]
Date of Birth: [**2040-11-16**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Transfer from ICU, patient originally presented with acute
shortness of breath.
Major Surgical or Invasive Procedure:
P-MIBI, gastric emptying study.
History of Present Illness:
Mr. [**Known lastname 11875**] is a 74 year old male with a history of HTN, DM2,
ESRD on HD with atrophic L kidney, who presented to the ED on
[**2115-6-24**] with a chief complaint of dyspnea on his way to
hemodialysis. The patient is a poor historian, and it is
difficult to get a history from him even with an interpreter,
however the following was obtained: He had last received his
regularly scheduled HD on [**2115-6-21**]. Patient denies any history of
chest pain, palpitations, or change in diet (no high salt
intake). He does describe some nausea, emesis, and lack of
apetite for the last few months. About 1 week ago he noted
increased peripheral edema, and on the night prior to admission
he began having increased SOB. He denies any fevers. He
describes a recent weight loss secondary to his nausea and
decreased apetite, however he is uncertain of how much. He may
have had some mild abdominal pain, but this is only over the
last few days.
On presentation to the ED, he was afebrile, with bp 220/148, HR
103, RR 30s, saturating 94-97% on 100%NRB. He was placed on
BIPAP and NTG drip with good response: RR decreased to 20s, BP
decreased to 173/115, and the patient was transfered to the MICU
for further management of what was felt to be most likely a CHF
exacerbation based on physical exam findings of volume overload.
No recent echo reports, however patient had a stress test in
[**2106**] with 9.5 minutes of [**Doctor First Name **] protocol, no ischemia or EKG
changes.
The patient was transferred to the MICU for further management
of his CHF exacerbation. A CXR showed moderate CHF with small
bilateral pleural effusions. EKG was without ST,T wave changes.
He received HD with good response - normalization of BP, IV
nitro drip was weaned. Received second HD [**6-25**] (day after
admission to ICU), and was subsequently transferred to the
floors.
Past Medical History:
HTN
DM2
Nephrolithiasis, s/p bilateral ureteral stents in [**2110**]
ESRD on HD (M,W,F)
Atrophic L kidney
Liver biopsy c/w granulomatous hepatitis
h/o infected R IJ permacath s/p removal 3/04
L forearm AVG [**1-17**]
Social History:
Patient denies ever drinking alcohol, smoking, or doing drugs.
Married, but no children. Lives at home where he says he has
plenty of support, but won't elaborate regarding who the support
is. Has difficulty with transportation to dialysis, and is very
interested in acquiring this transportation.
Family History:
Difficult to elicit, even with translator.
Physical Exam:
VS: 96.2, P 76, BP 126/81, R 16.
Gen: African American male, resting comfortably in bed, NAD.
HEENT: Anicteric sclera, [**Name (NI) 3899**], PEARL, pterygium in R eye.
Neck: No JVD, supple, no lymphadenopathy.
CVS: RR, normal rate, no M/R/G.
Lungs: Rales b/l at the bases.
Abd: Normoactive BS. Mild RUQ tenderness, worse with
inspiration. No organomegaly.
Extr: 1+ bipedal edema extending up to knees. Palpable radial,
DP pulses b/l.
Pertinent Results:
[**2115-6-24**] WBC-13.4*# RBC-4.15*# Hgb-14.2# Hct-44.5# MCV-107*#
MCH-34.3*# MCHC-31.9 RDW-13.3 Plt Ct-226
[**2115-6-24**] Neuts-66 Bands-0 Lymphs-29 Monos-5 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0
[**2115-6-28**] 03:30PM BLOOD WBC-8.1 RBC-4.27* Hgb-14.5 Hct-42.0
MCV-98 MCH-33.9* MCHC-34.5 RDW-13.8 Plt Ct-240
[**2115-6-27**] 07:10AM BLOOD Neuts-55.7 Lymphs-27.5 Monos-11.6*
Eos-4.6* Baso-0.7
[**2115-6-24**] PT-12.2 PTT-24.0 INR(PT)-1.0
[**2115-6-24**] Glucose-190* UreaN-42* Creat-7.5* Na-135 K-4.5 Cl-95*
HCO3-24 AnGap-21* Calcium-9.7 Phos-5.8* Mg-2.2
[**2115-6-29**] 07:35AM BLOOD Glucose-143* UreaN-40* Creat-6.7*# Na-138
K-3.9 Cl-95* HCO3-29 AnGap-18
[**2115-6-26**] 07:05AM BLOOD ALT-74* AST-28 AlkPhos-204* TotBili-0.5
[**2115-6-27**] 07:10AM BLOOD ALT-54* AST-22 AlkPhos-196* TotBili-0.5
[**2115-6-29**] 07:35AM BLOOD ALT-32 AST-19 AlkPhos-192* Amylase-228*
TotBili-0.5
[**2115-6-24**] CK(CPK)-213*, cTropnT-0.33*
[**2115-6-25**] CK(CPK)-160, CK-MB-5, cTropnT-0.42*
[**2115-6-25**] CK-MB-4 cTropnT-0.41*
[**2115-6-27**] 07:10AM BLOOD Lipase-84*
[**2115-6-27**] 07:10AM BLOOD calTIBC-231* VitB12-1102* Folate-16.9
Ferritn-1297* TRF-178*
[**2115-6-27**] 07:10AM BLOOD Triglyc-139 HDL-82 CHOL/HD-2.7
LDLcalc-115
[**2115-6-27**] 07:10AM BLOOD TSH-1.3
[**2115-6-27**] 07:10AM BLOOD Free T4-1.7
Echocardiogram [**2115-6-26**]: Left to right shunt across the
interatrial septum consistent with a stretched patient foramen
ovale or small atrial septal defect. Left ventircular wall
thickness was normal. The left ventricular cavity size is
normal. Resting regional wall motion abnormalities include
distal anterior and septal apical hypokinesis, inferior
hypokinesis/akinesis and basal inferoseptal hypokinesis with
mild hypokinesis elsewhere. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension.
Trivial/physiologic pericardial effusion.
Brief Hospital Course:
The patient was transferred to the MICU for further management
of his CHF exacerbation. A CXR showed moderate CHF with small
bilateral pleural effusions. EKG was without ST,T wave changes.
He received HD with good response - normalization of BP, IV
nitro drip was weaned. Received second HD [**6-25**] (day after
admission to ICU), and was subsequently transferred to the
floors.
1) CHF - The patient was still mildly volume overloaded on PE
upon arrival to the floors, with mild bipedal edema and rales at
the right base, [**Last Name (un) 11876**] he received hemodialysis M,T,W with more
than 11 kg fluid removed, and is without signs of failure on
physical exam currently. As to the cause of the CHF
exacerbation, renal feels that patient may not have been having
enough fluid removed at HD since patient has recently lost
weight, and therefore dry weight may have been overestimated,
and therefore they weren't removing as much fluid as they should
have been. They do not feel that the patient needs to be on
Lasix, as they will remove fluid via HD, which he will continue
as an outpatient M,W,F.
Cardiac enzymes were ordered to rule out a myocardial infarction
as a cause of his CHF, with Troponin T elevated, however in this
patient with renal failure, a TnI would be more useful. CK-MB
has been wnl. We also ordered an echocardiogram in order to
evaluate his pump function, which showed diffuse hypokinesis of
the left ventricle, as described in the pertinent results
section. As the patient has never had a stress test before, we
ordered a p-MIBI in order to further evaluate his cardiac risk,
which was a poor study secondary to failure of the patient to
achieve greater than 60% of his maximum heart rate, and was
stopped after 4 minutes. In light of this, the interpretation
of perfusion defects is somewhat unreliable. No perfusion
defects were seen on this limited study. What was able to be
determined, however, was that his EF was only 26%, indicating a
cardiomyopathy. Cardiology recommends a dobutamine echo as an
outpatient to further evaluate his coronary vasculature. We
started him on Aspirin 325 mg PO qday.
2) ESRD - Patient currently receiving HD and being followed by
renal. Most likely secondary to his DM, and HTN. We felt that
addition of an ACE-I would be beneficial in this patient with
Diabetes, CHF, and HTN, and started Lisinopril 2.5 mg qday,
discontinuing his calcium channel blocker in order to allow for
this addition. We also started him on nephrocaps 1 tab PO qday,
Phoslo 2 tabs TID for phosphate binding, and Renagel. We
continued his epogen, and held a couple of doses secondary to
normal hematocrit. He continued to put out some of his own
urine.
3) HTN - Patient's b.p. was elevated in the MICU, however has
been well controlled on the floors, and was responsive to fluid
removal. As discussed above, we discontinued his calcium
channel blocker (Nifedipine CR 30 mg PO qday), and started
Lisinopril 2.5 mg PO qday. We also decreased his atenolol to
once a day in order to add the Lisinopril.
4) Lipids - This patient was continued on Lipitor 10 mg PO qd.
We obtained a lipid profile to help evaluate his cardiovascular
risk, which showed: Chol 225, LDL 115, TG 139, HDL 82, ratio
2.7. This is a surprisingly good lipid profile, with quite high
HDL, and therefore his lipitor dose was maintained and not
increased, especially in light of his mild transaminitis.
4) Nausea/abdominal pain - The patient seems to have been having
some nausea, with decreased apetite and weight loss prior to
this hospitalization. He says these have resolved since
admission, however, and may have been related to uremia. A
gastric emptying study was performed which was normal, making
gastroparesis less likely in this diabetic patient. Of note,
the patient was noted to have changes consistent with chronic
pancreatitis on a MRI of the abdomen in [**2114-1-29**], and this may be
the cause of his recurrent nausea and vomitting. The patient is
being scheduled for an appointment with Dr. [**Last Name (STitle) 7307**] in
gastroenterology to further evaluate his nausea and vomiting.
He may want to consider a trial of pancrelipase.
5) Granulomatous Disease: The patient has a history of
granulomatous hepatitis on liver biopsy, and in light of his
nausea, we did a hepatic/biliary ultrasound which showed some
heterogeneity of the liver, with no distinct masses, no
choledocholithiasis or cholecystitis. His AST and ALT were
found to be 28, and 74, respectively, on [**6-26**], and 22, 54 on
[**6-27**], with an ALP > 200. He has had a transaminitis in the
past, which was what brought him to the attention of
gastroenterology.
His prior course: A hepatic ultrasound on [**2114-1-23**] showed a
heterogeneous liver with multiple small nodules and cirrhosis
versus metastatic disease as the primary cause, as well as
bilateral renal calculi. A follow up MRI on [**2114-1-29**] showed a
heterogeneous liver, and a liver biopsy revealed a granulomatous
hepatitis. Additionally, this patient has been found to have a
polyclonal hypergammaglobulinemia, and a CT of the
abdomen/pelvis on [**2111-5-15**] showed multiple buttock granulomas.
The patient has also been found to have bilateral hilar and
mediastinal lymphadenopathy on CT [**2115-4-30**] consistent with a
diagnosis of sarcoidosis.
In summary, it seems most likely that this is a patient with
sarcoidosis, when taking all evidence into account: Bilateral
hilar and mediastinal lymphadenopathy, restrictive PFTs,
granulomatous hepatitis, buttock granulomas, perhaps the chronic
nephrolithiasis, and now with a cardiomyopathy on echo and
stress test. We discussed the risks versus benefits of steroid
therapy in this patient in light of the possible myocardial
involvement (though we do not know that this is due to
sarcoidosis), however even if the myocardial involvement were
due to sarcoidosis we do not believe steroids would be
indicated. Not only have steroids not been conclusively shown
to be effective in sarcoidosis, but they also would not improve
any fibrosis that has already developed causing the organ
dysfunction that he has. Most importantly, this is a 74 year
old male with diabetes, hypertension, and renal failure -
steroids could exacerbate his diabetes, his hypertension, and
worsen his volume overload. It is therefore recommended to
simply continue observation. A dobutamine echo has been
recommended by cardiology to further evaluate whether or not
this cardiomyopathy is due to ischemia or another process (such
as sarcoidosis). If it is due to ischemia, he may be a
candidate for a cath. Dr. [**Last Name (STitle) 8499**] should make these
arrangements should he deem them appropriate.
5) DM - His diabetes was managed with an insulin sliding scale
while in the hospital, and finger stick readings were generally
less than 200. He seemed to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] in the 200s every
night at 10 pm, and the patient says that he does take
medication for his diabetes at home, however he was unable to
tell us what it was. We continued his insulin sliding scale,
and he will be restarted on his outpatient diabetes medications
by Dr. [**Last Name (STitle) 8499**] when he sees him next week.
5) GU - We continued this patient's Detrol while in the
hospital. He had a couple of episodes of incontinence after we
removed the foley catheter that he had while in the MICU. A UA
revealed both yeast, and bacteria, and we know he has had
persistent yeast in the urine in the past. We started a course
of Levaquin, renally dosed, to treat the UTI. He received a
loading dose of 500 mg while in the hospital, and will continue
250 mg PO q 48 hours after leaving the hospital, his second dose
being tomorrow ([**2115-6-30**]). He has been asymptomatic.
6) Prophylaxis: He was given subcutaneous heparin TID.
7) PT: The patient was able to walk up and down 2 flights of
stairs, and down the hallway without assistance. He took them
slowly and carefully, somewhat weakened from the last few days
of bedrest, though not unsteady. He feels ready to go, and has
a wife at home for support.
IN SUMMARY: More than 11 kg of fluid removed via HD this
admission. CHF exacerbation resolved. This patient should most
likely have a dobutamine echocardiogram set up as an outpatient.
He should also have an appointment with Dr. [**Last Name (STitle) 7307**] set up (I
am unable to do this now as it is the weekend) - I am not sure
if he will be able to do this on his own - maybe Dr. [**Last Name (STitle) 8499**]
can help to facilitate this. He will continue dialysis M,W,F.
He is on a 14 day course of Levaquin (7 doses) for a UTI. He
was started on Lisinopril. His CCB was stopped, atenolol was
decreased to qday. He was started on Aspirin. An echo and
stress test showed diffuse left ventricular hypokinesis, most
likely a cardiomyopathy. A diagnosis of Sarcoidosis is strongly
suspected after reviewing all of the information, however would
not start steroids.
Medications on Admission:
Atenolol 50 mg [**Hospital1 **]
Detrol 4 mg qhs
Humalin
Lasix 80 mg QOD on non-HD days
Nifedipine 30 mg PO qd
Protonix 40 mg PO qd
Lipitor 10 mg PO qd
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 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 325 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. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
5. Tolterodine Tartrate 4 mg Capsule, Sust. Release 24HR Sig:
One (1) Capsule, Sust. Release 24HR PO at bedtime.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
Disp:*15 Tablet(s)* Refills:*2*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO every other
day for 14 days: 7 doses.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
CHF exacerbation.
ESRD.
DM2.
Likely sarcoidosis.
Discharge Condition:
Stable
Discharge Instructions:
Take all of your medicines as directed. Do not take your
nifedipine (Procardia) anymore. Take atenolol only once a day.
New medications: Lisinopril, Aspirin.
Take levofloxacin (Levaquin) every other day for a total of 7
doses.
Return to the hospital if you become short of breath again.
See Dr. [**Last Name (STitle) 8499**] next Wednesday ([**2115-7-3**]) at 3:15.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7976**] Next Wednesday
([**2115-7-3**]) at 3:15. Call to change.
Gastroenterology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7307**] [**Telephone/Fax (1) 1954**]. Call to make
an appointment.
ICD9 Codes: 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7152
} | Medical Text: Admission Date: [**2158-8-8**] Discharge Date: [**2158-9-5**]
Date of Birth: [**2128-3-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Haldol / Compazine / Desipramine / Chlorpromazine
/ Imipramine / Zoloft / Shellfish Derived
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
transfered to [**Hospital1 18**] for Chest pain.
Transfered to [**Hospital Unit Name 153**] for: unresponsiveness/respiratory failure
Major Surgical or Invasive Procedure:
endotracheal intubation
central line
arterial line
History of Present Illness:
30 yo female morbid obesity past history of DVTs and PEs s/p IVC
filter placement 2 years ago who was transferred to [**Hospital1 18**] ED for
PE.
Initially went to [**Hospital 26380**] hospital on Thursday and had
bilateral DVTs + PEs (lower ext swelling) and was placed on
heparin + coumadin. After discharge, she returned to OSH with
horrible CP 2 days ago and also had leg pain. She was found to
have a worsening PE w/ increased clot burden despite being
supratherapeutic, with INR of 4.8, and filter placement.
Repeat CT at [**Hospital1 18**] ED -> small subsegmental right lower lobe
with no evidence of infarct; LENIs were not repeated.
Patient reports that she has had 2 days of sharp throbbing chest
pain that is worse upon respiration and radiates to lower L
chest, similar to pain she had with previous PEs. Also has had
3-4 days of BL leg pain and numbness along with 'sores' on lower
legs. Has difficulty moving legs, but unsure if due to pain or
weakness. Has been at [**Hospital **] Rehab since discharge from [**Hospital 27217**]
Hospital and reports being certain that she has been taking
coumadin daily.
.
Also has had 4 days indwelling catheter -> dark + bloody urine;
as per pt was being treated for UTI with ceftin
Past Medical History:
1. Borderline personality disorder
2. Mood Disorder, NOS
3. History of self-mutilation
4. History of DVT/PE
5. Obesity hypoventilation vs. sleep apnea
6. Asthma
7. Urinary Incontinence
8. History of hypercarbic respiratory failure
9. Obesity
10. History of suicidal ideation with multiple past attempts
11. History of MRSA cellulitis
12. History of Pneumonia
13. History of Bacteremia
Social History:
After recent admission for PE at [**Hospital 27217**] hospital, has been at
[**Hospital **] Rehab center in [**Location (un) **]. Pt reports having no family or
contacts. Denies cigarette or recreational drug use. Previous
social alcohol use but has not had drink for several months. Has
history of psychogenic hyporesonsiveness episodes requiring
intubation.
Family History:
Parents deceased; otherwise noncontributory.
Physical Exam:
98.9 100/65 108 18 98%on 3L
Gen: alert, cooperative, morbidly obese, in NAD.
Pulm: anterior exam, ctab w/o coarse breath sounds.
Cor: tachycardic, RR, nl S1S2
Abd: obese, protuberant, nontender.
Extrem: multiple pink tender blisters on anterior lower legs
1cm.
1+ DP and 2+ radial pulses. Acyanotic extremities.
Neuro: LE perception to light touch intact. Strength appears to
be limited by pain.
Pertinent Results:
[**2158-8-12**] 3:39 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2158-8-14**]**
GRAM STAIN (Final [**2158-8-12**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2158-8-14**]):
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 53485**] FROM
[**2158-8-10**].
[**2158-8-11**] 12:10 am BLOOD CULTURE Source: Line-central line.
**FINAL REPORT [**2158-8-17**]**
Blood Culture, Routine (Final [**2158-8-17**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
Brief Hospital Course:
FLOOR COURSE:
Ms. [**Known lastname **] was admitted with complaint of chest pain found to
have right subsegmental PE and supratherapeutic INR. Patient has
been maintained on room air while INR corrected in setting of
warfarin being held. Two days after admission, patient was found
incontinant of stool face down in her bed, unresponsive. Vitals
at that time were afebrile, SBP 120-130's, HR 110's, RR 12-18,
SpO2 100% RA, she had a pulse and did not appear to have
respiratory difficulty. She was not responsive to verbal or
tactile stimuli. Fingerstick was slightly elevated blood
glucose. Patient recieved small amount of narcotic, Narcan given
and she remained non-responsive. Also noted, patient had
flickering of eyelids, concerning for seizure. She recieved 5mg
ativan with no significant improvement. Due to concern for
possible ICH and inability to protect airway, patient was
transferred to [**Hospital Ward Name 332**] ICU for emergent intubation with plan for
CT Head. Of note, patient was vomitting [**3-14**] to ambu bag.
ICU course:
#Unresponsiveness: Upon further investigation of Ms. [**Known lastname **]
chart, it appears that she has a history of psychogenic
hyporesponsivenss requiring multiple intubations in the past.
Head CT returned negative and neuro team did not feel that this
episode was a seizure. Psych was consulted and said there was
nothing to do while patient was intubated.
#Respiratory Failure: During the code, patient was found to have
vomited resulting in an aspiration pneumonia. She was intubated
and vented and treated with empiric antibiotics. Sputum and
blood cultures grew staph aureus and she was continued on
Vancomycin and Meropenem, [**Last Name (un) **] changed to Linezolid on Day 8 due
to known MRSA in her sputum. On ICU Day 9, her left lower lobe
asp PNA seems to have cleared, but patient developed a new right
middle lobe infiltrate. She continued to have persistent
infiltrate on CXR L > R and ID was consulted. They recommended
continuing vancomycin therapy for MRSA and also obtaining input
from interventional pulmonology to evaluate for possible
empyema. IP did not feel there was an obvious complicated
effusion present. The patient was continued on the ventilator
and antibiotics. She had persistent hypoxic respiratory failure
requiring increasing levels of PEEP and 100% FiO2. She was
transitioned to APRV when unable to oxygenate on volume cycle
ventilation. Eventually she was placed back on ACV, but
required 100% FIO2 and high PEEP levels (20's). She desaturated
with any re-positioning adn we were unable to wean from the
ventilator..
#Septic shock: Found to have staph aureus in the blood. She was
hypotensive requiring pressors. By ICU Day 10, patient is still
dependent on pressors. She continues to spike fevers despite
broad spectrum antibiotic coverage. Blood culture from [**8-19**] grew
coag (-) staph in 1 of 2 sets; patient maintained on vancomycin.
An IJ tip grew yeast and the patient was started on fluconazole
per ID. A urine culture grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] and the patient
was treated with micafungin. The patient remained on pressor
support. The patient remained persistently febrile during her
hospital course. Infectious disease followed the patient each
day. She had documented infections including [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] in
urine, pseudomonas/klebsiella in sinuses, pseudomonas in sputum
as well as urine, and MRSA in lungs. Unfortunately, due to the
patient's body habitus, we were unable to evaluate her for
abscess with CT and had to rely on U/S, which did not show an
obvious abscess or loculated fluid.
#Bipolar: patient was continued on all psych meds as well as her
antidepressants until she began having high OG residuals and she
was not able to tolerate PO meds.
#Diabetes: given ISS, glargine, and closely monitored glucose
levels. She had an increasing insulin requirement during her ICU
course.
#Guardianship: [**Name2 (NI) **] not found to have a guardian or proxy.
Group home, Vinfen Corp, was contact[**Name (NI) **] and they reported that
there was no oone appropriate to provide guardianship. Legal
services at [**Hospital1 18**] is currently pursuing legal guardianship.
Eventually, a guardian was assigned who determined that the
patient's prognosis was extremely poor. Her code status was
changed to comfort measures only.
Medications on Admission:
OxycoDONE (Immediate Release) 5 mg PO/NG Q3H:PRN pain
Gabapentin 300 mg PO/NG Q8H
Acetaminophen 325-650 mg PO/NG Q6H:PRN fever>101
Ciprofloxacin HCl 500 mg PO/NG Q12H
Warfarin 5 mg PO/NG DAILY16
Insulin SC (per Insulin Flowsheet)
Vitamin D [**2148**] UNIT PO/NG DAILY
Omeprazole 40 mg PO DAILY
Fluoxetine 40 mg PO/NG DAILY bipolar depression
Divalproex (EXTended Release) [**2148**] mg PO
Divalproex (DELayed Release) 500 mg PO DAILY
Aripiprazole 30 mg PO/NG HS
Amantadine 100 mg PO/NG [**Hospital1 **]
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulmonary embolus
Psychogenic hyporesponsiveness
Aspiration pneumonia
Septic Shock
Respiratory Failure
Discharge Condition:
patient died in ICU after code status changed to comfort
measures only
ICD9 Codes: 5070, 2761, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7153
} | Medical Text: Admission Date: [**2195-2-19**] Discharge Date: [**2195-3-1**]
Date of Birth: [**2130-7-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64yo M with peripheral vascular disease (s/p left AKA),
hypertension, hyperlipidemia, chronic obstructive pulmonary
disease, and right deep venous thrombosis transferred from [**Hospital **]. He was at home and fell out of his wheelchair yesterday,
and couldn't get off the floor. Denies head trauma. Was taken to
[**Hospital3 **] and evaluated, then pt asked to be transferred here
because he has gotten most of his care here.
.
Prior to arrival, the patient got solumedrol and levofloxacin at
[**Hospital3 **] hospital. He got vanc and flagyl here. In our ED, he
was noted to have cough, wheezes, and bruises. He was found to
be hypoxic to 86% on RA on arrival, which improved to 99% on 4L
after nebs. VBG was 7/26/63/22. CXR showed possible left sided
pneumonia, but CT abdomen showed a left base pneumonia. The
abdominal CT also showed a large hematoma consistent with his
exam and history of falls. Though his creatinine was elevated,
the ED considered a CTA to rule out PE in the setting of a
positive D-dimer at [**Hospital3 **]; then considered a VQ scan but the
decision was made to defer these studies to the floor team. He
also had an elevated troponin of 0.05 and CK of 2935 (MB 24,
index 0.8) and was given aspirin. Cards was notified, but the
decision for official consult was deferred to floor team. The
patient was admitted to the MICU due to "tenuous respiratory
status". He is DNR/DNI.
Past Medical History:
1. History of seizure disorder, type unknown.
2. History of hypertension.
3. Chronic obstructive pulmonary disease.
4. History of left deep vein thrombosis.
5. History of peptic ulcer disease with gastrointestinal
bleed.
6. Remote history of osteoarthritis.
7. History of fracture of the left elbow.
8. Methicillin resistant Staphylococcus aureus infections in
[**2190-6-7**].
9. Vancomycin resistant enterococcus in [**2190-9-7**].
10. History of Clostridium difficile in [**2190-5-8**].
11. History of peripheral vascular disease, status post left
external iliac stenting in [**2189-12-8**].
Social History:
Lives at home alone in [**Location (un) 5110**]. No ETOH, tabacco x 40 years
currently 2 packs per day.
Family History:
Mother died of cancer, unknown which type or age at death.
Father died of MI in his 80s. Pt. has two brothers amd two
sisters.
Physical Exam:
V: T96.7 P62 BP 100/65 sat 92-95% 3LNC
Gen: sleepy but arousable. Gutteral voice difficult to
understand at times. No respiratory distress.
HEENT: right pupil reactive, left surgical. eyes disconjucate at
rest with right eye lateral deviated, but conjugate to movement
Neck: no JDV
Resp: wheezes diffusely with inspiration and expiration
CV: RRR nl s1s2 no MGR
Chest: left ecchymosis over chest above nipple, 10 cm in
diameter, well demarcated
Abd: ecchymotic, purple, with firm area left side. +BS nontender
Ext: left leg s/p AKA. small scab over [**Last Name (LF) **], [**First Name3 (LF) **] erythema.
right leg with erythema lower area, not warm, with some anterior
tibial ulcer 2 cm, and scab over medial malleolus (3 cm) without
drainage
Neuro: oriented to place, person, date
Pertinent Results:
[**2195-2-27**] 06:05AM BLOOD WBC-12.7* RBC-3.01* Hgb-9.7* Hct-29.0*
MCV-96 MCH-32.4* MCHC-33.6 RDW-15.9* Plt Ct-433
[**2195-2-26**] 05:38AM BLOOD Neuts-78.1* Lymphs-10.0* Monos-6.2
Eos-5.3* Baso-0.4
[**2195-2-26**] 05:38AM BLOOD Hypochr-3+ Anisocy-1+ Macrocy-3+
[**2195-2-27**] 06:05AM BLOOD PT-15.4* INR(PT)-1.4*
[**2195-2-21**] 06:20AM BLOOD ESR-40*
[**2195-2-27**] 06:05AM BLOOD Glucose-96 UreaN-31* Creat-1.0 Na-140
K-3.5 Cl-97 HCO3-35* AnGap-12
[**2195-2-20**] 03:20AM BLOOD CK(CPK)-2717*
[**2195-2-19**] 06:37PM BLOOD CK(CPK)-2208*
[**2195-2-19**] 01:32PM BLOOD CK(CPK)-2489*
[**2195-2-19**] 05:35AM BLOOD ALT-38 AST-85* CK(CPK)-2935* AlkPhos-128*
Amylase-29 TotBili-0.7
[**2195-2-19**] 05:35AM BLOOD Lipase-19
[**2195-2-24**] 06:15AM BLOOD proBNP-802*
[**2195-2-20**] 03:20AM BLOOD CK-MB-18* MB Indx-0.7 cTropnT-<0.01
[**2195-2-19**] 06:37PM BLOOD CK-MB-15* MB Indx-0.7 cTropnT-<0.01
[**2195-2-19**] 01:32PM BLOOD CK-MB-18* MB Indx-0.7 cTropnT-0.03*
[**2195-2-23**] 06:00AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.2
[**2195-2-24**] 06:15AM BLOOD Triglyc-148 HDL-56 CHOL/HD-2.8 LDLcalc-71
[**2195-2-21**] 06:20AM BLOOD CRP-102.9*
[**2195-2-27**] 06:05AM BLOOD Vanco-25.6*
[**2195-2-24**] 06:15AM BLOOD Phenyto-4.0*
Brief Hospital Course:
A/P: 64M with history of PVD and COPD presents s/p fall with
COPD exacerbation, PNA, and RLE cellulitis/vascular insuficiency
who expired in the MICU.
#) COPD exacerbation +/- PNA - Admitted to ICU for O2sat in the
80's on room air but mid 90's on 3L NC. Pt neg for influenza.
Started on Levofloxacin for COPD exacerbation and a question of
retrocardiac opacity on CXR. Also started on Nebulizers and
Prednisone IV then tapered to 60mg PO. Following stabilization
in the MICU, his floor course was marked by waxing and [**Doctor Last Name 688**]
respiratory status with O2sats ranging from 88-96% on a
significant O2 requirement (3-4L, patient is not on oxygen at
home). He recieved a 7 day course of Levofloxacin and 6 days of
Prednisone 60mg. He benefited from Chest PT and clearance of
secretions with improved clinical exam and O2sats. His O2sats
were thought to be lowered in his digits by the presence of
significant PVD and forehead O2sats were obtained showing better
saturation. Given waxing and [**Doctor Last Name 688**] respiratory status and
O2sats, a repeat CXR was performed which was essentially
unchanged and did not reveal any acute cardiopulmonary process.
A Chest CT was also performed to r/o any evidence of mucus plug
and showed tracheobronchomalacia, collapse of the LLL concerning
for PE, and R pericardic triangular opacity. The patient was
started on Heparin IV drip and given NaHCO3 in D5W and a CTA was
obtain that showed no PE. Subsequently, patient's sats dropped
to 83 % on 4 L. He was given nebs and the 96% on 4L but sats
dropped to 85% on 4L again and Bp dropped to 90s systolic.
Patient was disoriented and denied any complaints VBG
7.36/86/47. He was transferred to the ICU for further management
where his respiratory status continued to worsen. Diuresis was
attempted with lasix but the pt did not have much UOP. O2 sats
were lowered to the low 90's given pt's somnolence and concern
for CO2 retention, but he continued to remain somnolent. He
became diaphoretic and tachycardic and was started on BiPAP.
Multiple ABG's were attempted but only venous blood was
obtained. His family was notified that his clinical status was
declining and they felt that he would only want intubation if it
would be a quick turn around. However, given his poor lung
function it was felt that the pt's course on the ventilator
would likely be long. His family felt he would not want this,
and thus the pt was made CMO. He expired a few hours later.
.
#) RLE pain/erythema: There was a 1.5x1.5 inch circular scabbed
ulcer involving the medial malleolus with surrounding erythema.
The patient stated that he had had the ulcer for approximately
2-4 weeks. The foot was thought to be cold on exam in the MICU
and he did not have a DPP pulse by doppler u/s. He remained
afebrile throughout his course and was start4d on Vancomycin due
to concern for cellulitis and his history of MRSA cellulitis.
Given his severe PVD, vascular insufficiency was also a
potential cause of the pain, erythema, and ulcer formation.
Vascular surgery was consulted and they performed a RLE
arteriogram revealing severe vascular insufficiency. Vein
mappping of the upper extremities was performed and a candidate
graft from the left upper extremity was identified. Per vascular
surgery, the wound care included dry dressing changes with
accuzyme QD.
.
#) Elevated troponin/CK - CK elevation most likely from fall.
Trop more likely from renal insufficiency. EKG without acute
changes. Assymptomatic.
.
#) Renal failure - He presented with a creatinine of 1.6 which
trended down to his baseline of 0.8 during his course.
.
#) Frequent falls with hematoma - Could be from seizures or
baseline immobility. Denies loss of consciousness but somnolent
on admission. Dilantin level low, however patient says that he
has not had seizures in years and did not appear post-icatl
during intial evaluation. His home dose of AEDs was continued.
.
#) PVD with edema: Continued ASA. Consulted vascular surgery as
above.
.
#) HTN - Continued metoprolol with adeuqate control. Was held
for pharmacologic stress echo testing.
.
#) GI - Patient did not have any stools during his floor course
while on narcotics and was started on an aggressive bowel
regimen.
Medications on Admission:
Magnesium Oxide 400 mg PO BID
Atorvastatin 10 mg PO DAILY
Amlodipine 5 mg PO DAILY
Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed for COPD.
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID
Ibuprofen 400 mg PO Q8H prn
Phenytoin Sodium Extended 300 mg PO BID
Metoprolol 75mg PO
Furosemide 80 mg PO DAILY
Folic Acid 1 mg Tablet PO DAILY
Aspirin 325 mg po qd
Discharge Disposition:
Extended Care
Discharge Diagnosis:
COPD Exacerbation
Pneumonia
Right Leg cellulitis/vascular insufficiency
Discharge Condition:
expired.
Discharge Instructions:
pt expired.
Followup Instructions:
pt expired.
ICD9 Codes: 486, 5849, 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7154
} | Medical Text: Admission Date: [**2110-6-27**] Discharge Date: [**2110-7-11**]
Date of Birth: [**2110-6-27**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy twin 2 is a preterm
male infant, born at 34-1/7 weeks gestation by cesarean
section. Mother is a 33-year-old, gravida 5, para 3 to 5
woman with prenatal screens, A-, antibody negative, hepatitis
B surface antigen negative, GBS unknown, rubella immune and
RPR nonreactive. Pregnancy was dichorionic-diamniotic twin
gestation with no complications reported during pregnancy.
The mother was admitted on the day of delivery with history
of contractions intermittently for the past 2 days and
cervical dilation to 4 to 5 cm. As per parents' wishes,
delivery was performed by cesarean section. Apgars were 8
and 8. The baby required only some blow-by O2 in the
delivery room. However, on admission to the NICU, he was
noted to have grunting and retracting, and was placed on CPAP
with some improvement. Poor perfusion was noted initially
and the patient was treated with a normal saline bolus.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2135 grams (50th
percentile), length 46 cm (60th to 70th percentile), head
circumference 32 cm (50th percentile). Temperature 98.2,
heart rate 122, respiratory rate 40 to 70, blood pressure
69/39 (49), O2 saturation 90% on room air. General: Pink,
alert, active, AGA, preterm infant. HEENT: Anterior
fontanelle soft and flat. Normocephalic. Eyes with normal
red reflexes bilaterally. Palate intact. Respiratory:
Retractions and mild grunting, improved on CPAP.
Cardiovascular: S1 and S2 normal intensity, no murmur.
Abdomen: Soft with no organomegaly. GU: Normal male.
Testes down bilaterally. Neuro: Tone within normal limits.
Skin clear. Musculoskeletal: Hip laxity which increased
slightly with time. Physical measurements at discharge:
Weight 2135g, head circumference 31.5cm, length 46cm.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The baby was placed on nasal CPAP after
birth and was intubated on day of life #0 and given
surfactant x2. He was extubated to CPAP on day of life
#2 and remained on CPAP until day of life #5, when he
was weaned to room air. He has been on room air since
that time without apnea of prematurity.
2. Cardiovascular: The baby had normal blood pressure and
heart rate at birth but had poor perfusion, so was given
a normal saline bolus at birth. He has been stable
cardiovascular wise since that time.
3. Fluid, electrolytes and nutrition: The baby was started
NPO on IV fluids. He was started on feeds on day of
life #5 and they were advanced as tolerated. He is
currently on breast milk 24 with Enfacare, taking p.o.
p.g. feeds. He is also on a multivitamin.
4. GI: The baby was found to have hyperbilirubinemia with
a peak on day of life #4 of 11.3/0.3. He received
phototherapy for 3 days with a rebound bilirubin of
7.9/0.2. He continues to be slightly jaundiced with no
further issues.
5. Hematology: On admission, a CBC was done with a
hematocrit of 48.5 and platelets of 323,000. He was
started on iron sulfate on day of life #12.
6. Infectious disease: Rule out sepsis workup was done on
admission with a white count of 9.7 with 47 polys and 0
bands. He received ampicillin and gentamicin for 48
hours which were stopped with negative blood cultures.
7. Neurology: The baby always had a normal neurologic exam
and there has been no need for head imaging. He
continues in an off isolette for low temperatures.
8. Sensory: (A) Audiology - a hearing screen was not
performed prior to transfer. (B) Ophthalmology -
secondary to the baby's gestational age of greater than
32 weeks, no ophthalmology exam was done.
CONDITION AT DISCHARGE: Fair.
DISCHARGE DISPOSITION: To [**Hospital6 302**] level 2 NICU.
PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) 74231**] at South Core
Pediatrics.
CARE RECOMMENDATIONS:
1. Feeds at discharge: Please continue breast milk 24 with
Enfacare or Neosure powder and encourage p.o. feeds.
2. Medications: Multivitamin 1 mL p.o. daily, iron sulfate
2 mg per kilogram per day.
3. Iron and vitamin D supplementation: (A) Iron
supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age. (B) All
infants that are predominantly breast milk fed should
receive vitamin D supplementation at 200 international
units (may be provided as a multivitamin preparation)
daily until 12 months corrected age.
4. Car seat position screening was not done prior to
transfer.
5. State newborn screening status: The baby had 2 [**Name2 (NI) **]
newborn screens. The first one was within normal limits
and the second one has results pending.
6. Immunizations received: None.
7. Immunizations recommended: (A) Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following 4 criteria:
First, born at less than 32 weeks; second, born between
32 and 35 weeks with 2 of the following: Day care
during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school
age siblings; third, chronic lung disease; or fourth,
hemodynamically significant congenital heart disease.
(B) Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of
age. Before this age (and for the first 24 months of
the child's life), immunization against influenza is
recommended for household contacts and out of home
caregivers. (C) This infant has not received rotavirus
vaccine. The American Academy of Pediatrics recommends
initial vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks but fewer than 12 weeks of
age.
8. Followup appointment schedule recommended: No followup
appointments are scheduled at this time.
DISCHARGE DIAGNOSES:
1. Prematurity at 34-1/7 weeks gestation.
2. Twin gestation.
3. Respiratory distress syndrome.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 69933**]
MEDQUIST36
D: [**2110-7-11**] 13:13:43
T: [**2110-7-11**] 14:03:12
Job#: [**Job Number 74234**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7155
} | Medical Text: Admission Date: [**2139-10-26**] Discharge Date: [**2139-11-3**]
Date of Birth: [**2085-2-5**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape / Ativan
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Respiratory Distress.
Major Surgical or Invasive Procedure:
[**2139-10-28**]: Flexible bronchoscopy and Therapeutic aspiration of
secretions.
History of Present Illness:
54 yo woman with a history of myasthenia [**Last Name (un) 2902**], TBM, obesity,
anxiety, admitted to the medical ICU for weakness, respiratory
distress, possible myasthenia [**Last Name (un) 2902**] exacerbation.
MICU course
==[**2139-10-26**] - [**2139-10-28**]: She complained of neck extensor weakness,
urinary incontinence, and dyspnea. Initially treated with biPAP.
Had excellent NIFs (>-80) with suboptimal VCs (consistently < 1
L, though ?limited by effort and able to count [**1-21**] on single
breath). Had bronchoscopy with IP; tracheal stent unremarkable.
IVIG started [**2139-10-28**] to [**10-30**]. Psychiatry also consulted for
anxiety management. She was transferred to neuro service where
she felt well though c/o intermittent diplopia.
==[**2139-10-29**] - [**2139-10-31**]: readmitted to the MICU for dyspnea,
shallow breathing, diplopia, ptosis, concerning for myasthenic
crisis. ABG with significant respiratory acidosis 7.10/143/59.
NIFs -80s. improved after placed on BiPap and flumenazil trial
to counteract clonazepam 0.25mg given in the AM. given
solumedrol 125mg stress dose steroids. Azathioprine started
[**2139-10-29**] to supplement immunosuppression (cellcept, prednisone).
Urine culture with klebsiella, ciprofloxacin started on
[**2139-10-30**]--> changed to ceftriaxone on [**2139-10-31**].
Transfer to the floor with improved respiratory parameters:
[**2139-10-31**].
Currently, she says her breathing has improved though she still
feels tightness in her chest. She has no ptosis, diplopia,
dysarthria, and she can masticate without difficulty. However,
she notes that she increasingly forgets words. She continues to
have a cough productive of thick green to yellow sputum. She
continues to have non bloody loose stools about 4x/day. She has
baseline urinary incontinence, no hematuria, dysuria. No chest
pain, arthralgias, myalgias, leg swelling, abdominal pain.
Past Medical History:
--myasthenia [**Last Name (un) 2902**] (+MUSK Ab): dx [**4-30**], treated with
pyridostigmine, prednisone, cellcept, IVIG, plasmapheresis;
difficult fibroscopic intubation, unable to tolerate BiPAP.
--tracheomalacia s/p flexible and rigid bronchoscopy with stent
placement on [**2139-5-7**], Y stent replacement [**2139-10-15**]
--sinus tachycardia when awake or anxious, thought [**1-24**] to
autonomic instability from myasthenia [**Last Name (un) 2902**]
--DMII, diet controlled, on ISS while on steroids
--anxiety
--GERD
--obesity
--anxiety
--s/p cholecystectomy, appendectomy, tonsillectomy
--nephrolithiasis
Social History:
No smoking, etoh, illicit drug use. Lives alone. Does not use
home O2 since she has a gas stove, feels uncomfortable with
BiPAP. used to work as a case manager.
Family History:
father with CAD and DM, brother with bronchitis, no family hx of
myasthenia [**Last Name (un) 2902**], autoimmune disease.
Physical Exam:
VS: 96.8 140/80 134 20 90%3L
Gen: NAD, speaking in [**2-25**] word sentences, not using accessory
muscles to breathe
HEENT: PERRL, sclera anicteric, MMM, O/P clear
Neck: obese
Cor: tachycardic, no mrg
Pulm: rhonchorous bronchial sounds diffusely
Abd: obese, soft, NT ND
Ext: +1 non pitting edema, +DP and PT pulses b/l
Neuro: alert, oriented x 3. able to count [**1-18**] in 1 breath.
EOMI. Upgaze held for >20 seconds with no ptosis, however,
during conversation eyelids would droop. CNII-XII intact. [**4-27**]
strength upper and lower extremities. [**4-27**] neck extension and
flexion.
Pertinent Results:
[**2139-10-26**] WBC-7.5 Hct-43.2 Plt Ct-419
[**2139-10-29**] WBC-16.9* Hct-36.5 Plt Ct-322
[**2139-11-3**] WBC-7.4 Hct-39.4 Plt Ct-360
[**2139-10-26**] Glucose-119* UreaN-10 Creat-0.7 Na-143 K-4.5 Cl-103
HCO3-37*
[**2139-11-3**] Glucose-204* UreaN-14 Creat-0.8 Na-138 K-3.7 Cl-93*
HCO3-40*
[**2139-10-26**] cTropnT-<0.01
[**2139-11-1**] Calcium-8.8 Phos-2.6* Mg-2.1
[**2139-10-26**] FiO2-20 pO2-66* pCO2-75* pH-7.28*
[**2139-10-30**] pO2-54* pCO2-77* pH-7.36
...
[**2139-10-27**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
URINE CULTURE (Final [**2139-10-29**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
...
FECAL CULTURE (Final [**2139-10-30**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2139-10-30**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2139-10-29**]): NO OVA AND PARASITES SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2139-10-28**]):
Feces negative for C.difficile toxin A & B by EIA.
MICROSPORIDIA STAIN (Pending):
CYCLOSPORA STAIN (Pending):
OVA + PARASITES (Pending):
Cryptosporidium/Giardia (DFA) (Pending):
RESPIRATORY CULTURE (Final [**2139-10-29**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
...
CT-PE:
1. Tracheal stent is seen in situ and is patent throughout its
course.
2. Atelectasis at the lung bases along with retained secretions
in the right as well as the left lower lobe bronchi.
3. No pulmonary embolism or aortic dissection. Coronary arteries
arise from the normal expected anatomical location.
...
CXR [**2139-10-26**]: Low lung volumes which limits examination
sensitivity. Persistent bibasilar atelectasis. Early pneumonia
cannot be excluded.
CXR [**2139-10-31**]: Since yesterday, bilateral blunting of
costophrenic angles is unchanged. Lung volumes are still low.
Left basilar ill-defined opacity increased, could be early
pneumonia, aspiration, or atelectasis. Minimal left pleural
effusion increased. There is overall no other change.
Brief Hospital Course:
In brief, the patient is a 54 year old woman with MUSK Ab+
myasthenia [**Last Name (un) 2902**], tracheobroncomalacia, anxiety, and sinus
tachycardia who presented with gradual worsening in weakness
found to have a UTI whose course was complicated by hypercarbic
respiratory failure and intermittent hypoxia.
1. Dyspnea - admitting differential diagnosis included muscle
weakness (from myasthenia or other cause, incited perhaps by
UTI), structural abnormalities/TBM, anxiety, PE (which was ruled
out), CAD/ischemia (no ecg changes, not c/w history). Patient
had no fever, leukocytosis, or clear infiltrate to suggest
pneumonia as cause. Patient noted to have mild hypoxemia with
respiratory acidosis on admit and is a CO2 retainer at baseline.
A bronchoscopy was performed [**2139-10-28**] to rule out stent
obstruction, which revealed a patent stent with minimal mucous
impaction. Patient was followed in the MICU for the first two
days of her stay, with neuro consult, with adequate oxygenation
and NIF at -80 and vital capacity measurements of >500cc, with
assistance of breathing treatments (i.e. nebulizers).
Myasthenia [**Last Name (un) 2902**] exacerbation was not believed to be the sole
etiology of her [**Last Name (un) 7186**] of breath. Klonopin was initiated to
control an element of anxiety, with good relief. Patient
receieved her routine administration of IVIG over a three-day
course of 50g, 55g, and 55g, initated on [**10-28**]. She was
transferred to the neurology floor on [**10-28**]. On [**10-29**], she
developed respiratory distress in setting of not using her BIPAP
overnight, receiving benzos for anxiety, and SOB. CXR stable.
She was transferred back to the MICU where her PCO2 was found to
be 150. NIFs -80s. improved after placed on BiPap and
flumenazil trial to counteract clonazepam 0.25mg given in the
AM. given solumedrol 125mg stress dose steroids. She was then
transferred to the floor, where she continued to have twice
daily NIF and VC measurements (NIF -80s, VC 500-900). She was
weaned off O2, but triggered on [**2139-11-2**] for O2 sat 77% RA and
HR 150s while ambulating, likely related to exertion, minimal
ventilation, and reflex tachycardia on top of baseline
tachycardia. She was discharged on [**2139-11-3**] with instructions
to use 2L NC (while at rest, 93% on room air and 95% on 2L NC.
while walking, 87% on room air and 92-94% on 2L NC).
2. Myasthenia [**Last Name (un) 2902**] - contributation as above, noted to also
have neck weakness. Was continued on her prednisone, mestinon,
cellcept, and Bactrim ppx. As above, she received a 3-day
course of IVIG at 50g, 55g, and 55g, started on [**10-28**].
Azathioprine was started on [**2139-10-29**] to supplement
immunosuppression (cellcept, prednisone). She received bactrim
for prophylaxis. We avoided beta blockers, calcium channel
blockers, and quinolones due to potential exacerbation of
myasthenia [**Last Name (un) 2902**].
3. Anxiety - patient has history of anxiety and has been on
SSRI and benzos in past. A psychiatry consult was placed,
recommending outpatient follow-up. Patient was started on
klonopin tid for anxiety control with good effect. However,
after returning to the MICU for respiratory distress with
possible inciting cause of receiving clonazepam 0.25mg that
morning, all further benzodiazepines were avoided.
4. Tachycardia - had intermittent sinus tachycardia (150s when
walking, 80s when sleeping) with an unchanged ECG, reportedly at
her baseline. Avoided beta blockade and calcium channel
blockade due to myasthenia [**Last Name (un) 2902**] history.
5. Urinary incontinence - chronic problem with recent
worsening. Urine culture [**2139-10-27**] with klebsiella,
ciprofloxacin started on [**2139-10-30**]--> changed to ceftriaxone on
[**2139-10-31**]. WBC trended down. She was discharged on Keflex, with
total antibiotic course of 7 days. She was recommended to
discuss with her PCP [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13511**] to urogynecology.
6. Diarrhea - noted to have [**12-24**] month history of diarrhea with
subacute/chronic fecal incontinence, previously attributed to
mestinon in past. Cdiff cultures were negative and extensive
stool studies were unrevealing, some studies pending at
discharge. Neuro recommended outpatient MRI C-spine to r/o
trauma given her multiple procedures. She was continued on
loperamide.
7. Tracheobronchomalacia: followed by IP service, mucolytic
increased to TID.
8. DM2: placed on insulin sliding scale for better glycemic
control in the setting of steroid use.
Medications on Admission:
Prednisone 20 mg DAILY
Trimethoprim-Sulfamethoxazole 80-400 mg Tablet MWF.
Calcium Carbonate 500 mg TID
Pyridostigmine Bromide 60 mg Q6H
Dextromethorphan-Guaifenesin Ten (10) ML PO Q6H prn
Alendronate 70 mg Tablet QSUN
Fluticasone 50 mcg/Actuation Spray, (2) Spray Nasal [**Hospital1 **].
Alprazolam 0.25 mg Tablet Sig: 0.5 to 1 Tablet PO three times a
day as needed for anxiety.
Paroxetine HCl 10 mg Tablet 1.5 Tablets PO DAILY (Daily).
Guaifenesin 600 mg Tablet Sustained Release (2) Tablet [**Hospital1 **] ().
Loperamide 2 mg Capsule One (1) Capsule PO QID as needed
Insulin ?dosing
Omeprazole 40 mg twice a day.
Sodium Chloride 0.9 % Solution (1) neb Injection q6h
Mycophenolate Mofetil 1000 mg [**Hospital1 **]
Xopenex 0.63 mg/3 mL One (1) neb every 6-8 hours as needed.
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a
day for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q2 prn ().
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Paroxetine HCl 10 mg Tablet Sig: 1.5 Tablets PO once a day.
13. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
please take on empty stomach first thing in morning. and remain
upright for 30 minutes after.
14. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO twice a day
for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
15. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q8H (every 8 hours) as needed.
Disp:*30 inhaler* Refills:*0*
17. Home Oxygen
Home Oxygen via nasal cannula (2L) for O2sat <88%
18. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale unit Injection QACHS: please see insulin sliding scale
instructions included with discharge paperwork.
19. Azathioprine 100 mg Tablet Sig: One (1) Tablet PO twice a
day: please start 100mg dose on [**2139-11-12**].
Disp:*60 Tablet(s)* Refills:*0*
20. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
myasthenia [**Last Name (un) 2902**] crisis
tracheobronchomalacia
urinary tract infection
sinus tachycardia
Secondary diagnosis:
diabetes
anxiety
diarrhea
Discharge Condition:
stable. breathing comfortably with good oxygen saturation on
room air. 93%RA at rest. 87-88%RA with exertion. 94% with 2LNC
with exertion.
Discharge Instructions:
You were admitted for [**Last Name (un) 7186**] of breath and neck weakness.
You were given BiPAP and then weaned to nasal cannula oxygen.
You underwent flexible bronchoscopy to clean out secretions and
the stent looked in good shape. You received IVIG therapy and
new immunosuppression for your myasthenia [**Last Name (un) 2902**]. You were also
found to have a urinary tract infection and were treated with
antibiotics.
Please use 2L oxygen while exerting yourself. Please continue
your medications. Please continue your new immunosuppressant
azathioprine 50mg twice a day until [**2139-11-11**]. Please take
azathioprine 100mg twice a day starting [**2139-11-12**]. Please
continue your antibiotic Keflex for 2 days.
Please attend your recommended follow-up appointments.
Please call your doctors [**First Name (Titles) **] [**Last Name (Titles) 7186**] of breath, chest pain,
neck weakness, vision changes, or any other symptoms concerning
to you.
Followup Instructions:
Please follow up with:
--[**Last Name (Titles) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 2846**] Date/Time:[**2139-12-8**]
10:30, please call ([**Telephone/Fax (1) 44**] with additional questions.
--Dr. [**First Name (STitle) 9466**] [**Name (STitle) **] on Friday [**2139-11-6**] at 9am. Please call
[**Telephone/Fax (1) 250**] with questions.
--Interventional Pulmonology: The clinic will call you with an
appointment to be seen in ~2 weeks. Please call ([**Telephone/Fax (1) 3020**]
with questions.
--We recommend that you discuss with your PCP how to set up an
appointment with urogynecology to address your urinary
incontinence.
ICD9 Codes: 5990, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7156
} | Medical Text: Admission Date: [**2149-3-18**] Discharge Date: [**2149-3-27**]
Date of Birth: [**2068-1-30**] Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Bowel obstruction, COPD, PNA, NSTEMI
Major Surgical or Invasive Procedure:
s/p diverting colonostomy and Lysis of adhesions on [**3-13**] at
[**Hospital3 **]
History of Present Illness:
81yoM with COPD, Parkinsons disease, asbestosis who presented to
[**Hospital3 **] on [**3-11**] with abdominal pain, distension, and
cough, whose course was complicated by PNA and NSTEMI, now being
transferred to [**Hospital1 18**] with hemodynamic instability.
.
The patient had reported difficulty moving his bowels, abdominal
pain, and distension for 2 days prior to presentation to [**Hospital1 **] on [**3-11**]. He had a leukocytosis of 12 with left shift
of 80% PMN, 5% bands. He also reported upper respiratory
symptoms with recent CXR showing only evidence of abestosis and
had completed a course of Zithromax. He was determined to have
a bilateral lower lobe PNA and was started on Levofloxacin and
then broadened to Vanc/Zosyn, and was given duonebs and
Methylprednisolone 40mg IV. He was also diagnosed with bowel
obstruction and after three days of conservative management with
NGT, enemas, IVF, he underwent an exploratory laparotomy with
lysis of adhesions on [**3-13**] and ?colectomy with diverting
transverse loop colostomy. He had an NGT placed and was started
on TPN for nutrition. Post-op, he had a lateral wall NSTEMI
believed to be due to demand ischemia, and a TTE on [**3-17**] showed a
new diagnosis of severe aortic stenosis with normal EF. He was
started on a Heparin gtt. He was also found to be in an acute
CHF exacerbation with pulmonary edema on CXR, and was placed on
a non-rebreather. He was subsequently diuresed with Lasix 20-40
mg IV and had multiple episodes of hypotension. During his stay
at [**Hospital3 **], the patient's blood pressure and volume
status was difficult to manage and he was intermittently on
Phenylephrine and Neosynephrine. He has intermittently been on
bipap and was weaned to a venti-mask the day of transfer.
.
Additionally, the patient was also found to be anemic with a hct
ranging from 30-40, and was given 1 unit PRBC. He was also
found to have an elevated d-dimer and underwent LENI's which
were negative for DVT.
.
On arrival to the MICU, the patient was in moderate respiratory
distress on a venti-mask and was also very anxious. He
complained of abdominal pain at his colostomy and recent
surgical site, but otherwise denied other pain.
.
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:
- COPD
- Asbestosis
- Severe aortic stenosis (valve area 0.7cm2)
- Dyslipidemia
- Diverticulosis
- Parkinson's Disease
- Bipolar disorder
- History of exploratory laparotomy
- s/p bilateral knee replacement
- s/p s/p diverting colonostomy and Lysis of adhesions at [**Hospital1 **] on [**2149-3-13**]
Social History:
- Tobacco: Denies current use. Prior smoker.
- Alcohol: Denies current use.
- Illicits: Denies.
Married and lives with wife. Retired shipyard worker and
merchant seaman.
Family History:
NC.
Physical Exam:
Vitals: Not listed
General: Alert, oriented, moderate respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP ~13-14 cm
CV: Regular rate, tachycardic, normal S1 + S2, no murmurs or
extra heart sounds appreciate in the setting of diffuse
rhoncherous upper airway noises throughout
Lungs: Use of accessory muscles with labored breathing.
Tachypneic. Diffuse rhonchorous upper airway noises throughout.
Crackles at bases bilaterally. Minimal wheezes bilaterally.
Abdomen: Soft, tender at midline surgical site, ostomy pink and
intact, mild to moderately distended, hypoactive bowel sounds
GU: Foley in place
Ext: Warm, well perfused, equal thready DP pulses b/l, no
clubbing, cyanosis, trace pitting edema
Neuro: non-focal
Discharge:
T98.1 BP 123/50 103-123/50-61, P 70s-80s, 96% RA, 24 H I/O
[**0-0-**].
General: Alert, oriented, appears quite comfortable with
breathing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP 10 cm
CV: Regular rate and rhythm, normal S1, inaudible S2, parvus et
tardus, [**4-15**] late peaking systolic murmur with radiation to
carotids L>R vs carotid bruit, murmur heard across precordium
Lungs: Mildly Tachypneic. Diffuse rhonchorous airway noises
throughout. Crackles at bases bilaterally. Minimal wheezes
bilaterally.
Abdomen: Soft, tender at midline surgical site, ostomy pink and
intact, mild to moderately distended, positive bowel sounds
GU: No foley
Ext: Warm, well perfused, equal thready DP pulses b/l, no
clubbing, cyanosis, edema resolved
Neuro: non-focal
Pertinent Results:
OSH labs [**3-18**]:
131 96 30
-------------- 87
3.6 29 0.5
.
Ca 7.3, Mg 2.0, Phos 3.1
.
AST 31, ALT 5, Tbili 0.5, Albumin 1.9, TP 4.3
.
10.3
11.0 ------ 261
29.8
.
PT 12.1, INR 0.96, PTT 24.6
.
Troponin I 0.52
.
