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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7200
} | Medical Text: Admission Date: [**2199-11-10**] Discharge Date: [**2199-11-16**]
Date of Birth: [**2123-4-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
increased ostomy output
Major Surgical or Invasive Procedure:
bilateral percutaneous nephrostomy tube placement
History of Present Illness:
76 y/o F with a PMHx of anal CA/colon CA s/p colectomy [**8-/2199**]
and recent anal resection for residual disease on [**9-25**] who had
ureteral compression and hydro s/p bilat nephrostomy tube
placement [**8-/2199**] and recent removal on [**11-5**] who presents with
decreased UOP and increased anal leakage. Since having her tubes
pulled, she has had decreased UOP. She denies any pain/burning
with urination. Denies any fevers, +chills. No cough,
odynophagia. +nonbloody watery diarrhea since having tubes
pulled on [**11-5**]. No antecedent Abx course.
.
In the ED, VS were: T97.7, HR110, BP 115/58, RR22, 100%RA. In
the ED, her K was noted to be elevated, and EKG showed peaked T
waves. An emergent renal U/S showed worsening bilat
hyrdonephrosis. She received Levaquin 500mg IV x1, Calcium
gluconate 1g x1, amp D50 + 10u SC insulin, Kayexylate 30mL x1
and was taken to the IR suite for placement of (bilateral vs
unilateral) percutaneous nephrostomy tube placement.
.
Past Medical History:
OncHx:
Paget's disease of anal canal dx by path [**12-2**]. Subsequent
repeat biopsy [**8-3**] found residual/recurrent CIS. She was
admitted [**7-4**] for descending colectomy after an anal stricture.
Colon pathology demonstrated adenocarcinoma involving
lymphatics, submucosa, and superficial part of muscularis
propria. Omental specimens confirmed metastatic adenocarcinoma,
predominantly signet ring cell type. This was same histology as
previous anal Paget's disease from [**12-2**] biopsy. She was seen on
[**7-23**] by Dr. [**Last Name (STitle) **], and will be undergoing palliative surgery in
upcoming weeks
.
Other PMHx:
- Colon cancer s/p lap resection in [**2193**] at [**Hospital3 **]. Believed
to be node-negative, no chemo or radiation at time.
- HTN
- Extra-mammary Paget's disease s/p resection [**12-2**]
- s/p partial hysterectomy
- s/p breast reduction surgery
- h/o ophthalmologic zoster [**2192**]
.
Social History:
No EtOH or tobacco
Family History:
Noncontributory
Physical Exam:
VS: Temp:99.2 BP: 110-150/55-60 HR:110s RR:22 O2sat: 97-99%RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric
RESP: CTA b/l with good air movement throughout
CV: Tachycardic, regular. S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
BACK: L nephrostomy tube placed on left.
EXT: no c/c/e
SKIN: no rashes
NEURO: AAOx3. Cn II-XII intact.
Pertinent Results:
[**2199-11-10**] 01:05PM WBC-21.2*# RBC-4.00* HGB-11.7* HCT-35.1*
MCV-88 MCH-29.3 MCHC-33.3 RDW-15.8* PLT COUNT-437
[**2199-11-10**] 01:05PM NEUTS-92* BANDS-0 LYMPHS-6* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2199-11-10**] 01:05PM GLUCOSE-100 UREA N-89* CREAT-7.7*#
SODIUM-126* POTASSIUM-8.1* CHLORIDE-91* TOTAL CO2-19* ANION
GAP-24*
.
[**2199-11-10**]: Urine Culture: PSEUDOMONAS AERUGINOSA. >100,000
ORGANISMS/ML. pan-sensitive.
.
[**2199-11-10**]: Bilateral hydronephrosis, probably worse than the
[**2199-10-25**] study, but mildly improved since [**2199-9-13**] study.
Layering
material in the right upper pole may represent sediment or old
blood.
.
[**2199-11-10**]: L nephrostomy placement - Nephrostogram demonstrating
moderate left-sided hydronephrosis and proximal hydroureter.
Only a minimal amount of contrast was seen to pass beyond the
proximal ureter, although a guidewire was able to be threaded
through the course of the ureter into the bladder. Successful
placement of an 8 French percutaneous nephrostomy tube on the
left by way of a posterior mid pole renal calix. Approximately
10 cc of turbid urine drained to gravity during the procedure.
.
[**2199-11-11**]: R nephrostomy placement - Successful placement of an 8
French nephrostomy tube in the right kidney attached to a bag
for external drainage. Severe hydronephrosis and hydroureter on
the right side.
Brief Hospital Course:
In brief, the patient is a 76 y/o F with anal CA/colon CA s/p
resection, hx of hydro with bilateral nephrostomy tubes s/p
removal [**11-5**] here with decreased UOP, anal leakage found to have
new ARF and bilateral hydro.
.
1.) Bilateral hydronephrosis: The patient presented with
bilateral hydronephrosis following a recent removal of ureteral
stents that had been placed for her known cancer mass that had
been compressing her ureters. She had successful placement of
bilateral percutaneous nephrostomy tubes with gradual resolution
of the hydronephrosis. She will need f/u with IR in 3 months to
change tubes or earlier if decision made to eschange for
ureteral stents.
.
2.) Acute renal failure: Her baseline Cr is 1.8. On presentation
the Cr had increased to 7.7 secondary to the bilateral
hydronephrosis. It showed gradual improvement over the course
of the hospital stay. Her medications were dosed for her
impaired renal clearance. She will need a chem7 panel checked
approximately one week after discharge.
.
3.) Hypotension/Sepsis: Patient developed sepsis following
placement of R PCN tube UCx was positive for pan-sensitive
pseudomonas. There was no evidence of acute end-organ
hypoperfusion. She was briefly monitored in the ICU. She
recovered her hemodynamics. By time of discharge her WBC
continued to trend down. She will complete a 14 day total
course of antibiotics.
.
4.) Increased Ostomy output: subacute increase in ostomy output.
no blood. could be secondary to co-incident illness
(hydro/pyelo). A c dif toxin was negative. The increased ostomy
output began to slow prior to discharge. She will need to
follow-up with gen [**Doctor First Name **] as outpatient.
.
5.) Metabolic Acidosis: This was a mixed anion-gap, non-anion
gap acidosis due to a combination of renal failure (incr AG),
hyperphosphotemia (incr AG), increased ostomy output (low AG),
and dilutional acidosis from IVF (low AG). She did not have a
lactic acidosis. By time of discharge her anion gap was
improving. It was anticipated that the acidosis would continue
to resolve as her renal function improved.
.
6.) Anal CA s/p resection: no acute inpatient events other than
the hydronephrosis above. She will follow-up with her general
surgeon and meet with the radiation oncologist to discuss
further treatment options.
.
7.) Hypertension - blood pressure now resolving to baseline
after her brief period of hypotension following the nephrostomy
tube placement. Her home ACE inhibitor was discontinued in the
setting of renal failure.
.
8.) FEN: low potassium diet for now, replete as needed
.
9.) Access: PIV
.
10.) PPx: Hep SQ, ppi
.
11.) DISPO: she was discharged to home with close PCP [**Last Name (NamePattern4) 702**]
Medications on Admission:
Lisinopril 5mg po Qday
Centrum Silver
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Outpatient Lab Work
Please have your blood drawn in 4 days while you are taking the
ciprofloxacin so that the dose can be changed as necessary.
Please draw: Na, K, Cl, bicarbonate, BUN, Cr, CBC and send
results to Dr. [**First Name (STitle) **] [**Name (STitle) 2405**] (phone [**Telephone/Fax (1) 56399**])
4. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO once a day
for 9 days: please take as directed.
Disp:*18 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
6. Ostomy Care
ostomy care per protocol
7. Nephrostomy Tube
Bilateral Nephrostomy Tube care per protocol
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Bilateral Hydronephrosis
Pyelonephritis
Acute Renal Failure
.
Secondary:
Rectal Cancer
Discharge Condition:
good. ambulating with cane. afebrile. stable vital signs.
tolerating oral medications and nutrition.
Discharge Instructions:
You have been evaluated and treated for an infection in your
kidney and for an obstruction to the flow of urine. Tubes were
placed into your kidneys to drain the urine bypassing the
obstruction. A urine infection was found for which you will
complete the rest of the antibiotics at home. Your kidney
function was improving by time of discharge.
.
Please take the medications prescribed to you. Your lisinopril
was stopped during this admission. You and your primary doctor
can discuss starting a new blood pressure medicine as an
outpatient.
.
Please make and attend the recommended appointments.
.
If you develop any new or concerning symptom, particularly fever
to greater than 100.5F, decreasing urine output into the tubes,
persistent nausea, please seek medical attention.
.
You, Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) 13734**] should discuss which would be
the better option either changing the nephrostomy tubes
periodically or having them exchanged for ureteral stents.
Followup Instructions:
Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] office at [**Telephone/Fax (1) 56399**] to
schedule an appointment within 7-10 days. You will need to get
your blood drawn by the visiting nurse prior to that appointment
to confirm that you blood counts and kidney function are
improving appropriately.
.
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2199-11-22**]
at 3:15pm. Please call ([**Telephone/Fax (1) 6449**] with questions.
.
ICD9 Codes: 5849, 2762, 2767, 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7201
} | Medical Text: Admission Date: [**2160-3-23**] Discharge Date: [**2160-3-28**]
Date of Birth: [**2092-1-11**] Sex: M
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: This is a 68-year-old male with
a history of chronic obstructive pulmonary disease,
bronchiectasis, hypertension, and hypercholesterolemia who
was admitted to the Medical Intensive Care Unit on [**2160-3-23**] for a chronic obstructive pulmonary disease
exacerbation.
The patient has had recent admissions for chronic obstructive
pulmonary disease exacerbations in [**2159-11-27**] and in
[**2159-12-28**]. He was in his usual state of health until
three days prior to admission when he developed acute
shortness of breath and cough. There was no hemoptysis or
fevers, chills, nausea, vomiting, chest pain, abdominal pain,
orthopnea of paroxysmal nocturnal dyspnea. He had a
productive cough with brownish sputum.
In the Emergency Department, his saturations were 70% on room
air and 90% on 7 liters of oxygen. He was given Solu-Medrol
and levofloxacin as well as Combivent nebulizers and
transferred to the Medical Intensive Care Unit.
During the course of his stay in the Medical Intensive Care
Unit, his oxygen saturations were 92% on 50% oxygen. A chest
x-ray showed a right middle lobe opacity. He was maintained
on q.1h. nebulizers and changed to p.o. prednisone, and
eventually changed to q.4h. nebulizers with oxygen
saturations of 96% on 3 liters via nasal cannula. At that
point, he was transferred to the floor for further care.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Bronchiectasis.
3. Hypertension.
4. Hypercholesterolemia.
5. Pyloric stenosis.
6. History of bladder cancer.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: (Medications on transfer to the
floor were)
1. Prednisone 60 mg p.o. q.d.
2. Flovent meter-dosed inhaler.
3. Zantac.
4. Norvasc 5 mg p.o. q.d.
5. Zoloft 250 mg p.o. q.d.
6. Albuterol and Atrovent nebulizers q.4h.
SOCIAL HISTORY: A 55-pack-year history of tobacco; now, he
smokes five to six cigarettes per day. No drug or alcohol
use. The patient lives with his wife.
FAMILY HISTORY: Family history with coronary artery disease.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, temperature of 98.6, blood pressure of 119/68,
pulse of 80, respiratory rate of 23, oxygen saturation 96% on
3 liters through a nasal cannula. Generally, lying
comfortably in bed, in no apparent distress. Head, eyes,
ears, nose, and throat revealed anicteric sclerae, bilateral
surgical pupils. Extraocular muscles were intact. The
oropharynx was clear. Mucous membranes were dry. Neck
revealed no lymphadenopathy or jugular venous distention.
Lungs revealed prolonged expiratory phase with positive
end-expiratory wheezing. Cardiovascular examination revealed
distant heart sounds, a regular rate and rhythm. The abdomen
was soft and obese with a well-healed epigastric scar. No
tenderness or distention. Extremities revealed left hand
clubbing. No cyanosis or edema. Neurologically, alert and
oriented times three. No focal neurologic deficits.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count of 22.5, hematocrit of 39.6, platelets of 195. Chem-7
revealed sodium of 141, potassium of 3.8, chloride of 97,
bicarbonate of 34, blood urea nitrogen of 15, creatinine
of 0.7, blood sugar of 157.
RADIOLOGY/IMAGING: Chest x-ray showed a right middle lobe
pericardiac pneumonia with possible involvement of right
lower lobe.
HOSPITAL COURSE:
1. PULMONARY: The patient remained stable from a pulmonary
standpoint during the course of his stay on the [**Hospital6 2399**] Firm. He continued to have oxygen saturations in
the middle 90s on 3 liters via nasal cannula. The patient
had a Physical Therapy consultation which deemed him
requiring supplemental oxygen at home.
The patient's white blood cell count decreased throughout the
course of his stay in the hospital. His cough also cleared
throughout the course of his stay in the hospital. The
patient remained afebrile throughout the course of his stay
in the hospital. Prior to his discharge, a chest CT was
obtained which showed bilateral lower lobe bronchial wall
thickening, worse in the right lower lobe than the left with
associated areas of mucoid impaction in the right lower lobe.
There was also multifactorial patchy ground-glass opacity in
both lower lobes and the lingula as well as some minimal
consolidation at the right lung base. These findings likely
represented acute infectious bronchiectasis with associated
early developing bronchial pneumonia.
There was also a 5-mm diameter lung nodule in the right upper
lobe separated from areas of previous presumed infectious
changes in the lower lung zones. This nodule could
potentially represent a very early focus of tumor; however,
an acute infectious or inflammatory process was also on the
differential diagnosis. A follow-up chest CT was recommended
by Radiology in two to three months. The patient's primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **], was to schedule a
follow-up chest CT in two to three months to assess this new
lung nodule in the right upper lobe.
The patient was treated with Levaquin for his pneumonia.
2. CARDIOVASCULAR: The patient's blood pressure was
elevated during the course of his stay in the hospital, and
his Norvasc was increased to 7.5 mg p.o. q.d. with good
results.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease exacerbation with a
right middle lobe pneumonia.
2. Chest CT evidence of new lung nodule in the right upper
lobe; to be followed up by chest CT in two to three months.
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 500 mg p.o. q.d. (times 10 more days).
2. Prednisone 50 mg p.o. q.d. (with slow taper).
3. Albuterol and Atrovent nebulizers t.i.d.
4. Albuterol and Atrovent meter-dosed inhaler p.r.n.
5. Flovent meter-dosed inhaler 2 puffs b.i.d.
6. Norvasc 7.5 mg p.o. q.d.
7. Zoloft 250 mg p.o. q.d.
8. Calcium carbonate 500 mg p.o. t.i.d.
9. Vitamin D 800 IU p.o. q.d.
10. Home oxygen 2 liters.
11. Dyazide (37.5/25) 1 tablet p.o. q.d.
CONDITION AT DISCHARGE: The patient's condition was stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE FOLLOWUP: The patient was to follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 6366**], M.D. [**MD Number(1) 6367**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2160-4-1**] 11:08
T: [**2160-4-1**] 13:47
JOB#: [**Job Number 6368**]
ICD9 Codes: 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7202
} | Medical Text: Admission Date: [**2157-8-4**] Discharge Date: [**2157-8-17**]
Date of Birth: [**2082-6-28**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
Abdominal pain, bilateral ovarian masses on CT
Major Surgical or Invasive Procedure:
Total abdominal hysterecomty, bilateral salpingoophorectomy,
pelvic side wall tumor resection, omentectomy, cystoscopy,
proctoscopy
History of Present Illness:
Ms. [**Known lastname 1005**] presented to GYN Oncology secondary to a possible
diagnosis of advanced ovarian cancer. Ms. [**Known lastname 1005**] is a
75-year-old gravida 2, para 2 who has had, over the course of
the four to six months prior to presentation, nonspecific lower
abdominal discomfort.She felt that her problems were related to
irritable bowel syndrome. She reported bloating and a nagging
abdominal discomfort that worsened and extended up to her
xiphoid. While traveling in the [**Country 31115**], she had a
worsening discomfort and was seen by a physician, [**Name10 (NameIs) 1023**] ordered
imaging studies. An ultrasound revealed ascites and a CT scan
of the torso revealed ascites, bilateral cystic ovarian masses
and an omental cake. Also, noted was a left lower lobe nodule,
which had features consistent with inflammatory change. Imaging
studies were all consistent with advanced ovarian cancer. Ms.
[**Known lastname 1005**] has changed her diet so that she is able to tolerate
liquids and smaller portions of food. She denied constipation.
Decision was made to manage surgically.
Past Medical History:
PMHx:
Hypertension and diabetes, both of which are very well
controlled. Barrett's esophagitis. She denies any history of
cardiac disease and has recently had a stress test and EKG, both
of which normal. She denies any history of asthma or
thromboembolic disorder.
PSHx:
She underwent an appendectomy and cholecystectomy in [**2112**]. She
has had bilateral knee replacements and a left shoulder rotator
cuff surgery.
OB/GYN HISTORY:
She is gravida 2, para 2 woman. She denies any history of
pelvic infections or abnormal Pap smears and her last was
obtained two years ago.
Social History:
She is widowed. She is accompanied by her daughter. She lives
in [**State 760**] most of the year. She denies tobacco, drug or
alcohol use.
Family History:
Aunt with a history of ovarian cancer and mother with kidney
cancer. Three sisters with atrial fibrillation.
Physical Exam:
Physical Exam on Discharge:
VSS
Gen: NAD, Comfortable
CV: Regular rate rhythm
Pulm: Lungs clear to auscultation bilaterally
Abd: Soft, nondistended, nontender, +BS, incision clean dry
intact
Ext: Warm well perfused, nontender to palpation.
Pertinent Results:
[**2157-8-4**] 11:15AM BLOOD WBC-7.0 RBC-4.88 Hgb-10.2* Hct-33.8*
MCV-69* MCH-20.8* MCHC-30.0* RDW-16.5* Plt Ct-297
[**2157-8-5**] 09:57PM BLOOD WBC-15.0*# RBC-6.03* Hgb-12.5 Hct-42.5
MCV-71* MCH-20.8* MCHC-29.4* RDW-17.0* Plt Ct-336
[**2157-8-7**] 02:45PM BLOOD WBC-11.7* RBC-4.89 Hgb-10.2* Hct-33.4*
MCV-68* MCH-20.8* MCHC-30.5* RDW-17.6* Plt Ct-355
[**2157-8-7**] 10:05AM BLOOD Glucose-130* UreaN-18 Creat-0.8 Na-139
K-4.0 Cl-100 HCO3-28 AnGap-15
Brief Hospital Course:
Ms [**Known lastname 1005**] was admitted on [**2157-8-4**] with pelvic mass and likely
advanced ovarian cancer and on HD2 underwent diagnostic
laparoscopy, exploratory laparotomy, lysis of adhesions, total
abdominal hysterectomy, bilateral salpingo-oophorectomy, radical
resection of abdominopelvic tumor, omentectomy, and cystoscopy.
[**Hospital **] hospital course was complicated by atrial fibrillation
with rapid ventricular response, episode of hypoxia,ICU
transfer, post-operative ileus and UTI.
*) Atrial fibrillation with rapid ventricular response: This was
first noted on day of admission, [**2157-8-4**], when patient was in the
OR prior to surgery, case was cancelled and patient was
transferred to the floor, evaluated by cardiology and started on
PO metoprolol dosing, at which point she spontaneously converted
to normal sinus rhythm. Patient underwent a TTE the following
day which showed normal global and regional biventricular
systolic function with mild mitral regurgitation with good rate
control, and cardiology reported no contraindications to
surgery. Post operatively, atrial fibrillation with RVR
recurred on [**2157-8-7**], requiring diltiazem 45 mg IV and metoprolol
15 mg IV dosing, as well as diltiazem PO 30 mg PO QID, on top of
metoprolol dosing already being given. Patient was transferred
to the [**Hospital Unit Name 153**] due to need for diltiazem gtt. Cardiology continued
to follow and recommended no cardioversion as patient was
asymptomatic. The diltiazem drip was stopped and Ms [**Known lastname 1005**]
continued to be tachycardic and was unable to be controlled with
verapimil drip. Patient was started on metoprolol and digoxin IV
with good control. She was transferred back to the floor. After
over 24 hours in sinus rhythm patient converted back to afib
with RVR however again was asymptomatic and patient started back
on PO Metoprolol 100mg TID and spontaneously converted back to
sinus rhythm after 8 hours. Patient had two more episodes of
afib with RVR during hospital stay, patient was asymptomatic
through all episodes of afib with RVR. Digoxin was stopped by
cardiology as was felt to have little effect. Patient started on
therapeutic dose of lovenox with plans to initiate bridge to
coumadin once on consistent diet. Cardiology continued to
follow patient during hospitalization and prior to discharge
recommended patient go home on Metoprolol XL and [**Last Name (un) 28031**] with
follow up appointment with Dr [**Last Name (STitle) 171**] on [**2157-8-29**].
*) Ileus: Patient developed nausea and vomiting and KUB
consistent with ileus on post operative day 3 while in ICU. An
NGT was placed and put on suction and pt decompressed. Patient's
symptoms improved with NGT. This was continued on transfer to
the floor. Patient had return of bowel function after another
24 hours with NGT and at that time NGT was pulled and patient
tolerated sips. Patient tolerated slow advance of diet and was
tolerating a regular diet on discharge.
*) Urinary Tract Infection: On post operative day 9 patient
reported urinary frequency and urgency as well as multiple
episodes of incontinence. UA was positive and patient was
started on 7 day course of Cipro with some improvement in
symptoms. On day of discharge urine cultures came back with e.
coli resistant to cipro and patient switched to Macrobid 7 day
course.
*) Hypoxia: Patient developed hypoxia with oxygen saturations at
88% RA on post-op day 2. A CTA was done to rule out PE and CXR
showed no evidence of pneumonia. This was likely atelectasis.
Continued incentive spirometry. Resolved spontaneously.
*) Low urine output: Pt developed low urine output while in ICU.
Patient slowly responded to multiple IV boluses. Urine lytes
were sent and corresponded to a pre-renal source. Resolved on
transfer back to floor with consistent IV hydration.
*) Hypertension: Continued home amlodipine initially. This was
stopped as BP was controlled with metoprolol after development
of Afib with RVR. Amlodipine restarted once transferred back to
the floor in sinus rhythm. Switched back to home dose of [**Last Name (un) 28031**]
on discharge.
*) Ovarian cancer: Stage IIIC optimally cytoreduced serous
adenocarcinoma. Port placed for chemo prior to discharge. Plan
to follow up at [**Hospital1 107**] [**Doctor Last Name **]-Kettering for chemotherapy.
*) Diabetes mellitus: Patient on Januvia and metformin at home.
These were held while admitted and patient was placed on an
insulin sliding scale. Started back on home dose of metformin
once ileus resolved and tolerating PO. Instructed to resume
home medications on discharge.
Patient discharged in stable condition on [**2157-8-17**] with follow up
appointments with Dr [**Last Name (STitle) 171**] in cardiology and Dr [**Last Name (STitle) 2028**] with
plans to receive chemotherapy at [**Hospital1 107**] [**Doctor Last Name **]-Kettering.
Medications on Admission:
AMLODIPINE-OLMESARTAN Dosage uncertain
ATORVASTATIN Dosage uncertain
METOPROLOL SUCCINATE Dosage uncertain
PIOGLITAZONE Dosage uncertain
SITAGLIPTIN-METFORMIN Dosage uncertain
Discharge Medications:
1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 * Refills:*0*
2. docusate sodium 100 mg capsule Sig: One (1) capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 capsule(s)* Refills:*1*
3. alprazolam 0.25 mg tablet Sig: Two (2) tablet PO QHS (once a
day (at bedtime)).
4. acetaminophen 500 mg tablet Sig: One (1) tablet PO Q6H (every
6 hours) as needed for pain: Do not exceed 4000mg acetaminophen
in 24 hrs.
Disp:*50 tablet(s)* Refills:*0*
5. oxycodone 5 mg tablet Sig: One (1) tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 tablet(s)* Refills:*0*
6. Macrobid 100 mg capsule Sig: One (1) capsule PO twice a day.
Disp:*14 capsule(s)* Refills:*0*
7. metoprolol succinate 50 mg tablet extended release 24 hr Sig:
Three (3) tablet extended release 24 hr PO every twelve (12)
hours.
Disp:*180 tablet extended release 24 hr(s)* Refills:*2*
8. [**Last Name (un) 28031**] 10-20 mg tablet Sig: One (1) tablet PO once a day.
Disp:*30 tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Ovarian Mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 1005**],
You were admitted to the gynecologic oncology service after
undergoing the procedures listed below. You have recovered well
after your operation, and the team feels that you are safe to be
discharged home. Please follow these instructions:
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
Medication:
* Please resume taking your home medications for diabetes.
* Please stop taking prior blood pressure medications.
* Please take new medications for blood pressure/atrial
fibrillation until follow up with cardiology in 1 week at which
point they may be changed or adjusted.
* New medications: [**Last Name (un) 28031**] [**11-19**] Qday, Metoprolol XL 150mg taken
twice daily.
* Please take Macrobid (Nitrofurantoin) for 7 days twice a day
for urinary tract infection.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call [**Telephone/Fax (1) 2806**].
Followup Instructions:
You have an appointment with DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**9-8**] at 10:15am
Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2157-9-8**] 10:15
You have an appointment with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**8-29**] at
2:20pm. Please call [**Telephone/Fax (1) 1989**] if you need to change time or
reschedule. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2157-8-29**] 2:20
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
ICD9 Codes: 5990, 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7203
} | Medical Text: Admission Date: [**2169-11-11**] Discharge Date: [**2169-11-17**]
Date of Birth: [**2101-10-11**] Sex: F
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: This is a 68 year old female,
status post renal transplant in [**2169-7-11**], now complaining of
six hours of abdominal pain with nausea and vomiting and
diarrhea. The patient feels gas pain. No fever, no chest
pain, no shortness of breath, no urinary symptoms.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Gaucher disease.
3. Hypercholesterolemia.
4. Depression.
5. Glomerulonephritis.
PAST SURGICAL HISTORY:
1. Status post living related renal transplant [**2169-7-11**].
2. Status post right hip replacement due to avascular
necrosis.
3. Status post hysterectomy.
MEDICATIONS ON ADMISSION:
1. Coumadin 4 mg p.o. once daily.
2. Lopressor 50 mg p.o. twice a day.
3. Lipitor 20 mg p.o. once daily.
4. Zoloft 200 mg p.o. once daily.
5. CellCept [**Pager number **] mg p.o. three times a day.
6. Prednisone 7.5 mg p.o. once daily.
7. Prograf 3 mg p.o. twice a day.
8. Aspirin 81 mg p.o. once daily.
9. Protonix 40 mg p.o. once daily.
10. Folate 2 grams p.o. once daily.
11. TUMS 500 mg p.o. four times a day.
12. Trazodone 50 mg p.o. once daily.
13. [**Last Name (un) **] 20 mg p.o. once daily.
14. Ambien.
15. Colace.
ALLERGIES: Bactrim.
PHYSICAL EXAMINATION: Vital signs revealed temperature 99.0,
heart rate 86, blood pressure 135/58, respiratory rate 20.
The patient is uncomfortable. There is a bruit on the right
neck. The lungs are clear to auscultation bilaterally. The
abdomen is flat, soft, with no peritoneal signs. Rectal
positive guaiac. Extremities are warm.
LABORATORY DATA: On admission, white blood cell count was
7.6, with 20% bands and 65% polymorphonuclears, hematocrit
38.5, platelet count 257,000. Sodium 141, potassium 3.0,
chloride 101, bicarbonate 20, blood urea nitrogen 33,
creatinine 1.0, glucose 165, AST 38, ALT 20, alkaline
phosphatase 68, total bilirubin 0.8, lipase 16. Urinalysis
negative.
Abdominal x-ray shows no gas in the small bowel or colon.
Chest x-ray shows no signs of congestive heart failure or
pneumonia.
HOSPITAL COURSE: The patient was admitted the same day to
the Transplant Surgery service under Dr. [**Last Name (STitle) **]. A CT scan
of the abdomen and pelvis was ordered to rule out ischemic
bowel due to the patient's subjective complaints being most
severe than the actual objective signs on physical
examination. The CT of the abdomen and pelvis showed fluid
filled loops of bowel with no distention and no wall
thickening. Due to the patient's toxic looking appearance
and fever, the patient was taken immediately to the operating
room for an urgent laparotomy. Preoperatively, the patient
remained NPO, was started on intravenous fluids, and Zosyn
2.25 grams intravenously q8hours. The patient was also
transfused four units of fresh frozen plasma for an INR of
2.5. On hospital day one, the patient was taken to the
operating room for exploratory laparotomy and the findings
none (negative exploratory laparotomy). Postoperatively, the
patient was taken to the recovery room and from there she was
transferred to the floor where she continued to be NPO with
intravenous fluids on her home medications and
immunosuppression (Mycophenolate and Prednisone). The
patient was also started on Ancef perioperatively. Stool
samples were sent for culture, ova and parasites. The
patient's pain was well controlled with intravenous PCA
Dilaudid. On postoperative day one, the patient developed
fever of 102.3 and cultures were sent (urine and blood).
Renal transplant service was consulted to evaluate the
patient and provide recommendations due to the patient's
history of renal transplant. On postoperative day one, the
patient was also started on Tacrolimus, daily adjusted
according to daily levels. On hospital day one, of note, the
patient also underwent a renal ultrasound to evaluate her
kidney function and to rule out any perinephric fluid
collections; ultrasound was negative for fluid collections,
but there was good flow through the vasculature. On
postoperative day two, physical therapy was consulted to help
the patient with ambulation and regain preoperative
functional mobility. On postoperative day three, the patient
was able to tolerate p.o., was ambulatory, Foley
discontinued, and she was started on p.o. pain medications.
Urine culture and blood cultures returned negative, as well
as all the fecal studies were negative. However, the
patient's stool sample sent for Clostridium difficile colitis
returned a few days later positive. The patient was
discharged on postoperative day six to home.
FINAL DIAGNOSES:
1. Status post exploratory laparotomy.
2. Clostridium difficile colitis.
RECOMMENDED FOLLOW-UP: Dr. [**Last Name (STitle) **] on [**2169-11-30**], at the clinic
and with Dr. [**Last Name (STitle) **] [**2169-12-3**], same location. With Dr.
[**Last Name (STitle) 1366**] [**2169-12-14**], same location.
CONDITION ON DISCHARGE: Good and stable.
DISCHARGE STATUS: The patient was discharged to home.
MEDICATIONS ON DISCHARGE:
1. Flagyl 500 mg p.o. three times a day times fourteen days.
2. Metoprolol 50 mg p.o. twice a day.
3. Atorvastatin 20 mg p.o. once daily.
4. Sertraline 200 mg p.o. once daily.
5. Prednisone 7.5 mg p.o. once daily.
6. Folic Acid 1 mg p.o. once daily.
7. Calcium Carbonate 500 mg p.o. three times a day.
8. Docusate 100 mg p.o. twice a day.
9. Famotidine 20 mg p.o. twice a day.
10. Coumadin 2 mg p.o. q.h.s.
11. Mycophenolate Mofetil 250 mg p.o. twice a day.
12. Tacrolimus 1 mg p.o. twice a day.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2170-3-20**] 18:48
T: [**2170-3-20**] 18:54
JOB#: [**Job Number 96572**]
ICD9 Codes: 2762, 2765, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7204
} | Medical Text: Admission Date: [**2126-12-17**] Discharge Date: [**2126-12-27**]
Date of Birth: [**2065-11-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / Celery / apple / bees
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
shortness of breath, altered mental status
Major Surgical or Invasive Procedure:
Tracheostomy
Central Venous line
Endotracheal intubation
Arterial Line
History of Present Illness:
60yo woman w/ hx of COPD, PAH w/ cor pulmonale, right-sided CHF,
CKD who presents from rehab facility with several days of
fatigue and altered mental status. Over the past several months
she has undergone prolonged course with several hospitalizations
including a recent admission from [**Date range (1) 49798**] for shortness of
breath thought intially to be pneumonia but eventually
atrributed to COPD exacerbation as opposed to infection. Family
states she has never returned to baseline at rehab complaining
of increasing fatigue, continued shortness of breath, and now
altered mental status which was noted to be primarily increasing
somnolence. She otherwise has denied any fever, chills,
headache, cough, chest pain, abdominal pain, nausea or vomiting.
Of note she is supposed to be using bipap for severe OSA but has
poor compliance due to intolerance of the bipap.
.
In the ED, initial VS were: 97.7 92 97/72 28 95% neb. Physical
exam notable for tachypnea. She was given IV methylprednisone
125 mg, vancomycin, cefepime, azithromycin and nebs for COPD
exacerbation. 500 cc NS was given for tachycardia and low blood
pressure.
.
On arrival to the MICU, she was noted to be somewhat somnolent
but opened eyes to voice and followed basic commands. Her
respiratory effort was shallow with low tidal volumes and
generally low minute ventilation (range 4 to 6L/min) given her
severe hypercarbia. She subsequently was intubated.
.
Review of systems:
Unable to complete review due to patient being sedated and
intubated.
Past Medical History:
1. Morbid obesity (s/p gastric bypass)
2. Obstructive sleep apnea (noctural BiPAP 18/15, home oxygen
requirement of 3-4L via nasal cannula)
3. Obesity hypoventilation syndrome
4. Severe pulmonary artery hypertension (attributed to OSA)
5. Cor pulmonale (right heart failure attributed to severe
pulmonary hypertension)
6. Asthma
7. Osteoarthritis (bilateral knee involvement)
8. Diastolic heart failure (2D-Echo [**1-/2124**] showing LVEF 70-80%,
PAP 64 mmHg)
9. Chronic kidney disease (stage III-IV, baseline creatinine
1.8-2.2)
10. Rosacea
11. Hypertension
12. Iron deficiency anemia
11. s/p ventral hernia repair with mesh and component separation
([**5-/2119**])
12. s/p gastric bypass surgery ([**2113**])
13. s/p debridement of anterior abdominal wall and complex
repair ([**6-/2119**])
Social History:
Patient lives at home with disability services. She has 2 adult
children. She notes no toabcco use, rare alcohol use currently
but notes a former heavy alcohol history in the distant past.
She denies recreational substance use.
Family History:
Notable for diabetes mellitus in her mother and sister,
hypertension in siblings, mother and throughout the maternal
family as well as kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: P 100 BP 111/59 R 24 89% Bipap FiO2 60%
General: Alert but somnolent, follows commands
HEENT: MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
although heart sounds were muffled
Lungs: Dimished bilaterally w/ wheezing throughout all fields
Abdomen: Obese, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses throughout extremities,
trace edema
Neuro: Grossly intact
Pertinent Results:
ADMISSION LABS:
[**2126-12-17**] 10:10PM BLOOD WBC-9.8 RBC-3.33* Hgb-9.3* Hct-32.4*
MCV-97 MCH-27.8 MCHC-28.6* RDW-16.7* Plt Ct-202
[**2126-12-17**] 10:10PM BLOOD Neuts-88.8* Lymphs-7.3* Monos-1.9*
Eos-1.6 Baso-0.4
[**2126-12-18**] 04:55AM BLOOD PT-11.1 PTT-39.0* INR(PT)-1.0
[**2126-12-17**] 10:10PM BLOOD Glucose-102* UreaN-69* Creat-2.6* Na-141
K-4.5 Cl-86* HCO3-46* AnGap-14
[**2126-12-18**] 04:55AM BLOOD ALT-20 AST-27 LD(LDH)-389* CK(CPK)-36
AlkPhos-66 TotBili-0.4
[**2126-12-17**] 10:10PM BLOOD proBNP-4737*
[**2126-12-17**] 10:10PM BLOOD cTropnT-0.03*
[**2126-12-18**] 04:55AM BLOOD CK-MB-3 cTropnT-0.02*
[**2126-12-18**] 04:55AM BLOOD Albumin-3.4* Calcium-8.7 Phos-4.6* Mg-2.0
[**2126-12-17**] 11:07PM BLOOD pO2-119* pCO2-131* pH-7.20* calTCO2-54*
Base XS-17
[**2126-12-18**] 01:03AM BLOOD Type-ART Temp-37.6 PEEP-8 FiO2-40 pO2-54*
pCO2-140* pH-7.17* calTCO2-54* Base XS-15
[**2126-12-18**] 01:03AM BLOOD freeCa-1.15
[**2126-12-17**] 10:10PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2126-12-17**] 10:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2126-12-18**] 03:49PM URINE Hours-RANDOM UreaN-346 Creat-81 Na-35
K-53 Cl-37
[**2126-12-19**] 11:24AM URINE Hours-RANDOM UreaN-232 Creat-230 Na-LESS
THAN K-50 Cl-LESS THAN
.
MICRO:
[**12-17**] BLOOD CULTURE NO GROWTH TO DATE
[**12-17**] URINE CULTURE NEGATIVE
[**12-19**] BAL CULTURE PENDING
[**12-19**] RESPIRATORY VIRAL CULTURE PENDING
[**12-19**] URINE CULTURE PENDING
Brief Hospital Course:
Ms. [**Known lastname **] is a 60 year old woman with history of chronic
obstructive pulmonary disorder (COPD), pulmonary artery
hypertension (PAH) with cor pulmonale, (chronic kidney disease
(CKD) who presented from rehab facility with several days of
fatigue and shortness of breath.
# Hypercarbic respiratory failure: Required intubation in the ED
prior to transfer to the MICU. Likely a COPD exacerbation (with
pCO2 140 on admission) and recent non-compliance of her BiPAP at
rehab (although previously very compliant even during the day).
Also, she has obstructive sleep apnea which contributes to her
PAH and cor pulmonale. Lastly, a superimposed pneumonia was
considered [**1-30**] a small amount of opacity on initial CXR and one
fever. She was started on vancomycin/cefepime/levofloxacin
initially for empiric coverage of PNA, but suspicion was low
(she never had a WBC count or recurrence of fever) and
vanc/cefepime were stopped after a few days and she was
continued only on levofloxacin for 7 days for abx coverage in
the setting of a COPD exacerbation. She did have a bronch after
a few days on the ventilator which demonstrated severe airway
edema and almost complete airway collapse on exhalation. While
the most likely etiology of her airway edema and collapse was
from pulmonary edema and pulmonary parenchymal volume overload,
given she had signs of decreased left-sided cardiac output,
aggressive diuresis was not pursued. She was treated with
systemic and inhaled corticosteroids to address a possible
component of inflammation contributing to her airway edema, as
well a scheduled nebulizers for bronchodilation. Due to
persistent hypercarbic respiratory failure the patient underwent
a tracheostomy for long term assisted ventilation and CPAP.
Patient tolerated the procedure well. Her cultures remained
negative. Prior to discharge her vent settings were weaned to
pressure support 10, PEEP 5, FiO2 40% which she was tolerating
well.
# Abdominal pain. Patient started complaining of diffuse, crampy
abdominal pain several days prior to discharge. In reviewing
recent OMR notes, she has been extensively evaluated by her PCP
and GI over the month prior to admission for the same pain. KUB
showed diffuse gas distension throughout her bowels but no clear
obstructive process. Her tube feeds continued to be well
tolerated despite her pain, with minimal nausea and no vomiting,
and she continued to have multiple daily stools; all of which
decrease the liklihood of bowel obstruction. We restarted her on
Donnatal, a home medication that we were holding that GI had
suggested prior to admission to treat her symptoms. She was
being discharged on the day of restarting this medication so
efficacy of intervention will need to be assessed by ECF. She
was also started on simethicone and given zofran prn for mild
nausea that she experienced several times during her hospital
course.
# Acute kidney injury ([**Last Name (un) **]): Baseline creatinine 1.8, elevated
to 2.6 on admission. Fe Urea 15%, Fena 0.9%, both suggest
prerenal in etiology. She was also oliguric. Renal was
consulted and agreed with suspicion for pre-renal etiology. Her
urine output improved significantly after fluids and her BUN and
Cr had normalized at the time of discharge without further
intervention.
# Cor pulmonale/right sided heart failure: TTE in [**2123**] showed
estimated right atrial pressure of [**10-17**] mmHg; LV systolic
function was hyperdynamic (EF 70-80%), and the RV free wall was
hypertrophied with marked dilation and with depressed free wall
contractility consistent with severe right-sided dysfunction
with cor pulmonale resulting from severe pulmonary HTN and OSA.
She was intitially diuresed in the MICU, but then was given back
volume for oliguria and [**Last Name (un) **] as discussed above.
# Pumonary artery hypertension: Likely type 3 due to combination
of chronic hypoxemia from obstructive sleep apnea and COPD.
Discontinued sildenafil without any significant changes.
# Obstructive sleep apnea: Now with tracheostomy.
#Gout: initially lowered dose of allopurinol to 100mg po every
other day due to [**Last Name (un) **], but once renal function normalized she was
placed back on her home dose of allopurinol 300mg daily with
incident.
# Iron deficiency anemia: Continued iron supplementation when
taking PO.
Pt is being discharged to vent rehab.
Transitional issues:
1. Abdominal pain. Evaluated by PCP and GI for similar pain
prior to admission during [**2126-11-28**]. We will email her
gastroenterologist with whom she should followup if her pain
persists.
2. Physical therapy. She refused to work with PT on several
occasions during her ICU stay. We expressed the importance of PT
with both the patient and her family.
3. Acute kidney injury. Her creatinine trended upward on
admission, but then stablized and decreased to baseline levels
on discharge. Renal was consulted while inpatient and was in
agreement with the MICU team that etiology was likely pre-renal.
4. Family and patient education. Ms. [**Known lastname **] multiple, severe
cardiopulmonary comorbidities do not imply a seemless transition
from the ICU to rehab to home. She will likely suffer multiple
complications and set-backs along the way given her baseline
poor cardiopulmonary function. We endeavored to educate the
family about these realities as well as educate them about her
relatively limited anticipated life expectancy now that she is
(apparently) chronically vent-dependent and now (likely)
chronically critically ill. Her sister [**Name (NI) 4944**] seemed to
understand this, while other family members (particularly the
patient's mother and daughter) did not seem to comprehend the
severity of Ms. [**Known lastname **] circumstances and the high likelihood of
future adverse outcomes, morbidity, and - potentially -
mortality. Further frank discussions with the family and the
patient will be necessary to ensure that all parties are aware
of the possibilities associated with Ms. [**Known lastname **] clinical
circumstances.
Medications on Admission:
- sildenafil 20mg TID
- aspirin 81mg daily
- prednisone 10mg daily (until
- fluticasone 110mcg inhaled [**Hospital1 **]
- home oxygen 3-4 L/min N/C
- albuterol 90mcg HFA Q6hrs prn wheezing/SOB
- albuterol 2.5mg nebulized Q4hrs prn SOB
- allopurinol 300mg daily
- metolazone 5mg [**Hospital1 **]
- ISS QID
- acetaminophen 500mg Q6hrs prn pain
- ferrous sulfate 300mg daily
- metronidazole 1% gel topically daily
- docusate 100mg [**Hospital1 **]
- bisacodyl 10mg daily
- PEG 17g powder daily
- heparin SQ TID
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours).
Disp:*1 * Refills:*2*
2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every six (6) hours.
Disp:*1 * Refills:*2*
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
6. metolazone 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
9. Insulin
Please administer insulin as according to attached slinding
scale worksheet.
10. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for indigestion.
12. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg Tablet
Sig: One (1) Tablet PO TID (3 times a day).
13. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Five
(5) ml PO DAILY (Daily).
14. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Hypercarbic respiratory failure
Acute Kidney Injury
Cor pulmonale
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:
Ms. [**Known lastname **],
We appreciated the opportunity to partipate in your care at
[**Hospital1 18**]. As you transition to your extended care facility we
wanted to highlight several ongoing issues with your care:
1. Physical therapy: please work each day with the physical
therapy team. This will increase your strength and improve your
lung function.
2. Abdominal pain: your pain is similar to the chronic pain you
experienced prior to admission. We will contact your GI doctor
to discuss your hospitalization, but you should also schedule a
followup appointment with your GI doctor within the next several
weeks to further evaluate and manage your chronic abdominal
pain.
3. Obstructive sleep apnea: while you are on the vent you will
receive respiratory support while you are both awake and asleep.
When you are weaned from the vent you will need to continue
using your bipap machine while you are asleep. This is very
important as sleep apnea contributes to worsening of your
pulmonary function and heart failure.
4. Rehab course: we believe you are now ready to continue
rehabilitation from your illness at an extended care facility.
Please keep in mind that you were very sick while in the
hospital, and recovery may be prolonged despite not needing to
remain in the hospital at this time. To help guide what types of
things should prompt calling your primary care physician or
returning to the hospital, please refer to the information
listed below.
**You should call your primary care physician or return to the
ED if you experience: persistent high fever, increasing oxygen
requirements, severe nausea/vomiting, bloody diarrhea, decreased
urine output, bloody urine, confusion, loss of consciousness,
slurred speech, chest pain, or any other concerns.
Followup Instructions:
1. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3029**] at
the following appointment that has been scheduled for you:
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time: [**2127-1-14**] 10:20
2. Please follow up with the acute care surgery clinic in 2
weeks. Your appointment is [**2127-1-9**] at 2pm in the [**Hospital Ward Name **]
Office building at [**Hospital1 18**]. You can call [**Telephone/Fax (1) 600**] for any
questions.
Completed by:[**2126-12-27**]
ICD9 Codes: 5849, 2760, 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7205
} | Medical Text: Admission Date: [**2194-10-16**] Discharge Date: [**2194-11-13**]
Date of Birth: [**2119-1-20**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Right adrenal tumor
Major Surgical or Invasive Procedure:
Exploratory laparotomy, right adrenalectomy and right segment 6
resection
History of Present Illness:
The patient is a 75 y/o female who presents with a right adrenal
mass. The patient has been progressively feeling unwell since
[**Month (only) 116**]. After sustaining a fall, the patient started to have
worsening weakness and fatigue that she needed to start using a
walker to ambulate and had difficulty getting out of chairs.
She also reports increased facial hair in the past six months.
On imaging, the patient had a 10 x 7 cm right adrenal mass.
Further workup revealed that the patient had hypercortisolism.
On review of systems, the patient complains of pain and
increased difficulty in performing her activities of daily
living. The patient denies weight loss or weight gain.
Although, her obesity has become more central in nature and she
has had loss of hair on her scalp, while having increased facial
hair. She also reports increased bruising along her
extremities, some shortness of breath on exertion, thinning of
her skin, and decreased energy. The patient denies fever,
chills, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, constipation, or dysuria.
Past Medical History:
colon Ca s/p partial colectomy and adjuvant chemo - 8y ago
HTN
CCY [**2184**]
adrenal mass
mitral valve prolapse
Social History:
Lives alone in NJ, here living with daughter while undergoes
further evaluation and mgmt. Denies tobacco (<100 lifetime
cigarettes), social EtOH, no IVDU. Has 3 daughters and 2 sons
Family History:
DM in both brothers and both parents; F - prostate and liver Ca;
uncle - gastric Ca
Physical Exam:
T 96.3 P 66 BP 176/90 R 20 SaO2 95% RA
Gen - no acute distress, well-appearing, upper lip hirsutism
Heent - facial hirsutism, no scleral icterus, moist mucous
membranes
Lungs - clear to auscultation bilaterally
heart - regular rate and rhythm
abd - obese, soft, nontender, nondistended
Pertinent Results:
[**2194-10-16**] 08:08PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2194-10-16**] 08:08PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2194-10-16**] 08:08PM URINE RBC-0-2 WBC-1 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2194-10-16**] 08:08PM URINE AMORPH-FEW
[**2194-10-16**] 05:30PM GLUCOSE-124* UREA N-19 CREAT-0.4 SODIUM-142
POTASSIUM-2.9* CHLORIDE-98 TOTAL CO2-33* ANION GAP-14
[**2194-10-16**] 05:30PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-1.8
[**2194-10-16**] 05:30PM WBC-7.3 RBC-3.63* HGB-11.8* HCT-33.6* MCV-93
MCH-32.5* MCHC-35.0 RDW-16.4*
[**2194-10-16**] 05:30PM PLT COUNT-231
[**2194-10-16**] 05:30PM PT-10.8 PTT-19.1* INR(PT)-0.9
Brief Hospital Course:
She was taken to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for exploratory
laparotomy, right
adrenalectomy and right hepatic segment 6 resection. Please see
operative report for details. EBL was 3 liters. An introp U/S
revealed- liver echogenicity appeared unremarkable. Within the
posterior segment of the right lobe of the liver, there was s a
5.5 x 3.3 cm well- circumscribed, slightly hypoechoic lesion
that contained a degree of increased through transmission
suggesting at least some cystic components. The relationship of
this to the surrounding vasculature, particularly the posterior
branch of the right portal vein was demonstrated. No other
additional lesions were found.Two [**Doctor Last Name **] drains were removed by
postop day 5. Pathology returned positive for 1. Right adrenal
mass, excision (A-F):
Malignant neoplasm most consistent with adrenal cortical
carcinoma, see note.
2. Liver segment six, resection (G-O):
Malignant neoplasm most consistent with adrenal cortical
carcinoma, see note. Endocrinology was to follow and the plan
was to use ________ as an outpatient.
Postop she was in the SICU for fluid management and ATN.
Baseline creatinine was 0.6. Nephrology was consulted.
Creatinine trended down to 1.1 by POD 8. Renal u/s was normal.
Stress dose steroids were given preop and postop per
Endocrinology. Endocrinology preferred a slow 6 month steroid
taper. Dr. [**First Name (STitle) **] tapered prednisone after one week as she
developed an incision infection necessitating opening the
incision and using a wound vac. A CT of the abd was done on
which demonstrated Two ill-defined fluid collections
post-surgical site that were extrahepatic and could represent
postoperative seromas, bilomas, or less likely abscesses.
Multiple scattered foci of air, likely postoperative. 2.
Increased stranding about the head of the pancreas, possibly
pancreatitis. 3. Bibasilar atelectasis and small right pleural
effusion. Amylase and lipase were normal. LFTs preop were ast
1298, alt 1308, alk phos 64 and tbili 0.7. These trended down
postop with the exception of the alk phos which increased to as
high as 806 on HD 20. Subsequently, this has decreased some to
504 as of [**11-13**].
She required PICC line placement for IV antibiotics and TPN as
her kcals were insufficient. Her appetite was diminished. She
appeared apathetic on many days and expressed feelings of
sadness. Psychiatry saw her and agreed with the team that she
was experiencing intermittent delerium. There was concern that
she was experiencing the effects of less cortisol. Neurology
recommended a CT and EEG. A head CT was done for waxing/[**Doctor Last Name 688**]
mental status. This was negative for bleed/mass on [**10-29**]. An EEG
was performed which demonstrated mild encephalopathy. TSH was
3.4. Psychiatry did not recommend antidepressents or stimulants
at the time.
On CT a right pleural effusion was noted. She experienced desats
and sob. Pleuracentesis was performed on [**11-6**] (HD 20)with a
negative culture. A f/u cxr was improved and without
pneumothorax.
She developed a Klebsiella uti which was treated with Cipro and
Flagyl for the wound x 4 days. These antibiotics were switched
to Vanco and Meropenum when a wound culture identified strep
veridans, sparse yeast, Klebsiella which was pan sensitive and
staph coag positive resistent to levo/oxicillin/penicillin and
sensitive to vanco. Vanco levels were monitored. Creatinine
remained stable. She developed a 2nd UTI,yeast which was treated
with a GU Ampho bladder irrigant x3 days. This was due to finish
on [**11-13**] pm. Repeat u/a and cx were sent on [**11-13**].
A repeat abd CT revealed stable appearance of hepatic fluid
collections with some debris and air in the surgical bed.
Bibasilar atelectasis with stable right pleural effusion.
Stable appearance of right abdominal wall defect overlying
surgical site. Interval development of nonocclusive thrombus
within the intrahepatic inferior vena cava. She was started on
coumadin and IV heparin until she was therapeutic. INR Goal was
[**1-31**]. INR on [**11-13**] was 2.6
On [**11-12**] after taking off the vac and reviewing the CT, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**]
drain was inserted thru the wound into a peri-hepatic collection
and placed to bulb suction. Water soluble contrast was
administered at the bedside through this catheter. Contrast was
administered. Contrast was seen surrounding this wound and
draining along the right lateral aspect of the wound into
dressing, however, no definite communication into the abdominal
cavity noted. Midline chevron scar and multiple clips scattered
across the abdomen were seen. Remainder of abdomen was gasless.
Small amount of oral contrast seen in the rectum. She then
underwent successful drainage catheter placement in collection
in the subhepatic and hepatic areas on [**2194-11-12**].
The plan is for her to go to [**Hospital 100**] Rehab on TPN via a R picc
with a RUQ incision wound vac. She has 2 hepatic drains to
gravity drainage and meropenum/vanco will continue until next
week. She will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**11-17**] and
with endocrinology as an outpatient.
Please schedule GYN follow up of postmenopausal bleeding noted
on POD #5.Pelvic U/S (prelim report) - Study v. limited as
patient was not able to achieve proper positioning; uterus 8.0 x
4.4 x 4.5 cm; endometrium is not well visualized; ovaries not
visualized. She experienced minimal spotting while hospitalized.
Medications on Admission:
hydralazine 25q8, HCTZ 25, KCl 40"
Discharge Medications:
1. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): hold for sbp <140.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 doses.
6. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow
sliding scale Subcutaneous every six (6) hours.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic DAILY
(Daily).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): peri area.
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
check INR twice weekly. goal [**1-31**].
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): check vanco level twice
weekly.
14. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: per picc line
protocol.
16. Outpatient Lab Work
Labs every Monday and Thursday for cbc, chem 10, ast, alt, alk
phos, t.bili, albumin and inr. Fax to [**Telephone/Fax (1) 697**] attn: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], RN
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
R adrenal mass
Hepatic collections
IVC thrombus
malnutrition
UTI,yeast
pleural effusion
ARF, resolved
post menopausal bleeding
Discharge Condition:
good
Discharge Instructions:
Call Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, incision red/bleeding or draining pus, wound drain
dislodges, foul smelling wound or increased wound drainage,
increased shortness of breath.
Followup Instructions:
weekProvider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2194-11-17**] 11:30
please schedule follow up with Dr [**Last Name (STitle) 574**] [**Telephone/Fax (1) 6468**]
(Endocrinology) in 1 week. Attempt Monday appointment
GYN follow up [**Telephone/Fax (1) 2664**] & schedule TVU/S as outpt prior to
apt.
Completed by:[**2194-11-13**]
ICD9 Codes: 4240, 5845, 5119, 5990, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7206
} | Medical Text: Admission Date: [**2166-7-15**] Discharge Date: [**2166-8-7**]
Date of Birth: [**2166-7-15**] Sex: M
Service: NEONATOLOGY
This is an interim summary covering period from [**2166-7-15**], to
[**2166-8-6**].
Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 9449**] delivered at 27 and 6/7 weeks, 1030
gram infant male, [**Known lastname **] to a 32 year old gravida I, para 0,
now II, mother whose prenatal screens were O negative,
antibody negative, RPR nonreactive, rubella immune. The baby
was [**Name2 (NI) **] at 1751 hours on [**2166-7-15**]. Pregnancy was an IVF and
was complicated by endometriosis. Mother developed preterm
labor and was placed on Magnesium Sulfate and was given
betamethasone on [**2166-7-14**], and again on [**2166-7-15**]. Mother's
is GBS unknown and has received intrapartum antibiotics. The
infant delivered by primary cesarean section under spinal
anesthesia and handed over to pediatrics and provided routine
care. Apgar scores were eight and eight at one and five
minutes, respectively.
PHYSICAL EXAMINATION: Weight 1030 grams which is between
25th and 50th percentile, length 35 centimeters which is at
25th percentile and head circumference 25.2 centimeter which
is between 25th and 50th percentile. Anterior fontanelle is
open, flat and soft. No murmur. Lungs clear with
diminished breath sounds bilaterally. Soft abdomen. 2+
pulses. Alert and active. Skin clear with small strawberry
hemangioma on the left chest. Impression of preterm 27 and
[**7-11**] week gestation infant male with respiratory distress
syndrome.