Micro:
BCx at [**Hospital3 **] [**3-13**]: ntd
Peritoneal Tissue: negative
.
Images:
CXR OSH [**3-18**]: CHF has improved, decreased vascular congestion
and pulmonary edema. Smaller pleural effusions. Atelectasis at
the lung bases. NGT remains in position.
.
LENIs [**3-17**]: No DVT.
.
KUB [**3-17**]: Large amount of feces in the right colon. Several top
normal air-filled dilated small bowel loops. Small amount of
air in the left colon. No definite free air. Dense pleural
calcifications noted.
.
CT Abdomen/Pelvis [**3-11**]:
Modest hiatal hernia. Patchy bibasilar airspace process -
bibasilar atelectasis or subsegmental consolidations. Extensive
calcified pleural plaques. Colonic dilation (transverse colon
8cm) to the dital colon with marked stool burden and associated
physiologic small bowel obstruction. Marked dilation of small
bowel loops suggestive of obstructive pattern. No discrete
transition zone. Distal sigmoid diverticulosis without
diverticulitis. Small left inguinal hernia.
.
TTE [**3-16**]:
EF 50-55%. Preserved systolic function. Borderline inferior
wall hypokinesis. LA enlargement. Severe aortic stenosis
(valve area 0.72 cm2, mean gradient 33mmHg). Mild aortic
regurgitation. Mildly thick mitral valve with mitral annular
calcification and mild MR. Moderate TR.
.
ADMISSION LABS AT [**Hospital1 18**]:
[**2149-3-18**] 10:00PM BLOOD WBC-15.5* RBC-4.85 Hgb-13.4* Hct-40.8
MCV-84 MCH-27.7 MCHC-32.9 RDW-15.2 Plt Ct-423
[**2149-3-18**] 10:00PM BLOOD Neuts-86.0* Lymphs-7.8* Monos-4.5 Eos-1.2
Baso-0.5
[**2149-3-19**] 04:10AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+
Ellipto-OCCASIONAL
[**2149-3-18**] 10:00PM BLOOD PT-11.3 PTT-28.5 INR(PT)-1.0
[**2149-3-18**] 10:00PM BLOOD Glucose-107* UreaN-38* Creat-0.7 Na-138
K-4.6 Cl-101 HCO3-29 AnGap-13
[**2149-3-18**] 10:00PM BLOOD ALT-9 AST-43* LD(LDH)-278* AlkPhos-59
TotBili-0.4
[**2149-3-18**] 10:00PM BLOOD Albumin-3.5 Calcium-8.9 Phos-4.3 Mg-1.9
[**2149-3-18**] 10:00PM BLOOD Triglyc-66
[**2149-3-20**] 07:40AM BLOOD Vanco-12.9
[**2149-3-20**] 04:06AM BLOOD Digoxin-0.5*
[**2149-3-18**] 09:50PM BLOOD Type-ART Temp-36.4 O2 Flow-12 pO2-71*
pCO2-50* pH-7.37 calTCO2-30 Base XS-1 Intubat-NOT INTUBA
[**2149-3-19**] 09:44AM BLOOD Type-ART Temp-36.6 Rates-/13 FiO2-40
pO2-88 pCO2-47* pH-7.44 calTCO2-33* Base XS-6 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2149-3-18**] 09:50PM BLOOD Lactate-0.7
[**2149-3-20**] 04:22AM BLOOD freeCa-1.06*
At discharge:
[**2149-3-27**] 08:04AM BLOOD WBC-8.7 RBC-3.67* Hgb-10.4* Hct-30.7*
MCV-84 MCH-28.4 MCHC-34.0 RDW-16.3* Plt Ct-493*
[**2149-3-27**] 08:04AM BLOOD Glucose-161* UreaN-9 Creat-0.8 Na-139
K-4.0 Cl-102 HCO3-31 AnGap-10
MICRO:
[**2149-3-18**] 10:00 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2149-3-21**]**
MRSA SCREEN (Final [**2149-3-21**]): No MRSA isolated.
[**2149-3-18**] 9:40 pm URINE Source: Catheter.
**FINAL REPORT [**2149-3-20**]**
URINE CULTURE (Final [**2149-3-20**]): NO GROWTH.
URINE LEGIONELLA: NEG
BLOOD CULTURES: NGTD
===============
STUDIES/IMAGES:
===============
ECG Study Date of [**2149-3-18**] 10:51:48 PM
Supraventricular tachycardia. Consider atrial flutter with 2:1
block. There are also two wide complex beats which may be
ventricular. ST-T wave
abnormalities. No previous tracing available for comparison.
Clinical
correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
147 0 124 318/470 0 -13 152
# CT ABD AND PELVIS WITH ORAL CONTRAST ON [**3-19**]:
FINDINGS: Coronary and aortic annulus calcifications are seen.
Calcifications of the pericardium are seen.
Pleural plaques are seen. Bilateral basilar atelectases are
identified.
ABDOMEN: The liver is with no gross pathology. The gallbladder
is within
normal limits. There is no intra- or extra-hepatic biliary duct
dilatation. Calcifications of the spleen are seen.
The pancreas is with no gross pathology. Both kidneys are
unremarkable. No
stones or hydronephrosis are seen within the kidneys.
The patient is status post colectomy with diverting
double-barrel colostomy. Diverticulosis is seen in the sigmoid
colon without signs of diverticulitis. The small bowel is
unremarkable. No signs of bowel obstruction are seen. No
peritoneal lymphadenopathy is seen. There are no signs of
retroperitoneal hematoma.
Note is made to a small fluid collection with small gas bubble
within it along the incision line. The collection is anterior to
the peritoneum and measures 25 x 58 mm (2, 47).
Atherosclerotic changes are seen along the course of the aorta.
PELVIS: Foley catheter is seen within the urinary bladder, which
is not fully distended.
The prostate is within normal limits. Small amount of fluid is
seen in the
presacral region.
OSSEOUS STRUCTURES: Degenerative changes are seen in the spine
with no
concerning lytic or osteoblastic lesion.
IMPRESSION:
1. No evidence of hematoma.
2. Post operation fluid collection along the incision line, as
described.
ECHO [**2149-3-26**]:
The left atrium is mildly dilated. 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. The diameters of
aorta at the sinus, ascending and arch levels are normal. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is critical aortic valve stenosis
(valve area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2149-3-19**], the
function of the distal segments appears normal on the current
study. Estimated aortic valve area is slightly less. The other
findings are similar.
Brief Hospital Course:
81yoM with COPD, Parkinsons disease, asbestosis who presented to
[**Hospital3 **] on [**3-11**] found to have LBO s/p loop colostomy,
course complicated by PNA and vasopasm vs aborted STEMI from
thrombus or embolus w/ newly found severe AS transferred to
[**Hospital1 18**] with hemodynamic instability now stable. Echo results show
mostly apical hypokinesis c/w possible stress induced
cardiomyopathy now resolved.
.
#. Respiratory Distress: Patient presented profoundly volume
overloaded with labored breathing, elevated JVP ~13-14cm and
crackles bilaterally, hypertension in the 180's systolic at
admission which is consistent with fluid overload. Also with
evidence of multifocal pneumonia on CT chest from OSH initially
treated with Levofloxacin then broadened to Vanc/Zosyn for which
he completed an 8 day course. Respiratory status significantly
improved with diuresis, initially on Lasix gtt then transitioned
to boluses. He then had persistent hypotension for which lasix
drip was held. He was maintained euvolemic off lasix with
breathing back to baseline. Pt with very mild swelling of
extremities but given pt's preload dependence for blood
pressure, further diuresis was held.
.
#. Aborted MI vs Vasospasm: Patient had vasospasm or transient
thrombotic/emobolic event post-op, causing I and aVL ST
elevation with reciprocal lead depression seen on OSH EKG. This
resolved on further EKGs and the echo does not show focal
deficits in this distribution. Pt was given heparin at that
time. Most likely patient has stable CAD with an acute event
that spontaenously resolved given the very mild troponin
elevation at OSH and echo findings. Pt had no chest pain, trops
trended down, EKG unremarkable for ischemia while here. [**Hospital 75195**]
medical management was continued for stable CAD, including
Aspirin 81 mg daily, Atorvastatin 80 mg daily, and Toprol 12.5
mg. Pt should be considered for LHC/RHC with vasodilator trial
for aortic valve eval, vessel evaluation, ?primary pulmonary
hypertension given severe lung disease.
.
# Acute on chronic systolic and diastolic CHF from stress
induced cardiomyopathy: Pt initially grossly volume overloaded
thought to be from diastolic failure secondary to aortic
stenosis. Echo on [**3-19**] showed mild regional left ventricular
systolic dysfunction with mostly apical hypokinesis, at least
moderate pulmonary hypertension, and moderate diastolic
dysfunction. Pt responded well to lasix but became hypotensive
with continued diuresis and this was held with restoration of
blood pressure with gentle fluid boluses. On repeat echo before
discharge regional wall motion abnormalities resolved. Notably,
pt did have I and aVL ST elevation which does not correspond
with apical hypokinesis. Most likely pt had a stress induced
cardiomyopathy which may have exacerbated hypotension and volume
overload on top of his diastolic dysfunction. The patient was
tolerating metoprolol well at time of discharge. Captopril was
tried during hospitalization, but pt became hypotensive; most
likely from too much afterload reduction for patient's aortic
stenosis.
.
#. Aortic Stenosis: Patient with severe aortic stenosis with
valve area 0.8cm2. Developed pulmonary edema and diastolic
failure from this. Management discussed above. Cardiology
follow-up as outpatient with possible cath and surgical AVR
evaluation if indicated. Given severe lung disease and high
pulmonary artery pressures on echo, would consider vasodilator
trial as well if PVR high.
.
# Hypotension: Thought to be from severe AS leading to
significant pre-load dependence, stress-induced cardiomyopathy,
multifocal pna, possible medication effects (seroquel and
lorazepam). Overdiuresis led pt to became hypotensive and
episodes of hypotension also seemed to correlate with
administration of seroquel for the patient's bipolar disorder.
Thus, patient was placed on haldol. Pt's blood pressures were
in the 110s-120s at discharge with maintanence of euvolemia as
well as improvement in heart function on repeat echo.
.
#. Atrial Flutter: Patient with evidence of 2:1 aflutter at 150
bpm for less than 48 hours, which resolved. Most likely this was
stress related. Rates at that time controlled with metoprolol
and digoxin. There was no need for anticoagulation given the
event was <48 hours and pt had no recurrence. Pt was continued
on metoprolol for CHF and CAD and digoxin was stopped.
.
#. RUE Swelling: Patient with RUE swelling concerning for
thrombus. RUE US neg for DVT
.
#. Parkinson's Disease:
- Continue Carvidopa-Levodopa per home regimen
.
#. Bipolar Disorder: D/C??????ed seroquel given oversedation and
hypotension. Psych was consulted and recommended starting
patient on Haldol 1mg [**Hospital1 **], however given hypotension this was
decreased to 0.5mg [**Hospital1 **]. Pt did well on this regimen. We retried
seroquel before discharge, but this again resulted in
hypotension, thus the patient was maintained on haldol. Will
need outpatient psych followup.
.
# s/p large bowel obstruction: Patient presented to OHS with
abd distention and was found to have ? large bowel obstruction.
He had diverting colonostomy and Lysis of adhesions on [**3-13**] at
[**Hospital3 **]. He now has a colostomy that has been draining
liquid brown stool. He had a repeat abd CT with oral contrast on
[**3-19**]. Our surgery team was consulted and he has possible lower
L colon obstruction, past the stoma, concerning for malignancy.
He will need to have a colonoscopy either from his rectum or
from the stoma (if it is done from the stoma) he will need be at
least 3 weeks post op. He is tolerating his diet well. Staples
were removed here, but retention sutures to be removed in 30
days from surgery by surgeons at [**Hospital3 **].
.
# Anemia: Labs c/w mix of anemia of chronic disease and [**Doctor First Name **], but
predominant ACD likely given lower serum iron, low TIBC and
transferrin, and normal ferritin. Would tend to expect high
ferritin but possibly normal from [**Doctor First Name **] and [**Doctor First Name **] possible given
left colonic obstruction/mass.
.
# Code: Full (confirmed with pt)
.
TRANSITIONAL:
1) The surgeons at [**Hospital1 **] who did your colostomy. They should
remove the sutures a month from the surgery and decide how they
would like to proceed with the colostomy
2) GI doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] who will need to perform a colonoscopy
for concern of lower left colon obstruction
3) Your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] who is aware of these health issues
4) Cardiology who will [**First Name (STitle) 4656**] you for aortic valve repair as
well as coronary disease
5) Lung doctors [**First Name (Titles) **] [**Last Name (Titles) 4656**] your COPD and Absestosis
6) Neurology for your parkinsons
7) Psychiatry for Bipolar
Medications on Admission:
Home Medications: ([**First Name8 (NamePattern2) **] [**Hospital1 **] records)
- Guaifenesen/codeine 5mL qid prn cough
- Oxybutynin 10 mg daily
- Neurontin 600 mg tid
- Combivent 2 inhalations qid
- Ventolin 2 inhalations qid prn
- Senokot 2 tabs qhs
- Docusate 200 mg qhs
- Seroquel XR 600 mg qhs
- Carbidopa/Levodopa 25/100 mg 2 tabs tid
- Clonazepam 0.5 mg po daily
.
Transfer Medications:
- Metoprolol 25 mg po tid
- Atorvastatin 80 mg po qhs
- Aspirin 325 mg daily
- Vancomycin
- Zosyn 3.375 IV q6h
- Seroquel 400 mg qhs
- Digoxin 0.125 mg po daily
- Lactobacillus 1 tab [**Hospital1 **]
- Pantoprazole 40 mg IV daily
- Insulin regular SC sliding scale
- Tylenol 650 mg po prn
- Albuterol/Ipratropium nebs q4h
- Docusaete 200 mg qhs
- Senna 10 ml qhs
- Carbidopa/Levodopa 2 tabs tid po
- Clonazepam 0.5 mg po daily
- Oxybutynin 10 mg po daily
- Albuterol inhaler prn
- Gabapentin 600 mg po with meals
- Guaifenesin/Codeine 5 mg qid prn
- Zofran 4 mg IV q6h prn
- Fentanyl IV
- Phenyleprhine gtt
- Norepinephrine gtt
- Heparin IV gtt
- TPN
Discharge Medications:
1. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig: One
(1) Tablet Extended Rel 24 hr PO once a day.
2. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) inh
Inhalation four times a day.
4. Xopenex HFA 45 mcg/actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 unit* Refills:*2*
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
6. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO at
bedtime.
7. carbidopa-levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
8. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
13. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: 0.5
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
14. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Aortic stenosis, Pneumonia, Hypotension, Coronary
vasospasm vs aborted STEMI, Acute systolic and diastolic heart
failure
Secondary: Parkinson's, Bipolar
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 18**] for low blood pressure in the setting
of a pneumonia and severe aortic stenosis. You had a recent
surgery at [**Hospital3 4107**] for a large bowel obstruction after
which you developed many complications including pneumonia,
heart failure, low blood pressure, and a small heart attack.
You were treated with antibiotics, diuretics, and medications to
help improve your heart function.
It will be very important for you to follow up with your
outpatient providers as you have many medical conditions that
need follow up.
This includes:
1) The surgeons at [**Hospital1 **] who did your colostomy. They should
remove the sutures a month from the surgery and decide how they
would like to proceed with the colostomy
2) GI doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] who will need to perform a colonoscopy
for concern of lower left colon obstruction
3) Your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] who is aware of these health issues
4) Cardiology who will [**First Name (STitle) 4656**] you for aortic valve repair as
well as coronary disease
5) Lung doctors [**First Name (Titles) **] [**Last Name (Titles) 4656**] your COPD and Absestosis
6) Neurology for your parkinsons
7) Psychiatry for Bipolar
The following changes were made to your medication:
STOP Seroquel as this medication seemed to be tied to low blood
pressure. This can be tried again when you are healthier at the
discretion of your psychiatrist and primary care physician
START Haldol for bipolar disorder
START Atorvastatin for coronary artery disease
START Xoponex inhaler for COPD
STOP Albuterol inhaler (If Xoponex is not covered by your
insurance, then it is okay to continue using albuterol instead)
START Toprol for coronary artery disease
START Aspirin for coronary artery disease
START Multivitamin
Followup Instructions:
**It is recommended you schedule a follow up with your Primary
Care Physician [**Name Initial (PRE) 176**] 1 week of discharge.**
The following appointments were made for you:
Department: CARDIAC SERVICES
When: FRIDAY [**2149-4-4**] 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
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2149-4-10**] at 2:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2149-4-10**] at 3:00 PM
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2149-4-10**] at 3:00 PM
With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
Completed by:[**2149-4-1**]
ICD9 Codes: 486, 4241, 4280, 4589, 2724, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7157
} | Medical Text: Admission Date: [**2189-1-5**] Discharge Date: [**2189-1-8**]
Date of Birth: [**2113-11-5**] Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
female who is well-known to the [**Hospital **] Community Health
Center, is mentally retarded, has diabetes mellitus type 2,
hypertension, a history of ETOH abuse who presented to her
PCP on the day of admission complaining of 2 weeks of cough
and lethargy. She was found to have a BP of 60/palp and
difficulty ambulating.
She was brought by ambulance to the [**Hospital1 18**]-ED where her BP was
noted to be 73/56, and she was noted to be in possible atrial
flutter on EKG. She was treated with adenosine which
produced a 3:1 conduction, and then with diltiazem at 10 mg
IV which put her in normal sinus rhythm. She also received a
total of 6 liters of normal saline IV fluid with a BP up to
111/60, and ceftriaxone 1 gm IV, and the sepsis protocol was
initiated. Her temperature in the ED was 99.8. A left
subclavian triple-lumen catheter was placed for access, and
she was admitted to the [**Hospital Unit Name 153**].
REVIEW OF SYMPTOMS: She denied chest pain, dizziness. She
complained of a mild cough but no sputum. She denied
dysuria, urinary frequency, diarrhea and abdominal pain. A
question was raised whether the patient's history was
reliable, as she denied ETOH, because she is known to ingest
alcohol.
PAST MEDICAL HISTORY:
1. Mental retardation diagnosed in [**2167**] with no formal
evaluation by psych or neuro.
2. Chronic active hepatitis B.
3. Diabetes mellitus type 2.
4. Hypertension.
5. ETOH abuse.
6. Cirrhosis.
MEDICATIONS AT HOME:
1. Hydrochlorothiazide 50 qd.
2. Lisinopril 5 qd.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives in a home on her own. ADL
are performed by patient. IQ 53. Ethics is involved but
there is no healthcare proxy. The patient smokes. The
patient drinks. The guardianship process is underway.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.1, pulse
72, BP 123/90, respiratory rate 20, oxygen saturation 97% on
2 liters.
GENERAL: A frail, elderly female, lying in bed, no acute
distress.
HEENT: Mucous membranes moist. Oropharynx clear with
whitish discharge on tongue. Pupils equal, round and
reactive to light.
NECK: Supple. No JVD. No LAD. Left subclavian
triple-lumen catheter in place.
CARDIOVASCULAR: Normal S1, S2, regular rate and rhythm
without murmur.
PULMONARY: Clear to auscultation bilaterally, no wheezes.
ABDOMEN: Positive bowel sounds, soft, nontender,
nondistended without hepatosplenomegaly. Mild discomfort in
the right upper quadrant.
EXTREMITIES: No edema bilateral lower extremities, warm, 2+
DP pulse left, 1+ DP pulse right.
NEURO: [**4-15**] motor strength in bilateral lower extremities,
[**4-15**] left upper extremity, [**3-16**] right upper extremity.
Reflexes 1+ throughout. Very slow finger-to-nose. Oriented
to season, not to year or to place.
LABORATORIES ON ADMISSION: White count 17.9, hematocrit
42.7, platelets 255, sodium 133, potassium 3.7, chloride 94,
bicarb 24, BUN 49, creatinine 2.1, glucose 138, calcium 10.2,
mag 2.2, phos 4.3, albumin 2.9, ALT 192, AST 291, alk phos
197, T-bili 1.7, lactate 5.2. Blood cultures and urine
cultures have been no growth to date. UA was negative. An
EKG showed AFIB versus AFLUTTER versus MAT at 150 beats per
minute which converted to normal sinus at 75 after diltiazem,
with a normal axis, no Q waves, and no acute ST-T wave
changes. A chest x-ray initially showed mild CHF with left
lung base patchy atelectasis, no pneumothorax, no effusions,
no consolidations. Right upper quadrant ultrasound showed
coarse liver echo texture, no masses, no intrahepatic ductal
dilatation, no free fluid in the abdomen. The portal vein
was patent. The common bile duct was 7.5 mm. There was
gallbladder wall thickening but this was not consistent with
acute cholecystitis. It was consistent with cirrhosis.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was initially
admitted to the [**Hospital Unit Name 153**] under the sepsis protocol. She did
quite well with fluids, and ceftriaxone IV. The next day she
was called out to the floor and transferred that night to the
[**Company 191**] Medicine service.
1) SEPSIS/HYPOTENSION/ID: The patient presented severely
dehydrated with a creatinine 4x her baseline. She also had
an elevated white count, elevated lactate, and was
hypotensive. She responded quite well to aggressive fluid
repletion, and also to ceftriaxone empiric treatment. She
was essentially afebrile throughout, never really showing any
signs of infection. Ceftriaxone was continued for 3 days. A
follow-up chest x-ray was read as left lower lobe
consolidation, could be consistent with pneumonia, though the
patient did not have other signs or symptoms of pneumonia.
At this point, she was transitioned to Levofloxacin 500 po
qd. She should complete a 5-day course of the Levofloxacin.
The patient presented with what sounded like a viral
syndrome, initially a chest x-ray without signs of pneumonia.
It is possible that burgeoning pneumonia brought her in and
it developed over several days radiographically. It is also
possible that this left lower lobe consolidation is
atelectasis and that she never had a bacterial pneumonia.
She is also to follow-up with her PCP on [**Name9 (PRE) 766**], [**1-12**].
2) ACUTE RENAL FAILURE: The patient's baseline creatinine
noted to be 1.0. She presented at 2.1. This was felt to be
purely prerenal. As she responded well to fluids, her
creatinine is actually 0.5 today. Her urine output was
adequate. This was felt simply due to hypotension and volume
depletion.
3) TACHYCARDIA: On presentation, the patient was in a SVT
felt to be atrial flutter versus atrial fib versus multifocal
atrial tachycardia. After fluids and diltiazem, she
converted to normal sinus rhythm and essentially remained in
normal sinus rhythm. This was felt probably the result
rather than the cause of her hypotension. A TSH was checked
which was normal. We do not believe the patient requires
further evaluation at this time.
4) ELEVATED LFTS: The patient has a history of ETOH abuse,
hepatitis B and known cirrhosis. When she presented, her
LFTs were elevated and they consistently trended down over
the course of her stay. Her LFT elevations were likely
multifactorial due to hypotension, her Hep B, and possible
alcohol ingestion. The right upper quadrant ultrasound
showed no signs of cholecystitis, and there were no clinical
signs of cholangitis. Also of note, the patient's INR
appears at baseline to be slightly elevated likely due to
decreased hepatic function combined with perhaps poor
nutritional intake.
5) ETOH ABUSE: The patient denied alcohol intake; however,
she is known to consume alcohol. She was placed on a CIWA
scale for diazepam. However, few doses were needed. She did
not appear to be in withdrawal.
6) DIABETES MELLITUS TYPE 2: The patient is diet controlled
at home. She was placed on qid fingersticks and regular
insulin sliding scale, but had good control on her own.
7) HYPERTENSION: The patient is on hydrochlorothiazide and
lisinopril at home. These medications were held in the
setting of hypotension. We will hold them on discharge, and
they can be restarted as needed by her PCP next week.
8) HEME: The patient was admitted with a hematocrit of 43
which decreased to 33 with aggressive hydration, and then
came up to 35. This was likely due to fluid shifts rather
than to any acute blood loss. Her hematocrit settled out
around 33-36. There were no signs of bleeding at any time.
DISPOSITION: The patient was evaluated by physical therapy.
Upon conversations with the patient's primary nurse [**First Name8 (NamePattern2) **]
[**Last Name (Titles) **], it was felt that she was pretty close to her
baseline. At this time, the final decision had not been made
whether the patient would be discharged to an extended care
facility or home with services.
DISCHARGE DISPOSITION: To either extended care facility or
homeless services.
DISCHARGE INSTRUCTIONS:
1. You are to see Dr. [**Last Name (STitle) 3649**] on [**2189-1-12**] at 10:00 am, or
perhaps this will be the nurse, Ms. [**Last Name (Titles) 931**].
2. You should contact your primary doctor, or come to the ED
with any fever, chills, shortness of breath, nausea or
vomiting.
DISCHARGE MEDICATIONS:
1. Colace 100 mg [**Hospital1 **].
2. Thiamine 100 mg qd.
3. Folic acid 1 mg qd.
4. Multivitamin qd.
5. Levofloxacin 500 mg 1 tablet q 24 h x 5 days.
DISCHARGE DIAGNOSES:
1. Sepsis or hypovolemia.
2. Atrial flutter.
3. Acute renal failure, now resolved.
4. Possible pneumonia versus atelectasis.
MAJOR PROCEDURES: Central venous catheter placement.
DISCHARGE CONDITION: The patient is taking good PO, able to
ambulate, appears euvolemic.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4704**], M.D. [**MD Number(1) 4705**]
Dictated By:[**Last Name (NamePattern1) 6006**]
MEDQUIST36
D: [**2189-1-8**] 10:40
T: [**2189-1-8**] 10:48
JOB#: [**Job Number 108669**]
ICD9 Codes: 0389, 5849, 2765, 486, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7158
} | Medical Text: Admission Date: [**2164-11-28**] Discharge Date: [**2164-12-6**]
Date of Birth: [**2164-11-28**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: The patient is an 1880 g female
infant born at an estimated gestational age of 30 and 5/7
weeks. She is currently 8 days old with a corrected gestation
[**Doctor Last Name **]
age of 31 and 6/7 weeks. The mother is a 40- year- old, gravid
a
2, para [**11-30**], woman with prenatal screens: B+, antibody negativ
e,
hepatitis B surface antigen negative, RPR nonreactive, rubella
immune, GBS unknown.
The mother's past medical history is notable for spina bifida
occulta and infertility. The pregnancy is notable for a donor
egg
IVF gestation. Fetal survey was within normal limits. There wa
s a
premature rupture of membranes on [**2164-11-5**], and the
mother was admitted to [**Hospital3 **] and treated with
Magnesium Sulfate and antibiotics. A course of Betamethasone w
as
complete on [**2164-11-6**]. The mother was transferred to Be
th
[**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2164-11-23**], due to a
biophysical profile of 6 out of 8 and proceeded to develop
spontaneous preterm labor. Her delivery was by spontaneous
vaginal delivery. There was a maternal fever to 100.6??????and feta
l
tachycardia during labor. Antibiotics were started two hours
prior to delivery.
The infant was vigorous at delivery and received blow-by
oxygen. Apgar scores were 7 at one minute and 8 at five
minutes. She was transferred to the NICU for prematurity.
PHYSICAL EXAMINATION: Vital signs: On admission temperature
was 99.7??????, heart rate 190, respirations 68, blood pressure
54/34 with a mean of 44, oxygen saturation 95% in room air.
General: The infant was a well-appearing preterm baby.
[**Name (NI) 4459**]: Anterior fontanele open and flat, nondysmorphic,
palate intact, mild nasal flaring, normal red reflex
bilaterally. Cardiovascular: Regular, rate and rhythm.
Normal S1 and S2. No murmur. Normal pulses. Chest:
Minimal subcostal retractions. Good aeration bilaterally.
No crackles. Abdomen: Soft, nondistended. No
hepatosplenomegaly or masses. Patent anus. GU: Normal
female external genitalia. Neurological: Active and
responsive to stimulation. Normal tone. Moving all
extremities symmetrically. Normal reflexes.
Musculoskeletal: Normal spine, hips, and clavicles. No
deformities noted.
HOSPITAL COURSE: 1. Respiratory: The infant had mild
retractions and nasal flaring for the first 2-3 days of life;
however, she has remained stable in room air without any need
for respiratory support.
She has had occasional episodes of desaturation was started on
Caffeine for apnea of prematurity, after which the desaturatio
ns
resolved.
2. Cardiovascular: The infant has been hemodynamically
stable. A soft intermittent murmur was noted on day of life
#4. Chest x-ray showed normal cardiac silhouette, and four
extremity blood pressures were normal. The murmur has since
resolved.
3. Fluids, electrolytes and nutrition: The infant was
initially started on intravenous fluids. She had an initial D
-
stick shortly after birth of 22, but since then has not had an
y
significant hypoglycemia. She had some spitting with advancem
ent
of feeds, but is currently tolerating full enteral feedings vi
a
gavage tube of PE22.
Weight on the day of discharge is 1.77 kg, length 43 cm, head
circumference 28.75 cm.
4. Gastrointestinal: The infant was treated wtih phototherap
y
for hyperbilirubinemia. Peak bilirubin on day of life #3 was
12.5. Single phototherapy, which was discontinued on day of l
ife
#6. Rebound bilirubin on day of life #7 was 5.4.
5. Hematologic: The infant had an initial CBC with a white
count of 7, hematocrit 39.6, platelet count 248. She has not
received any transfusions.
6. Infectious disease: The infant was treated with
Ampicillin and Gentamicin for 48 hours due risk factors for
sepsis. Her blood culture was negative, and she has had no
clinical signs of sepsis.
7. Neurologic: A screening head ultrasound on day of life #7
was notable only for subtle increased echogenicity of the
ependymal lining of the ventricles. Although this may simply
represent a technical artefact, the radiologist also noted
that this oculd be suggestive of chemical
ventriculitis secondary to a small intraventricular hemorrhage
.
There was no germinal matrix hemorrage or intraventricular blo
od
noted, and the ventricles were normal in size. A repeat head
ultrasound should be performed in [**1-1**] days.
8. Sensory: The infant will require both a hearing screen an
d
an ophthalmologic exam prior to discharge home.
9. Psychosocial: A [**Hospital6 256**]
Social Work has been involved with the family. We have held
a family meeting, as well as frequent bedside updates.
CONDITION ON DISCHARGE: Fair.
DISPOSITION: Discharged to Level II Nursery.
PRIMARY CARE PHYSICIAN: [**Name Initial (NameIs) 23198**].
CARE RECOMMENDATIONS: Feeds at discharge: Premature Enfamil
with HMF 22 kcal per ounce at 140 cc/kg/day all PG.
MEDICATIONS: Caffeine citrate 12 mg PG every day.
CAR SEAT POSITIONING: Screening should be performed prior to
discharge.
STATE NEWBORN SCREENING: Has been sent.
Hearing SCreens have not been done and are suggested prior to
ultimate dischargeischarge homeI
ZATIONS RECEIVED: The infant
has not ultimate discharge home.
immunizations and will require hepatitis B vaccine prior to
discharge home.
Synagis RSV prophylaxis should be considered from [**Month (only) 359**] [**Last Name (un) **]
ugh
[**Month (only) 547**] for infants who meet any of the following three criteria
:
1) born at less than 32 weeks, 2) born between 32 and 35 weeks
with plans for daycare during RSV season, with a smoker in the
household, neuromuscular disease, airway abnormalities, or wit
h
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 influenzae to protect the infant.
DISCHARGE DIAGNOSIS:
1. Prematurity.
2. Rule out sepsis.
3. Feeding immaturity.
4. Hyperbilirubinemia.
5. Apnea of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 50798**]
MEDQUIST36
D: [**2164-12-5**] 08:05
T: [**2164-12-5**] 08:13
JOB#: [**Job Number 52502**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7159
} | Medical Text: Admission Date: [**2154-5-4**] Discharge Date: [**2154-5-15**]
Service:
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old man, with
a history of dementia and atrial fibrillation, who presents
from home. He originally went to an outside hospital where a
chest x-ray revealed left pleural effusion and a large
cardiac silhouette. The patient was found to have increasing
shortness of breath and pleuritic chest pain radiating to his
back, and was transferred to the [**Hospital1 **]
Hospital for further evaluation and work-up. The patient
denies nausea, vomiting, diaphoresis, but does admit to
shortness of breath and chest pain, as above.
PAST MEDICAL HISTORY: 1) Atrial fibrillation, 2) Status post
spinal fusion, 3) History of prostate cancer, status post XRT
in [**2142**], 4) Mitral valve prolapse, 5) Status post knee
surgery, 6) Status post appendectomy, 7) History of pneumonia
eight months ago.
ALLERGIES: None.
MEDICATIONS: 1) coumadin 5 mg po qd, 2) lasix 20 mg po qd,
3) digoxin 0.25 mg po qd, 3) Aricept 5 mg po qd, 4) KCL 20 mg
po qd.
PHYSICAL EXAM ON ADMISSION: Generally, agitated, demented.
JVP was at 8 cmH2O. Distant heart sounds. Pulsus 15 mmH2O.
Bilateral rales at the bases. Decreased breath sounds, left
greater than right, at the bases. II/VI systolic murmur.
White count 8.5, crit 32.2, platelets 422. Sodium 138,
potassium 4.6, chloride 101, bicarb 25, BUN 31, creatinine
0.9, glucose 162. CT chest and abdomen revealed no aortic
dissection, but did reveal a 4x4 abdominal aortic aneurysm,
infrarenal, cardiomegaly, and a large pericardial effusion
with bilateral pleural effusions. EKG was atrial
fibrillation at a rate of 110, biphasic T waves in 4 through
6, but no alternans, no decreased voltage.
HOSPITAL COURSE - 1) PERICARDIAL EFFUSION: The patient was
monitored closely with daily measurements of his pulsus
paradoxus and close blood pressure monitoring, as it was
thought that he had possible impending tamponade. Serial
echocardiograms revealed some echocardiographic evidence for
tamponade, but the patient was able to maintain a normal to
high blood pressure.
Nevertheless, on hospital day #5, the patient was taken to
the Catheterization Lab and a pericardiocentesis was
performed where blood was removed from the pericardial space,
and there was found to be a loculated pericardial effusion
with significant amounts of blood clot. The patient's INR
was 6.5 at admission which may have explained the patient's
bloody pericardial effusion. There was cytology done on this
sample that was negative; however, malignancy was still a
concern in this patient with a history of prostate cancer.
The patient's pleuritic chest pain, shortness of breath
improved after pericardiocentesis. The patient was monitored
in the CCU for 48 hours, and the patient had symptomatic
improvement, was able to be weaned off the minimal amount of
oxygen, had decreased shortness of breath.
2) PLEURAL EFFUSION: The patient's pleural effusion was also
tapped and almost 2 liters of fluid were removed. This was
consistent with an exudative effusion; however, there was no
obvious cause for exudative effusion, no Gram stain findings.
The fluid culture was negative. The patient was afebrile
throughout his hospitalization and showed no sign of
infection. Again, malignancy was at the top of the list for
the possible etiology of the effusions. The pleural disease
service was consulted and considered pleuroscopy with biopsy.
However, the patient's pleural effusion did not
reaccumulate; therefore, pleuroscopy was not pursued.
However, at a future date pleuroscopy could be pursued for
both biopsy and pleurodesis if this patient has recurrent
problems with pleural effusions and shortness of breath.
3) ATRIAL FIBRILLATION: The patient's atrial fibrillation
was uncontrolled for several days with a high rate of 131-40.
Minimal rate control was pursued because of the patient's
possible tamponade physiology. When the patient's
pericardial effusion was further characterized and tapped,
more aggressive rate control was pursued with Lopressor which
was titrated up to 75 mg po tid. The patient was also
started on Norvasc for rate control and blood pressure
control. The patient's heart rate was better controlled at
the time of discharge, between 80 and 90.
The patient had a run of CHF when his rate was quite high in
the context of this pericardial effusion. The patient was
diuresed in the CCU, and the patient was no longer short of
breath, and was off oxygen at the time of discharge.
4) DEMENTIA: The patient had definite sundowning. He was
started on Zyprexa at 5:00 pm each day with prn Risperdal.
The patient responded well to this regimen and was minimally
disruptive. At time of discharge, the patient did require
1:1 sitter for much of his hospitalization, but this was
discontinued several days prior to discharge.
5) ACTIVITY LEVEL: The patient became physically
decompensated after being in bed for several days with his
shortness of breath and pericardial effusion. The patient
was seen by physical therapy and evaluated, and thought to be
a good candidate for acute rehab, as he had been pretty
independent and functional prior to discharge.
DISCHARGE CONDITION: Good. The patient was discharged to
acute rehab.
DISCHARGE MEDICATIONS: 1) Norvasc 7.5 mg po qd, 2)
Olanzapine 7.5 mg po q 5:00 pm every night, 3) Lopressor 75
mg po tid, 4) Risperdal 1 mg po bid prn, 5) digoxin 0.25 mg
po qd, 6) subcu heparin 5,000 U q 12 h, 7) lasix 20 mg po qd,
8) docusate 100 mg po bid, 9) Donepezil 5 mg po q hs.
DISCHARGE DIAGNOSES: 1) Congestive heart failure. 2)
Pericardial effusion. 3) Pleural effusion. 4) Atrial
fibrillation with rapid ventricular response. 5) Dementia.
6) Status post prostate cancer.
[**Doctor First Name 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. [**MD Number(1) 9632**]
Dictated By:[**Last Name (NamePattern1) 7942**]
MEDQUIST36
D: [**2154-5-15**] 08:39
T: [**2154-5-15**] 07:57
JOB#: [**Job Number 99862**]
ICD9 Codes: 4280, 5119, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7160
} | Medical Text: Admission Date: [**2127-6-22**] Discharge Date: [**2127-6-26**]
Date of Birth: [**2068-10-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
58 M with h/o DM, hyperlipidemia, hypertension, neuropathy,
tenosynovitis, and chronic headaches presents with sharp
left-sided chest pain radiating to his left shoulder and scapula
which started yesterday morning. The pain was slightly worsened
by movement. He felt slightly lightheaded and short of breath.
He has a history of capsulitis to which he initially attributed
the pain to, however pain did not improve with Tylenol, so he
presented to the ED. In the ED, pain slightly improved with SL
NTG x3 and aspirin. EKG was without acute changes and cardiac
enzymes have been negative. He was admitted to the observation
unit where he had continued chest pain that again slightly
improved with SL NTG and admitted to medicine. Patient
describes the pain as a constant, sharp pain. Has never
experienced this before.
.
On the medicine service, he continued to have chest pain.
Cardiology was consulted and recommended cardiac catheterization
given atypical chest pain that has persisted for over 24 hours.
Pain was again slightly improved with SL NTG x3, IV morphine 2mg
x3, and IV metoprolol 5 mg x1. EKG over the course of the day
showed that he has progressively peaking T waves. Patient was
started on a heparin drip for concern for ACS. He continued to
have pain. Nitro drip was unable to be started on the floor to
help in controlling pain and so patient was transferred to the
CCU for further management.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, or
syncope
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- DM
- Hyperlipidemia
- Hypertension
- Hypothyroidism
- Tenosynovitis
- Tension Headaches
- Peripheral Neuropathy
- Palmar Contracture
- Peptic Ulcer and GI bleed - last bleed in [**2097**]
- h/o TIA x5
Social History:
-Tobacco history: former smoker - quit [**2115**]
-ETOH: denies
-Illicit drugs: denies
Former ENT physician in [**Country 532**]. Married.
Family History:
Father with CAD (60s). No premature heart failure or sudden
cardiac death.
Physical Exam:
VS: 98, L 140/79, R 140/80, 98, 18, 96% 2L
Gen: WDWN male in NAD, AAOx3
Eyes: No conjunctival pallor. No icterus.
ENT: MMM. OP clear.
CV: JVP low. Normal carotid upstroke without bruits. PMI in 5th
intercostal space, mid clavicular line. RRR. nl S1, S2. No
murmurs, rubs, clicks, or gallops. Full distal pulses
bilaterally. No femoral bruits.
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged
by palpation. No abdominal bruits.
Heme/Lymph/Immune: No CCE, no cervical lymphadenopathy.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**2-1**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred.
PSYCH: Mood and affect were appropriate.
Pertinent Results:
ADMISSION:
[**2127-6-22**] 01:37PM BLOOD WBC-4.3 RBC-5.03 Hgb-14.6 Hct-43.4 MCV-86
MCH-29.0 MCHC-33.6 RDW-13.5 Plt Ct-208
[**2127-6-22**] 01:37PM BLOOD Neuts-62.4 Lymphs-30.5 Monos-4.7 Eos-1.1
Baso-1.4
[**2127-6-23**] 08:00AM BLOOD PT-11.4 PTT-29.6 INR(PT)-0.9
[**2127-6-22**] 01:37PM BLOOD Glucose-156* UreaN-23* Creat-1.4* Na-141
K-4.6 Cl-102 HCO3-33* AnGap-11
[**2127-6-24**] 03:10AM BLOOD ALT-17 AST-16 CK(CPK)-65 AlkPhos-72
Amylase-21 TotBili-0.9
[**2127-6-24**] 03:10AM BLOOD Lipase-32
[**2127-6-22**] 01:37PM BLOOD cTropnT-<0.01
[**2127-6-22**] 07:30PM BLOOD cTropnT-<0.01
[**2127-6-23**] 12:50AM BLOOD CK-MB-3 cTropnT-<0.01
[**2127-6-23**] 08:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2127-6-23**] 09:08PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2127-6-24**] 03:10AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2127-6-23**] 08:00AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2
[**2127-6-26**] 06:40AM BLOOD Triglyc-134 HDL-56 CHOL/HD-2.8 LDLcalc-76
LDLmeas-78
[**2127-6-22**] 01:37PM BLOOD D-Dimer-152
[**2127-6-26**] 06:40AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE
[**2127-6-26**] 06:40AM BLOOD HCV Ab-NEGATIVE
DISCHARGE:
[**2127-6-26**] 06:40AM BLOOD WBC-4.4 RBC-5.06 Hgb-14.3 Hct-43.6 MCV-86
MCH-28.3 MCHC-32.9 RDW-13.6 Plt Ct-212
[**2127-6-26**] 06:40AM BLOOD Glucose-108* UreaN-15 Creat-1.0 Na-142
K-3.8 Cl-102 HCO3-31 AnGap-13
[**2127-6-26**] 06:40AM BLOOD Albumin-4.6 Calcium-9.0 Phos-3.6 Mg-1.8
Cholest-159
REPORTS:
[**2127-6-22**] Cardiology ECG
Normal sinus rhythm. Possible left atrial enlargement. Minor
non-specific
ST-T wave abnormalities. Compared to the previous tracing of
[**2122-5-8**] heart rate has decreased. Non-specific ST-T wave
abnormalities are slightly less marked. Otherwise, no diagnostic
change.
[**2127-6-22**] Radiology CHEST (PA & LAT)
FINDINGS: The heart and mediastinal contours are normal. The
hila are normal appearing bilaterally. The lungs are clear of
masses or consolidations. There is no pleural effusion or
pneumothorax. Bony structures are grossly intact.
IMPRESSION: No acute cardiopulmonary process.
[**2127-6-23**] Cardiology ECHO
The left atrium is elongated. 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. The aortic root is
mildly dilated at the sinus level. The ascending aorta and
aortic arch are mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation with normal valve morphology.
CLINICAL IMPLICATIONS:
Based on [**2124**] 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.
[**2127-6-24**] Cardiology C.CATH
1. Selective coronary angiography of this right dominant system
revealed
no significant CAD. The LMCA and LCX were without
angiographically
apparent disease. The LAD had a 30% stenosis in the proximal
LAD. The
RCA had a proximal 30% stenosis.
2. The celiac artery, superior mesenteric artery, and renal
arteries
(bilaterally) were selectively engaged and found to have no
significant
disease.
3. Central aortic pressure and left sided filling pressures were
both
normal.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal diastolic function.
3. Normal celiac, superior mesenteric, and renal arteries.
3. Dilated bowel loops seen under fluoroscopy.
[**2127-6-24**] Radiology CTA CHEST W&W/O C&RECON
1) No pulmonary embolism or acute aortic pathology.
2)Mild linear atelectasis and dependent atelectasis in the lower
lobes
bilaterally.
3)Sub-2-mm nodules in the right upper lobe and right lower lobe
do not require followup in the absence of smoking history. If
there is a smoking history, followup CT thorax should be
performed in one year to evaluate interval change.
4)Moderately severe coronary artery calcification and small
hiatal hernia.
[**2127-6-24**] Radiology ABDOMEN (SUPINE & ERECT
ABDOMEN PORTABLE, TWO VIEWS: The ascending colon is dilated to
7.7 cm. there is a large amount of air in the small and large
bowel. However, air is seen all the way to the sigmoid colon and
rectum. Small bowel loops are not significantly dilated,
measuring up to 2.6 cm. There is no evidence of free air.
IMPRESSION: Findings consistent with ileus.
Brief Hospital Course:
58M with [**Location (un) 47**] risk factors of diabetes, hypertension, and
hyperlipidemia who presented with new acute onset chest pain.
.
# CHEST PAIN: The patient continued to have chest pain on the
floor with an EKG showing new prominent T waves although cardiac
biomarkers were negative. There was concern for cardiac ischemia
given his multiple cardiac risk factors. He was started on a
heparin drip, aspirin, beta blocker and high dose statin. He
was taken for cardiac catheterization which was negative for
coronary artery disease. He then underwent CTA which was
negative for PE or for any other cause of his chest pain.
Finally, he underwent EGD which revealed possible varices which
was followed up by GI. It also showed mild esophagitis for which
he was started on a PPI. He also had a small hiatal hernia. The
cause of his chest pain was unclear although it may have been
due to esophagitis. He was chest pain free upon discharge.
.
# DIABETES: He was continued on his insulin pump as well as a
sliding scale with close monitoring for sugars.
.
# ACUTE RENAL FAILURE: His renal function was found to be
slightly worse than baseline. This was thought to be pre-renal
in setting of dehydration. He was given fluids and his
creatinine returned to [**Location 213**]. He was continued on lisinopril
for his proteinuria. His renal function was at baseline by
discharge.
.
# CONSTIPATION: Patient had not had a bowel movement in several
days and KUB was concerning for ileus. His abdominal exam
however remained benign and he denied any pain. He moved his
bowels prior to discharge with the help of a bowel regimen.
.
# INCIDENTAL LUNG NODULE: Found on CTA, because of his smoking
history he will need a repeat CT scan in 1 year ([**6-10**]), and this
will be communicated to his PCP.
.
# HYPERLIPIDEMIA: He was continued on a statin.
.
# HYPERTENSION: continued lisinopril and started low dose
metoprolol
.
# Hypothyroidism: continued levothyroxine
.
# h/o tension headaches: continued nortriptyline
.
# Tenosynovitis - takes methotrexate at home qFriday: held
methotrexate in acute setting and this was restarted upon
discharge.
.
# h/o TIA x5 - no neurological deficits noted. Patient has not
been on anticoagulation in the past. Patient was continued on a
statin.
Medications on Admission:
Insulin pump
Levothyroxine 125 mcg daily
Lisinopril 5 mg daily
Nortriptyline 25 mg daily
Methotrexate (unknown dose) weekly (last taken on Friday)
Folic Acid 1 mg daily
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Insulin Pump Reservoir 3 mL Misc Sig: One (1) Miscellaneous
once a day: As directed.
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
9. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Atypical chest pain
2) Esophageal varices
3) Constipation
4) Possible esophageal spasm
5) Possible gastroesophageal reflux disease
6) Gastritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted for chest pain. Fortunately, all our testing was
negative for the most life-threatening causes of chest pain,
including a heart attack, pulmonary embolism, pneumothorax, or
aortic dissection. You also underwent a scope of your upper GI
tract which showed mild inflammation and varices of your
esophagus. You should undergo an ultrasound of your liver and
follow up with the GI department for these findings. Although we
don't have a definitive diagnosis on the cause of your chest
pain, the two most likely possibilities include esophageal
spasm, for which you are being treated with nifedipine (calcium
channel blocker) as well as gastroesophageal reflux for which
you are being treated with pantoprazole (a proton pump
inhibitor). We have set you up with cardiology and the GI team
to follow up your chest pain as an outpatient. Fortunately, most
of your symptoms improved the last 2-3 days prior to admission,
possibly due to starting these medications. If you develop
severe chest pain again, you should call your doctor or come to
the emergency department. And although your cardiac
catheterization was negative for obstructive disease, you should
still be on a life-long baby aspirin and a cholesterol lowering
[**Doctor Last Name 360**] such as atorvastatin to keep your LDL cholesterol below
70.
We have made the following changes to your medications.
- START taking aspirin 81mg by mouth daily
- START taking pantoprazole 40mg by mouth daily
- START taking nifedipine 60mg by mouth daily
- START taking atorvastatin 40mg by mouth daily
- DISCUSS with your doctor about the esophageal varices and
whether the methotrexate may be contributing before continuing
to take this medicine
Followup Instructions:
Department: HMFP
When: TUESDAY [**2127-7-1**] at 9:00 AM
With: N [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Department: [**State **] SQ
When: TUESDAY [**2127-7-8**] at 12:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: [**Last Name (un) 12214**] [**Doctor Last Name **] MED GRP
When: TUESDAY [**2127-7-15**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD [**Telephone/Fax (1) 5068**]
Building: [**Location (un) **] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Completed by:[**2127-9-22**]
ICD9 Codes: 5849, 3572, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7161
} | Medical Text: Admission Date: [**2165-8-13**] Discharge Date: [**2165-8-22**]
Service: MEDICINE
Allergies:
Tramadol / Advil / Nsaids / Hydrocodone
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Bedside Debridement R Heel Ulcer
History of Present Illness:
Mr. [**Known lastname **] is an 86M with PMH significant for h/o duodenal ulcer
s/p partial duodenectomy, who presents from [**Hospital 100**] Rehab after
melena noted on [**8-11**]. Denied CP, SOB, abd pain, N/V, though his
son had noted some increased confusion during the previous few
days. He was found to have a hct drop from baseline 29 to 19,
and was sent to the ED. EMS VS BP 110/60, HR 92, RR 18. In the
ED, initial VS were T: 99.4F, HR: 119, BP 108/39, RR 19, SaO2
100%. ECG demonstrated NSR at 96bpm, LAD, incomplete RBBB, poor
r-wave progression. A decision was made not to place NGT since
patient uncooperative, and due to concerns about aspiration. A
16ga and an 18ga PIVs were placed, and he was given 2U PRBC and
2L NS, and was given protonix 40mg IV. GI was consulted, and is
aware. Mr. [**Known lastname **] was also found to have a UTI, and was given
Levofloxacin 500mg IV. He was transferred to the [**Hospital Unit Name 153**] for
monitoring.
.
Originally had GIB in [**8-17**] with black, tarry stools, dx'ed as
PUD. He had a hip replacement in [**11-17**], and was d/c'ed on
coumadin. Later that month, he re-presented to [**Hospital1 **] with bloody
stools, hypotensive, and anemic to hct 14.7. EGD demonstrated
bleeding duodenal ulcer, but epi was not attempted [**2-14**] inability
to visualize clot. He was taken for angio and embolization, with
subsequent rebleeding requiring ex lap, duodenotomy, oversewn
ulcer, j-tube placement and biopsy of liver mass. He was
continued on a proton pump inhibitor. He failed various swallow
evaluations and was fed through his J-tube. Course was
complicated by difficulty weaning from vent and MRSA PNA and
pseudomonas UTI and bacteremia. Also found to have superficial
femoral vein clots, and IVC filter was placed. Had subsequent
LGIB in [**2-18**], with colonoscopy revealing grade 1 internal
hemorrhoids, and a cecal popyp, which was cauterized. Course c/b
c. diff colitis, s/p flagyl and PO vanc treatment x total 28
days. Also with 06/06 admission for J-tube replacement, with
Klebsiella UTI sensitive only to Bactrim, Unasyn, Zosyn, and
carbapenems.
.
in the [**Hospital Unit Name 153**], initial BPs found to be SBP 80s-90s, HR 80s. Given
1L NS over 1 hour, which raised SBP to 100s-110s. UOP 80mL in
first hour. Repeat hct 19.1 -> 21.8 after 2U PRBC, started two
additional units PRBCs over two hours each. NGT placement was
attempted, but aborted after multiple unsuccessful attempts,
significant patient distress, and transient desats to 90%. Spoke
with GI, who plans to scope on [**8-14**] unless becomes unstable.
Past Medical History:
1. Hypertension
2. Chronic obstructive pulmonary disease
3. Osteoarthritis
4. Osteopenia
5. Dementia
6. Depression
7. Status post bilateral inguinal hernia repair
8. Status post bilateral cataract surgery
9. Status post right total hip replacement
.
Cardiac:
Stress [**2164-9-6**]: no ecg changes. Moderate fixed inferior wall
perfusion defect. LV EF of 60%.
Echo [**2165-1-9**]: LV EF>55% no LVH, nl RV size/fxn. 1+AR, PAP wnl
Social History:
Currently a patient at [**Hospital **] rehab. Patient is on the waiting
list at [**Hospital1 5595**]. The patient previosly reported that his parents as
well as his siblings were all killed during the holocaust. He is
a retired meat manager at a local supermarket. He immigrated
from [**Country 532**] in the late [**2099**]. The patient had denied any
tobacco or alcohol use
Family History:
noncontributory
Physical Exam:
VS: T: 99.1F BP: 99/38 HR: 85 RR: 20 SaO2: 96% 1L NC
Gen: Cachectic Caucasian male, mildly distressed, disoriented
HEENT: Sclerae anicteric, OP dry
CV: RRR, nl S1 and S2, III/VI SEM loudest at apex
Pulm: Poor inspiratory effort, decreased breath sounds
throughout, no clear w/r/r
Abd: Soft, no clear tenderness, though pt uncooperative with
exam, no erythema with mild white discharge around J-tube site,
no HSM, +BS
Extr: +stage III coccyx ulcer, dressing c/d/i, +R heel ulcer,
necrotic, dressing c/d/i. 1+ DPs bilaterally, extremities warm.
+clubbing
Neuro: A&Ox1, MAEW, uncooperative with formal exam
Pertinent Results:
[**2165-8-13**] 09:55PM COMMENTS-GREEN TOP
[**2165-8-13**] 09:55PM LACTATE-2.8*
[**2165-8-13**] 08:20PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2165-8-13**] 08:20PM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2165-8-13**] 08:20PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2165-8-13**] 07:30PM GLUCOSE-96 UREA N-27* CREAT-0.6 SODIUM-141
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-25 ANION GAP-16
[**2165-8-13**] 07:30PM CK(CPK)-49
[**2165-8-13**] 07:30PM CK-MB-NotDone cTropnT-0.03*
[**2165-8-13**] 07:30PM WBC-10.2 RBC-2.67*# HGB-5.8*# HCT-19.1*#
MCV-72* MCH-21.8*# MCHC-30.5* RDW-17.9*
[**2165-8-13**] 07:30PM NEUTS-76.8* LYMPHS-13.1* MONOS-6.6 EOS-2.8
BASOS-0.6
[**2165-8-13**] 07:30PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-2+
MICROCYT-3+
[**2165-8-13**] 07:30PM PLT COUNT-609*
[**2165-8-13**] 07:30PM PT-12.9 PTT-21.7* INR(PT)-1.1
..
MR R foot:
1. Posterior calcaneal edema. Given the close proximity to the
soft tissue ulcer, findings are highly suspicious for
osteomyelitis. (it is not clear whether the cortical loss seen
on the xray is secondary to infection or post- surgical. The
marrow edema seen in the calcaneus likely reflects a combination
of osteomyelitis (closer to the ulcer) and surorunding reactive
edema, but the precise demarcation between these two areas
cannot be assessed by imaging.
2. Edema of the quadratus plantae muscle -- the ddx includes
both infeciton and reactive edema.
3. No bone or soft tissue abcess identified.
..
R foot XR:
1. Soft tissue deformity with subcutaneous emphysema and
corresponding bony destruction of the posterior right calcaneus
consistent with diagnosis of osteomyelitis.
2. Extensive [**Month/Day/Year 1106**] calcifications and diffuse osteopenia.
Brief Hospital Course:
1) Melena: EGD ([**8-14**]) showed 2 duodenal ulcers without visible
vessel, adherent clot or active bleeding. HCT has been stable
since 4 units total on admission.
Treated initially with protonix 40mg IV bid, transitioned to
lansoprazole 30 mg per J tube [**Hospital1 **], H.Pylori treatment with
amox/clairithromycin/PPI, amoxicillin was d/c'd due to zosyn
administration for UTI/osteo.
.
2) Hypotension: Was likely due to combination of GIB and sepsis
from UTI. Responded to IVF and antibiotics/blood. Remained
normotensive during rest of admission.
.
3) UTI: Urine Cx with Klebsiella (ESBL) sensitive only to
Bactrim, carbapenems, Zosyn, and Unasyn.
- Will treat with Zosyn 4.5mg IV q6h for 2 weeks
.
4) Right Heel ulcer: pressure ulcer of right heel necrotic with
evidence of underlying osteo on XR, on Vanco 1 gm IV q12 for
gram + coverage as well as zosyn. Consulted [**Hospital1 1106**] and seen by
Dr. [**Last Name (STitle) **] is [**Last Name (STitle) 1106**] surgeon as well. Was discussed and felt
that only definitive treatment would be AKA, but given age and
comorbidities and risk of surgery sons opted for conservative
course of antibiotics and follow up with Dr. [**Last Name (STitle) **]. Patient
also will be seen by Dr. [**Last Name (STitle) **] at [**Hospital 100**] Rehab to minitor his
wounds.
.
5) Dementia: Has agitation, likely with overlying delerium from
UTI
Resolved agitation/delirium after treatment of infections.
.
6) FEN: Resume tube feeds, monitor lytes and replete prn
.
7) Ppx: Pneumoboots for DVT ppx, PPI twice daily, BR
.
8) Access: PICC line
.
9) Full Code.
.
10) Contact/HCP/POA: [**Name (NI) **] [**Name (NI) **] (son): [**Numeric Identifier 52080**] (h),
[**Telephone/Fax (1) 52081**] (c). Local son: [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 48070**]
Medications on Admission:
1. Acetaminophen 325mg 1-2 tabs PO bid.
2. Erythromycin 5 mg/g Ointment 0.5 OU QID
3. Papain-Urea 830,000-10 unit/g-% Spray, 1 Spray prn for R heel
.