HOSPITAL COURSE:
1. Respiratory - Initially intubated and ventilated and was
given two doses of surfactant. Was extubated to CPAP on day
three and stayed on CPAP from day three until day eight. The
infant was taken off CPAP to nasal cannula at 300 cc and room
air on day nine but needed to go back on CPAP on day ten.
Stayed on CPAP from day ten to day thirteen and was
reintubated on day fourteen because of intercurrent sepsis
episode. Stay ventilated from day fourteen to day sixteen
and was again extubated to CPAP on day seventeen and has
stayed on CPAP since then. He is currently on 5cm of prong
CPAP. He is also on caffeine for apneic spells.
2. Cardiovascular - He initially had normal blood pressure
and no murmur. Noted to have a murmur on day three for which
was treated with indomethacin and subsequently there has been
no murmur heard.
3. FEN - Initially started on 160 cc/kg/day of D10 and was
started on BN on day one and was started on trophic feeds on
day two which were discontinued on day three because of the
patent ductus arteriosus. Was restarted on feeds on day eight
and gradually increased on feeds but by day thirteen he was
on 80 cc/kg breast milk 20. The feeds were discontinued at
this time because of the intercurrent infection. The feeds
were discontinued from day fourteen until day sixteen and
restarted on feeds on day sixteen and now is on full feeds
breast milk 20 at 150 cc/kg and the plan is to continue going
up on the caloric density. Last set of electrolytes were
sodium 145, potassium 5.1, chloride 113, and bicarbonate 21.
4. Gastrointestinal - No abdominal issues. The baby had
physiologic jaundice and was started on phototherapy from day
one and stayed under phototherapy and phototherapy was
discontinued on day ten. The last bilirubin was 2.1/0.3 on
the fifth day.
5. Hematology - Initial hematocrit at birth was 50.0%
Hematocrit on day fifteen was 30.5% for which was transfused
with packed cells 20 cc/kg on day sixteen. The last
hematocrit on day seventeen was 45.0%.
6. Infectious disease - The infant was given 48 hours rule
out with ampicillin and gentamicin which were discontinued
after 48 hours. He was given vancomycin and gentamicin for
seven days from day fourteen until day twenty-one for pale,
mottled and lethargy and also left shift on the complete
blood count. Blood culture did not grow anything. The
lumbar puncture was normal.
7. Neurology - The infant had head ultrasound on day seven
which was normal and the plan is to repeat head ultrasound on
day thirty.
8. Blood group is A negative and Coombs negative.
Diagnoses:
1. Prematurity
2. Respiratory distress syndrome.
3. Hyperbilirubinemia - resolved.
4. Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (STitle) 42761**]
MEDQUIST36
D: [**2166-8-7**] 17:47
T: [**2166-8-7**] 18:08
JOB#: [**Job Number 37943**]
ICD9 Codes: 769, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7207
} | Medical Text: Admission Date: [**2198-5-29**] Discharge Date: [**2198-6-20**]
Date of Birth: [**2164-1-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
motor cycle collision
Major Surgical or Invasive Procedure:
Intubated x 2
Percutaneous tracheostomy
Right chest tube
ORIF left humerus
History of Present Illness:
33 year old male s/p MCC presented to [**Location (un) 745**]-Welleslwy and was
transferred by med-flight to [**Hospital1 18**]. The patient was driving at a
high rate of speed, lost control of his motorcycle, was ejected,
and rolled 30 feet. He was intubated and a right chest tube was
placed at the OSH prior to transfer.
Past Medical History:
HIV+
Social History:
married, lives in [**Hospital1 **] NH, no tob, h/o IVDA on methadone
Family History:
NC
Physical Exam:
100.9F, 72, 120/p, 96% ambu bag
pupils [**3-15**] equal, sluggishly reactive. GCS 3T. midface
unstable ?fx
trachea midline, no JVD
blood in mouth, no ear or nasal discharge
CTAB, r chest tube in place, chest wall stable
abd soft, ND
rectal decr tone, no high riding prostate
ext palpable pulses, RUE appear broken
Neck/back: no step offs
Pertinent Results:
[**2198-5-29**] 06:35PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-POS
[**2198-5-29**] 10:23PM TYPE-ART PO2-164* PCO2-42 PH-7.39 TOTAL
CO2-26 BASE XS-0
[**2198-5-29**] 10:23PM LACTATE-3.1*
[**2198-5-29**] 08:24PM GLUCOSE-148* UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-26 ANION GAP-10
[**2198-5-29**] 08:24PM WBC-20.6* RBC-4.01* HGB-12.2* HCT-36.5*
MCV-91 MCH-30.4 MCHC-33.4 RDW-12.7
[**2198-5-29**] 08:24PM PT-14.3* PTT-23.6 INR(PT)-1.3
[**2198-5-29**] 08:24PM PLT SMR-NORMAL PLT COUNT-194
[**2198-5-29**] 06:10PM AMYLASE-50
[**2198-5-29**] 06:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
CXR/PXR: LLL atelectasis/consolidation, R tension PTX, multi R
rib fx
CT Head: mucosal sinus thickening
CT C spine: mult R rib fxs, B thoracic vertebral transverse
process fx, left C5-6 facet fx, R tension PTX, subQ emphysema
CT Chest/Abd/Pelvis: large R tension PTX, collapse of RUL/LUL,
atelectasis bilateral lower lobes, mult. R rib fractures,
transverse processes fx T2/T3, ? small subcapsular hematoma
CT face: neg
CXR [**6-11**]: worse LLL atelectasis
Brief Hospital Course:
TRAUMA:
The patient was admitted to the SICU on [**2198-5-29**]. He was
initially loaded on dilantin and given ativan prn for seizure
prophylaxis. His preliminary radiology studies revealed
(1)multiple right rib fractures, (2)bilateral thoracic vertebral
transverse process fractures T2/3, (3)left C5-6 facet fracture,
and (4)right tension pneumothorax. His C-spine was cleared by
MRI which showed no fracture or ligamentous injuries. After a
prolonged course of intubation (see below), swelling of the left
shoulder was noted and an xray on [**2198-5-29**] revealed a L humeral
head fracture. The patient was taken to the OR with the
orthopedic surgeons on [**2198-6-12**] for ORIF of the left humerus.
ID:
The patient became febrile on HD#3 and was started on levoquin
and vancomycin. His sputum culture from [**2198-5-31**] grew out MSSA
and the vanco was d/c'ed on [**2198-6-4**] while the levoquin was
continued for a total of 12 days. Despite a tooth extraction on
[**2198-6-2**], and multiple line changes the patient remained febrile.
A sputum culture from [**2198-6-12**] grew MRSA and the vancomycin was
re-started on [**2198-6-14**]. He was also started on bactim prophylaxis
because he had thrush and there was a concern for PCP pneumonia,
but [**Name Initial (PRE) **] CD4 count was 324 and the bactrim was d/c'ed. The
possibility of starting HAART was discussed with the ID team,
and they felt that the therapy should be started as an
outpatient. The patient was given dicscharge instructions to
follow up in the [**Hospital **] clinic.
RESPIRATORY:
The patient was brought from the OSH intubated, and self
extubated on HD# 6. He required re-intubation the following day
due to excessive secretions. He had a few episodes of hypoxia
and a worsening CXR. The decission was made to place a
percutaneous tracheostomy on HD # 9. After the trach was placed
he continued to have episodes of hypoxia and a CTA was performed
which was negative for PE.
The patient was discharged to a tracheostomy care rehab facility
and will finish his 10 day course of vancomycin and will take 3
more weeks of lovenox there.
Medications on Admission:
methadone 20"
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Elixir Sig: 0.5-1 Elixir PO Q4-6H
(every 4 to 6 hours) as needed.
2. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) as needed for Thrush.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
6. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours) for 3 weeks.
7. Methadone HCl 40 mg Tablet, Soluble Sig: One (1) Tablet,
Soluble PO TID (3 times a day).
8. Lorazepam 1 mg Tablet Sig: 2-4 Tablets PO Q2-4H (every 2 to 4
hours) as needed.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
12. Vancocin HCl 1,000 mg Recon Soln Sig: One (1) gram
Intravenous twice a day for 4 days: Last day [**2198-6-23**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
motor cycle collision
left humerus fracture
Discharge Condition:
stable
Discharge Instructions:
Take your medications as prescribed
Wear sling, Left shoulder pendulum swings exercises, left elbow
and wrist may move as comfortable.
Call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] to 101.4F, redness or pus around your
wound, change in color or sensation of your hand, trouble
breathing, chest pain, or any other concerns
Followup Instructions:
Please follow up in the infectious disease clinic as soon as
possible. Please call for an appointment, [**Telephone/Fax (1) 457**].
Please follow up in the trauma clinic in 2 weeks. Please call
for an appointment, [**Telephone/Fax (1) 2359**].
Please follow up with Dr [**Last Name (STitle) 2719**] (orthopedics) in [**3-15**] weeks.
Please call for an appointment, [**Telephone/Fax (1) 1228**].
ICD9 Codes: 5185, 5180, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7208
} | Medical Text: Admission Date: [**2171-4-4**] Discharge Date: [**2171-4-9**]
Date of Birth: [**2086-10-29**] Sex: F
Service: MEDICINE
Allergies:
Calcium Channel Blockers
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
hypoxia, lip and tongue swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84yo w/PMHx significant for HTN, CKD, CVA (hemiplegia in [**2155**]),
diastolic heart failure, HLD, PVD refered from [**Hospital 100**] rehab
after bolus fluids for [**Last Name (un) **] given poor PO intake and elevated Cr
on labs (felt to be pre-renal) and lasix held yesterday. However
after fluids bolus of 1L, pt became hypoxic to 85% w/crackles. K
elevated to 5.5 at [**Hospital **] rehab, got kayexalete. She was then
given 60mg lasix w/out much improvement despite diuresis at
which point transferred to [**Hospital1 18**]. Pt has had gradual decline in
MS (somnolent, but no confusion). Also developed large tongue
and protruding lower lip concerning for angioedema in setting of
chronic ACEI use. However, per report swelling developed slowly
since her recent ED admission on [**2171-4-1**] during which she was
started on augmentin. Other than this she has had no medications
but has been on enalapril for extended period (duration
unknown).
Of note, pt was hospitalized ~1 mo ago for PVD, failed LLL
angioplasty and stent intervention for ischemia which failed and
amputation under consideration for chronic non healing ulcer. Pt
has been on oxycodone for pain which has resulted in sedation
and consequently poor PO intake. Pt now has Cr of 3.3 (baseline
2.0) on labs. Also had bought of cellulitis for which she
presented to ED on [**4-1**] which was treated w/augmentin and
cellulitis improved.
In ED, arousable, follows comands, VS 98.4 74 139/59 20 97% 4L,
now on 2L 96%. Diffuse crackles throught; no lower extremity
edema,benign ab exam. Replaced foley with stable inguinal
hematoma (firm indurated, no erythematous or warm there for [**1-18**]
days). Elected not to image given ok VS and no abnormalities on
exam, hemotoma has been stable. On CXR pt had retro-cardiac
opacity, given recent outbreak of RSV at nursing home, pt was
given Vanc/Cipro (HCAP).
On the floor, appears in NAD however does have swelling of the
lower lip, [**Last Name (un) 2599**] and eyes. Has difficulty pronouncing words
given lip and tongue swelling. Denies pain but does say that her
foot bothers her. States that her breathing is fine, no chest
pain, no abdominal pain
Review of sytems:
(+) Per HPI. has leg pain from chronic PVD
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
- CORONARY ARTERY DISEASE
- HEART FAILURE, DIASTOLIC
- HYPERTENSION
- HYPERCHOLESTEROLEMIA
- DM-2
- RENAL INSUFFICIENCY [**6-/2153**]
- ?ATHEROEMBOLIC DISEASE
- BELL'S PALSY
- STROKE [**8-/2156**] CVA w/L hemiplegia, wheelchair bound; has
decreased speech at baseline but generally good comprehension
- GASTROINTESTINAL BLEEDING [**11/2155**]
- MULTINODULAR GOITER
- LOWER EXTREMITY EDEMA 99
- HEADACHES
- ANEMIA (IRON/B12)
- CHRONIC NONHEALING UCLER ON TOE--> Left lower extremity
ischemia with ulceration of left 3rd toe
- glaucoma
- cataracts
-dementia
-constipation
-diabetic retinopathy
- macular degeneration
- a fib
- peripheral edema
Social History:
coming from [**Hospital **] rehab. Russian speaking but some English.
Married, daughter and son.
Family History:
Non-contributory
Physical Exam:
Admission:
Vitals: 98.3,130/72, 69, 16, 93% 2L
General: Sleepy but rousable, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, lower lip,
eyes and tongue swollen
Neck: supple, JVP not elevated, no LAD
Lungs: fine crackles at bases but no [**Hospital **] wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool, no edema, chronic PVD non-healing ulcer on 3 toe
Pertinent Results:
[**2171-4-4**] 06:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2171-4-4**] 06:30PM URINE RBC-7* WBC->182* BACTERIA-FEW YEAST-NONE
EPI-55 TRANS EPI-2
CXR [**2171-4-5**]:
There is severe cardiomegaly associated also with bilateral
hilar enlargement, findings that might be consistent with
complex valvular problems as well as cardiomyopathy. There are
most likely present bilateral pleural effusions. There is no
evidence of pulmonary edema. Calcified right pleural plaques are
redemonstrated. There is no evidence of pneumothorax
TTE [**2171-4-5**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
are mildly thickened (?#). There is mild aortic valve stenosis
(valve area 1.2-1.9cm2). No aortic regurgitation is seen. There
is mild functional mitral stenosis (mean gradient 6 mmHg) due to
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild left ventricular
hypertrophy with preserved global biventricular systolic
function. Mild aortic stenosis and mitral regurgitation. Mild
functional mitral stenosis from annular calcification.
[**2171-4-4**] 03:59PM BLOOD WBC-5.2 RBC-3.20* Hgb-9.3* Hct-28.7*
MCV-90 MCH-29.1 MCHC-32.4 RDW-16.6* Plt Ct-185
[**2171-4-7**] 09:15AM BLOOD WBC-5.5 RBC-3.56* Hgb-10.1* Hct-31.0*
MCV-87 MCH-28.4 MCHC-32.6 RDW-16.1* Plt Ct-255
[**2171-4-4**] 03:59PM BLOOD Neuts-74.1* Lymphs-17.6* Monos-6.1
Eos-1.0 Baso-1.1
[**2171-4-5**] 04:22AM BLOOD PT-14.2* PTT-36.2* INR(PT)-1.2*
[**2171-4-4**] 03:59PM BLOOD Glucose-145* UreaN-99* Creat-3.2* Na-144
K-4.6 Cl-111* HCO3-20* AnGap-18
[**2171-4-9**] 09:14AM BLOOD Glucose-163* UreaN-71* Creat-2.3* Na-145
K-4.9 Cl-112* HCO3-24 AnGap-14
[**2171-4-4**] 03:59PM BLOOD CK-MB-4 cTropnT-0.09* proBNP-[**Numeric Identifier 2600**]*
[**2171-4-5**] 04:22AM BLOOD Calcium-8.1* Phos-8.0*# Mg-2.7*
[**2171-4-9**] 09:14AM BLOOD Mg-3.2*
[**2171-4-6**] 06:45AM BLOOD C4-51*
[**2171-4-6**] 11:00AM BLOOD Vanco-19.1
[**2171-4-4**] 7:00 pm BLOOD CULTURE 2ND.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2171-4-6**]):
Reported to and read back by DR. [**Last Name (STitle) **]. [**Doctor Last Name 2601**] ON [**2171-4-6**] AT
0610.
GRAM POSITIVE COCCI IN CLUSTERS.
Other blood culture from [**2171-4-4**] no growth by the time of
discharge
Blood cultures x 2 on [**4-6**] no growth by the time of discharge
Brief Hospital Course:
84yo w/PMHx significant for HTN, CKD, CVA (hemiplegia in [**2155**]),
diastolic heart failure, HLD, PVD refered from [**Hospital 100**] rehab for
hypoxia after receiving IVF, along with tongue and lip swelling
for the last few days concerning for angioedema.
ANGIOEDEMA: the patient was seen by the allergy consult team
([**First Name8 (NamePattern2) 2602**] [**Doctor Last Name 2603**]) who thought this was consistent with angioedema,
she was started on dexamethasone 4mg q8hrs and H2 blockers. her
symptoms improved and she was sent to the regular medical wards
from the ICU. Her steroids were tapered to 2mg po q8hrs on [**4-8**]
and stopped completely on [**4-9**].
PULMONARY EDEMA: She improved with blood pressure control. Her
home lasix of 40mg po daily was restarted on [**4-9**] as she had
some rales at the R base of her lung and mild shortness of
breath. Her O2 sat was 95% on room air. Her creatinine had
improved. In addition for BENIGN HYPERTENSION her ACEi had been
stopped as noted above and she was started on hydralazine 25mg
po q6hrs, her nifedipine was increased to 60mg po bid (from 40mg
po bid) and her imdur was increased from 30mg po daily to 60mg
po daily.
ACUTE ON CHRONIC RENAL FAILURE: urine electrolytes consistent
with a pre-renal cause but given recent angiogram this also
could be related to contrast nephropathy. Her renal failure
improved with time and blood pressure control. Her creatinine
at discharge was 2.3 (baseline 2-2.2). Chem 7 should be checked
in the next 5-7 days to ensure stability.
TOE ULCERATION, PERIPHERAL VASCULAR DISEASE: non infected toe
ulceration. She had a recent angiogram and will f/u with
podiatry and vascular surgery (appointments have been made)
URINARY TRACT INFECTION: Started on PO cipro on [**2171-4-5**]. She has
completed a 5 day total course.
POSITIVE BLOOD CULTURE: on [**4-4**], this was treated with
vancomycin until it returned as 1/2 bottles from one set of coag
negative staph. At this point she did not have a PICC or mid
line or any other foreign body. She was afebrile and had no
white blood cell elevation, her vancomycin was last dosed on
[**2171-4-6**] (1 gram IV), this was likely a contaminant so
antibiotics were discontinued.
DIABETES TYPE II: the patient was on pioglitazone as an
outpatient, given pulmonary edema this was stopped. While inpt
on steroids she was treated with an insulin sliding scale, on
discharge she was switched to glipizide xl 2.5mg po daily, this
can be further adjusted as an outpatient.
For her history of CVA with chronic left sided hemiparesis and
depression as well as iron and B12 deficiency anemia, the
patient continued on her home med regimen.
Medications on Admission:
-augmentin 250mgBID [**4-1**] to [**4-11**]
-oxycodone ER 10mg [**Hospital1 **]
-oxycodone IR7.5mg Q4h/prn
-calcitriol 0.25mcg daily
-artificial tears
-nitroglycerin 2% ointment 0.5inch daily
-bisacodyl 10mg qpm
-bisacodyl 10mg suppository
-omeprazole 20mg
-oxcarbazepine 150 mg
-polyethlen glycol 17 [**Hospital1 **]
-isosorbide mononitrate 30mg
-trazadone25mg qhs
-??trazadone 12.5mg --> total 37.5mg
-nifedipine 40mg [**Hospital1 **]
-iron 325 daily
-aspirin enteric 81mg
-pioglitazone 30mg daily
-acetaminophen 325 mg TID
-citalopram 20mg
-heparin sq
-milk of mag 30mg daily
-vasotec 10mg daily, stopped prior to admission on [**2171-4-2**]
-furosemide given PRN at [**Hospital 100**] Rehab, was on 40mg daily started
[**2171-3-16**]
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-18**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO BID (2 times a day).
8. trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO at bedtime as
needed for insomnia.
9. nifedipine 60 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO twice a day.
10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
14. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily).
16. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Hypoxia and shortness of breath due to acute diastolic CHF
exacerbation
Acute on chronic kidney failure, CKD4
Angioedema
UTI
Peripheral vascular disease
Chronic non-healing left toe ulcer
Hypertension
Hyperlipidemia
CAD
Chronic diastolic CHF
CVA, late effects
Depression
Iron deficiency and B12 deficiency anemia
DM2 uncontrolled with PVD complications
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with shortness of breath due to volume
overload. Continue to take lasix.
You had acute on chronic kidney failure likely due to an effect
of medications and due to volume depletion within the blood
vessel (despite having too much fluid elsewhere).
You had swelling of your lip due to angioedema - probably an
allergic reaction to either ACE inhibitors (of which your
chronic medicaion vasotec is one example) or augmentin (which
you were recently started on for cellulitis). From now on please
avoid all ACE inhibitor medications and penicillin containing
antibiotics.
You had a urinary tract infection. You were treated with 5 days
of ciprofloxacin.
MEDICATION CHANGES:
Your OXYCONTIN was stopped and your pain was treated with short
acting OXYCODONE in the hospital
Your BLOOD PRESSURE MEDICATIONS were adjusted:
NITROPASTE was STOPPED
NIFEDIPINE was INCREASED from 40mg twice daily to 60mg twice
daily
IMDUR was INCREASED from 30mg daily to 60mg daily
HYDRALAZINE 25mg four times daily was added
YOUR DIABETES MEDICATIONS WERE ADJUSTED:
PIOGLITAZONE was STOPPED
GLIPIZIDE was STARTED
Followup Instructions:
Department: PODIATRY
When: TUESDAY [**2171-4-16**] at 2:35 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
Department: VASCULAR SURGERY
When: MONDAY [**2171-4-22**] at 4:15 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5849, 5990, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7209
} | Medical Text: Admission Date: [**2125-10-16**] Discharge Date: [**2125-10-19**]
Date of Birth: [**2079-11-7**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Ciprofloxacin
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
fever, chills, right sided flank pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
45 y/o lady with recent history or 5.5 mm right mid ureteral
stone w/ hydronephrosis and underwent cystoscopy and stent
placement at OSH on [**2125-9-26**]. During the procedure she was
noted to have pyohydronephrosis. Following procedure patient
developed sepsis requiring ICU admission. Cultures were positive
for E.coli. Patient was discharged on [**2125-10-4**] in stable
conditions with oral Bactrim. She also had herpes vaginal
eruption and was treated with 3 days of oral antiviral agents.
At office follow up on [**2125-10-7**] pt complained of LUTS and was
found to have 1700 ml residual in her bladder an indwelling
foley was placed which subsequently fell out (?). She came to [**Hospital6 84784**] ED with abdominal pain and urinary retention on
[**2125-10-11**]. Her foley was replaced and drained 1000 mls following
placement. Labs showed a normal Cr and WBC, UA pertinent for
[**11-23**] WBC, she was started on IV Levaquin. She was continued on
urecholin and flomax. She was discharged with oral bactrim.
Patient called her PCP yesterday with bilateral lower extremity
calf pain/cramp and itching/rash. BLE US was negative for DVT.
Her pain and rash resolved but overnight she started to develop
fever and chills to 103.8 at home. She went to OSH ED. She was
diagnosed with suspected urosepsis and was transfered here per
family request.
.
In the [**Hospital1 18**] ED, initial vs were: T102 P112 BP94/54 R20 O2
sat100% RA. Patient was given 1 gram of vancomycin and 1 gram of
rocephin prior to transfer to [**Hospital1 18**]. She also recieved 25 mg of
IV benadryl prior to transfer. She recieved 2L NS in [**Hospital1 18**] ED on
top of ? 2 to 3 L of NS she recieved PTA. Central line was
placed in ED. She was started on levophed.
.
On arrival to the ICU, her vitals were, T:101 BP:114/99 P:102
R:19 O2: 100% on 4LNC. Patient still has fevers and chills. Mild
diffuse abdominal discomfort. Mild diffuse headache. She denies
any neck stiffness, photophobia/phonophobia, change in
vision/hearing, focal weakness, numbness, chest pain, shortness
of breath, nausea, vomitting, diarrhea. No other complaints.
Past Medical History:
nephrolithiasis 5.5mm R s/p Ureteral stent [**2125-9-26**]-complicated
by urosepsis as above
Urinary retention as complication of above
Uterine fibroids s/p D&C
c section X2
Vagianal HSV
Social History:
Lives at home with boyfriend [**Name (NI) **]. She denies tobacco or street
drugs. [**3-7**] drinks per week. Two children.
.
Family History:
Mother and sister with kidney stones
Physical Exam:
Vitals: Tm 101.4 at 4am 98.5 70-80s 18 110-130/80s 98%RA
Pain: denies
Access: PIV
Gen: nad
HEENT: mm dry
CV: RRR, [**2-9**] SM
Resp: CTAB, no crackles or wheezing
Abd; soft, nontender, no CVAT, +BS
Ext; no edema
Neuro: A&OX3, nonfocal
Skin: no rash
psych: appropriate
.
On discharge
Vitals: T 97.4 120/80 76 16 98%RA
Pain: denies
Access: PIV
Gen: nad
HEENT: mmm
CV: RRR, [**2-9**] SM
Resp: CTAB, no crackles or wheezing
Abd; soft, nontender, no CVAT, +BS
Ext; no edema
Neuro: A&OX3, nonfocal
Skin: no rash
psych: tearful
.
Pertinent Results:
WBC 6.7 93%N --> 3.3 66%N-->4.7
(wbc 9.4 with 13%bands OSH on [**10-16**])
hgb 9-10s (was 10s recently at OSH) MCV 79
plt 190
.
INR 1.3
.
Chem panel: BUN 8/0.6 (creat 1.0 on admission)
K 4.6 Mag 1.6
.
lactate 1.8->0.8
.
Fe 13, TIBC 200, Ferritin 180
.
UA [**10-16**] here negative, UCx neg
UA [**10-16**] at OSH +LE, [**11-23**] wbc, 1+ bacteria, Cx pending
.
.
Blood Cx [**10-16**] X2 NTD
Blood Cx [**10-17**] X1 NTD
.
OSH Ucx on [**9-19**] with Ecoli
OSH UCx [**10-16**] NTD (confirmed on [**10-19**])
OSH blood Cx [**10-16**] X2 NTD (confirmed on [**10-19**])
.
.
Imaging/results:
CTU [**10-16**]: IMPRESSION:
1. Appropriate position and function of the right ureteral
stent. No
evidence for obstruction.
2. Abnormality in the right lower pole as described above is
likely a sequela from prior percutaneous nephrostomy tube
placement. Please correlate with patient's history. There is no
evidence for a renal abscess.
3. 4-mm stone in the distal ureter.
4. 2.1 cm mass in the endometrial cavity. This may represent a
submucosal fibroid; however, differential diagnosis includes
endometrial polyp or carcinoma. Further evaluation with
ultrasound is recommended.
5. Findings consistent with hematocolpos. Please correlate with
menstrual status.
.
Brief Hospital Course:
Briefly, 45year old female who is otherwise healthy was found to
have obstructing kidney stone in [**9-12**], which was then
complicated by UTI and hydro requiring cystoscopy with stent
placement [**9-26**], found pus, developed florid urosepsis (wbc 40,
bandemia), UCx Ecoli, Rx Iv Abx in ICU then d/c'd [**10-4**] with
bactrim, completed course. Saw GU on [**10-7**], found to have urinary
retention, foley placed, fell out at some point. Seen again at
OSH ER [**10-11**] with new fever/abd pain, had urinary retention,
mildly dirty UA, got IV levaquin X3days, then d/c [**10-14**] on
bactrim and foley. Cultures negative at that time but pt did
have bandemia. Then on [**10-15**], had pain and LE cramps, called
PCP, [**Name10 (NameIs) **] neg, went to ER because of low fevers, but d/c home.
that night, [**10-15**] developed fever 103.8, back to ER,
hypotensive, mildly dirty UA, got vanc/rocephin, transfered to
[**Hospital1 18**] for urosepsis, got 2L OSH, 2L here, and levophed started
in ER and RIJ placed and t/f to ICU. Started vanc/meropenem. 2L
more IVF given [**10-16**] (total 6-7L) and pressors weaned off [**10-16**]
midday, then HDS. last temp 101.4 on [**10-17**] am, afebrile since.
All Cx NTD. Vanc d/c'd on [**10-17**]. Kept on meropenem. CT nothing
acute, stent in place, no perinephric abcess, etc. Other
infectious w/u with CXR, blood cx, flu, echo negative. Pt
transfered out of ICU on [**10-17**]. On transfer to floor, low grade
temps, afebrile by next day. Tolerated PO and walking around.
Was emotional given her protracted illness. OSH cultures from
[**10-16**] UCx and Blood cx all negative. Given her improvement with
meropeneum and presumed failure with bactrim and allergy to
fluroquinolones and PCN, decision made to complete 14days with
ertapenum (day [**4-13**] on discharge). PICC placed prior to d/c. VNA
set up for teaching and monitoring and safety labs. Discussed
plan with patient and her current PCP (who is Ob/Gyne) Dr
[**Last Name (STitle) **] who will follow up on labs. He will refer her to a PCP
since her medical problems are a bit more complex than previous.
She was also interested in f/u here with Urology. Appt made for
[**10-29**] with Dr. [**Last Name (STitle) **]. this will be after completion of her Abx and
the hope is that she can have more definitive treatment by
removal of the stone and stent at that time. She also has had
recent issues with urinary retention, likely complication of her
illness and narcotics. She is told not to have any decath trials
until her stone/stent issue has resolved given high risk for
repeat infeciton in case of retention. Thereafter she can have
decath trials per GU or further w/u if fails. Rest of her plan
is outlined below.
.
.
Below is progress note from day of discharge:
.
45year old female with complicated recent urological history
with obstsructing stone s/p stent [**9-26**] complicated by urosepsis,
then urinary retention and recurrent [**Hospital **] transfered from OSH
with fevers/hypotension, presumed urosepsis. t/f out of ICU on
[**10-17**].
.
.
Sepsis, presumed urosepsis: UA mildly dirty (had been on
bactrim) but has stent in place and stone which may be nidus,
all in setting of urinary retention and foley.
-continue meropenem for now, day [**4-17**]-->will give a dose of
Ertepenum before d/c to make sure tolerates. Plan is for 14day
course. PICC to be placed today (afebrile since [**10-17**] am,
cultures neg) and safety labs in one week
-f/u OSH Urine Cx from [**10-16**] and blood cx are NTD
-discussed with urology, made appt with Dr. [**Last Name (STitle) **] [**10-29**] at
8am(once Abx course completed), for removal of stone/stent for
more definitive treatment
-foley in place as below
-reviewed lower pole findings with urology/radiology as pt did
not have PCN-they are not concerned
.
.
Fever: as above, presumed urinary source. CXR neg. flu neg. no
diarrhea. no other localizing complaints. Possible related to
bactrim but wouldnt have expected sepsis picture with drug
fever. S/p vanc [**10-16**] and [**10-17**], stopped.
-plan is for two weeks ertapenem
.
.
Urinary retention: unclear cause but definately contributing to
recurrent UTIs. may be due to narcotics patient was Rx during
1st hospitalization in [**9-12**]
-keep foley in for now, will need close follow up with GU here
for further management
-flomax 0.4
.
.
Leukopenia: from review of OSH records, it appears pt mounted a
white count as high as 40 when septic. Recently she has been
more leukopenic. Suspect due to bactrim.
-follow as outpt. will need safety labs on Abx.
.
.
Constipation: no BM Xseveral days, then had one on [**10-18**]
-add senna and dulcolax
-abdominal exam benign
.
.
Anemia: microcytic, likely Fe deficient based on Fe studies. Hgb
currently [**8-12**], recently baseline was 10s from OSH. Likely has
acute illness/ACD component. No obvious bleeding or hemolysis.
stable.
-start Fe supp with colace on discharge
-needs outpt further w/u
.
.
Nephrolithiasis: complicated history as above. recurrent
Urosepsis. Has 4mm stone and stent in place.
-discussed with urology, appointment [**10-29**] as above for
definitive treatment
.
Dispo/Code: full code. will try to get PICC today and arrange
for home Abx and teaching. f/u wtih Dr.[**Last Name (STitle) **] [**Last Name (STitle) **] [**10-29**]. Pt to f/u
with PCP in one week for labs.
Communication: Patient. Contact: Boyfriend, [**Name (NI) **], [**Telephone/Fax (1) 84785**]
HCP is sister [**Name (NI) **].
Medications on Admission:
Tamsulosin-started [**10-7**]
bactrim-for UTI
percocet
Discharge Medications:
1. Ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection
NOW () for 10 days.
Disp:*qs Recon Soln(s)* Refills:*0*
2. PICC line care per
PICC line care per [**Location (un) 6138**] Home care. To be removed after
antibiotics (approx 10days).
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-5**] Sprays Nasal
QID (4 times a day) as needed for nasal dryness.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*qs Capsule, Sust. Release 24 hr(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
Disp:*qs Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] homecare
Discharge Diagnosis:
Urosepsis
Nephrolithiasis s/p stent and 4mm stone
Anemia, Iron def
Discharge Condition:
STABLE
Discharge Instructions:
You were admitted for another infection of your urinary tract.
You keep having these infections likely because of an infected
stone. You were treated wtih a strong antibiotic with
improvement (meropenem) and you will go home on a similar
antibiotic (ertepenum) for 10more days (14days total). You have
an appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] this on [**10-29**] where he will
discuss removal of the stone and stent to prevent further
infections.
you will have blood draw in one week while you are on the
antibiotic. please make sure the results are forwarded to Dr.
[**Last Name (STitle) **] and call him the next day to discuss
Please keep the foley catheter in until urology says it is okay
to remove. Your urinary retention may take some time to resolve.
You are also started on iron supplements and stool softeners.
Your anemia shows that you are Iron deficient. This may be due
to your periods if they are heavy. However, if your periods are
not heavy then you should ask your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]
workup on other causes of anemia if your levels remain low.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2125-10-29**] 8:00
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7210
} | Medical Text: Admission Date: [**2190-11-6**] Discharge Date: [**2190-11-21**]
Date of Birth: [**2190-11-6**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 2816**] is the 2.060
kg product of a 35 and [**2-2**] week gestation, born to a 37 year-
old, Gravida V, Para 4 now 5 woman.
PAST OBSTETRIC HISTORY: Notable for spontaneous vaginal
delivery x4. Prenatal screens were as follows: B positive,
Direct Coombs negative. Hepatitis surface antigen negative.
RPR nonreactive. Rubella immune. GBS unknown.
ANTENATAL HISTORY: Pregnancy was complicated by gestational
hypertension, treated with Labetalol and Nifedipine.
Gestational diabetes mellitus, controlled with diet. Mother
was admitted with worsening pre-eclampsia and treated with
magnesium sulfate before being induced and proceeding
subsequently to Cesarean section for suspected placental
abruption and non reassuring fetal heart rate tracing.
Rupture of membranes occurred 25 minutes prior to delivery
and yielded bloody amniotic fluid with meconium staining.
There was no intrapartum fever or other clinical evidence of
chorioamnionitis. Antepartum antibiotics were administered
beginning 7 hours prior to delivery. Delivery was with
epidural anesthesia. Infant emerged active, orally and
nasally bulb suctioned, dried, brief free flow oxygen.
Subsequently, infant was pink and in no distress. Apgars were
7 at 1 minute and 8 at 5 minutes.
PHYSICAL EXAMINATION: Weight 2.060 kg. Head circumference
31.5 cm. Length 47 cm. Anterior fontanel soft and flat, non
dysmorphic facies. Palate intact. Mouth normal. Red reflex
deferred. No nasal flaring. Cardiovascular: Well perfused,
regular rate and rhythm. Femoral pulses normal. S1 and S2
normal. No murmur. Respiratory: No retractions, good breath
sounds bilaterally. No adventitial sounds. Abdomen: Soft,
nondistended, no organomegaly, no masses. Bowel sounds
active. Anus patent. Three vessel umbilical cord.
Genitourinary: Normal female genitalia. CNS: Active,
responds to stim. Tone normal and symmetric. Moves all
extremities. Suck, root and gag intact. Facies symmetric.
Integumentary normal. Musculoskeletal: Normal spine, limbs,
hips and clavicles.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Female First Name (un) 55288**]
has been stable in room air since admission to the NICU. She
has had occasional apnea and bradycardia episodes, not
requiring methylxanthine therapy.
Cardiovascular: She has been stable without issue. Heart
rates have been ranging 110s to 150s. Blood pressure 74/40
with a mean of 53.
Fluids, electrolytes and nutrition: Birth weight was 2.060.
Discharge weight is 2200g. Total fluids initially were 60 cc per
kg/day of D-10-W with ad lib enteral feeding on top of that.
Infant remains euglycemic weaning IV fluid over the next 48
hours, at which time she maintained glucoses with enteral
feedings exclusively. She is currently receiving 150 cc/kg
per day of Special Care 20 calorie, the majority of which is
by PG tube.
Gastrointestinal: Peak bilirubin was on day of life #3 of 8.7
over 0.3. She is currently not receiving treatment.
Hematology: Hematocrit on day of life #2 of 51.6. Infant has
not required any blood transfusions.
Infectious disease: CBC and blood culture obtained on day of
life #2 in response to 2 episodes of significant apnea and
bradycardia which was out of norm for her. CBC had a white
count of 7.1, platelets of 193. 36 polys, 0 bands. Blood
cultures remain negative to date.
Neuro: Infant has been appropriate for gestational age.
Hearing has not yet been performed, should be done prior to
discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**Name6 (MD) 70638**] [**Name8 (MD) 70639**], MD, telephone
number [**Telephone/Fax (1) 36247**].
CARE RECOMMENDATIONS: Continue 150 cc/kg per day of Special
Care 20 calorie.
MEDICATIONS: Not applicable.
CAR SEAT POSITION SCREENING: Not yet performed.
STATE NEWBORN SCREENS: Sent most recently on [**11-9**].
IMMUNIZATIONS: Infant received hepatitis B vaccine.
DISCHARGE DIAGNOSES:
1. 35 and [**2-2**] week infant.
2. Infant of a diabetic mother.
3. Transient hypoglycemia.
4. Rule out sepsis.
5. Apnea and bradycardia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2190-11-11**] 02:30:24
T: [**2190-11-11**] 06:47:05
Job#: [**Job Number **]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7211
} | Medical Text: Admission Date: [**2174-4-13**] Discharge Date: [**2174-4-16**]
Date of Birth: [**2134-3-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Transfer from OSH with hypoxic respiratory failure
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
Patient is a 40 yo male with h/o asthma transferred from OSH
after intubation for hypoxic respiratory failure. Per report,
patient went to work and was on break when he came out of the
bathroom with his inhaler, passed out, was reportedly apneic by
his co-workers and subsequently vomited feculant appearing
vomitus. He could not be intubated in the field, so he was
bagged and had ? seizure described as rhythmic movements arm and
head and was incontinent of urine. On arrival to the ED at OSH,
T 96.1, HR 140s, BP 198/112, O2 sats 86% on ambu bag. He was
sedated and intubated and an NG tube was placed which yielded ?
feculent material. CT head, CTA chest and CT abd were performed.
He received levofloxacin 500 Iv x1, flagyl 500 IV x1, ativan 2
mg IVx3, morphine 10 mg IVx3 and was started on propofol drip
and transferred to [**Hospital1 18**].
.
On arrival to [**Hospital1 18**] he was intubated and sedated satting 100 %
on AC TV 560/16 100% FiO2 and Peep 5. NG tube in place with
hemeoccult positive output. On speaking with his wife, over the
past 2 months has has been using his inhalers increasingly, at
times multiple times per day. He saw his PCP [**Name Initial (PRE) **] 5 days ago at
which time he was started on advair and prednison taper x 7
days. She reports that he had no fevers, chills, cough, URI sx,
abd pain, N/V, diarrhea or any other symptoms. He did have a
coughing spell 2 days ago during which he nearly vomited. His
only recent travel was to [**State 108**] from [**3-26**]. No sick
contacts. Of note, they have been remodeling their home and
paiting and sanding which may have made his asthma symptoms
worse. Denies use of NSAIDS.
Past Medical History:
Asthma- never hospitalized, only on steroid a couple of times
per wife. Until recently only used inhalers occasionally
Occasional GERD treated with PRN Tums
Social History:
Lives with wife. [**Name (NI) 1403**] as corrections officer. Has been using
chewing tobacco for the past 9 months. occasionally smokes
cigars. No cigarette. Drinks socially. No other drugs. (all
history from wife)
Physical Exam:
Vitals: T 96.4 BP 128/89 HR 98 RR 16 % O2 sats 100% on AC TV
560/16 100% FiO2 and Peep 5
General: Intubated and sedated
HEENT: PERRL, NG tube in place with hemoccult positive drainage
CV:RR, nl S1, S2, no m/g/r
Lungs: CTA anteriorly with few crackles at left base, no wheezes
Abd: Distended, positive BS, soft, non-tender, no
hepatosplenomegaly
Ext: no edema, 2+ DP pulses
Neuro: Intubated and sedated, before sedation was following
commands per OSH report
Skin:no rashes
Pertinent Results:
[**Location (un) 620**] (OSH) CT head: negative for bleed or mass effect
[**Location (un) 620**] (OSH) CTA: not optimal PE is study, but no obvious PE,
minimal atelectasis on right, evidence of aspiration versus
aspiration PNA
CT abd (prelim): no acute pathology
.
EKG: Sinus tachy 125, nl axis, nl intervals, no ST T wave
changes
Brief Hospital Course:
Mr. [**Name14 (STitle) 72442**] is a 40 yo male h/o asthma with recent exacerbation
transferred from OSH intubated after hypoxic respiratory failure
possibly secondary to aspiration event in the setting of asthma
exacerbation.
.
# Hypoxic respiratory failure: Given recent events with
increasing need for MDIs and coughing fit 2 days ago with near
vomiting, it is possible that the patient had an asthma
exacerbation, hyperventilated, fainted, and had an aspiration
event leading to his intubation. He had no wheeze on exam on
arrival to [**Hospital1 18**] and does not seem acutely bronchospastic which
doesn't support this picture. There is evidence of pneumonitis
on CT scan at [**Location (un) 620**] [**Hospital1 18**]. No evidence of PE, although not an
optimal study, although this is lower on the differential given
his history. The patient was successfully extubated on [**4-13**] and
was stable on 3 L NC, later weaned to RA without problem. [**Name (NI) **]
was conservatively treated with levofloxacin and flagyl for
possible aspiration PNA, although he may in fact have only
aspiration pneumonitis. He was also treated with aggressive
nebs, singular, and a slow steroid taper to continue over 2
weeks after discharge. He will follow up with Dr. [**Last Name (STitle) **] in
pulmonary clinic in the next available appointment slot. He will
have outpatient PFTs checked at that time.
- Interestingly, the patient had continued tachycardia
throughout his stay even after marked improvement with the above
treatment. Given his recent plane ride to [**State 108**] we decided to
repeat his CTA chest. This study revealed a segmental PE. The
patient was started on lovenox [**Hospital1 **] and was discharged with this
treatment with instructions to call his PCP on [**Name9 (PRE) 766**] to set up
a coumadin regimen. He should take lovenox as a bridge to
anticoagulation, then should be anticoagulated on coumadin for a
total of at least 6 months.
.
# Hemoccult positive NG output: On admission the patient was
found to have NG tube output which was hemoccult positive. His
HCT remained stable. He has no history of GI bleed, does have
some mild GERD, denies NSAID or excessive alcohol use. He was on
steroids, which increases his risk of gastritis. The patient
was kept on a twice daily PPI while in house and is discharged
on a daily PPI for gastritis. This may be further worked up as
an outpatient if indicated when he follows up with his PCP.
.
At the time of discharge the patient was able to ambulate while
on room air without desaturation. He will follow up with his PCP
and in our pulmonary clinic as above.
Medications on Admission:
Home Meds:
Advair
Albuterol Inhaler
Prednisone taper
.
Meds on transfer:
Levofloxacin 500 mg Iv x1
Flagyl 500 mg Iv x1
Solumedrol 125 mg IV x1
Morphine 10 mg IV x3
Ativan 2 mg IV x3
Magnesium sulfate 2 g x1
Propofol drip
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*3*
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 disk* Refills:*2*
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:*3*
4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
Disp:*1 inhaler* Refills:*3*
7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours): take 2 puffs at least every 4
hours without fail. You may take it every 2 hours if needed.
Disp:*1 inhaler* Refills:*3*
8. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 6 days: take 2 daily for 3 days, then decrease to 1 daily
for 3 days, then change to 5mg dose pills.
Disp:*9 Tablet(s)* Refills:*0*
9. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day
for 9 days: after finishing 20mg dose: take 3 daily for 3 days,
then decrease to 2 daily for 3 days, then decrease to 1 daily
for 3 days then stop.
Disp:*18 Tablet(s)* Refills:*0*
10. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours): 100mg sc q12h.
Disp:*10 syringes* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
asthma exacerbation
aspiration pneumonia
pulmonary embolus
Discharge Condition:
Stable. Able to ambulate without desaturating.
Discharge Instructions:
Please call the pulmonary clinic at [**Telephone/Fax (1) **] and ask for the
next available appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) **].
.
Please call your primary care physician on [**Name9 (PRE) 766**] for an
immediate appointment. He will start you on a medication called
coumadin to thin your blood. You will have your levels of this
medication checked and lovenox should be taken until your levels
of coumadin are appropriate.
.
Please take all of these medications as directed until told to
change or do otherwise by Dr. [**Last Name (STitle) **]. Please take your antibiotics
for 7 more days only. All other medications should be ongoing.
.
* It is very important that you use your lovenox injections
twice per day. Do not stop this until told to do so by your PCP.
.
**Note that your prednisone should be decreasing over the next
15 days. You have prescriptions for 20mg tabs and for 5mg tabs
to make this easier for you. Please take 40mg (2 of the larger
tabs) for the next three days, then decrease to 20mg (1 of the
larger tabs)for three days. Then take 15mg (3 of the smaller
tabs) for three days, then 10mg (2 of the smaller tabs) for
three days, then decrease to 5mg (1 small tab) for three days,
then stop. This should take a total of 15 days.
.
If you have fever, chills, trouble breathing or other concerning
symptoms please call your physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], or come to the
emergency room.
Followup Instructions:
Please call the pulmonary clinic at [**Telephone/Fax (1) **] and ask for the
next available appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) **].
.
Please call your primary care physician [**Name9 (PRE) 766**] for the next
available appointment as above.
Completed by:[**2174-4-19**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7212
} | Medical Text: Admission Date: [**2121-10-9**] Discharge Date: [**2121-10-23**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
Worsening lower extremity
Major Surgical or Invasive Procedure:
-
History of Present Illness:
This is a [**Age over 90 **] y/o female with h/o lower extremity and no known
cardiac history who presents today after her visiting nurse
noticed that she had worsening lower extremity edema and
crackles on exam. The patient denies any CP/SOB, abd pain,
fever/chills, weakness/numbness.
In the ED the patient had an O2 sat 93-95% on RA. A chest x-ray
was done which showed enlargement of the heart, small effusion
at the right base, no overt signs of failure, and clear lungs.
Labs were notable for elevated Cr of 1.6. (Baseline 1.1), BNP
[**Numeric Identifier 24310**] and elevated trop .44(in the setting of new afib and ARF).
An EKG down showed low voltage and afib.
Past Medical History:
New onset afib
Bilateral edema
Hypothyroidism
Decubitus ulcers
Osteoarthritis
s/p cholecystecomy
Social History:
Lives with daughter. [**Name (NI) **] has been sedentary for the past 10
years.
Family History:
n/c
Physical Exam:
Physical Exam
VS T afeb, HR 60, BP 119/70, RR15, O2sat 95%RA
Gen: NAD, sitting in bed eating ice chips
HEENT: MMM, OP clear
Heart: irreg, no gmr
Lungs: crackles at bases, decreased breath sounds at bases
Abdomen: benign
Ext: 2+ pitting edema, scaling, erythematous
Pertinent Results:
Labs
[**2121-10-10**] 05:05AM BLOOD TSH-2.6
[**2121-10-9**] 02:20PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 24310**]*
[**2121-10-9**] 02:20PM BLOOD cTropnT-0.44*
[**2121-10-10**] 05:05AM BLOOD Glucose-162* UreaN-40* Creat-1.6* Na-137
K-3.7 Cl-99 HCO3-24 AnGap-18
[**2121-10-10**] 07:17PM BLOOD D-Dimer-1177*
[**2121-10-9**] 03:09PM BLOOD PT-15.8* PTT-33.1 INR(PT)-1.7
[**2121-10-10**] 05:05AM BLOOD Plt Ct-254
.
Echo [**2121-10-10**]
Conclusions:
The left and right atrium is moderately dilated.No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is moderate global
left ventricular hypokinesis. The right ventricular cavity is
markedly dilated with moderate global free wall hypokinesis.
[Intrinsic right ventricular systolic function may be more
depressed given the severity of tricuspid regurgitation.] There
is abnormal diastolic septal motion/position consistent with
right ventricular volume overload. The aortic valve leaflets
are moderately thickened. There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation
is seen. At least moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
IMPRESSION: Marked right ventricular cavity enlargement with
systolic
dysfunction. Pulmonary artery systolic hypertension. Mild aortic
regurgitation. At least moderate tricuspid regurgitation.
.
[**2121-10-13**]
Chest X-ray
IMPRESSION: AP chest reviewed in conjunction with a CT scan
[**2121-10-11**].
Moderate-sized right pleural effusion is slightly larger, but
lungs are clear. Heart and right pulmonary artery remain
substantially enlarged. Tiny left pleural effusion may be
present, but not appreciably changed. No pneumothorax.
Brief Hospital Course:
This is a [**Age over 90 **] y/o female with a history of hypothyroidism who
presented to the hospital with worsening lower extremity edema
and new onset atrial fibrillation. The pt was found to have
chronic pulmonary embolisms on imaging, right heart failure on
TTE, and hematemesis on [**10-20**] requiring MICU transfer. The pt
returned to the floor on [**10-22**].
.
Her hospital course is as follows;
.
1. Rhythm: New Onset Afib :
Upon admission, an EKG was done and the patient was found to be
in atrial fibrillation. The time frame for which the patient
had been in atrial fibrillation was unclear. With the concern
that she may have a thrombus, she was anti-coagulated with
heparin.
It is important to note that the patient has a history of
hypothyroidism and was being treated with levoxyl. A TSH level
was checked to determine whether or not the patient now had
hyperthyroidism causing her atrial fibrillation. The TSH level
was normal at 2.6.
.
Anticoagulation was later held because of the patient's
hematemesis; the pt was also felt to be a fall risk. The pt was
started on low dose digoxin prior to discharge to help with
cardiac output and rate control.
.
2. Congestive heart failure:
The patient had an elevated BNP of [**Numeric Identifier 7923**] on admission. The
patient also had an elevated troponin on admission of 0.44.
This troponin leak was attibruted to her congestive heart
failure/demand ischemia and her poor renal function. The initial
plan of management was to diurese that patient. An ECHO was
done which showed marked right ventricular cavity enlargment and
EF of 30%. Due to the patient's decompensated right heart
function and thus obvious preload dependency, she was cautiously
diuresed. The pt was initially continued on lopressor 12.5 mg
po bid, however this was held given the pts GI bleed and low BP
prior to discharge. The pt was started on low dose digoxin
0.0625 mg po qd prior to discharge.
.
3. Pulmonary Embolism
With depressed right ventricular function, CT-A was performed to
rule out a pulmonary embolism. CT-A was consistent with
chronic pulmonary embolism. D-dimer was 1177. Lower extremity
dopplers were negative. Due to the patient's history of
hematuria while previously on heparin, she was place on a
non-aggressive heparin sliding scale.
.
Given her frail condition and episode of hematemesis, the risk
to benefit of anticoagulation was greater.
.
3. Lower extremity edema
Lower extremity dopplers were obtained and were negative.
Attributing her edema to her congestive heart failure, the
decision was made to cautiously diurese the patient. The
concern stemmed from the fact that she was preload dependent.
The pt was not diuresed for several day prior to discharge given
that she was hypotensive.
.
4. ARF
Due to her congestive heart failure, the patient was unable to
maintain forward flow to adequatly perfuse her kidneys. Her
creatinine was elevated at 1.6 on admission and it increased to
1.9. The pts Creatinine was back down to 1.1 at discharge.
.
5. Hypoxia
Throughout her course the patient would have brief episodes of
hypoxia. With minimal exertion her oxygen saturation would fall
to the mid-80%. During these episodes she was place on a 100%
non-rebreather and her 02sats would improve to the mid-90s. The
patient was later transitioned to a 2L nasal cannula where she
maintained O2 sats in the high 90s. Chest X-ray was consistent
with congestive heart failure.
.
6. Hematemesis
The patient's course was later complicated by a hematemesis.
The patient vomited 200cc on [**10-20**], she became tacchycardic to
the 120 and hypotensive w/ SBPs in the 80s. Her Hct dropped
from 33 to 29 after hematemesis on [**10-20**]. Pt was given FFP/1U
PRBC and started on Protonix gtt on [**10-20**], transferred to MICU,
and GI was consulted. She was managed conservatively with PPI
gtt and reversal of coagulopathy with Vit K and FFP (limited
amount of FFP due to CHF and tenuous volume status). Pt s/p 1U
FFP [**10-21**] and 10 mg Vit K SC. GI did not perform EGD given the
pts elevated INR and multiple comorbidities. The pt returned to
the floor on [**10-22**], and she was started on Protonix 40 mg IV bid.
This was changed to po prior to discharge.
.
7. Osteoarthritis
The patient's pain was controlled with Tramadol. However this
was later discontinued when the patient was found lethargic one
morning.
.
8. Change in mental status
On [**2121-10-17**] the patient was found to be lethargic. The patient's
INR was 2.9. A head CT ruled out any intracranial hemorrage.
The risk to benefit of anticoagulation was greater. For this
reason the patient's anticoagulation was stopped.
.
9. Anemia: On admission, pt had a hct of 40. The likely
etiology of her anemia was an upper GI bleed. Her hct was stable
at 26.4 prior to discharge.
.
10. UTI: The pt was found to have an E.Coli/Proteus UTI
pan-sensitive. She was on cipro x 4 days (start [**10-12**] for dirty
UA), changed to amp [**10-16**] in setting of interaction between
coumadin and cipro (INR up to 2.7 that day and pt felt to be a
fall risk). She was then placed on levofloxacin 250 mg po qd
for a 7 day course prior to discharge.
.
11. Elevated WBC: Pt WBC rose to 19 prior to discharge. This
was felt to be likely secondary to a partially treated UTI
(apparently pt did not receive all of her antibiotic doses while
in the MICU), as well a possible C. diff infxn. The pt had a
large loose bowel movement prior to discharge. C. diff cultures
were obtained and will need to be followed up after discharge.
The pt was empirically started on flagyl 500 mg po tid for a 14
day course.
.
The pt is DNR/DNI
--treat for 10 days; Amoxicillin chosen as pt may need H. Pylori
tx.
Medications on Admission:
All: Sulfa
Meds:
Ultram
Levoxyl
Lasix
Potassium
Discharge Medications:
1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
Disp:*10 tubes* Refills:*2*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
5. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
7. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
8. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
13. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 14 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Congestive heart failure
Atrial fibrillation
Hypothyroidism
UTI
Discharge Condition:
stable, blood pressure stable, satting at 99% on 2L NC
Discharge Instructions:
You are to return to the hospital immediately if you should
experience any chest pain, shortness of breath or any other
worrisome symptom.
.
Please take your medications as prescribed, you will need 7 days
of levofloxacin and 14 days of flagyl.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 5263**] in [**12-15**] weeks after discharge.
Please call her at [**Telephone/Fax (1) 250**] with any questions.
ICD9 Codes: 5849, 5789, 5990, 5070, 2851, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7213
} | Medical Text: Admission Date: [**2118-1-14**] Discharge Date: [**2118-1-19**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Speech difficulties and right sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a [**Age over 90 **] year old woman with a history of atrial
fibrillation off Coumadin since [**2117-12-31**] in the setting of
recent
spontaneous hemoperitoneum requiring exploratory laparatomy and
splenectomy for grade III splenic laceration, hypertension,
prior
TIA, and CAD who presents as a CODE STROKE for aphasia and right
face/arm weakness.
I spoke with [**Doctor First Name **] at [**Telephone/Fax (1) 30046**]. The patient woke up normal this morning, was in
the
gym doing leg exercises with PT and talking normally. At 10:30
am, PT called to say that she was alert but nonverbal. When
evaluated by [**Doctor First Name **] found to have a right facial droop and right
arm flaccid, not answering any questions. EMS was called.