4. CALCIUM 500+D 1 tab PO bid
5. Folic Acid 1mg PO qD.
6. Thiamine HCl 100mg PO qD.
7. Toprol XL 25mg PO qD
8. Zinc Sulfate 220mg PO qD.
9. Ascorbic Acid 500mg PO bid
10. Mirtazapine 15mg PO qHS
11. Albuterol 1 neb q4-6h prn
12. Tamsulosin 0.4mg PO qHS.
13. Famotidine 20mg PO qD
14. Ferrous Sulfate 325mg PO qD
15. Seroquel 25mg PO bid
16. Ativan 0.5mg PO q6hr prn agitation
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
2. Erythromycin 5 mg/g Ointment Sig: 0.5 in Ophthalmic QID (4
times a day).
3. Papain-Urea 830,000-10 unit/g-% Spray, Non-Aerosol Sig: One
(1) Appl Topical [**Hospital1 **] PRN ().
4. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 2 weeks.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO
DAILY (Daily).
11. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed.
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO BID (2 times a day): The Patient MUST recieve
a PPI [**Hospital1 **] for his ulcer.
13. Iodosorb 0.9 % Gel Sig: One (1) appl Topical qd (): Please
apply to R heel with dressing change daily. This will need to be
ordered from [**Hospital 100**] Rehab.
14. Zosyn 4.5 g Recon Soln Sig: 4.5 g Intravenous every eight
(8) hours for 2 weeks.
Disp:*qs 2 weeks* Refills:*0*
15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 24H (Every 24 Hours) for 2 weeks.
Disp:*14 g* Refills:*0*
16. Heparin Flush 100 unit/mL Kit Sig: Two (2) cc Intravenous
once a day: for PICC care.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Upper GI Bleed
Urosepsis
R Heel Osteomyelitis
Discharge Condition:
stable
Discharge Instructions:
Please continue your regular medications and in addition you
will continue vancomycin and zosyn IV for your foot infection
for 2 weeks. Please follow up with Dr. [**Last Name (STitle) **], and follow up
with your PCP. [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] will follow up with you in 2 weeks
at [**Hospital 100**] Rehab. Please order Iodosorb gel to be used to dress
patient's R heel ulcer. Please make sure patient is recieving a
PPI twice daily for his duodenal ulcer, an H2 blocker is not an
acceptable substitution. Please place patient in a Kinair bed or
an equivalent to halp prevent progression of his wounds.
Followup Instructions:
1. Please arrange to have patient sent by ambulance to his
appointment: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2165-9-10**] 1:45pm, you can call [**Telephone/Fax (1) 1241**] if you have
questions. They are located on the [**Location (un) 442**] of the [**Hospital Unit Name 3269**].
2. Please also make sure pt. is seen by Dr. [**Last Name (STitle) **] when he
visits [**Hospital 100**] Rehab in 2 weeks to evaluate his wounds.
3. Please follow up with your PCP in the next 1-2 weeks as well.
ICD9 Codes: 2851, 5990, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7162
} | Medical Text: Admission Date: [**2109-12-18**] Discharge Date: [**2110-1-2**]
Date of Birth: [**2056-4-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Burr hole placement
Central lines
LP
PICC line
History of Present Illness:
53 yo F w/ Hx of HTN and obesity s/p remote gastric bypass p/w
fever, altered mental status and hypoxia. Started having
headaches about one week ago and then yesterday had nausea and
vomiting and was noted by her husband to be less responsive.
About one week ago the pt. went to her PCP and was prescribed
tetracycline for a bump on her foot which was persistently
painful. Today her husband called home to check on her because
she did not go to work and she did not answer. Her daughter
found her unresponsive and unable to breath so called 911. She
was intubated at NWH and CT head showed diffuse edema w/ near
herniation. she was given acyclovir, CTX and vancomycin. She was
noted to be febrile there to 104F. At [**Hospital1 18**] she was difficult to
oxygenate, CXR showed ARDS and her PEEP was increased to 20 w/
100% FIO2 to maintain her oxygenation.
No specific sick contacts but pt. had been complaining about
being exposed to sick people at Shaws grocery store.
In the ED, initial VS: 137, 87/54 on neo 5, 100% on FIO2 100%
and PEEP of 20. on Versed 10mg/hr, fentanyl 25mcg/hr. CMV 100%,
400x22, PEEP 20. Overbreathing. Has L fem line, R IO,
peripherals.
Past Medical History:
HTN
FMG
obesity s/p gastric bypass
Rosacea
asthma
Social History:
Patient lives with husband [**Name (NI) 11805**], who also works as a cashier
at Shaws. She quit smoking 25 years ago, denies alcohol or
illicit drug use.
Family History:
NC
Physical Exam:
On admission
Vitals - T: 100.6 BP: 100/72 HR: 128 RR: 22 02 sat: 99% on FIO2
100% PEEP 20
GENERAL: Sedated on vent
HEENT: Pupils 5->3mm w/ light, Multiple dental caries and
erythematous gums.
CARDIAC: regular, tachycardic, distant heart sounds
LUNG: diffuse inspiratory and expiratory rhonchi.
ABDOMEN: Obese, well healed midline gastric bypass scar, LTCS
scar, soft, ND
EXT: Cold, mottled skin
DERM: No rashes.
Pertinent Results:
=============
Labs
=============
Admission labs
[**2109-12-18**] 09:50PM BLOOD WBC-32.1* RBC-3.73* Hgb-11.9* Hct-37.6
MCV-101* MCH-31.9 MCHC-31.6 RDW-15.2 Plt Ct-374
[**2109-12-18**] 09:50PM BLOOD Neuts-97.2* Lymphs-1.9* Monos-0.8*
Eos-0.1 Baso-0.1
[**2109-12-18**] 09:50PM BLOOD PT-15.9* PTT-32.7 INR(PT)-1.4*
[**2109-12-18**] 09:50PM BLOOD Glucose-210* UreaN-13 Creat-0.9 Na-143
K-3.6 Cl-110* HCO3-19* AnGap-18
[**2109-12-18**] 09:50PM BLOOD Lipase-10
[**2109-12-18**] 09:50PM BLOOD CK-MB-44* MB Indx-10.2*
[**2109-12-18**] 09:50PM BLOOD Albumin-3.4 Calcium-7.8* Phos-5.6* Mg-1.9
[**2109-12-18**] 07:25PM BLOOD Glucose-172* Lactate-3.2* Na-135 K-3.5
Cl-105
===============
Micro
===============
FINAL REPORT [**2109-12-19**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2109-12-19**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2109-12-19**]):
Negative for Influenza B.
=============
Radiology
=============
CT Head [**12-18**]
Largely stable appearance of diffuse sulcal effacement and loss
of ambient
cisterns, consistent with diffuse brain edema. No new
intracranial hemorrhage or herniation.
RUQ u/s [**12-20**]
Extremely limited study due to body habitus.
Cholelithiasis with distended gallbladder. HIDA scan can be done
for further evaluation if clinically warranted.
CT Spine [**12-27**]
Technically very limited study. Pneumonic infiltrates in both
lungs, more evident on the right side. Right renal cystic mass.
Suboptimal
position of left central venous line.
CT Head [**12-27**]
No definite sign of a brain abscess. Please note that this study
is very insensitive in the detection of meningeal inflammatory
disease.
ADDENDUM: There is also mild atherosclerotic calcification of
the distal left vertebral artery at the level of the foramen
magnum
============
Cardiology
============
TTE [**12-20**]
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 10-20mmHg. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
top normal/borderline dilated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is severe global left ventricular hypokinesis
(LVEF = 20-30 %). There is no ventricular septal defect. Right
ventricular chamber size is normal. with depressed free wall
contractility. The ascending aorta is moderately dilated. The
number of aortic valve leaflets cannot be determined. The aortic
valve is not well seen. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
==============
Neurology
==============
EEG [**12-23**]
This is an abnormal portable EEG due to slowing and
disorganization of the background rhythm with periods of
semi-rhythmic
generalized moderate to high voltage theta/delta activity at
times
concerning for sharp and slow wave activity. These findings
suggest a
moderate to severe encephalopathy with underlying cortical
irritability.
Medications, toxic/metabolic disturbances, and infection are
common
causes. Although no electrographic seizures were seen during
this
recording, the rhythmic theta/delta activity is concerning for
possible
development of seizure activity and would recommend continuous
video EEG
monitoring for further characterization and evaluation. Note is
made of
an irregular rhythm with frequent PVCs.
EEG [**12-26**]
This telemetry captured no pushbutton activations. Routine
sampling showed primarily an encephalopathic background but with
many
generalized frontally predominent sharp wave epileptiform
discharges.
These were seen in isolation rather than reptitively or in an
electrographic seizure. A single suspicious event occured at
13:00 on
the afternoon of [**12-25**]. This showed a sudden appearance of
alpha
frequency activity primarily in the right central parietal area
but with
spread to the left frontal region and with an increase in
frequency over
30 seconds. By video, this was associated with apparent
hyperventilation. This raises the possibility of a single
seizure.
Otherwise, there were frequent epileptiform sharp wave
discharges but no
clear seizures.
Brief Hospital Course:
# Encephalitis/meningitis: Severe cerebral edema on CT head. LP
was performed by IR that showed with 7000 WBCs, 1000RBCS protein
645, glucose 34. Opening pressure was 37 and bolt was placed
with initial ICP 25. Patient required mannitol and hypertonic
salien with improvement to 13. The following day ICPs were
stable around 10 and the ICU team stopped hypertonic saline and
manatol. Etiology felt to be likely bacterial meninigitis but
CSF did not grow bacteria because patient was started on
antibiotics prior to fluid collection. Patient received 2 week
course of vanco/cefepime/ampicillin. Bolt was placed by
neurosurgery to decompress on admission, which was removed on
[**12-23**]. On [**12-24**] patient was found to be seizing on EEG and
dilantin was started with a bolus followed by standing Q8 hour
dosing. Plan for patient to continue dilantin until she can
follow up with neurology as an outpatient. The patient had
persistent fevers which were felt to be due to VAP and dvt (see
below). CT spine and head were performed to rule out absess
which were negative, and patient as afebrile prior to transfer
to the medicine floor.
# Respiratory failure: Patient intubated for hypoxia intially
and weaning was somewhat limited by depressed mental status and
high peep requirements due to the patients body habitus. Also
complicated by VAP which was treated with an 8 day course (see
below). Patient was eventually extubated on [**12-31**] with 2 hour
transition to CPAP prior to tolerating 2 L of oxygen later that
day. Towards the end of her ICU admission she was diuresed well
with intermittent doses of Lasix 20mg IV. She continued to
autodiurese after this likely back down to her baseline volume
status. Once on the medicine floor, she easily transitioned to
room air. She no longer has an oxygen requirement is has an
oxygen saturation of 96-98% on room air.
# RUQ pain/pancreatitis: Patient had intermittent abdominal pain
on the ventilator with mildly elevated lipase. Ultrasound was a
poor study, and patient had mildly elevated lipase. Pain
improved when patient was extubated and she told the MICU team
that pain was only related to coughing fits and likely MSK in
nature. Pain has completely resolved and the patient is
tolerating a regular diet.
# VAP: On [**12-24**], new bilateral consolidations were noted on CXR
and GNRs in the sputum. Patient was initially managed on
ceftriaxone which was increased to cefepime for a total of 8
days of vanco/cefepime for VAP treatment ending on [**2110-1-2**].
# DVT: During fever workup, LENI was positive for LLE dvt.
Patient was initially started on heparin drip followed by
coumadin. Because this was presumed to be a provoked dvt, a
hypercoagulable workup was not pursued. Her INR was found to be
supratherapeutic, and her coumadin has been held for 3 days. As
antibiotics are being discontinued on [**2110-1-2**], a rapid drop in
PT/INR may be noted. Patient will need to have coumadin
restarted at extended care facility with a goal INR of [**2-5**].
She will likely require anticoagulation for 3-6 months.
#Elevated cardiac enzymes: On admission, cardiac enzymes were
mildly elevated. There were no st elevations on EKG. Most likely
demand in the setting of sepsis. An echocardiogram was completed
that showed marked systolic heart failure with an estimated LV
EF of 20-30%. While in hospital, she was started on aspirin 81
mg, Lisinopril 5 mg PO daily, and her home atenolol was
transitioned to metoprolol
25 mg PO BID.
#Anemia: Patient was found to have hematocrit on presentation of
37.6 that drifted down to a nadir of 25.3 and currently is 29.4.
Iron studies were completed and she appears to have iron
deficiency anemia. She was restarted on her home dose of iron
and added ascorbic acid to increase absorption.
#Weakness: After extubation, patient complained of generalized
weakness. This is likely due to her long hospitalization and
deconditioning. She worked with physical therapy in hospital,
and will require aggressive physical therapy at her rehab
facility.
Medications on Admission:
FeSO4 325mg QD
Naproxen 500mg TID
Diltiazem 180mg QD
Tetracycline 500mg QD
Atenolol 25mg QD
Tylenol
Albuterol
simvastatin 20mg QHS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipatin.
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Four (4)
Capsule PO Q8H (every 8 hours).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for sob, wheeze.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for sob, wheeze.
8. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Coumadin to be dosed to maintain INR of [**2-5**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary:
- Meningoencephalitis
- Nonconvulsive seizure
- Acute systolic heart failure
- Ventilator associated pneumonia
- Left lower extremity DVT
- Pancreatitis
- Right thyroid nodule measures 3.8 x 3.2 cm
- 0.9 x 1.2 x 1.3 cm hepatic cyst
Secondary:
- Morbid obesity s/p gastric bypass [**2100**]
- Hypertension
- Hyperlipidemia
- Asthma
- Arthritis
- Fibromyalgia
- Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and Oriented
Level of Consciousness: Alert and interactive
Activity Status: Out of bed with assist
Discharge Instructions:
You were emergently transferred to this hospital from
[**Hospital3 1196**] because you were unresponsive. A tube
was placed in your airway to help you breathe, and CTs were
performed that showed severe swelling in your head.
You were initially treated in the emergency department and
received antibiotics and further tests. You were in the medical
intensive care unit for almost two weeks for a presumed
bacterial meningitis.
While on the ventilator, you were found to have a pneumonia and
were continued on your antibiotics.
While in the hospital, you also developed a blood clot in your
left leg. You were initially started on blood thinning medicine
and the began taking a medicine called coumadin to continue to
keep your blood thin. You will need to remain on this medicine
for approximately 3-6 months.
After antibiotics and further treatment, the tube was able to be
taken out of your airway. You transitioned to the floor and
were able to have several tubes removed.
During your stay, you worked with the physical therapists in
order to regain strength.
New Medications:
(1) Coumadin, dosed as needed by extended care facility to
maintain INR [**2-5**].
(2) Lisinopril 5mg by mouth once daily
(3) Metoprolol 25 mg by mouth twice daily
(4) Aspirin 325mg by mouth daily
The following medications were changed:
(1) Diltiazem 120mg by mouth daily (lower dose)
The following medications were discontinued:
(1) Atenolol 25 mg by mouth daily
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD (Infectious Disease)
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2110-1-15**] 9:50
Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. (Neurology) Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2110-1-30**] 2:00
Completed by:[**2110-1-2**]
ICD9 Codes: 2760, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7163
} | Medical Text: Admission Date: [**2190-7-6**] Discharge Date: [**2190-7-7**]
Date of Birth: [**2153-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
ethanol abuse
Major Surgical or Invasive Procedure:
none
History of Present Illness:
MICU GREEN RESIDENT ADMIT NOTE
.
CC:[**CC Contact Info 64928**].
HPI:
This is a 37 year old male with a history of alcohol abuse with
multiple attempts at detox who presented to the ED for ETOH
detox. He feels that he is currently feeling as though he is
"at the end of [his] rope." He last drank about 12-24 hours ago
and has recently been feeling as though alcohol does not make
him feel better. He self-referred himself to the ED to "get the
alcohol out of my system." In the ED he felt shaky,
diaphoretic, and nauseous, consistent with his usual sypmtoms of
withdrawl. Per ED report, he was combative and required an
intermittent 1:1 security sitter.
.
He was in the ED for approximately 14 hours prior to being
admitted to the MICU. Initial EDVS HR 109 177/97 and afebrile.
He received a total of 10 mg of ativan during his stay in the
ED. HE also received a banana bag and 2 L IVF. In the MICU he
reports that he still feels shaky, and nauseous, though somewhat
improved. He denies any other ingestiosn.
.
He reports that he drinks about 1 pint of vodka per day for over
20 years. He considers himself a binge drinker, drinking
heavily for several days at a time, but not necessarily on a
daily basis. He reports having had multiple episodes of "DTs."
When asked to describe these DTs, he describes them as periods
of "sweating, shaking, and sometimes hallucinations" that
self-resolve over the course of a few days. He has had one
seizure event many years ago, that he believes was related to
his ETOH.
.
PMH:
Alcohol abuse and dependence: At [**Hospital1 **] for detox about [**3-2**]
months prior. He completed detox and then began drinking again
soon afterwards.
Suicide attempt in [**12-3**], requiring inpt psych admisison
Depression: He has a counselor/therapist that he used to see at
the [**Hospital3 33953**] Community Center. He had been on prozac and
seroquel until he stopped going to his therapy sessions a few
months ago.
.
Medications:
None
.
Allergies:
NKDA
.
Social Hx:
Born in [**Location (un) 3678**], MA. Lives alone, 1PPD x 20 years, denies
illict drugs.
.
Family Hx:
Mother- alcohol dependence
.
PE:
VS: 158/110 HR 103 Afebrile 97% RA RR 12
GEN: Awake, alert, oriented x 3
HEENT: AT, NC, PERRLA, EOMI. Neck supple, no LAD.
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL, right lower extremity large
ecchymoses, multiple scars and superficial lacerations
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
asterixis
PSYCH: Slow speech, at times tangential, flat affect
.
LABS:
See below
.
Imaging:
None
.
Brief Hospital Course:
37 year old male with a history of alcohol abuse and dependence
who presents for alcohol detoxification. Pt. left AMA
.
Alcohol abuse, dependence: With BAL 411, significant history of
ETOH withdrawl. Given nausea and difficulty tolerating POs,
will give IV ativan (less corrosive to veins than IV valium).
He was transitioned to PO valium. He left AMA.
.
Elevated Anion gap: Anion gap of 18. Suspect ketoacidosis
secondary to alcohol binge, supported by ketones in urine.
Denies other toxin ingestion. There was no osmolality gap.
.
Depression: Difficult to assess for primary psychiatric illness
at this time in the setting of active withdrawal.
.
History of suicide attempt: pt. explicitly denied any wish or
plan of self harm.
.
#CODE: FULL
.
#COMMUNICATION: patient
.
#DISPO: pt left ama
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
ethanol abuse
Discharge Condition:
ama
Discharge Instructions:
pt. left ama
Followup Instructions:
ama
Completed by:[**2190-7-7**]
ICD9 Codes: 2762, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7164
} | Medical Text: Admission Date: [**2201-5-12**] Discharge Date: [**2201-6-5**]
Date of Birth: [**2201-5-12**] Sex: M
Service: Neonatology
IDENTIFICATION: Baby [**Name (NI) **] [**Known lastname 1794**] is a 24 day old former 35 [**4-28**] wk
premature infant with a history of respiratory distress syndrome
and apnea of prematurity who is being discharged from the [**Hospital1 18**]
NICU.
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 1794**] is a 3.8 kg
product of a 35 [**4-28**] week gestation born to a 28-year-old G2, P1,
woman with history of type 1 diabetes. Prenatal screens were
unremarkable, and included blood type A positive, antibody
negative, hepatitis surface antigen negative, RPR nonreactive,
rubella immune, GBS unknown. Pregnancy was reportedly
unremarkable. Mother presented on day delivery with lower
abdominal pain, and ultrasound suggested a thin-walled uterus.
With her history of diabetes and prior c-section, mother was
considered to be at high risk of uterine dehiscence, and she was
taken for elective c-section.
At delivery, attended by L&D staff and anesthesia, patient
required brief positive pressure ventilation, with Apgars of 6
and 8. The NICU NNP was called to the delivery room
at approximately 10 to 15 minutes of age for respiratory
distress. The patient was pink in room air with mild
grunting, flaring, retracting. He was brought to the newborn
intensive care unit after visiting with parents.
PHYSICAL EXAMINATION AT ADMISSION:
WT 3810 gm (>90%) HC 35 cm (>90%) L 57 cm (>90%).
GEN: well perfused, well-saturated on blow-by oxygen.
SKIN: without lesions.
HEENT: Within normal limits.
CARDIOVASCULAR: Normal S1 and S2 without murmurs.
LUNGS: Coarse equal breath sounds bilaterally. Mild to
moderate grunting, flaring, retracting on cannula.
ABDOMEN: Benign
GENITALIA: Normal male. Anus patent.
HIPS: Normal.
NEUROLOGIC: Nonfocal and age appropriate.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The infant was admitted to the newborn intensive
care unit. He was on nasal cannula briefly with increased oxygen
requirements, and was transitioned quickly to CPAP. He continued
to have increased oxygen requirements. Chest x-ray was consistent
with moderate hyaline membrane disease. The infant was intubated
and received 1 dose of surfactant. He was extubated within the
first 24 hours of age to nasal cannula oxygen which he remained
on for a total of 4 days. He has subsequently been on room air
without evidence of respiratory distress. The infant has had mild
apnea/bradycardia events,
with the most recent episode of apnea/bradycardia on [**2201-6-1**]. These events have been mild, occasionally requiring
stimulation but mostly self-resolving and characterized by brief
dips in heart rate and oxygen saturation. They are presumed to
be secondary to apnea of prematurity or immaturity of respiratory
control. She has not received methylxanthine treatment.
CARDIOVASCULAR: The infant remained hemodynamically stable
throughout hospital course. A murmur was noted to develop,
thought to be most with consistent with persistent pulmonary
stenosis. CXR, EKG, 4-extremity BP, and hyperoxia test were all
within normal limits.
FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was 3.91 kg.
The infant was started on 60 cc per kg per day of D10W.
Enteral feedings were initiated on day of life 3. The infant was
gradually advanced to PO ad lib feedings, taking in adequate
amounts of BM 20 with appropriate weight gain. His discharge
weight is 4110 gm. Infant was started on tri-vi-[**Male First Name (un) **].
GASTROINTESTINAL: Peak bilirubin was on day of life 5 of
15.4/0.4. He received phototherapy for a total of 24 hours at
which time it was discontinued and he has had no further
issues. Last bilirubin was 8.5/0.3 on day of life 7.
HEMATOLOGY: Hematocrit on admission was 47.8. He has not
required any blood transfusions.
INFECTIOUS DISEASE: CBC and blood culture were obtained on
admission. CBC was benign and blood cultures remained
negative after 48 hours at which time ampicillin and
gentamycin were discontinued. The infant has had no further
issues with sepsis.
NEUROLOGIC: He has been appropriate for gestational age.
SENSORY: Hearing screen has been performed with automated
auditory brain stem responses and the infant passed in both
ears.
PSYCHOSOCIAL: A social worker has been involved with this
family. The contact social worker is [**Name (NI) **] [**Name (NI) **] and can
be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Location (un) 64028**].
Telephone No. [**Telephone/Fax (1) 64029**].
CARE RECOMMENDATIONS: Continue ad lib feeding breast milk.
MEDICATIONS: Continue Tri-vi-[**Male First Name (un) **].
CAR SEAT POSITION SCREEN: Car seat position screening was
performed and the infant passed with 90-minute screen.
THE STATE NEWBORN SCREEN: The last State Newborn Screen was
sent on [**2201-5-26**] and was within normal limits.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2201-5-20**].
DISCHARGE DIAGNOSES: 35 and 6/7 weeks infant.
Respiratory distress syndrome treated with surfactant.
Rule out sepsis with antibiotics.
Mild hyperbilirubinemia.
Apnea/bradycardia of prematurity.
Murmur, likely peripheral pulmonic stenosis.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Name8 (MD) 64030**]
MEDQUIST36
D: [**2201-6-4**] 23:33:36
T: [**2201-6-5**] 01:46:04
Job#: [**Job Number 64031**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7165
} | Medical Text: Admission Date: [**2117-11-28**] Discharge Date: [**2117-12-10**]
Date of Birth: [**2117-11-28**] Sex: M
Service: NEONATOLOGY
HISTORY OF THE PRESENT ILLNESS: This is an interim dictation
summary covering the time course from [**2117-11-29**] to [**2117-12-10**].
The patient is a term newborn with features consistent with
trisomy 21 who was transferred to the NICU for evaluation of
possible cardiac disease. The mother is a 37-year-old G3,
P2-3, apparently uncomplicated gestation. No notations of
features consistent with Down's syndrome on the antenatal
ultrasound. No karyotype noted. Birth weight 3,725 grams.
PHYSICAL EXAMINATION ON ADMISSION: Dysmorphic consistent
with trisomy 21 including a flattened occiput, low-set ears,
upslanting palpebral fissures, palmar creases, hypoplastic
nipples, axial hypotonia, Brushfield's spots not examined.
Room air saturations in the high 90s. Lungs: Clear. Heart:
Normal S1, loud S2, grade I/VI systolic ejection murmur at
the middle left sternal border. No diastolic murmur noted.
Pulses normal. Abdomen: Benign. Genitalia: Normal male.
Neurologic: Notable for generalized hypotonia.
Spine intact. Hips normal.
HOSPITAL COURSE: 1. RESPIRATORY: The patient was initially
on nasal cannula 02 as high as 3 liters, gradually weaned on
02 requirement and the patient was weaned to room air on
[**2117-12-6**]. The patient was noted to have upper airway
congestion felt to be inhibiting ability to p.o. feed. The
patient was started on Neo-Synephrine nasal drops on [**2117-12-6**]
and was continued for three days. Also started on [**2117-12-7**]
on dexamethasone ophthalmic drops to the nose for three days.
Currently receiving no intranasal treatment. The upper
airway congestion improved remarkably with this treatment.
Currently, one day off of all nasal treatment with no
rebound-effecting congestion seen.
2. CARDIAC: The patient is with low oxygen saturations
noted in the Newborn Nursery including desaturations with
crying and with feeding. Echocardiogram performed on the
date of admission to the NICU which revealed a common AV
canal and pulmonary hypertension. Cardiology was consulted
and involved throughout. Symptoms of pulmonary hypertension
gradually resolved and the patient with evidence of fluid
overload beginning on [**2117-12-8**]. The patient was started on
q.o.d. Lasix with a good response. Planned for surgical
repair at six months of age.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: Initially n.p.o. on
IV fluids at 60 cc per kilogram per day; p.o. feeds initiated
on day of life number four and tolerated well. The patient
advanced rapidly to full feeds and calories advanced for
growth. Currently on 150 cc per kilogram per day of breast
milk 26. Initially with poor p.o. intake; however, p.o.
intake improving in the past several days, currently taking
about two-thirds of feeds p.o. Glucose was monitored and
remained stable throughout, maintaining good urine output
throughout. Electrolytes on [**2117-12-1**] revealed a sodium of
140, K 4.4, chloride 104.
4. HYPERBILIRUBINEMIA: The bilirubin levels were monitored.
The bilirubin peaked at 16.1/0.4 on day of life number four
and the patient was started on phototherapy. The
phototherapy was discontinued on [**2117-12-6**] with a bilirubin of
8.0/0.3.
5. HEMATOLOGY: Crit 66.2% on admission. The patient has
not required any blood products.
6. INFECTIOUS DISEASE: CBC and blood cultures sent on
admission. White count 16.8 with 72 polys and 6 bands,
platelets 263,000. The patient was not treated with
antibiotics. Blood cultures revealed no growth.
7. GENETICS: The Genetics Team was consulted given features
consistent with trisomy 21. The initial FISH suggestive of
trisomy 21 and final chromosomes with 47 XY, consistent with
trisomy 21. Genetics met with the family as well as the
[**Hospital 10814**] Clinic Program from [**Hospital3 1810**]. The dad has
been doing extensive [**Location (un) 1131**] on the topic.
8. PSYCHOSOCIAL: [**Hospital1 18**] Social Work was involved with the
family. The contact social workers name is [**Name (NI) **] and she
can be reached at [**Telephone/Fax (1) 8717**].
DR.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 50-477
Dictated By:[**Last Name (NamePattern1) 50027**]
MEDQUIST36
D: [**2117-12-10**] 06:13
T: [**2117-12-10**] 19:02
JOB#: [**Job Number 50733**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7166
} | Medical Text: Admission Date: [**2153-1-16**] Discharge Date: [**2153-1-19**]
Date of Birth: [**2079-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Respiratory depression.
Major Surgical or Invasive Procedure:
[**Hospital1 **]-ventricular ICD upgrade
History of Present Illness:
73yoM retired surgeon with history of Parkinson's disease (?
diffuse [**Last Name (un) 309**] body disease), HTN, DM, systolic HF (EF 20% in
[**11-4**]), history of CVA (residual left visual field cut), AF s/p
AVN ablation and pacer, admitted initially to CMI for BiV ICD
placement [**1-15**], with post-procedure admission planned for
heparin-coumadin (indication for anticoagulation AF - CVA).
Intra-procedure, received haldol 5 mg IV, fentanyl 200 mg IV,
and versed 1.5 mg IV and noted to be poorly responsive to
commands and low RR in recovery area; [**Hospital Unit Name 196**] called to evaluate.
VBG at that time 52/46/7.37. At 1 hr post-procedure, patient
began to become more responsive to commands and increased level
of consciousness.
Patient being transfer to CCU for observation of his clinical
status.
Past Medical History:
1. Parkinsons Disease. ? LBD
2. DM II
3. HTN
4. Autonomic dysfunction-hx of orthostatic hypotension. Treated
with Florinef in the past, was d/c'd due to fluid retention.
Restarted [**5-4**].
5. CAD- s/p MI in [**2120**], s/p CABG
6. CHF- Echo [**11-4**]-: Regional LV wall motion abnormalities
include: basal anteroseptal - akinetic; mid anteroseptal -
akinetic; basal inferoseptal -akinetic; mid inferoseptal -
akinetic; basal inferior - akinetic; mid inferior- akinetic;
basal inferolateral - akinetic; mid inferolateral - akinetic;
septal apex- akinetic; inferior apex -akinetic; [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**]
dilated. RA is moderately dilated.
The left ventricular cavity is moderately dilated. There is
severe global left ventricular hypokinesis. Overall left
ventricular systolic function is severely depressed (EF <20)
7. Stroke [**11-2**]- right PCA, residual left field cut
8. Sick Sinus syndrome, s/p PCM
9. A.fib/SVT, s/p ablation
[**56**]. Hypercholesterolemia
11. Cervical stenosis
12. H/o back pain and L1 compression fxr
13. Anemia
14. h/o prostate CA, s/p [**Year (2 digits) 16859**] ([**2146**]) and hormonal tx
15. h/o renal stones and s/p lithotripsy
16. s/p appy
Social History:
Lives with his wife. There is becoming an increasingly difficult
situation due to the need for live-in/24 hr care at home. There
is an
ongoing dialogue about this, but no plans have been made
definitively. He is a retired physician. [**Name10 (NameIs) **] [**Name11 (NameIs) **], occasional
EtOH.
Family History:
HTN, colon ca, Parkinson's
Physical Exam:
VS: T BP 133/76 HR 80 RR 19 Sats 97 RA
Gen: patient somnolent, slowly responds to questions.
HEENT: no JVD, no LAD
Chest: Left side pacemaker poket with compression dressing,
small hematoma,
Lungs: clear to auscultation b/l, no crackles or wheezes
Cardiovascular: RRR, s1-s2 normal, holosytolic murmur in the
apex
Abdomen: Bowel sounds +, non tender, non distended.
GU: condom catheter in place
Extremities: no LE edema, right groin site clean, no ozzing.
peripheral pulses upper and lower extremities normal.
Neuro: a&ox3, cn ii-[**Doctor First Name **] intact; resting tremor.
Pertinent Results:
[**2153-1-16**] 07:30AM BLOOD WBC-6.1 RBC-4.43* Hgb-12.3* Hct-37.1*
MCV-84 MCH-27.8 MCHC-33.2 RDW-14.8 Plt Ct-147* Neuts-76.4*
Lymphs-17.9* Monos-4.7 Eos-0.8 Baso-0.2
[**2153-1-16**] 07:25AM BLOOD INR(PT)-1.6
[**2153-1-16**] 07:30AM BLOOD Glucose-92 UreaN-19 Creat-1.2 Na-145
K-4.0 Cl-107 HCO3-27 AnGap-15
[**2153-1-16**] 09:28PM BLOOD ALT-15 AST-21 LD(LDH)-236 AlkPhos-56
TotBili-1.0
[**2153-1-16**] 07:30AM BLOOD Digoxin-0.6*
[**2153-1-16**] 09:28PM BLOOD Phos-4.6* Mg-1.8
[**2153-1-16**] 05:39PM BLOOD Lactate-1.3
.
[**2153-1-16**] 09:28PM Hct-30.3*
[**2153-1-17**] 06:07AM Hct-27.5*
[**2153-1-17**] 05:00PM Hct-24.8*
[**2153-1-18**] 10:45AM Hct-29.4*
[**2153-1-18**] 04:38PM Hct-28.0*
.
[**2153-1-17**]:
CHEST PA AND LATERAL.
Compared to the prior radiograph obtained yesterday, there is
decreased CHF. There is mild cardiomegaly. There are small
bilateral effusions, more on the left. The new biventricular
pacer device is seen in the left hemithorax. The pacer leads are
seen in the right atrium and two in the floor of the right
ventricle. The previous abandoned right pacer leads are also
seen in the right atrium and right ventricle. No pneumothorax.
Persistent left lower lobe atelectasis/consolidation.
IMPRESSION:
1. Improving CHF.
2. Small bilateral layering pleural effusions, more on the left.
3. Persistent left lower lobe atelectasis/consolidation.
4. Good position of the new biventricular pacer device.
.
[**2153-1-17**]:
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no intra- or extra-axial hemorrhage. The
appearance of
the ventricles, cisterns, and sulci is unchanged. There is no
mass effect,
hydrocephalus, or shift of the normally midline structures. The
[**Doctor Last Name 352**]-white
matter differentiation is preserved.
The visualized mastoid air cells are clear. Again noted is sinus
mucosal
thickening bilaterally in the maxillary sinuses, not fully
characterized here.
IMPRESSION:
1. Similar sinus mucosal thickening.
2. No evidence of significant interval change.
3. Similar appearance of the brain including prominent
encephalomalacic
changes in the right occipital lobe, and possibly in the left
occipital lobe as well.
.
[**2153-1-17**]:
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is a biventricular
pacemaker in place, not fully characterized here, and evidence
of prior sternotomy. There are large bilateral pleural effusions
with adjacent areas of compressive atelectasis. Otherwise, the
lung bases are clear.
Within the limitations of the non-contrast study, the liver,
gallbladder,
pancreas, spleen, and adrenal glands are within normal limits. A
7-mm
nonobstructing stone is again visualized in the left kidney, as
well as a 12 mm stone in the left renal pelvis. These are
unchanged. A small new 2- mm nonobstructing stone is now seen in
the right kidney. Left-sided
hydronephrosis has resolved. Within the limitations of the
non-contrast study, the appearance of the kidneys is otherwise
unremarkable.
There is calcification of the abdominal aorta, and of the
splenic artery. The stomach, small and large bowel are
unremarkable. There is no retroperitoneal or mesenteric
lymphadenopathy, or free air or fluid.
Along the anterior left lateral ribs at the base of the chest,
there is a soft tissue density, not fully characterized here,
which may represent a small hematoma or inflammatory stranding
from recent pacer placement. Its
extent is not delineated here. There is no evidence of a
retroperitoneal
hematoma.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is considerable
amount of stool in the rectum. The prostate, seminal vesicles,
and bladder are within normal limits. There is a 5-mm calcific
density in the distal left ureter, which could represent a
nonobstructing stone. It was not seen previously.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
Degenerative changes of the lumbar spine are seen.
IMPRESSION:
1. Large bilateral pleural effusions.
2. Possible hematoma along the left basal chest wall, in the
subcutaneous
tissues, not fully evaluated here.
3. No evidence of retroperitoneal hematoma.
4. Multiple nonobstructing stones in the kidneys bilaterally, as
well as a 6- mm calcific density in the left pelvis, which may
represent a nonobstructing renal stone in the left ureter.
.
[**2153-1-18**]:
TECHNIQUE: Left upper extremity venous ultrasound and Doppler
examination,
and limited evaluation of the subcutaneous tissues of the left
upper
hemithorax.
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the left internal
jugular,
axillary, basilic, and paired brachial veins show no evidence of
deep vein
thrombosis. Because of the presence of the overlying pacer, the
left
subclavian vein could not be evaluated. No intraluminal thrombus
is
identified.
In the tissues overlying the pacemaker, there is heterogeneous
appearance,
which may represent postoperative change, but the presence of
hematoma cannot be excluded. No large discrete fluid collection
is identified. Laterally, near the insertion of the pectoralis
major muscle, the appearance suggests either edematous muscle or
complex fluid, but the static images presented are
indeterminant.
IMPRESSION:
1. Heterogeneous tissue in the region of the pacer, which is
indeterminant in etiology.
2. Suggestion of edematous left pectoral muscle and/or complex
fluid,
suggested by resident review in real time scanning. However on
the static
images, it is difficult to discern the relationship between the
muscle, the adjacent heterogeneous soft tissue, and the pacer.
A followup ultrasound for evaluation and comparison, or
alternatively a CT, which may show an area of hyperdensity to
correspond to an acute hematoma if present, is suggested.
.
Day of discharge labs:
[**2153-1-19**] 07:30AM BLOOD WBC-9.9 RBC-3.26* Hgb-10.0* Hct-27.6*
MCV-85 MCH-30.5 MCHC-36.0* RDW-15.6* Plt Ct-116*
[**2153-1-19**] 07:30AM BLOOD PT-14.4* PTT-31.8 INR(PT)-1.4
Brief Hospital Course:
A 73yoM with parkinson disease, HTN, DM, systolic HF (EF 20% in
[**11-4**]), history of CVA (residual left visual field cut), AF s/p
AVN ablation and pacer, inmediate s/p BiV pacer upgrade with
slowly recover after sedation transfer to CCU for monitoring.
After the haldol wore off, mental status was felt to return to
baseline. Of note, hematocrit was noted to drop on the day of
procedure. CT abd/Pelvis was done and was negative for
retroperitoneal bleed. Left upper extremity also noted to be
more swollen on [**1-18**] and ultrasound was performed which was
negative for DVT.
# mental status change: Patient likely sensitive to sedation,
requiring , more alert, able to follow simple commands. He is
able to movilize all extremities, still somnolent. more likely
given his baseline disease, he is more sensitive to sedation.
Patient seemed to recover in the 10-12 hours post-sedation.
Head CT was performed and was negative for intracranial bleed.
Neurology was consulted and agreed that mental status changes
likely to haldol being given.
.
1. Parkinson's disease: will continue home medications sinemet,
mirapex and pramipexol.
2. CV:
Rhythm: h/o Afib - heparin bridge to coumadin. Heparin was
stopped in setting of hematocrit drop and restarted on [**2153-1-19**].
S/P BiV pacer- he was given Vancomycin Iv x 3 doses.
AV paced
Carvedilol continued for rate control
Pace maker checked on [**2153-1-19**].
Pump: EF 17% on MIBI, currently euvolemic. Will continue
Carvediolol and Furosemide home dose and digoxin. We will
recommend to discusse with your primary cardiologist regarding
Ace inhibitor medications
CAD: continue aspirin, statin, Carvedilol
3. Heme: On admission Hct noted to be 37. This was likely
hemoconcentrated as Hcts from 3 weeks prior were 31-32.
However, given Hct decrease to 25, CT scan of Abd/Pelvis and
including upper thighs done and negative for hematoma or bleed.
He was tranfused 2 units of pRBCs and Hct increased. Hematocrit
should be monitored on an outpatient basis.
4. left upper extremity swelling: noted on [**1-18**]. Concern for
DVT or bleed. Ultrasound of upper extrmity done and negative for
DVT.
5. GERD: Continue Pantoprazole
6. FENA: Cardiac healthy -diabetic diet.
7. Dispo: to rehab. Patient should have Hematocrit checked on
[**1-22**] (Hct 27.6 on [**1-19**]). Left upper extremity swelling seems to
be resolving. His left arm may be elevated to decrease
swelling, but is not to be elevated above shoulder level given
new biVentricular pacemaker placement.
Full code
Medications on Admission:
Carbidopa-Levodopa 25-100 mg qAM
Carbidopa-Levodopa 25-100 mg qHS
Acetaminophen 325 mg q4-6h
Carbidopa-Levodopa 50-200 mg Q6H
Mirapex 0.25 mg TID
Fluoxetine 20 mg QD
Fludrocortisone 0.2 mg QD
Donepezil 5 mg qHS
Pantoprazole 40 mg/ QD
Carvedilol 12.5 mg [**Hospital1 **]
Clonazepam 0.5 mg Qhs bedtime
Digoxin 125 mcg Tablet daily
Provigil 100 mg Tablet/ qd
Atorvastatin 10 mg Tablet QD
Furosemide 20 mg Tablet QD
Aspirin 81 mg Tablet, QD
Warfarin 5 mg Tablet qhs
Modafinil 200 mg ebery morning.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
5. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig:
One (1) Tablet PO QID (4 times a day).
8. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig:
One (1) Tablet PO 2200 ().
9. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for 4 days.
12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia. Tablet(s)
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Bupropion 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
15. Modafinil 100 mg Tablet Sig: One (1) Tablet PO once a day.
16. Potassium Chloride 20 mEq Packet Sig: Two (2) PO once a
day.
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
s/p pacemaker placement
Parkinson's disease
Discharge Condition:
stable
Discharge Instructions:
You need to have your PT/INR level checked in 3 days for
coumadin titration and a serum creatinine checked in one week
(because of numerous renal stones that could obstruct your urine
output and harm your kidneys).
Please have your hematocrit checked on [**1-22**] (3 days after
discharge), please have these results sent to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] office, ([**Telephone/Fax (1) 9530**].
Followup Instructions:
Please call Dr[**Name (NI) 8996**] office to make an appointment in [**2-2**]
weeks. ([**Telephone/Fax (1) 103173**]) [**Hospital Ward Name **] 4
.
Please call Dr.[**Name (NI) 10444**] office on ([**Telephone/Fax (1) 63315**] to scheduled
an appointment in the next 1-2 months or earlier if indicated.
Completed by:[**2153-1-19**]
ICD9 Codes: 4280, 2859, 412, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7167
} | Medical Text: Admission Date: [**2176-5-31**] Discharge Date: [**2176-6-7**]
Date of Birth: [**2095-12-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2176-5-31**] - Coronary artery bypass grafting x3: Left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft, diagonal branch of the posterior
descending artery.
[**2176-6-1**] - Re-exploration for bleeding
History of Present Illness:
80 year old very active man was recently referred for stress
testing after complaining of occasional exertional chest
heaviness. He exercises on the
treadmill for one hour a day. Occasionally he will notice mild
chest heaviness after 30-40 minutes. This easily resolves when
slowing down. He has also noticed that his exercise routine is a
little bit more difficult to do than it had been in the past.
Nuclear stress testing has revealed inferolateral ischemia with
a normal LVEF. He was then referred for a cardiac
catheterization
which revealed two vessel coronary artery disease. He presents
today for surgical evaluation.
Past Medical History:
Past Medical History
-Hypertension
-Hyperlipidemia
-Moderate mitral regurgitation
-Trace guaiac positive stool s/p treatment for H Pylori and
Colon
polypectomy [**2175**]
-Histoplasmosis (remote)
Past Surgical History
-s/p Resection of basal cell carcinoma (nose)
-s/p Remote L5 back surgery
-s/p Resection of pilonidal cyst
-s/p Trigger finger release bilaterally x 2
-Tenosynovitis of hand s/p surgery
-s/p Cataract surgery bilaterally [**2173**]
-s/p Ptosis eyelid surgery
-s/p Tonsillectomy
Social History:
Lives with: Wife
Occupation: Retired. Previously employed in finance.
Tobacco: Quit pipe in [**2147**], quit cigarettes in [**2133**].
ETOH: [**1-21**] glasses of wine per night
Family History:
Non-contributory
Physical Exam:
Pulse: 54 Resp: 16 O2 sat: 98%
B/P Right: 123/80 Left: 132/83
Height: 6'1" Weight: 147 lb
General: Well-developed male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] +BS [X]
Extremities: Warm [X], well-perfused [X] Edema: none
Varicosities: superficial
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:
[**2176-5-31**] ECHO
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The RV systolic function
is normal.
The ascending aorta is mildly dilated. There are simple atheroma
in the descending thoracic aorta. No thoracic aortic dissection
is seen.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Mild (1+) aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened and appear mildly
tethered. Mild to moderate ([**1-21**]+) central mitral regurgitation
is seen.
POST-CPB:
The LV systolic function remains normal. The MR remains mild to
moderate. The TR is mild to moderate. There is no evidence of
dissection.
Dr. [**Last Name (STitle) **] was notified in person of the results at time of
study.
Admission
[**2176-5-31**] 07:46AM HGB-13.7* calcHCT-41
[**2176-5-31**] 07:46AM GLUCOSE-98 LACTATE-2.0 NA+-137 K+-3.6 CL--100
[**2176-5-31**] 12:11PM FIBRINOGE-209
[**2176-5-31**] 12:11PM PT-14.4* PTT-35.6* INR(PT)-1.2*
[**2176-5-31**] 12:11PM PLT COUNT-135*
[**2176-5-31**] 12:11PM WBC-11.4*# RBC-2.92*# HGB-9.3*# HCT-26.7*#
MCV-92 MCH-31.8 MCHC-34.8 RDW-12.6
[**2176-5-31**] 01:36PM UREA N-16 CREAT-0.8 SODIUM-141 POTASSIUM-3.7
CHLORIDE-107 TOTAL CO2-26 ANION GAP-12
Discharge
[**2176-6-4**] 04:36AM BLOOD WBC-10.4 RBC-3.49* Hgb-10.4* Hct-30.5*
MCV-88 MCH-29.9 MCHC-34.2 RDW-16.9* Plt Ct-222#
[**2176-6-4**] 04:36AM BLOOD Plt Ct-222#
[**2176-6-4**] 04:36AM BLOOD PT-13.0 INR(PT)-1.1
[**2176-6-4**] 04:36AM BLOOD Glucose-117* UreaN-24* Creat-1.1 Na-139
K-4.0 Cl-100 HCO3-35* AnGap-8
[**2176-6-3**] 01:18AM BLOOD ALT-16 AST-40 LD(LDH)-203 AlkPhos-44
TotBili-2.6*
[**2176-6-3**] 01:18AM BLOOD Albumin-3.4* Calcium-8.2* Phos-2.4*
Mg-2.3
Radiology Report CHEST (PA & LAT) Study Date of [**2176-6-4**] 9:05 AM
FINDINGS: As compared to the previous radiograph, the lung
volumes have
slightly decreased. Bilateral small areas of pleural effusions
with
subsequent areas of atelectasis. Moderate cardiomegaly without
pulmonary
edema. No evidence of pneumonia. No pneumothorax. Unchanged
position and
course of the right internal jugular vein catheter.
Brief Hospital Course:
Mr. [**Known lastname 39477**] was admitted to the [**Hospital1 18**] on [**2176-5-31**] for
surgical management of his coronary artery disease. He was taken
directly to the operating room where he underwent coronary
artery bypass grafting to three vessels. Please see the
operative report for details. In summary he had:
Coronary artery bypass grafting x3: Left internal mammary artery
graft to left anterior descending, reverse saphenous vein graft,
diagonal branch of the posterior descending artery.
Postoperatively he was taken to the intensive care unit for
monitoring. He extubated and was hemodynamically stable. On POD1
and the nurse noted acute bleeding into the chest tube system,
he was taken emergently to the operating room where he
underwent a re-exploration for bleeding. During this episode he
had: mediastinal
re-exploration with closure of perforation in the right vein
graft. Hemostasis was acheived and he was returned to the
intensive care unit for monitoring. He awoke neurologically
intact and was extubated. Beta blockade, aspirin and a statin
were resumed. During the post-op course he developed atrial
fibrillation and was treated with amiodarone after which he
converted to normal sinus rhythm. On postoperative day three, he
was transferred to the step down unit for further recovery. He
was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. Abx started for phlebitis.
He continued to make steady progress and was discharged home on
postoperative day 6.
All follow-up appointments were advised.
Medications on Admission:
Norvasc 2.5mg daily, Hydrochlorothiazide 25mg daily, Isosorbide
mononitrate 30mg daily, Crestor 40mg daily, Toprol XL 25mg,
aspirin 162mg daily, Multivitamin daily, Omega-3 fatty acids
daily, SL Nitro prn
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 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:*2*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg daily x1 wk then 200mg daily.
Disp:*35 Tablet(s)* Refills:*1*
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
11. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 2 weeks.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
13. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
14. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-21**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*2 bottles* Refills:*0*
15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for pruitis.
Disp:*2 bottles* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA
Discharge Diagnosis:
-Coronary artery disease
- phlebitis
-Hypertension
-Hyperlipidemia
-Moderate mitral regurgitation
-Trace guaiac positive stool s/p treatment for H Pylori and
Colon
polypectomy [**2175**]
-Histoplasmosis (remote)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol and Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema-trace bilat
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
***Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time: [**2176-6-27**] 1:15
Cardiologist: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2176-7-5**]
9:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 2912**] [**Telephone/Fax (1) 8543**] in [**4-23**] 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:[**2176-6-6**]
ICD9 Codes: 4019, 2724, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7168
} | Medical Text: Admission Date: [**2128-3-5**] Discharge Date: [**2128-3-15**]
Date of Birth: [**2054-12-30**] Sex: F
Service: MEDICINE
Allergies:
Captopril / Sulfa (Sulfonamide Antibiotics) / Simvastatin /
Neurontin / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 69390**]
Chief Complaint:
acute on chronic renal failure
Major Surgical or Invasive Procedure:
Right swan catheter placement s/p removal
Right temporary dialysis line placement s/p removal
Right internal jugular tunneled dialysis line placement
History of Present Illness:
73 yr old patient with chronic CHF r/t non ischemic dilated
cardiomyopathy, EF 20%, CRF from h/o renal cell carcinoma,
mono-clonal gamopathy, htn, no acute indication for HD.has an
AICD for primary prevention. She is transferred from [**Hospital1 882**]
for management of acute on chronic renal faillure.
.
In [**Month (only) **] was admitted to [**Hospital1 **] for back pain and
incidentally found to have gallbladder stones. On that
admission she was treated with vand and unasyn followed by
Augmentin for a total of a 10 day course end [**2128-3-2**] for GB PPX
and UTI. She was discharged to rehab.
.
She then was re-presented to [**Hospital1 **] with nausea, vomiting x6
episodes NBNB and diarhea, and renal failure thought to be
secondary to dehydration. ERCP was planned at [**Hospital1 112**]; however,
this was cancelled secondary to renal failure. She was
transferred to [**Hospital1 18**] for further management. Of note her
Creatinine on admission was 3.5 and is now up to 4.5 (baseline
2.5-3.0). Given her history the initial though was that she was
dry and they gave her 750cc NS, however her creatinine went up.
Thinking she was suffering from poor forward flow in the setting
of her volume overload she was restarted on her torsemide with
worsening of her renal function. The patient has never been
dialyzed and has no acute indication.
.
She was transferred to the [**Hospital1 **] for further management, though why
cardiology is unclear.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
DM (last A1c 7.6)
Renal cell carcinoma s/p nephrectomy [**2119**]
MGUS vs Myeloma
CRI (baseline 2.5 --> 4.49)
Pacemaker
Gout
Right nephrectomy
Pyleonephritis
Hyperlipidemia
Ischemic Cardiomyopathy (EF 20 %)
Hypertension
Osteoporosis
Chronic back pain (on fentanyl)
h/o pyelo c/b urosepsis
Social History:
No tobacco, alcohol, or drugs. She is married and lives with
family.
Family History:
No cardiovascular history
Physical Exam:
VS: T=97.5 BP=103/62 HR=59 RR=18 O2 sat=91%RA
GENERAL: WDWN W in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of beyond jawline cm.
CARDIAC: AICD, Pacer in place PMI laterally displaced 5th
intercostal space, midclavicular line. RR, normal S1 early
crescendo decrescendo murmure no S2. No No thrills, lifts. No
S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse crackles noted
ABDOMEN: Obese Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: Edematous to thighs, but non-pitting
SKIN: several echymoses noted.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Pertinent Results:
I. Labs
A. Admission
[**2128-3-6**] 01:19AM BLOOD WBC-5.3 RBC-3.36* Hgb-11.1* Hct-32.8*
MCV-98 MCH-32.9* MCHC-33.7 RDW-14.3 Plt Ct-309
[**2128-3-6**] 01:19AM BLOOD Glucose-118* UreaN-123* Creat-5.1*#
Na-130* K-4.2 Cl-96 HCO3-17* AnGap-21*
[**2128-3-6**] 01:19AM BLOOD ALT-222* AST-146* LD(LDH)-276* CK(CPK)-45
AlkPhos-191* TotBili-0.7
[**2128-3-6**] 01:19AM BLOOD Albumin-3.8 Calcium-8.7 Phos-6.9* Mg-2.5
[**2128-3-6**] 03:08PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2128-3-6**] 03:08PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2128-3-6**] 03:08PM URINE RBC-0 WBC-0 Bacteri-MOD Yeast-NONE Epi-1
RenalEp-<1
[**2128-3-6**] 03:08PM URINE CastHy-9*
[**2128-3-6**] 03:08PM URINE AmorphX-OCC
[**2128-3-6**] 03:08PM URINE Mucous-RARE
[**2128-3-6**] 03:08PM URINE Eos-NEGATIVE
[**2128-3-6**] 03:08PM URINE Hours-RANDOM UreaN-397 Creat-119 Na-LESS
THAN K-38 Cl-LESS THAN TotProt-29 Prot/Cr-0.2
B. Discharge/Misc
[**2128-3-12**] 06:10AM BLOOD WBC-6.0 RBC-3.17* Hgb-10.0* Hct-31.5*
MCV-99* MCH-31.7 MCHC-31.9 RDW-15.5 Plt Ct-196
[**2128-3-12**] 06:10AM BLOOD Glucose-96 UreaN-57* Creat-4.4*# Na-130*
K-4.4 Cl-97 HCO3-23 AnGap-14
[**2128-3-12**] 06:10AM BLOOD ALT-105* AST-61* LD(LDH)-247 AlkPhos-199*
TotBili-0.8
[**2128-3-12**] 06:10AM BLOOD Calcium-7.9* Phos-4.8* Mg-2.2
[**2128-3-8**] 06:40AM BLOOD calTIBC-332 VitB12->[**2117**] Ferritn-131
TRF-255
[**2128-3-8**] 06:40AM BLOOD TSH-0.86
[**2128-3-8**] 06:40AM BLOOD Cortsol-48.2*
[**2128-3-7**] 02:50PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2128-3-7**] 05:04PM BLOOD ANCA-NEGATIVE B
[**2128-3-7**] 05:04PM BLOOD [**Doctor First Name **]-NEGATIVE
C. MM work-up
[**2128-3-10**] 06:58AM BLOOD b2micro-15.7*
[**2128-3-9**] 04:33PM BLOOD IgG-1705* IgA-73 IgM-11*
[**2128-3-7**] 02:50PM BLOOD C3-113 C4-14
[**2128-3-7**] 02:50PM BLOOD HCV Ab-NEGATIVE
[**2128-3-9**] 04:33PM BLOOD FREE KAPPA AND LAMBDA, WITH K/L RATIO
Test Result Reference
Range/Units
FREE KAPPA, SERUM 94.0 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 14.3 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 6.57 H 0.26-1.65
Interpretation: In serum, the kappa/lambda ratio
of whole immunoglobulin molecules is 2:1, whereas
the kappa/lambda ratio of free light chains is
1:1.5. The latter is attributed to the occurrence
of lambda light chains as dimers whose serum [**1-18**]-
life is approximately 3 times longer than that of
monomeric kappa light chains. Excess production
of kappa or lambda light chains alters the kappa/
lambda ratio. Alterations that fall outside the
normal range are attributed to the presence of
monoclonal light chains. Monoclonal light chains
are found in serum of patients with multiple
myeloma, the light chain variant of MM,
Waldenstrom's macroglobulinemia, mu-heavy chain
disease, primary amyloidosis, light chain
deposition disease, monoclonal gammopathy of
undetermined significance, and lymphoproliferative
diseases such as B-CLL. Measurement of free light
chain concentration in serum is useful for
diagnosis, prognosis, monitoring disease activity
and following response to therapy of these
disorders.
Chronic infection and chronic inflammatory
diseases, as well as renal insufficiency, may be
accompanied by a diffuse increase in both kappa
and lambda free chains, but the kappa/lambda ratio
remains within the normal limits. The serum
concentration of free light chains increases with
age over 60 years; light chains may reach 50 mg/L
in those 70-80 yrs of age; in these cases the
kappa/lambda ratio still remains within normal
limits.
Physicians, who are accustomed to the
identification of clonal protein by electro-
phoretic means, may order immunofixation in
addition to free light chain immunoassay. In
rare instances, immunofixation may identify
monoclonal light chain protein in the absence
of abnormalities in the quantitative light chain
immunoassays.
[**Doctor Last Name 2809**] [**Female First Name (un) **] et [**Doctor Last Name **]., Serum reference intervals and
diagnostic ranges for free kappa and free lambda
immunoglobulin light chains: Relative sensitivity
for detection of monoclonal light chains. Clin
Chem [**2119**],48:1437-1444.
THIS TEST WAS PERFORMED AT:
[**Company **]/CHANTILLY
[**Numeric Identifier 14272**]
CHANTILLY, [**Numeric Identifier 14273**]
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 14274**], MD
PROTEIN AND IMMUNOELECTROPHORESIS
Protein Electrophoresis
ABNORMAL BAND IN GAMMA REGION
BASED ON IFE (SEE SEPARATE REPORT),
MONOCLONAL IGG KAPPA DETECTED
NOW REPRESENTS, BY DENSITOMETRY, ROUGHLY
24% (1500 MG/DL) OF TOTAL PROTEIN
INTERPRETED BY [**Name6 (MD) 761**] [**Name8 (MD) 762**], MD, PHD
Prot. Electrophoresis, Urine
NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN
ALBUMIN IS THE ONLY PROTEIN DETECTED
FOR ACCURATE QUANTITATION, ORDER RANDOM URINE ALBUMIN/CREATININE
RATIO
INTERPRETED BY [**Name6 (MD) 761**] [**Name8 (MD) 762**], MD, PHD
II. Microbiology
[**2128-3-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2128-3-6**] URINE URINE CULTURE-FINAL INPATIENT
III. Radiology
A. Renal US
INDICATION: Acute renal failure.