She was initially sent to [**Hospital6 17032**], where
vitals were temp 97.9, bp 122/47, HR 84, RR 20, SaO2 92%. Exam
showed right facial droop, right 0/5, and follows commands with
her left arm/leg. Head CT reportedly showed no ICH. She was
given
ASA 300 mg PR and transferred to [**Hospital1 18**]. She was not thought to
be
a tPA candidate at that time.
Her recent medical history is as follows: She was initially
admitted to [**Hospital3 7571**]Hospital on [**2117-12-31**] for hematemesis.
Her INR was reversed. She underwent gastroscopy which showed no
ulcer, but did show gastritis and duodenitis. CT was consistent
with intraperitoneal bleed. She received 2 U PRBCs and was
transferred to [**Hospital1 2025**] for spontaneous hemoperitoneum of unclear
etiology while on Coumadin. She received 2 more U PRBCs on
admission to [**Hospital1 2025**] causing her Hct to bump from 24->31, and
requiried Neo for a period of time. She underwent an exploratory
laparotomy (as her Hct initially appropriately bumped to 31 but
then decreased to 27 within hours) and was found
intraoperatively
to have a grade III splenic laceration so a splenectomy was
performed on [**2118-1-3**]. An umbilical hernia was also repaired
intraoperatively. She was transferred to the SICU, where
post-operatively she had 2 successive runs of ventricular
tachycardia (with negative troponins). On POD 3 she was
transfused 2 more U PRBCs since her Hct had slowly trended down
to 25.5, and this bumped to 36.7 then stabilized at 32. She was
sent to rehab on [**2118-1-12**]. On POD 3 she complained of foot pain
consistent with her prior diagnosis of gout, and this migrated
to
other joints to rheumatology was consulted and recommended a
prednisone taper and continuing colchicine. Per the discharge
summary, the "surgeons did not restart coumadin due to fall risk
and need for recent splenectomy due to fall." The report that
the
cardiologists could restart coumadin as an outpatient "if he
determines the risk of stroke from atrial fibrillation is
significant." She has been off Coumadin since [**12-31**], and she was
not put on an ASA.
In the ED, a Code Stroke was called at 13:24, and neurology was
immediately at the bedside.
In the ED, a Code Stroke was called at 13:24, and neurology was
immediately at the bedside.
NIHSS Score:
1a. LOC: 0
1b. LOC Questions: 2 (does not answer either question)
1c. Commands: 2 (does not follow either command to open eyes or
squeeze either hand)
2. Best Gaze: 2 (left gaze preference not overcome by Doll's
eyes)
3. Visual Fields: X (unable to test, but does not BTT on the
right)
4. Facial Palsy: 2 (right)
5. Motor Arm: 4 (right)
6. Motor Leg: X (unable to test, as cannot lift either leg off
the bed, does wiggle toes bilaterally, but more spontaneous
movements of the left foot than the right)
7. Limb Ataxia: X
8. Sensory: X
9. Best Language: 3 (global aphasia)
10. Dysarthria: X
11. Extinction/Neglect: X
NIHSS Score Total: 15
Past Medical History:
-Atrial fibrillation currently off Coumadin
-Hypertension
-TIA
-CAD s/p MI [**2115**]
-Gout
-CRI
-OA
-Spontaneous hemoperitonem of unclear etiology while on Coumadin
s/p exploratory laparotomy, and intraoperative splenectomy for
grade III splenic laceration discovered intra-operatively
[**2118-1-3**]
-s/p umbilical hernia repair [**2118-1-3**]
-s/p spinal surgery
Social History:
She has been living in rehab since her recent
discharge from [**Hospital1 2025**].
Family History:
NA
Physical Exam:
Physical Examination:
VS: temp 97.6, bp 120/76, HR 67, RR 12, SaO2 97% on 4L, FSBG 155
Genl: Awake, does not follow commands
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Slightly irregular (but not definitely irregularly
irregular), Nl S1, S2, III/VI systolic murmur best at the LUSB,
no rubs or gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NTND abdomen, surgical scar in her abdomen
clean/dry/intact
Neurologic examination:
Mental status: Awake, does not follow commands to open/close
eyes
or squeeze hands bilaterally. Globally aphasic, cannot produce
any words, speech nonfluent, cannot read, cannot repeat. Unable
to say her age or the month.
Cranial Nerves: Pupils equally round at 4 mm and minimally
reactive to light. Blinks to threat on the left, but not on the
right. Left gaze deviation, and does not pass midline upon
Doll's
eyes maneuver. Flat right NLF.
Motor/Sensation: Decreased tone in her right arm, but normal
tone
elsewhere. No observed myoclonus, asterixis, or tremor. Cannot
move her right arm against gravity, but does keep her left arm
extended against gravity. Wiggles toes bilaterally but on the
left much more than the right. Does not move her bilateral LE
against gravity. Grimmaces to nailbed pressure on the right hand
but does not withdraw her arm. Triple flexes her RLE to nailbed
pressure.
Reflexes: 2+ in right biceps, brachioradialis, triceps and trace
on the left. 0 and symmetric in knees and ankles. Toes upgoing
bilaterally.
Pertinent Results:
[**2118-1-14**] 02:10PM PT-12.1 PTT-33.1 INR(PT)-1.0
[**2118-1-14**] 02:10PM WBC-12.0* RBC-3.75* HGB-11.0* HCT-33.8*
MCV-90 MCH-29.4 MCHC-32.6 RDW-15.6*
[**2118-1-14**] 02:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2118-1-14**] 02:18PM LACTATE-2.4*
[**2118-1-14**] 02:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
[**2118-1-14**] 02:43PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2118-1-14**] 11:07PM CK-MB-NotDone cTropnT-0.01
Brief Hospital Course:
Ms. [**Known lastname 12184**] was admitted to the neurology service and
emergently taken to the interventional angio suite for MERCI
retrieval and IA tPA. Clot removal was attempted and she was
admitted to the ICU post-procedure. There she was extubated the
following days but her deficits persisted with a R hemiplegia
and aphasia. She was then transferred to the floor for further
care. Her CT head showed some bleeding in the site of her stroke
as well as residual contrast. She underwent secondary stroke
prevention evaluation with TTE, FLP and A1c. Her exam remained
stable however and she did not have consistent ability to follow
commands or speak. Her R hemiplegia was persistent as well and
she was noted to fail a swallow evaluation twice.
Given the extent of her injury, her current status and exam was
discussed at length with her HCP- [**Name (NI) **] [**Name (NI) 30047**]. She was also
noted to develop PNA and had increasing tachypnea, oxygen
requirement and a leukocytosis. Mr. [**Name13 (STitle) 30047**] decided to make
her CMO and she was therefore started on morphine, oxygen and
scopolamine. She was also started on Ativan for intermittent
tachypnea and continued on oxygen for comfort. She will be
transferred to inpatient hospice.
Medications on Admission:
Lopressor 12.5 mg PO q6 hr
Zocor 20 mg qhs
Lasix 40 mg [**Hospital1 **]
Isordil 5 mg [**Hospital1 **]
Prednisone taper (it appears that she is currently on 20 mg [**Hospital1 **]
x5 doses, then 10 mg [**Hospital1 **] x6 doses then 5 mg [**Hospital1 **] x6 doses)
Colchicine 0.6 mg PO every other day
Omeprazole 20 mg [**Hospital1 **]
Heparin 5000 U SC tid
Colace 100 mg [**Hospital1 **]
Senna 1 tablet PO bid
Dulcolax 10 mg PR daily
Tylenol 650 mg PO q6 hr prn
Oxycodone 5 mg PO q4 hr prn
Discharge Medications:
1. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
2. Acetaminophen 650 mg Suppository Sig: [**2-12**] Suppositorys Rectal
Q6H (every 6 hours) as needed for fever or pain.
3. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q1H
(every hour) as needed for pain/aggitation.
4. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) ML PO Q1H
PRN () as needed for aggitation, tachypnea.
5. Oxygen
Via Nasal Canuli or face mask as needed for tachypnea
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Stroke
Discharge Condition:
R hemiplegia; CMO
Discharge Instructions:
Comfort measures only
Followup Instructions:
NA
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 2760, 4019, 2720, 2749, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7214
} | Medical Text: Admission Date: [**2131-6-3**] Discharge Date: [**2131-6-5**]
Date of Birth: [**2086-8-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
G-J Tube Malfunction
Major Surgical or Invasive Procedure:
GJ tube replacement
History of Present Illness:
This is a 44 yo with chronic respiratory failure secondary to
[**Doctor Last Name **] muscular dystrophy, history of recurrent pneumonia and
c.diff colitis who presents with J tube dislodging. Per nursing
report from [**Hospital **] rehab where he was noted at 11:20 AM with
his G/J tube dislodged. Tube was manually placed back in to
keep tract open.
Of note, he was admitted to the MICU in [**3-28**] with fracture of
jejunostomy tube and required retrieval from gastric lumen. At
that time, after removal of J tube, GJ cathether was replaced
and pt was discharged back to rehab facility.
In the ED, initial vs were: T 98.9 92/53 HR 80. Per ED sign
out, IR was contact[**Name (NI) **] with plans for IR guided G/J tube
replacement for tomorrow.
On the floor, he has no complaints.
Past Medical History:
[**Doctor Last Name **] muscular dystrophy
Chronic respiratory failure s/p tracheostomy placement,
currently on mechanical ventilation, vent dependent AC
500/15/FiO2 21%/PEEP 5
H/o recurrent C. diff infection and pneumonia
Social History:
Patient chronically vented. He is a non-smoker. Has lived at
[**Hospital1 **] for 2 years.
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
Father with stroke. No history of muscular dystrophy.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Trach in place
Lungs: Clear anteriorly
CV: RRR nl s1 s2, no m/r/g
Abdomen: +G tube loose, with surrounding erythema, mild
discharge surrounding tube, mild TTP at site of G tube. +BS.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2131-6-3**] 04:30PM WBC-11.0 RBC-4.56* Hgb-11.6* Hct-35.7* MCV-78*
Plt Ct-338
[**2131-6-3**] 04:30PM Neuts-76.9* Lymphs-14.3* Monos-6.9 Eos-1.5
Baso-0.5
[**2131-6-3**] 04:30PM PT-13.4 PTT-28.0 INR(PT)-1.1
[**2131-6-3**] 04:30PM Glucose-84 UreaN-21 Cr-0.2* Na-138 K-4.1 Cl-103
HCO3-22
[**2131-6-3**] 04:30PM ALT-21 AST-28 LD(LDH)-249 AlkPhos-117
TotBili-0.5
[**2131-6-3**] 04:30PM Albumin-3.8
URINE:
[**2131-6-4**] 12:39PM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2131-6-4**] 12:39PM Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2131-6-4**] 12:39PM RBC-0-2 WBC-[**3-23**] Bacteri-OCC Yeast-NONE Epi-[**3-23**]
MICRO:
[**2131-6-4**] BCx: NGTD
[**2131-6-4**] UCx: NGTD
[**2131-6-4**] SputumCx: oral flora
STUDIES:
[**2131-6-4**] GJtube replacement:
The patient was brought to the fluoroscopic suite and placed on
the table in supine position. The anterior abdomen was prepped
and draped in the usual sterile fashion. Minimal amount of oral
contrast injection into the tube demonstrates a tract into the
stomach and the duodenum. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was introduced through
the catheter and the catheter was taken out. Over the wire, a
new MIC gastrojejunostomy tube was placed. 22-French
gastrojejunostomy tube was placed. Post-procedure contrast
injection
demonstrates optimal position of the tube in the stomach and the
jejunum. The balloon was inflated with 7 cc of saline.
IMPRESSION:
Successful fluoro-guided exchange of 22 French MIC
gastrojejunostomy catheter.
[**2131-6-4**] CXR:
As compared to the previous radiograph, there is no relevant
change. Unchanged position of the tracheostomy tube. Unchanged
near complete collapse of the right lung, with deviation of the
mediastinal structures to the right. Mild overinflation of the
left lung. No evidence of parenchymal opacities seen on the
left.
DISCHARGE LABS:
[**2131-6-5**] 09:00AM WBC-10.5 RBC-4.22* Hgb-10.9* Hct-33.6* MCV-80*
Plt Ct-272
[**2131-6-5**] 09:00AM Glucose-88 UreaN-7 Creat-0.1* Na-135 K-5.0
Cl-107 HCO3-17
[**2131-6-5**] 09:00AM Calcium-8.6 Phos-2.5* Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname **] is a 44 yo male with [**Doctor Last Name **] muscular dystrophy
with resultant chronic respiratory failure, ventilator dependent
here for G-J tube replacement.
1. G-J Tube: Admitted after G-J tube was dislodged with tube
peripherally reinserted to keep tract open. There was no
surrounding erythema, discharge or other evidence of underlying
abscess/ infection. A G-J tube study with contrast was
performed to confirm dislodgement of tube. Morning after
admission, IR replaced G-J tube under fluro guidance without
complications. Tube feeds may be restarted following discharge
from hospital.
2. Right lung partial collapse: On CXR to evaluate low grade
fever, patient noted to have partial collapse of right lung
despite preservation of repiratory status with no subjective
complaints. Vigorous suctioning did not improve aeration.
Bronchoscopy with BAL done to further evaluate showed no
occluding mass or mucus plugging. Initially placed on vanc/
zosyn for concern of ventilator associated pneumonia; however
with good O2 sats on outpt vent settings and no other clinical
signs of PNA this was discontinued. On note, on prior admission
in [**Month (only) 958**], left lung was similarly occluded and now has clear
lung fields.
3. Transient hypotension: On [**6-4**], patient noted have
asymptomatic hypotension with SBP in 70s and sinus tachycardia
in low 100s. Initially, there was concern that patient was
developing septic physiology with low grade temp to 99.6,
leukocytosis to 11.6. Metoprolol was held. Blood, urine, stool
cultures collected, bronchoscopy with BAL performed and patient
started empirically on vanc/ zosyn. Blood pressure and heart
rate returned to [**Location 213**] with 1 L NS bolus. As initial
infectious evaluation returned negative and hypotension/
tachycardia felt to be response to mild volume depletion,
antibiotics were discontinued. Patient remained afebrile with
SBP in low 100s for remainder of hospital course. Metoprolol
was not restarted on discharge, and should be re-evaluated as an
outpatient. Of note, final BAL cultures were still pending at
the time of discharge
4. Fluid status/ electrolytes: Following fluid bolus for
relative hypotension and [**Name2 (NI) 107070**] IVF with D51/2NS, patient
appearred to be relatively volume overloaded. Received IV lasix
x 1 prior to discharge. Electrolytes should be followed as an
outpatient given recent diuresis. If patient has persistent
volume overload, lasix may be continued as an outpatient.
5. [**Doctor Last Name **] musculodystrophy: stable, remains vent dependent
ADDENDUM:
mother noted that patient appeared more lethargic following G-J
tube placement. This was thought to be secondary to sedating
analgesics used during procedure. However mental status should
be followed carefully over next several days. Additionally,
heart rate still in low 100s on discharge, likely due to
discontinuation of home metoprolol.
Medications on Admission:
Lorazepam 1 mg q4 h prn
Jevity 1.2 cal TF 45cc/h, H2O 75cc q3H
Combivent 2 puffs [**Hospital1 **]
Metoprolol 12.5 Daily
Morphine 2 mg SQ q4h prn
Scopolamine patch q72h
Chlorhexidine [**Hospital1 **]
Zolpidem Tartrate 10 mg QHS
Alumina/mag/simethicone 30 cc q8 prn
Ondansetron 4 mg q8h prn
Paroxetine 40 daily
Metoclopramide 10 QID
Lactobacillus TID
Lansoprazole 30 daily
Ergocalciferol 800 daily
Discharge Medications:
1. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation twice a day.
2. Scopolamine Base 1.5 mg Patch 72 hr [**Hospital1 **]: One (1) patch
Transdermal every seventy-two (72) hours.
3. Ativan 2 mg/mL Solution [**Hospital1 **]: One (1) mg Injection every four
(4) hours as needed for anxiety.
4. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Mucous
membrane twice a day.
5. Zolpidem 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime)
as needed for Insomnia.
6. Maalox 200-200-20 mg/5 mL Suspension [**Hospital1 **]: Thirty (30) cc PO
every eight (8) hours as needed for indigestion.
7. Zofran 2 mg/mL Solution [**Hospital1 **]: Four (4) mg Intravenous every
eight (8) hours as needed for nausea.
8. Paroxetine HCl 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a
day.
9. Metoclopramide 10 mg IV Q6H
10. Lactobacillus Acidophilus Oral
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
12. Vitamin D 400 unit Tablet [**Last Name (STitle) **]: Two (2) Tablet PO once a day.
13. Furosemide 10 mg/mL Solution [**Last Name (STitle) **]: Ten (10) mg Injection once
a day as needed for fluid overload: may need daily for next few
days, but then can be d/c'd if pt is no longer fluid overloaded.
14. Morphine 2 mg/mL Syringe [**Last Name (STitle) **]: Two (2) mg Injection every
four (4) hours as needed for pain: hold for sedation; administer
SQ.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnosis:
GJ tube dislodgement
Transient hypotension
.
Secondary Diagnosis:
Muscular dystrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname **],
.
You were admitted to the hospital because your GJ tube was
dislodged. You had it replaced by the interventional
radiologists. It is now working, so you can continue to receive
tube feeds and medications through this tube.
.
The following changes were made to your medications:
#. HOLD Metoprolol, as your blood pressures were low-normal.
This can be restarted if your blood pressure rises.
#. START Lasix 10mg IV for the next several days, as you likely
are fluid overloaded from receiving intravenous fluids while in
the hospital. This can be stopped if your volume status
normalizes.
.
It was a pleasure meeting you and taking part in your care.
Followup Instructions:
Please follow up with your primary care physician when you're
back at [**Hospital1 **].
ICD9 Codes: 5180, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7215
} | Medical Text: Admission Date: [**2153-7-26**] Discharge Date: [**2153-8-1**]
Date of Birth: [**2073-7-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
CHEST PAIN
Major Surgical or Invasive Procedure:
CABG x5 (Lima->Lad, SVG->OM1&2/RCA/PLV)
History of Present Illness:
80yo M with history of DMII now with exertional CP and positive
stress test referred for outpt. stress test.
Past Medical History:
HTN
Hyperlipidemia
DMII
h/o increased LFTs
HOH
Social History:
quit tobacco 30-40yo
ETOH:2-3 beers/day
retired [**Hospital1 **] carpenter
Family History:
denies CAD
Physical Exam:
ADMISSION PE:
VSS: 5'7", 183Lbs, RR-18,P-78,142/80
General: NAD
HEENT: WNL
Lungs: CTA (B)
CVS: RRR
ABD: soft/NT/ND + BS
EXT: warm, N0 C/C/E
Pertinent Results:
[**2153-7-31**] 06:35AM BLOOD WBC-8.6 RBC-3.25* Hgb-10.4* Hct-29.4*
MCV-90 MCH-31.9 MCHC-35.2* RDW-15.1 Plt Ct-190#
[**2153-7-26**] 12:30PM BLOOD WBC-4.1 RBC-3.32* Hgb-10.8* Hct-30.4*
MCV-92 MCH-32.4* MCHC-35.4* RDW-14.8 Plt Ct-137*
[**2153-7-28**] 03:40AM BLOOD PT-15.4* PTT-36.9* INR(PT)-1.4*
[**2153-7-26**] 12:30PM BLOOD PT-15.1* PTT-34.7 INR(PT)-1.3*
[**2153-7-31**] 06:35AM BLOOD Glucose-110* UreaN-18 Creat-0.7 Na-140
K-3.5 Cl-103 HCO3-28 AnGap-13
[**2153-7-26**] 12:30PM BLOOD Glucose-136* UreaN-17 Creat-0.6 Na-139
K-4.0 Cl-107 HCO3-23 AnGap-13
[**2153-7-26**] 12:30PM BLOOD ALT-38 AST-49* CK(CPK)-59 AlkPhos-131*
Amylase-11 TotBili-0.9 DirBili-0.3 IndBili-0.6
[**Known lastname **] [**Known lastname 108702**],[**Known firstname **] [**Medical Record Number 108703**] M 80 [**2073-7-16**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2153-7-29**]
10:14 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2153-7-29**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 108704**]
Reason: s/p ct d/c
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with
REASON FOR THIS EXAMINATION:
s/p ct d/c
Final Report
HISTORY: Status post DC of chest tube.
CHEST, SINGLE AP VIEW.
Compared with [**2153-7-27**], multiple lines and tubes have been
removed, including a
left-sided chest tube. Still seen is a right IJ sheath tip over
proximal SVC.
The patient is status post sternotomy, with enlarged
cardiomediastinal
silhouette, which is stable. There is patchy opacity in the left
perihilar
region and left base, improved compared with [**2153-7-27**]. Minimal
atelectasis or
scarring is present at the right base.
No pneumothorax is identified. However, subtle pneumothorax
might be obscured
on this view due to the overlying first rib.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: SUN [**2153-7-29**] 2:41 PM
Imaging Lab
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **] [**Known lastname 108702**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 108705**] (Complete)
Done [**2153-7-27**] at 11:22:32 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2073-7-16**]
Age (years): 80 M Hgt (in): 67
BP (mm Hg): 130/70 Wgt (lb): 180
HR (bpm): 60 BSA (m2): 1.94 m2
Indication: Coronary artery bypass grafting
ICD-9 Codes: 440.0, 424.1
Test Information
Date/Time: [**2153-7-27**] at 11:22 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% >= 55%
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
Poor Transgastric windows
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
No LV aneurysm. Moderate regional LV systolic dysfunction. No LV
mass/thrombus. Moderately depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in ascending aorta. Normal aortic arch diameter.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. No MS. Physiologic MR
(within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
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 atrial septal defect is seen by 2D or color Doppler.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. No left ventricular
aneurysm is seen. There is moderate regional left ventricular
systolic dysfunction with moderate hypokinesis mid and distal
segments of anteriior, anteroseptal and lateral walls.. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is moderately depressed (LVEF=30
%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Physiologic mitral
regurgitation is seen (within normal limits).
There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in
person of the results on [**Known firstname 449**] [**Last Name (NamePattern1) 108706**] at 8:30AM.
Post-Bypass:
Normal RV systolic function.
Overall LVEF 45%.
Thoracic aortic contour is intact.
Mild AI.
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
Brief Hospital Course:
Mr. [**Known lastname **] [**Known lastname **] is an 80yo M taken to the Operating room on
[**2153-7-27**] with Dr.[**Last Name (STitle) 914**] and underwent a CABGx 5 with Lima
grafted to the LAD, SVG to the Diag1/2, OM, and PLV. BPT=116
min, XCT=96min. Please refer to Dr[**Last Name (STitle) 5305**] Operative report
for further details. He was transferred to the CVICU intubated,
requiring low dose levophed. Otolaryngology was consulted
postoperatively for bleeding from the oropharynx.
Reccommendations were followed/appreciated, and Mr.[**Known lastname **] [**Known lastname **] was
placed on Bactraban and nasal spray. He was extubated and weaned
off drips in a timely fashion. On POD #2 he remained in the
CVICU due to pleasant confusion and the need for close neuro
assesment. On POD#3 he was transferred to the floor, tubes and
lines were dc'd, beta-blockade and an ACE-I was instituted as
soon as BP allowed. The remainder of his postoperative course
was essentially uneventful with mental confusion improved with
low dose haldol. He was ready for discharge on POD#5 to rehab.
Medications on Admission:
Toprol XL 25(1)
Lisinopril 10(1)
Metformin 1000(2)
Glipizide 10(1)
Lipitor 20(1)
ASA 325(1)
NTG sl prn
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Tablet(s)
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID
(2 times a day) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
9. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days: wean over a week .
Disp:*14 Tablet(s)* Refills:*0*
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
12. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
s/p CABG x5
HTN
DM
Dyslipidemia
HOH
Discharge Condition:
GOOD
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 171**] (cardiology) in 2 weeks ([**Telephone/Fax (1) 9410**] please call
for an appointment.
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (NamePattern4) 108707**] (PCP) in 2 weeks please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2153-8-1**]
ICD9 Codes: 4111, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7216
} | Medical Text: Admission Date: [**2200-12-15**] Discharge Date: [**2201-1-17**]
Date of Birth: [**2200-12-15**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is the 2420 gm
product of a 34 [**3-9**] week gestation born to a 29 year old G1
P1 mother with prenatal screens of B positive, antibody
negative, RPR nonreactive, rubella immune, hepatitis surface
antigen negative, GBS unknown. Past medical history notable
for pulmonic stenosis and acoustic neuroma. This pregnancy
uncomplicated until onset of preterm labor, only 1 cm dilated
with fetal heart rate decel. Therefore, delivered by
cesarean section with rupture of membranes at delivery for
clear fluid. Mother did receive gent and clinda greater than
four hours prior to delivery.
Called to the O.R. by Dr. [**First Name (STitle) 3459**]. Baby emerged with
spontaneous cry. Received blow-by O2 and then developed some
apnea which required positive pressure ventilation with
several breaths. Grunting and flaring and retracting when
respiratory effort resumed. Apgars were 6 and 7. Infant was
transferred to the newborn intensive care unit for further
management of prematurity.
PHYSICAL EXAMINATION: On admission weight was 2420 gm, 60th
percentile; length 43.5 cm, 25th percentile; head
circumference 32 cm, 50th percentile. Overall not dysmorphic
with appearance consistent with estimated gestational age of
34+ weeks. Anterior fontanelle soft and flat. Positive red
reflex bilaterally. Palate intact. Positive grunting,
flaring and retractions. Breath sounds quite clear,
symmetric, slightly hyperdynamic precordium. Regular rate
and rhythm without murmur. Peripheral pulses 2+ including
femorals. Abdomen benign, nontender, nondistended, no
hepatosplenomegaly or masses. Normal female genitalia for
gestational age. Normal back and extremities with stable
hips. Skin pink, ruddy. Capillary refill two to three
seconds. Positive acrocyanosis. Appropriate tone and
strength.
HOSPITAL COURSE:
1. Respiratory. Grunting, flaring and retracting persisted,
prompting initiation of CPAP. She remained on CPAP for a
total of 24 hours, weaned to nasal cannula on which she
remained for 48 hours and has remained in room air throughout
the remainder of her hospital course. She has never required
intervention for apnea or bradycardia of prematurity.
Stridor was noted on day of life 27. Otolaryngology was
contact[**Name (NI) **] and Dr. [**Last Name (STitle) 46298**] evaluated the infant and
recommended followup one month after discharge for
laryngomalacia. His telephone number is [**Telephone/Fax (1) 42941**], beeper
number [**Pager number **]. This did not cause any problems with her
respiratory stability.
2. Cardiovascular. Has been hemodynamically stable with a
soft murmur noted on admission which continues to persist.
Echocardiogram performed on [**1-12**] revealed mild PPS
with normal arch, small ASD. Cardiology followup recommended
in six months.
3. Fluids, electrolytes and nutrition. Birth weight was
2420 gm. Discharge weight was 3070 gm. Infant was initially
started on 80 cc per kg per day of D10W. Enteral feedings
were initiated on day of life one. She achieved full enteral
feedings by day of life eight and has been stable with full
enteral feedings throughout her hospital course. Currently
she is ad lib feeding Enfamil 24 calorie, taking in adequate
amounts.
4. Hematology. Hematocrit on admission was 43.6. She has
not required any blood transfusions during this hospital
course.
5. Infectious disease. CBC and blood culture were obtained
on admission. CBC was negative. Infant received 48 hours of
antibiotics at which time blood cultures remained negative
and antibiotics were discontinued at that time. She has had
no further issues with sepsis during the hospital course.
6. Neurologic. The infant has been neurologically
appropriate and exam has been consistent with gestational
age.
7. Sensory/audiology. Hearing screen was performed with
automated auditory brain stem response. The infant passed in
both ears.
8. Psychosocial. The social worker has been involved with
the family and can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To the care of parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38896**], telephone number
[**Telephone/Fax (1) 38898**]. Fax: [**Telephone/Fax (1) 46299**].
CARE RECOMMENDATIONS: Continue ad lib feedings of Enfamil 24
calorie.
MEDICATIONS: None.
CAR SEAT: Car seat position screening test was performed and
the infant passed.
STATE NEWBORN SCREEN: The latest state newborn screen reports
have been within normal limits.
IMMUNIZATIONS: The infant received hepatitis B vaccine on
[**2200-12-24**] and will be due for dose #2 on [**2201-1-24**]. She
received Synagis vaccine on [**2201-1-15**]. Next synagis
dose is due [**2201-2-12**].
Recommended immunizations include Synagis RSV prophylaxis
which should be considered from [**Month (only) 359**] through [**Month (only) 547**] for
infants who meet any of the three following criteria: (1)
born at less than 32 weeks; (2) born between 32 and 35 weeks
with plans for daycare during RSV seasons, with smokers in
the household or preschool sibs; (3) with chronic lung
disease. Influenza immunization should be considered
annually in the fall for preterm infants with chronic lung
disease once they reach 6 months of age. Before this age
family and other caregivers should be considered for
immunization against influenza to protect the infant.
FOLLOWUP:
1. Otolaryngology with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46298**] at [**Hospital3 18242**]. Pager number is [**Telephone/Fax (1) 38834**], pager number [**Pager number **].
To be followed up one month after discharge.
2. Cardiology at 6 months of age at [**Hospital3 1810**]. Dr.
[**Last Name (STitle) 10123**], [**Telephone/Fax (1) 46300**].
3. CareGroup VNA: P: [**Telephone/Fax (1) 37503**]; F:[**Telephone/Fax (1) 38333**]
DISCHARGE DIAGNOSES:
1. Premature infant born at 34 4/7 weeks gestation,
corrected at 39 2/7 weeks gestation.
2. Mild respiratory distress syndrome.
3. Rule out sepsis with antibiotics.
4. Atrial septal defect, peripheral pulmonic stenosis.
5. Laryngomalacia.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 38294**]
MEDQUIST36
D: [**2201-1-17**] 05:04
T: [**2201-1-17**] 18:00
JOB#: [**Job Number 46301**]
ICD9 Codes: 769, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7217
} | Medical Text: Admission Date: [**2123-4-2**] Discharge Date: [**2123-4-7**]
Date of Birth: [**2057-1-21**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
66 yoF w/ a h/o myasthenia [**Last Name (un) 2902**] presents with labored
breathing. The patient had been at [**Hospital6 10353**] for the
past 1 month with pneumonia and COPD. She had planned on being
transferred to rehab today and had also had a scheduled
neurology appointment. While at the neurologist's office she was
noted to have labored breathing. She did not feel subjectively
short of breath and per her daughter, she had similar breathing
for the month. While at the neurologist's office the physician
stated that she appeared in no shape to go to rehab and should
go to the emergency room.
The patient currently denies any SOB, chest pain, pleuritic
chest pain, hemoptysis or cough. She has been relatively
immobile at the hospital, but with assistance can walk with a
walker. Her husband noticed some pedal edema (bilateral) 3 days
ago. Per her daughter she has memory deficits and occasional
confusion.
The patient denies urinary complaints, constipation or diarrhea,
nausea / vomiting, no fevers / chills.
In the ED, initial VS: T 97 HR 90 BP 128/80 RR 24 O2 sat: 100%
on 3L. She underwent a CTA of her chest which revealed
subsegmental PEs. Her EKG revealed an STE so a code stemi was
called, cardiology fellow evaluated the patient and deemed this
not to be a STEMI and suggested a CTA of her chest. The patient
had rec'd ASA and plavix load (300mg). VS prior to tranfer HR
92, BP 99/62, RR 28, 96% on 3L.
Past Medical History:
1. Myasthenia [**Last Name (un) 2902**] Dx in [**2121**]: primary neurologist in
[**Location (un) 38**], mild crisis in past marked by visual changes
(diplopia) nd generalized weakness, treated with mestinon 60mg
TID, prednisone and cellcept. At baseline, uses wheelchair for
any extended travel and walks around the home with a walker,
ADLs with support by her husband- primary caretaker
2. Stroke, [**2121**]- residual weakness in BLLE
3. History of lung CA in [**2116**], s/p chemoradiation, treated by
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4223**] in [**Hospital1 392**], ? small cell lung cancer.
4. Atrial fibrillation on dig/coumadin
5. Hypertension
6. Hypercholesterolemia
7. OSA
8. GERD
9. Chronic low back pain
10. Spine surgery, [**2120**]
11. Bilateral knee arthroscopy
12. Degenerative arthritis
13. Cholescystecomy
Social History:
She was discharged from [**Hospital1 18**] to [**Hospital 671**] Rehab. Has a prior
history of heavy smoking.
Family History:
Noncontributory
Physical Exam:
(Per Admitting Resident)
Vitals - T: 96.9 BP: 100/48 HR: 94 RR: 26 02 sat: 95% on 3L NC
GENERAL: NAD, AOx3
HEENT: MMM, EOMI, PERRL, conjunctiva pink, sclera anicteric
CARDIAC: RRR, no m/r/g
LUNG: CTAB although decreased breath sounds throughout
ABDOMEN: soft, NT, ND, no masses or organomegaly, BS+
EXT: WWP, trace bilateral edema
There is normal muscle bulk and tone throughout. Neck extension
is 5-/5, and neck flexion is 5-/5.
D B T WF WE ADM IP Q HS DF
L 4+ 5- 5- 5 5 4 4- 5 4+ 4
R 4+ 4+ 5- 5 5 5- 4- 5- 4+ 4
At time of discharge, VS 97.9 76 HR 70s-80s BP 120/72 RR 20-24
92-95% 2L NC
She had decreased BS on pulmonary exam with scant expiratory
wheezes and basilar rales. Has 1+ pitting edema B/L. Patient
weak overall related to illness and MG but neuro exam unchanged
from admission.
Pertinent Results:
Admission Labs
[**2123-4-2**] 01:10PM BLOOD WBC-7.9 RBC-4.15* Hgb-12.8 Hct-38.3
MCV-92 MCH-30.9 MCHC-33.5 RDW-17.6* Plt Ct-106*#
[**2123-4-2**] 01:10PM BLOOD Neuts-90.4* Lymphs-6.0* Monos-3.2 Eos-0.1
Baso-0.2
[**2123-4-2**] 01:10PM BLOOD PT-18.3* PTT-20.6* INR(PT)-1.7*
[**2123-4-2**] 01:10PM BLOOD Glucose-177* UreaN-28* Creat-1.1 Na-135
K-5.0 Cl-91* HCO3-32 AnGap-17
[**2123-4-2**] 01:15PM BLOOD Lactate-2.7*
Discharge Labs
[**2123-4-6**] 04:59AM BLOOD WBC-5.8 RBC-3.42* Hgb-11.1* Hct-32.3*
MCV-95 MCH-32.4* MCHC-34.3 RDW-18.1* Plt Ct-122*
[**2123-4-6**] 04:59AM BLOOD PT-19.7* PTT-84.5* INR(PT)-1.8*
[**2123-4-6**] 04:59AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-136
K-4.5 Cl-99 HCO3-29 AnGap-13
.
[**2123-4-7**] 05:25AM BLOOD WBC-5.6 RBC-3.21* Hgb-10.4* Hct-30.4*
MCV-95 MCH-32.3* MCHC-34.1 RDW-18.3* Plt Ct-127*
[**2123-4-7**] 05:25AM BLOOD PT-21.2* PTT-48.5* INR(PT)-2.0*
[**2123-4-7**] 05:25AM BLOOD Glucose-119* UreaN-18 Creat-0.9 Na-135
K-4.3 Cl-99 HCO3-24 AnGap-16
Cardiac Enzymes
[**2123-4-2**] 01:10PM BLOOD CK(CPK)-34 CK-MB-NotDone cTropnT-0.04*
[**2123-4-2**] 08:35PM BLOOD CK(CPK)-53 CK-MB-NotDone cTropnT-0.07*
[**2123-4-3**] 03:15AM BLOOD CK(CPK)-25* CK-MB-NotDone cTropnT-0.05*
proBNP-1523*
Urine Studies
[**2123-4-3**] 03:06AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.039*
[**2123-4-3**] 03:06AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2123-4-3**] 03:06AM URINE RBC-8* WBC-2 Bacteri-NONE Yeast-RARE
Epi-0
IMAGING:
CXR ([**4-2**]) - IMPRESSION: Left basilar atelectasis. Unchanged
cardiomegaly.
CTA Chest ([**4-2**]) - IMPRESSION:
1. Left lower lobe segmental and subsegmental acute pulmonary
embolism.
2. Persistent but slightly decreased right infrahilar density
now measuring 11 x 13 mm. As mentioned previously, PET-CT is
recommended to exclude underlying neoplasm.
3. Interval resolution of left upper lobe opacity. Left upper
lobe 7-mm nodule unchanged from the most recent prior, but new
from [**2122-3-8**]. Follow up chest CT in [**9-19**] months is
recommended.
4. Extensive atherosclerotic [**Date Range 1106**] disease.
5. Multiple new wedge deformities within the thoracic spine.
Bilateral LE LENIs - IMPRESSION: Nonocclusive thrombus extending
from the distal right common
femoral vein into the mid superficial femoral vein and proximal
deep femoral vein.
Echo ([**4-5**]) - The left atrium is elongated. The right atrium is
markedly dilated. The right atrial pressure is indeterminate.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). The right ventricular cavity is moderately
dilated with borderline normal free wall function. The aortic
root is moderately dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a
promient fat pad.
IMPRESSION: Normal left ventricular size with preserved global
and regional systolic and diastolic function. Moderately dilated
right ventricle with borderline normal free wall function in the
setting of abnormal septal motion/position consistent with right
ventricular pressure/volume overload. Moderate aortic root
dilatation. Moderate tricuspid regurgitation. Moderate pulmonary
artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2122-8-25**],
the pulmonary artery systolic pressures are higher. The other
findings are similar
Brief Hospital Course:
66 y/o F w/ a h/o myasthenia [**Last Name (un) 2902**], COPD and recent
hospitlization for PNA/COPD presents from neurologist oupt
office for labored breathing found to have pulmonary emboli.
# Pulmonary Emboli: The patient had no history of PE in the
past. She was on coumadin for afib and CVA but subtherapeutic on
admission. She was continued on coumadin, with an increased dose
and goal more in the 2.5-3 range. She was also started on a
heparin gtt which . She had lower extremity ultrasounds
performed which showed nonocclusive thrombus extending from the
distal right common femoral vein into the mid superficial
femoral vein and proximal deep femoral vein. Her clinical status
improved, and she was called out to the medicine floor service
on the day after her admission. She had an echo performed that
did show evidence of right-sided heart strain, consistent with
PE (see above for full report) but no evidence of right heart
failure and was relatively unchanged from prior. At the time of
discharge, her coumadin dose was still being titrated to bring
her INR to a therapeutic level. She remained on a heparin gtt to
bridge for 24-48 hours.
# COPD: She had significant wheezing initially and was
maintained on standing nebs then transitioned to home regimen
advair and tiotropium with albuterol prn. She was on 30 mg of
prednisone at the time of admission. She remained on this dose
throughout her hospitalization, and a taper was begun at the
time of discharge. Follow-up was arranged with an outpatient
pulmonologist given she did not have a pulmonologist or recent
PFTs
# ?STE in AVR on EKG: As stated in the HPI, cardiology fellow
evaluated the patient in the ED and deemed this not to be a
STEMI and suggested a CTA of her chest. She had serial cardiac
enzymes drawn which were stable. She denied any chest pain on
the medicine floor and repeat EKGs were without ST elevatoin. .
# Afib: She was continued on rate control with metoprolol and
cardizem. Digoxin was initially held but later restarted.
Metoprolol and cardizem doses were decreased, as pt had
bradycardia. Heparin gtt and coumadin as above.
# ARF: Improved with hydration to a normal creatinine level.
Lisinopril was initially held but then restarted when creatinine
improved and lasix dose was decreased to 20mg daily.
Electrolytes and renal function should be repeated in [**2-10**] days.
# OSA: Continued on CPAP at night.
# Myasthenia [**Last Name (un) **]: Continued on mestinon and imuran. Follow-up
arranged with neurologist Dr. [**Last Name (STitle) 1206**].
# Depression: Continued on provigil and zoloft.
# DM: Continued on lantus 20 units and insulin sliding scale.
# LLL nodule: Of note, imaging showed a LLL ground glass nodule
that should have f/u CT scan in [**9-19**] months (see report) and
also right infrahilar density which was decresae din size from
prior but which recommended outpatient PET scan to determine if
possible malignancy given history of lung cancer.
Medications on Admission:
advair 500/50 [**Hospital1 **]
cardizem cd 360mg daily
colace 100mg po bid
coumadin 5mg daily
digoxin 0.25mg daily
Duonebs qid
ferrous sulfate 324mg po daily
imuran 150mg po daily
K dur 20meq daily
Lantus sc qhs
RISS
Lasix 40mg po daily
Lopressor 25mg po q8hrs
Mestinon 60mg po tid
MVI daily
Oscal 1250mg po bid
Prednisone 30mg daily (plan taper, 30mg po daily until [**4-4**] then
20mg daily)
Prilosec 20mg daily
Lisinopril 20mg daily
Modafinil 200mg po daily
Senna
Spiriva daily
Vitamin D 400u [**Hospital1 **]
Zolfot 25mg po daily
Coumadin 5mg / 7.5mg daily
.
Discharge Medications:
1. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO four times
a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Warfarin 3 mg Tablet Sig: Three (3) Tablet PO once a day.
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulization Inhalation Q4H (every 4
hours).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
7. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
9. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours.
10. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO As Directed:
Please take 2 tablets (20 mg) daily for five days, then 1 tablet
(10 mg) daily for 5 days, then stop.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Modafinil 200 mg Tablet Sig: One (1) Tablet PO once a day.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO twice a
day.
17. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
18. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) capsule Inhalation once a day.
20. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
21. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO twice a day.
22. Heparin (Porcine) in NS (PF) 1,000 unit/500 mL Parenteral
Solution Sig: Titrate to PTT 60-80 units Intravenous continuous
for Until INR therapeutic x 48 hours days: Please titrate to
goal PTT 60-80. Would d/c when INR [**2-10**] x 48 hours. .
23. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
24. Humalog 100 unit/mL Solution Sig: 1-12 units Subcutaneous
every 6-8 hours: Per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
PRIMARY:
- Pulmonary Embolism
- COPD exacerbation
SECONDARY:
- Myasthenia [**Last Name (un) **]
- Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Lethargic but arousable
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were brought to the hospital for difficulty breathing, and
were found to have a blood clot in your lung. You were initially
admitted to the ICU, where you were treated with a heparin drip.
Since your coumadin levels were below therapeutic, your coumadin
dose was titrated to bring your anticoagulation levels within
the therapeutic range. You will remain on the heparin drip until
your INR (coumadin level) is in a good range for 48 hours.
Your medications have changed as follows:
- CHANGE cardizem to 60 mg four times a day
- CHANGE coumadin to 9 mg daily and your facility will follow
your coumadin levels
- DECREASE your metoprolol tartrate to 12.5 mg three times a day
- DECREASE your lasix to 20mg daily
- Your duonebs were changed to albuterol nebs
It was a pleasure taking part in your medical care.
Followup Instructions:
Please follow-up as below:
Appointment #1
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1206**]
Specialty: Neurology
Date/ Time: [**4-14**] at 11am
Location: [**Hospital Ward Name **], [**Hospital Ward Name 23**] bldg, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 44**]
Appointment #2
MD: Dr [**First Name8 (NamePattern2) 450**] [**Last Name (NamePattern1) 437**]
Specialty: Pulmonology
Date/ Time: [**4-30**] at 8:30am
Location: [**Hospital Ward Name 516**], [**Location (un) 11633**], [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 612**]
Special instructions for patient: You will have a breathing test
first followed by an appt with the doctor
You should also arrange a follow-up appointment with a primary
care physician if you are discharged from [**Hospital 80550**] rehab facility
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
ICD9 Codes: 5849, 2720, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7218
} | Medical Text: Admission Date: [**2191-11-7**] Discharge Date: [**2191-11-25**]
Date of Birth: [**2155-5-17**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Fevers, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 36 yo male with a history of cerebral palsy,
epilepsy, aspiration, aphasia who was previously diagnosed with
right lower lobe pneumonia on [**2191-10-5**] and completed a 10 day
course of levofloxacin. However, he was brought to ED by group
home staff on [**2191-11-7**] with fevers to 101 and productive cough -
unclear if white or yellow phlegm. The patient was febrile in
the ED with a WBC of 18.8 and placed on Levo/Flagyl for
aspiration pneumonia with CXR showing persistent cavitary RLL
pneumonia with effusion. He was found to have a lung abscess and
treated with IV Levo/Clinda.
Past Medical History:
cerebral palsy
mental retardation
seizures
Social History:
denies drugs, EtOH, tobacco
Lives in group home
Family History:
noncontributory
Physical Exam:
Tc=96.1 P=114 BP=130/78 RR=23 100% O2 I/O = 2075/1630
Gen - aphasic, very thin male, may at times respond to command,
alert
HEENT - PERLA, EOMI
Heart - increased rate, RRR, no M/R/G, clear S1, S2
Lungs - decreased BS at right base with crackles in mid-right
lung and bibasilar
Abd - NT, ND + BS
Ext - no cyanosis/positive clubbing/no edema, moves all four
extremities spontaneously
Pertinent Results:
CXR [**2191-11-7**] AP: Peristent right lung opacification - pleural
effusion with rounded lucency suggesting cavitation.
Brief Hospital Course:
36 yo M w/cerebral palsy, epilepsy, history of recurrent
aspiration pneumonias, aphasia now with right lower lobe lung
asbcess.
CT Chest [**2191-11-7**]: Necrotizing pneumonia in RML and RLL, lung
abscess. Cannot tell if effusions given limited study secondary
to scoliosis. Of note, bright contrast in gallbladder - sludge
vs. stone vs. contrast reaction vs. prior study residual
1. RLL pneumonia - CT notable for lung abscess. Pulmonology was
consulted and recommended Levofloxacin/Clindamycin. The patient
will need a course of 4 weeks of Levofloxacin/Clindamycin and
then clinda for as long as needed. Last day of levofloxacin is
[**12-5**]. Once the four week course is concluded, a repeat
chest xray should be taken to evaluate for resolution of the
lung abscess. If the abscess persists or the patient's
fevers/cough persist, clindamycin should be continued until
these resolve. An active issue in-house was the patient's
ability to take oral antibiotics as he intermittently spit the
antibiotics out. Therefore, a PICC was placed on [**2191-11-11**] for IV
antibiotics. Near the date of discharge, the patient was
tolerating his oral antibiotics. However, if he does not take
these antibiotics, he should be administered the IV form through
the PICC in his right arm. The PICC may then be removed after
antibiotics use has been completed.
2. Fevers - Patient's temp down to 100s with antibiotics. He
remained afebrile while on antibiotics.
3. Epilepsy - The patient's dilantin dose was adjusted secondary
to a subtherapeutic level. He was maintained on Dilantin 100 mg
PO Q8 hours. Plan to continue dilantin at current dose and check
dilantin level on Monday, [**11-28**] and adjust dilantin level
as needed.
4. Recurrent aspirations - The patient's family was concerned
that the patient had lost at lost a great deal of weight at the
group home where he staying. He had tolerated ground feeds while
at home with his mother one year ago. As a result, a video
speech and swallow evaluation was performed and showed that the
patient was aspirating all consistencies of food and had a
suppressed cough reflex most of the time. While eating on the
floor with aspiration precautions, the patient aspirated and
became hypoxic to 40% and went up to 90% with aggressive
suctioning. He was therefore transferred to the [**Hospital Unit Name 153**] for
aggressive respiratory management where he was maintained on a
shovel face mask of 9 L O2, kept NPO and continued on IV
antibiotics. Intubation was not required and he was subsequently
transferred to the floor.
Neurology was consulted to evaluate the patient (known to Dr.
[**Last Name (STitle) 2442**] to evaluate if the patient's dysphagia was related to
his known cerebral palsy or represented a new neurologic event.
The family was also concerned because they stated that the
patient was able to walk with assistance one year ago. A CT of
the head showed no acute change that would explain the patient's
decline and inabilities to swallow or walk. Neurology
recommended the patient follow up with Dr. [**Last Name (STitle) 2442**]. In terms of
the patient's dysphagia, the family indicated that they felt the
patient most enjoyed eating and in order to maintain his quality
of life, we should continue to feed him ground food knowing that
he will ultimately aspirate. Thus, the patient was continued on
a ground diet with thickened liquids which he tolerated.
5. Tachycardia - Of note patient with noted resting tachycardia
in 110-120 level. It is believed this is related to dehydration
as the patient responded to IV fluids.
6. Depression - The patient was noticed to be withdrawn during
most of his hospital course. However, he interacts more when his
family is present. As a result, Remeron 7.5 mg was started to
treat his depression.
Medications on Admission:
Outpatient:
Dilantin 300 mg PO daily
Tums
Vitamin D
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. Clindamycin Palmitate 75 mg/5 mL Recon Soln Sig: Twenty (20)
ml PO Q6H (every 6 hours) for 6 weeks.
Disp:*3360 ml* Refills:*0*
6. Phenytoin 100 mg/4 mL Suspension Sig: Six (6) ml PO Q12H
(every 12 hours).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
9. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection
injection Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Lung abscess
Epilepsy
Aspiration
Discharge Condition:
Stable
Discharge Instructions:
Please call your primary care physician or return to the ER if
you experience any shortness of breath or persistent fevers
despite antibiotics.
Followup Instructions:
The patient should follow up with his primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in 2 weeks by calling 1-[**Telephone/Fax (1) 3505**] to schedule an
appointment.
Provider [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 3506**] Date/Time:[**2191-12-6**] 11:30
ICD9 Codes: 5070, 2765, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7219
} | Medical Text: Admission Date: [**2166-12-27**] Discharge Date: [**2166-12-29**]
Date of Birth: [**2138-1-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Tylenol OD
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 28 yo man who presented to OSH after taking 30
capsules of tylenol, developing elevation of transaminases in
the 5000s as well as decreased synthetic hepatic function. In a
suicide attempt while "feeling insane and hearing voices" on
[**2166-12-24**] he slit his wrists and then decided that that wasn't
going to work and took approximately 30 tylenol PM. He called
his mother to apologize and then fell asleep. He boyfriend
arrived and took him to the hospital. On arrival at OSH he
received charcoal, mucomyst about 24 grams. On admission to OSH
ast 189, alt 170, alb 5.2, tbili 2.5, ap 54; acetominophen level
81, bicarb 21, creat 1.4, alcohol level < 5. Over the next few
days tranaminase increaed to 5000.
In the MICU, the patient continued to receive NAC. His
LFT's/INR began to trend down. He was transferred to the floor
on [**2165-12-28**]
Past Medical History:
Anxiety/Depression, possible bipolar disorder (after starting
SSRI in [**Month (only) 321**] had what sounds like manic episode) -- only on
medication since [**Month (only) 321**]
Social History:
homosexual, has boyfriend; lives with roommate (not boyfriend)
in [**Location (un) **]. works at an ad agency. +ETOH - 5x/week (6 pack each
time he drinks); +smoking 1/2pack to 1 pack per day; +drug use
(never IV drugs), last used crystal meth/coke last weekend.
Family History:
Great grand mother - [**Name (NI) 16941**] suicide
Grandmother with depression
Father - alcoholic
Mother - healthy
Physical Exam:
T97.2 BP 98/60 HR 67 RR 18 O2100%RA
General - NAD, lying comfortably in bed
HEENT - PERRL, EOMI
CV - RRR
Chest - CTA B/L
Abdomen - soft, NT/ND
Ext - healing slits on wrist
Pertinent Results:
[**2166-12-27**] 08:09PM BLOOD WBC-5.8 RBC-4.01* Hgb-13.1* Hct-34.8*
MCV-87 MCH-32.7* MCHC-37.7* RDW-12.4 Plt Ct-138*
[**2166-12-28**] 03:21AM BLOOD WBC-7.6 RBC-4.18* Hgb-13.5* Hct-36.4*
MCV-87 MCH-32.3* MCHC-37.1* RDW-12.6 Plt Ct-168
[**2166-12-29**] 05:10AM BLOOD WBC-9.9 RBC-4.71 Hgb-15.0 Hct-40.8 MCV-87
MCH-31.9 MCHC-36.9* RDW-12.7 Plt Ct-236
[**2166-12-27**] 08:09PM BLOOD PT-16.1* PTT-31.1 INR(PT)-1.8
[**2166-12-27**] 08:09PM BLOOD Plt Ct-138*
[**2166-12-28**] 03:21AM BLOOD PT-15.5* PTT-28.8 INR(PT)-1.6
[**2166-12-28**] 03:21AM BLOOD Plt Ct-168
[**2166-12-29**] 05:10AM BLOOD PT-13.5* PTT-27.8 INR(PT)-1.2
[**2166-12-29**] 05:10AM BLOOD Plt Ct-236
[**2166-12-27**] 08:09PM BLOOD Glucose-92 UreaN-7 Creat-0.9 Na-140 K-3.9
Cl-105 HCO3-28 AnGap-11
[**2166-12-27**] 08:09PM BLOOD ALT-3970* AST-2395* LD(LDH)-757*
AlkPhos-66 TotBili-0.5
[**2166-12-28**] 03:21AM BLOOD ALT-3794* AST-1667* AlkPhos-59
TotBili-1.0
[**2166-12-29**] 05:10AM BLOOD ALT-2929* AST-603* LD(LDH)-223 AlkPhos-78
TotBili-0.9
[**2166-12-27**] 08:09PM BLOOD TotProt-5.8* Albumin-3.4 Globuln-2.4
Calcium-8.8 Phos-3.4 Mg-1.7 Cholest-85
[**2166-12-28**] 03:21AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.7
[**2166-12-29**] 05:10AM BLOOD Albumin-4.4 Calcium-10.0 Phos-4.2 Mg-2.0
[**2166-12-27**] 08:09PM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND IgM
HBc-NEGATIVE IgM HAV-PND
[**2166-12-27**] 09:05PM BLOOD Lactate-1.2
Brief Hospital Course:
The patient is a 28yo man with hepatic failure s/p tylenol
overdose, transferred to [**Hospital1 18**] for transplant evaluation. Now
with LFT's trending down.
Tylenol Toxicity - the patient was originally admitted to the
ICU for close monitoring. His LFTS trended down from
5000-->2900/603, INR 1.8-->1.2 by 48 hours after ingestion. The
patient was originally treated with IV NAC as he was in the
probably hepatic toxicity range on the nomogram. We continued
to trend his labs. He was treated with NAC (total of 10 doses)
until his INR was normal and was clinically improved (LFTs were
trending down). Hepatitis/HIV seroligies were sent and pending
upon tranfer to the inpatient psych floor. He will need to
follow up in the liver clinic as an outpatient.
Suicide Attempt - The patient was seen by psychiatry and
maintained on section 12 with a 1:1 sitter for his entire stay
in the ICU and medical floor. No antidepressents were
initiatied on the medical floor.
The patient was transferred to inpatient psych on [**2166-12-29**].
Medications on Admission:
Paxil (started in [**Month (only) 321**])
Meds at OSH:
folic acid
thiamine
mvi
anzemet
prevacid
serax
morphine
mucomyst
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Tylenol Overdose
Discharge Condition:
Stable; liver function trending towards the normal range.
Afebrile; without complaints.
Discharge Instructions:
--Please follow up in the liver clinic next week to check your
liver function.
--Please avoid all tylenol products until your liver function
tests have returned to [**Location 213**].
Followup Instructions:
--Please follow up with Dr [**Last Name (STitle) 64537**] (psychiatrist) within [**12-8**]
days of discharge from your inpatient psych unit.
-- Please call the liver clinic for an appoitment within 1 week
of discharge. [**Telephone/Fax (1) 2422**]. You will need to have your blood
work done at that time.