COMPARISON: None available.
FINDINGS: The right kidney is surgically absent and the right
renal fossa is unremarkable. The left kidney is 12 cm in length
and normal in echotexture. There is no hydronephrosis or
evidence of nephrolithiasis. The urinary bladder is
unremarkable.
Color Doppler analysis of the left kidney reveals abnormal
arterial waveforms throughout the kidney well as involving the
left main renal artery, specifically with evidence of to and fro
flow, raising the possibility of reversal of flow in diastole.
The left main renal vein appears patent. Note that color Doppler
analysis was limited overall as the patient had severe
difficulty with breath holding.
IMPRESSION:
Technically limited study with evidence of to and fro flow in
the renal
arteries on the left, raising the possibility of reversal of
flow in diastole. Overall, this finding is nonspecific, though
raises concern for elevated renal parenchymal pressure. If
clinically relevant, these findings could be further evaluated
via an MRI. Results were provided as a wet read on ED dashboard
at the time of dictation.
.
B. [**2128-3-8**]
CHEST PORT. LINE PLACEMENT
Reason: Check HD line placement.
FINDINGS: Right IJ dialysis catheter tip lies in the region of
the lower SVC. Cardiac pacing leads are stable. Severe
enlargement of the cardiac silhouette persists with relatively
mild vascular congestion, raising the possibility of
cardiomyopathy or pericardial effusion.
The study and the report were reviewed by the staff radiologist.
C. CXR([**2128-3-11**])
A AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Decreased breath sound and CHF.
There is mild cardiomegaly. Left transvenous pacemaker leads
terminate in
standard position in the right atrium, right ventricle and
through the
coronary sinus. Bilateral pleural effusions larger on the right
side are
associated with atelectasis. There is increased kyphosis. Mild
vascular
congestion has improved.
D. Skeletal survey ([**2128-3-10**])
INDICATION: 73-year-old female with MGUS and question lytic
lesions of
multiple myeloma.
COMPARISON: Chest CT dated [**2124-10-12**] and chest
radiograph dated
[**2128-3-10**].
SKELETAL SURVEY
CALVARIUM: There are multiple punctate lucent lesions within the
calvarium
concerning for myelomatous deposits.
THORACIC AND LUMBAR SPINE: On a background of diffuse
demineralization, there
is focal kyphosis within the upper/mid thoracic spine secondary
to a
compression fracture of a upper/mid thoracic vertebral body with
approximately
70% loss of vertebral body height. This is new compared to
[**2124-10-12**]. The hemithoraces demonstrate bilateral pleural effusions
and
atelectasis.
PELVIS: There are severe degenerative changes of the left
sacroiliac joint.
RIGHT AND LEFT FEMURS: There are subtle lucencies within both
femurs without
cortical destruction which may represent myelomatous deposits
versus
osteopenia.
HUMERI: There are no lytic lesions concerning for myelomatous
deposits.
Clips are seen within the abdomen.
IMPRESSION:
1. Multiple punctate lucencies in the calvarium concerning for
myelomatous
deposits.
2. Wedge compression fracture of an upper/mid thoracic vertebral
body, age
indeterminate.
E. VEIN MAPPING - pending
III. Cardiology
A. EKG
Cardiology Report ECG Study Date of [**2128-3-7**] 4:45:56 PM
A-V sequentially paced rhythm with capture. Wandering baseline.
Compared to the previous tracing of [**2124-10-13**] the rhythm is now
A-V sequentially paced and the rate has slowed. Otherwise, no
diagnostic interim change.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 0 160 496/496 0 -180 -9
B. ECHO ([**2128-3-11**])
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF= 20-25 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is moderately
dilated with depressed free wall contractility. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. 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. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Severe [4+] tricuspid regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. [In the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is no pericardial effusion.
IMPRESSION: Mild symmetric LVH. Moderately dilated LV with
severe global hypokinesis. Diastolic dysfunction. Dilated and
hypokinetic right ventricle with severe tricuspid regurgitation
and likely pulmonary artery hypertension. Evidence of
pressure/volume overload. Mild aortic and moderate aortic
regurgitation.
Brief Hospital Course:
HOSPITAL COURSE:
73-year-old female with dilated cardiomyopathy (EF 20%), s/p
nephrectomy for renal cell carcinoma in [**2119**] with left solitary
kidney, hypertension, diabetes, MGUS that presented with 1-month
history of nausea and vomiting thought to be related to
cholelithiasis with plan for initial plan for ERCP. She
subsequently went into acute on chronic renal failure with
etiology unknown after extensive work-up. One consideration is
multiple myeloma given findings on skeletal survey.
.
HOSPITAL COURSE:
# Acute on chronic renal failure:
Patient has underlying renal disease and is s/p right
nephrectomy in setting of renal cell carcionoma in [**2119**] with
left solitary kidney. Her baseline creatinine is 3 with
subsequent elevation to 6.3 with BUN 141 on admission. The
etiology of her renal failure was initially thought to be
hypovolemia at the [**Hospital1 882**], but she was unresponsive to fluids.
No recent contrast exposure. She was subsequently underwent
diuresis with thought that poor forward output in setting of
cardiomyopathy could be the etiology; however, this as well did
not improve her renal function. On admission, she displayed
signs and symptoms consistent with uremia. Her volume status was
difficult to assess. The differential was broad given her
comorbidities. Renal US showed elevated renal parenchymal
pressure. MRI was going to be performed to rule out renal vein
thrombosis, but the patient had a pacemaker. Renal consultants
suggested transfer to the CCU with placement of a SG catheter to
assess volume status and possibly initiation HD or UF. Given PA
numbers as below, patient was thought to be euvolemic to mildly
hypervolemic. Labs were significant for negative ANCA, [**Doctor First Name **],
urine eosinophils and normal complement levels. Work-up for
myeloma was performed as described below. She had two sessions
of HD in the CCU, which she tolerated, without any fluid
removed. She subsequently continued HD on the cardiology floor
with fluid removal limited by hypotension at times. She had
associated pleural effusions with goal to be net negative with
dialysis, which was possible with downtitration of carvedilol.
She should continue to receive dialysis with goal net negative
given pleural effusions.
In addition, her hepatitis panel was negative, and PPD was 0 mm
of induration for outpatient dialysis screening purposes. She
received vein mapping during hospitalization for potential
future placement of fistula access on non-dominant left arm,
which should be spared from blood draws, blood pressure
measurements, or other procedures.
She was started on sevelamer, nephrocaps.
# MGUS - The patient has a diagnosis of MGUS. Her SPEP at
[**Hospital1 882**] on [**2128-2-23**] showed IgG [**2019**], free Kappa 160.74 (H),
Free K/L ratio 8.82 (H), M-spike concentration of 1.42 g/dL.
Urine showing Bence-[**Doctor Last Name **] protein and faint monoclonal free
kappa. Labs showed similar values here. Her last bone marrow
biopsy was in [**2115**]. Oncology consult at [**Hospital1 882**] felt that
condition was stable. Heme/Onc followed patient in house and
recommended above tests in addition to a skeletal survey, which
suggested multiple punctate lucencies in the calvarium
concerning for myelomatous
deposits. A bone marrow biopsy was discussed with the patient
who refused as she wanted to discuss this procedure with her
primary care doctor. The issue of whether she has MGUS or
perhaps myeloma remains moot. Her labs showed stable anemia, no
hypercalcemia. In the setting of unexplained oliguric renal
failure, cast nephropathy is a consideration, and ruling out
myeloma should be considered on an outpatient basis. Another
consideration is if her cardiomyopathy is perhaps related to
this process.
.
# Non-ischemic chronic systolic and diastolic cardiomyopathy
(Last EF 20 %):
She did not appear to have an acute on chronic heart failure
exacerbation on admission. Her mild hypervolemia may be
secondary to renal failure. She was continued on carvedilol as
above. No ACEi/[**Last Name (un) **] was given in setting of renal failure and
relative hypotension. As above, she had a PA catheter placed in
the CCU, with values of mean RA 26, v-waves to 50mmHg,
RVSP/RVEDP ~50/14 and PA pressures 50/22 on entry; Mean wedge
19mmHg; PA pressures increased to 60/28 after the procedure. She
was determined to be euvolemic to mildly volume up. TTE showed
mild symmetric LVH, moderately dilated LV with severe global
hypokinesis, diastolic dysfunction, dilated and hypokinetic
right ventricle with severe tricuspid regurgitation and likely
pulmonary artery hypertension with evidence of pressure/volume
overload and mild aortic and moderate aortic regurgitation.
.
# Hyponatremia: Most likely hypervolemic hyponatremia given CHF
and volume overload.
Her admission Na was 134. Her volume status by SG catheter was
as above. TSH was normal, and cortisol was appropriately
elevated in setting of acute illness. Etiology is likely
multifactorial with no mental status changes. Na level should
continued to be monitored.
.
# Metabolic encephalopathy
Patient was AAOx2-3 at times at [**Hospital1 882**] and [**Hospital1 18**]. Etiology
likely multifactorial given uremia, narcotics, electrolyte
abnormalities, acute illness with prolonged hospitalization.
Patient was encouraged to use assistive devices such as glasses.
Husband visited daily to assist with re-orientation.
.
# Macrocytic anemia
Admission Hgb 11.1 and stable. The differential is broad
including primary marrow process vs. nutritional deficiency vs.
anemia of chronic renal disease.
Iron and B12 studies were suggestive of iron deficiency for
which oral iron with anti-constipation regimen was started.
.
# Cholelithiasis
Patient was going to undergo ERCP at [**Hospital1 112**] for stone extraction at
some point; however, ERCP deferred in setting of actue on
chronic renal failure. Abdominal US on [**3-5**] at [**Hospital1 882**] showing
cholelithiasis with two gallstones within gallbladder neck. KUB
not suggesting bowel obstruction. Patient continues to have some
abdominal tenderness but has remained afebrile with no
leukocytosis suggesting against systemic infection. Repeat RUQ
US showed cholelithiasis without cholecystitis. Given concurrent
transaminitis discussed below, there was a concern for a stone
in the CBD, but the etiology of this issue is likely
multifactorial. The patient should at some time on an outpatient
basis have this issue discussed with her primary care doctor for
further evaluation. She was able to take adequate PO intake
without significant vomiting or nausea.
.
# Transaminitis
OSH LFTs on [**2128-2-25**] showing ALT 58, AST 22, ALKP 188 with
uptrend to ALT 143 AST 111 ALPKP 255 TBili 0.8 on [**2128-3-3**].
Discharge LFTs ALT 105, AST 61, LD 2476, ALP 199, Tot bili 0.8
with overall downtrend. Etiology likely multifactorial including
passive congestion from chronic heart failure, possible
medication side effect from amiodarone, resolving biliary
process. Non-hepatic causes such as thyroid disorder or
rhabdomyolysis unlikely given TSH and CK. Intrinsic hepatic
causes are not suggested by laboratory (hepatitis panel) or
imaging (no lesions noted). She should have repeat LFTs in [**1-18**]
weeks to ensure downtrend with continued monitoring.
.
# Hypertension
She was continued on carvedilol, which was reduced from 6.25 mg
to 3.125 mg given relative hypotension with dialysis.
.
# S/p ICD/[**Hospital1 **]-V pacer
Patient in paced rhythm. She was continued on amiodarone, which
should not be discontinued unless discussing with her primary
cardiologist.
.
# DM2
She was continued on insulin.
.
# Chronic pain - Primary pain generator is her back for which
XR showed wedge compression fracture of an upper/mid thoracic
vertebral body (age indeterminate). Patient was continued on
fentanyl patch and PO dilaudid.
.
# Code: Full. Consider outpatient discussion of code status and
goals of care. Patient is NOT likely to survive cardiopulmonary
arrest especially with such severe heart failure.
Medications on Admission:
Tylenol 650mg q6h
Amiodarone 200mg [**Hospital1 **]
Aspirin 81 daily
Coreg 6.25 [**Hospital1 **]
Colace
Fenatanyl 25 ucg q72H
Apresoline 25mg TID
Dilaudid .5mg q4h prn pain
Lantus 10 units qHS
HSS
Lidoderm patch
Maalox liquid 30ml q4h prn
omeprazole 20mg daily
Senna 2 tabs [**Hospital1 **]
Demadex 80mg [**Hospital1 **]
Discharge Medications:
1. heparin (porcine) 1,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**] unit
Injection PRN (as needed) as needed for line flush: Dialysis
Catheter (Temporary 3-Lumen): DIALYSIS Lumens/ DIALYSIS NURSE
ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen.
.
2. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Coreg 3.125 mg Tablet Sig: One (1) Tablet PO twice a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. hydromorphone 2 mg Tablet Sig: 0.25 Tablet PO Q6H (every 6
hours) as needed for pain.
9. Other
Humalog insulin sliding scale
10. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
12. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
14. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
15. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
16. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: acute on chronic renal failure, chronic non-ischemic
systolic heart failure (EF 20 %), hyponatremia, acute metabolic
encephalopathy, macrocytic anemia, cholelithiasis,
transaminitis, atrial fibrillation, monoclonal gammopathy of
uncertain significance
Secondary: Diabetes mellitus, low back pain secondary to
compression fracture
Discharge Condition:
Mental Status: Confused - sometimes. Alert and oriented to
person, place, sometimes time.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were transferred from The [**Hospital1 882**] to [**Hospital1 18**] for acute on
chronic renal failure of unknown etiology. You were started on
dialysis. It was also discussed that you may have possibly
developed multiple myleoma but did not want to pursue bone
marrow biopsy. You should talk to your outpatient hematologist
about this matter.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Medication changes:
START ferrous sulfate for anemia (low blood count)
START nephrocaps for kidney health
START sevelamer for kidney health
CHANGE coreg from 6.25 mg by mouth twice daily to 3.125 mg by
mouth twice daily
STOP apresoline 25 mg by mouth three times daily
STOP demadex 80 mg by mouth twice daily
Followup Instructions:
[**2128-3-15**] with Dr. [**Last Name (STitle) 84995**] (oncology) ([**Location (un) **] [**Location (un) 2274**])
[**2128-3-23**] with Dr. [**Last Name (STitle) 94422**] ([**Location (un) **] [**Location (un) 2274**])
[**2128-3-31**] with Dr. [**Last Name (STitle) **] ([**Location 1268**] [**Location 2274**])
[**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 69391**]
ICD9 Codes: 5845, 2761, 4254, 4280, 4241, 2724, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7169
} | Medical Text: Admission Date: [**2101-8-6**] Discharge Date: [**2101-8-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Transferred from [**Hospital3 628**] for management of tachy-brady
syndrome/cardiac pauses.
Major Surgical or Invasive Procedure:
1)Temporary pacing wire placement
2)Permanent dual pacemakder placement
History of Present Illness:
[**Age over 90 **] year old male with a history of DVT/PE on coumadin,
intermittent AF, CHF with EF 45% who presents from [**Hospital 620**] Hosp
for multiple pauses in the setting of CHF exacerbation. The
patient initially presented to his PCP in [**Name9 (PRE) **] for a routine
visit and was found to be tachycardic with an "abnormal ECG",
per patient's niece. He was subsequently admitted to [**Hospital 882**]
hospital ([**Date range (1) 57274**]/07). In the ED, he was tachypneic,
tachycardic, and hypoxemic. CXR at the time showed bibasilar
consolidations and TTE revealed a slightly depressed EF (45%)
and elevated PA pressures. He was treated for both CHF and
community-acquired pneumonia.
.
The patient did well until [**8-2**], when he went for follow-up to
the pulmonologist, where he had a CXR revealing pulmonary edema
with similar symptoms of shortness of breath and hypoxia and was
admitted to [**Hospital3 **] for CHF exacerbation (BNP 6141,
Trop 0.055). However, on [**8-4**], he was transferred to the ICU for
persistent tachycardia to the 110s thought to be AF/flutter. He
was started on digoxin load and maintenance, IV lopressor, and
IV lasix while there. On [**8-6**] he had 2 episodes of cardiac pauses
(10s at 10:30am, 24s at 4:30pm). BP remained stable during these
episodes. He was transferred to [**Hospital1 18**] for further management.
On transfer from [**Location (un) 620**]-- SBP 110s, HR 80s, afib with PVCs and
no pauses, 100% on 2L.
.
On review of symptoms, he admits to DVT/PE, but he denies any
prior history of stroke, TIA, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Past Medical History:
1)DVT/PE on coumadin-In [**11-5**], the patient had several episodes
of shortness of breath in the setting of left leg swelling for
4-6 weeks. US showed clot from the left common femoral vein to
the left popliteal vein. PE CT showed non-oclusive pulmonary
emboli bilaterally in the upper lobe arteries. On ECHO, there
was no evidence for right sided heart strain. He was discharged
on Coumadin 5mg Daily with INR goal of [**3-5**].
2)Intermittent AF-Present during the [**7-7**] [**Hospital 882**] Hospital
admission. At this time, he was started on Diltiazem.
3)CHF-ECHO in [**11-5**] at an OSH showed an EF of 60% with LVH, nml
LV size. Dilated LA, RA. Nomral size RV and nml RV function.
Mild AS, Trace TR. In [**7-7**], an ECHO at an [**Last Name (LF) 57275**], [**First Name3 (LF) **] was 45%
with LVH, nml LV size, Dilated LA. RV enlargement with
hypokinesis, mild AS, 1+ MR, 1+TR, PAP of 34mmHg.
4)Hearing loss with hearing aids
5)Right bundle branch block, ? trifascicular block-In 4/89, EKG
showed 1st degree AV block and RBBB.
6)History of asbestos exposure
7)Hernia repair in 4/95
Social History:
Patient previously lived alone in [**Location (un) 620**]. His brother lives
near by and checks on him frequently. The patient was a former
shipyard worker, carpenter. He stopped smoking 20 years ago and
he uses alcohol rarley. His brother [**Name (NI) 122**] is his health care
proxy and his [**Last Name (LF) 21457**], [**Name (NI) **] [**Name (NI) 57276**] is his alternate health care
proxy.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T: 98.0 , BP: 108/58 , HR: 77 , RR: 24 , O2 %: 91 on 2L
Gen: Patient awake, interactive, and oriented to person and
place. Mood and affect is appropriate.
HEENT: Normal cephalic atraumatic. Sclera anicteric.
Extra-ocular movements intact. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8-9cm.
CV: Regular heart rate. Normal S1 and S2. II/VI systolic
murmur heard loudest at the apex. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Soft bibasilar crackles
improved from yesterday.
Abd: Soft, non-tender, non-distended, no masses.
Ext: No lower extermity edema. 2+ dorsal pedal pulses.
Skin: Bilateral lower extremity venous stasis changes.
Pulses:
Right: Carotid 2+, DP 2+
Left: Carotid 2+, DP 2+
Pertinent Results:
EKG:Atach vs afib, RBBB w LAFB, Q in II, III, aVF, 1mm STD/TWI
in V2-4
.
CXR [**2101-8-6**]: Calcified pleural plaques consistent with previous
asbestos exposure. There is blunting of the bilateral
costophrenic angels that may be pleural thickening or pleural
effusions.
.
CXR [**2101-8-9**]: Confirms placement of a pacemaker with leads in
the right atrium and right ventricle. There is improvement of
the bilateral infiltrates. A 10mm in diameter denisty was noted
in the upper lobe of the right lung. Pleural plaques are
unchanced from previous studies.
.
ECHO [**2101-8-8**]: Sym LVH, nml LV cavity size, global LV hypokinesis
with LVEF of 35%. RA dilation. RV dilation with depressed RV
function. Moderate AS with peak velocity of 3.0, peak gradient
of 36mmHg. 1+ AR, 1+ MR, trivial TR.
.
.
Head CT [**2101-8-9**]. Demonstrated no acute intracranial process
ushc as mass effect, infarcts, intracranial hemorrhage. IThere
is calcification of the flax cerebri.
.
Video Swallowing Study [**2101-8-11**]-Showed mild dysphagia and
aspiration on thin liquids corrected by compensatory maneurves
such as chin tuck.
.
Admission Labs:
[**2101-8-6**] 11:23PM TYPE-ART TEMP-36.1 PO2-66* PCO2-46* PH-7.44
TOTAL CO2-32* BASE XS-5 INTUBATED-NOT INTUBA
[**2101-8-6**] 11:23PM LACTATE-1.2
[**2101-8-6**] 11:23PM O2 SAT-93
[**2101-8-6**] 11:23PM freeCa-1.18
[**2101-8-6**] 11:05PM GLUCOSE-126* UREA N-29* CREAT-1.2 SODIUM-139
POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-31 ANION GAP-12
[**2101-8-6**] 11:05PM estGFR-Using this
[**2101-8-6**] 11:05PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-2.5
[**2101-8-6**] 11:05PM WBC-9.6 RBC-4.20* HGB-13.3* HCT-40.5 MCV-96
MCH-31.8 MCHC-33.0 RDW-15.3
[**2101-8-6**] 11:05PM PT-24.0* PTT-30.0 INR(PT)-2.4*
[**2101-8-6**] 11:05PM PLT COUNT-176
.
Discharge Labs:
[**2101-8-12**] 05:00AM BLOOD WBC-9.2 RBC-4.02* Hgb-12.7* Hct-38.5*
MCV-96 MCH-31.6 MCHC-33.0 RDW-15.3 Plt Ct-163
[**2101-8-12**] 05:00AM BLOOD Glucose-99 UreaN-29* Creat-1.0 Na-141
K-4.1 Cl-101 HCO3-30 AnGap-14
[**2101-8-8**] 03:24AM BLOOD ALT-25 AST-24 LD(LDH)-221 AlkPhos-84
TotBili-0.6
[**2101-8-12**] 05:00AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.3
[**2101-8-7**] 06:00AM BLOOD TSH-1.4
[**2101-8-12**] 05:00AM BLOOD PT-17.4* PTT-38.2* INR(PT)-1.6*
.
MICRO:
[**2101-8-10**] 6:37 am STOOL
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2101-8-11**]): FECES
POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Brief Hospital Course:
Mr. [**Name14 (STitle) 57277**] is [**Age over 90 **] year old man with a history of DVT/PE on
coumadin, A-Fib/aflutter, CHF with an EF of 45% who presents
with a CHF exacerbation and extensive cardiac pauses during
sleep. The patient was transferred to the [**Hospital1 **] CCU for further
work up
.
Asystolic Pauses/Rhythm-On admission, the patient was found to
be in A-fib with episodes of bradycardia and sinus pauses
(lasting up to 20-30 seconds.) This was thought to that was
thought to be possibly due to tach-brady syndrome and
significant conduction system disease. The patient was placed
on telemetry and followed with serial EKG. On [**2101-8-7**], a
temporary pacing line was placed. Metoprolol was used to
control episodes of tachycardia to the 120's. On [**2101-8-8**], a dual
pacemaker device with leads in the right atrium and ventricle
was placed. The pacemaker was interrogated on [**2101-8-9**] and PA
and lateral chest x-rays confirmed the pacemaker placement. He
should follow up with his cardiologist and the device clinic to
assess proper pacemaker functioning
.
A-fib: On admission, Digoxin was discontinued because this
medication was thought to be contributing to asystolic pauses.
The patient was rate controlled with metoprolol 25mg PO TID. On
[**2101-8-9**], with resolution of the cardiac pauses with pacemaker
placement, Digoxin 0.125mg every other day was restarted. It is
hoped that the patient will be able to be converted into sinus
rhythm. This will be attempted after a full month of
anticoagulation on coumadin at therapeutic levels. Then,
chemical cardioversion should be attempted as an outpatient.
.
CHF: Pt admitted with dyspnea and likely CHF exacerbation in
the setting of a-fib and cardiac asystole. OSH medical records
indicated normal LVEF of greater than 55% in [**11-5**]. However, on
this hospitalization, the Left ventricular ejection fraction was
found to be 35%, with global left ventricular hypokinesis, left
ventricular hypertrophy, and Aortic stenosis. This change in
cardiac function is believed to be due to cardiomyopathy from
abnormal rhythm/prolonged atrial tachycardia. The patient was
treated with IV lasix and over the lengths of hospital stay, he
diuresed more than 9L. The patient's heart rate was controlled
with metoprolol in the hopes that a slower heart rate would
allow more effective filling of the ventricles. And ACE
inhibitor was not started for afterload reduction because of the
patient's low blood pressures, but can be considered in the
future. As an outpatient, Mr. [**Known lastname 57278**] should get an ECHO in a
month or so to reassess cardiac function. It is very likely
that the LVEF will improve with the normalization of his rhythm.
.
DVT/PE/Anticoagulation: The patient was on home coumadin for
treatment of his PE and a-fib. His INR was 2.4 on admission.
The coumadin was held and sliding scale heparin was started in
preparation for the pacemaker placement. The patient was given
2 units of fresh frozen plasma to correct his INR to below 1.8.
After the pacemaker was placed, the patient was put on Lovenox
as a bridge until his coumadin became therapeutic. On
discharge, the patient was on coumadin 5mg a day with Lovenox
80mg SC with an INR of 1.6. When the patient reaches a
therapeutic INR of [**3-5**] for 48 hours, the patient should
discontinue Lovenox and continue on coumadin mg PO daily.
.
Change in mental status-On [**2101-8-9**], the patient became somnolent
and PO medications were not administered. A head CT was
obtained that showed no acute intracranial process. An ABG was
also obtained that showed adequate oxygenation and electrolytes
were normal. The patient became more alert and was able to eat
breakfast on [**2101-8-10**]. The patient's metal status continued to
improve for the rest of the hospitalization.
.
Pulmonary Nodule-With resolution of the pulmonary edema, a
pulmonary nodule in the Right upper lobe of the lung was found
on chest x-ray on [**2101-8-9**]. The family decided to follow this
result with an outpatient CT.
.
Difficulty Swallowing: On [**2101-8-10**], the patient underwent a
swallowing evaluation that showed aspiration. The patient was
scheduled for a video swallow study that was performed on
[**2101-8-11**] and showed mild dysphagia for thin fluids that could be
corrected with compensatory maneuvers. It was felt that the
patient could continue on a regular diet as long as compensatory
maneuvers such as a chin tuck were performed during feeding.
The patient should follow up with speech therapy for a
re-evaluation.
.
C.diff-Patient was found to be C.diff positive by stool cultures
on [**2101-8-10**]. The patient was started on Flagyl 500mg PO TID for
a 14 day course.
.
The patient was placed on a bowel regimen, cardiac diet, and is
full code.
.
Medications on Admission:
Home Medications:
diltiazem 45mg po q8
lasix 40mg po daily
coumadin 3mg po qhs
ipratropium 0.5mg q6
guafenesin 10ml po q6
senna 2 tabs [**Hospital1 **]
multivitamin
colace 100mg po prn
acetaminophen 650mg prn
levalbuterol 0.63mg q4 prn
benzonate 100mg po tid prn
mom prn
dulcolax prn
lactulose prn
mechanical soft diet, nectar thick liquids
Transfer Medication from Outside hospital:
lasix
captopril 6.25 po tid
Coumadin 5mg daily
Digoxin 0.125mg daily
Nystatin
Lasix 40mg daily
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*30 Tablet(s)* Refills:*2*
2. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
3. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust accordingly for a goal INR [**3-5**].
Disp:*30 Tablet(s)* Refills:*2*
4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed for wheezing, SOB.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
8. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours): to take until therapeutic on
coumadin for 48hours.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 14 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
asystolic pauses
atrial fibrillation
congestive heart failure
right upper lobe pulmonary nodule
C. difficile infection
Discharge Condition:
stable
Discharge Instructions:
You were admitted for a bad heart rhythm and congestive heart
failure. A pacemaker was placed during this admission. You
also have C. diff infection for which we are treating you with
an antibiotic. Please take all medications as prescribed and
keep all follow up appointments.
.
You were also found to have an incidental pulmonary nodule on a
chest x ray. Please follow up with your primary care physician
to consider further imaging.
.
Please call your physician or call 911 if you experience chest
pain, shortness of breath, fevers, abdominal pain, nausea,
vomiting, or other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in his [**Location (un) 620**]
office([**Telephone/Fax (1) 4105**]) on [**2101-8-25**] at 3PM. If you are unable to
keep this appointment, please contact him.
.
You have an appointment in the DEVICE CLINIC for your pacemaker
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2101-8-15**] 3:00
.
You will need a follow up appointment with your PCP as soon as
possible. Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 57279**]
ICD9 Codes: 4280, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7170
} | Medical Text: Admission Date: [**2105-2-28**] Discharge Date: [**2105-3-1**]
Date of Birth: [**2067-9-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
dyspnea, chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 37 year-old female with a history of metastatic
cholangiocarcinoma who presents with dyspnea and abdominal pain.
.
In the ED, initial VS were 100.8 rectal, 119, SBP 80 (per old
records lives in 90s), 20, 98% RA. She was given 2L NS with
improvement of her BP to 115/75. She was noted to have
significant ascites on exam, but otherwise unchanged. On her lab
work, she was noted to have significnant leukocytosis, no bands,
and thrombocytosis. Sodium was 113 with AG of 14. She had a CTA
torso which showed no PE, but marked ascites and worsening of
her metastatic disease. Otherwise no definite pathology. Her
LFTs were unremarkable. Transplant surgery evaluated the patient
for purulent discharge from her biliary drain, but this was felt
to be unchanged. Paracentesis was not performed. The patient was
given vanco/zosyn for empiric coverage. She had 2 PIVs placed,
and transferred to the ICU for the above. Her vitals at the time
of transfer were VS: 118, 115/74. 100%RA.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
.
Past Medical History:
1) Chloangioncarcinoma with neuroendocrine features (as below)
2) Cholelithiasis with large CBD stone
.
ONCOLOGIC HISTORY: *per Heme/Onc note
Mrs. [**Known lastname **] is a 37-year-old, who has a long history of
cholelithiasis since more than 20 years ago. Post-partum day 3
([**2104-11-11**]) she underwent IR drainage and pigtail catheter
placement into her gallbladder with fluid consistent with
carcinoma with neuroendocrine features. She was discharged on
[**11-15**] with an indwelling cholecystostomy tube; however, she was
readmitted a week later due to abdominal pain. [**2104-11-21**] Abd CT
noted multiseptate lesion and progression in dilation of
gallbladder. [**2104-11-24**] chest and pelvic CT negative for distant
mets. On [**2104-11-27**] CT guided bx of the lesion showed positive
malignant cells, consistent with carcinoma. [**2104-11-25**] octreotide
scan showed exophytic component of the multiseptated segment III
lesion displays very avid octreotide uptake, compatible with
neuroendocrine tumor. Discussed her case on GI tumor conference
and it was determined that she has unresectable gallbladder
small cell cancer.
- [**2104-12-8**] C1D1 Cisplat/VP16
- [**2104-12-9**] C1D2 VP16
- [**2104-12-10**] C1D3 VP16
- [**2104-12-29**] C2D1 Cisplat/VP16
- [**2104-12-30**] C1D2 VP16
- [**2104-12-31**] C1D3 VP16
Social History:
Lives at home with husband and 2 daughters. One daughter 8 years
old and one daughter born [**2104-11-8**]. Was employed in food
service prior to illness. Tobacco: None EtOH: None
.
Family History:
No history of cancer or diabetes.
Father died in his 80s from heart disease
Physical Exam:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
Admission labs:
[**2105-2-28**] 07:15PM BLOOD WBC-16.7*# RBC-3.10* Hgb-7.7* Hct-24.3*
MCV-78* MCH-24.8* MCHC-31.8 RDW-18.6* Plt Ct-1053*
[**2105-2-28**] 07:15PM BLOOD Neuts-98* Bands-0 Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2105-2-28**] 07:15PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-2+ Polychr-NORMAL
[**2105-2-28**] 07:15PM BLOOD PT-13.3 PTT-33.8 INR(PT)-1.1
[**2105-2-28**] 07:15PM BLOOD Glucose-89 UreaN-43* Creat-0.9 Na-113*
K-6.6* Cl-81* HCO3-18* AnGap-21*
[**2105-2-28**] 07:15PM BLOOD ALT-20 AST-51* CK(CPK)-184* AlkPhos-91
TotBili-0.3
[**2105-2-28**] 07:15PM BLOOD CK-MB-5
[**2105-2-28**] 07:15PM BLOOD cTropnT-<0.01
[**2105-2-28**] 07:15PM BLOOD Albumin-2.7* Calcium-7.8* Mg-2.6 Iron-14*
[**2105-2-28**] 07:15PM BLOOD calTIBC-265 Ferritn-312* TRF-204
[**2105-2-28**] 07:15PM BLOOD Osmolal-259*
[**2105-2-28**] 07:17PM BLOOD Lactate-2.2*
[**2105-2-28**] 09:06PM BLOOD K-4.8
[**2105-2-28**] CTA chest, CT abd and pelvis:
1. No evidence of pulmonary embolism.
2. Mild progression of innumerable diffuse hepatic, mesenteric,
peritoneal
and pelvic metastases.
3. Mild right renal hydroureteronephrosisis new.
4. Diffuse esophageal wall thickening may represent esophagitis.
Correlate
with symptoms.
Brief Hospital Course:
This is a 37 year-old female with a history of end stage
metastatic cholangiocarcinoma who presents with chest pain and
dyspnea noted to be hypotensive and hyponatremic with low grade
fevers
Sepsis: The patient was initially thought to be septic given
her low grade fevers, tachycardia, and leukocytosis, with a
possible source being peritonitis. She was covered broadly with
vancomycin and zosyn and blood and urine cultures were sent. An
abdominal paracentesis was planned but not performed because of
the patient's inability to remain motionless and comfortable
during the procedure. The procedure was planned to be performed
under IR-guidance but she expired prior to its exeution.
# Hyponatremia: The patient's hyponatremia was thought to be
hypovolemic hyponatremia. She received IVF with some
improvement in her sodium levels.
# Anemia: The patient was found to have a microcytic anemia,
likely secondary to anemia of chronic inflammation. Her stools
were planned for guaiac. She did not receive any transfusions
while she remained in the [**Hospital Unit Name 153**].
# Cholangiocarcinoma: The patient has metastatic cancer and is
followed by Dr. [**Last Name (STitle) **]. Clinically, she has significant ascites
and undergoes frequent paracentesis. The palliative care
service was also consulted. Her cause of death is unclear but
likely related to her metastatic cancer.
# Code: DNR/DNI- confirmed with patient & husband via
interpreter
Medications on Admission:
per OMR
Dexamethasone 4 mg [**Hospital1 **]
Lorazepam 0.5 mg q4-6 PRN
Ondansetron 8 mg q8 PRN
Prochlorperazine 10 mg Q6H PRN
Spironolactone 25 mg daily
MVI daily
patient states she takes only oxycodone for pain.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
cholangiocarcinoma
sepsis
Discharge Condition:
expired
Discharge Instructions:
N/a
Followup Instructions:
n/a
Completed by:[**2105-3-3**]
ICD9 Codes: 0389, 2761, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7171
} | Medical Text: Admission Date: [**2190-2-8**] Discharge Date: [**2190-2-11**]
Service: NEUROLOGY
Allergies:
Keflex / Lipitor
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Transient right hand weakness and speech arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is an 88 year-old right-handed man with a PMH of recent
SDH in addition to seizures, CAD and afib now off Coumadin. He
was admitted on [**1-24**] after a fall from a tread mill while on ASA
and coumadin. He was found to have a 7mm L
parietal/occipital SDH. He was admitted to the neurosurgery
service for evaluation. His hospital course at the time was
complicated by a worsening mental status on admission and he was
found to have an expanding bleed. His INR was 2.8 on arrival and
he was reversed with Factor 9, FFP, Plts, and VitK. He was
intubated and admitted to the ICU and his course was also
remarkable for significant HTN which required a Nipride drip at
times. After extubation his exam was felt to be non-focal and he
was eventually discharged to rehab.
He presented again today after transfer from an OSH with a 20
minute episode of R hand weakness and difficulty getting words
out. He states that he was in his USOH this morning when he sat
down to eat breakfast. He was speaking on the phone with his
wife when he abruptly felt that his R hand was "weak" and he
dropped the spoon. He did not see any additional movements or
jerking. He then felt that his mouth "was full of cotton" and
when he tried to speak his words were both slurred and difficult
to produce. He recalls that he knew what he wanted to say but
had difficulty producing the words. He did not make paraphasic
errors but after a minute or so from the onset he stopped
speaking. He was able to understand others however.
The entire episode lasted about 20 minutes after which he was
back to baseline. He denied HA or vision changes as well as
numbness or tingling. He was not aware of any involvement of the
leg but recalls that [**Name8 (MD) **] RN at the rehab thought he had a facial
droop.
He was taken to an OSH where he was hypertensive to the 200's
and a head CT was done. This allegedly showed new hyperintensity
in his persistent L parietal subdural hematoma. He was then
transferred here where he was seen in the ED by neurosurgery who
felt that his CT was stable without of evidence mass effect or
shift and recommended that he start Keppra as he was "not been
on seizure prophylaxis". Additionally, he remained severely
hypertensive and was given atenolol and lisinopril PO,
hydralazine 10mg IV, labetalol 10mg IV.
ROS:
The pt denied headache, loss of vision, blurred vision,
diplopia, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Pt unsure if he has had any bowel or bladder
incontinence or retention. Denied difficulty with gait. The pt
denied recent fever or chills but has felt cold in the ED.
Past Medical History:
- A-fib now off coumadin
- HTN
- HLD
- CAD
- Parkinson's ?
- ? CAROTID STENOSIS
- PUD
- pacemaker implantation in [**2179**]
- BPH
- Seizure disorder (last seizure 15-20 yrs ago) with GTC
- Appy
- Eye surgery for congenital cataracts/lens implants
- Hernia surgery
- Glomerulonephritis 2 yrs ago
- recent SDH as above
- ? IVC filter
Social History:
-currently resides at rehab
-EtOh: denies
-tobacco: denies
-drugs: denies
Family History:
NC
Physical Exam:
Vitals: T: 97.7 P: 61 R: 12 BP: 193/82 SaO2: 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: decreased breath sounds bilaterally
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 commands.
There was no evidence of apraxia or neglect. Recent and remote
memory intact.
Cranial Nerves:
No evidence of anosmia. PERRL 3 to 2mm and brisk. VFF to
confrontation. There is no ptosis bilaterally. Fundoscopic exam
revealed no papilledema, exudates, or hemorrhages. EOMI without
nystagmus. Facial sensation intact to pinprick. No facial
droop, facial musculature symmetric. Hearing intact to
finger-rub bilaterally. Palate elevates symmetrically. [**5-25**]
strength in trapezii and SCM bilaterally. Tongue protrudes in
midline.
Motor System:
Normal tone throughout. Muscle bulk normal. No pronator drift
bilaterally.
No asterixis noted. Full motor strength in all groups tested.
Reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Sensory System:
Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception.
Coordination:
R sided postural tremor and intention tremor.
Gait: deferred given concern for severe HTN
Pertinent Results:
[**2190-2-10**] 06:06AM BLOOD WBC-5.8 RBC-3.60* Hgb-11.4* Hct-32.7*
MCV-91 MCH-31.7 MCHC-35.0 RDW-14.8 Plt Ct-206
[**2190-2-10**] 06:06AM BLOOD Glucose-104 UreaN-15 Creat-0.9 Na-135
K-3.6 Cl-101 HCO3-29 AnGap-9
[**2190-2-8**] 01:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-2-8**] 10:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-2-9**] 06:38AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-2-10**] 06:06AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.7
[**2190-2-9**] 06:38AM BLOOD %HbA1c-5.8
[**2190-2-9**] 06:38AM BLOOD Triglyc-94 HDL-49 CHOL/HD-2.9 LDLcalc-72
[**2190-2-8**] 10:30PM BLOOD TSH-4.1
[**2190-2-9**] 06:38AM BLOOD Carbamz-3.5*
Echocardiogram: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (LVEF 50~55%). Mild mitral
regurgitation.
CT Head: Evolving Left frontoparietal subdural hematoma is
unchanged in
size and distribuation.
CTV: No evidence of intracranial venous thrombus.
Carotid US: Bilateral 60~69% stenosis.
EEG: Drowsy but normal EEG otherwise.
Brief Hospital Course:
The pt is an 88 year-old RH man with a complex PMH including
seizures, CAD and afib off coumadin and a recent SDH. He
presented with transient difficulty producing
speech and R hand weakness. His exam is remarkable for
parkinsonian features but is otherwise non-focal. Given his
presentation, his symptoms could be due to a TIA vs. seizure
hence he was admitted for possible stroke work-up and seizures.
Because of his pacemaker, it was not possible to obtain a MRI
but CT was obtained which showed stable, old SDH without signs
of increase in size or new hemorrage. He has R IJ thrombus
hence CT venogram was obtained but he has no evidence of
intracranial venous thrombus. Also echo and carotid US plus
labs including fasting lipid panel and HbA1C were obtained - all
within normal range and/or stable.
His Tegretol level was subtherapeutic hence his dose was
increased to 300mg daily from 200 and EEG was also obtained
which was essentially normal. His Na+ dropped to 132 from 136
and likely due to Tegretol hence he will ne discharged with labs
of chem 7 every Friday to monitor for his sodium.
He remained symptom-free during this admission and he was
evalutated per PT and OT for return to [**Hospital3 7665**].
As for his atrial fibrillation, he was restarted on aspirin 81mg
during this admission but given his risk factor and the fact
that his SDH was "traumatic," will consider restarting Coumadin
in ~ 2 weeks when he follows up with Dr. [**Last Name (STitle) **]. He will also
get a head CT prior to seeing Dr. [**Last Name (STitle) **].
Medications on Admission:
1. Carbamazepine 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO DAILY (Daily).
2. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO QD ().
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
18. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-22**]
Drops Ophthalmic PRN (as needed).
20. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Qday ().
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-22**] Inhalation Q6H (every 6 hours) as needed.
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
14. Carbamazepine 100 mg Tablet Sustained Release 12 hr Sig:
Three (3) Tablet Sustained Release 12 hr PO DAILY (Daily).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
18. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
19. Outpatient Lab Work
Chem 7 (Na+, K+, Cl-, HCO3-, BUN, Cr and Glucose) every Friday.
20. Non-contrast head CT on the morning before seeing Dr. [**First Name8 (NamePattern2) **]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Discharge Disposition:
Extended Care
Facility:
northeast acute rehab
Discharge Diagnosis:
TIA
Seizure disorder
hx of L SDH
Atrial fibrillation - off Coumadin since SDH ([**2190-1-24**])
Discharge Condition:
Stable - Bilateral (L>R) intention and postural tremor plus
Parkinsonian features but otherwise non-focal exam.
Intermittent stuttering of speech as well.
Discharge Instructions:
You were admitted after an episode of R arm weakness and speech
trouble concerning for small stroke/transient ischemic attack or
seizure activity. Due to your pacemaker, you were not able to
get a MRI but repeat CTs were not indicative of new infarct or
worsening of your prior SDH.
Given that your Tegretol (carbamazepine) level was low, it was
increased to 300mg daily with improved level on repeat check.
You did not have further episodes of weakness during this
admission but your speech was stuttering at times hence CT of
head was again repeated on [**2-11**] which was stable. Also, you
were restarted on Aspirin 81mg daily.
You will be returning to [**Hospital 5130**] Rehab for continued
physical and occupational therapy. You will be following up
with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] during which you will have a repeat
head CT prior to the appointment and if no new bleed, you will
likely be restarted on Coumadin for your atrial fibrillation.
Please take your meds as prescribed. You will also need weekly
labs including Na+ because Tegretol can cause hyponatremia. On
the day of your discharge, your Na+ was 132.
Please call your PCP or go to the nearest ED if you have
worsening weakness, speech trouble, numbness and/or visual
problems.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2190-3-15**] 2:30 - you may be called to reschedule this
appointment; also you will have a head CT on the morning before
your appointment.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2190-3-10**] 8:40
Provider: [**Name10 (NameIs) 27270**] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2190-7-8**] 9:00
Completed by:[**2190-2-11**]
ICD9 Codes: 2761, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7172
} | Medical Text: Admission Date: [**2105-2-9**] Discharge Date: [**2105-2-13**]
Date of Birth: [**2038-12-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Accupril / Zestril / Avandia / Tetanus
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
ASD closure/resection left atrial myxoma [**2105-2-9**]
History of Present Illness:
66 yo female with dizziness and bradycardia noted on Holter
monitor.
Dyazide was reduced and workup revealed left atrial mass.
Referred for surgery.
Past Medical History:
left atrial mass
hypertension
insulin-dependent diabetes mellitus
bradycardia
remote fractured ankle
bilat. carotid disease
Social History:
works part time
no tobacco use
no ETOH used
lives with husband
Family History:
aunt with CABG in her 70's
father with CAD and CABG in his 80's
Physical Exam:
HR 54 147/62
5" 132#
WDWN in NAD
skin/HEENT unremarkable
neck supple, full ROM
CTAB
RRR 2/6 murmur
soft, NT, ND, + BS
extrems warm, well-perfused, no edema or varicosities noted
neuro grossly intact
no carotid bruits appreciated
Pertinent Results:
Conclusions
PREBYPASS
A mass consistent with a myxoma or tumor is seen in the body of
the left atrium along the lower anteroseptal area of the
interatrialo septum. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. Physiologic mitral regurgitation is seen
(within normal limits).
POSTBYPASS
There is preserved biventricular systolic function. The LA mass
is no longer visualized. The interatrial septum is intact by 2d,
Color Doppler and by agitated saline at rest and with Valsalva
manuever. The study is otherwise unchanged compared to
prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2105-2-9**] 10:05
[**2105-2-12**] 06:55AM BLOOD WBC-9.5 RBC-3.14* Hgb-9.5* Hct-27.1*
MCV-86 MCH-30.3 MCHC-35.1* RDW-14.4 Plt Ct-154
[**2105-2-12**] 06:55AM BLOOD Glucose-113* UreaN-22* Creat-0.8 Na-139
K-4.2 Cl-103 HCO3-30 AnGap-10
Brief Hospital Course:
Admitted [**2-9**] and underwent surgery with Dr. [**Last Name (STitle) **]. Transferred
to the CVICU in stable condition on phenylephrine and propofol
drips. Extubated that evening.
Given first dose of lopressor 12.5mg and developed bradycardia
w/ HR 30's. Paced until recovered -in junctional rhythm
60's-70's. Chest tubes d/c'd w/ stable CXR.
transferred from the ICU to the floor. Rhythm converted to
sinus. The patient made excellent progress on the floor,
showing good strength and balance with physical therapy. Pacing
wires were discontinued without incident. She was discharged in
good condition to home on POD 4 with appropriate follow up
instructions.
Medications on Admission:
ASA 81 mg daily
calcium 1000 mg [**Hospital1 **]
diovan 160 mg daily
dyazide 37.5/ 25 mg daily
folic acid 400 mcg daily
actos 45 mg daily
glucophage 1000 mg daily
byetta 10 mg SQ [**Hospital1 **]
glipizide 5 mg [**Hospital1 **]
MVI daily
fish oil 1200 mg [**Hospital1 **]
cinnamon 500 mg [**Hospital1 **]
red yeast rice 600 mg [**Hospital1 **]
Discharge Medications:
1. Pioglitazone 15 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
5. Exenatide 10 mcg/0.04 mL Pen Injector Sig: One (1)
Subcutaneous once a day.
Disp:*qs * Refills:*2*
6. 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*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. 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*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
left atrial mass s/p resection
hypertension
insulin-dependent diabetes mellitus
bradycardia
remote fractured ankle
bilat. carotid disease
Discharge Condition:
good
Discharge Instructions:
no lotions , creams or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100.5, redness, drainage or weight
gain greater than 2 pounds in 2 days
no driving for one month
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**1-2**] weeks
see Dr. [**Last Name (STitle) **] in [**2-3**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
call for all appts.
Completed by:[**2105-2-13**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7173
} | Medical Text: Admission Date: [**2149-5-16**] Discharge Date: [**2149-5-20**]
Date of Birth: [**2100-1-17**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Altered mental status/TCA overdose
Major Surgical or Invasive Procedure:
CVL, attempted a lines
History of Present Illness:
49F sent in by ambulance to ED after found with altered mental
status s/p likely suicide attempt by medication overdose.
Patient was found at home after friends found suicide note,
transported by ambulance to [**Hospital1 18**] ED altered, agitated. Per EMS
report, there were two empty desipramine bottles in her
apartment (total likely 50 pills) leading to high suspicion of
TCA overdose.
.
In the ED, vitals on arrival were T 99.3, HR 91, BP 89/72 RR23
O2 sat 99% on 100% NRB. On exam in the ED she was found to be
delirious and agitated and to have intermittent nystagmus and
myoclonic jerking. Her pupils were reactive 4->2. Her tox screen
came back positive for TCA, negative for all other substances on
serum screen. Lactate:1.8. Patient intubated for airway
protection, then weaned down to 100% on FiO2 of 50, PEEP 5, TV
450, propofol used for sedation. Also started on neosynephrine
1.5mcg/kg, after her hypotension not responsive s/p 7L fluid in
total (NS). Also given bicarb - 2 to 3amps push, then 150/hr
3amp bicarb gtt, 200cc/hr with multiple ABGs. Patient with
multiple EKGs with wide complex tachycardia, QRS 128-148.
.
Full history and ROS unable to obtain as patient
intubated/sedated on arrival to MICU.
Past Medical History:
clonazepam 1mg TID - full bottles
lamictal 300mg daily- full bottles
desipramine 250mg PO - per records, was filled on [**5-14**] and there
were two empty bottles in apartment (30 pills/bottle)
Social History:
Unknown
Family History:
Unknown
Physical Exam:
On admission
GENERAL: intubated, sedated
HEENT: sluggish but reactive, 6->4mm, evidence of small
laceration in anterior tongue, +Horiz/vertical nystagmus
Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or gallops. JVP=7
LUNGS: soft, decreased BS
EXTREMITIES: Hyperreflexic bilaterally, with intermittent
myoclonic symmetric jerks in all extremities. Equivocal toes,
without clonus
Pertinent Results:
[**2149-5-16**] 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
.
CT head [**2149-5-17**]
IMPRESSION: No evidence of acute intracranial hemorrhage or
major territorial infarct detected. MRI is more sensitive for
the detection of acute ischemia.
.
CXR [**2149-5-19**]
The endotracheal tube is seen with the tip 5.3 cm above the
carina. The NG
tube is seen traversing the esophagus with tip and side port in
the expected location of the stomach.
The cardiac silhouette, mediastinal and hilar contours are
unchanged. There is no pneumothorax. An interval decrease of
bilateral pleural effusions is noted, along with an artificial
appearance of increased interstitial markings, representing
otherwise unchanged moderate fluid overload. Retrocardiac
atelectasis is unchangeed. No new focal parenchymal opacity is
identified to suggest pneumonia.
IMPRESSION: Interval decrease of bilateral pleural effusions.
Unchanged
moderate fluid overload. No new focal parenchymal opacity to
suggest
pneumonia.
Brief Hospital Course:
49F with prescribed desipramine at home found with altered
mental status at home with likely TCA overdose.
.
#. TCA overdose: TCAs were the likely cause of her altered
mental status on presentation given positive TCA serum tox
screen and the empty bottles in her apartment. On admission the
patient had evidence of both cardiotoxicity with widened QRS,
and neurotoxicity with myoclonus and hyper-reflexia. Toxicology
followed the patient closely. She was started on a HCO3 gtt in
the ED and her EKGs were followed closely and had a prolonged
QRS. Her electrolytes were aggressively repleated. A head CT
was negative for bleed. An EEG was done but the results were
pending at the time of her death. She was on benzos as part of
her sedation and also to help with seizure prophylaxis. She was
hypotensive likely secondary to her overdose and required
pressors. A central line was placed and multiple A lines were
attempted but difficult given how edematous the patient had
become. Given no further progression of her EKGs (although QRS
was still wide) approximately 60 hrs into her hospital course
her HCO3 gtt was discontinued (TCA toxicity typically resolves
in 24hrs).
On [**5-19**] the patient began to exhibit difficulty with oxygenation.
Her CXR had air bronchograms and concern for ARDS. She was put
on PEEP and low TV per ARDS protocal. She was started on
vancomycin and ceftriaxone for PNA coverage given that she was
spiking fevers and with difficult to read CXR. Her EKG
deteriorated overnight from [**Date range (1) 26511**]/09 and she was restarted on
her bicarb gtt. She was given hypertonic saline as well as fat
emulsion. Her EKG continued to progress to a ventricular rhythm
with widened QRS and slurring of the S wave in AVR. She was
continued on levophed and phenylephrine with plans to switch to
an epinephrine gtt and isoproterenol. At this time, she went
into a pulseless ventricular rhythm and CPR was initiated
with-in seconds. She was given a lidocaine push and started on
lidocaine gtt given that lidocaine is preferable in TCA
overdose. She was coded for approx 20-25 minutes with an
initially shockable rhythm, but then remained refractory to
resussitation efforts. She expired on [**2149-5-20**] at 9:13 am. Dr.
[**Last Name (STitle) **], her attending, was present for the entire length of the
code. Her psychiatrist Koldzic was on vacation but the covering
psychiatrist was contact[**Name (NI) **]. Our only contacts at the time of
death were Rabbi [**First Name8 (NamePattern2) **] [**Last Name (Titles) 37791**] and her friend [**Name (NI) 1022**] [**Name (NI) 80762**] were both
contact[**Name (NI) **]. [**Name2 (NI) **] case was sent to the medical examiner.
Medications on Admission:
clonazepam 1mg TID - full bottles
lamictal 300mg daily- full bottles
desipramine 250mg PO - per records, was filled on [**5-14**] and there
were two empty bottles in apartment (30 pills/bottle)
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2149-5-20**]
ICD9 Codes: 5070, 2768, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7174
} | Medical Text: Admission Date: [**2108-2-21**] Discharge Date: [**2108-4-14**]
Date of Birth: [**2045-4-2**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Kefzol / Sulfa (Sulfonamide Antibiotics) /
Shellfish Derived
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Weakness and Shortness of breath
Major Surgical or Invasive Procedure:
[**2108-2-27**] Right sided cardiac catheterization
History of Present Illness:
62 year old woman with pmh significant for dilated right sided
systolic heart failure and diastolic left sided heart failure,
presenting with hypoxia and hypotension in the setting of
diarrhea. The patient states for 3 days prior to her ICU
admission she had diarrhea and extreme fatigue and DOE. She was
only able to walk a few steps prior to stopping. Normally she
can walk a [**12-23**] flight of stairs prior to stopping due to fatigue
and DOE but in total able to walk up 2 flights of stairs. She
was admitted to the [**Hospital Unit Name 153**] and rehydrated, it was thought that her
cardiac index was low due to her dehydration and than she now
had a significant shunt through a large PFO (based on + bubble
then TEE) which was worsening her oxygenation. Her blood
pressure was improved with IVF and dopamine and renal was
consulted for her renal failure who thought it was secondary to
her low cardiac output state. She has been feeling slightly
better over the past few days however still very fatigued and
has not walked so is unable to give a history in regards to DOE.
She has stable [**1-24**] pillow orthopnea now and prior to admission,
no PND. She has noticed an increase in her lower extremity edema
since admission. Her diarrhea has stopped. No chest pain. No LH
or syncope, no F/C/NS or any other complaints.
.
She was transferred from the [**Hospital Unit Name 153**] to the [**Hospital1 1516**] service for a R
heart cath to [**Hospital1 4656**] the effect of NO on reducing PVR to see
if PFO closure would be helpful.
Past Medical History:
- Diastolic LV failure, pulmonary hypertension, RV systolic
dysfunction
- Tricuspid regurgitation, evaluated by cardiac [**Doctor First Name **]. not
operative candidate at this time.
- Atrial fibrillation on aspirin. Decision not to persue
anticoagulation
- Ulcerative Colitis
- Liver disease, (congestion vs. EtOH vs. primary biliary
pathophys.)
- Alcohol abuse, remote
- Ventral hernia repair
- Back surgery
- History of GI bleed, [**10-28**] with 5cm duodenal ulcer
- Hypokalemia
- Hyponatremia
- hypertension
- hypercholesterolemia (TG 53, Chol 145 HDL 71 LDL 63 on
[**10/2107**])
Social History:
The patient is married. She does have an abusive partner but
states that she feels safe at home. She has very supportive
children and 17
grandchildren. She drinks ETOH socially and denies smoking
Family History:
Father with MI at age 68. Mother with breast cancer at 52
Physical Exam:
VS: afebrile. HR 100 BP 123/56 96% on 2L
GEN: NAD, AOX3
HEENT: JVP 14cm, MM slightly dry, OP clear
CARD: [**1-27**] HSM at LLSB, RRR, normal S1, S2
PULM: CTAB
ABD: obese, soft, NT, ND, no masses, BS+
EXT: 3+ edema bilaterally, L > R. Midcalf measurements
circumference: L 56cm, R 49cm.
unilateral LUE swelling
NEURO: CN2-12, AOx3, 5/5 strength in all 4 extremities
Pertinent Results:
[**2108-2-21**] CXR: Since [**2108-1-13**], right pleural effusion
decreased, now small with improved adjacent atelectasis. Left
pleural effusion also decreased, now tiny. Left-sided central
venous line was removed. There is no interstitial edema and no
focal area of consolidation. Cardiomegaly persists.
.
[**2108-2-22**] ECHO: The left atrium is moderately dilated. No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). A right-to-left shunt across the interatrial
septum is seen at rest. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The right ventricular cavity is moderately dilated with
moderate global free wall hypokinesis. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The tricuspid valve
leaflets fail to fully coapt. Moderate to severe [3+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2108-1-23**], a
right-to-left shung is now identified (no saline used on the
prior study). Right ventricular free wall motion is minimally
more depressed. The severity of mitral regurgitation is reduced
(may be related to lower systemic blood pressure). This
constellation of findings is suggestive of primary RV
cardiomyopathy (ARVC, myocarditis, ischemia) or prior large
intracardiac shunt/ASD and LESS suggestive of a primary
pulmonary process (e.g., pulmonary embolism, COPD, PPH, etc.).
.
[**2108-2-22**] Renal ultrasound: Unremarkable examination without
evidence of hydronephrosis.
.
[**2108-2-23**] RUQ US: No biliary ductal dilation. Probable gallbladder
sludge. Right pleural effusion.