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7220
} | Medical Text: Admission Date: [**2164-7-3**] Discharge Date: [**2164-7-12**]
Date of Birth: [**2100-5-24**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
woman with no significant past medical history, who developed
Strep pneumopericarditis. She was in her usual state of
health until four days prior to admission, when she began to
notice myalgias in her proximal joints, knees, back, and in
her chest. Over the next day, she also developed right sided
pleuritic chest pain and tachypnea with splinting. At home,
she took her temperature which was 102.9, and treated with
ibuprofen and acetaminophen. She had one syncopal episode,
and believed it to be related to being "sick" as she has
experienced syncope with illness before. She took a Vicodin
for the pain and felt better.
The next day her tachypnea and dyspnea worsened, and her
husband brought her to the Emergency Department. A
transthoracic echocardiogram was performed demonstrating
enlarged pericardial effusion without echographic signs of
tamponade. Electrocardiogram showed diffuse ST elevations
and evidence of electrical alternans.
PAST MEDICAL HISTORY:
1. Anemia, hematocrit in the low 30's since young adulthood.
2. Mild digital osteoarthritis.
3. History of trochanteric bursitis.
4. Insomnia.
5. History of pneumonia [**2161**].
6. G4 P3 M1.
MEDICATIONS ON ADMISSION:
1. Colace.
2. Valium 5 mg po q hs.
3. Multivitamin po q day.
ALLERGIES: Codeine and Darvon both cause nausea.
FAMILY HISTORY: Family history of malignant hyperthermia.
SOCIAL HISTORY: Denies tobacco. Has two drinks per week.
Lives in [**Location **]. Has three kids. Married to Dr.
[**Known lastname 7626**], physician here at [**Hospital1 188**].
SIGNIFICANT LABORATORIES ON ADMISSION: White count 25.2 with
81 neutrophils and 11% bands, hematocrit 33. Bicarb 24. ESR
123. CK 36.
Chest x-ray: Right costophrenic angle blunted. Left
costophrenic angle blunted with obscuring of the left
hemidiaphragm.
BRIEF HOSPITAL COURSE:
1. Pericardial effusion/tamponade. The patient was taken
emergently to the Cardiac Catheterization Laboratory. There
was elevation, and there was complete equalization of filling
pressures with decreasing cardiac output and a pulsus
paradoxus of 22 mm Hg all consistent with tamponade.
Pericardiocentesis was performed, 680 cc thick fibrinous
fluid was removed, bedside echocardiogram confirmed almost
complete removal of the pericardial fluid.
The patient's symptoms of dyspnea resolved almost
immediately, and pulsus returned to 10. Right atrial
pressures, however, remained elevated at 16 with positive
Kussmaul's sign consistent with effusive constrictive
syndrome.
The patient was transferred to the CCU for observation.
Pansensitive Strep pneumo grew from culture of the
pericardial fluid. Viral and fungal cultures were negative.
The patient was initially treated with Vancomycin/Zosyn. ID
was consulted, and recommended changing to ceftriaxone.
Dr. [**Last Name (STitle) **] followed the patient in the CCU with serial
echocardiograms as well as onto to the floor. She remained
hemodynamically stable and the effusion appeared smaller on
[**2164-7-5**] than previously suggesting resolution. The patient
will follow up in one month after discharge with Dr.
[**Last Name (STitle) **] with a repeat echocardiogram. She will continue
ceftriaxone 2 grams IV q24h for one month.
The ID consult service recommended pneumococcal vaccine which was
given prior to discharge. The ID fellow, [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) 1774**],
[**First Name3 (LF) **] arrange [**Hospital **] Clinic followup to check serum
immunoglobulins once the patient has recovered from her acute
illness.
Of note, followup blood cultures were all negative for
growth. The initial Streptococcus pneumonia bacteria were
sensitive to ceftriaxone, erythromycin, levofloxacin,
penicillin, tetracycline, trimethoprim/sulfa, and Vancomycin.
On day of discharge, the patient is afebrile with a white
count of 10.3.
2. Pleural effusion. On initial chest x-ray, the patient was
noted to have bilateral pleural effusions. A chest x-ray was
obtained demonstrating right greater than left pleural
effusions with increased fluid in the major fissure. These
effusions were loculated on CT scan with a foci of
ground-glass attenuation and thickened septal lines. Repeat
CT scan showed evidence of progression of the effusions. In
addition, the patient had a persistent O2 requirement of 2
liters. The patient underwent thoracentesis when she was in
the Intensive Care Unit.
Dr. [**Name (NI) **] and Dr. [**Last Name (STitle) **] consulted with Dr. [**Last Name (STitle) 175**],
who all decided bilateral VATS was the best approach for Mrs.
[**Known lastname 7626**]. The procedure was performed and four chest tubes
placed. The patient's pain was maintained under control with
epidural anesthesia. The drainage from the chest tubes
gradually resolved. The tubes were pulled without
complication and the patient's oxygen requirement resolved.
Of note, the cultures of the pleural effusions are negative
to date, however, these were drawn after the patient was
started on antibiotics. The effusions are felt to be
infectious in etiology.
Cytology is negative for malignant cells, demonstrates
numerous reactive cells including neutrophils, lymphocytes,
histocytes, and mesothelial cells. The patient will follow
up with Dr. [**Last Name (STitle) 175**] in one week.
By the end of the hospital course, the patient was using only
Tylenol with oxycodone 5 mg for pain management.
3. Atrial fibrillation concurrent with pericarditis. This is
felt to be typical of a pericardial inflammation. The
patient was started on an amiodarone load, and will continue
as an outpatient on daily amiodarone for one month. She will
be maintained on aspirin, but no further anticoagulation as
the risk for hemorrhagic pericarditis is too high. She had
several episodes of atrial fibrillation (six times lasting
hours during the hospital stay). She was started on low-dose
beta blocker for rate control. She was monitored on
Telemetry.
On day of discharge, she had a normal sinus rhythm and will
follow up with Dr. [**Last Name (STitle) **] in one month.
4. HSV-I oral lesions. During the initial workup of
positives of the pericarditis, a throat swab was obtained in
the Intensive Care Unit. This was positive for HSV-I. By
the end of her course, Mrs. [**Known lastname 7626**] had developed oral
lesions consistent with HSV-I virus. She was started on
acyclovir 400 mg po 5x/day. This dose was decreased to tid
and will be continued for the remainder of a two week course.
5. Diarrhea. The patient developed diarrhea felt to be
related to antibiotics. Clostridium difficile was negative
and the diarrhea resolved prior to discharge on loperamide.
6. Pedal edema. Towards the end of the hospital course, Mrs.
[**Known lastname 7626**] developed [**1-26**]+ pitting pedal edema as well as 1+
edema in her hands. This was felt likely secondary to low
albumin and poor nutrition. She received Boost supplements
with meals and was given a prescription for [**Male First Name (un) **] hose to be
worn at home.
DISCHARGE DIAGNOSES:
1. Strep pneumopericarditis and pericardial effusion.
2. Pericardial tamponade.
3. Paroxysmal atrial fibrillation.
4. Bilateral pleural effusions.
5. Status post bilateral VATS.
6. Herpes simplex virus oral lesions.
DISCHARGE MEDICATIONS:
1. Diazepam 5 mg po q hs.
2. Multivitamin one tablet po q day.
3. Docusate sodium 100 mg po bid.
4. Amiodarone 200 mg po q day.
5. Ceftriaxone 2 grams IV q24h x4 weeks.
6. Oxycodone 5 mg po q8h prn pain.
7. Metoprolol 12.5 mg po bid.
8. Pantoprazole 40 mg po q day.
9. Aspirin 325 mg po q day.
10. Acyclovir 400 mg po q day x12 days (total of 14 day
course).
11. Loperamide 2 mg po qid prn diarrhea.
12. Lidocaine solution tid prn mouth pain.
[**Doctor First Name **] [**First Name8 (NamePattern2) 1243**] [**Name8 (MD) **], M.D. [**MD Number(1) 3025**]
Dictated By:[**Last Name (NamePattern1) 11873**]
MEDQUIST36
D: [**2164-7-15**] 16:36
T: [**2164-7-24**] 06:21
JOB#: [**Job Number 102388**]
ICD9 Codes: 5119, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7221
} | Medical Text: Admission Date: [**2109-6-15**] Discharge Date: [**2109-6-22**]
Service: TRA
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old gentleman
who was transferred from an outside hospital after he was
found down. The reason for his fall was unknown. He did
have some loss of consciousness and was noted to be bleeding
from the nose. A balloon was placed at the outside hospital
in the nares to control the bleeding. On transfer, the
patient was awake, somewhat confused and interaction was
difficult due to his profound deafness. He had bruising
extensively to the left side of his face.
PAST MEDICAL HISTORY:
1. Myelomonocytic leukemia diagnosed five years ago with low
platelets and low hematocrit.
2. Chronic renal failure with a baseline creatinine of 3.2.
3. Hypertension.
4. Status post coronary artery bypass graft.
5. Hypothyroidism.
6. Unknown abdominal surgery.
7. Hypercholesterolemia.
HOSPITAL COURSE: The patient underwent normal trauma
protocol when he was admitted to [**Hospital6 649**]. He had multiple images which included chest
x-ray which was negative, a pelvic x-ray which was negative,
and a head computerized tomography scan showed that he had a
right frontal subarachnoid hemorrhoid with small hemorrhagic
contusions in the right temporal lobe. He had multiple
facial fractures including a left zygomatic arch fracture, an
anterior, medial and lateral left maxillary sinus fracture
and anterior medial right maxillary sinus fracture. He had
an inferior and lateral wall right orbital fracture, and a
left orbital wall fracture with no evidence of an entrapment.
The remainder of his images were negative including a
computerized tomographic urogram.
The patient was initially admitted to the Intensive Care Unit
for q. 1 neurologic checks of his intracranial bleed and to
monitor his posterior pharynx bleed which was controlled by a
packing which was placed by Otorhinolaryngology. On hospital
day #3 he was transferred to the floor where he was
hemodynamically stable. Oral and Maxillofacial Surgery was
called to consult on his facial fractures but given his
numerous other comorbidities the risk of operation was
thought to be too great. While on the floor it was noticed
that the patient developed hematuria and was unable to void
secondary to clots in the Foley catheter. Continuous bladder
irrigation was started and a urology consult was obtained.
His creatinine also began to rise and a renal consult was
obtained as well. The patient became oliguric making 20 cc
of urine over eight hours and he was transferred to the
Intensive Care Unit for central venous catheter placement to
better monitor his fluids. Extensive discussion with the
family, specifically the son and daughter, took place. The
patient was made Do-Not-Resuscitate and Do-Not-Intubate and
was to have no hemodialysis.
On [**2109-6-22**], in the evening, the patient was noted to
have low oxygen saturations. Oxygen saturations continued to
decline and the son was notified who reiterated the Do-Not-
Resuscitate, Do-Not-Intubate status. The patient expired at
9:50 on [**2109-6-22**] and the family was notified.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Last Name (NamePattern1) 41037**]
MEDQUIST36
D: [**2109-6-23**] 03:02:50
T: [**2109-6-23**] 06:37:58
Job#: [**Job Number 55998**]
ICD9 Codes: 5990, 5845, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7222
} | Medical Text: Admission Date: [**2144-8-1**] Discharge Date: [**2144-8-6**]
Date of Birth: [**2075-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
CP
Major Surgical or Invasive Procedure:
PCI with angioplasty and DES to Mid-RCA
History of Present Illness:
68-year-old woman haitian Crecole speaking only with history of
type 2 DM, hypertension and hyperlidpedemia who presented to
[**Hospital1 18**] ED with 3 days of chest pain. Patient reports that about
three days ago while she was putting her clothes in the laundry
she had suddedn onset of substernal chest pain with radiation to
her neck, right arm and her abdomen. She attributed this pain
to indigestion. The pain was [**4-16**] and remained constant. Today
at 6:30am patient patient acutely worsened [**9-16**] associated with
nasuea, diaphoresis and shonrtess of breaht.
.
In the ED, initial vitals were 45 96/45 16 100% RA. ECG showed
ST Elevation Myocardial Infarction in inferior leads. She was
given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1
and heparin 4000 units IV bolus. She was noted to be bradycardic
and hypotensive and thus given atropine 1mgx2 and started on
dopamine gtt which improved her blood pressure. She was
transfer to Cath lab.
.
In the Cath lab, she was noted to acute mid RCA occlusion which
was treated with angioplasty x 3 (10 mm/12 mm/14 mm) with
residual thrombus which was exported and Promus DES was placed
in mid RCA. His cath lab course was complicated by intermittent
complete heart block requiring temporary pacemaker pre-stenting
though she was conducting 1:1 in NSR after stenting. She was
also noted to have AIVR. Dopamine at 5 mcg/kg/min was turned
off at the end of her cath lab course. A small 1.5cm hematoma
was visible at the RFV access site after the case, and manual
pressure was applied for 10 minutes.
.
In the CCU, she did not report chest pain, discomfort,
palpatations or shortness of breath. She desnies any history of
chest pain.
Past Medical History:
DM2
HTN
TB
peripheral neuropathy
aseptic thrombophlebitis of the left internal jugular in [**2130**].
Social History:
Lives with husband, ha two children who live in [**Country 2045**]. Creole
speaking from [**Country 2045**] 14 years ago. Three children. No history
of tobacco, ETOH or illicit.
Family History:
non-contributory
Physical Exam:
Admission Physical:
GENERAL: Appears well NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. MMM
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: 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: Wamr and well perfused No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2144-8-1**] 11:35AM BLOOD WBC-10.8# RBC-3.35* Hgb-10.3* Hct-30.8*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.8 Plt Ct-178
[**2144-8-1**] 11:35AM BLOOD PT-12.5 PTT-30.7 INR(PT)-1.2*
[**2144-8-1**] 11:35AM BLOOD Glucose-394* UreaN-22* Creat-1.2* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2144-8-1**] 11:35AM BLOOD CK-MB-11* MB Indx-1.2
[**2144-8-1**] 05:15PM BLOOD CK-MB-16* MB Indx-1.9
[**2144-8-2**] 05:28AM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-3.44*
[**2144-8-1**] 11:35AM BLOOD CK(CPK)-891*
[**2144-8-1**] 05:15PM BLOOD CK(CPK)-821*
[**2144-8-2**] 05:28AM BLOOD CK(CPK)-555*
Cardiac Cath
1) Selective coronary angiography of this co-dominant system
demonstrated three-vessel coronary artery disease. The LMCA had
mild
luminal irregularities. The proximal-mid LAD had an 80%
trifurcation
lesion that was tightest at the large diagonal branch takeoff;
there was
a high diagonal branch (functionally a ramus) that had diffuse
proximal
70% stenosis. The LCx was a diffusely-diseased vessel with a
likely
stump-occluded OM2 and severely diseased distal vessel; it
provided a
smaller left PDA. The mid-RCA was 100% occluded without
anterograde
flow into the distal vessel; there was also haziness noted at
the AM
origin. The ostial RCA had a 30-40% stenosis.
2)
3) During the procedure, and given the degeneration of the
conduction
disease to high-grade heart block associated with hypotension, a
temporary pacing wire was inserted through the 5 French venous
sheath
with successful capture at 80 bpm and [**7-17**] mA. After the PCI,
pacing
was discontinued, and the patient remained in sinus rhythm with
1:1
conduction at a rate of 80 bpm with normotensive blood
pressures. The
temporary pacing wire was therefore removed and the dopamine was
discontinued.
4) After the procedure, the 6 French right femoral arteriotomy
site was
AngioSealed with adequate hemostasis. The 5 French right femoral
venous
sheath was left in place in case of worsening conduction disease
overnight. A small 1.5cm hematoma was noted after the
procedure.
FINAL DIAGNOSIS:
1. Inferior wall STEMI with high-grade AV block.
2. Successful emergent primary PCI of occluded mid RCA with
PTCA, export
thrombectomy, and Promus drug eluting stent.
3. Emergent temporary pacing wire placement with active pacing
during
the procedure.
.
TTE: [**2144-8-3**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall. The remaining segments
contract normally (LVEF = 40 %). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Pulmonary artery hypertension.
.
CLINICAL IMPLICATIONS:
Based on [**2138**] 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.
.
Discharge Labs:
Brief Hospital Course:
68-year-old woman, Haitian-Creole speaking, with history of type
2 DM, hypertension, and hyperlidpedemia, presented with inferior
STEMI now s/p DES to mid RCA.
.
# STEMI: Patient with multiple cardiovascular risk factors
(uncontrolled diabetes, uncontrolled hypertension and
hyperlidemia) presented with worsening chest pain. ECG was
consistent with ST elevation myocardial infarction in inferior
leads. She was given aspirin 325 mg, plavix 600 mg, eptifibatide
180 mcg/kg x 1 and heparin 4000 units IV bolus. She was noted to
be bradycardic and hypotensive and thus given atropine 1mgx2 and
started on dopamine gtt which improved her blood pressure. She
was transfer to the Cath lab. In the Cath lab, she was noted to
have acute mid RCA occlusion which was treated with angioplasty
x 3 (10 mm/12 mm/14 mm) with residual thrombus, which was
removed, and Promus DES was placed in the mid RCA. Her Cath lab
course was complicated by intermittent complete heart block
requiring temporary pacemaker pre-stenting though she was
conducting 1:1 in NSR after stenting. She was also noted to
have AIVR. Dopamine at 5 mcg/kg/min was turned off at the end
of her Cath lab course. She had an ECHO report that showed mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall with EF 40%. Mild
symmetric left ventricular hypertrophy with regional systolic
dysfunction c/w CAD (PDA distribution). Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Pulmonary artery hypertension.
During her CCU course, patient had one episode of shortness of
breath and increased respiratory rate with bilateral crackles on
exam. She was treated with Lasix which improved her sxs and she
had no further episodes of chest pain or shortness of breath
during her hospital stay. Patient was evaluated by physical
therapy on the day of discharge and determined safe to go home.
Patient will follow up with Dr. [**Last Name (STitle) 10156**] in Cardiology and
with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She was discharged on the
following medications: Lasix, metoprolol, lisinopril,
atorvastatin, and Plavix.
.
# Arrythmia: Patient had bradycardia with dropped beats and
atrial ectopy likely in the setting of reperfusion post [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 10157**]. She did not have any symptomatic episodes of
bradycardia during her CCU course. She was also started on low
dose metoprolol which she tolerated very well.
.
# Diabetes Type 2: Poorly controlled and complicated by diabetic
nephropathy, retinopathy, and neuropathy. Last A1c was 8.7 in
3/[**2143**]. She was continued on 11units of NPH and insulin sliding
scale. On discharge, she was put on ----.
.
# Anemia: Hematocrit during this admission was around 30.
Prior HCT on OMR from [**2141**] shows HCT of 37.9. Unclear etiology.
No source of obvious bleeding and normal coags. Patient will
follow up with PCP for further management.
.
# Hypertension: Patient blood pressure was well controlled on
low dose metoprolol. Her home chorthalidone, amlodopine, and
lisinopril were initally held due to low bps. She was
discharged on metoprolol, lisinopril and lasix.
.
# Hyperlidemia: Started atorvastain 80mg daily.
.
Transitional Issues:
- needs close follow-up with Cardiology, PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] recommend [**Last Name (un) **] consultation for DM
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Ranitidine 150 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 325 mg one tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
2. Ranitidine 150 mg PO BID
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 40 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablets by mouth daily Disp #*30 Tablet
Refills:*2
10. Outpatient Lab Work
Please check Chem-7 at [**Hospital6 733**] on [**2144-8-11**] with
results to Dr. [**Last Name (STitle) 6215**] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD-9 428
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Inferolateral ST elevation myocardial infarction
acute systolic congestive heart failure
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 10158**],
It was a pleasure taking care of your during your admission at
[**Hospital1 18**]. You were admitted because you were having chest pain and
you were found to have a heart attack for which you had a stent
placed in your heart. You have also been started on new
medications (aspirin and clopidogrel) to prevent the stenting of
the clot which you should continue to take unless told otherwise
by your cardiologist.
Weigh yourself every day before breakfast. Call Dr. [**Last Name (STitle) **] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.
The visiting nurse will help you with a low salt diet.
.
Please continue to take your medications as directed in your
discharge medication sheet. Please do not stop any medication
especially clopidogrel unless told by your cardiologist. You
risk having a heart attack if you do not take this medicine
every day.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2144-9-3**] at 1 PM
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: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2144-8-11**] at 11:50 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4280, 2724, 3572, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7223
} | Medical Text: Admission Date: [**2160-6-23**] Discharge Date: [**2160-7-1**]
Date of Birth: [**2076-2-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2160-6-23**] 1. Aortic valve replacement with a [**Street Address(2) 6158**]. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 4041**] tissue valve, reference number [**Serial Number 24303**],and serial number
[**Serial Number 24304**].
2. Coronary artery bypass grafting x2 with the left internal
mammary artery to the left anterior descending artery and
reverse saphenous vein graft to the 2nd diagonal artery.
History of Present Illness:
Patient is an 84yo male with history of CAD s/p RCA stents x 2,
PVD s/p RSFA stent with ongoing claudication, known AS with
serial echos now severe with new report of shortness of breath
over the last few months when walking his dog for 20 minutes. He
also reports bilateral claudication.
Past Medical History:
Aortic stenosis
Cholecystectomy
Parotid tumor removed from behind right ear
Arthritis
Mocardial infarction (NSTEMI [**2146**])
Coronary artery disease s/p RCA stent x 2 ( [**2146**],[**2152**])
Peripheral vascular disease s/p RSFA stent ([**2155**])
Hypertension
Hyperlipidemia
Anemia
Cataract removal
Social History:
Independent. Widowed, lives alone with dog (12yo golden
retriever). Walks dog [**Hospital1 **], attends [**Company 3596**] 3x/wk to do eliptical
machine. One son, local. Drives himself to appts.
Lives with: alone
Occupation: retired printing company
Tobacco: 2-3ppd age 16-70's, none current
ETOH: none current
Family History:
Mother deceased age 50's, brain Ca. Father deceased age 69, CAD.
Brother deceased age 50's, liver dz. Brother alive, CAD. Son,
57yo, alive and well.
Physical Exam:
Pre op exam:
Pulse:52 B/P: Right 142/58 Resp: 16, O2 Sat: 97%
Height: 5 feet 7 inches Weight: 150 pounds
General: Alert well developed elderly male in NAD at rest.
Skin: color pale, skin warm and dry, no lesions noted.
HEENT: normocephalic,anicteric, EOMIs. Oropharynx moist.
Neck: supple, trachea midline, no jvd. No carotid bruits noted
Chest: CTA
Heart: III/VI murmur RSB radiating throughout precordium
Abdomen: soft, flat,nontender
Extremities: trace LLE edema, 2+ RLE edema. Right >left
chronically
Neuro: A+O x 3
Pulses:
Femoral: Right cath site Left 2+
Dorsalis Pedal: Right +1 Left +1
Posterior Tibial: Right +1 Left +1
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.0 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aorta - Annulus: 2.6 cm <= 3.0 cm
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Descending Thoracic: *3.1 cm <= 2.5 cm
Aortic Valve - Mean Gradient: 40 mm Hg
Findings
LEFT ATRIUM: Marked LA enlargement. Depressed LAA emptying
velocity (<0.2m/s) No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Mildly dilated
ascending aorta. Mildly dilated descending aorta. Complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Severely
thickened/deformed aortic valve leaflets. Bioprosthetic aortic
valve prosthesis (AVR). Moderate (2+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe
mitral annular calcification.
Pre-op labs:
[**2160-6-23**] 04:01PM GLUCOSE-152* LACTATE-2.0 NA+-136 K+-5.1
CL--118*
[**2160-6-23**] 04:02PM FIBRINOGE-164*
[**2160-6-23**] 04:02PM PT-17.9* PTT-41.0* INR(PT)-1.7*
[**2160-6-23**] 04:02PM PLT COUNT-131*
[**2160-6-23**] 04:02PM WBC-10.8 RBC-2.23*# HGB-6.9*# HCT-20.9*#
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.1
[**2160-6-23**] 05:25PM UREA N-21* CREAT-0.9 SODIUM-143 POTASSIUM-5.0
CHLORIDE-117* TOTAL CO2-19* ANION GAP-12
[**2160-7-1**] 04:38AM BLOOD WBC-11.4* RBC-2.79* Hgb-8.7* Hct-26.2*
MCV-94 MCH-31.3 MCHC-33.3 RDW-14.2 Plt Ct-197
[**2160-7-1**] 04:38AM BLOOD Plt Ct-197
[**2160-7-1**] 04:38AM BLOOD PT-29.2* PTT-108.8* INR(PT)-2.8*
[**2160-7-1**] 04:38AM BLOOD Glucose-113* UreaN-45* Creat-1.4* Na-139
K-4.5 Cl-105 HCO3-25 AnGap-14
[**2160-7-1**] 04:38AM BLOOD Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname 11270**] was a same day admission and on [**6-23**] was brought
directly to the operating room where he underwent an aortic
valve replacement and coronary artery bypass graft x 2. Please
see operative report for surgical details. In summary he had: 1.
Aortic valve replacement with a [**Street Address(2) 6158**]. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**] tissue
valve, reference number [**Serial Number 24303**],and serial number [**Serial Number 24304**].
2. Coronary artery bypass grafting x2 with the left internal
mammary artery to the left anterior descending artery and
reverse saphenous vein graft to the 2nd diagonal artery. His
cardiopulmonary bypass time was 154 minutes with an aortic
crossclamp time of 134 minutes. he tolerated the operation well
and post operatively was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours he was weaned
from sedation, woke neurologically intact and extubated. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. On POD2 the patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were removed per cardiac surgery protocol without
complication. He will remain on plavix for his right coronary
stent that was not bypassed. The patient was evaluated by the
physical therapy for assistance with strength and mobility. The
patient had several episodes of post operative atrial
fibrillation and was treated with beta blockers, Amiodarone and
eventually started on Coumadin therapy. On post-operative day
five his right leg, where he had an SFA stent placed in [**2155**],
became acutely painful, pulseless, and cool. A vascular consult
was called and heparin was initiated, following which the
clinical exam improved. The patient is to follow up with Dr.
[**Last Name (STitle) 3407**] as an outpatient. An ultrasound ruled out a deep vein
thrombosis. ABI studies were obtained which showed, significant
aorto right iliac and bilateral SFA disease, significant flow
deficit right lower extremiity, probable right SFA occlusion.
The extremity is still without palpable pulses, but it warmer on
exam. By the time of discharge on POD 8, the patient was
therapeutic on Coumadin therapy with an INR of 2.8. Pain was
controlled with oral analgesics. The patient was discharged to
home with services in good condition with appropriate follow up
instructions for couamdin with PCP and vascular surgery.