.
[**2108-2-27**] Cardiac Cath:
1. Resting hemodynamics demonstrated marked elevation in
biventricular filling pressures, with a baseline RVEDP of 33
mmHg and a mean PCWP of 37 mmHg; moderate pulmonary hypertension
with a mean PA pressure of 48 mmHg; and preserved cardiac
output. There was no evidence of right-to-left shunting at the
current loading conditions.
2. Treatment with 100% FiO2 demonstrated mild improvedment in
pulmonary
vascular resistance with slight worsening of the PCWP.
3. Treatment with inhaled NO at 40ppm did not change the
pulmonary
pressures significantly.
.
[**2108-3-1**] Cardiac MR:
1. Limited and incomplete study secondary to early termination
of protocol due to MR system failure. Recommend repeat study at
later stage.
2. The left upper, left lower, right upper, and right lower
pulmonary veins were visualized in their correct anatomical
positions and entered the left atrium. Other anomalous pulmonary
venous drainage or ASD cannot be definitively excluded.
3. Normal left ventricular cavity size with normal global
systolic function.
4. Moderate right ventricular enlargement with mild systolic
dysfunction. No CMR evidence of right ventricular fatty
infiltration/dysplasia.
5. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was mildly increased.
6. Moderate [**Hospital1 **]-atrial enlargement.
7. A note is made of moderate right pleural effusion and right
lower lobe
basal atelectasis.
.
[**2108-3-2**] Cardiac CT:
1. No evidence of anomalous pulmonary vein return. There are two
right and
two left pulmonary veins draining into the left atrium.
2. Interval decrease in moderate amount of right pleural
effusion associated with compressive right lower lobe
atelectasis.
3. Unchanged mild cardiomegaly.
4. 3.6-mm lung nodule. If patient has history of smoking or
other known risk factors, a followup in one year is recommended.
5. Asymmetric breast parenchyma (left > right). Please correlate
with
physical examination.
Brief Hospital Course:
62 yo female with history of A-fib, CHF, PUD, and Ulcerative
Colitis, presented with hypoxia and hypotension. Both hypoxia
(secondary to shunting) and hypotension resolved with fluid
resucitation in the ICU. She was transferred to the cardiology
floor where she has been closely monitored and her heart failure
treated with aggressive diuresis. She began having rectal
bleeding and was transferred to the [**Hospital Ward Name **] for endoscopy w/
general anesthesia. Cscope report read: 2 small superficial
ulcerated areas with very active oozing and adherent clot were
noted in the sigmoid and distal transverse colon. The rest of
the colonic mucosa looked normal - no evidence of active
ulcerative colitis. A single clip was successfully applied to
the transverse lesion and 2 clips were successfully applied to
the sigmoid lesion. Otherwise normal colonoscopy to cecum. Her
bleeding continued slowly but her Hct remained stable and after
a short stay in the ICU she was transferred back to the
cardiology service for diuresis. ON the cardiology floor she had
very poor urine output with lasix gtt so was transferred to the
CCU for ultrafiltration. The following is a problem based brief
hospital course after her transfer to the CCU.
# CHF: Patient has a known complicated CHF history requiring
multiple hospitalizations. Patient's right sided heart failure
was presumed to be secondary to left diastolic heart failure (EF
55%). During this admission she was found to have a PFO which
demonstrated R to L flow and caused her hypoxia. Increasing
left sided pressures with IV hydration in the ICU resolved the
shunt and hypoxia. Patient was then transferred to the floor.
Right heart cath was performed. Pulmonary hypertension did not
respond to nitric oxide. Decision was made to treat CHF with
aggressive diuresis. Diuresis was titrated up to lasix gtt at
30 cc/hr and metalozone 5 mg po bid with minimal output. At
this point patient became hypoxic and hypotensive with acute
renal failure again and diuresis was discontinued. Her
hypoxia/hypotension improved and her UOP continued to be poor so
she was restarted on lasix drip with metolazone and transferred
back to cardiology. The patient continued to have poor uop
despite lasix gtt at 30. She was transferred to the CCU for UF
to remove the excess fluid. Over the next few days she was net
negative > 20L. A repeat RH cath showed minimal elevation of PA
pressures and PVR. After UF patient had TTE that showed
improvement in pressures and UF was discontinued. Her CVP was
less than 10, compared to 35+ initially. Subsequetly she was
able to maintain a urine output of 30-60 ml/hr without lasix
drip. Eventually her vasopressin and phenylephrine were
discontinued. She was transitioned to oral midodrine. She
occasionally required neosynephrine to keep her MAPs >50 however
she continued to have good uop regardless of her pressor
requirement. On her repeat TTE, there was evidence of
persistent tricuspid regurgitation despite improvement in her
volume status. The idea of performing a tricuspid valve
repair/replacement was discussed with CT surgery and she had a
cardiac MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] her right heart function. As she
improved significantly and she was able to maintain her blood
pressures and UOP on midodrine alone for many days, the decision
was made to postpone discussion of TVR until a later date. She
was able to be started on low dose metoprolol 12.5mg [**Hospital1 **] without
a significant drop in her blood pressure. She was also
restarted on a lower dose of spironolactone 25mg. She was
discharged with this medication regimen and strict instructions
to monitor her weights daily, and restrict her sodium intake to
2gm per day. The patient will follow up with Dr. [**First Name (STitle) 437**] in 2
weeks. VNA will be provided to ensure medication and nutrition
compliance and daily weights are documented.
# ARF: Baseline Cr 1.2. Creatinine peaked during this admission
at 3.4 shortly after presentation likely secondary to ATN from
hypotensive insult. Renal was consulted and patient's
mesalamine was held, and discontinued. Diuresis was held
initially and her creatinine returned to baseline. With
reinitiation of diuresis patient's creatinine again started to
rise up to 3.6. She was transferred to the CCU and started on UF
as above. After aggressive diuresis, her creatinine continued to
trend down suggesting poor forward flow from poor CO from RHF as
the cause for her ARF. Her renal function was at her baseline
on discharge.
# Bacteremia: Patient had hypotension and peripheral
vasodilation with elevated WBC about 1 month into her
hospitalization. Cultures were drawn and she was found to have
serratia from the PA catheter line and coagulase negative staph
from the A-line. She was started on Vanc, aztreonam (allergy to
cefalosporins and ARF so gentamicin contraindicated), and cipro.
The lines were discontinued. Sensitivities of GNRs showed
Serratia sensitive to Cipro. She was continued on cipro and
aztreonam was discontinued. GPCs were coag negative staph.
Repeat TTE showed no vegetations. Follow up blood cultures
remained negative. The patient was afebrile many days after
discontinuing antibiotic therapy.
# UTI: Patient had positive UA with GNRs (>100,000) on her urine
culture. She was started on Cipro as above. Sensitivities showed
seratia and enterobacter both sensitive to cipro. The patient
completed a course of cipro prior to discharge and did not
require additional antibiotics.
# Atrial fibrillation: Patient has history of chronic atrial
fibrillation. She was remained rate controlled thoughout
admission. She was not on anticoagulation at presentation. She
was treated with daily aspirin and metoprolol until the onset of
significant GI bleed. At this time both were held. She
underwent PFO closure on [**2108-3-14**] and was not restarted on
anticoagulation because of her GIB. She was able to be
restarted on metoprolol 12.5mg [**Hospital1 **] for rate control. No other
anticoagulation other than aspirin was initiated prior to
discharge given her GI bleed.
# Hyponatremia: Na 131 on presentation. Patient was clearly
hypervolemic. Hypervolemic hyponatremia was related to heart
failure and volume overload. The sodium continued to slowly
decrease without neurologic compromise. In part this was
attribute to vasopressin use in addition to CHF. On discharge
her sodium had returned to 130.
# LFT abnormalities: Elevated AST and Alk phos with normal ALT
on presentation. Liver US showed no pathology. Per outpatient GI
workup LFT abnormalities are likely attributed to congestive
hepatopathy. Will have the patient follow up with Dr. [**Last Name (STitle) 497**] as
an outpatient.
# CODE: FULL CODE
.
# CONTACT: [**Name (NI) **] (son and HCP) [**0-0-**]
Medications on Admission:
Insulin SC sliding scale
MetronidAZOLE Topical 1 % Gel
Miconazole 2% Cream
Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN
Oxycodone-Acetaminophen 1 TAB PO Q6H:PRN pain
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
Pantoprazole 40 mg IV Q12H
Artificial Tears 1-2 DROP BOTH EYES PRN
Ferrous Sulfate 325 mg PO DAILY
FoLIC Acid 1 mg PO DAILY
Gabapentin 100 mg PO HS
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metronidazole 1 % Gel Sig: One (1) Appl Topical DAILY (Daily)
as needed for acne.
Disp:*1 tube* Refills:*0*
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*2*
11. Midodrine 10 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Disp:*180 Tablet(s)* Refills:*2*
12. Gabapentin 100 mg Tablet Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*60 Capsule(s)* Refills:*2*
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
14. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
Patent Foramen Ovale with shunting
Right sided Congestive Heart Failure
Atrial fibrillation
Acute renal failure
Discharge Condition:
The patient was hemodynamically stable prior to discharge.
Discharge Instructions:
You were admitted to the hospital for weakness and shortness of
breath. You were found to have low blood pressure and low
oxygen levels. You were admitted to the ICU. After you were
stablized you were transferred to the floor. There you
underwent cardiac catheterization and a series of imaging to
[**Hospital 4656**] causes of your heart failure. You were treated with
medications to reduce the pressure in your heart and to help
your breathing.
.
Please weigh yourself daily and report weight gain of more than
3 pounds per day or more than 6 pounds per 3 days to Dr. [**First Name (STitle) 437**].
.
Please restrict your sodium intake to 2gm per day.
.
The following changes were made to you home medications:
.
1) STOP Toprol 125mg
2) STOP Mesalamine (Asacol)
3) STOP Torsemide
4) Decrease Spironolactone to 25mg daily
5) STOP Colchicine and Codeine
6) START Aspirin 325 mg by mouth daily
7) START Midodrine 20mg three times a day for your blood
pressure
8) START Metoprolol 12.5mg twice a day
9) START Metronidazole 1 % Gel Appl Topical DAILY as needed for
acne
10) START Trazodone 25 mg at bedtime as needed
11) START Gabapentin 200 mg at bedtime
12) START Albuterol 90 mcg/Actuation Aerosol Two puffs
Inhalation every four hours as needed for shortness of breath or
wheezing.
.
Please notify your physician or return to the hospital if you
experience if you experience increased shortness of breath,
chest pain, loss of consciousness, fever, chills, or any other
symptom that is concerning to you.
Followup Instructions:
Please keep all of your previously scheduled appointments as
listed below:
1)Provider [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2108-3-26**]
1:30pm
2)Provider [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2108-3-15**] 11:00
3)Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13472**], MD Phone:[**Telephone/Fax (1) 13473**]
Date/Time:[**2108-3-16**] 10:30
Completed by:[**2108-4-14**]
ICD9 Codes: 5845, 2761, 2851, 5990, 2762, 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7175
} | Medical Text: Admission Date: [**2176-2-16**] Discharge Date: [**2176-2-22**]
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
found down, SAH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]yo woman with poorly controlled HTN
(baseline 160s per PCP), h/o paroxysmal atrial tach,
hypothyroidism, moderate dementia who was found down at NH today
in her own urine. Pt does not recall falling, does not recall
any symptoms prior to fall. Does not recall whether she hit her
head. She was brought to the ER where she was found to be
hypertensive with BP 222/111, to have no bruises or stigmata of
fall. According to her brother she was only mildly off her
baseline mental status in the ER.
.
Head CT done due to fall showed small parietal SAH. She was seen
by neurosurgery and neurology who recommended BP control, no
antiepileptics given small size of SAH, and repeat head CT in
the AM. She was started on a nitroglycerin drip with goal SBP
<165. She was given one dose of hydralazine and aspirin x 1. EKG
showed prominent T waves but when repeated several times over
several hours showed no evolution. She denied chest pain,
shortness of breath but did contain of some dizziness and
unsteady gait. She also reported a feeling like something was in
her throat and she had to clear her throat although no itching,
no difficulty breathing. She was seen putting her finger in her
mouth and possibly touching near her uvula.
.
She was admitted to the ICU for blood pressure control and
monitoring. On arrival to the ICU she was found to be
disoriented, attempting to crawl out of bed, refusing to
cooperate or to answer questions. She repeatedly clears her
thorat and says she feels like something is "cack there." She
denies all other complaints and does not let me complete ROS as
she no longer wishes to cooperate.
.
Paperwork from her home facility states that her blood pressure
medications are typically taken at 8am, although we do not have
dispense records to confirm that she received these today. Notes
that her BP at 9:30am was 160/80, however she then fell and
after the fall it was 190/90.
.
Past Medical History:
Dementia
HTN - baseline sbp 160s per pcp
paroxysmal atrial tachycardia
Hypothyroidism s/p resection of funcitoning goiter
s/p R hip replacement
L hip ORIF
Social History:
Lives at Nursing Home. uanble to elicit further history.
Family History:
unable to elicit
Physical Exam:
T 98.7 HR 76, BP 165/64, 94% on RA
Gen: attempting to climb out of bed, refusing to answer
questions, insisting on going home, does not know where she is,
refuses to tell me her name, repeatedly clearing her throat
HEENT: surgical pupils, MM moist, uvula notably injected and
edematous although not obstructing airway
Cor: RRR, s1s2, no murmur
Pulm: CTAB, limited cooperation
Abd: distended, soft, NT, +BS
Ext: no edema, w/w/p
Neuro: pt not following commands at present however by report in
ER she had 5/5 strength throughout and was intact to light
touch.
Pertinent Results:
remarkable for WBC 15.9, 6% bands, 86% polys; CK 1182->1250, MB
18->14; trop 0.08->0.03, MB index 1.5->1.1. creatinine 1.2 (at
last check 1.6).
.
Studies:
EKG: NSR at 60, nl axis, nl intervals, tall T waves, persistent
on repeat EKG. no ST changes, no Q waves, no TWI.
CXR: No radiographic evidence of traumatic injury.
.
CT head:
A tiny amount of subarachnoid blood is seen within a single
right
parietal focus. No additional intra- or extra-axial hemorrhage
is seen. There is no mass effect or shift of normally midline
structures. Small lacunar infarcts are noted within the left
coronal radiata and bilateral external capsules. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. The visualized paranasal
sinuses and mastoid air cells are clear. No fractures are
identified. The bones of the skull are diffusely demineralized.
IMPRESSION: Small right parietal subarachnoid hemorrhage.
Brief Hospital Course:
[**Age over 90 **]yo woman with paroxysmal atrial tachycardia, hypothyroidism
poorly controlled HTN wtih baseline sbp 160s presented s/p
unwitnessed fall found in urine with new small SAH on head CT
and BP 222/111 on arrival to ER.
.
# Subarachnoid hemorrhage. The patient was admitted after a fall
and was found on CT head to have a small SAH. It is not clear if
this was due to hypertension (on admission approximately
200/100) or fall (NO stigmata of head trauma). The patient was
seen by neurosurgery and neurology in the ED. She was managed
medically with bp control. Without mass effect or ongoing
bleeding, the patient was not given seizure prophylaxis. The
patient had a repeat CT scan the following morning after
overnight ICU monitoring that revealed no change in the SAH. The
patient requires ongoing blood pressure control with target
130-160/70-80. The patient should avoid blood thinning
medications such as aspirin and heparin products until her SAH
resolves.
.
# HTN. The patient presented with marked hypertensive urgency.
She initially was placed on a labetolol drip. After confirmation
of her home meds, these were re-instituted. She continued to
have periods of elevated blood pressure (up to 190 systolic) for
which she received intermittent hydralazine. Her amlodipine was
upregulated with much improved control over the 24 hours prior
to discharge.
.
# Mechanical fall vs. syncope. The patient was a poor historian
and her fall was unwitnessed, though she was found in her own
urine. The patient was maintained on tele without event. She had
no EKG changes. She had a cardiac enzyme elevation on admission
though these trended downwards. Echo revealed mild AS and no
other mechanical explanation for her fall. Carotid ultrasound
showed some bilateral plaque without hemodynamically significant
stenosis on preliminary read. The patient had an EEG with some
signs of frontal cortical irritability likely secondary to the
SAH though no signs of seizure activity. Repeat EEG showed
slowing at the right parietal lobe again consistent with SAH and
no other concerning activity.
.
# Altered mental status. The patient is known to have baseline
'moderate' dementia. The patinet's brother and son described her
baseline mental status as poorly oriented to place and time. The
patient had waxing and [**Doctor Last Name 688**] consciousness/orientation
consistent with sundowning. She had no signs of infection, a
post-ictal state to explain her symptoms. Her TSH was in normal
limits. This almost certainly represents baseline dementia
exacerbated by sundowning in an elderly woman in a new
environment with loss of orienting cues. The patient
intermittently required haldol and disintegrating olanzapine
tabs at times of agitation.
.
# Hypothyroidism. TSH normal. Continued on home synthroid.
.
# Code status: DNR/DNI
.
# Communication: [**Name (NI) **] [**Name (NI) **], brother and HCP (c) [**Telephone/Fax (1) 107869**],
(h) [**Telephone/Fax (1) 107870**] (w) [**Telephone/Fax (1) 107871**]. PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 140**] [**Last Name (NamePattern1) 141**]
[**Telephone/Fax (1) **].
.
Medications on Admission:
Levoxyl 75mcg po qday
Dyazide (hydrochlorothiazide/triamterene) 1 cap po qday
ECAsa 81mg po qday
Atenolol 25mg po qday
Avapro (irbesartan) 150mg po qday
Lipitor 10mg po qday
Ca + Vit D (citracal) 2 tabs qday
folgard 2.2mg po qday
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Citracal + D 250-200 mg-unit Tablet Sig: Two (2) Tablet PO
once a day.
5. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO qday ().
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for Agitation.
8. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Fall
Stable subarachnoid hemorrhage
Hypertensive urgency
.
Hypothyroidism
Dementia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted because of a fall. Work-up was negative for a
cardiac or neurologic explanation for your fall. It is likely
that you had a mechanical fall.
.
You were found to have a small, stable bleed around your brain.
This may be due to extremely high blood pressure or from your
fall. You do not have any signs of ongoing bleeding. Please take
all of your blood pressure medications. Your target blood
pressure is systolic 130-160, diastolic 70-80.
.
You had episodes of confusion, agitation and disorientation
while in the hospital. This is in part due to baseline dementia.
Your dementia was exacerbated by new surroundings and loss of
orienting cues.
.
Follow-up with Dr. [**Last Name (STitle) 141**].
.
Take all medications as prescribed.
.
Call your doctor or return to the hospital for any new or
worsening dizziness, lightheadedness, blurred vision, nausea,
vomiting, severe headache, falls, chest pain or other concerning
symptoms.
Followup Instructions:
Dr. [**Last Name (STitle) 141**] [**2176-3-31**] 09:45AM
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 2761, 5849, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7176
} | Medical Text: Admission Date: [**2152-2-9**] Discharge Date: [**2152-2-23**]
Date of Birth: [**2074-4-3**] Sex: F
Service: MEDICINE
Allergies:
Atorvastatin / Zestril / Cephalosporins / Penicillins
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
unresponsive, hypoxia
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
77 yo female who lives at [**Hospital3 1186**] (baseline, oriented to
person and place) had a fall at [**Hospital3 1186**]. 4 hrs later found
unresponsive. Intubated at scene. CXR with RLL
collapse/infiltrate; bronch/endotracheal specmen grew MSSA.
Also with COPD exacerbation, on prednisone and vancomycin (given
unknown PCN/ceph allergy). Extubated last week, failed (believed
[**1-7**] COPD) and re-intubated. Extubated again on [**2152-2-18**] and now
stable on 2L. Post-second extubation, made DNR/DNI.
_______________
MICU summary by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]:
HPI: 78f, h/o DM, HTN, found unresponsive 4 hrs after she was
put into bed after a fall, intubated on scene, now more
responsive - intubated/sedated. According to notes, she fell out
of bed around 2am (denied trauma to head); assessment revealed
normal vitals and patient was apparently mentating
appropriately. She was put back in bed. About 3 hours later, she
was found by staff to be unresponsive (she had been complaining
of SOB--85% RA, improved with O2). VS were otherwise stable, BG
was 97. EMS was called, and she was intubated on the seen and
brought to the ED. In the ED, she was hypertensive (220/palp),
afebrile, was responsive to commands when off sedation. Initial
gas showed severe acidosis (7.11/111/141), potassium was
increased to 6 with a creatinine of 1.8. One set of CEs that
were negative. EKG showed sinus brady with no obvious ST/T
changes. She was given 3 L IVF (was transiently hypotensive to
90s while on propofol -- this resolved off propofol and with
IVF). She was found to have a positive UA and was given a dose
of levofloxacin. She was given kayexalate for hyperkalemia
(improvement of K to 5.3). FAST scan was negative, and she had
CT neck/head. CT neck was significant for ?right RP soft tissue
prominence (no fracture or dislocation), and CT head was
negative for acute event. She was transferred to the [**Hospital Unit Name 153**] for
further management.
__________________________________________
MICU course -- per [**Hospital Unit Name 153**] notes:
[**2-10**]: Bronch without mucous plug. BAL with 1+GPC pairs. Vanc and
prednisone started. Echo with preserved EF, sm-mod pericard
effusion.
[**2-11**]: Failed PS trial due to tachypnea/tachycardia. Restarted
lasix and increased lopressor. Added back home clonidine.
Changed TFs started. Proteus returned [**Last Name (un) 36**] to
cephalosporins/zosyn, so switched cipro to ceftriaxone
[**2-12**]: Cleared c-spine clinically. On PS for several hours. UOP
very low, gave repeated fluid boluses. Lasix d/c'd for rising
Creatinine.
[**2-13**]: Extubated, but retained C02/somnolent and required
re-intubation. Lantus restarted at 1/2 home dose.
[**2-14**]: RUE US - for DVT. Spoke with brother RE: trach, he's
thinking about it but likely will pursue. Increased BP meds
(clonidine). Diuresed with lasix X 2.
[**2-15**]: Brother re: trach: no. Prednisone tapered to 40. Lantus
increased to 30.
[**2-16**]: DNR/DNI per family. Plan thoracentesis tomorrow,
extubation Fri.
[**2-17**]: Further discussion with family. No plan for trach. [**Female First Name (un) **]
planned but not a large enough effusion. D/c'd antibiotics.
[**2-18**]: Extubated. Tolerating at time of writing. Officially
DNR/DNI: No re-intubation planned if she worsens.
Past Medical History:
1. Status post right total knee replacement
2. DM II, c/b neuropathy and nephropathy.
3. Osteoarthritis.
4. Hypertension.
5. Asthma.
6. Hypercholesterolemia.
7. Parkinson's.
8. Obesity.
9. GERD.
10. Bipolar/paranoia.
11. History of falls.
Social History:
Shx: lives in an [**Hospital3 **] facility. No known h/o tobacco
or alcohol use.
Family History:
NC
Physical Exam:
temp 96.5 BP 171/74 HR 58 RR 18 sats 99% on 2 liter oxygen
nasal canula
gen: very awake, very alert, pleasant, no acute distress,
cooperative
patient examined sitting up in a chair
HEENT: anicteric sclera
chest: good inspiratory air movement; a bit ronchorous on
expiration throughtout
heart: RRR; I could not notice a murmur
abd: has PEG. very soft. BS+. not tender at all. is mildly
distended tympanitic - notably upper [**12-7**] of abdomen (she is
sitting in chair)
ext: trace pitting edema LE bilaterally
pulses: 2+ DP pulse bilaterally
neuro: knows her full name. knows president is "[**Doctor Last Name **]."
Identifies all 4 family members in the room correctly.
eyebrows up symmetrically
tongue is midline
biceps is 4+/5 bilaterally
handgrip is [**3-9**] bilaterally
quads is [**4-8**] bilaterally
plantarflexion feet is [**4-8**] bilaterally
dorsiflexion feet is [**4-8**] bilaterally
sensation to light touch is intact on her face/arms/legs (she
correctly identifies the body part I touched)
Pertinent Results:
[**2152-2-9**] 07:29PM TYPE-ART TEMP-38.0 RATES-20/ TIDAL VOL-400
PEEP-10 O2-60 PO2-88 PCO2-51* PH-7.37 TOTAL CO2-31* BASE XS-2
-ASSIST/CON INTUBATED-INTUBATED
[**2152-2-9**] 04:53PM TYPE-ART TEMP-36.6 PO2-241* PCO2-48* PH-7.35
TOTAL CO2-28 BASE XS-0 INTUBATED-INTUBATED
[**2152-2-9**] 04:53PM LACTATE-0.7
[**2152-2-9**] 02:59PM GLUCOSE-88 UREA N-36* CREAT-1.4* SODIUM-147*
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-25 ANION GAP-15
[**2152-2-9**] 02:59PM CK(CPK)-44
[**2152-2-9**] 02:59PM CK-MB-4 cTropnT-0.03*
[**2152-2-9**] 02:59PM CALCIUM-9.3 PHOSPHATE-3.0# MAGNESIUM-2.6
[**2152-2-9**] 02:59PM TSH-1.2
[**2152-2-9**] 02:59PM WBC-9.4 RBC-3.76* HGB-11.2* HCT-34.4* MCV-92
MCH-29.9 MCHC-32.7 RDW-16.7*
[**2152-2-9**] 02:59PM PT-12.6 PTT-20.3* INR(PT)-1.1
[**2152-2-9**] 02:59PM PLT COUNT-305
[**2152-2-9**] 01:00PM PO2-205* PCO2-33* PH-7.46* TOTAL CO2-24 BASE
XS-1 COMMENTS-GREEN TOP,
[**2152-2-9**] 01:00PM K+-5.3
[**2152-2-9**] 08:15AM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.025
[**2152-2-9**] 08:15AM URINE BLOOD-NEG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-8.0
LEUK-MOD
[**2152-2-9**] 08:15AM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2152-2-9**] 08:15AM URINE HYALINE-0-2
[**2152-2-9**] 08:15AM URINE 3PHOSPHAT-FEW
[**2152-2-9**] 07:56AM TYPE-ART TIDAL VOL-280 PO2-231* PCO2-87*
PH-7.16* TOTAL CO2-33* BASE XS-0 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2152-2-9**] 06:49AM RATES-/16 PEEP-5 PO2-141* PCO2-111* PH-7.10*
TOTAL CO2-36* BASE XS-1 INTUBATED-INTUBATED COMMENTS-GREEN TOP
[**2152-2-9**] 06:49AM K+-5.8*
[**2152-2-9**] 06:45AM GLUCOSE-125* UREA N-42* CREAT-1.8* SODIUM-143
POTASSIUM-6.0* CHLORIDE-107 TOTAL CO2-28 ANION GAP-14
[**2152-2-9**] 06:45AM estGFR-Using this
[**2152-2-9**] 06:45AM ALT(SGPT)-15 AST(SGOT)-17 LD(LDH)-251*
CK(CPK)-60 ALK PHOS-106 AMYLASE-25 TOT BILI-0.2
[**2152-2-9**] 06:45AM LIPASE-26
[**2152-2-9**] 06:45AM CK-MB-NotDone cTropnT-0.02*
[**2152-2-9**] 06:45AM ALBUMIN-4.2 CALCIUM-10.0 PHOSPHATE-5.8*
MAGNESIUM-2.9*
[**2152-2-9**] 06:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2152-2-9**] 06:45AM WBC-9.3 RBC-3.87* HGB-11.8* HCT-37.5 MCV-97
MCH-30.5 MCHC-31.5 RDW-16.6*
[**2152-2-9**] 06:45AM PT-12.5 PTT-22.6 INR(PT)-1.1
[**2152-2-9**] 06:45AM PLT COUNT-334
.
CTA chest:
1. No pulmonary embolism or acute aortic pathology.
2. Right lower lobe collapse, left lower lobe partial collapse
and patchy atelectasis of the aerated portions of lung.
3. Small bilateral pleural effusions.
4. Endotracheal tube terminates in low position 1-2 cm above the
carina.
4. Multiple enlarged mediastinal lymph nodes up to 12 mm are
nonspecific.
5. Moderate pericardial effusion.
6. Emphysema.
7. 3 cm predominantly low attenuation lesion of the left hepatic
lobe is incompletely characterized, but has features suggestive
of a hemangioma. This could be confirmed with ultrasound.
.
CT C spine: 1. No evidence of acute fracture or dislocation.
2. Soft tissue prominence mostly within the right
retropharyngeal space and extending anterior and medial to the
right carotid space. This likely represents a hematoma, possibly
related to patient's traumatic injury or traumatic intubation.
3. Prominent interseptal thickening within the apices, may be
related to underlying failure/volume overload as suggested on
chest radiograph done on same day.
4. Multilevel spondylytic changes.
.
head CT: No intracranial hemorrhage or mass identified.
.
abd U/S: 2.9-cm lesion of the left hepatic lobe could represent
an atypical hemangioma but is not definitively characterized by
ultrasound. It does not have particularly worrisome features. If
clinically indicated, it could be further characterized with MR
after the patient's acute medical problems have resolved.
.
TTE: The left atrium is normal in size. There is moderate
symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall
left ventricular systolic function is normal (LVEF>55%).
Transmitral Doppler
and tissue velocity imaging are consistent with Grade I (mild)
LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are
mildly thickened. Physiologic mitral regurgitation is seen
(within normal
limits). The left ventricular inflow pattern suggests impaired
relaxation.
There is a small to moderate sized pericardial effusion. There
are no
echocardiographic signs of tamponade.
Brief Hospital Course:
## PULM - Respiratory failure that was thought to be
multifactorial (PNA, COPD, RLL collapse, tracheomalacia,
diastolic heart failure) has resolved and pt now on 2 Liters of
oxygen by nasal canula with sats of 99%. She is completing a 2
weeks course of vancomcycin for MSSA PNA.
## CARDS - hx of HTN and is on MANY medications for control and
still has elevated BP. Has diastolic CHF. Initially BP meds held
given instability, but then restarted. On [**2-22**] she triggered on
the floor for flash pulmonary edema with elevated BP. After
giving IV lasix and better BP control her CHF improved. She may
need continued diuresis at NH. Will need daily weights, 1500 cc
fluid restriction.
## GI - has hx of PEG and I am not sure why. Tolerates po,
apparently. Of note, imaging studies found a possible
hemangioma on liver. Will need f/u abdominal MRI per PCP as an
outpatient.
## GU - Cr back to normal, follow up with PCP after diuresis.
## ID
s/p treatment for proteus UTI and also proteus PNA (sputum +
currently finishing abx for MSSA PNA. Pt on vanco bc of
concerns of allergies to PCN. Last day will be [**2-25**] of vanco.
# ENDO. Pt has DM with HgAIC in [**2149**] of 10. Pt with multiple
cardiac risk factors so would hope to get better glucose
control. Currently on ss insulin.
Restarted pt's home lantus dose.
code status: DNR/DNI
decision maker is her brother [**Name (NI) **] [**Name (NI) 3234**] [**Telephone/Fax (1) 19567**]
Medications on Admission:
1. Novolin R sliding scale
2. Toprol XL 100mg po bid
3. Tylenol 500mg, one tab qid po
4. Alprazolam 0.5 mg tablet po qhs
5. Fleets enema 1 rectally daily prn constipation (2 hr after
docolax supp if no BM)
6. Bisocodyl 10 mg supp rectally daily prn constipation (give 24
hrs after MOM of no BM)
7. MOM 30 ml via g-tube daily prn constipation (give on 3rd day
without BM)
8. Alprazolam 1 mg tablet po bid prn anxiety/agitation
9. Combivent inhaler 2 puffs by mouth qid prn wheezing
10. Tylenol 650 mg via g-tube q 4 hr prn pain/temp >100
11. Duonieb neb 0.02% qid prn congestion/SOB
12. Lantus 35 units sc q evening
13. Neurontin 50 mg po qhs
14. Isosorbide 60 mg po daily
15. Norvasc 10 mg po daily
16. Prilosec 20 mg po daily
17. Seroquel 100 mg po daily at 4pm
18. Quinine sulfate 260 mg po daily at 8pm
19. Clonidine HCl 0.1 mg po q 12 hr
20. Depakote 250 mg po bid
21. Furosemide 40 mg po daily
22. Senna 2 tablets po bid
Discharge Medications:
1. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
6. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO BID (2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
10. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
14. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous at bedtime.
15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale sliding scale Subcutaneous four times a day.
16. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
17. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Prednisone 10 mg Tablet Sig: taper as directed Tablet PO
once a day: Take 3 tabs daily for 3 days, then 2 tabs daily for
3 days, then 1 tab daily for 3 days, then stop.
Disp:*18 Tablet(s)* Refills:*0*
19. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
21. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
23. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 24H (Every 24 Hours) for 3 days.
Disp:*3 g* Refills:*0*
24. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Diastolic Congestive Heart Failure
Staph Pneumonia
Respiratory Failure
COPD
Discharge Condition:
stable
Discharge Instructions:
Continue your medications as listed. Please continue a 1500 cc
fluid restiction, and a low salt diet. Please make sure to weigh
yourself daily and call your doctor if you gain more than 3lbs.
Please make sure you follow up with your PCP [**Last Name (NamePattern4) **] [**12-7**] weeks.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **] in [**12-7**] weeks. Please discuss
having a follow up abdominal MRI with him to evalaute the liver
mass seen on ultrasound.
ICD9 Codes: 2762, 5849, 2767, 5990, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7177
} | Medical Text: Admission Date: [**2200-7-28**] Discharge Date: [**2200-8-16**]
Date of Birth: [**2126-1-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Scheduled cardiac catherterization for further assessment of
aortic stenosis
Major Surgical or Invasive Procedure:
[**2200-7-31**] - 1. Aortic valve replacement with a 21 mm [**Last Name (un) 3843**]
[**Doctor Last Name **] magna pericardial valve. 2. Left atrial exploration and
ligation of left atrial appendage.
History of Present Illness:
Pt is a 74 yo man with h/o stroke in [**2186**] on warfarin, recent
TIA in [**5-1**], a. fib, HTN, and dyslipidemia who presents for
scheduled cardiac catheterization for further assessment of
aortic stenosis. Pt reports he was recently diagnosed by
echocardiogram in [**7-1**]. He planning for a AVR with Dr.
[**Last Name (STitle) **], [**First Name3 (LF) **] R.
.
Pt reports he is in his usual state of health. He denied any
chest discomfort or palpitations at rest or with exertion. He
does become DOE after 1 flight of stairs. This has been
progressively worse over the last few months, esp. after his TIA
(presented with general weakness and diplopia x 2-3 hours in
[**5-1**]) after which he had been "taking it easy." He had no
recent syncopal events. He does have a remote history of
syncope during a humid day after standing up too quickly.
.
Pt denied paroxysmal nocturnal dyspnea, orthopnea, ankle edema.
He also denied HA, cough, hemoptysis, N/V/D, abdominal pain,
melena, or BRBPR, and recent fevers or chills. He denies
exertional buttock or calf pain.
Past Medical History:
1. Aortic stenosis
2. A. fib
3. HTN
4. Hypercholesterolemia
5. h/o TIA (generalized weakness, diplopia, dysarthria) in
[**5-1**]
6. h/o stroke (R-sided paresthesias) in [**2186**]
7. h/o intermittent vertigo after L ear infection
7. h/o hernia repair
8. h/o L shoulder surgery
Social History:
Social history is significant for the 15 pack years, quit 37
years ago. He has 1 beer/day. He denies recreational drug use.
Family History:
Father died of stroke in his 40s. Brother has HTN and MS. Pt
is unaware of h/o MI, SCD.
Physical Exam:
VS - P76, BP165/68, R18, 97% RA
Gen: older male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple without JVD. No carotid bruits noted.
CV: PMI located in 5th intercostal space, midclavicular line.
Irreg. irreg, normal S1, S2. Grade II/VI high-pitched
crescendo-decrescendo murmur best heard at RUSB radiating to
apex. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: warm, no edema.
Skin: No stasis dermatitis, ulcers, scars.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2200-7-28**] 05:17PM PT-15.2* PTT-30.0 INR(PT)-1.4*
[**2200-7-28**] 05:17PM PLT COUNT-147*
[**2200-7-28**] 05:17PM WBC-8.3 RBC-5.16 HGB-14.7 HCT-42.5 MCV-82
MCH-28.5 MCHC-34.7 RDW-16.2*
[**2200-7-28**] 05:17PM GLUCOSE-92 UREA N-14 CREAT-1.3* SODIUM-140
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-31 ANION GAP-13
[**2200-7-29**] Cardiac Cath
1. Coronary angiography of this right dominant system revealed
moderate two vessel coronary artery disease with slow perfusion
consistent with microvascular dysfunction. The LMCA had ostial
20%
and distal 40% stenoses. The proximal LAD had a 40-50% stenosis
at S1.
The distal LAD wrapped well around the apex. The D1-D4 vessels
(D2
being the largest) were patent. The LCx had a 50% stenosis in a
small
distal AV groove just after takeoff of the major OM2. The RCA
had a 30%
stenosis at the origin, and mild diffuse disease was noted
throughout.
There was a large RPL.
2. Resting hemodynamics revealed elevated left sided filling
pressures with LVEDP of 21-23 mmHg. There was moderate
pulmonary
hypertension with PASP of 46-47 mmHg. The cardiac index was
depressed
at 1.1 L/min/m2 with modest augmentation of cardiac output with
dobutamine to 15 mcg/kg/min (with minimal change in heart rate
and only
mild increase in systemic systolic arterial pressure), based on
a
measured oxygen consumption post-sedation. The SVR and PVR were
elevated at 3994 and 222 dynes-sec/cm5.
3. The mean aortic valve gradient was 42 mm Hg at rest with a
calculated aortic valve area of 0.5 cm2 WIth dobutamine
infusion at 15
mcg/kg/min, the gradient rose to 56 mm Hg, with calculated valve
area of
0.5 cm2. The calculated valve area will UNDERESTIMATE the true
valve
area in the setting of his known aortic regurgitation.
4. Left ventriculography showed a moderate-severely calcified
aortic
valve, mild (1+) non-ectopic mitral regurgitation, and normal
wall
motion with estimated ejection fraction of 60%.
[**2200-7-30**] Carotid Study
There is a less than 40% right ICA stenosis and less than 40%
left ICA stenosis with antegrade flow in both vertebral
arteries.
[**2200-8-6**] Ultrasound
1. Limited study.
2. Gallstone, without evidence of cholecystitis.
3. Slightly echogenic liver, likely steatotic, however, other
forms of liver disease such as significant hepatic fibrosis or
cirrhosis cannot be totally excluded.
4. Bilateral pleural effusions.
[**2200-8-10**] CT Scan
1. Stranding seen adjacent to the pancreas tail, consistent with
mild uncomplicated pancreatitis. No evidence of pseudocyst
formation or other sequelae of pancreatitis.
2. Peripherally-enhancing relatively low attenuation lesion seen
within the spleen, most likely representing a hemangioma, or
possibly other vascular lesion.
3. Cholelithiasis.
4. Bilateral pleural effusions with associated atelectasis.
[**2200-8-14**] CXR
Left lower lobe atelectasis and pleural effusions have improved
and nearly resolved. No pneumothorax is identified. The left
subclavian line remains in the mid SVC.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2200-7-28**] for surgical
management of his aortic stenosis. As his coumadin had been
stopped 4 days prior to admission, heparin was started for
anticoagulation given his chronic atrial fibrillation. He
underwent a cardiac catheterization in preparation for surgery
which showed mild two vessel coronary artery disease, severe
aortic stenosis, mild pulmonary hypertension and a normal left
ventricular function. Given his past history of stroke, a
neurology consult was obtained. A head CT scan showed a moderate
degree of small vessel ischemic changes and scattered lacunes.
His risk of perioperative stroke was thus estimated to be around
4.8-8.8% and he was cleared for surgery. On [**2200-7-31**], Mr. [**Known lastname **] was
taken to the operating room where he underwent an aortic vakve
replacement using a 21mm pericardial valve and a left atrial
appendage ligation. Postoperatively he was taken to the
intensive care unit for monitoring. On postoperative day one,
Mr. [**Known lastname **] was found to not be appropriately following commands
but moved all extremities and remained intubated. He developed
rapid atrial fibrillation and cardioversion was attempted
unsuccessfully. Amiodarone was thus started for rate control. On
postoperative day three, Mr. [**Known lastname **] was extubated. He was slow to
improve neurologically however was making steady progress. He
was transfused with packed red blood cells for postoperative
anemia. Ceftriaxone was started for possible aspiration
pneumonia however his chest x-rays remained normal. His
ceftriaxone thus discontinued. Mr. [**Known lastname **] continued with high
nasogastric tube output and he was held NPO for a suspected
ileus. His output eventually decreased and his NG tube was
removed on postoperative day 6. Mr. [**Known lastname **] soon developed emesis
and his NG tube was replaced. Laboratory studies were consistent
with pancreatitis and TPN was started for nutrition. The genral
surgery service was consulted for assistance with his
pancreatitis. A CT scan was performed which showed stranding
seen adjacent to the pancreas tail which was consistent with
mild uncomplicated pancreatitis however no evidence of
pseudocyst formation or other sequelae of pancreatitis was
identified. Mr. [**Known lastname 50840**] nasogastric tube (NGT) output slowly
decreased. On [**2200-8-7**], he transferred to the step down unit for
further recovery. TPN continued for nutrition. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. Coumadin was continued for
anticoagulation for atrial fibrillation. He continued to be
gently diuresed towards his preoperative weight. Slowly Mr.
[**Known lastname 50840**] lipase and amylase trended back towards normal. An oral
diet was started and slowly advanced as tolerated. Stopped [**8-15**].
Pt stable for DC
Medications on Admission:
Metoprolol 175 mg po daily
lipitor 20 mg po daily
furosemide 20 mg po daily
quinopril 20 mg po daily
coumadin as directed
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 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Enalapril Maleate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once):
follow INR goal is [**12-28**] (afib).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Quinapril 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
AS s/p AVR
Hyperlipidemia
HTN
AF
Sick Sinus Syndrome
Cholilithiasis
Stroke [**2186**]/ [**5-1**]
Postoperative pancreatitis
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist/pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10543**] in [**11-26**] weeks.
[**Telephone/Fax (1) 4475**]
Please have thyroid studies done in 1 month. Newly started on
levothyroxine, a medication for hypothyroidism.
Completed by:[**2200-8-16**]
ICD9 Codes: 4241, 2930, 4019, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7178
} | Medical Text: Admission Date: [**2126-8-5**] Discharge Date: [**2126-8-16**]
Date of Birth: [**2080-5-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
transfer for sepsis, DKA
Major Surgical or Invasive Procedure:
triple lumen catheter placement
intubation
History of Present Illness:
HPI: 46 yo M with IDDM presented to an OSH after being found
unresponsive in bed by parents at 10am. Per parents, FS "too
high", no h/o trauma, no empty bottles or suicide attempt. Pt
reported to be nauseated in the past 2-3 days.
OSH Course: Initial VS: 95.6 BP 83/34 HR 118 RR 12 Shallow
breaths 93% on NRB. Initial glucose 2150, AG 33, Cr 4.3. ABG:
7.05/22/211/6.03 on 100%O2-Ambu bag. Pt received Ceftriaxone
2gm, Vanco 1gm x1, acyclovir 500mg x1, narcan 2mg, insulin 14U
IV x1, 16 U IV, 20IV, + Insulin gtt 7 units/hr-->10units/hr,
NaHCO3 2amps x1. At time of transfer AG 26, gluc 1645, BUN/Cr
74/3.8, Calcium 7.3, K 3.4. Head CT negative but + for
sinusitis, LP done and treated for possible bacterial/viral
meningitis, and PNA. Pt transferred to [**Hospital1 18**] for further
management of severe DKA, ARF, MS changes, septic shock on
levophed and dopamine gtt prior to transfer.
Past Medical History:
-IDDM
-Medullary sponge kidney
-Nephrolithiasis
-nueropathy
-chronic back pain
Social History:
-Divorced, lives at home with parents, 2 children.
-Tob 1/2ppd, No ETOH use, no other drug use or IVDU
Family History:
M: Leukemia, currently undergoing chemotherapy
F: CAD, HTN
Physical Exam:
VS: 97.5 BP 90/66 HR 96 RR 27 95% AC 600X12 FiO2 1.00 PEEP 10
GEN: Intubated, shivering off sedation
HEENT: ETT in place, PERRL 3-2mm, anicteric sclera
RESP: coarse BS throughout, no wheezing
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft, Distended, +tenderness noted with grimacing,
diminished BS
EXT: Non pitting peripheral edema, warm, 1+ DP pulses
NEURO: not following commands, hyporeflexic (sedated)
Pertinent Results:
[**2126-8-5**] 10:25PM GLUCOSE-668* UREA N-47* CREAT-2.1*#
SODIUM-152* POTASSIUM-3.4 CHLORIDE-133* TOTAL CO2-11* ANION
GAP-11
[**2126-8-5**] 10:25PM ALT(SGPT)-12 AST(SGOT)-20 LD(LDH)-158
CK(CPK)-232* ALK PHOS-80 AMYLASE-140* TOT BILI-0.1
[**2126-8-5**] 10:25PM LIPASE-24
[**2126-8-5**] 10:25PM ALBUMIN-2.7* CALCIUM-5.5* PHOSPHATE-1.9*
MAGNESIUM-1.9
[**2126-8-5**] 10:25PM TSH-0.37
[**2126-8-5**] 10:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2126-8-5**] 10:25PM WBC-12.9* RBC-3.28* HGB-9.9* HCT-31.4* MCV-96
MCH-30.1 MCHC-31.4 RDW-13.7
[**2126-8-5**] 10:25PM NEUTS-56 BANDS-10* LYMPHS-31 MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-2*
[**2126-8-5**] 10:25PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
[**2126-8-5**] 10:25PM PLT COUNT-298
[**2126-8-5**] 10:25PM PT-14.7* PTT-29.3 INR(PT)-1.3*
Brief Hospital Course:
AP: 46 yo M with hx of IDDM with DKA & sepsis, initially
intubted on pressors and admitted to the ICU for further care
and management.
1. Respiratory failure/MRSA pneumonia: Patient was initially
placed on broad spectrum antibiotics with vancomycin,
ceftriaxone, and flagyl for hypotension in the setting of DKA.
A sputum culture was obtained that grew out MRSA. He was
continued on vanc for a total 10 day course. All blood cultures
taken at our hospital were negative. He was sucessfully weaned
off of mechanical ventilation and then diuresed with resulting
return to baseline function and no oxygen requirement. At the
time of discharge the patient had resolved leukocytosis and was
afebrile with a markedly improved CXR.
2. DKA: Patient was initially placed on an insulin gtt per
protocol and was followed with serial chem 10s and ABGs until
his anion gap closed. He was then transitioned to Lantus and a
humalog sliding scale. Patient initially had early morning
hypoglycemia on a dose of Lantus 20 units daily and this was
decreased to 16 units. However the patient's BG then was
consistently in the mid 200s. In consultation with [**Last Name (un) **] DM
management team who have been following the pt during this
hospitalization it was decided to increase the lantus dose to 18
units daily and titrate the humalog scale. He has follow up
appointments with [**Last Name (un) **] on [**8-19**].
3. Thrombocytopenia: Patient had transient thrombocytopenia
while in the ICU that resolved prior to transfer to the floor.
A HIT-Ab was sent which was negative. He had no evidence of
petechiae or easy bruising.
4. Skin lesions: S/p fluid overload & edema with blisters. He
was followed by the wound consult nurse and had dressing changes
daily. There were no signs of ceullulitis at these sites. He
will have VNA follow up at home for continued dressing changes.
.
5. ARF: Patient experienced ARF on admission most likely
secondary to profound volume depletion. He was aggressively
hydrated with IVF and his serum cr returned to baseline upon
arrival to the general floor.
6. Depression--Pt was placed back on his prior dose of Celexa.
Discharge Medications:
1. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*11 * Refills:*2*
3. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Insulin Glargine 100 unit/mL Solution Sig: One (1) 18
Subcutaneous at bedtime.
Disp:*1 18* Refills:*2*
5. humalog sliding scale
For breakfast, lunch and dinner:
BG 0-50 1 glass of OJ
51-100 0 units
101-150 7 units Humalog SC
151-200 10 units Humalog SC
201-250 12 units Humalog Sc
251-300 14 units Humalog SC
301-350 16 units Humalog SC
351-400 18 units Humalog SC
For Bedtime, if BG is >200
201-250 2 units Humalog SC
251-300 3 units Humalog SC
301-350 4 units Humalog SC
351-400 5 units Humalog SC
>400 call your PCP
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
7. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**1-22**] Tablet,
Delayed Release (E.C.)s PO daily PRN as needed for constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
DKA
sepsis
MRSA PNA
bilateral UE blisters
Discharge Condition:
good
Discharge Instructions:
Patient will have VNA nursing to help with dressing changes. He
will follow up with the [**Last Name (un) **] center for further DM. He should
return to the ER or call his PCP if he develops fevers, chills,
nausea or vomiting. He should monitor his BG 4 times daily and
call his PCP if he has a BG >375.
Followup Instructions:
[**8-19**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**], NP - 10 am [**Hospital **] Clinic
[**8-20**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN - 8:30 am.
He should follow up with his PCP [**Last Name (NamePattern4) **] [**1-22**] weeks.
ICD9 Codes: 2762, 5849, 3572, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7179
} | Medical Text: Admission Date: [**2176-1-10**] Discharge Date: [**2176-1-16**]
Date of Birth: [**2116-12-12**] Sex: M
Service: SURGERY
Allergies:
Tylenol / Potassium
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
progressively increased swelling of his graft site since surgery
Major Surgical or Invasive Procedure:
[**2176-1-11**] Ultrasound-guided access for vascular imaging,
aortic catheterization with abdominal aortogram and pelvic
runoff, right common iliac artery stent, right external iliac
artery stent, right to left femoral to femoral bypass,
removal of axillary to femoral bypass graft.
History of Present Illness:
59M Hispanic male s/p left axillofemoral bypass on [**2175-4-3**] with PTF Propaten graft. He has a long history of severe
symptomatic left aorto-iliac disease thigh and calf claudication
with ambuation, L>R. He has had significant improvement in his
claudication symptoms since his surgery, however he has had
progressively increased swelling of his graft site since
surgery.
He was recently discharged for increased swelling of the graft
site for concern of graft site infection v. seroma v. allergic
reaction, and was on IV anti-biotics. Since then, he has
continued to have further expansion of the graft site with
tightness.
Past Medical History:
-Coronary artery disease
-myocardial infarction in [**2166**], status post percutaneous
coronary intervention, vessel intervene unknown.
-systolic congestive heart failure recurrent with ejection
fraction of 20%.
- diabetes,controlled.
- hypertension, controlled
- bilateral renal artery stenosis status post renal artery
stenting bilaterally.
- hypercholesteremia
- subarachnoid hemorrhage secondary to cerebral aneurysm s/p
aneurysm clipping in [**2163**].
Social History:
Non contributory
Family History:
Non contributory
Physical Exam:
VS T 99.9 P3 BP 142/72 RR 20 O2 sat 97% on RA
Gen: AAOx3, NAD
Heart: RRR, no murmur
Lungs: clear by auscuktatiob bilaterally
Abd: soft, non-tender, non-distended
Skin: incision dry and intact
Ext: well perfused no edema
Pulses: Fem [**Doctor Last Name **] DP PT
[**Name (NI) 167**] palp dop palp palp
Left palp dop palp palp
Pertinent Results:
[**2176-1-15**] 04:41AM BLOOD WBC-9.4 RBC-3.02* Hgb-9.9* Hct-27.5*
MCV-91 MCH-33.0* MCHC-36.2* RDW-14.2 Plt Ct-188
[**2176-1-15**] 04:41AM BLOOD Plt Ct-188
[**2176-1-15**] 04:41AM BLOOD Glucose-116* UreaN-24* Creat-2.1* Na-136
K-4.4 Cl-106 HCO3-25 AnGap-9
[**2176-1-14**] 07:11PM BLOOD CK(CPK)-106
[**2176-1-14**] 07:11PM BLOOD CK-MB-2 cTropnT-<0.01
[**2176-1-15**] 04:41AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.5
[**2176-1-12**] 10:54AM BLOOD Glucose-94
[**2176-1-11**] 08:41PM BLOOD Glucose-83 Lactate-1.2 Na-137 K-3.5
Cl-110 calHCO3-21
Cardiology Report
ECG Study Date of [**2176-1-10**] 9:16:54 PM
Sinus rhythm with ventricular premature beats. Left ventricular
hypertrophy with ST-T wave changes. Compared to the previous
tracing of [**2175-9-19**] the ventricular premature beat is new and
the ventricular rate is slightly faster.
TTE (Complete) Done [**2176-1-11**] at 8:46:47 AM
Conclusions
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is severe global left ventricular hypokinesis with akinesis of
the inferior and inferolateral walls. (LVEF = 20-25 %). A left
ventricular mass/thrombus cannot be excluded. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size 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. Moderate (2+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPERSSION: Severe global hypokinesis with akinesis of the
inferior and inferolateral walls. Diastolic dysfunction. At
least moderate mitral regurgitation with an eccentric jet due to
tethering of the posterior mitral valve leaflet by the infarcted
infero-lateral wall.
ECG Study Date of [**2176-1-11**] 4:15:34 PM
Sinus rhythm. Baseline artifact. T wave inversions in the
lateral leads.
Early R wave transition. Possible right ventricular hypertrophy.
Possible
left ventricular hypertrophy. The ST-T wave changes may be
related to
left ventricular hypertrophy. Compared to the previous tracing
of [**2176-1-10**]
there is no significant change.
ECG Study Date of [**2176-1-12**] 12:50:16 PM
Sinus rhythm with premature atrial contractions. Possible
biventricular
hypertrophy with extensive ST-T wave changes secondary to left
ventricular
hypertrophy. Compared to the previous tracing of [**2176-1-11**] there
is no
significant change.
Radiology Report
CHEST (PRE-OP PA & LAT) Study Date of [**2176-1-10**] 8:28 PM
Final Report COMPARISON: [**2175-9-19**].
FINDINGS: There is a tortuous thoracic aorta. Heart size is
within normal
limits. No radiographic evidence of pneumonia present. Pulmonary
vascularity appears within normal limits. No effusion or
pneumothorax.
IMPRESSION: No acute cardiopulmonary process identified.
CHEST (PORTABLE AP) Study Date of [**2176-1-12**] 9:07 AM
Final Report
REASON FOR EXAMINATION: Evaluation of Swan-Ganz position.
Portable AP chest radiograph was compared to [**2176-1-11**].
The patient was extubated. The Swan-Ganz catheter tip is at the
right main
pulmonary artery. The cardiomediastinal silhouette is unchanged.
Bibasilar
atelectasis are unchanged. No edema or pneumothorax is present.
Brief Hospital Course:
[**2176-1-10**] Patient admitted for increased swelling of Axillary to
femoral bypass graft,
seroma versus infection, claudication. Routine nursing, labs,
NPO post MN and IVF and Bicarb drip start at MN. Pre-op
EKG-Sinus rhythm with ventricular premature beats. Left
ventricular hypertrophy with ST-T wave changes. Compared to the
previous tracing of [**2175-9-19**] the ventricular premature beat is
new and the ventricular rate is slightly faster. Pre-op CXR-No
acute cardiopulmonary process identified. Pre-op and consented
for abdominal aortogram and pelvic runoff, right common iliac
artery stent, right external iliac artery stent, right to left
femoral to femoral bypass and removal of axillary to femoral
bypass graft.
[**2176-1-11**] TTE ECHO-that showed severe global hypokinesis with
akinesis of the inferior and inferolateral walls. Diastolic
dysfunction. At least moderate mitral regurgitation with an
eccentric jet due to tethering of the posterior mitral valve
leaflet by the infarcted infero-lateral wall. Taken to OR and
underwent Ultrasound-guided access for vascular imaging,aortic
catheterization with abdominal aortogram and pelvic runoff,
right common iliac artery stent, right external iliac
artery stent, right to left femoral to femoral bypass,removal of
axillary to femoral bypass graft. A-line, PA line, foley
catheter and JP drains were placed intra-op. Cultures sent in
OR. Patient tolerated procedure. Transferred to CVICU post-op
for recovery and further monitoring. Patient was hypotensive
post-op, placed on pressors, transfused with 1 unit PRBC, sedate
and intubated. Started ABX vanco/Cipro and Flagyl. Pulses stable
pulse signals. DVT prophylaxis. Pain control.
[**2176-1-12**] Patient was extubated in CVICU, remains on ABX
Vanco/Cipro/Flagyl. T maxed 101.7. Pulse status stable. Pressors
weaned off, vitals stable. Started diet. Tranferred to VICU [**Hospital Ward Name 121**]
5 w/ telemetry for further monitoring. Pain managed w/ prn.
[**2176-1-13**] Patient remains febrile T maxed 101.4 pan cultured, the
rest of his vitals stable. PA line changed to tripple lumen
line-placement confirmed by CXR- also showed no evidence of
pulmonary vascular congestion and no signs of new parenchymal
infiltrates. JP remain in place. Pulse status stable. Physical
therapy consult- started out of bed to chair activity. Cultures
from the OR came back negative. [**2176-1-14**] Patient c/o vertigo-
became intermittent, remains febrile T maxed 101.2. Remains on
ABX (Vanco/Cipro/Flagyl). Patient c/o chest pressure with a 9
beat run for V-tach, EKG done and cardiac enzymes sent. All came
back negative and R/O for MI. Electrolytes repleted. No further
episodes of V-tach. Cultures from [**2176-1-11**] came back negative.
A-line d/c'd.
[**2176-1-15**] Patient's fever is now coming down, T maxed 99.9.
Remains to have intermittent dizziness, w/ VSS. Made floor
status w/ telemetry. Foley d/c'd and voiding. Remains on ABX.
Cultures from [**1-13**] remain pending. Rehab screening.
[**2176-1-16**] Vitals stable overnight, patient is feeling better he
wants to go home instead of rehab. All cultures came back
preliminary negative. Patient discharged to home in good
condition, tolerating diet, ambulating, and voiding adequately,
will FU with Dr. [**Last Name (STitle) 1391**] in 2 weeks.
Medications on Admission:
plavix 75 mg po qd
ASA 81 mg po qd
carvedilol 12.5 mg [**Hospital1 **]
felodipine 5 mg po qd
lisinopril 20 mg po qd
digoxin 0.25 mg po qd
lasix 40 mg po qd
zocor 40 mg po qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for temperature.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Axillary to femoral bypass graft seroma vs infection,
claudication.
history of Coronary artery disease, s/p MI [**2166**], status post PCI
vessel intervention unknown
history of chronic systolic congestive failure with ejection
fraction of 20% compensated
history of type 2 diabetes controlled with diet
history of hypertension
history of bilateral renal artery stenosis status post renal
artery stenting bilaterally
history of hypercholesteremia on statin
history of subarachnoid hemorrhage secondary to cerebral
aneurysm with aneurysm clipping and second aneurysm embolization
in [**2163**].
Discharge Condition:
Good
Discharge Instructions:
walk essential distances only until FU
ace wrap left lower extremity from foot to knee when walking
elevate lower extremities when sitting
no driving till seen in FU with Dr. [**Last Name (STitle) 1391**]
may shower, no tub baths
continue stool softener while on pain medications
continue current medications as directed
keep FU appointments
call Dr.[**Name (NI) 1392**] office for FU appointment ([**Telephone/Fax (1) 4852**]
call if you have a fever of more than 101.5, pain swelling, and
draining of your incisions
Followup Instructions:
Call Dr. [**Last Name (STitle) 1391**] for FU appointment in 2 weeks Phone: ([**Telephone/Fax (1) 29063**]
Completed by:[**2176-1-16**]
ICD9 Codes: 5845, 4271, 2762, 4280, 412, 2720, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7180
} | Medical Text: Unit No: [**Numeric Identifier 70859**]
Admission Date: [**2105-1-31**]
Discharge Date: [**2105-2-8**]
Date of Birth: [**2105-1-29**]
Sex: F
Service: NB
HISTORY: Baby girl [**First Name8 (NamePattern2) **] [**Known lastname **]-[**Known lastname 50359**] delivered at 39 and
6/7 weeks gestation with a birth weight of 3045 grams, and
was admitted to the newborn intensive care unit from the
newborn nursery at 2 days of life for fever and ill
appearance.
Mother is a 30-year-old gravida 1, para 0 (now 1) mother with
an uncomplicated pregnancy. Prenatal screens included blood
type A+, antibody screen negative, rubella immune, hepatitis
B surface antigen negative, RPR nonreactive, and group B
strep negative. The intrapartum course was unremarkable, with
rupture of membranes of clear fluid about an hour prior to
delivery. No maternal fever. No maternal antibiotics. The
infant emerged vigorous by spontaneous vaginal delivery.
Apgar scores were 9 at one minute and 9 and five minutes.
In the newborn nursery, the infant initially did well; was
breast feeding well with stable vital signs. The second day
of life, the infant became jittery, irritable, was feeding
poorly, spitting up, and was pale. The temperature went up to
100.7 axillary, was 100.8 rectally; prompting transfer to the
newborn intensive care unit. The mother and father had not
been ill. There was no history of oral herpetic sores. No
recent lesions, and no history of genital herpes.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2840 grams, down
7% from birth weight. VITAL SIGNS: Temperature of 99.5
axillary, heart rate 120s to 140s, blood pressure 90s/50s,
oxygen saturations 97% on room air. Oxygen saturations noted
to drift to high 80s while sleeping or sucking on pacifier.
GENERAL: A well-developed infant, jittery and irritable with
a high-pitched cry. Skin pale, warm, with cool extremities.
HEENT: Head with fontanelle soft and flat. Ears and nares
normal. Mildly asymmetric facies within intact facial
movements. Intact suck. Eyes equally reactive to light. NECK:
Supple. No lesions. CHEST: Well aerated, clear breath
sounds. No grunting, flaring or retracting. CARDIAC: Regular
rate and rhythm without murmur. Femoral pulses 2+. ABDOMEN:
Soft, no hepatosplenomegaly, no masses, bowel sounds present.
GU: Normal female. Anus patent. EXTREMITIES: Hips and back
normal. No lesions. Somewhat cool distal extremities. NEURO:
Increased tone, jittery, without clonus.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY: Had several episodes of apnea on admission.
Subsequently had some desaturations at rest and with
sucking on a pacifier, with the last episode on [**2-3**], [**2105**]. Has completed 5 consecutive days without any
apnea, bradycardia or desaturations prior to discharge.
2. CARDIOVASCULAR: Received a normal saline bolus on
admission for a sodium of 147. Had normal blood pressures
and heart rates. Recent blood pressure 80/45 with a mean
of 56.
3. FLUIDS, ELECTROLYTES, NUTRITION: Due to spitting up and
no interest in feeding, received IV fluids after
admission for about 12 hours until was interested in
feeding again. Blood glucoses were always in the normal
range. Electrolytes on admission; sodium 147, potassium
4, chloride 105, CO2 of 26, calcium 10.5. Discharge
weight 3180.
4. GI: Spitting resolved within 24 hours of admission.
Abdominal exam has always been normal. Bilirubin on day
of life #2 was a total of 2.4, direct 0.2. Has not been
jaundiced. AST and ALT were done on admission as part of
sepsis eval. The ALT was 12, AST 42.
5. INFECTIOUS DISEASE: A CBC, blood culture, lumbar puncture
and urine culture were all done on admission. The CBC
showed a white count of 14.1; with 49 poly's; 2 bands;
platelets 294,000; hematocrit 49.6%. The urine culture
was negative. The blood culture was negative. The LP
showed 5 WBCs, 38 RBCs, with 40% poly's. The culture was
negative. The Gram stain was negative. The infant
received 7 days of ampicillin and gentamicin for presumed
sepsis with a gentamicin level of trough 0.6, peak 8.8.
6. NEUROLOGY: On admission was jittery with increased tone,
which resolved by 24 hours of life when the infant's exam
was normal for age. A head ultrasound was done as part of
the workup and was normal.
7. SENSORY: Hearing screening was performed with automated
auditory brain stem response, passed both ears.
CONDITION ON DISCHARGE: Stable term infant.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 47763**]
[**Location (un) **], [**University/College 70860**], [**Location (un) 86**], [**Numeric Identifier 70861**];
telephone number ([**Telephone/Fax (1) 56620**].
CARE AND RECOMMENDATIONS:
1. Feeds: Ad lib breast feeding.
2. Medications: Ferrous sulfate 0.3 mL p.o. once a day using
a diluted solution that is 25 mg/mL, which equals 2 to 3
mg/kg/day. Was placed on Tri-Vi-[**Male First Name (un) **], but spit after
receiving it, so is no longer receiving Tri-Vi-[**Male First Name (un) **].
3. State newborn screen was drawn on [**2105-1-31**].
Received hepatitis B immunization on [**2105-1-31**].
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age term female.
2. Presumed sepsis.
3. Apnea and desaturations, resolved.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2105-2-6**] 16:03:38
T: [**2105-2-6**] 16:46:59
Job#: [**Job Number 70862**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7181
} | Medical Text: Admission Date: [**2156-9-22**] Discharge Date: [**2156-9-25**]
Date of Birth: [**2156-9-22**] Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 68249**] [**Known lastname 68250**] is a 2700 gram 35 amd [**2-10**]
weeker, admitted to the newborn intensive care nursery for
management of prematurity.
The mother is a 21-year-old gravida 3, para 2, now 3 woman.
Prenatal screens included blood type A positive, antibody
screen negative, RPR nonreactive, rubella immune, hepatitis B
surface antigen negative, and group B strep positive.
Maternal history notable for insulin dependent diabetes
mellitus, anemia, and a heart murmur of unknown etiology. The
pregnancy was complicated by preterm labor requiring
hospitalization twice during the pregnancy. She received one
course of betamethasone. A fetal echo was done secondary to
maternal insulin dependent diabetes mellitus and was normal.
She presented in preterm labor and progressed to spontaneous
vaginal delivery under epidural anesthesia on [**2156-9-22**]. Interpartum antibiotics were given about 3 hours prior
to delivery for GBS colonization. Membranes ruptured about
4.5 hours prior to delivery. There was no maternal fever.
[**Known lastname 68249**] emerged with spontaneous respiratory effort and good
tone. She received some free flow oxygen. Her Apgar scores
were 8 and 9 at 1 and 5 minutes respectively.
PHYSICAL EXAMINATION: Weight 2700 grams (50 to 75th
percentile), length 45.5 cm (25th to 50th percentile), head
circumference 32 cm (25th to 50th percentile). Anterior
fontanel was soft and flat, cutis aplasia with an 8 cm long
affected area along sagittal suture from the anterior
fontanel to the posterior fontanel around a 6 cm linear
region with 2 cm long x 1.5 cm wide defect with visible dura
in the mid scalp. Slightly depressed nasal bridge, normally
set ears, intact palate, clear breath sounds, no murmurs,
soft abdomen, three-vessel cord, no hepatosplenomegaly.
Normal female external genitalia. Patent anus. No sacral
dimple. Normal tone in all extremities equally. Asymmetric
face when she cries with decreased movement on the right.
Warm extremities. Good perfusion. Ruddy active.
SUMMARY OF HOSPITAL COURSE BY SYSTEM: RESPIRATORY: No
issues. Breathes comfortably in the 30 to 50s'
CARDIOVASCULAR: An echocardiogram was done per recommendation
of genetics given that a number of cutis aplasia syndromes
are associated with structural heart disease. The
echocardiogram showed a patent foramen ovale versus a small
atrioseptal defect and a patent ductus arteriosus with
bidirectional flow. The heart was structurally normal. Her
heart rate ranges in the 130's to 150's. Recent blood
pressure 84/53 with a mean of 64.
FLUIDS, ELECTROLYTES AND NUTRITION: Started on ad lib feeds
on admission to the NICU with Similac 20 with iron. Initial
bedside blood glucose was 36 which increased to 63 after
feeding, and thereafter with feeding she has maintained her
blood glucoses in the 70's to 80's. At discharge she was ad
lib feeding with [**Doctor Last Name **]-20 or breast feeding if available. Her
discharge weight is 2625 grams.
GASTROINTESTINAL: A bilirubin done on [**9-24**] (day of
life 2) showed a total of 3.9, direct 0.3. Bilirubin was
repeated prior to discharge on [**2156-9-25**] and is
pending.
HEMATOLOGY: Hematocrit on admission 53.6%,
INFECTIOUS DISEASE: CBC and blood culture were drawn on
admission and she received 48 hours of ampicillin and
gentamycin secondary to preterm labor, prematurity, maternal
colonization, group B strep with less than 4 hours of
interpartum peripheral access. The CBC was benign. The blood
culture was negative.
NEUROLOGY: Head ultrasound was done and was normal.
Examination is age appropriate.
SENSORY: Hearing screening was performed with automated
auditory brain stem responses. Results pending.
GENETICS: Genetic consult was done secondary to the cutis
aplasia. Geneticist on examination found the cutis aplasia -
minimal eyebrows, prominent lips, mildly protuberant tongue,
hypertelorism but not otherwise grossly dysmorphic. The level
of suspicion for trisomy-13 and [**Doctor Last Name 79**]-[**Doctor Last Name 9279**] was low but
recommended karyotype be done which was drawn prior to
discharge on [**2156-9-25**], and is pending.
PLASTIC SURGERY: Plastic surgery found the cutis aplasia of
the scalp to be a linear stripe of hairless scar tissue from
anterior fontanel to posterior fontanel 8 cm long just
posterior to the posterior fontanel, an area of 1.5 x 0.5 cm
open wound that appeared not to be full thickness.
It was recommended to treat the baby with bacitracin ointment
to the lesion about 5 times a day and the mother may shampoo
the baby's hair with follow up with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**] in 10
days.
PSYCHOSOCIAL: [**Hospital1 18**] social worker is involved with the
family. The contact social worker is [**Name (NI) 553**] [**Name (NI) **]. She can be
reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable term infant.
DISCHARGE DISPOSITION: Discharged home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 3504**] [**Last Name (NamePattern1) **], [**Apartment Address(1) 68251**], [**Hospital1 189**], [**Numeric Identifier 23661**]. Telephone No.: [**Telephone/Fax (1) 68252**]. Fax: [**Telephone/Fax (1) 68253**].
CARE RECOMMENDATIONS:
1. Feeds: Ad lib feels with [**Doctor Last Name **]-20 with iron or breast
feeding.
2. Medications: Bacitracin to scalp 5 times a day.
3. Car seat position screening test was performed.
4. State newborn screen was drawn on [**9-24**] and is
pending.
5. Immunizations received: She received Hepatitis B
immunization on [**2156-9-24**].
FOLLOW UP APPOINTMENTS SCHEDULED/ RECOMMENDED:
1. An appointment with pediatrician within 2 days of
discharge.
2. Follow up with genetics clinic at [**Hospital3 **] in
6 to 8 weeks. After discharge the parents will call for
appointment.
3. Appointment with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], from plastic surgery
[**59**] days after discharge. Parents to call for appointment.
Phone No. [**0-0-**].
4. [**First Name (Titles) **] [**Last Name (Titles) 28085**] made to VNA of
Greater [**Hospital1 189**]: Tel No. [**Telephone/Fax (1) 68254**].
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age, preterm female.
2. Cutis aplasia.
3. Physiologic jaundice.
4. Rule out sepsis.
5. Infant of diabetic mother.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2156-9-24**] 23:37:49
T: [**2156-9-25**] 03:03:56
Job#: [**Job Number 68255**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7182
} | Medical Text: Admission Date: [**2195-1-22**] Discharge Date: [**2195-1-23**]
Date of Birth: [**2133-4-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
intracerebral hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 61596**] is a 61 year old male presenting as transfer from
and
outside hospital with large ICH. He was found in his garage
unresponsive this evening with a bag of cocaine next to him. He
was last seen well ~6 hours prior. BP at the scene was
220's/110's. He was taken to an OSH where his temperature was
noted to be 88 degrees, head CT revealed a large Left basal
ganglia hemorrhage with extensive intraventricular spread to
lateral, 3, 4th, communicating hydrocephalus and dissection down
into the brainstem. His examination was notable mid position and
equal pupils unreactive to light, intact gag, no purposeful
withdrawal of extremities. He was intubated at the OSH and
transferred to [**Hospital1 18**] for further care. Neurosurgery was
consulted
and based on poor examination and CT findings was not felt to be
a candidate for decompression or drainage.
Past Medical History:
Hep C on interferon
GERD
HTN
Social History:
Lives with his wife, children in the area. No illicit drug use.
Family History:
Not elicited
Physical Exam:
Vitals: T 97 (on bear hugger), BP 160/96, HR 62, R 14, 100% CMV
Gen- critically ill, unresponsive to noxious stimulation
HEENT- NCAT, MMM, Anicteric sclera
Neck- C-collar
CV- RRR, no MRG
Pulm- scattered crackles.
Abd- soft, nd, bs+
Extrem- no CCE
NEUROLOGIC EXAM:
MS- no response to deep noxious stimulation.
CN- pupils equal at 4mm and unreactive to light, gaze
midposition, absent dolls, absent corneal reflex, intact gag. no
response to nasal tickle.
Motor/Sensory- no spontaneous movements. internally rotates
towards noxious stimulus in bilateral UE's. Triple flexion to
noxious in bilateral LE's.
DTR's- brisk, symmetric throughout.
plantar response upgoing bilaterally.
Pertinent Results:
[**2195-1-22**] 10:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
Head CT-
There is a large parenchymal hemorrhage in the left cerebral
hemisphere, measuring approximately 8.5 x 4.7 in greatest
dimension, with
surrounding edema. Blood products are present in both lateral
ventricles,
third as well as the fourth ventricle. There is mass effect on
the
ipsilateral lateral ventricle body as well as contralateral
ventricular
dilatation. There is 7-mm shift of the septum pellucidum as well
as rightward subfalcine herniation. There is global sulcal
effacement, highly concerning for cerebral edema. There is
obliteration of the suprasellar cistern, as well as
contralateral temporal [**Doctor Last Name 534**] enlargement.
Evaluation of the posterior fossa is limited by an artifact,
however there is high attenuation in the pons and possibly mid
brain, concerning for additional foci of hemorrhage.
Brief Hospital Course:
Mr. [**Known lastname 61596**] is a 61 year old male found unresponsive with
massive intracerebral hemorrhage. Etiology based on location is
likely hypertensive hemorrhage in the setting of cocaine use.
His condition upon arrival was consistent with severe neurologic
injury without chance of meaningful neurologic recovery. The
patient's condition was discussed at length with his wife and
family. He was admitted to the ICU and later extubated for
comfort measures only. The patient expired promptly following
extubation with his family at the bedside.
Medications on Admission:
Interferon
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
large L basal ganglia
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7183
} | Medical Text: Admission Date: [**2164-12-12**] Discharge Date: [**2164-12-24**]
Date of Birth: [**2105-9-12**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
xfer from OSH s/p cardiac arrest
Major Surgical or Invasive Procedure:
Cardiac catheterization
ICD Placement
History of Present Illness:
HPI: Patient is a 59 year-old man with hx of aortic valve
replacement (congenital bicuspid valve [**2149**] with aortic
insufficiency, redo [**8-/2164**] secondary to [**3-9**]+ AI and perivalvular
leak at [**Hospital1 18**]), DDD pacer for complete heart block [**2159**],
Thalassemia, HTN who was transferred from an OSH after suffering
cardiac arrest yesterday evening.
.
Reportedly, patient was in USOH, compliant with medications day
of admission to OSH. Was getting oil change, then suddenly found
down. EMS arrived at sceen 10 minutes later, patient in Vfib,
defibrillated x 2, and again 5 times by EMS on way to hospital,
with eventual restoration of AV paced rhythm. Amiodarone gtt
instituted. Patient intubated. [**Location (un) 2611**] coma scale 3 on arrival.
CT Head showed subgleal hematoma but no intracranial bleeding.
Pacemaker interrogation performed, no pacemaker dysfunction.
ECHO at OSH showed LV systolic function of 25-30% with abnormal
septal motion and severe anterior hypokinesis with distal septal
and apical dyskinesis. Neurology saw patient, repeated CT scan
which was negative for acute bleed. EEG done, results pending.
INR on day of transfer was 3.1.
.
Day after, patient becoming more responsive, intermittently
responding appropriately to commands. Patient of [**Last Name (un) **]
Papageorgious, xferred here for further management. [**Last Name (un) 1291**] [**2151**]
(bicuspid aortic valve), re-do Aortic Valve Repair [**8-/2164**]
Past Medical History:
1. St. [**Male First Name (un) 923**] Mechanical [**Male First Name (un) 1291**] (Primary [**2151**], re-do [**8-/2164**])
2. Pacer [**2159**] DDD for Complete Heart Block
3. Thallasemia
4. Hypertension
Social History:
smokes cigars occ.
drinks 2 beers a day
lives with wife and 3 kids
runs own company
Family History:
non-contrib.
Physical Exam:
VS: Afebrile, HR 70, BP 113/70, 100% O2Sat
GEN: sedated, intubated, arousable
HEENT: MMM. ET tube in place. No JVD.
CV: S1 Metallic S2. II/VI SEM preceding metallic valve sound
LUNGS: CTA Anteriorly.
ABD: soft, NT/ND. +BS
EXT: 2+ DPs. No C/C/E
Pertinent Results:
ECHO [**2164-12-13**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is
mildly-to-moderately depressed (ejection fraction 40 percent)
secondary to severe hypokinesis of the anterior free wall and
apex. No masses or thrombi are seen in the left ventricle. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. A bileaflet aortic valve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis. 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 no
pericardial effusion. Compared with the findings of the prior
report (images unavailable for review) of [**2164-2-23**], the
aortic regurgitation is reduced.
.
CARDIAC CATH [**2164-12-14**]
1. Selective coronary angiography in this right dominant
patient revealed no angiographically apparent coronary artery
disease.
The LMCA, LAD, LCX, RCA and their branches were without flow
limiting
disease. The LCx was a small vessel and the lateral wall was
supplied
via RCA.
2. Limited resting hemodynamics revealed systemic pressures of
130/67/88
FINAL DIAGNOSIS:
1. Coronary arteries are normal
.
CT HEAD [**2164-12-14**]
1. No intracranial hematoma. Subcutaneous/subgaleal hematoma at
the right frontal region, without underlying skull fracture.
2. No CT features of acute cerebral infarcts. If clinically
indicated, MRI is a more sensitive study to exclude acute
cerebral ischemia.
.
EEG
IMPRESSION: This is an abnormal EEG due to the presence of a
diffusely
slow background rhythm with bursts of generalized slowing
consistent
with a mild to moderate encephalopathy of toxic, metabolic, or
anoxic
etiology. No evidence of ongoing or potential seizure activity
was seen
during this tracing.
.
CXR PA and LAT
INDICATION: Newly placed dual chamber ICD. Check position.
FINDINGS: PA and lateral chest views have been obtained with the
patient in upright position. There is status post sternotomy,
and in the aortic valve area, the semitranslucent structures of
a butterfly type (St. [**Male First Name (un) 923**]) aortic valve prosthesis can be
identified. The heart size is now within normal limits and
clearly smaller than on a previous PA and lateral chest
examination of [**2164-8-30**]. A permanent pacer is present in
left anterior axillary position connected to a dual
intracavitary pacing system with termination points in the right
atrial appendage and apical portion of right ventricle
correspondingly. In addition to these wires already present on
examination [**8-30**], there are now two electrodes approach
from the right subclavian route also terminating in right atrial
and right ventricular position as demonstrated on both frontal
and lateral view. The right ventricular wire with two local
electrode enforcements (ICD) traverses from the right axilla
over to the left side where it is connected with the permanent
pacer capsule. The thin right-sided right atrial wire terminates
blindly in the right axilla.
The pulmonary vasculature is normal without evidence of
congestive pattern. No acute infiltrates are seen, and the
lateral and posterior pleural sinuses are free. No evidence of
pneumothorax on either side. Comparison with a most recent AP
single view examination of [**2164-12-19**] demonstrates
unchanged findings.
IMPRESSION: Uncomplicated placement of additional pacer
electrodes for unusual connection, see description. Remarkable
reduction and normalization of heart size since [**8-30**].
.
Brief Hospital Course:
Patient is a 59 year-old gentleman s/p [**Month (only) 1291**] with re-do in [**8-/2164**]
who presented to an OSH with VFib arrest, tranferred here for
further management. The following issues were addressed during
his hospital stay:
.
# VFIB ARREST/ICD PLACEMENT/HEMATOMA
Exact etiology remains unclear. Laboratory values from OSH not
consistent with acute ischemic event, though ECHO suggested some
new anterior wall motion dysfunction. Patient underwent coronary
catheterization at [**Hospital1 18**] which revealed normal coronaries.
Patient reportedly compliant with medications, pacemaker
interrogation successful at OSH. No significant electrolyte
abnormalities or QT interval prolongation noted, blood cultures
negative from OSH. Patient was evaluated by the
Electrophysiology service and ICD was ultimately placed in left
arm with slight difficulty in positioning leads. Course
complicated by hematoma at pacer entry sites (L and R arm),
controlled with pressure dressings. Patient transfused 1 unit
PRBCs given blood loss secondary to hematomas. Given ECHO
findings suggestive of possible ischemic event, patient was
started on Lipitor 10mg PO qd and Toprol XL 100.
.
# RESPIRATORY (INTUBATION)
Patient had been intubated for airway protection at OSH during
arrest episode. Patient successfully extubated at [**Hospital1 18**] the
following day after CXR was unremarkable for pulmonary
pathology. Patient had some stridor post-extubation which was
treated with racemic epinpehrine. No further respiratory issues
were experienced.
.
# NEUROLOGIC (HEAD HEMATOMA/CONFUSION/MEMORY LOSS)
Patient had 2 Head CT scans on day of admission at OSH which
showed sub-galeal hematoma but no intracranial bleeding. Given
amnesia, confusion, and lethargy, patient received repeat Head
CT at [**Hospital1 18**] which was negative for acute bleed, intracranial
mass, or other concerning pathology. Symptoms improved over
time. Patient was evaluated by the neurology service and anoxic
brain injury specialist. No extensive cortical damage, patient
diagnosed with executive dysfunction; some improvement in
function expected over the next 6 months, but prognosis for
returning to work and/or living independently are poor. Patient
received an EEG which showed slowing consistent with
anoxic/toxic injury; no seizure activity was noted. Patient will
follow-up with behavioral neuro service as outpatient. Patient
was discharged to rehab facility under brain injury division for
targeted care. Patient started on Seroquel 25mg PO BID given
agitation/unrest and low dose Trazadone 25mg PO qd for sleep at
night.
.
# PROSTHETIC AORTIC VALVE
Patient had therapeutic INR on presentation to OSH. Patient's
Coumadin was held in preparation for cardiac cath and ICD
placement, and was maintained on heparin gtt in interim.
Coumadin re-started once ICD placed, and patient kept on heparin
gtt until INR therapeutic. Goal INR 2.5-3.5.
.
# L ARM CELLULITIS
Patient developed L arm cellulitis from IV site, treated with PO
Keflex and warm compresses. Patient was afebrile and without
leukocytosis.
.
# HEMATURIA/INCONTINENCE
Patient experienced hematuria while under heparin gtt after
foley was discontinued, likely due to irritation and trauma. PTT
was in therapeutic range, and drip was necessary due to
prosthetic valve. Hematuria improved when transiently off
heparin gtt, and will likely cease once patient off heparin.
Patient also incontinent of urine when nursing staff not
accessible. Patient otherwise able to void normally when
accompanied to the bathroom by nursing. We do not suspect
underlying urinary pathology anf attribute incontinence to
mental status.
Medications on Admission:
MEDS:
1. Coumadin 5mg PO qd alternating with 7.5 mg PO qd
2. Folic Acid 1mg PO qd
3. Norvasc 5mg PO qd
4. Omeprazole 20mg PO qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days. Capsule(s)
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Sleep/sedation.
9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Please have your INR checked and dose adjusted
accordingly. Goal INR 2.5-3.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary
1. VFib Arrest s/p ICD placement
2. Anoxic Brain Injury
Secondary
1. HTN
2. Thalassemia Minor
Discharge Condition:
hemodynamically stable
Discharge Instructions:
1. Please take all medications as prescribed
2. Please make all follow-up appointments
3. If you develop chest pain, shortness of breath, palpitations,
or other concerning signs/symptoms, please contact your PCP or
report to the nearest Emergency facility.
Followup Instructions:
1. Device clinic in 1 week: Provider: [**Name10 (NameIs) 676**] CLINIC
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2165-1-1**] 10:00. [**Location (un) 436**], [**Hospital Ward Name 23**]
Clinical Center, [**Hospital Ward Name 516**] of [**Hospital1 1170**]
2. Please follow-up with Dr. [**Last Name (STitle) 1911**] in [**1-8**] months
3. Please make an appointment to see your PCP [**Last Name (NamePattern4) **] [**10-19**] days: Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 16963**].
Please keep all previously scheduled appointments:
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2165-5-30**] 10:30
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2165-5-30**]
10:00
Completed by:[**2164-12-24**]
ICD9 Codes: 4275, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7184
} | Medical Text: Admission Date: [**2111-12-31**] Discharge Date: [**2112-1-3**]
Date of Birth: [**2045-6-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 66 yo man with pmhx MCA stroke [**7-7**] and [**12-7**],
hyperlipidemia, HTN, DM who presents from [**Hospital 38**] rehab with
altered mental status for the last three days. His wife reported
that he was barely responsive on the day of admission and he was
sent to the ED. Of note, he has also been having very loose
stools for the last three days and was c dif positive on tuesday
and started on flagyl. He spiked fever on monday and had low
grade temps at rehab since then. He was on IVF at rehab per his
wife.
Past Medical History:
R M1 segment MCA stroke [**7-/2111**] with residual left facial droop,
left hand weakness/stiffness, mild dysarthria
hyperlipidemia
hypertension
diabetes, diagnosed [**8-/2111**], initially diet controlled w/ FS
100s,
last A1C 6.8, started on metformin
h/o tobacco use, quit after stroke [**7-/2111**]
s/p tonsillectomy
Social History:
tob 2.5ppd x 50yrs, h/o heavy EtOH use, "in recovery" 21yrs,
no drug use, married
Family History:
mother died age 66, had HTN, stroke; father died age 87
Physical Exam:
VS: T 97 HR 127 Bp 102/51, RR 27, SaO2 92% on 100% NRB
Genl: tacchypneic, not responsive to questions or sternal rub,
withdrew to painful stimuli
HEENT: NCAT, Pupils 2 mm and slugishly reactive, MM dry
Neck: supple, no bruits
CV: irreg and tacchy, nl S1, S2, difficult to appreciate murmur
over loud chest sounds
Chest: anterior exam was diffusely rhoncherous
Abd: soft, NTND, BS+
Ext: warm and dry
Pertinent Results:
ADMISSION LABS
[**2111-12-31**] 08:10PM BLOOD WBC-5.5 RBC-4.19* Hgb-12.7* Hct-37.9*
MCV-91 MCH-30.4 MCHC-33.6 RDW-14.1 Plt Ct-192
[**2111-12-31**] 08:10PM BLOOD Neuts-79* Bands-5 Lymphs-5* Monos-6 Eos-0
Baso-0 Atyps-5* Metas-0 Myelos-0
[**2111-12-31**] 08:10PM BLOOD Plt Ct-192
[**2112-1-1**] 12:17AM BLOOD Fibrino-649*
[**2112-1-2**] 04:17AM BLOOD Fibrino-806*# D-Dimer-1592*
[**2112-1-1**] 12:17AM BLOOD Ret Aut-0.6*
[**2111-12-31**] 08:10PM BLOOD Glucose-144* UreaN-93* Creat-3.6*#
Na-149* K-3.9 Cl-109* HCO3-25 AnGap-19
[**2112-1-1**] 12:17AM BLOOD ALT-46* AST-105* LD(LDH)-318* AlkPhos-41
TotBili-0.2
[**2111-12-31**] 08:10PM BLOOD Calcium-8.4 Phos-4.0 Mg-2.4
[**2112-1-1**] 12:17AM BLOOD Hapto-305*
[**2112-1-1**] 12:17AM BLOOD TSH-0.36
[**2112-1-1**] 06:23AM BLOOD Phenyto-4.8*
[**2112-1-2**] 04:17AM BLOOD Phenyto-8.4*
[**2111-12-31**] 11:39PM BLOOD Type-ART Temp-36.1 pO2-52* pCO2-48*
pH-7.25* calTCO2-22 Base XS--6
.
LACTATES:
[**2111-12-31**] 08:18PM BLOOD Lactate-2.6*
[**2111-12-31**] 11:39PM BLOOD Lactate-1.3
[**2112-1-1**] 06:55AM BLOOD Lactate-1.2
[**2112-1-2**] 03:03PM BLOOD Lactate-2.3*
.
IMAGING
----------------
[**12-31**] head CT
Evolution of right MCA territory infarction with cortical
laminar necrosis.
.
[**1-1**] chest X ray
Airspace process of both lower lungs consistent with aspiration
or pneumonia.
.
[**1-2**]/ EEG
evidence of encephalomalacia, no epileptiform focus (prelim
read)
Brief Hospital Course:
Mr. [**Known lastname 23203**] is a 66 yo man with pmhx HTN, DM2, hyperlipidemia, R
MCA CVA who presented with altered mental status, fever, c diff,
seizure and was found to have pna and uti.
.
In the ED, initial vs were: T 98.4 HR 103 BP 120/60 R 26 O2 sat
90 % on RA. He was given 1 g vanco, 1 g ceftriaxone, 500 mg IV
flagyl, 975 mg rectal tylenol, 3 liters IVF for presumed UTI and
pna. He had a seizure in ED characterized by tonic clonic
movements witnessed and he was given 2 mg ativan. CT head done
in ED showed evolution of R MCA infarction. While in the ED, he
went into afib with rvr to the 140s which was new for the
patient. He was bolused with fluids but not given beta blockers
because of borderline low blood pressure. Patient was also noted
to be hypoxic to 80s on room air and cxr showed b/l infiltrates.
He was put on NRB and sats went up to mid 90s. Patient's family
confirmed DNR/DNI and did not want central line placed either.
.
On admission to the ICU, patient was tachy to 120-140s, SBP low
100s, afebrile, RR 20-30s and satting 88-90% on 100% NRB.
.
#. MS [**Name13 (STitle) 52034**] had multiple reasons for ms changes. Most
likely reason is infection given fever, newly diagnosed pna and
uti and recently diagnosed c diff infection. Patient had normal
ms after his cva and was alert and oriented x 3 before the past
few days when he began to spike fevers. He is somnolent now
after seizure in ED follwed by ativan and morphine. His stoke
may also be contributing although head CT showed evolution of
cva not a new stroke or bleeding into the stroke already
present. He was initially treated with vanc, zosyn and flagyl
He was given a dilantin load and then continued on q 8 hour
dilantin at 100 mg. EEG was done although seizure occured in
setting of fever of 104 which is likely culprit although he does
have known stroke focus. He was not communicative, but did move
right side, respond to painful stimuli and eye flutter to voice.
Neurology consulted but not following. MS changes likely
multifactorial, infection (PNA, UTI, Cdiff), stroke, hypoxia, w/
some residual deficits from old stroke. His mental status did
not recover after 2 days and after conversation with his wife,
his status was changed to [**Name (NI) 3225**].
#. Hypoxia- Patient had a large Aa gradient. This is likely due
to pna. He is unlikely to have PE given supratherapeutic INR of
6.1 and his cxr shows b/l infiltrates c/w pna. This could be
aspiration pna given ms changes and recent stroke. Pt may also
have a component of fluid overload from IVF given in ED.
He was treated with vanc and zosyn for broad coverage of nursing
home/hosp acquired pna and aspiration. Non-invasive ventilation
was started but he became uncomfortable, NC was used, then
discontinued after he became [**Name (NI) 3225**].
.
#. Hypotension- Fever, bandemia, consolidations on cxr, dirty
ua, recent c dif dx point towards sepsis as likely cause.
Patient also in afib with rvr which is contributing. Attempted
to slow hr down with 5 mg IV lopressor and pressure dropped to
70s systolic. He was given IVF to keep MAP > 65. No central
access or a-line was placed as per his wife.
.
# cdif- He was continued on IV flagyl as he could not take po
due to mental status changes.
.
#. UTI- UA positive for leuks, bacteria and nitrites. He was
treated with vanc and zosyn as he was covered for PNA was well.
Antibiotics were discontinued when the patients status was
changed to [**Name (NI) 3225**]
.
#. PNA- Patient could have nursing home associated pna and he
has recently been hospitalized. He had bands on diff,
consolidation on cxr and fever. Treated initially with
vanc/zosyn, then discontinued.
.
#. ARF- likely pre-renal given low bp and afib with rvr, sepsis.
Bolused w/ IVF and renally dosed meds. Held lisinopril.
.
#. Stroke- Patient has known MCA infarct and on CT head here he
has evolution of infarct but no new stroke or bleed.
Dilantin loaded and maitenance doses given, INR was
supratherapeutic, held coumadin
continued asa pr.
.
#. Seizure- patient had seizure in ED likely related to high
grade fever or known cva. Given ativan in ED. Dilantin as above
and eeg with results as reported.
.
#. hyperlipidemia- held statin as npo
.
#. HTN-held anti-hypertensives as pt was hypotensive
.
#. Afib- patient already supratherapeutic on coumadin, rate
under better control after 5 mg IV lopressor
.
#. DM- RISS, finger sticks qachs
.
#. FEN- IVF bolus to keep MAP > 65, replete lytes prn, npo
.
#. PPx- IV protonix, no need for subq heparin as last INR was 6
.
#. Access: 2 PIV, family does not want central access
.
#. Communication: with wife: [**Name (NI) 2048**] [**Name (NI) 23203**], p# is (c)
[**Telephone/Fax (1) 52033**], (h) [**Telephone/Fax (1) 52032**]
.
#. Code: DNR/DNI confirmed with wife
.
#. Dispo: ICU level of care for now
.
#.
MICU INTERN PROGRESS NOTE UPDATED [**2112-1-2**]
A/P: Pt is a 66 yo man with pmhx HTN, DM2, hyperlipidemia, R MCA
CVA [**12-7**] and [**7-7**] who presents from rehab w/ 1 week of diarrhea,
cdiff confirmed at rehab, did not improve on IV flagyl at rehab,
presenting with Acute MS changes, seizure, Afib w/ RVR, found to
have PNA, UTI, hypoxia with supratherapeutic INR.
.
#. MS changes- Unlikely Non-convulsive status epilepticus, but
needs to be ruled out still.
- EEG today to rule out epileptic focus and NCSE
- Cont infection rx as below.
- Monitor for clinica sz activity if worsens give ativan,
otherwise avoid ativan.
- If aggitated use haldol rather than ativan.
.
#. Hypoxia- Patient has large Aa gradient. This is likely due to
pna. He is unlikely to have PE given supratherapeutic INR of 6.1
and his cxr shows b/l infiltrates c/w pna. Possible Asp PNA
given stroke hx.
-Cont Rx with Vanc and zosyn for PNA covergage given
NH/rehab/hosp exposure.
-discuss non-invasive vent w/ family.
-DNI
.
#FEVER to 101.1 [**1-2**]
-cont ABX
-po liquid tylenol
-pan culture
.
#. [**Name (NI) **] Resolved, Pt had SIRS like picture on admission.
-Leukocytosis and bandemia
-IVF to keep MAP > 65, UOp >25cc/hr
-no central access or a-line per wife
- IF respiratory status declines, could consider brief
peripheral pressors to avoid fluid overload.
.
# cdif- Send repeat Cdiff eia.
-Pt spiked through IV flagyl at rehab,
-added PO Vanc starting [**1-2**]
.
#. UTI- UA positive for leuks, bacteria and nitrites.
-[**12-31**] Ucx grew GNR
-F/u sensi.
-Cont Zosyn, narrow coverage as sensitivities return.
.
#. PNA- Patient could have nursing home associated pna and he
has recently been hospitalized. Has bands on diff, consolidation
on cxr and fever.
-treat w/ vanc and zosyn
-check sputum cx
-urine legionella ag pending
.
#. [**Name (NI) 10271**] Pt has ATN like picture. FENA of 3.6% on [**1-1**].
-Cr improving from 3.2 to 2.5
-cont to follow urine lytes.
-dose meds renally
-hold lisinopril.
.
#. Stroke- Patient has known MCA [**12-7**] and [**7-7**] infarct and on CT
head here he has evolution of infarct but no new stroke or
bleed.
-dilantin load and maitenance doses
-check level in am
-INR supratherapeutic, will hold coumadin
-cont asa pr
.
#. Seizure- patient had seizure in ED likely related to high
grade fever
-cont dilantin 100mg TID, check daily levels
-eeg today r/o NCSE
-ativan for breaking any clinical seizures.
.
#. hyperlipidemia- hold statin as npo
.
#. HTN-hold anti-hypertensives as pt is hypotensive at this time
.
#. Afib w/ RVR. Difficult to control likely related to
infection. Did not respond to lopressor.
-Better response to dilt,
-cont Dilt drip
.
#. Hypernatremia:
-continue D5W and free water boluses.
.
#. Coagulopathy: INR 7.5, PTT 78 not on heparin,
-5mg Vitamin K SQ
-cont to monitor
.
#. DM- RISS, finger sticks qachs
.
#. FEN- IVF bolus to keep MAP > 65, replete lytes prn, Place
dopoff, nutrition consult.
.
#. PPx- IV protonix, no need for subq heparin as last INR was 6
.
#. Access: 2 PIV, family does not want central access
.
#. Communication: with wife: [**Name (NI) 2048**] [**Name (NI) 23203**], p# is (c)
[**Telephone/Fax (1) 52033**], (h) [**Telephone/Fax (1) 52032**]
.
#. Code: DNR/DNI confirmed with wife
.
#. Dispo: ICU level of care for now
.
Medications on Admission:
senna
zocor 80 mg qd
coumadin
dulcolax daily
zofran 4 mg prn
oxycodone 5 mg q4 prn
sorbitol 30 cc qd
cardizem 30 mg q6
colace 100 mg [**Hospital1 **]
pepcid 20 mg [**Hospital1 **]
neurontin 300 mg tid
sliding scale insulin
lisinopril 5 mg qd
combivent q4 prn
tylenol prn
asa 325 mg daily
Discharge Medications:
pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired
Discharge Condition:
pt expired
Discharge Instructions:
non-applicable
Followup Instructions:
non-applicable
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2112-5-12**]
ICD9 Codes: 0389, 486, 5990, 5849, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7185
} | Medical Text: Admission Date: [**2151-1-2**] Discharge Date: [**2151-1-9**]
Date of Birth: [**2094-1-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 7202**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization with stent placement
angiography of mesenteric and renal arteries
esophagogastroduodenoscopy
History of Present Illness:
54 yo F with CAD s/p 4 stents, +smoker, DM2, HTN, PVD,
hypercholesterolemia, family history of premature CAD now with
chest pain. She states she was sitting in her living room around
8 p.m. when she started to feel SOB. Went upstairs and sat on a
stool and states began to have CP. CP described as stabbing in
the middle to L chest, radiating to L arm and jaw. States she
was feeling hot but no diaphoresis, n/v. +SOB. Took 3 NTG each
15 mins apart with no relief so called EMS. States the pain was
similar to that she had when she had her previous MI's. EMS
found her tachycardic and gave 6 Adenocard, 25mg cardizem, 1"
nitropaste, and ASA.
.
At [**Hospital3 **] she arrived with a HR of 140 in Afib. BP was
195/106. Was given 25mg Cardizem. HR was still 140 and a
diltiazem drip was started. She converted to NSR with HR in the
60's and the diltiazem drip was stopped. Nitropaste was removed.
Trop was was 0.16 and ECG was concerning for ST elevations and
pt was sent in helicopter to [**Hospital1 18**] for possible cath.
.
On arrival to [**Hospital1 18**] pt stated she was having some CP and was
started on nitro gtt. CP went away, but nitro was titrated up to
90 mcg for
high systolic BP's in the 180's-190's. HR in the 60's. She was
given 25mg metoprolol po and 12.5mg captopril po. Stated she
still had a small tingling sensation in her L jaw, and c/o
headache, but otherwise was CP free.
.
She states she has been having CP with SOB at least 1-2 times
per week for the last few weeks. States it comes on both at rest
and when she is walking or doing other activities. States
exerting herself does not bring on the CP. It usually resolves
with 2 NTG's and is accompanied by SOB. States lately the
episodes have been coming more often and seem to last longer.
Past Medical History:
-CAD s/p 4 stents at [**Hospital1 112**]
--Cath [**2147-12-27**] at [**Hospital1 18**] showed LAD with diffuse disease, 70%
focal stenosis mid segment. Stent placed to mid RCA. LVEF 45%
with global hypokinesis.
-HTN
-DM2
-h/o renal artery stenosis s/p B stents
-h/o PVD s/p stents in bilateral LE's
-hypercholesterolemia
-s/p partial hysterectomy
-s/p cholecystectomy
-Fatty liver
-h/o ETOH abuse
-obesity
-cerebral aneurysm clipping [**8-22**]
Social History:
Lives with husband. [**Name (NI) **] 2 sons and one daughter. Is disabled s/p
aneurysm clipping. Smokes 1 ppd. Drinks a beer "once in awhile",
no h/o withdrawal sx's. Son is coming home from [**Country 2451**] today.
Family History:
Mother had DM and died of MI at age 59. Father died of throat
and lung cancer age 61.
Physical Exam:
PE: 98.6 HR 72, BP 187/80, RR 16, O2sat 100% on 2L NC
Gen: in nad.
HEENT: PERRLA, EOMI, OP clear and moist.
CV: RRR, +[**12-28**] HSM at LUSB.
Lungs: CTAB
Abd: +ttp of RUQ. +bs. No rebound or guarding.
Ext: no c/c/e.
Pulses: no palpable pulse R groin, L femoral very faint. PT 2+
bilaterlly, DP: 2+ L, 1+ R.
Pertinent Results:
[**2151-1-2**] 02:05AM WBC-13.2* RBC-4.27 HGB-12.6 HCT-36.0 MCV-84
MCH-29.5 MCHC-34.9 RDW-15.3
[**2151-1-2**] 02:05AM PLT COUNT-286
[**2151-1-2**] 02:05AM PT-12.0 PTT-22.7 INR(PT)-1.0
[**2151-1-2**] 02:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2151-1-2**] 02:05AM CK-MB-13* MB INDX-12.3* cTropnT-0.16*
[**2151-1-2**] 02:05AM LIPASE-48
[**2151-1-2**] 02:05AM ALT(SGPT)-21 AST(SGOT)-33 CK(CPK)-106
AMYLASE-72 TOT BILI-0.2
[**2151-1-2**] 09:30AM CK-MB-48* MB INDX-15.6* cTropnT-0.60*
[**2151-1-2**] 09:30AM CK(CPK)-308*
[**2151-1-2**] 09:30AM GLUCOSE-178* UREA N-14 CREAT-1.3* SODIUM-137
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15
.
ECGs: at OSH: NSR at 66 nl axis, nl intervals, poor R wave
progression. Q in III. 2mm ST elevation in III comp to prior.
1mm ST elevation V2-V3 present on old ECG.
-at [**Hospital1 18**] 01:23 - NSR at 73, nl axis, nl intervals. TWI V6 old
comp to prior. 1mm ST elevations V1-V3 old comp to prior from
[**2147**].
Brief Hospital Course:
.
# CAD: She was diagnosed with a non-ST elevation MI and was
started on IV heparin and loaded with clopidogrel. As she was
asymptomatic at the time, the plan was made to stabilize her
with antiplatelet agents and plan for catheterization on [**1-4**].
She had recurrent chest pain the next day and was started on
integrilin, after which time she was chest pain-free. Her peak
CK was 347, MB 49, and troponin T 1.68. She underwent cardiac
catheterization on [**1-4**], with PCI to the an 80% stenotic lesion
of the ostial RCA. She was continued on ASA 325, Plavix,
lipitor 80, and beta blocker. She had no further chest pain.
She was discharged to PCP follow up with establishment of
Cardiology follow up.
.
# CHF: TTE on [**1-5**] with EF 50%, mild LVH, mildly dilated
ascending aorta with no AI. She was volume overloaded on exam
after her procedure and was diuresed with IV Lasix. She was
maintained on a beta blocker, ACE-inhibitor, and oral Lasix.
She was euvolemic on discharge.
.
# Atrial fibrillation: She has a history of paroxysmal atrial
fibrillation with RVR at the outside hospital that converted
with diltiazem. She had an episode of RVR in CCU, that was
treated with diltiazem gtt, after which she converted to NSR.
She was maintained on a beta blocker and was in sinus rhythm on
discharge. She was not started on anticoagulation due to her
recent GI bleed.
.
# HTN: She is not adherent to her medication regimen as an
outpatient. Her hypertension was thought to be a likely trigger
for her AF w/ RVR. She was severely hypertensive in the CCU to
the 230s/100s. Her blood pressure was controlled in the CCU
with labetalol and nifedipine gtt. She was hypertensive off the
drips on the floor. Her severe renal artery stenosis was
thought to be the main cause for her refractory hypertension.
She was discharged on carvedilol, lisinopril, and furosemide.
She was discharged to follow up with her PCP for further
titration of her medications.
.
# GI bleed: She had melenic stools in the cath holding area on
[**1-4**] while on aspirin, clopidogrel, IV heparin, and integrilin.
She had patent celiac and mesenteric arteries on angiography, so
ischemic bowel was thought to be unlikely. GI was consulted and
performed an EGD that showed gastric erosions and duodenitis as
the only sources of upper GI bleed. She was started on IV
pantoprazole and carafate with close monitoring of her
hematocrit. She required a total of 8U PRBC. Her hematocrit
stabilized and her diet was advanced. She had no further
episodes of melena during her stay. She was encouraged to have
a colonoscopy as an outpatient as she has never had one before.
.
# RP bleed: She had severe hypertension during the [**1-4**] cardiac
catheterization requiring nitroprusside. Her renal arteries
were engaged during the cath, and she was found to have severe
in-stent restenosis of her right renal artery, but attempts at
intervention were unsuccessful. In the cath holding area, she
became hypotensive and had a large melenic stool. She was taken
back to the cath lab where she was found to have patent celiac
and superior mesenteric arteries, but had bleeding from the
right kidney which was stopped with balloon tamponade. No
further chest pain. A CT abdomen was performed that showed a
large perinephric hematoma extending into the retroperitoneum.
Transplant Surgery was following. Surgical intervention was not
indicated as she was hemodynamically stable. Repeat CT showed
stable hematoma and her hematocrit stabilized.
.
# ARF: She has known RAS s/p stenting, and was thought to
likely have some hypertensive nephropathy as well. Her baseline
creatinine was unknown. Her creatinine was 1.5 on the day of
cath, and her FENa was 0.9%, indicating a prerenal state.
Angiography showed right renal artery in-stent restenosis. She
likely had some hypoperfusion to the R kidney in setting of
bleed. She also received a large dye load for aniography of
coronaries, mesenterics, renals, and iliacs. Her left kidney
appeared atrophic on imaging. Her creatinine increased to 1.6
and was then stable for several days. She was discharged on an
ACE-inhibitor, with PCP follow up for further management.
.
# Glucose intolerance: She was hyperglycemic throughout her
stay. She has no known diagnosis of diabetes. Her HgA1C was
6.7. She was maintained on an insulin sliding scale.
.
# Code status: FULL
.
Medications on Admission:
Aspirin 325 daily
States she last saw her PCP 2 months ago who recommends she take
many other meds but she has not been able to afford them.
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
Primary:
Non-ST elevation MI
Congestive heart failure, systolic
GI bleed, source unknown
Hypertension
Renal artery stent restenosis
Renal failure, likely acute on chronic
Secondary:
Peripheral vascular disease
Primary:
Non-ST elevation MI
Congestive heart failure, systolic
GI bleed, source unknown
Hypertension
Renal artery stent restenosis
Renal failure, likely acute on chronic
Secondary:
Peripheral vascular disease
Discharge Condition:
good, hematocrit stable, chest pain free, BP fairly
well-controlled, creatinine stable
Discharge Instructions:
It is very important that you take all of your medications as
prescribed.
.
If you experience chest pain, shortness of breath, dizziness,
bloody or black stools, or other concerning symptoms, please
call your doctor or go to the ER.
Followup Instructions:
1) Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 24354**], to
schedule a follow up appointment within the next week. You
should have your hematocrit and renal function labs checked.
Please discuss colonoscopy with Dr. [**First Name (STitle) **].
Completed by:[**2151-4-1**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7186
} | Medical Text: Admission Date: [**2106-5-14**] Discharge Date: [**2106-5-18**]
Date of Birth: [**2059-12-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
several years of DOE and progressive SOB-treated for asthma. CT
scan showed TBM- Y stent placed but had persistant cough.
Major Surgical or Invasive Procedure:
bronchoscopy
tracheoplasty
History of Present Illness:
The patient is a delightful
athletic young man who has a several year history of
progressive dyspnea on exertion who has been found to have
severe tracheobronchomalacia. He underwent extensive
evaluation in the tracheobronchomalacia protocol, including
respiratory questionnaires, 6-minute walk test, functional
bronchoscopy, dynamic airway CT scan, pulmonary function
tests and a stenting trial. He did well from the stenting
trial with an excellent response. His flexible bronchoscopy
and dynamic airway CT scan demonstrated severe
tracheobronchomalacia. His pulmonary function tests
demonstrated good lung capacity based on DLCO. We felt that
he was, therefore, an excellent candidate for
tracheobronchoplasty with mesh. Therefore, he was taken to
the operating room for the following operation.
Past Medical History:
HTN, HA, GERD, bilateral inguinal hernia, bilateral carpal
tunnel, appy, left foot neuroma
Social History:
lives w/ wife in [**Name (NI) 29586**]
Family History:
non-contributory
Physical Exam:
general: well appearing robust man w/ cc shortness of breath,
cough.
HEENT: unremarkable
Chest: wheezes on expir R>L
Cor: RRR S1, S2
Abd: round, soft, NT, ND, +BS
Extrem: no C/C/E
Neuro: A+OX3. No focal deficits.
Pertinent Results:
[**2106-5-14**] 04:27PM TYPE-ART PO2-102 PCO2-67* PH-7.24* TOTAL
CO2-30 BASE XS-0
Brief Hospital Course:
pt was admitted and taken to the OR [**5-14**]/for a
tracheobroncheoplasty.
OR course was uneventful. An epidural was placed for pain
control. Extubated post op and tranferred to the CSRU for
pulmonary/airway maintainance and monitoring. Pleural and
subcutaneous chest tubes to sxn w/ serosang drainage. maintained
on prophylactic vancomycin to protect mesh.
POD#1 Bronchoscopy done for minimal secretions.
POD#2 transferred out of ICU. [**Doctor Last Name 406**] drains placed to bulb sxn w/
minimal serosang drainage.
POD#3 doing well. Epidural for pain control. [**Last Name (un) 1815**] reg diet.
ambulating well on room air w/ sats >94%.
POD#4 epidural d/c'd-[**Last Name (un) 1815**] po pain med. pleural [**Doctor Last Name **] d/c'd and
subcutaneous [**First Name8 (NamePattern2) **] [**Doctor Last Name **] remained in place to bulb sxn. Pt
taught how to empty [**Doctor Last Name **] drain and will call the office w/
drainage amounts. Pt d/c'd to nearby hotel on po levoflox x 2
weeks. He will return on wednesday [**5-26**] for a flex bronch and his
drain will be d/c'd at that time.
Medications on Admission:
lisinopril 5, HCTZ 25, Lexapro 40, P.O. dilaudid
.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Escitalopram 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. drain care
please empty and record your bulb drainage and bring to your
follow up appointment.
Please call the office daily to report the drainage from the
bulb [**Telephone/Fax (1) 170**]
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
8. medication change
do not take your lisinopril while you are taking lopressor.
Discharge Disposition:
Home
Discharge Diagnosis:
TBM-tracheoplasty
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] if you develop fever,
chills, chest pain shortness of breath or problems with the
drain.
DO NOT shower, swim or tub bath until your drain is removed.
Followup Instructions:
You have a follow up appointment on [**2106-5-26**] 9am for a
bronchoscopy in interventional pulmonology [**Telephone/Fax (1) 3020**] with Dr.
[**Last Name (STitle) 952**]. DO NOT EAT OR DRINK anything after midnight on tuesday
[**2106-5-25**].
Completed by:[**2106-5-19**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7187
} | Medical Text: Admission Date: [**2196-12-8**] Discharge Date: [**2196-12-14**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
cardiac catherization complicated by femoral artery bleed
Major Surgical or Invasive Procedure:
cardiac catherization
History of Present Illness:
89 yo female with history of severe CAD including CABG (SVG->OM,
SVG->RCA, LIMA->LAD) followed by artherectomy for SVG total
occlusion and recent cath ([**2196-11-21**]) for accelerating anigina
resulting in stent to 95% ostial LMCA lesion who as transferred
to [**Hospital1 18**] from [**Hospital **] hospital for recurrent chest burning times
2 days without ECG changes or +CE's. Decison made for repeat
diagnostic catherization to assess patency of LMCA stent; wich
showed patent stent however procedure complicated by commonn
femoral artery aneursym and brisk retroperitoneal bleed. Pt was
able to be succesfully [**Hospital 79818**] tamponade just proximal to the
aneurysm. During which Pt recieved two units PRBC and started
on dopamine gtt. Upon arrival to the CCU, Pt c/o left abd pain
and nausea. Denies any chest discomfort or anginal equivalent.
Past Medical History:
1) coronary artery disease
2) hypertension
3) dyslipidemia
4) hypothyroidism
5) dejenerative joint disease
6) h/o spinal stenosis - treated with epidural injections
7) COPD
8) hiatal hernia
9) s/p cholecystectomy
[**02**]) chronic renal insufficiency (crn. baseline 1.8)
Social History:
Quit smoking 30yrs ago. No alcohol. Lives alone in senior
houing. Ambulates with cane.
Family History:
mother - ca
father - MI at age 60
Physical Exam:
VS: 95.2, 69, 130/60 (MAP 80) on dopa 10
PE:
Lying in bed, comfortable
Anicteric, MMM, OP wnl
supple, JVP not appreciable
RRR, nl S1/S2, [**2-9**] SM
anteriorly CTA-B
obese, significant LLQ tendernes, ND, no rebound/guarding,
Hypoactive BS
stable left groin hematoma, FEM 2+
Ext without edema, warm and perfused, DP 1+ with R>L
A&O
Pertinent Results:
[**2196-12-9**] 12:33AM BLOOD Hct-37.3 Plt Ct-219
[**2196-12-9**] 04:09AM BLOOD WBC-16.1*# RBC-3.62* Hgb-11.5* Hct-34.3*
MCV-95 MCH-31.9 MCHC-33.7 RDW-14.2 Plt Ct-188
[**2196-12-9**] 09:30AM BLOOD Hct-26.2*
[**2196-12-9**] 09:29PM BLOOD Hct-28.9*
[**2196-12-10**] 06:00AM BLOOD WBC-7.5# RBC-3.17* Hgb-10.1* Hct-28.9*
MCV-91 MCH-31.9 MCHC-34.9 RDW-15.5 Plt Ct-133*
[**2196-12-10**] 12:48PM BLOOD Hct-34.0*
[**2196-12-10**] 05:29PM BLOOD Hct-34.7*
[**2196-12-11**] 05:30PM BLOOD WBC-8.3 RBC-3.59* Hgb-11.3* Hct-33.6*
MCV-94 MCH-31.5 MCHC-33.6 RDW-14.8 Plt Ct-129*
[**2196-12-9**] 12:33AM BLOOD Plt Ct-219
[**2196-12-10**] 06:00AM BLOOD Plt Ct-133*
[**2196-12-11**] 06:50AM BLOOD Plt Ct-113*
[**2196-12-11**] 05:30PM BLOOD Plt Ct-129*
[**2196-12-9**] 04:09AM BLOOD Glucose-170* UreaN-29* Creat-1.2* Na-142
K-4.3 Cl-112* HCO3-24 AnGap-10
[**2196-12-10**] 06:00AM BLOOD Glucose-76 UreaN-26* Creat-1.2* Na-144
K-3.9 Cl-112* HCO3-25 AnGap-11
[**2196-12-11**] 06:50AM BLOOD Glucose-79 UreaN-23* Creat-1.1 Na-141
K-3.9 Cl-111* HCO3-26 AnGap-8
[**2196-12-9**] 04:09AM BLOOD CK(CPK)-190*
[**2196-12-10**] 11:11PM BLOOD CK(CPK)-158*
[**2196-12-9**] 04:09AM BLOOD CK-MB-4 cTropnT-<0.01
[**2196-12-10**] 11:11PM BLOOD CK-MB-2 cTropnT-<0.01
[**2196-12-9**] 04:09AM BLOOD Calcium-7.4* Phos-3.2 Mg-1.8
[**2196-12-10**] 06:00AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.8
[**2196-12-11**] 06:50AM BLOOD Calcium-7.6* Phos-2.5* Mg-1.9
ECHO
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. The aortic valve leaflets (3) are mildly thickened.
3. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
4. There is mild pulmonary artery systolic hypertension
CCath
Brief Hospital Course:
89 yo female with extensive CAD s/p CABG and TO SVG and recent
95% LM lesion stented. Pt with recurrent angina like symptoms,
resulting in repeat diagnostic cath c/b FA bleed and aneurysm
requiring multiple blood transfusions and pressors.
1) CAD: Pt with extensive CAD s/p CABG and recent LMCA stent
who presented for repeat diagnostic catherization that showed
patent stent but complicated by common femoral artery bleed.
Given Pt's HD instability post-procedure, Pt was only continued
on [**Last Name (LF) **], [**First Name3 (LF) **] and Plavix; while holding BB. After
stabilization Pt was restarted on a BB. Pt will continue to be
managed medically. [**Hospital **] medical regimen consisting of
atenolol 12.5 mg qd (to be titrated up as outpatient as
tolerated), [**Hospital **] 325 qd, Plavix 75 mg qd times 9 months,
Simvastatin 10 mg qd. On transfer Pt recieving Cozaar 50 mg qd,
which was held during hospital stay due to HD instability; it
should be added back on as an outpatient when seen next week by
PCP if Pt continues to be stable.
2) Vascular: As above, Pt's catherization complicated by CFA
aneurysm and bleed. Initial external pressure unsuccesful in
stopping the bleed. Attempt to asses artery from the other
femoral artery unsuccessful given extensive artherosclerosis.
However, with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 79818**] [**Last Name (un) **] from a the same FA was able to be
advanced to the aneursym with succesful tamponade. CT confirmed
significant retroperitoneal bleed. Pt did require 2 emergent
units of PRBC and the initiation of dopamine gtt given
hypotension. Pt aggresively hydrated overnight, with serial
Hcts being stable. Hct then began to trend down requiring an
additional 4 units of PRBC the following day. Hemodynamically
Pt improved and was weaned off dopamine. Vascular surgery
followed throughout and was integral in her management. Hct
stabilized once again; not requiring further transfusions or
exploratory surgery.
3) Pump: A p-MIBI earlier in the year with evidence of EF 72%.
Pt without history of CHF or LV dysfunction. Pt hypovelemic
secondary to RP bleed and was aggresively hydrated during
initial hospital days. [**Last Name (un) **] held due to this instability and BB
started at a lower dose. Out Pt cardiac regimen as above and
weill be titrated to maximum effect as outpatient given Pt's
ability to tolerate.
4) CRI: Pt with known CRI with a reported baseline Cr 1.8 prior
to admission. Initial Cr 2.1 however remaining Cr ranged from
1.2 - 1.1. Pt managed with mucomyst prior to and proceeding
catherization as well as receiving D5 with NaBicarb. No
evidence of renal failure or insufficiency during hospital stay.
Pt to be followed up as outpatient.
Medications on Admission:
[**Last Name (un) **] 81
Plavix 75
Cozaar 50
Indur 30
Zocor 30
Levoxyl 0.25
Iron
Protonix 40
Procrit times one
Discharge Medications:
1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 9 months.
Disp:*30 Tablet(s)* Refills:*6*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
4. 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:*3*
5. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*6*
6. 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:*3*
7. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
Thirty (30) ML PO QID (4 times a day) as needed for indigestion.
13. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
discomfort.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
CAD with patent LMA stent
common femeral artery bleed
Discharge Condition:
good
Discharge Instructions:
please attend all follow up appointments as scheduled below. If
you are unable to, please call and reschedule as soon as
possible.
call your PCP or return to ED if persistent fever greater than
101.4, chest discomfort typical of your angina, abrupt shortness
of breath, persistent nausea and vomitting, inability to
tolerate food or liquid, severe weight gain, severe leg or
abdominal pain.
Followup Instructions:
please follow up with PCP, [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 133**])
Friday [**2196-12-23**] at 3:00, if unable to make please call and
rechedule.
Please make a follow up appointment to be seen by a cardiologist
of either Dr[**Initials (NamePattern4) 15012**] [**Last Name (NamePattern4) 7027**] or with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who
can be reached at [**Telephone/Fax (1) 5003**].
ICD9 Codes: 5849, 2765, 496, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7188
} | Medical Text: Admission Date: [**2114-5-24**] Discharge Date: [**2114-6-6**]
Date of Birth: [**2050-7-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
hepatocellular carcinoma and two pulmonary nodules found on PET
scan
(FDG avidity in the right upper lobe nodule)
To undergo resection with Dr [**First Name (STitle) **] and Dr [**Last Name (STitle) 77624**]
Major Surgical or Invasive Procedure:
[**2114-5-24**] Exploratory laparotomy, resection segment 4B, Flexible
bronchoscopy, VATS right upper lobectomy, mediastinal lymph node
dissection.
[**2114-5-28**] cardiac catheterization with stenting of RCA
History of Present Illness:
Mr. [**Known lastname 77625**] was involved in a motor vehicle accident [**2-20**] and
on a CT scan an incidental 3-cm lesion involving the left lobe
of the segment 4B was found. He had further workup including a
chest CT which demonstrated 2 small lung nodules. He was seen
by thoracic surgery and underwent a flexible bronchoscopy with
biopsy and cervical mediastinoscopy which was unremarkable. A
PET scan showed + right upper lobe nodule. It was decided to
proceed with right upper lung lobectomy and liver resection for
removal of the lesion.
Past Medical History:
type 2 diabetes mellitus, history of alcohol abuse, duodenal
ulcer
Social History:
50-pack-year tobacco use, history of alcohol abuse. He works as
a floor sander.
Family History:
Mother had myocardial infarction in her 70s.
Father had myocardial infarction in his 70s and had an unknown
type of cancer.
Physical Exam:
VS: 98.3, 105, 89/45, 8, 100%
Gen: A+O, MAE
Card: Reg rhythm, tachy
Resp: CTA bilaterally
Abd: Soft, non-tender, non-distended, + BS
Extr: No edema
Dressings C/D/I
Pertinent Results:
[**2114-5-24**] 06:34PM BLOOD WBC-19.0* RBC-3.17*# Hgb-9.8*# Hct-29.1*#
MCV-92 MCH-31.1 MCHC-33.8 RDW-13.7 Plt Ct-348
[**2114-5-24**] 06:34PM BLOOD PT-14.4* PTT-34.6 INR(PT)-1.3*
[**2114-5-24**] 06:34PM BLOOD Glucose-173* UreaN-29* Creat-0.9 Na-141
K-5.2* Cl-112* HCO3-21* AnGap-13
[**2114-5-24**] 06:34PM BLOOD ALT-67* AST-96* LD(LDH)-185 AlkPhos-61
Amylase-116* TotBili-0.6
[**2114-5-24**] 06:34PM BLOOD Albumin-3.2* Calcium-8.8 Phos-4.1 Mg-1.1*
[**2114-5-27**] 10:05PM BLOOD CK-MB-8 cTropnT-0.16*
[**2114-5-28**] 02:27AM BLOOD CK-MB-9 cTropnT-0.39*
[**2114-5-28**] 10:05AM BLOOD CK-MB-33* MB Indx-10.0* cTropnT-1.12*
[**2114-5-28**] 03:41PM BLOOD CK-MB-29* MB Indx-10.3* cTropnT-1.07*
[**2114-5-28**] 09:47PM BLOOD CK-MB-14* MB Indx-7.9* cTropnT-1.01*
[**2114-5-29**] 04:12AM BLOOD CK-MB-10 MB Indx-7.8*
[**2114-5-29**] 04:12AM BLOOD cTropnT-0.93*
Pathology:
[**2114-5-24**]
Lung, right upper lobe, lobectomy (G-P):
a. Moderately differentiated adenocarcinoma; see synoptic
report #1.
b. Immunostains of the tumor cells are positive for cytokeratin
7 and TTF-1, and negative for cytokeratin 20 and HepPar1, with
satisfactory controls. This immunophenotype supports a pulmonary
origin.
Gallbladder, cholecystectomy (Q):
a. Mild chronic cholecystitis.
b. No calculi present.
Liver, segment 4A, resection (R-U):
a. Hepatocellular carcinoma, well-differentiated; see synoptic
report #2.
b. Immunostains of the tumor cells are diffusely and strongly
positive for HepPar1, with satisfactory controls, supporting the
diagnosis
Imaging:
[**2114-5-24**] echo: The left atrium is normal in size. Overall left
ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets appear
structurally normal with good leaflet excursion. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation.
[**2114-5-28**] Cardiac cath: Selective coronary angiogrpahy in this
right dominant system revealed one vessel coronary disease. The
LMCA was free of angiographically apparent CAD. The LAD had
minimal luminal irregularities. The LCX had a 30% proximal
lesion. The RCA had a 99% mid vessel stenosis and an aneuysm of
the ostium which was present at baseline.
2. Resting hemodynamics revealed nromal systemic blood pressure.
3. Successful stenting of a a heavily calcified mid RCA lesion
with a
2.5 X 8 mm Driver and a 2.5 X 12 mm Vision bare metal stents
(see PTCA
comments for detail).
[**2114-5-28**] echo: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
basal to mid inferior akinesis and inferoseptal and
inferolateral hypokinesis. Overall EF 40-45%. The estimated
cardiac index is normal (>=2.5L/min/m2). The right ventricular
cavity is mildly dilated There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is mildly elevated. There is no pericardial
effusion. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Mild to moderate focal left ventricular dysfunction
consistent with CAD. Mild right ventricular dilation with
preservation of apical motion (base less well seen), mild
pulmonary hypertension, and septal flattening. Cannot rule out
pulmonary embolism.
Compared with the prior study (images reviewed) of [**2114-4-4**],
the focal wall motion abnormalities and right ventricular
findings are new. \
Brief Hospital Course:
Mr. [**Known lastname 77625**] was admitted to the hepatobiliary surgery service
and was followed closely by the thoracic surgery service after
his surgeries on [**5-24**]. For details of the surgeries, please
refer to the operative notes. He was kept in the PACU for close
monitoring post op. He had an epidural in place which was held
due hypotension. He had 2 chest tubes in place as well as an
abdominal JP drain. On POD 1 ([**5-25**]) his chest tubes were placed
to water seal, the epidural was continued and he was stable for
transfer to the floor. On POD 2 ([**5-26**]), he was doing well and
his pain was well controlled with the epidural/PCA and chest
tube #1 was removed and the 2nd chest tube was placed to bulb
suction.
On POD 3 ([**5-27**]) he was started on clear liquid diet. Overnight
he had acute mental status changes with increased O2
requirements and respiratory distress. EKG showed new Afib and
Lopressor was given with no change. ABG showed decreased PaO2.
CXR demonstrated increased left lung opacity. He was
transferred to the SICU for further management. He was
intubated and diltiazem IV drip for afib was started. Cardiac
enzymes revealed increased troponins with new ischemia on EKG. A
Heparin drip and pressors were started. IV antibiotics were
started for possible sepsis.
Cardiology was consulted and he was taken emergently to the cath
lab for a PTCA and stenting (bare metal)of RCA on the morning of
POD 4 ([**5-28**]). He was started on aspirin, plavix and was
maintained on integrelin x 18 hours post procedure. Lower
extremity US which were negative for DVT and a bronchoscopy
which was clear. He remained intubated on POD 5 ([**5-29**]). The
epidural was d/c'd on POD 6 ([**5-30**]).
Overnight he had a acute change in neurological exam where he
was only moving his LUE to sternal rub and not moving his RUE
and had R pupil > L pupil. Sedation (versed & propofol)was
turned off. A stat head CT was done which showed no evidence of
acute intracranial pathology. Two units of PRBC were transfused
for a hct of 25.8. Neuro exam improved. He was slowly weaned off
of pressors and given lasix for volume overload. CXR showed
Asymmetrical interstitial edema affecting the left lung to a
greater degree than the right. Nebs were given. A low dose
propofol drip was used for agitation. He was weaned off the vent
on [**6-2**].
On [**6-2**], he was transferred out of the SICU to the [**Hospital Ward Name 121**] 10
(med-[**Doctor First Name **] unit) where he continued to improve. The CT was d/c'd
without incident. CXR on [**6-3**] showed persistent right-sided
moderate-to-large pneumothorax, unchanged and left-sided
effusion and left basilar atelectasis persisted. Breath sounds
were diminished on the left. O2 was weaned off. He was assisted
OOB. The foley was removed and diet was advanced. Vicodin was
used for pain with break thru dilaudid. It was noted that he had
periods of forgetfulness. PT declared him safe for discharge
home as he was ambulatory and able to do stairs.
On [**6-6**], the JP drain was removed. Vital signs and labs were
stable. He was ambulatory and tolerating a regular diet. Follow
up appointments with Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 5795**] were made as
well as with Dr. [**Last Name (STitle) **] (Oncology). A follow up appointment with
Cardiology was to be made.
Medications on Admission:
metformin 1000mg [**Hospital1 **]
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H () as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Outpatient Physical Therapy
Cardiac rehab post MI (STEMI)
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatoma
Right upper lobe carcinoma
s/p STEMI with RCA stent placement [**2114-5-28**]
Discharge Condition:
Stable/good
Discharge Instructions:
Please call Dr[**Name (NI) 670**] office at [**Telephone/Fax (1) 673**] if you have
fevers > 101, chills, nausea, vomiting, diarrhea, yellowing of
skin or eyes, shortness of breath, chest pain,inability to eat
or take medications.
Monitor incision for redness, drainage or bleeding
No heavy lifting. No driving or alcohol while taking pain
medication
Followup Instructions:
-Follow up with Oncology, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/Dr. [**Last Name (STitle) **] on
Tuesday, [**6-12**] at 3pm, [**Hospital Ward Name 23**] building, [**Location (un) **], phone
[**Telephone/Fax (1) 77626**].
-CXR at [**Hospital1 18**] [**Hospital Ward Name 23**] Building [**Location (un) **] [**2114-6-21**] at 3:30 then go
to -[**Location (un) **] for follow up with Dr. [**Last Name (STitle) 11482**] [**Name (STitle) 77627**]
(Thoracic)at 4pm 5/8([**Telephone/Fax (1) 1504**]
Follow up with Cardiology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] .
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2114-6-14**] 1:10
Completed by:[**2114-6-6**]
ICD9 Codes: 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7189
} | Medical Text: Admission Date: [**2193-10-17**] Discharge Date: [**2193-10-21**]
Date of Birth: [**2117-4-27**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
GI Bleed, Syncope
Major Surgical or Invasive Procedure:
Push Enteroscopy ([**2193-10-18**])
Impression:
- Mucosa suggestive of Barrett's esophagus
- Clotted blood in the stomach body
- Erythema and congestion in antrum suggestive of mild gastritis
- 1.5cm cratered ulcer in duodenal bulb with visible vessel. 5cc
of 1:10,000 epinephrine, heater probe and one endoclip applied
with successful hemostasis.
History of Present Illness:
This is a 76 year-old male with a history of metastatic small
cell lung cancer, ESRD on PD who is being transferred to [**Hospital1 18**]
for push enteroscopy after presenting to [**Hospital6 **]
with black stool, syncope, and hypotension.
.
He reports that on [**10-12**], he had his first episode of large dark
black loose bowel movement. He had had a normal brown BM the day
prior and denies any h/o BRBPR or GIB previously. He had no
abdominal pain nor nausea/vomiting prior to the event. Shortly
thereafter, he experienced LOC although the events surrounding
this are not entirely clear. He is not sure exactly what he was
doing and does not recall fall from what distance. He denies
hitting his head, but did scrape his right anterior calf. He
presented at that time to [**Hospital6 **] where he
underwent EGD which reportedly showed candidal esophagitis and a
nonbleeding duodenal ulcer. He received 2U prbcs and hct
stabilized thereafter. He was discharged home on [**10-14**] on
protonix and fluconazole and nystatin.
.
He is unsure if his BMs upon discharge revealed any blood or
black expect for he again noted a large black loose BM on [**10-16**].
He again had a syncopal event upon rising thereafter and
presented again to [**Hospital6 33**]. There he was found to
be tachy to low 100s with SBPs in the 70s-80s. He was reportedly
fluid resuscitated with crystalloid and received a total of 3
units prbcs with resolution of his tachycardia and improvement
in BPs. Repeat EGD demonstrated duodenitis but again no clear
evidence of active bleed. He was prepped for colonoscopy at
[**Hospital3 **] (clear output [**Name8 (MD) **] RN signout). He is now being
transferred to [**Hospital1 18**] for push enteroscopy and colonoscopy. Hct
was 27 on presentation (was 34 on most recent discharge) and
prior to transfer was 28.7 after 3U prbcs.
Past Medical History:
-Metastatic small cell lung cancer s/p chemotherapy (no rx since
[**11-8**])
-ESRD on PD since [**6-9**]
-DVT and PE [**11-8**] s/p IVC filter (never on coumadin)
-"Suspected HIT in past" per [**Hospital3 **] d/c summary (unclear
hx)
-BPH
-s/p ventral hernia repair
-Anemia
-Chronic LE edema
Social History:
Widowed. Lives alone at home. Has two sons both of whom live
locally and are involved in his life and health care. Son [**Name (NI) **]
is HCP. 60+ packyear history of smoking cigarettes prior to
diagnosis of lung cancer. Occasional EtOH, perhaps [**2-3**]
drinks/week.
Family History:
Noncontributory
Physical Exam:
GEN: Elderly gentleman in NAD.
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM.
NECK: No JVD, carotid pulses brisk, no cervical lymphadenopathy,
trachea midline
COR: RRR, soft systolic murmur heard best at apex.
PULM: course BS bilaterally and diffusely rhonchorus, no
wheezing.
CHEST: Right sided tunnelled HD line site CDI.
ABD: PD site right lower abdomen CDI. Distended, but soft, +BS.
NTTP.
EXT: 3+ b/l LE pitting edema (L very sl. greater than right)
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength and sensation
to soft touch grossly intact.
SKIN: No jaundice, cyanosis, or gross dermatitis. Confluent
ecchymoses bilateral forearms.
Pertinent Results:
[**2193-10-17**] 07:21PM BLOOD WBC-9.0 RBC-2.91* Hgb-9.4* Hct-25.8*
MCV-88 MCH-32.4* MCHC-36.7* RDW-16.8* Plt Ct-88*
[**2193-10-17**] 07:21PM BLOOD PT-11.5 PTT-22.0 INR(PT)-1.0
[**2193-10-17**] 07:21PM BLOOD Glucose-131* UreaN-42* Creat-1.6* Na-146*
K-3.0* Cl-110* HCO3-27 AnGap-12
[**2193-10-17**] 07:21PM BLOOD Albumin-3.0* Calcium-8.0* Phos-1.7*
Mg-1.8
.
Push enteroscopy
A single acute cratered 1.5cm ulcer was found in the first part
of the duodenum. A visible vessel suggested recent bleeding.
5 cc.epinephrine 1/[**Numeric Identifier 961**] was injected into the ulcer base and
heater probe applied for hemostasis with success to the ulcer in
the duodenal bulb.One endoclip was successfully applied to the
duodenal bulb ulcer for the purpose of hemostasis.
Impression: Mucosa suggestive of Barrett's esophagus
Clotted blood in the stomach body
Erythema and congestion in antrum suggestive of mild gastritis
1.5cm cratered ulcer in duodenal bulb with visible vessel. 5cc
of 1:10,000 epinephrine, heater probe and one endoclip applied
with successful hemostasis.
Recommendations: Continue IV PPI drip
Follow serial Hct,
Continue NPO
Check H. pylori serology and treat if positive
Brief Hospital Course:
76 year-old male with a history of metastatic small cell lung
cancer who presented to OSH with syncope and black stool x 2
without clear source of bleed on EGD at the OSH.
# Upper GI bleed from bleeding duodenal ulcer: Initial EGD at an
OSH showed a nonbleeding duodenal ulcer with repeat scope
showing duodenitis without evidence of ulceration. GI bleed
considered likely to be from small bowel AVM vs. ulceration
distal to segments scoped. Right sided colonic source was also
considered a possibility. Thus, patient was transferred to [**Hospital1 18**]
for push enteroscopy and colonoscopy for further work up. Push
enteroscopy revealed a 1.5cm cratered ulcer in duodenal bulb
with visible vessel. 5cc of 1:10,000 epinephrine, heater probe
and one endoclip applied with successful hemostasis. H/H has
been stable, along with sx. He was continued on IV protonix for
completion of 72h and then switched to po pantoprazole. His H.
pylori serologies were pending at time of discharge, but are now
negative. He will not need treatment. His hematocrit remained
stable. His diet was advanced to regular and he tolerated this
well.
.
# Anemia, Chronic anemia from chronic disease, and acute anemia
due to acute blood loss. Patient required 2 units of PRBC during
his [**Date range (1) **] admission and then an additional 3 units since
[**10-16**] (recieved at OSH prior to tx here). On admission, HCT=25.8
which increased to 30.4 after the endoscopy. This remained
stable for the duration of his hospital stay.
.
# Candidal esophagitis: Reportedly, the initial EGD at [**Hospital **] indicated candidal esophagitis, with initiation of
fluconazole and nystatin. Repeat EGD a few days later did not
state presence of candidal esophagitis. Enteroscopy performed at
[**Hospital1 18**] also did see this finding. Fluconazole and nystatin were
discontinued after 4 days of treatment. Patient has denied
dysphagia or odynophagia.
.
# ESRD on PD: Per records - seems pt with bx [**6-9**] - chronic AIN
with signs ATN - overall more consistant with possible FSGS -
Patient continues to recieve PD per home regimen here. Phosphate
was low on admission with daily increase to near normal levels.
He was continued on peritoneal dialysis.
.
# Lower extremity edema. He was given one dose of Lasix for his
lower extremity edema with some improvement in his symptoms, but
with rise in creatinine. He was given a prescription for Lasix
but should discuss use of this medication with his PCP and
nephrologist. This was communicated to the patient.
.
# Small cell lung cancer: Metastatic and not currently
undergoing any therapy. Followed by Dr. [**Last Name (STitle) 58562**]. Plan to f/u as
outpt.
.
# BPH: Patient is oliguric, taking flomax, which was held
initially for concerns of hypotension. This medication was
restarted. His Foley was removed, and he voided without
problems.
.
# h/o DVT/PE/thrombocytopenia: s/p IVC filter. With history of
HIT and GI bleed, prophylaxis with pneumoboots.
.
He remained DNR/DNI throughout his hospital stay. He was
discharged to home with services.
Medications on Admission:
PhosLo
Flomax
Renagel
Colace
Dialyvite
Protonix
Fluconazole
Nystatin suspension
Ambien CR prn
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Ambien CR 12.5 mg Tablet, Multiphasic Release Sig: One (1)
Tablet, Multiphasic Release PO at bedtime as needed for
insomnia.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Renagel Oral
6. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a
day.
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Please
discuss use of Lasix with your nephrologist before starting this
medication. .
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
1. Upper GI bleed from duodenal ulceration
2. Acute blood loss anemia
3. ESRD on peritoneal dialysis
4. DVT s/p IVC filter placement
5. Peripheral edema.
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with GI bleeding. Your blood count was stable
after leaving the ICU.
If you develop fevers, chills, nausea, vomiting, or shortnes of
breath, please call your primary care doctor or go to the
emergency room.
Followup Instructions:
Please follow up with your primary care doctor in [**1-2**] weeks.
Your H. pylori serology is still pending, and your PCP will be
[**Name (NI) 653**] with the result when it returns.
An appointment was made for you with Dr. [**Last Name (STitle) **]. The appointment
is on Friday [**11-1**] at 11:30am in the [**Location (un) 8072**] office.
ICD9 Codes: 5856, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7190
} | Medical Text: Admission Date: [**2168-7-19**] Discharge Date: [**2168-7-21**]
Date of Birth: [**2110-10-9**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Syncope.
Major Surgical or Invasive Procedure:
Cardiac catheterization
ICD placement ([**Hospital3 **])
History of Present Illness:
Patient is a 57 y/o Mandarin only woman with no significant PMHx
who presents as a transfer from [**Hospital3 **] Hospital for
ventricular tachycardia with prolonged QT after presenting there
originally for syncope. The patient was in her usual state of
health until yesterday morning when she woke up and a general
sensation of malaise, before getting on a bus tour from [**Location (un) 7349**] to
[**Hospital3 **] that left yesterday morning. After exiting the bus in
[**Hospital3 **], she walked to her hotel and had a witnessed syncopal
event where she fell forward and hit her head on a glass door.
She was incontinent of urine, and regained conciousness after
2-3 minutes per the husband. There were no tonic-clonic
movements witnessed. She does describe some palpitations and
light-headedness prior to syncopizing. She denies recent chest
pain, shortness of breath, fevers, chills, N/V/D, illnesses.
She denies any past history of syncope.
At [**Hospital3 **] Hospital, she ws found to have brief runs of NSVT,
then had a run of 15 seconds that broke spontaneously. An EKG
there revealed AV conduction delay, RBBB, inferior Q waves and a
prolonged QT (~750msec). She was loaded with amiodarone 150mg
IV, then started on a drip at 1mg/min gtt. She also got
magnesium 2gm IV. Labs were notable for a K of 4.3, Mg 2.4, CK
281, MB 1.7, Trop neg, and negative Head CT She was transferred
to [**Hospital1 18**] for further management.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denies recent fevers, chills or rigors.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY: possible myocarditis at 6 or 7 years old
3. OTHER PAST MEDICAL HISTORY:
Osteoarthritis of left knee
Unknown thyroid surgery approximately 20 years ago
Social History:
Lives in [**Location 7349**] with husband, originally from [**Name (NI) 651**] and works in
nail salon
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Father passed
at age 84 from old age. Mother died at 80 from emphysema. No
family history of sudden death, syncope.
Physical Exam:
GENERAL: WDWN female in NAD. Responds appropriately to
questions.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Horizontal scar
anterior neck at cricoid cartilage.
NECK: Supple with JVP of 2 cm. No carotid bruits, no LAD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic murmur heard best at lower
sternal border. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, on anterior exam
ABDOMEN: Soft, NTND. No HSM or tenderness. + bowel sounds
EXTREMITIES: No c/c/e. No femoral bruits. 2+ DP/PT pulses. Right
groin site c/d/i, no tenderness, no hematoma/bruising.
Pertinent Results:
Labs:
[**2168-7-19**] 06:25PM GLUCOSE-148* UREA N-10 CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12
[**2168-7-19**] 06:25PM ALT(SGPT)-70* AST(SGOT)-48* LD(LDH)-224 ALK
PHOS-63 TOT BILI-0.7
[**2168-7-19**] 06:25PM ALBUMIN-4.4 CALCIUM-8.4 PHOSPHATE-3.8
MAGNESIUM-2.8*
[**2168-7-19**] 06:25PM TSH-0.82
[**2168-7-19**] 06:25PM T4-6.1
[**2168-7-19**] 06:25PM WBC-11.2* RBC-4.53 HGB-13.3 HCT-38.6 MCV-85
MCH-29.3 MCHC-34.4 RDW-13.9
[**2168-7-19**] 06:25PM PLT COUNT-213
[**2168-7-19**] 06:25PM PT-12.3 PTT-24.6 INR(PT)-1.0
.
TTE:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Doppler parameters are most consistent with Grade I
(mild) left ventricular diastolic dysfunction. There is no left
ventricular outflow obstruction at rest or with Valsalva. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Preserved global and regional biventricular systolic function.
No significant valvular abnormality seen. No resting or
inducible outflow tract obstruction.
.
Cardiac Cath:
1. Selective coronary angiography in this right dominant system
demonstrated no angiographically apparent flow-limiting disease.
The
LMCA was patent. The LAD had 25% proximal stenosis and luminal
irregularities to 20% in the mid-segment. There was a large D1
and the
distal LAD wrapped around the apex. In the LAD there was slow
flow
consistent with microvascular dysfunction. The LCx had a
proximal 20%
stenosis. It supplied a modest very high OM1 and a larger OM2,
as well
as a large OM3/LPL and an OM4/LPL2. The was slightly slow
pulsatile
flow consistent with microvascular dysfunction. The RCA had
minimal
luminal irregularities to 15% Ther were multiple RPDAs and the
mid-distal septum was supplied by a large AM. Again, there was
slightly
slow pulsatile flow consistent with microvascular dysfunction.
2. Limited resting hemodynamics revealed mild-moderate left
ventricular
diastolic dysfunction was an LVEDP of 19 mmHg. There was
moderate
systemic systolic arterial hypertension with an SBP of 162 mmHg.
3. Left ventriculography revealed a calculated LVED of 55-65%
with mild
global hypokinesis, worse in the anterobasal segment. There was
2+
mitral regurgitation.
FINAL DIAGNOSIS:
1. No angiographically apparent flow-limiting coronary artery
disease;
however, there was atherosclerosis and diffuse slow flow
consistent with
microvascular dysfunction.
2. Mild to moderate left ventricular diastolic dysfunction.
3. Moderate systemic systolic arterial hypertension.
4. Mild global hypokinesis with calculated LVEF of 55-65%
Brief Hospital Course:
57 year old female with no sig PMHx who presents as transfer
from [**Hospital3 **] Hospital with syncope found to have ventricular
tachycardia. s/p Cardiac cath at [**Hospital1 18**].
.
# RHYTHM: Patient with no PMHx who had sudden LOC with rapid
spontaneous return of conciousness with no intervention. Has
long QT on EKG (750 ms) as well as sinus bradycardia. At OSH had
sinus bradycardia, then PVC and started with Torsades De Pointes
(TDT). She received magnesium and 150 mg IV amiodarone. The Diff
dx considered included ischemic CAD, structural disease,
electrical abnormalities with long QT sydromes, hypothyroidism.
Had cath with patent coronary arteries. She was on no
medications. Her thyroid function test were within normal range.
Her echo did not show structural abnormalities. Amiodarone was
stopped initially was started on metoprolol 25 mg TID (to
decrease chances of PVCs on TW and Torsades). She also was
started on spironolactone to raise her potassium. She had no
more episodes on telemetry and underwent PPM/ICD Placement
without complications ([**Hospital3 **]). She was discharged home with
PCP and cardiology follow up in [**Location (un) 7349**].
.
# CORONARIES: s/p cardiac cath today with clean coronaries as
per the report in the previous section on Pertinent Results.
Has Q waves in II, III, aVF, V4-V6 cannot rule out prior
inferior/lateral MI. Her CE were negative.
.
# PUMP: No known history of heart failure. Clinically not in
heart failure, no crackles, no lower extremity edema, no
elevated JVD. Normal echocardiogram.
.
# Elevated liver enzymes - Patient had elevated liver enzymes at
OSH. Had hepatitis panel drawn and were pending last time we
checked. Will need to follow up Hepatitis panel from [**Hospital3 **]
Hospital - [**Telephone/Fax (1) 29170**]. Her AST 70, ALT 48, AP 63, TB 0.7.
.
# Thyroid Surgery - Unknown what surgery was for. Patient not
on thyriod replacement. Euthyroid.
Medications on Admission:
unknown painkiller for her osteoarthritis - has not taken for
greater than 1 week
Denies OTC, herbal, prescription meds
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 86964**],
It was a pleasure to take care of you at [**Hospital1 **]
Hospital in [**Location (un) 86**]. You were admitted to [**Hospital3 **] Hospital after
fainting and found to have an irregular heart beat and given
medication to help your heart return to normal rhythm. You were
transferred to [**Hospital1 18**] for further management of this [**Last Name **]
problem.
At [**Hospital1 18**] you underwent a study to evaluate the vessels of your
heart called a cardiac catheterization procedure. It showed that
you did not have a recent heart attack and that your blood
vessels on your heart are not the reason for your fainting
spell.
You were taken for placement of an ICD device which will prevent
your heart from entering that arrhythmia that caused you to
faint. This will need to be followed by a cardiologist in NY
where you live. The wound will need to be evaluated by your
PCP/Dr. [**First Name (STitle) **] next week at your appointment scheduled below.
.
The following changes have been made to your medications:
* You were started on a medication called spironolactone to
increase your potassium and keep it in the high side to prevent
your arrhytmia. You will need to take one tab (25 mg ) twice a
day.
* You will need to take a beta-blocker to prevent your
arrhythmia. It is called Toprol-XL 50 mg daily.
* We will give you a medication for pain control. Your pain
should imrpove within a few days ([**4-1**])
* Given your recent procedure you will need antibiotics for 2
days: Cephalexin 500 mg Capsule
You cannot lift anything heavier than 10 pounds or lift your arm
above your shoulder given yoru recent ICD placement.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] [**2168-7-27**] Wednesday at 3:00pm for wound
check.
You will also need a cardiologist and/or electrophysiologist.
Completed by:[**2168-7-21**]
ICD9 Codes: 4271, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7191
} | Medical Text: Admission Date: [**2192-11-3**] Discharge Date: [**2192-11-12**]
Date of Birth: [**2115-3-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2192-11-5**] Coronary Artery Bypass Graft x 5
History of Present Illness:
This 77 year old man was transferred from [**Hospital3 417**] for
management of three vessel disease requiring CT Surgery
evaluation. He presented there with recurrent chest pain
starting at 22:00 on the date of admission while lying in bed,
lasting 1 hour before calling EMS. + SOB. He had transient
chest pain the night prior. He denies any DOE, PND, orthopnea,
palpitations, ankle edema, dizziness that he recalls. He feels
like he may fatigue more easily with exertion lately.
En route, the monitor showed ST elevations in inferior wall with
reciprocal changes in lateral leads. He was given ASA, sl Nitro
x2, with positive EKG changes and resolution of CP. In the ED,
vitals were 98.2F, H76, R16, 138/78, 98%Patient taken emergently
to cath lab. He received ASA, 600mg Plavix load, 80mg lipitor
and a 4000 U IV Heparin bolus.
An intra aortic balloon was placed and he was painfree.
Past Medical History:
Hypertension
Benign prostatic hypertrophy
Social History:
lives with his wife. Is generally very active. Feels like he can
walk 1 mile and no trouble with flight of stairs at home.
-Tobacco history: 50 year smoking hx, up to 2 packs per day
-ETOH: ~6 beers a day
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Mother had cancer.
Physical Exam:
PHYSICAL EXAMINATION on Admission:
VS: T=afebrile BP= 152/73 HR=70 RR= - O2 sat=100%
GENERAL: NAD, denies chest pain. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Left eye was 3.5 mm and R eye was
2mm (could not fully eval b/c of light brightness), EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma. No carotid bruits noted
NECK: Supple with JVP at jaw when lying flat.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, sound of balloon pump, otherwise no m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. Exam limited to anterior b/c pt need to lie
flat given balloon pump
ABDOMEN: Soft, NTND. No HSM or tenderness. Can hear pumping of
IABP.
EXTREMITIES: No LE edema, pulses present but feet cool. No
c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII grossly intact. Oriented A&O x3, able to relate
history
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Pre-op labs:
[**2192-11-3**] 03:03AM BLOOD WBC-5.9 RBC-4.31* Hgb-13.6* Hct-39.7*
MCV-92 MCH-31.7 MCHC-34.4 RDW-13.4 Plt Ct-217
[**2192-11-3**] 03:03AM BLOOD Glucose-103* UreaN-15 Creat-0.7 Na-137
K-4.1 Cl-101 HCO3-26 AnGap-14
[**2192-11-3**] 03:03AM BLOOD ALT-22 AST-26 LD(LDH)-166 CK(CPK)-222
AlkPhos-55 TotBili-0.3
[**2192-11-3**] 02:03PM BLOOD CK-MB-2 cTropnT-0.05*
[**2192-11-3**] 03:03AM BLOOD %HbA1c-5.5 eAG-111
[**2192-11-3**] 03:03AM PT-12.5 PTT-31.8 INR(PT)-1.1
[**2192-11-3**] 11:03AM CK-MB-3 cTropnT-0.04*
[**2192-11-3**] 02:02PM URINE RBC->50 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2192-11-3**] 02:02PM URINE BLOOD-LG NITRITE-NEG PROTEIN->300
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
Post-op labs:
[**2192-11-12**] 04:50AM BLOOD WBC-9.5 RBC-2.80* Hgb-8.4* Hct-24.8*
MCV-89 MCH-29.9 MCHC-33.7 RDW-14.2 Plt Ct-486*
[**2192-11-12**] 04:50AM BLOOD Plt Ct-486*
[**2192-11-5**] 01:59PM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2*
[**2192-11-12**] 04:50AM BLOOD Glucose-104* UreaN-11 Creat-0.7 Na-133
K-3.7 Cl-99 HCO3-27 AnGap-11
[**2192-11-12**] 04:50AM BLOOD ALT-31 AST-23 AlkPhos-49 Amylase-165*
TotBili-0.5
[**2192-11-11**] 07:30AM BLOOD ALT-34 AST-32 AlkPhos-48 Amylase-200*
TotBili-0.5
[**2192-11-12**] 04:50AM BLOOD Lipase-269*
[**2192-11-11**] 07:30AM BLOOD Lipase-339*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 3.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 91 ml/beat
Left Ventricle - Cardiac Output: 7.21 L/min
Left Ventricle - Cardiac Index: 3.66 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 7 < 15
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Ascending: 2.6 cm <= 3.4 cm
Aorta - Arch: 2.6 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 24
Aortic Valve - LVOT diam: 2.2 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 0.64
Mitral Valve - E Wave deceleration time: 202 ms 140-250 ms
TR Gradient (+ RA = PASP): 18 to 21 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Normal ascending aorta
diameter. Normal aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with basal inferior
hypokinesis. The remaining segments contract normally (LVEF =
50-55%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. 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: Mild regional left ventricular systolic dysfunction,
c/w CAD. No surgically-significant valvular or proximal aortic
disease.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2192-11-3**] 12:10
Radiology Report CHEST (PA & LAT) Study Date of [**2192-11-11**] 4:14
PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 87668**] Reason: evaluate
effusions/atx
Final Report
Two views of the chest demonstrate marked cardiomegaly. Status
post CABG.
Left lower lobe atelectasis, small left pleural effusion.
Essentially no
change since prior study. Upper lung zones are clear.
DR. [**First Name11 (Name Pattern1) 3993**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3994**]
[**Hospital 93**] MEDICAL CONDITION: 77 yo man with ileus and dilated
cecum
REASON FOR THIS EXAMINATION: change air fluid levels and cecum
diameter.
Final Report:
Two views of the abdomen demonstrate multiple radiopaque
densities in the mid abdomen likely representing pills. Since
the prior study, there has been interval decompression of the
cecum. On the prior study, it measured 12 cm. Currently it
measures approximately 8.1 cm. There are multiple dilated small
bowel segments and air is seen throughout the transverse colon
and in the rectum. These findings likely represent the sequela
of postoperative ileus.
DR. [**First Name11 (Name Pattern1) 3993**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3994**]
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=======================================================Radiology
Report ABDOMEN (SUPINE & ERECT) [**2192-11-8**] 10:11 PM
Clip # [**Clip Number (Radiology) 87669**]
Reason: s/p CABG w/abdominal distention r/o ileus/obstruction
Final Report
ABDOMINAL RADIOGRAPH, SUPINE UPRIGHT VIEWS: There are multiple
loops of
dilated large and small bowel seen overlying the mid abdomen. A
single loop of small bowel in the left lower quadrant measures
3.5 cm which is above the normal limit. There is diffuse
dilatation of the cecum which measures approximately 11 cm. No
free air is seen in upright film to suggest perforation. These
findings are concerning for postoperative ileus. Sternotomy
wires are visualized overlying the midline thoracic vertebral
bodies and degenerative changes of the lumbar spine are evident.
IMPRESSION: Diffusely dilated loops of small bowel and colon.
Significantly dilated cecum measuring approximately 11 cm in
largest diameter. No free air to suggest perforation. These
findings are concerning for postoperative ileus.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] SENAPATI
Brief Hospital Course:
On transfer to [**Hospital1 18**] he was stable with an intra-aortic balloon
pump in place. Cardiothoracic surgery was consulted and saw him
for evaluation for revascularization. He had received a Plavix
loading dose of 300mg during catheterization so surgery was
delayed until Monday [**2192-11-5**] while Plavix washed out.
While awaiting surgery overnight on [**9-19**] he had a moderate
hematoma and bleeding from the balloon pump site but the
hematocrit remained stable at 36.
He also had hematuria with Foley insertion which was likely
related to minor trauma with placement given his known prostatic
hypertrophy. Urojet lidocaine was used to improve his comfort
level. Urology follow-up is recommended after pt is discharged.
He went to the Operating Room on [**11-5**] where revascularization
was performed, please see operativer ereport for details in
summary he had: coronary artery bypass grafting x5 with the left
internal mammary artery to the left anterior descending
artery and reverse saphenous vein grafts to the posterior
descending artery, the obtuse marginal artery, and saphenous
vein Y-graft to the ramus intermedius artery and the diagonal
artery. His bypass time was 104 minutes, with a CROSSCLAMP TIME
of 83 minutes.
He tolerated the operation well, weaned from bypass on Propofol
and Neo Synephrine. He remained stable and the balloon pump was
removed after the operation in the CVICU. He was weaned from
the ventilator and and pressors. He was begun on beta blockers
and diuresed towards his preoperative weight.
The chest tubes and pacing wires were removed per cardiac
surgery protocols. Physical Therapy was consulted for strength
and mobility. He experienced atrial fibrillation which
converted to sinus rhythm after treatment with amiodarone and
lopressor. His oral lopressor was increased.
He did develop a post-operative ileus. General surgery was
consulted. NG tube was inserted and the patient remained NPO.
Ileus eventually resolved, and bowel function returned. Diet was
advanced as tolerated. The remainder of his post-op course was
uneventful.
By post-operative day 7 he was ready for discharge to home. All
follow-up appointments were advised.
Medications on Admission:
Proscar
Flomax
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Please take 400mg once a day until [**11-20**] then decrease to 200 mg
daily until follow up with cardiologist .
Disp:*40 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks: with lasix.
Disp:*14 Tablet(s)* Refills:*0*
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary Artery Bypass Grafts x 5
Myocardial Infarction
Hypertension
Benign prostatic hypertrophy
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
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
Wound check [**Hospital Ward Name 121**] 6 with NP/PA [**11-19**] at 1100 am [**Telephone/Fax (1) 170**]
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**12-5**] at 1pm
Cardiologist: Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**12-17**] at 10:30am at [**Street Address(2) **],
Suite 205W, [**Hospital1 1474**], [**Numeric Identifier 8728**]. The location is in parking lot
near the ER entrance at [**Hospital3 417**] hospital.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10381**]) in [**5-21**] weeks
You will need a colonscopy in the next few weeks - Dr [**Last Name (STitle) **]
office is contacting Dr [**Name (NI) **] office to set up - they should be
contacting you
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2192-11-12**]
ICD9 Codes: 9971, 2761, 4240, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7192
} | Medical Text: Admission Date: [**2175-8-16**] Discharge Date: [**2175-8-21**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F AF on warfarin (goal INR 3 as previous atrial emboli), s/p
MVR with tissue valve, history of DVT, PE (DVT [**11-19**], PE '[**57**]),
CHF/cardiomyopathy EF 15-20 %, HTN, previous strokes presenting
from rehabilitation where she is for a recent mechanical fall
complicated by lower back pain, recurrent UTI, A. fib on
Coumadin presenting with hypotension and leukocytosis from rehab
in the context of a long term indwelling foley. EMS was called
for asymptomatic hypotension at rehab (76/54) with initial EMS
VS BP 81/46 with repeat 82/49 and HR in 60s. The impression of
the rehab per note was no constitutional symptoms such as fever,
chills, or major change in clinical appearance. She was not
started empirically on antibiotics. It was favored to be an UTI
in setting of indwelling foley for urinary retention. Her WBC on
[**8-11**] was 8.4 with WBC 18.4 on [**2175-8-16**] with 91.5 % neutrophils.
Of note, she was recently hospitalized from [**2175-8-5**] to [**2175-8-10**]
with trouble coordinating her left arm and dysarthria in setting
of a fall at rehab. An extensive neurological work-up revealed
evidence of subacute infarction in right anterior parietal lobe
favored to be embolic. She was discharged to rehab.
.
In the ED, initial vs were: 10 96.6 62 73/50 1 98% RA. Exam with
no focal findings except for cloudy urine in Foley catheter.
Labs significant for WBC 17, stable Hct although MCV 81, Diff N
85.1 L 9.8, lactate 2.2, Na 132, Cl 94, BUN 41, Cr 1.8 (baseline
1.3 - 1.6), Glc 108. UA significant for large LE, Bld, RBC 13,
WBC 35, Few Bacteria, CastHy 9. She was given linezolid 600 mg
IV x 1. CXR performed showing LLL opacification consistent with
atelectasis vs. early pneumonia cannot be excluded. Blood and
urine cultures were drawn. EKG showing atrial fibrillation, LBBB
similar compared to prior. She received 1 L of NS.
She was admitted for hypotension and presumed urosepsis. Sepsis
pathway not utilized secondary to improved blood pressure with
IVF resuscitation in setting of low EF.
Admission VS: 108/68, 62, 14, 100% RA; Access: 2x20G
Past Medical History:
Afib on coumadin (goal INR 3)
hx of DVT, PE (DVT [**11-19**], PE '[**57**])
CHF/cardiomyopathy EF 20-25%, last echo [**3-23**]
Moderate Tricuspid Regurgitation
s/p MVR w/porcine tissue '[**61**]
HTN (SBP 120's at baseline)
hypothyroidism
atrial emboli- INR should be 3
DJD
h/o CVA p/w slurred speech and facial droop
CKD baseline Cr 1.4-1.6
Social History:
Pt normally lives alone when not in rehab, does some of cooking,
has cleaning and shopping aid, has three daughters who are very
supportive. Walks very short distances, slowly, with walker but
primarily in wheel chair. Denies EtOH, tobacco and illicits.
Family History:
SSA trait
No hx of stroke, DM, HTN or heart disease
Physical Exam:
Admission:
General Appearance: Well nourished, No acute distress, No(t)
Overweight / Obese, No(t) Anxious, No(t) Diaphoretic
Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Conjunctiva
pale, No(t) Sclera edema
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,
No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube
Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical
adenopathy
Cardiovascular: (PMI Normal), (S1: Normal, No(t) Absent), (S2:
Normal), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,
No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Breath Sounds: Clear : , Crackles : fine at right lung base,
No(t) Wheezes : )
Abdominal: Soft, Non-tender, No(t) Bowel sounds present, No(t)
Distended, No(t) Tender: , No suprapubic tenderness
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing, distal
extremities cool to touch bilateral UE and LE
Musculoskeletal: Muscle wasting, Unable to stand
Skin: Not assessed, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): , Movement: Purposeful, No(t)
Sedated, No(t) Paralyzed, Tone: Not assessed
Discharge:
Vitals: 96.3-98.3, 101-130/60-79, 56-73, 18-20, 94-100% RA
General: NAD, AOx3; able to roll herself over in bed.
HEENT: OP clear, MMM, sclera anicteric.
Neck: L-side bandage removed; JVP flat; no LAD, no carotid
bruits
Cardiac: RRR, no m/r/g appreciated
Lungs: CTAB
Abdomen: positive bowel sounds, soft, non-tender, non-distended
Ext: no C/C/E; 2 radial pulses, DP pulses b/l
Skin: no rashes, jaundice or eccymoses noted
Neuro: AOx3, CN2-12 intact; no decreased sensation to touch
throughout; proprioception in both large toes b/l. L hand
weakness persists.
Pertinent Results:
[**2175-8-16**] 07:15PM WBC-17.0* RBC-4.59 HGB-13.2 HCT-37.1 MCV-81*
MCH-28.8 MCHC-35.6* RDW-17.9*
[**2175-8-16**] 07:15PM NEUTS-85.1* LYMPHS-9.8* MONOS-3.4 EOS-1.3
BASOS-0.3
[**2175-8-16**] 07:15PM PLT COUNT-412
[**2175-8-16**] 06:42PM LACTATE-2.2*
[**2175-8-16**] 06:25PM GLUCOSE-108* UREA N-41* CREAT-1.8*
SODIUM-132* POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-29 ANION GAP-13
[**2175-8-16**] 03:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2175-8-18**] 08:35AM BLOOD TSH-4.2
[**2175-8-18**] 08:35AM BLOOD Cortsol-17.2
[**2175-8-21**] 05:35AM BLOOD WBC-5.7 RBC-4.66 Hgb-13.0 Hct-39.2 MCV-84
MCH-27.9 MCHC-33.1 RDW-18.0* Plt Ct-334
[**2175-8-21**] 05:35AM BLOOD Glucose-89 UreaN-16 Creat-1.1 Na-133
K-5.2* Cl-102 HCO3-24 AnGap-12
[**2175-8-21**] 05:35AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.6
[**2175-8-20**] 07:45AM BLOOD PT-37.7* PTT-40.6* INR(PT)-3.8*
URINE CULTURE (Final [**2175-8-19**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
Blood Cultures X2 Pending:
XXXXXXX
CXR [**2175-8-16**]:
IMPRESSION: Left lower lobe opacification, likely atelectasis,
though early
pneumonia is not excluded.
EKG [**2175-8-16**]:
Atrial fibrillation with controlled ventricular response. Left
bundle-branch block with secondary ST-T wave abnormalities.
Compared to the previous tracing of [**2175-8-6**] no diagnostic
change.
INR Pending from [**2175-8-21**]:
XXXXX
Blood cultures from [**2175-8-16**] Pending
Brief Hospital Course:
[**Age over 90 **]-year-old woman with a past medical history of atrial
fibrillation with previous stroke, CHF with EF 15-20%, HTN, and
previous MVR and a chronic indwelling foley found to be
hypotensive, a result of UTI and medications.
# Complicated Enterococcus UTI. Urinary tract infection is
complicated given chronic foley placed and WBC 17 in setting of
hypotension. Given her history of [**Age over 90 **] UTI, she was started
empirically on linezolid ([**2175-8-16**]), as well as
piperacillin/tazobactam for possible pneumonia. Her white count
fell by the following morning and her lactate normalized and
piperacillin/tazobactam was stopped. Patient was then
transitioned to linezolid and cefepime. When sensitivities of
the infection returned as enterococcus, patient was transitioned
to ampicillin. Her white count decreased and she was afebrile.
Her foley was removed and patient was able to void without
difficulty into diapers which were changed appropriately.
Patient is to finish PO course of PO ampicillin on [**8-27**].
# Hypotension. Differential diagnosis for hypotension is quite
broad and includes cardiac versus metabolic versus
medication-related including large dose of home torsemide (30mg
TID), oxycodone which the patient is on secondary to hip pain.
Initial hypotension was responsive to 500cc NS, and patient was
hemodynamically stable throughout admission without fluid or
pressor support. We had the patient discharged on a reduced
dose of her torsemide and losartan, with the possibility to
increase as an outpatient.
# Atrial fibrillation. Patient has history of atrial
fibrillation and tissue MVR with goal 2.5 to 3.5 due to previous
atrial emboli. INR was elevated and warfarin was held, with
discharge INR at 2.5 and most recent dose of coumadin 5mg daily
started with follow up on Friday with PCP.
# Back pain/ pain along right thigh. Likely sciatica given
positive straight leg raise test versus piriformis syndrome.
Patient was initially treated with oxycodone, however was
altered during the course of the hospitalization briefly, which
resolved when oxycodone was stopped and tramadol was started.
Patient was intermittently given tramadol with good control of
her pain. By time of discharge, patient was able to get out of
bed with assist to chair and without pain.
# Chronic systolic heart failure. Patient with EF 15-20% on
ECHO in [**2-24**] with significant dyssynchrony but normally
functioning mitral prosthesis and moderate TR. Patient's CHF was
not active during this hospitalization.
# CKD. Baseline Cr 1.4-1.7 with admission Cr 1.8. This is
likely prerenal given the patient's apparent hypovolemia, and
her creatinine fell to 1.6 the following morning. At discharge,
patient's creatinine was at 1.1.
# Mild hyponatremia. Likely volume depleted given low urine Na
and Cl. TSH and cortisol normal. Resolved during
hospitalization.
# Hypothyroidism. She was continued on her home synthroid with
a normal TSH.
# Transitional issues:
-Please check INR, goal 2.5 to 3.5. Warfarin was held
throughout hospitalization. was 2.5 upon discharge, with
resumption of most recent warfarin dose.
-Please check blood pressure
Medications on Admission:
- acetaminophen 975 mg PO TID
- ASA 81 mg PO qD
- calcium carbonate 650 mg PO BID
- cholecalciferol 1000 unit PO qD
- levothyroxine 88 mcg PO qD
- lidocaine patch PO qD
- losartan 25 mg PO qD
- metoprolol succinate 12.5 mg PO qD
- torsemide 30 mg PO TID
- warfarin 5 mg PO qPM
- oxycodone 5 mg PO BID
- oxycodone IR 5 mg PO q 4 hr prn pain
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Daily PRN as needed
for body pain .
4. torsemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*0*
5. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*0*
6. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours) as needed for UTI for 8 days: [**Date range (1) 100323**].
Disp:*0 Capsule(s)* Refills:*0*
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
8. docusate sodium 100 mg Tablet Sig: 1-2 Tablets PO twice a day
as needed for constipation.
Disp:*0 Tablet(s)* Refills:*0*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
Disp:*0 Tablet(s)* Refills:*0*
10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day.
11. calcium carbonate 650 mg calcium (1,625 mg) Tablet Sig: One
(1) Tablet PO twice a day.
12. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
Discharge Diagnosis:
Primary Diagnosis: Complicated Enterococcal Urinary Tract
Infection, Systolic heart failure, Hypertension, Acute kidney
injury, Back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was our pleasure to take care of you at [**Hospital1 18**].
You were admitted for low blood pressure likely related to an
infection in your bladder and from taking too much torsemide.
We found that the infection was due to a bacteria called
enterococcus which is sensitive to ampicillin, which we are
being treated with.
For follow up, please continue rehabilitation at your current
rehabilitation center and keep the following appointments below.
We have made the following changes in your medications:
START Ampicillin until [**2175-8-29**]
START Tramadol for pain
START Colace as needed for constipation
STOP Oxycodone as it caused you to be confused
DECREASE Torsemide to 30mg DAILY as this may have also
contributed to your low blood pressures.
DECREASE Losartan to 12.5mg DAILY as this may have also
contributed to your low blood pressures.
Please continue taking all your other home medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please attend the following appointments:
Department: [**Hospital3 249**]
When: FRIDAY [**2175-8-25**] at 10:40 AM
With: [**Doctor First Name **] FERN, RNC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: FRIDAY [**2175-9-22**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2175-10-25**] at 11:00 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 4254, 2761, 2930, 4280, 5990, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7193
} | Medical Text: Admission Date: [**2149-1-13**] Discharge Date: [**2149-1-21**]
Date of Birth: [**2098-10-28**] Sex: F
Service: ACOVE MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is a 50-year-old
female with multiple medical problems status post recent
admission to Medicine for hyponatremia and seizures who
presented with generalized weakness and inability to transfer
herself at home with a swollen knee. In the ED, she was
noted to have focal seizures and left facial twitching. She
denied generalization. Treated with Ativan 2 mg IV. A left
subclavian line was placed for IV access. Swollen left knee
prompted a tap of the knee times three with no fluid
obtained. Left lower extremity negative with no DVT. The
patient was given vancomycin times one dose prophylactically
after knee tap. U/A revealed positive UTI. The patient was
given Levaquin in the ED. Positive urinary incontinence
without dysuria, without back pain, but has knee pain.
PAST MEDICAL HISTORY:
1. Complex partial seizure with a right temporal occipital
lobectomy, VP shunt in [**2137**].
2. OCD.
3. Depression.
4. Chronic left lower extremity edema.
5. History of bilateral hip arthroplasty.
6. History of MRSA infection in the left hip.
7. Left hip osteoporosis.
8. Anorexia.
9. B12 deficiency.
10. Anemia.
11. Incontinence.
12. PVD.
13. SIADH secondary to Tegretol.
ADMISSION MEDICATIONS:
1. Tiagabine 4 mg q.h.s.
2. Amoxapine 50 mg twice a day.
3. Oxybutynin 10 twice a day.
4. Protonix 40 once a day.
5. Risperidone 1 twice a day.
6. Loxapine 60 once a day.
7. Phenobarbital 30 three times a day.
8. Baclofen 10 four times a day.
9. Hydrazine 25 p.m.
10. Sodium chloride 4 grams three times a day.
11. Lactulose 30 three times a day p.r.n.
12. Colace 100 twice a day.
13. Calcium.
14. Vitamin D.
15. Senna one twice a day.
16. Tegretol XL 200 a.m., 200 afternoon, 300 p.m.
17. Hydrocortisone cream p.r.n.
18. Ibuprofen 600 p.r.n.
19. Oxycodone sustained release 10 twice a day.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood
pressure 110/70, pulse 100, respiratory rate 20, temperature
99.3, saturating 100% on 2 liters. General: The patient was
frail and ill appearing. HEENT: The extraocular movements
were intact. The oropharynx was clear. Neck: Supple.
Chest: Clear to auscultation bilaterally. Cardiovascular:
Regular rate and rhythm, normal S1, S2, negative murmur,
rubs, or gallops. Abdomen: Soft, nontender, nondistended.
Back: She has a stage I sacral decubitus. Extremities:
Left foot erythematous, 4+ edema to the knee. Pain over the
left knee without appreciable effusions, without warmth.
Upper extremity revealed bilateral hand erythema, [**12-5**]+ edema.
Neurological: The patient was alert and oriented times
three.
LABORATORY DATA UPON ADMISSION: White count 6.0, hematocrit
28.9, platelets 440,000. Sodium 134, potassium 4.4, chloride
84, bicarbonate 27, BUN 11, creatinine 0.2, glucose 86. The
U/A revealed greater than 50 white cells, moderate
leukocytes, positive nitrates. The urine culture is pending.
LENI negative for DVT.
Knee film revealed osteopenia.
HOSPITAL COURSE: The patient is a 50-year-old female well
known to the team who presented with a potential seizure,
SIADH, although not with obvious hyponatremia and UTI.
1. INFECTIOUS DISEASE: The patient's UTI was treated with
Cipro. The patient also had likely cellulitis of the hands.
The patient was started on a 14 day course of vancomycin.
The patient had a PICC line placed for vancomycin prior to
discharge.
2. NEUROLOGIC: The patient was continued on medications
without seizures. The patient has very small seizures. The
patient was also found to be unresponsive one morning.
The patient was transferred to the SICU which is likely
urosepsis. The patient responded with fluids and
antibiotics. The patient was discharged back to the floor
the next day without incident.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient had a
sodium of 134, retested the patient's sodium was 120, 134 was
likely an error in the laboratory. The patient's sodium came
up appropriately with fluid restriction and salt tabs.
4. KNEE PAIN: No workup was really done. This patient is
well known to Dr. [**Last Name (STitle) 7111**] and is to have outpatient workup of
pain.
5. PSYCHIATRY: The patient's medicines were continued.
6. GASTROINTESTINAL: The patient was put on a bowel
regimen. Protonix was continued.
7. ENDOCRINE: The patient was continued on calcium, vitamin
E.
8. PAIN: MS04 and Oxycodone were held as the patient was
found to be unresponsive. The patient was changed to
Percocet.
9. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
given a regular diet with Boost.
10. LINES: The patient's left subclavian was changed to a
PICC.
DISCHARGE CONDITION: Fair.
DISCHARGE DIAGNOSIS: Unable to care for self.
DISCHARGE MEDICATIONS:
1. Tiagabine 4 q.h.s.
2. Amoxapine 50 b.i.d.
3. Oxybutynin 10 b.i.d.
4. Pantoprazole 40 once a day.
5. Risperidone one twice a day.
6. Loxapine 60 once a day.
7. Phenobarbital 30 three times a day.
8. Baclofen 10 four times a day.
9. Hydroxyzine 25 p.r.n.
10. Sodium chloride 4 grams t.i.d.
11. Colace 100 twice a day.
12. Calcium 500 three times a day.
13. Vitamin D 400 once a day.
14. Senna one twice a day.
15. Carbamazepine 200 in the a.m., 200 in the p.m., 300 in
the evening.
16. Ibuprofen for pain.
17. Acetaminophen for pain.
18. Ciprofloxacin 500 b.i.d.
19. Vancomycin 750 b.i.d.
20. Lactulose 30 three times a day.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 23023**]
MEDQUIST36
D: [**2149-1-17**] 04:35
T: [**2149-1-17**] 23:13
JOB#: [**Job Number **]
ICD9 Codes: 5990, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7194
} | Medical Text: Admission Date: [**2151-5-4**] Discharge Date: [**2151-5-10**]
Date of Birth: [**2090-12-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
coronary artery bypass x 3(LIMA-LAD, SVG-Diag, SVG-PDA) [**2151-5-6**]
History of Present Illness:
This 60 year old white male presented at [**Hospital3 1280**] with known
coronary disease but worsening dyspnea with exertion and
fatigue. A stress est was positive with LV dilatation on
stressing, and catheterization revealed triple vessel disease.
He was transferred for surgery.
Past Medical History:
hypercholesterolemia
R eye does not fully close resulting in dry eyes
s/p Left hip replacement
s/p multiple knee surgeries
s/p repair of torn/ruptured achillies tendon-bilat
Social History:
Lives with:wife and son
Occupation:owns own real estate management company
Tobacco:denies
ETOH:occasional
Family History:
noncontributory
Physical Exam:
admission:
Pulse:61Resp: 16 O2 sat: 96 on RA
B/P Right:126/62 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
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: none Left:none
Pertinent Results:
[**2151-5-10**] 04:30AM BLOOD WBC-9.8 RBC-4.46* Hgb-13.4* Hct-39.3*
MCV-88 MCH-30.1 MCHC-34.2 RDW-13.3 Plt Ct-216
[**2151-5-8**] 06:00AM BLOOD WBC-12.8* RBC-4.58* Hgb-13.9* Hct-41.0
MCV-89 MCH-30.3 MCHC-33.9 RDW-13.4 Plt Ct-147*
[**2151-5-6**] 04:27PM BLOOD PT-13.8* PTT-25.8 INR(PT)-1.2*
[**2151-5-9**] 04:15AM BLOOD Glucose-106* UreaN-17 Creat-1.1 Na-137
K-4.0 Cl-98 HCO3-27 AnGap-16
[**2151-5-8**] 06:00AM BLOOD Glucose-111* UreaN-18 Creat-1.4* Na-137
K-4.4 Cl-100 HCO3-30 AnGap-11
[**2151-5-9**] 04:15AM BLOOD Mg-2.2
Intra-op TEE
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits).
POSTBYPASS
Biventricular systolic function is preserved. The study is
otherwise unchanged from prebypass.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2151-5-6**] where the patient underwent CABG x 3.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Vancomycin was
used for surgical antibiotic prophylaxis given the preoperative
stay of greater than 24 hours. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. The
patient was neurologically intact and hemodynamically stable on
no inotropic or vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 4 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to home in
good condition with appropriate follow up instructions.
Medications on Admission:
atenolol 25'
simvastatin 40'
ibuprofen 800'
thera tears eye gtts
aspirin 325'
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
hyperlipidemia
s/p left total knee replacement
s/p knee surgeries
chronic dry eye- right
benign prostatic hypertrophy
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. 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.**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**6-7**] at 1:30
Please call to schedule appointments with:
Primary Care/Card.: Dr. [**Last Name (STitle) **],AUROBINDO [**Telephone/Fax (1) 8058**] in
[**12-12**] 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:[**2151-5-10**]
ICD9 Codes: 4111, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7195
} | Medical Text: Admission Date: [**2156-4-1**] Discharge Date: [**2156-4-2**]
Date of Birth: [**2091-4-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Admitted for right heart catheterization and evaluation for
weaning off milrinone therapy
Major Surgical or Invasive Procedure:
cardiac catheterization and Swan Ganz catheter placement
History of Present Illness:
Patient is a 64 year old man with a history of end stage
ischemic cardiomyopathy s/p CABG in [**2135**] now with improved EF to
35-40% on Milrinone at 0.6mcg/kg/min since [**2151**]. At that time,
he was not a heart transplant candidate due to irreversible
pulmonary hypertension. Over the years he has been doing
extremely well without significant heart failure. He has not
been on diuretics in years. Last echo from [**2154**]: LVEF 35-40%. He
was admitted for RHC and hemodynamics on and off milrinone to
assess for possible weaning off of milrinone. Right heart
catheterization was performed, and he tolerated the procedure
well. PA pressures 35/15, PCWP 22, CO 3.47 and CI 1.97 on
milrinone .6 mcg.kg/min.
.
Patient reports he has been feeling quite well. Denies any
increasing SOB, CP, palpitations, dizziness, lightheadedness,
fevers. He does report a dry cough that is occasionally
productive of small amounts of white sputum. He has been taking
sugar free robitussin as home. Two of his daughters at home
currently have colds. He has had the flu shot.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
.
Past Medical History:
1) Ischemic Cardiomyopathy (EF15-20% at worst and started on
milrinone in [**2151**], last echo in [**2154**] with EF35-40%) s/p [**Hospital1 **]-V
Pacer/ICD ([**11-12**])
2) CAD/CABG [**2135**] (SVG-LAD-s/p stent in [**2148**], SVG-LCX(known
occlusion), LIMA to diag, SVG to RCA-known occlusion, stent to
LM into LCX)
3) DMII
4) CRI (Cr 1.3-1.8)
5) Anemia of Chronic Disease
6) HTN
7) Lichen Simplex Chronicus
8) h/o left subclavian vein occlusion
9) Hernia repair [**2151**]
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
.
Cardiac History: CABG, in [**2145**] anatomy as above
.
Percutaneous coronary intervention, as above
.
Pacemaker/ICD placed in [**2151**]
.
Social History:
Lives with wife and daughters. [**Name (NI) **] five children and two
grandchildren. Born in [**Country 9819**] - has lived in USA for ten
years. Previous leather goods importer/exporter. Never smoked
cigs, drank ETOH or used recreational drugs.
.
Family History:
Brother had MI at 48. Mother had DM, CHF and MI and unknown age.
Father had CAD, but no MI.
.
Physical Exam:
VS: T 97.3, BP 116/76 , HR 75 , RR 17 , O2 100% on RA
Gen: Eldery 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 could not assess JVP as lying flat after cetherter
placement.
CV: RR, normal S1, S2. II/VI SEM at LLSB
Chest: Resp were unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi anteriorly.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Well-healed midline scar
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 2+ DP, PA catheter in place
without ooze
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
.
Pertinent Results:
MEDICAL DECISION MAKING
.
EKG demonstrated V pacing, rate 72
.
2D-ECHOCARDIOGRAM performed on [**9-15**] demonstrated: The left
atrium is mildly dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated with
mild-moderate global hypokinesis (EF 35-40%) and septal near
akinesis. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
HEMODYNAMICS: RA 8, RV 40/4, PCWP 22, PA 35/15
.
LABORATORY DATA:
[**2156-4-1**] 01:11PM WBC-3.9* RBC-4.08* HGB-12.6* HCT-36.8*
MCV-90# MCH-31.0 MCHC-34.4 RDW-14.4
[**2156-4-1**] 01:11PM PLT COUNT-161
[**2156-4-1**] 01:11PM PT-12.5 PTT-48.3* INR(PT)-1.1
[**2156-4-1**] 01:11PM GLUCOSE-73 UREA N-22* CREAT-1.2 SODIUM-144
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-25 ANION GAP-12
[**2156-4-1**] 01:11PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-2.2
.
.
.
.
.
Cardiac catheterization ([**2156-4-1**]) -
1. Resting hemodynamics revealed high-normal right-sided
filling
pressures with RVEDP 9 mmHg. Mild elevation of pulmonary
arterial
systolic pressures with PASP 35 mmHg. Elevated mean wedge of 22
mmHg.
Depressed cardiac output with CI 2.0 L/min/m2.
FINAL DIAGNOSIS:
1. Mild elevation of filling pressures on chronic milrinone.
2. Transfer to CCU for milrinone wean with swan in place.
.
.
Trans-Thoracic Echocardiogram ([**2156-4-1**]) -
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears moderately-to-severely
depressed (ejection fraction 30 percent) secondary to akinesis
of the septum and hypokinesis of the rest of the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. There are focal calcifications in the aortic arch. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are mildly thickened. There is no aortic valve
stenosis. No 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 are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2154-9-24**], the left ventricular ejection fraction is
somewhat reduced.
.
.
Trans-Thoracic Echocardiogram ([**2156-4-2**]) -
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is moderate to severe
global left ventricular hypokinesis (LVEF = 30 %). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The supporting structures
of the tricuspid valve are thickened/fibrotic. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2156-4-1**], the findings are similar.
.
.
Brief Hospital Course:
ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS:
#. Ischemic cardiomyopathy - The patient has a known history of
ischemic cardiomyopathy with an EF of 15-20% in [**2151**] and has
been on milrinone since then. Repeat TTE in [**9-/2154**] revealed
improvement in his EF to 35-40%. He had not been requiring
standing diuretics, and has been doing quite well at home. He
underwent cardiac catheterization that showed mildly elevated
filling pressures, and Swan-Ganz catheter placement in the cath
lab showed a Cardiac Index of 1.97 on milrinone. He had a TTE
that showed moderately-to-severely depressed LV systolic
function (EF 30%) secondary to akinesis of the septum and
hypokinesis of the rest of the left ventricle. He was weaned off
the milrinone with a stable Cardiac Index of 1.94 off milrinone.
Repeat TTE after weaning off milrinone was similar to that done
while he was on milrinone. He was able to be discharged home off
of milrinone. He was otherwise continued on his home
medications, and discharged on these without any changes.
.
Medications on Admission:
milrinone via a continuous infusion at 0.6 mcg/kg/minute
Aspirin 325 mg daily
Lipitor 20 mg daily,
Bumex 0.5 mg only as needed - has not taken in 3 months
Coreg 12.5 mg twice a day
Plavix 75 mg daily
digoxin 0.125 mg a half a tablet daily
Imdur 30 mg a half a tablet at bedtime
lisinopril 5 mg daily
multivitamin daily
Glipizide 4 mg QAM and 2 mg QPM
.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO QHS (once a day (at
bedtime)).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Amaryl 2 mg Tablet Sig: Two (2) Tablet PO qam.
10. Amaryl 2 mg Tablet Sig: One (1) Tablet PO qpm.
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) mL Intravenous once a day: 2 mL of 100 Units/mL heparin (200
units heparin) each lumen Daily. Inspect site every shift.
Disp:*120 ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
physicians' home care-[**Hospital1 **]
Discharge Diagnosis:
Primary:
1. acute on chronic systolic heart failure
Secondary:
1. coronary artery disease
2. diabetes mellitus
3. chronic renal insufficiency
4. hypertension
5. hyperlipidemia
Discharge Condition:
Ambulatory. O2 sats in 90s on room air. BP and HR stable.
Discharge Instructions:
You were admitted to the hospital for evaluation of your heart
failure. Your medication milrinone was stopped.
increases by > 3 lbs. Please adhere to a 2 gm sodium diet.
Please restrict fluid intake to 2 liters per day.
Avoid heavy lifting (>10 lbs) for the next week to rest your
groin after the catheterization.
Please follow up with Dr. [**Last Name (STitle) 1968**] and Dr. [**First Name (STitle) 437**] as below.
Please call your doctor or return to the hospital if you
experience worsening shortness of breath, chest pain,
lightheadedness, palpitations, or any other concerns.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2156-4-7**] 9:50
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Phone: [**Telephone/Fax (1) 3512**] Date/Time:
[**2156-4-19**] 1:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2156-6-1**]
1:30
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2156-6-1**] 2:00
ICD9 Codes: 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7196
} | Medical Text: Admission Date: [**2105-4-4**] Discharge Date: [**2105-4-10**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
Intubation
Endoscopy
History of Present Illness:
88 year old female with hx of a. fib and right brachial artery
embolism on dabigatran, CAD, diastolic CHF, HTN, hypothyroidism
presenting with dysphagia. Pt was recently admitted
[**Date range (1) 22336**] for DOE and melenotic stools; Hct was found to
be 22 from baseline 40. She underwent extensive GI workup
including EGD, colonoscopy and capsule endoscopy that was
largely unrevealing for source of bleed. She was started on
omeprazole for gastritis. She received total of 4 units PRBCs
during admission with Hct in low 30s on discharge. She was
discharged on lower dose of dabigatran and lower dose of
atenolol. She was discharged to rehab where she had
difficulties with constipation and intermittent dysphagia. She
was discharged home approximately one week ago and has
complained of intermittent dysphagia. On day of admission, she
had difficulties even swallowing water. Reports vomiting twice.
In the ED, initial VS were: 96.6 50 167/69 16 94% RA. She was
evaluated by GI who plan to perform EGD tonight. Anesthesia was
called for intubation for MAC anesthesia. CXR was unremarkable.
CT chest showed fluid distention of the stomach and fluid
layering up to mid esophagus.
Past Medical History:
CAD s/p DES to LAD and OM1, [**2098**]
Mild biventricular systolic/diastolic CHF (compensated)
Reactive Airway Disease
Hypothyroidism
Hypertension
Hyperlipidemia
Osteoporosis
Previous pneumonia
Atrial Fibrillation, not anticoagulated [**1-8**] falls
Bilateral rotator cuff repair
Status post right hip repair [**2096**].
Social History:
quit smoking 9 years ago, glass wine per day.
Family History:
sister - deceased from CVA
Physical Exam:
ADMISSION PHYSICAL EXAM
96.6 50 167/69 16 94% RA.
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: bibasilar crackles, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis;
trace b/l edema
Neuro: CNII-XII intact, following commands, moving all
extremities
Discharge PE:
T97.8, HR 77, BP 133/60, RR 18, 94% RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular rhythm, normal S1 + S2, 2/6 systolic
murmur heard at R and L sternal border
Lungs: minimal bibasilar crackles, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis;
trace b/l edema at ankle
Neuro: CNII-XII intact, following commands, moving all
extremities
Pertinent Results:
ADMISSION LABS
[**2105-4-4**] 04:35PM BLOOD WBC-5.5# RBC-4.39# Hgb-10.5* Hct-35.5*
MCV-81* MCH-24.0*# MCHC-29.7* RDW-17.2* Plt Ct-123*
[**2105-4-4**] 04:35PM BLOOD Neuts-83.4* Lymphs-8.9* Monos-6.7 Eos-0.7
Baso-0.3
[**2105-4-4**] 04:35PM BLOOD PT-14.9* PTT-50.3* INR(PT)-1.4*
[**2105-4-4**] 04:35PM BLOOD Glucose-102* UreaN-23* Creat-1.0 Na-133
K-6.4* Cl-92* HCO3-28 AnGap-19
[**2105-4-4**] 04:35PM BLOOD Calcium-8.3* Phos-4.0 Mg-2.3
[**2105-4-4**] 04:35PM BLOOD TSH-2.1
[**2105-4-4**] 04:35PM BLOOD Digoxin-0.7*
Discharge labs
[**2105-4-10**] 07:00AM BLOOD WBC-3.3* RBC-3.89* Hgb-9.1* Hct-31.1*
MCV-80* MCH-23.4* MCHC-29.3* RDW-17.3* Plt Ct-108*
[**2105-4-10**] 07:00AM BLOOD Glucose-101* UreaN-22* Creat-1.0 Na-137
K-3.9 Cl-99 HCO3-32 AnGap-10
IMAGING
CXR [**2105-4-4**]
FINDINGS: PA and lateral views of the chest were obtained.
Cardiomegaly is again noted with diffuse ground-glass opacity
concerning for pulmonary edema. Bilateral pleural effusions are
present, left greater than right with bibasilar consolidation,
likely representing compressive atelectasis. No pneumothorax is
seen. Aortic calcifications again noted. Bony structures are
demineralized.
IMPRESSION: Pulmonary edema, bilateral effusions and bibasilar
atelectasis, stable cardiomegaly.
CT CHEST [**4-4**]
1. Fluid distension of the esophagus suggesting dysmotility.
2. Left adrenal nodule is incompletely assessed. Elective
evaluation with
dedicated adrenal protocol CT may be performed as an outpatient.
EGD [**2105-4-4**]:
Impression:
Food in the whole Esophagus
Erythema and friability in the lower third of the esophagus
compatible with esophagitis
Retained fluids in stomach
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations:
Trial clears with close monitoring. Continue PPI to allow
esophagitis to heal. F/u TSH. Barium swallow and esophageal
manometry should be done to evaluate motility within the
esophagus. Can consider further motility evaluation if it
becomes clear that the stomach as well as colon are involved as
well and if the above is unrevealing.
Barium Swallow [**2105-4-5**]
FINDINGS: The patient has mild esophageal dysmotility. The
primary stripping wave breaks in the mid to distal esophagus.
There is a moderate amount of residual contrast in the esophagus
after swallowing, even in the upright position. There is no
abnormal dilation, stricture, or evidence of achalasia. The
esophagus distends normally. The 13-mm tablet passes easily into
the stomach.
IMPRESSION: Mild esophageal dysmotility. No evidence of
achalasia.
Manometry [**2105-4-8**]: no signs of achalasia, final read pending
Brief Hospital Course:
Patient is a 88 year old female with hx of a. fib and right
brachial artery embolism on dabigatran, CAD, diastolic CHF, HTN,
hypothyroidism who presented with dysphagia and was found to
have esophagitis and food particles throughout the esophagus
without evidence of stricture on barium swallow. Manometry
showed no signs of achalasia.
Dysphagia: Patient presented with intermittent dysphagia. She
had a CT of the chest which showed large amounts of food in the
esophagus with air fluid levels. She was intubated for her EGD
given food seen on CT scan and concern for aspiration. Her EGD
showed large amounts of food in the esophagus as well as
esophagitis without evidence of strictures or malignancies. Food
was removed and she was extubated without incident. Barium
swallow showed no stricture. Manometry showed no signs of
achalasia. She was advanced to clear liquids then full liquids
and finally to a pureed diet which she tolerated. She was given
pantoprazole IV initially and then started on po omeprazole 40
mg po BID. She was discharged on pureed diet after the nutrition
specialist gave her diet education. Etiology of dysphagia
remains unclear. Gastroenterology thinks esophagitis likely is
contributing to esophageal dysmotility, though there is concern
for dysmotility elsewhere in the GI tract including in the colon
given constipation and the stomach as this was full of food. No
clear metabolic cause for this has been discovered, however.
Patient will be closely followed by GI to discuss further work
up as indicated.
Diastolic CHF: Torsemide dosing recently increased from 20mg to
40mg for worsening LE edema. She initially appeared euvolemic
on exam and torsemide was initially held. It was restarted when
she developed an O2 requirement on [**2105-4-6**]. She then was
oxygenating well on room air and had minimal LE edema. Her
torsemide dose was subsequently decreased from 40 mg to 20 mg
prior to discharge as she developed a contraction alkalosis and
appeared euvolemic to slightly dry. She was instructed to weigh
or if she developed lower extremity edema.
Intubation: Pt electively intubated with fentanyl/versed for MAC
anesthesia/EGD. She was extubated following the procedure
without complications.
Atrial fibrillation: Rate controlled on atenolol and digoxin. On
dabigatran on off-label dosing for afib and right brachial
artery embolism.
Hypothyroidism: TSH within normal limits. She was continued on
her home levothyroxine.
Anemia: Recent extensive workup for source of anemia was
unrevealing (pt is s/p EGD, colonoscopy, capsule endoscopy).
Hct remained at her baseline in low 30s. She will need a repeat
colonoscopy in 6 months as outpatient
Thrombocytopenia: Has long-standing thrombocytopenia. Platelet
count remained in her baseline range. She had no evidence of
active bleeding
# Transition issues:
1. Patient needs to be followed up on her dysphagia as
outpatient, and further work up should be discussed with GI
2. Patient needs to monitor her daily weight for appropriate
volume status
3. Patient needs a repeat colonoscopy in 6 months as outpatient
4. Patient needs to be followed up for thrombocytopenia and
leukopenia as outpatient with consideration of hematology follow
up if this fails to resolve
5. Patient complained of difficulty hearing, and found to have
bilateral ear wax impaction. Attempt to remove ear wax but
unsuccessful. She was given prescription for Carbamide Peroxide
to use as outpatient.
6. Left adrenal nodule found incidentally on CT chest, should
have adrenal protocol CT as outpatient to further assess
# Communication: [**Name (NI) **] [**Name (NI) 575**] (son, [**Name (NI) 382**] [**Telephone/Fax (1) 22335**];
[**Telephone/Fax (1) 22334**]
# Code: Full (confirmed with HCP)
Medications on Admission:
1. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO once a day.
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (1-2 times a day).
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. torsemide 40 mg Tablet daily(recently doubled)
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 c.
8. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO
TID (3 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Dabigatran Etexilate 75 mg PO TID
2. Atenolol 25 mg PO DAILY
hold for sbp < 100 or hr < 60
3. Torsemide 20 mg PO DAILY
4. Carbamide Peroxide 6.5% 5-10 DROP AD [**Hospital1 **] Duration: 4 Days
RX *carbamide peroxide 6.5 % twice a day Disp #*1 Bottle
Refills:*0
5. Digoxin 0.0625 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg twice a day Disp #*60 Capsule Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
11. Simvastatin 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
Primary: Dysphagia
Secondary: diastolic heart failure, hypertension, atrial
fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with trouble and pain with
swallowing. You had an endoscopy to look at your esophagus and
food was found within your esophagus as well as irritation of
your esophagus called esophagitis. We also performed a barium
swallow study which did not show any strictures. A study called
esophageal manometry was performed and showed no evidence of
achalasia. You can further discuss the final result with your GI
doctor.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than [**1-9**] lbs.
Followup Instructions:
Please keep the following appointments:
Department: [**Hospital3 249**]
When: MONDAY [**2105-4-20**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2105-5-6**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 22337**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 4280, 4019, 2449, 2724, 2859, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7197
} | Medical Text: Admission Date: [**2113-3-29**] Discharge Date: [**2113-4-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Hypoxic respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a [**Age over 90 **]F with hx of Rheumatoid Arthritis,
osteroarthritis, malnutrition, recently admitted to [**Hospital1 18**] with
diffuse esophageal spasm with subsequent recent admission to [**Hospital1 112**]
with GIB, who recent finshed a course of abx for UTI, and is
currently undergoing treatement for Clostridium difficile
infection. She is brought to the ED today by her family, as
she's had a 7 day course of progressive lethargy, anorexia,
cough productive for clear sputum, & pleuritic chest pain.
There are no reported fevers or chills, nausea, vomiting,
aspiration events, recent travel, or smoking. The family does
report that she's had increasing erythema at the sacrum and
worsening of her lower extremity skin tears. They also report
that she's had dependent edema without changes in her urinary
habits.
ED Course: She was found to be slighly unresponsive and in no
apparent distress, and vital signs were remarkable for an oxygen
saturation in the mid-80's. She had a CXR done that revealed
infiltrates vs effusions bilaterally, and her labs were notable
for a WBC count of 17 with 92% PMNs. She was subsequently given
IV CTX/Flagyl/Azithromycin. Given her clinical findings and
ongoing hypoxia she was admitted to the [**Hospital Unit Name 153**] for observation.
Past Medical History:
1. Rheumatoid arthritis for
2. Osteoporosis.
3. Hiatal hernia.
4. Intermittent cognative impariment of unclear cause,
5. Failure to thrive
6. Urinary incontinence.
7. Intermittent leg edema
Social History:
Patient resided at the [**Hospital 599**] Nursing Home in past; however,
daughter and granddaughter took the patient home after discharge
on [**3-2**]. Her daughter [**Name (NI) 1258**] is very involved with her care. On
last admission, the did not want to send her to rehab. EtOH:
none. Tobacco: none. Illicits: None.
Family History:
noncontributory
Physical Exam:
Tmax: 36.2 ??????C (97.2 ??????F)
Tcurrent: 36.2 ??????C (97.2 ??????F)
BP: 143/119(125) {133/68(85) - 143/119(125)} mmHg
RR: 20 (20 - 30) insp/min
Heart rhythm: SR (Sinus Rhythm)
Peripheral Vascular: (Right radial pulse: 1+), (Left radial
pulse: 1+ (Right DP pulse: Not assessed), (Left DP pulse: Not
assessed)
Skin: sacral skin breakdown with surrounding erythema, dressed
bilateral skin tears
Neurologic: Responds to: voice, Movement: MAEW, Tone: increased
upper extremity tone
HEENT: AT/NC, patient did not open eyes, dry MM, poor dentition,
no JVD
CARDIAC: irregular rhythm, S1/S2, [**1-4**] holosystolic murmur @ RUSG
LUNG: decreased air movement bilaterally, without wheezes,
rales, or rhonci
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
M/S: moving all extremities well, no cyanosis, clubbing o
Pertinent Results:
CXR [**3-31**]
PORTABLE AP SEMI-UPRIGHT CHEST RADIOGRAPH: The cardiomediastinal
silloutte is stable, however partially obscured by large
bilateral pleural effusions that are unchanged. There is no
pulmonary edema or evidence of pneumonia
CXR [**3-30**]
IMPRESSION: Pulmonary edema with enlarging bilateral pleural
effusions significantly worse since [**3-3**].
KUB [**3-31**]
IMPRESSION: Paucity of bowel gas component, which could be seen
with obstruction. If clinically indicated, either a repeat study
or a CT may be obtained for better characterization
TTE [**3-30**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF 70-80%). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The supporting structures of the tricuspid valve are
thickened/fibrotic. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: hypertrophic, hyperdynamic left ventricle with very
small cavity size; at least moderate mitral regurgitation and
moderate-to-severe tricuspid regurgitation
Brief Hospital Course:
1. Aspiration Pneumonia
- Patient was maintained on Vancomycin and Zosyn
- Aspiration Precautions were continued
- Family declined PEG
- Geriatrics were consulted
2. C. Difficile Colitis
- Patient was maintained on Flagyl
- Plan was for 2 weeks post cessation of vanco/zosyn
- Serial toxin assay
3. Severe Malnutrition
- No NGT or PEG per family
- Continous Aspiration
4. Sacral Decubitus
- Vascular Consultation
- Wound Care Consult
- Wound Care
5. Coagulopathy
- Nutritional
# GOALS OF CARE: patient was extensively consulted on by
palliative care and geriatrics. Lengthy discussions with the
family. Patient was CMO/DNR/DNI with plans to discharge to
hospice on [**2113-4-6**], however she expired prior to discharge
Medications on Admission:
Docusate 100mg PO BID
Lidocaine patch 5% on 12 hrs, off 12 hrs daily
Megestrol 40mg qhs
Miconazole 2% topical daily
Mirtazapine 15mg qhs
Omeprazole 40mg daily
Sucralfate 1gm q6h
Boutreaux butt past daily
Oxycodone prn (rarely takes)
Senna 2 tabs daily prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Aspiration Pneumonia
C. Diff Colitis
Septicemia
Pressure Ulcers
Severe Malnutrition
Coagulopathy
Discharge Condition:
Expired
Discharge Instructions:
You are going home with hospice services. They will be your
primary contact for symptom management.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2113-4-11**]
1:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2113-4-13**] 12:00
ICD9 Codes: 5070, 0389, 5849, 2760, 2762, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7198
} | Medical Text: Admission Date: [**2135-5-13**] Discharge Date: [**2135-5-18**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Hyperglycemia, abdominal pain, n/v
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a 56 year old female with hx of DMI (x5 years),
b/l dropped feet, [**Doctor Last Name **] disease with frequent admissions for
diabetic Ketoacidosis presenting with DKA and gastroparesis
flare.
.
The patient reports that she has had abdominal pain for the past
2-3 days, which is consistent with her gastroparesis. Nausea and
vomitting has increased in intensity over the past 3 days. She
was unable to tolerated a diet all day yesterday, so her
daughter called EMS. The patient reports that she continued to
vomit overnight. The patient reports fevers to 102-103. She
reports [**10-30**] abdominal pain. She has not had emesis since last
night. She reports no chills. some cough, nonproductive. no
dysurea. no diarrhea, but reports being chronically constipated,
has not had BM in 3 days. The patient was confused in the ER,
but on the floor she is A&Ox3. Patient also reports that FS have
been increaseing
.
In the ER, intial vitals were, T 97.7, BP 133/58, HR 110, RR 16,
O2sat 100%. Her access was very difficult to obtain in the ER,
an eventually a femoral cvl was obtained. After this, she
recieved 2L NS, insulin IV bolus of 7units, then drip at
7units/hour. She had a foley placed. Her anion gap was 33.
.
Review of sytems:
(+) Per HPI
(-) Denies ,chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied shortness of breath. Denied chest pain or tightness,
palpitations. Denied diarrhea. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
# 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
- Frequent episodes of DKA
- DKA has been complicated by CVA, 3 episodes suspected
(including [**2135-5-14**] episode)
# Diabetic polyneuropathy and gastroparesis
# Hypertension
# Grave's disease s/p RAI [**2129**]
# Reactive airway disease
# Seronegative arthritis, followed in rheumatology
# Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
never been on antiviral therapy, acquired via blood transfusion
during surgery in [**2110**]
# GERD
# Migraines
# Bilateral knee arthroscopy in [**5-24**]
# s/p TAH and pelvic floor surgery with bladder lift
# Depression
# Bone spurs in feet
# 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:
Admission:
Vitals: T: 96.4 BP: 161/71 P: 120 R: 23 O2: 100% on 2L
General: Alert, oriented, no acute distress
[**Date Range 4459**]: Sclera anicteric, mucous membranes dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, tender to palpation throughout, no rebound, no
acute abdomen
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Patient has b/l drop foot.
.
On discharge:
Vitals: T: 98.1 BP: 124/86 P: 77 R: 16 O2: 97% on 2L
General: Alert, oriented, no acute distress
[**Date Range 4459**]: Sclera anicteric, mucous membranes moist, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, tender to palpation throughout, no rebound, no
acute abdomen
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Patient has b/l drop foot. Right fourth toe with ulcer on
the medial aspect, minimal swelling.
Pertinent Results:
CBC:
[**2135-5-13**] 12:30PM BLOOD WBC-14.8*# RBC-4.07*# Hgb-11.3*#
Hct-38.0# MCV-93 MCH-27.8 MCHC-29.8* RDW-15.6* Plt Ct-323
[**2135-5-13**] 05:48PM BLOOD WBC-15.7* RBC-3.51* Hgb-9.9* Hct-32.0*
MCV-91 MCH-28.2 MCHC-31.0 RDW-15.1 Plt Ct-288
[**2135-5-17**] 06:30AM BLOOD WBC-4.2 RBC-3.30* Hgb-9.6* Hct-29.1*
MCV-88 MCH-29.0 MCHC-32.9 RDW-15.6* Plt Ct-194
Chem Panels:
[**2135-5-13**] 12:30PM BLOOD Glucose-733* UreaN-33* Creat-1.7* Na-130*
K-5.6* Cl-90* HCO3-7* AnGap-39*
[**2135-5-13**] 02:50PM BLOOD Glucose-733* UreaN-34* Creat-1.6* Na-135
K-4.2 Cl-98 HCO3-LESS THAN
[**2135-5-17**] 06:30AM BLOOD Glucose-144* UreaN-4* Creat-0.7 Na-140
K-3.4 Cl-105 HCO3-28 AnGap-10
[**2135-5-13**] 10:53PM BLOOD Calcium-7.4* Phos-1.3*# Mg-1.7
[**2135-5-14**] 04:24AM BLOOD Calcium-7.1* Phos-2.6* Mg-3.0*
[**2135-5-17**] 06:30AM BLOOD Calcium-8.6 Phos-1.8* Mg-1.6
TFTs:
[**2135-5-14**] 02:49PM BLOOD TSH-1.4
[**2135-5-14**] 02:49PM BLOOD Free T4-0.93
U/A:
[**2135-5-16**] 04:14PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005
[**2135-5-16**] 04:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2135-5-16**] 04:14PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-1
Micro:
[**2135-5-16**] Blood Culture, Routine-PENDING INPATIENT
[**2135-5-16**] Blood Culture, Routine-PENDING INPATIENT
[**2135-5-16**] URINE CULTURE-Negative
[**2135-5-13**] MRSA SCREEN-Negative
Radiology:
CT HEAD W/O CONTRAST
1. Questionable early cytotoxic edema in the right MCA
distribution,
concerning for acute infarction. Based on clinical symptoms, MR
head already been ordered.
2. No evidence of acute hemorrhage.
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRV HEAD W/O
CONTRAST; MRA NECK W&W/O CONTRAST
IMPRESSION:
1. No evidence of an acute infarction or other acute
intracranial
abnormalities.
2. Technically limited head MRV.
3. Slightly limited head MRA without evidence of significant
stenosis or
aneurysm larger than 3 mm.
4. Normal neck MRA.
CHEST (PA & LAT) IMPRESSION:
No acute cardiopulmonary findings.
.
Discharge labs:
[**2135-5-18**] 06:40AM BLOOD WBC-5.5 RBC-3.24* Hgb-9.7* Hct-28.7*
MCV-89 MCH-30.0 MCHC-33.7 RDW-15.5 Plt Ct-218
[**2135-5-18**] 06:40AM BLOOD Glucose-175* UreaN-9 Creat-0.8 Na-137
K-3.5 Cl-104 HCO3-30 AnGap-7*
Brief Hospital Course:
This patient is a 56 y/o F with history of DMI with frequent
admissions for DKA, [**Doctor Last Name 933**], who presents with DKA and
gastroparesis flare.
.
Diabetic Ketoacidosis: Patient with numerous admissions for DKA.
Infectious workup was negative. It appears that patient
developed DKA in the setting of a flare of her gastroparesis.
She was started on Insulin gtt in the ER 7unit bolus then
7units/hour. She was initially admitted to the ICU. Her gap
closed quickly on the insulin drip and she was started on her
home dose of lantus 32 units twice daily. She was hypovolemic
and was given fluid boluses with potasium. After her anion gap
closed she was called out to the floor for ongoing care. Her
electrolytes continued to improve, and her bicarb gradually
returned to [**Location 213**]. [**Last Name (un) **] was consulted, and assisted with
insulin titration. Her lantus dose was changed to [**Hospital1 **] dosing,
briefly at 20 units [**Hospital1 **], however she developed recurrent
hypoglycemia and her lantus was titrated down to 15 units [**Hospital1 **],
with a sliding scale. This can be titrated back up as
necessary.
.
Acute Renal Failure:
Patient had acute renal failure on admission due to dehydration
in setting of DKA. Creatinine was 1.7 on admission (baseline is
0.8). This resolved over the course of the admission with IV
fluids/hydration.
.
Nausea/[**Hospital1 **]/Gastroparesis:
The patient stated that she had a flare of her gastroparesis
prior to developing this episode of DKA, with 10/10 abdominal
pain and no bowel movement x3 days. Her gastroparesis improved
and she was able to tolerate a regular diabetic diet without
difficulty. There was no evidence of obstruction. She was
continued on her home medications for her gastroparesis.
.
Right arm weakness:
After MICU callout, patient complained of R arm paresthesias,
weakness, and loss of coordination. Evaluating MD had concern
for possible CNS ischemic event, and thus an urgent Neuro
consult was obtained. A repeat head CT was performed, as well
as extensive MRI imaging of the head/neck (MRI, MRA, MRV, see
results). There was initially concern of a "cortical hand"
(cortical CVA) from the Neuro team, and patient was placed on
Q2hr neuro checks, the patient was layed flat to promote CNS
perfusion, and her antihypertensives were held. However, imaging
and further evaluation by the Neurology attending was not
consistent with a CNS event. At this time, patient is NOT
thought to have had a CVA. Her symptoms gradually improved.
Patient did have some R arm edema, due to IV access and
aggressive hydration, which may have caused some altered
sensation. Note that at the time of initial identification of
the neurologic complaints, her calcium level was noted to be
low, however this corrected to 8.3 once an albumin level was
obtained, and thus not likely to contribute to her symptoms.
.
Hypertension:
Patient was initially somewhat hypertensive, but this improved
with continuation of her home blood pressure medications.
.
[**Doctor Last Name 933**] Disease:
- continued Methimazole 10 mg three times a day
.
Reactive airway disease: currently stable
- continued Albuterol inhaler as needed
- continued Advair 250/50 twice daily
- continued Montelukast 10 mg daily
.
Diabetic Neuropathy with diabetic ulcer:
Patient with known bilateral foot drop. Pt was noted to have a
small wound on her left second toe from injury several weeks ago
which appeared to be healing well, without any evidence of
infection. She was [**Doctor Last Name 1988**] to see podiatry as an outpatient.
Pt's Gabapentin was initially decreased to 300 twice daily
given her acute renal failure, but this was increased back to
her home dose of 900 mg three times daily once her renal
function improved back to baseline.
.
Migraines: none currently
- Her Amitriptyline 25 mg Tablet Nightly was initially held
given her altered mental status on admission. This medication
was later resumed.
.
Hepatitis C: stable currently.
.
Pending labs:
Blood cx [**5-16**] still pending at discharge.
.
Key follow up:
1. Podiatry for ulcer evaluation on [**5-31**].
2. Diabetes management with titration up of lantus.
Medications on Admission:
Albuterol inhaler as needed
Advair 250/50 twice daily
Aspirin 81 mg Tablet Daily
Amitriptyline 25 mg Tablet Nightly
Methimazole 10 mg three times a day
Metoclopramide 10 mg Tablet QIDACHS
Montelukast 10 mg daily
Pantoprazole 40 mg Tablet daily
Simvastatin 10 mg Tablet daily
Sulfasalazine 500 mg twice daily
Hyoscyamine Sulfate 0.125, 3 tabs three times daily
Losartan 50 mg daily
Docusate Sodium 100 mg twice a day.
Humalog sliding scale
Toprol 25mg daily
Percocet 7.5-500 mg every 6 hours as needed pain
Diazepam 5 mg Tablet twice a day.
Hxdroxyzine 25mg every 6 hours PRN itching
Vitamin D 50,000 weekly
Zomig 2.5 mg Tablet daily as needed nausea
Gabapentin 900 mg Capsule 3 times a day
Insulin Lantus 32 units Sc twice a day
Miralax 17gm daily PRN.
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette 1-2 drops PRN
Prednisolone Acetate 1 % 1 drop twice daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12 hr
Sig: One (1) Capsule, Sust. Release 12 hr PO Q 8H (Every 8
Hours).
13. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
17. Zolmitriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed for nausea.
18. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
19. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous twice a day: Give 1/2 dose if NPO.
20. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) mg PO DAILY (Daily) as needed for constipation.
21. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
22. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety.
23. Humalog 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous QAC and QHS.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 1495**] [**Hospital 11042**] Rehab
Discharge Diagnosis:
# Diabetic ketoacidosis
# Type I Diabetes
# Acute renal failure
# Gastroparesis flare
# Right hand weaknes
# Acute encephalopathy
# Diabetic foot ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with an episode of your DKA, likely triggered
by a flare of your gastroparesis. Please monitor your glucose
closely, and follow up with your [**Last Name (un) **] providers.
.
You have an ulcer on your right fourth toe which does not appear
infected. You will see a podiatrist in 2 weeks to evaluate it.
Please contact them earlier if it worsens.
.
You also had right arm weakness and pain. The neurologists
recommended an EMG if your symptoms persist.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] H.
Appointment: [**Last Name (LF) 766**], [**5-23**], 2pm
Location: UPHAMS CORNER HEALTH CENTER
Address: [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 58270**]
Phone: [**Telephone/Fax (1) 7538**]
Department: PODIATRY
When: TUESDAY [**2135-5-31**] at 2:45 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Contact Dr. [**Last Name (STitle) 557**], Neurology, ([**Telephone/Fax (1) 13172**] if you continue
to have weakness in your right hand for an EMG test.
ICD9 Codes: 5849, 3572, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7199
} | Medical Text: Admission Date: [**2138-6-19**] Discharge Date: [**2138-6-30**]
Date of Birth: [**2071-5-23**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Complex pelvic mass.
Major Surgical or Invasive Procedure:
Total abdominal hysterectomy, bilateral salpingo-oophorectomy,
extensive pelvic adhesiolysis, pelvic and periaortic
lymphadenectomy, omentectomy.
History of Present Illness:
This patient, a 67 year old female, with a past medical history
significant for multiple small bowel obsructions and ventral
hernia and known left ovarian mass for 10 year was admitted to
[**Hospital3 8834**] [**2138-1-10**] for a small bowel
obstruction. Her symptoms resolved with consrevative therapy,
however a MR enterography performed. An As an incidental
finding, a complex left adnexal mass was seen. This imaging was
then followed by a dedicated pelvic MR. This was read here at
[**Hospital1 69**] by Dr. [**First Name4 (NamePattern1) 2092**] [**Last Name (NamePattern1) **]. The
uterus and right adnexa were unremarkable. In the expected
location of the left adnexa, a 4 x 6 x 4 cm complex lesion was
noted with an avidly enhancing 2 cm component. The MRI
impression included in the differential diagnosis was an
epithelial neoplasm of the ovary, versus an endometrioma with an
associated malignancy. A recent CA-125 was 11 on a scale of
0-35. The MR enterography showed a 6 cm lower abdomen wide neck
ventral hernia containing multiple loops of small bowel. She
was asymptomatic. The patient was seen in consultation
concurrently by Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**], who planned abdominal
exploration with abdominal wall reconstruction and also by GYN
Oncology. Surigcal excision TAH-BSO and frozen section were
recommended. The patient presented to [**Hospital1 18**] for surgical
intervention.
Past Medical History:
PMH: Breast CA, Morbid Obesity, Pre-DM, Dizzy Spells, HTN,
Hiatal Hernia, GERD, Mild Anemia, Arthritis/Gout, Glaucoma,
Bowel Obstructions.
Social History:
Ex-smoker, but having quit over 40 years ago. Drinks socially.
Denies substance abuse. Lives with her husband, [**Name (NI) 122**].
Family History:
Family history is negative for breast, colon, uterine, or
ovarian cancer.
Physical Exam:
PHYSICAL EXAMINATION Inpatient
Vitals: T: 96.9 degrees Farenheit, BP: 98/46 mmHg supine, HR 80
bpm, RR 18 bpm, O2: 100% on 2L NC.
Gen: Mildly lethargic, arousable, NAD
HEENT: No conjunctival pallor. MMM. OP clear.
NECK: Supple, No LAD. JVP low. Normal carotid upstroke
CV: PMI in 5th intercostal space, mid clavicular line. RRR. nl
S1, S2. II/VI <> sys murmur. + S4.
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Surgical dressing in place. Soft, NT, ND. No HSM.
EXT: WWP. 2+ LE edema. Full distal pulses bilaterally.
SKIN: Scattered ecchymoses
NEURO: A&Ox3. CN 2-12 grossly intact. Moving all extremities
At Discharge:
General: Patient appears well, NAD, VSS, Tolerating a regular
diet.
Cardiac: RRR
Pulm: No issues, CTA
Abd: Obese abd, no nausea, no vomiting, Surgical wound intact,
Left JP drain removed on day of discharge, Right JP drain
draining 95cc overnight and to remain in place until follow-up.
Lower Extremities: Obese, no significant edema noted.
Pertinent Results:
[**2138-6-28**] 05:35AM BLOOD WBC-7.4 RBC-2.82* Hgb-8.8* Hct-26.5*
MCV-94 MCH-31.3 MCHC-33.4 RDW-14.1 Plt Ct-383
[**2138-6-27**] 08:55PM BLOOD Hct-26.9*
[**2138-6-27**] 08:30AM BLOOD WBC-7.1 RBC-2.44* Hgb-7.5* Hct-23.2*
MCV-95 MCH-30.9 MCHC-32.5 RDW-12.8 Plt Ct-386
[**2138-6-26**] 12:45PM BLOOD WBC-7.5 RBC-2.44* Hgb-7.8* Hct-23.4*
MCV-96 MCH-32.0 MCHC-33.4 RDW-12.8 Plt Ct-349#
[**2138-6-22**] 06:55AM BLOOD WBC-7.3 RBC-2.52* Hgb-8.3* Hct-24.2*
MCV-96 MCH-32.9* MCHC-34.2 RDW-12.2 Plt Ct-183
[**2138-6-21**] 09:57AM BLOOD WBC-7.2 RBC-2.62* Hgb-8.8* Hct-24.9*
MCV-95 MCH-33.6* MCHC-35.3* RDW-12.2 Plt Ct-195
[**2138-6-30**] 09:16AM BLOOD PT-25.4* PTT-27.2 INR(PT)-2.4*
[**2138-6-29**] 02:45AM BLOOD PT-22.6* PTT-69.2* INR(PT)-2.1*
[**2138-6-28**] 09:50AM BLOOD PTT-82.4*
[**2138-6-28**] 05:35AM BLOOD Plt Ct-383
[**2138-6-28**] 05:35AM BLOOD PT-19.7* PTT-150* INR(PT)-1.8*
[**2138-6-27**] 10:55PM BLOOD PTT-62.9*
[**2138-6-27**] 08:30AM BLOOD PT-13.7* PTT-64.9* INR(PT)-1.2*
[**2138-6-26**] 12:45PM BLOOD PT-12.2 PTT-23.5 INR(PT)-1.0
[**2138-6-20**] 06:29PM BLOOD PT-11.9 PTT-24.3 INR(PT)-1.0
[**2138-6-20**] 01:06AM BLOOD PT-12.8 PTT-23.8 INR(PT)-1.1
[**2138-6-30**] 07:35AM BLOOD Glucose-125* UreaN-13 Creat-0.6 Na-142
K-4.4 Cl-103 HCO3-31 AnGap-12
[**2138-6-29**] 02:11AM BLOOD Na-143 K-3.4 Cl-103
[**2138-6-28**] 05:35AM BLOOD Glucose-122* UreaN-9 Creat-0.7 Na-145
K-3.6 Cl-105 HCO3-30 AnGap-14
[**2138-6-27**] 08:30AM BLOOD Glucose-154* UreaN-11 Creat-0.7 Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2138-6-23**] 03:10PM BLOOD CK(CPK)-177
[**2138-6-22**] 11:21PM BLOOD CK(CPK)-234*
[**2138-6-23**] 03:10PM BLOOD CK-MB-2 cTropnT-0.04*
[**2138-6-23**] 01:52PM BLOOD cTropnT-0.04*
[**2138-6-23**] 05:50AM BLOOD cTropnT-0.04*
[**2138-6-22**] 11:21PM BLOOD CK-MB-3 cTropnT-0.06*
[**2138-6-30**] 07:35AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.8
[**2138-6-29**] 02:11AM BLOOD Mg-1.6
[**2138-6-28**] 05:35AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.4*
[**2138-6-27**] 08:30AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.6
[**2138-6-24**] 06:10AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9
[**2138-6-23**] 01:52PM BLOOD Calcium-8.2* Phos-2.6* Mg-2.4
Pathology [**2138-6-19**]:
1. Uterus and cervix, right tube and ovary (A-D):
- Uterus with atrophic endometrium and adenomyosis.
- Unremarkable cervix.
- Ovary with benign simple cyst.
- Unremarkable fallopian tube.
2. Left tube and ovary (E-J):
Clear cell carcinoma, see synoptic report.
3. Pannus (K):
Skin and fibroadipose tissue with focal fibrosis.
4. Abdominal wall (L):
Dense fibroconnective tissue with foreign body giant cell
reaction and scar.
5. Left pelvic lymph node (M-S):
Seven lymph nodes, no malignancy identified (0/7).
6. Left peri-aortic lymph node (T):
One lymph node, no malignancy identified (0/1).
7. Omentum (U):
Unremarkable fibroadipose tissue.
ECG [**2138-6-22**]: Regular SVT @ ~ 160 bpm. No obvious PWs.- Per
Cardiology
ECG1 [**2138-6-23**]: atrial fibrillation at 58. -Per Cardiology
ECG2 [**6-23**]: sinus @ 80. Nl A/I. Low voltage. Compared to prior,
now in sinus, otherwise findings similar. - Per Cardiology
CTA Chest [**2138-6-26**]
IMPRESSION:
1.Bilateral pulmonary emboli with new linear atelectasis in the
lower lobes.
2.Small dependent fluid postoperative collection surrounding the
spleen.
The findings of the pulmonary emboli were conveyed to Dr.
[**Last Name (STitle) 28528**] at the time of reporting.
Brief Hospital Course:
The patient was admitted to the [**Hospital Ward Name 332**] Intensive Care Unit after
total abdominal hysterectomy, bilateral salpingo-oophorectomy,
extensive pelvic adhesiolysis, pelvic and periaortic
lymphadenectomy omentectomy intubated for observation on
[**2138-6-19**]. All tissues from the case were sent to pathology for
evaluation. The patient was
In the ICU the patient received boluses of intravenous fluids
for low urine output with good affect. The patient was extubated
and started on a PCA for post-operative pain control, and
transferred to the inpatient floor where she was placed on
telemetry. She was followed closely by General Surgery as well
as GYN Oncology. On the inpatient [**Hospital1 **] the patient developed
atrial fibrillation with a heart rate up to 150s. She noted
nausea and diaphoresis with the episode but was otherwise
asymptomatic and the episode was hemodynamically tolerated. She
received Lopressor 5 mg IV x 3 with decrease in her HRs to <100.
However, rates returned to the 150s and she was given diltiazem
10 mg IV which reportedly dropped her HRs to the 30s and SBPs to
60s. However, this was transient and resolved without
intervention. She again had ventricular rates into the 150s and
she received an additional 5 mg of IV Lopressor with HR drop to
<100. This am, she spontaneously converted to sinus rhythm.
Cardiology was consulted for further management which
recommended continuing Lisinopril 20mg daily, initiating
Lopressor 25mg three times daily, Aspirin 325mg daily,
Echocardiogram which showed LVEF >55%, no aortic regurgitation,
mitral mildly thickened mitral valve leaflets. Mild (1+) mitral
regurgitation, mild pulmonary artery systolic hypertension, and
no pericardial effusion, control of surgical pain, hold Dyazide
diuretic, continue statin, and check TSH which was normal at
2.5mg. The patient recovered well from surgery, increased her
activity as tolerated, progressed her diet, and remained in
normal sinus rhythm. On [**2138-6-26**], the GYN oncology surgical team
became concerned that the patient may have had atrial
fibrillation related to pulmonary emboli given her prolonged
operative case, new diagnosis of cancer, and obesity. The
patient was not short of breath, expressing complaints of chest
pain, hypoxic, or tachycardic at this time. A CTA was obtained
[**2138-6-26**] which showed Bilateral pulmonary emboli with new linear
atelectasis in the lower lobes and small dependent fluid
postoperative collection surrounding the spleen. The patient was
a started on intravenous Heparin and Warfarin therapy was
initiated with the INR goal of [**2-12**]. The Heparin gtt was
monitored closely with every six hour PTT values. The patient
remained on telemetry on the inpatient floor without issue on
intravenous Heparin and Warfarin PO until [**2138-6-27**] when, after
missing approximately two doses of Lopressor by mouth developed
short bursts of sinus tachycardia which resolved with Lopressor
by mouth. The patient was monitored with daily INR values and
dosed with 5 mg of Warfarin. On discharge the patient's INR was
2.4 and she was discharged on 4mg of Warfarin daily with follow
up with her primary care provider on Thursday [**2138-7-3**] for INR
check and dose adjustment. The patient's bowel function returned
appropriately post-operatively and she was tolerating a regular
diet on discharge. On discharge, the left [**Location (un) 1661**]-[**Location (un) 1662**] drain
was discontinued however, the Right drain remained in place with
the intention of the drain being discontinued at follow-up. The
surgical incision was closed and remained stable. The patient
was discharged home with appropriate medical instruction and
follow-up. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**], the patient's primary care
provider, [**Name10 (NameIs) **] [**Name (NI) 653**] and aware of the [**Hospital 228**] hospital
coarse and discharge.
Medications on Admission:
Arimidex 1 mg daily
Azopt 1% 1gtt OD twice daily
Keflex prior to dental work
Lisinopril 20 mg daily
Meclizine 25 mg TID prn
Simvastatin 20 mg daily
Timolol eyedrops 0.5% OU [**Hospital1 **]
Triamteren-Hydrochlorothizide 37.5/25
Vitamin C 1000 mg daily
Aspirin 81 mg daily
Vitamin D 1000 iu
Biotin 2500 mg
calcium with D
Multivitamins
Omega fish oils
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain: Do not take more than 4000mg
of Tylenol daily.
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain for 5 days: Please do not drink alcohol or
drive a car while taking this medication. Take as prescribed.
Disp:*40 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily () as
needed for Br CA hx.
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
Please take daily at 400pm. Please follow-up with your primary
care who will be managing this medication. .
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Complex pelvic mass, malignant ovarian neoplasm on frozen
section.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgical managment of the
complex mass located in your pelvis. You had quite an extensive
surgery as listed below. Pathology reports indicated that the
left ovary showed cancerous tissue. You were admitted to the
intensive care unit overnight after your surgery for monitoring
and then your were transfered to the inpatient floor. You have a
very low abdominal incision which is closed with staples. This
may be left open to air, you may apply a dry sterile gauze if
the skin becomes irritated. Monitor for signs of infection
including; white/green drainage, incresing warmth or redness of
the skin, increased pain, or if you develop a fever. Call the
office if you develop these symptoms or report the emergency
room if severe. You had 2 [**Location (un) 1661**]/[**Location (un) 1662**] drains in your incision,
one of them was removed prior to your discharge. The other
remains in place. Please follow the instructions given to you by
the nurses. If you have [**Last Name (un) 57199**] than 100 cc of drainage in the
blub of the drain in one day please call the office, if the
drain begins to ooze outside on the dressing incertion site onto
the gauze dressing please call the office. The dressing should
remain intact and do not shower until after you see Dr. [**Last Name (STitle) 519**].
This drain will be removed at the same time as your staples at
your first follow-up visit. Watch for similar signs of infection
at the JP drain site. No heavy lifting for [**4-15**] lbs unless
instructed otherwise by Dr. [**Last Name (STitle) 519**].
On the floor you had a rapid heart rate in an irregular rythm
called atrial fibrillation. The surgical team consulted the
cardiology team who recommended we start you on the medication
lopressor. This fast heart rate was controlled with this
medication. It is important that you follow-up with your primary
care provider for blood pressure monitoring as this is a new
medication. You may want to consider purchasing a blood pressure
cuff which you can monitor your blood pressure at home with.
Normal blood pressure is 120/80, if the top number is ever
higher than 160 or lower than [**Age over 90 **] you should call the doctor. If
your top number is very low wait to consult the primary care
office's nurse prior to taking this medication. The cause of
this atrial fibrillation was determined to be multiple small
blood clots in your lungs called pulmonary emboli. These can
happen when peaople are immobile or have conditions that make
them more likely to develop a blood clot. Cancer can do this.
You were started on a heparin drip to thin the blood to prevent
the clot from growing and transitioned to Coumadin a medication
you will take by mouth for 6months-1 year. You will take 4mg of
this medication by mouth daily preferably, in the afternoon
around 4pm, however this will be up to you. It is good to take
it at this time if you will go ot have your blood drawn in the
monring. You will require frequent blood laboratory value
monitoring which will be preformed by your primary care
provider. [**Name10 (NameIs) **] is very important that you take this medication as
presecribed and report to the office to have your laboratory
values checked because you will be at increased risk to bleed.
Your primary care provider will be managing the dose of your
coumadin, it is important that you follow their recommendations
exactly. You are at increased risk for bleeding, please follow
the coumadin and food teaching sheets and monitor yourself for
brusing, bloody stools, fast heart rate, or low blood pressure.
You have an appointment with your primary care provider as
listed below and it is important that you see her. Please keep
this appointment.
Monitor your bowel function and eat small frequent meals.Stay
well hydrated. If you become nauseated, constipted, vomit, or
your abdomen becomes distended call your doctor. If severe come
to the emergency room.
You will see GYN Oncology as written below. Your oncologist is
planning on adressing the plan for further care at this visit.
You have not been taking your Dyazide (water pill) during this
admission. Please discuss this with your primary care physician.
[**Name10 (NameIs) 357**] hold of on restarting your other vitamins besides the
iron and folic acid you were taking here and discuss with your
primary care.
Take care!
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2138-7-3**] 12:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**]
Date/Time:[**2138-7-7**] 10:30
Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2138-7-7**] 9:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2138-6-30**]
ICD9 Codes: 5180, 2859 |
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