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. PleTAL *NF* (cilostazol) 100 mg Oral daily
5. Clopidogrel 75 mg PO DAILY
6. Loperamide 4-6 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Aspirin 81 mg PO DAILY
9. flaxseed oil *NF* 1,000 mg Oral daily
10. Multivitamins 1 TAB PO DAILY
11. Fish Oil (Omega 3) [**2147**] mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *8 HOUR PAIN RELIEVER 650 mg 1 Tablet(s) by mouth q6h prn
Disp #*60 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 Tablet(s) by mouth daily Disp
#*60 Tablet Refills:*2
3. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 Tablet(s) by mouth q 4 h prn Disp #*45
Tablet Refills:*0
4. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 Tablet(s) by mouth daily Disp #*60
Tablet Refills:*1
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 Tablet(s) by mouth daily Disp #*60
Tablet Refills:*2
6. Loperamide 4-6 mg PO QID:PRN diarrhea
RX *Anti-Diarrheal (loperamide) 2 mg 2-3 tablets by mouth prn
Disp #*60 Tablet Refills:*0
7. Amiodarone 400 mg PO BID
x 7 days, then decrease to 200 mg [**Hospital1 **] x 7 days, then decrease to
200 mg daily
RX *amiodarone 200 mg 2 Tablet(s) by mouth [**Hospital1 **] x 7 days, then
decrease to 1 tab (200 mg) [**Hospital1 **] x 7 days, then decrease to 1 tab
daily (200 mg) Disp #*60 Tablet Refills:*0
8. Furosemide 40 mg PO BID Duration: 10 Days
RX *Lasix 40 mg 1 Tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
9. Warfarin MD to order daily dose PO DAILY16
Tablet Refills:*2
10. Warfarin 0.5 mg PO ONCE Duration: 1 Doses
RX *Coumadin 1 mg 0.5 (One half) Tablet(s) by mouth once Disp
#*1 Tablet Refills:*0
11. Fish Oil (Omega 3) [**2147**] mg PO DAILY
RX *Fish Oil 120 mg-180 mg 1 Capsule(s) by mouth daily Disp #*60
Tablet Refills:*1
12. flaxseed oil *NF* 1,000 mg Oral daily
RX *flaxseed oil 1,000 mg 1 Capsule(s) by mouth daily Disp #*60
Tablet Refills:*1
13. Multivitamins 1 TAB PO DAILY
RX *Daily Value 1 Tablet(s) by mouth daily Disp #*60 Tablet
Refills:*1
14. Metoprolol Tartrate 25 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 Tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
15. Ranitidine 150 mg PO DAILY
RX *Zantac 150 mg 1 Tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Aortic stenosis and coronary artery disease s/p Aortic valve
replacement and coronary artery bypass graft x 2
Post operative atrial fibrillation
PMH:
Cholecystectomy
Parotid tumor removed from behind right ear
Arthritis
Mocardial infarction (NSTEMI [**2146**])
s/p RCA stent x 2 ( [**2146**],[**2152**])
Peripheral vascular disease s/p RSFA stent ([**2155**])
Hypertension
Hyperlipidemia
Anemia
Cataract removal
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
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-
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2160-7-31**] 1:30
Cardiologist: Dr. [**Last Name (STitle) 1911**] [**Telephone/Fax (1) 11767**] Date/Time:[**2160-7-14**]
11:20
Vascular: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2160-7-22**] 10:30
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 24305**] in [**4-3**] weeks [**Telephone/Fax (1) 24306**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for atrial fibrillation
Goal INR 2-2.5
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
[**Last Name (STitle) 24307**] to phone fax
Completed by:[**2160-7-1**]
ICD9 Codes: 4241, 412, 9971, 2851, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7224
} | Medical Text: Admission Date: [**2127-7-9**] Discharge Date: [**2127-7-17**]
Date of Birth: [**2058-6-10**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Levofloxacin / Nifedipine / Tetracycline
/ Lisinopril / Cefaclor
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 69 yo WF with h/o idiopathic pulmonary fibrosis
and severe pulmonary HTN who presented with hypoxia, SOB and c/o
cough. She had previously been followed by Dr. [**Last Name (STitle) 55911**] at
[**Hospital6 16029**] in [**Location (un) 5583**]. SOB has been progressive
over a period of years since being diagnosed with IPF and PH in
[**2124**]. Since then, her O2 requirement has steadily gone up from
2L NC to 12 L NC. Over the past few weeks, she has been unable
to walk more than a few steps before being winded and is now
unable to sit up in bed without dyspnea. She also c/o worsening
cough with green-yellowish sputum as well as nasal discharge and
chest congestion for the past 10 days. Denies fevers, chills,
sick contacts and no recent travel. As per patient, she had CT
chest performed in [**2-21**] that showed a stable appearance of her
lungs. Recent TTE reportedly measured pulmonary artery systolic
pressures of 81 mmHg, PCWP 42 mm Hg. Pulmonologist then
prescribed Tracleer and Rivatio (Sildenafil) which she has not
taken due to her fear of medication side effects. She also
wishes to have another opinion by a pulmonologist here at [**Hospital1 18**].
She explains that she has been rejected as a possible recipient
at 2 lung transplant centers, once because of her age and the
last because of her weight. She is still being evaluated at the
[**State 78655**] for a possible bilateral lung transplant.
In the ED, patient was afebrile, RR 20, O2 sat 92% on 8L NC.
However, she markedly desaturated to 70% with coughing and
removal of O2 with eating. She was placed on 80% FM with
improvement in saturations to 95%. Given O2 requirement and
extreme of hypoxic values she was admitted to MICU for further
care. ROS was otherwise notable for urinary frequency and panic
attacks.
Past Medical History:
Pulmonary Fibrosis (per OSH CT report, has biopsy proven UIP/IPF
however patient denies ever having any invasive biopsy
performed)
Pulmonary HTN
HTN
Hypothyroidism
Diverticulosis
Eczema
Psoriasis
Anxiety
h/o Afib with RVR, self terminated to NSR in [**2126**]
Social History:
The patient lives in [**Location 22201**] [**State 350**]. Prior 30 pack year
history of tobacco, quit in [**2108**]. No EtOH, denies illicit drug
use. Lives alone at home with good social supports from church.
Retired book-keeper/administrative assistant.
Family History:
No family h/o pulmonary disease.
Physical Exam:
VS: 97.7 146/60 68 28 93% high flow 95% FM
GEN: anxious appearing female awake, alert
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP
moist and without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. II/VI SEM along LSB.
CHEST: Resp slightly labored with some accessory muscle use. dry
crackles b/l
ABD: Soft, NT, ND, no HSM
EXT: No c/c/e
SKIN: No rash
Pertinent Results:
Labs on Admisssion:
Na 136, K 4.4, Cl 99, Bicarb 29, BUN/Cr 16/0.8, glucose 118, WBC
10.6 (70% N, 19% L, 6% E), Hct 36.9, Platelets 218.
Lactate 1.2
PT 13.8, PTT 23.1, INR 1.2
WBC-10.6 RBC-4.26 HGB-12.2 HCT-36.9 MCV-86 MCH-28.7 MCHC-33.2
RDW-13.1
[**2127-7-10**] UA: negative
EKG - NSR @ 70 bpm, nl axis, nl intervals, no ST elevations or
depressions, TWI III, aVF, no priors for comparison.
.
CT chest [**2-21**] (from [**Hospital6 16029**]) - essentially
stable appearance of the lungs with fibrotic change,
honeycombing, and intralobular septal thickening compatible with
known diagnosis. Interval improvement in patchy airspace disease
in the superior segments of bilateral lower lobes as compared
with prior CT.
CT chest [**2127-7-10**]: Extensive reticular opacities and honeycombing
with multifocal ground glass opacities bilaterally. Overall, CT
shows worsening of fibrosis as compared to [**2-21**] CT
[**2127-7-10**] CXR (AP) : In comparison with the study of [**7-10**],
allowing for differences in technique, there is no interval
change. Again, there is extensive reticular opacification
persisting throughout both lungs, consistent with the clinical
history of pulmonary fibrosis.
[**2127-7-10**]: TTE results : left and right atrium moderately dilated.
RA pressure 10-20mmHg. Mild symmetric LVH. LVEF 60-70%. There is
mild aortic valve stenosis and 1+ AR. Severe 3+ TR seen. Severe
pulmonary artery systolic hypertension (60-95%). Dilated PA. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. No
pericardial effusion.
Brief Hospital Course:
The patient is a 69 yo WF with h/o idiopathic pulmonary
fibrosis, severe pulmonary HTN who presented with hypoxia, SOB,
cough who continued to improve clinically with oxygen
saturations consistently >90% on support, was also given
sildenafil with some clinical improvement initially, discharged
with pulmonary follow up.
.
# SOB/hypoxia - patient had poor pulmonary reserve at baseline
given setting of her idiopathic pulmonary fibrosis/usual
interstitial pneumonitis and severe pulmonary hypertension. She
has history of noncompliance and has collected a plethora of
input from multiple major medical facilities regarding her
prognosis and diagnosis. She had not followed up with treatment
recommendations from pulmonologist at [**Hospital1 11485**] and was not
taking bronchodilators, inhalers, or steroids at this time. She
states she has had prior course of azithromycin for bronchitis
and pneumonia with improvement in her symptoms. Despite
saturations in 70s on arrival to ED patient very stable on Fio2
40% facemask with sats > 93%. As per pulmonary consult, patient
was started on sildenafil, steriods, high flow facemask with
home oxygen. The patient was discharged with pulmonary follow
up.
.
# Cough - Chest congestion, cough improving. Patient completed
a course of azithromycin.
.
# Anxiety - Reasonable considering severity of disease and
oxygen requirement. If exacerbates, will seek further
intervenion. Patient was started on benzodiazepines as needed.
.
# HTN - Sildenafil started for pulmonary HTN in MICU. As also
lowers BP, beta-blocker dose reduced. Patient not happy with
this, as she feels increased heart rate is contributing to her
increased oxygen demand. Sildenafil continued at decreased dose
until discharge.
.
# Hypothyroidism - Continued synthroid.
Medications on Admission:
Synthroid 100 mcg daily
Betamethasone Biproprionate 0.05% cream prn
Atenolol 37.5 [**Hospital1 **] (prescribed as 75 mg daily, pt's friend
reports she often takes [**1-17**] to [**1-21**] of her pills throughout the
day)
Discharge Medications:
1. Oxygen Therapy
Please use 10L of nasal cannula at rest and upon periods of
exertion or transition please use the provided non-rebreather
facemask.
2. Betamethasone Dipropionate 0.05 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H PRN ().
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-15**] Sprays Nasal
QID (4 times a day) as needed.
6. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
8. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Sildenafil 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection ASDIR8 (ASDIR).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 11485**] VNA
Discharge Diagnosis:
1. Idiopathic Pulmonary Fibrosis
2. Pulmonary Hypertension
Discharge Condition:
Pt. stable, with oxygen saturations between 97-99 on 5L NC and
Facemask when non-ambulatory.
Discharge Instructions:
You are being discharged with 10 L of nasal cannula with a
non-rebreather face mask for periods of exertion or transition.
Please take Viagra as prescribed.
Followup Instructions:
1. Dr. [**Last Name (STitle) 55911**], [**2127-8-18**] 11:45 AM
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2127-10-27**]
ICD9 Codes: 4168, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7225
} | Medical Text: Admission Date: [**2147-6-19**] Discharge Date: [**2147-6-26**]
Date of Birth: [**2099-1-26**] Sex: F
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: The patient is a 48 year old
female with past medical history of ethanol abuse,
hypertension, chronic pancreatitis, narcotic abuse, recurrent
falls. On [**2147-6-19**], she was found at home on the floor
unresponsive with agonal breathing and diffuse bleeding. She
was brought to the Emergency Department where she was
intubated for airway protection and treated for possible drug
overdose.
On head CT she was found to have a subarachnoid hemorrhage,
subdural hemorrhage with midline compression and a large
intraparenchymal pontine hemorrhage.
PHYSICAL EXAMINATION: On examination on admission, she was
found to be unresponsive to verbal stimuli. Head, eyes,
ears, nose and throat examination revealed a left facial and
periorbital edema, left subconjunctival hemorrhage. The
pupils are 2.0 millimeters, fixed and nonreactive, no doll's
eyes, positive corneal reflex, slight gag reflex.
Neurologically, she had posturing of bilateral arms plus left
lower extremity to painful stimuli. Toes were bilateral
upward. Left ankle clonus greater than right ankle clonus.
Cardiovascular - regular rate and rhythm. Respiratory was
clear to auscultation bilaterally. The abdomen was soft.
LABORATORY DATA: Her laboratories were unremarkable. Serum
ethanol 136. Positive urine benzodiazepine. The rest of the
toxicology screen was negative.
HOSPITAL COURSE: Neurosurgery was consulted and it was
determined that there were no therapeutic options at this
time. Family decided that under the circumstances, this
patient should be made comfort measures only, no fluids, no
blood draws, will keep comfortable.
Her hospital course was uneventful. The patient was
comfortable throughout hospitalization. Over the course of
days, she was in the MICU in the beginning and transferred
from the MICU to the floor. She was kept comfortable with
intravenous Morphine. She also had a Scopolamine patch
placed q72hours for reduction of airway secretions. On
[**2147-6-25**], her respirations started to slow and on [**2147-6-26**],
this patient passed away. The family was present. The
attending was notified.
CAUSE OF DEATH: Respiratory arrest secondary to dehydration
and sepsis and renal failure.
The precipitating cause of death was severe brain injury
secondary to fall and/or seizure at home.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-398
Dictated By:[**Last Name (NamePattern1) 1737**]
MEDQUIST36
D: [**2147-8-14**] 14:22
T: [**2147-8-21**] 19:52
JOB#: [**Job Number **]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7226
} | Medical Text: Admission Date: [**2127-7-11**] Discharge Date: [**2127-7-18**]
Date of Birth: [**2049-5-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Influenza Virus Vaccines / Iodine; Iodine
Containing
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78 y/o F with new diagnosis of metastatic ovarian cancer who was
brought in for confusion. Today she presented to [**Hospital1 **] [**Location (un) **] for
a blood draw and was confused. She eloped before a section 12
could be completed. After going home, she was unable to get
upstairs and her cab called 911; she was initially brought to
[**Last Name (un) 4199**]. Her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 410**] had a Section 12 enforced and she
was transferred here for further care. Per notes, she had been
acting strangely at home since her recent discharge on [**6-26**]. She
denies any changes in her mental status, but does note that she
is alone and has no one to help her. She denies SI/HI, visual or
auditory hallucinations.
.
In the ED, initial vs were: T 98.0, P 68, BP 96/58, R 14, O2 sat
98% on RA. Pt then became hypotensive to 60s/30s, although was
mentating throughout with no complaints except "fatigue." She
received 3L NS and was started on peripheral dopamine. She was
covered with broad spectrum abx and received cipro in the ED,
with an order to get vanco and flagyl after transfer to the
MICU. She was seen by psych in the ED who did not find her
competent to leave AMA. A bedside echo showed no pericardial
effusion.
.
On the floor, she is comfortable and complaining of only being
very tired. She denies recent fevers, chills. No dizziness or
falls. She does say she has been getting weaker and that she has
new swelling in her bilateral extremities. Her legs are tender.
She does not have chest pain or shortness of breath. She does
not want to have any interventions tonight because she is
"tired," but would be ok with interventions later. She is
planned for chemo in the next few weeks per her. She has not
been needing her antinausea meds yet as she hasn't started
chemo; taking her other meds as prescribed.
.
Review of sytems:
(+) Per HPI - weight gain, swelling, abdominal girth
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
Metastatic Ovarian Cancer
Malignant Pleural Effusion s/p Pleurex Cath
Hypertension
COPD
Chronic renal insufficiency (baseline 1.8)
Hyperlipidemia
S/p tonsillectomy and appendectomy
Social History:
Patient lives at home with her cat; apparently has been not
taking care of herself and just sitting on the porch without
eating or drinking. She is originally from [**Country 6607**] and her family
still all lives there; has many friends who live in the area.
Has history of tobacco use.
Family History:
father died @ 74 - MI, smoked
mother died - CAD, type 2 DM
youngest of 10 children, 1 sister still living, age 84
strong family hx of CAD in siblings
nephew - DM
no children
Physical Exam:
Vitals: T: 96.7, BP: 106/46, P: 71, R: 16, O2: 95% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi; R pleurex catheter in place, no erythema, mild drainag
in tube
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: firm, distended, nontender to palpation, BS are
hypoactive but present, no obvious fluid wave
GU: foley
Ext: cool, 3+ edema to thigh, tender to palpation bilaterally,
dopplerable pulses
Pertinent Results:
[**2127-7-11**] 08:58PM LACTATE-2.3*
[**2127-7-11**] 08:53PM LD(LDH)-1463* ALK PHOS-119* TOT BILI-0.2
[**2127-7-11**] 08:53PM LIPASE-12
[**2127-7-11**] 08:53PM ALBUMIN-2.9*
[**2127-7-11**] 08:53PM CORTISOL-44.8*
[**2127-7-11**] 08:53PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-7-11**] 08:53PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2127-7-11**] 08:53PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2127-7-11**] 08:53PM URINE RBC-0-2 WBC-[**5-14**]* BACTERIA-MOD
YEAST-NONE EPI-0-2 RENAL EPI-0-2
[**2127-7-11**] 08:53PM URINE GRANULAR-[**5-14**]* HYALINE-[**5-14**]*
[**2127-7-11**] 08:53PM URINE MUCOUS-OCC
[**2127-7-11**] 06:04PM GLUCOSE-66* UREA N-72* CREAT-3.4* SODIUM-139
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-19* ANION GAP-23*
[**2127-7-11**] 06:04PM CALCIUM-8.9 PHOSPHATE-4.1 MAGNESIUM-2.1
[**2127-7-11**] 06:04PM WBC-10.9 RBC-3.90* HGB-10.8* HCT-35.3* MCV-91
MCH-27.7 MCHC-30.6* RDW-15.2
[**2127-7-11**] 06:04PM NEUTS-91.9* BANDS-0 LYMPHS-5.1* MONOS-2.7
EOS-0.1 BASOS-0.1
[**2127-7-11**] 06:04PM PLT COUNT-401
[**2127-7-11**] 10:30AM GLUCOSE-78
[**2127-7-11**] 10:30AM UREA N-70* CREAT-3.3* SODIUM-140
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-23 ANION GAP-18
[**2127-7-11**] 10:30AM ALT(SGPT)-35 AST(SGOT)-92*
[**2127-7-11**] 10:30AM %HbA1c-5.9
[**2127-7-11**] 10:30AM WBC-12.2* RBC-3.82* HGB-10.7* HCT-33.8*
MCV-88 MCH-28.0 MCHC-31.7 RDW-15.8*
[**2127-7-11**] 10:30AM NEUTS-90.2* BANDS-0 LYMPHS-5.8* MONOS-3.8
EOS-0.1 BASOS-0
[**2127-7-11**] 10:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2127-7-11**] 10:30AM PLT SMR-NORMAL PLT COUNT-402
[**2127-7-10**] 10:00AM GLUCOSE-25* UREA N-63* CREAT-3.3*#
SODIUM-132* POTASSIUM-5.4* CHLORIDE-97 TOTAL CO2-7* ANION
GAP-33*
.
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion. There
is an anterior space which most likely represents a fat pad.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. The right
ventricle is not well seen but is probably normal. No pathologic
valvular abnormality seen. Moderate pulmonary artery systolic
hypertension.
.
IMPRESSION:
Stable right chest tube with no pneumothorax and clear lungs.
.
IMPRESSION:
1. Sludge in the gallbladder, but otherwise no son[**Name (NI) 493**]
evidence of acute cholecystitis.
2. Small amount of ascites in the abdomen.
The study and the report were reviewed by the staff radiologist.
.
IMPRESSION:
No evidence of hydronephrosis bilaterally.
Moderate amount of free fluid in the abdomen.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
78 y/o F with hx of HTN, COPD, and new diagnosis of metastatic
ovarian cancer who presents with delerium, ARF and hypotension.
.
# Hypotension: The patient presented with hypotension, thought
to be either secondary to sepsis versus poor PO intake in the
weeks prior to admission. The patient was initally placed on
Levophed and broad spectrum antibiotics, and she remained stable
with these interventions. However, throughout this admission,
she became progressively more hypotensive despite Levophed,
fluid boluses, and broad spectrum antibiotics. Given the
patient's prior wishes of minimally invasive procedures, and her
poor prognosis, further pressors were not added, and the patient
expired on [**2127-7-18**].
.
# ARF: The patient has a history of CKD stage IV with baseline
creatinine around 1.8. Her creatinine increased to 3.4 on this
admission, and she became oliguric. Renal was consulted, and
the patient was found to have muddy brown casts in her U/A,
consistent with ATN. She was placed back on Levophed in an
attempt to increase UOP; however, this had minimal effect. The
patient expired on [**7-18**], before her renal function had
recovered.
.
# Delerium: The patient presented with AMS in the setting of
hypotension. Psychiatry was consulted, and her mental status
gradually improved over this admission. However, the patient
did not appear to regain capacity to discuss her medical
condition with the primary team or oncology.
.
# Ovarian Cancer: She was recently diagnosed with metastatic
ovarian cancer. She was seen by heme/onc on this admission, who
deferred chemotherapy in the setting of infection and altered
mental status.
Medications on Admission:
Amlodipine 5 mg daily
Atenolol 50 mg daily
Lipitor 10 mg daily
HCTZ 25 mg daily
Lorazepam 0.5 mg q6hr PRN for nausea
Zofran 8 mg PO tid PRN for nausea
Prochlorperazine 10 mg q6hr PRN for nausea
Ascorbic Acid 500 mg daily
Cyanocobalamin 500 mg daily
Albuterol MDI PRN for wheezing
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2127-7-18**]
ICD9 Codes: 4589, 0389, 5845, 2930, 2762, 496, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7227
} | Medical Text: Admission Date: [**2171-5-26**] Discharge Date: [**2171-6-6**]
Date of Birth: [**2112-11-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
neutropenic fever
Major Surgical or Invasive Procedure:
Intubation
Lumpar puncture
History of Present Illness:
58M w/ IgA predominant multiple myeloma s/p recent high dose
Cytoxan [**2171-5-18**] in preparation for stem cell mobilization
admitted to [**Hospital Unit Name 153**] for febrile neutropenia.
Recently d/c'd from BMT service on [**5-18**] after treatment with
high dose Cytoxan in preparation for stem cell mobilization. Per
pt and wife, he has experienced increased anorexia and some
nausea with one episode of vomitting over the last week. No
fevers or chills. No abdominal pain. Notes thrush but no
dysphagia. Notes onset of cough with white sputum over the last
day. No chest pain. No urinary or bowel changes, no diarrhea. No
rashes. He does have skin breakdown near sacrum which doesn't
appear to have changed significantly. No pain at dialysis
catheter site. No sick contacts. Reports compliance w/ abx and
neupogen. Mild HA but no vision changes. ?mild increased
confusion in terms of getting days of week mixed up. No
neck/back pain.
On evening of admission, he developed nausea and vomitting and
then was noted to have temperature to 101. In ED, noted febrile
to 101.2, tachy to 100, hypotensive to systolic 60's. Labs
notable for neutropenia w/ trilineage decrease. Lactate 1.3. UA
notable for tr ketone and prbc/wbc. CXR w/ increased left sided
pleural effusion. Blood cultures drawn and pt received
Vancomycin and Cefepime and several liters of IVF. SBP improved
to 100's.
Onc. History:
USOH until [**6-/2170**], when he developed a rotator cuff
injury of his right shoulder. He was initially treated with
supportive therapy. However, he developed progressive pain in
his right clavicle, associated with increasing fatigue. On
further evaluation he was anemic and had a high total protein.
He was hypercalcemic and had a component of renal insufficiency.
He was seen by Dr. [**Last Name (STitle) 65635**] on [**2170-7-17**]. Bone marrow
aspirate revealed a hypercellular marrow with 50% plasma cells.
His hemoglobin was 12.4, BUN 39, creatinine was 2.4, and LDH was
normal. On physical examination, he had a 3 cm expandable mass
in his right mid clavicle. He was diagnosed with a stage IIB
IgA kappa multiple myeloma.
.
- Started on high-dose Decadron, thalidomide and Zometa. He
received 100 mg of thalidomide q.h.s. Intially IgA decreased on
this treatment, but he developed progressive renal
insufficiency. Despite a trial of the plasmapheresis, his renal
function continued to deteriorate and he was started on
hemodialysis on [**2170-8-2**].
.
- Prior to his progressive renal insufficiency, he did have an
upper respiratory tract infection characterized by low- grade
fevers and nonproductive cough. All cultures were negative.
Skeletal survey revealed multiple lytic lesions throughout his
thorax. There were lesions in his sternum, posterior ribs, and
vertebral bodies. He continued on Decadron, thalidomide, and
hemodialysis.
.
- In [**10/2170**], he noticed the onset of progressive right hip
pain. This interfered with his ability to walk. Apparently, an
MRI of the area did not reveal a lytic lesion. The question was
raised of avascular necrosis considering his recent use of
steroids. He was noted to have a lytic lesion in his C-spine
and received local radiation therapy, and is advised to wear a
cervical collar.
.
- In the [**12/2170**], he was switched from dexamethasone and low
dose of thalidomide to Velcade + decadron. He has tolerated
the Velcade well. He was seen at the [**Hospital 4601**] Cancer Center
by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**], who recommended that he continue on the
Velcade. He continued to have ongoing renal insufficiency and
was on 3-times- a-week hemodialysis.
.
- He was hospitalized in NH on [**2171-3-25**] with hypotension and
fever.
He was suspected to have adrenal insufficiency, considering his
use of steroids. Blood cultures were positive for coag-negative
staph, and he was started on a course of vancomycin. Dialysis
catheter was changed. A new dialysis catheter was inserted on
[**2171-4-1**]. He continued on HD TIW. [**4-11**]: Noted progressive pain
in his right hip. He is using the wheelchair. He cannot walk
more
than [**Age over 90 **] yards because of pain in his right hip. Repeat MRIs
did not reveal lytic lesions.
Past Medical History:
1. IgA predominant multiple myeloma dx'd [**7-10**] progessive despite
initial therapy w/ Decadron/Thalidomide/Zometa later changed to
Velcade/Decadron now s/p recent high dose Cytoxan [**2171-5-18**] and
awaiting stem cell mobilization
2. ESRD on HD presumed secondary to myeloma
3. recent coag negative staph bacteremia at osh [**3-11**]
4. s/p left av fistula w/ ligation during hospitalization [**5-11**]
5. ?adrenal insuffiency at osh
6. htn
7. hyperlipidemia
8. cervical lytic lesion
9. ?restrictive lung pattern by pft (fev1/fvc 117% predicted w/
fev1 of 68% predicted, and decreased TLC)
Social History:
married with wife and works as designer
Family History:
He has 3 siblings; one of them has prostatic
cancer. He has 2 adult children.
Physical Exam:
GEN: Thin male lying in bed with NC on dyspnea with short
sentences.
HEENT: mmm, OP clear, PERRL
CVR: RRR, nl s1, s2 no r/m/g
Chest: Bilateral crackles. [**Date range (1) 5082**] way up bilaterally.
ABD: NABS, soft, nontender
EXT: 2+ lower extremity edema bilaterally
NEuro: A&O X 3.
Sacrum: stage 1 decub.
Pertinent Results:
137 | 105 | 20 AGap=14
-------------<87
4.0 | 22 | 3.8
Ca: 9.2 Mg: 2.3 P: 3.4
Vanco: 21.6
1.2>---<8.7
....25.9
Gran-Ct: 780
PT: 15.2 PTT: 37.1 INR: 1.4
CK: 14 MB: 3 Trop-*T*: 0.41
Brief Hospital Course:
A/P: 55 yom with IGa Mutiple myeloma, complicated by renal
failure and multiple osteolytic lesions s/p recent cytoxan
therapy awaiting auto transplant admitted with febrile
neutorpenia.
.
# Febrile neutropenia: Patient with nausea, vomiting and caugh
prior to admission. Sources include lungs, ?secondary to decub
(only stage 1), or line related (has tunnled line catheter). He
was admitted to the ICU initially and received IVF for
hypotension. He defervasced and once hemodynamically stable was
transferred to the floor. After transfer he was continued on
Cefepime, Vancomycin (by level) and levofloxacin. He was noted
to have a pleural effusion which was tapped and revealed a
transudate with no organisms on gram stain and cultures. During
his hospitalization he was converted to hospice care, and
patient was sent home off Abx.
.
# Pleural effusion: noted to have pleural effusion on
echocardiogram so had a Chest CT which revevealed a large
leftsided effusion. This was tapped and revealed a transudate.
Patient's sob and dyspnea improved significantly after
thoracentesis. 2 days later sob worsened and on CXR was noted
to have recurrance of pleural effusion. Effusion was thought
likely secondary to inflammatory reaction to the plasmacytomas
seen on CT. Rad/Onc was consulted for possible radiation to the
plasmacytoma, however they did not believe that radiation would
change management as pt had several lesions. Interventional
pulmonary was consulted for possible pleuradisis vs pigtail
catheter placement given quick reaccumulation of the effusion.
They did not believe that pleuradisis would be useful as the
effusion was a transudate. Repeat thoracentesis was perfored on
[**6-1**]. Pt was successfully extubated on [**6-4**], and continued to
oxygenate well on supplemental o2.
.
# Mutliple myeloma - Once afebrile pt underwent pharesis for
stem cell collection. He had 3 cycles however the yield was low
and for now the plan is to hold off on further stem cell
collection. Further work up and management per Dr. [**First Name (STitle) 1557**].
Supportive meastures for pain control with fentynyl patch and
oxycodone, cervical collar and levaquin and bactrim prophylaxis
were continued. Pt was discharged home with hospice care.
.
#. Hypotension: on admission thought secondary to sepsis vs post
dialysis hypotension. It resolved with fluids. Midodrine was
added per renal.
.
#. ESRD - Dialysed per Renal team's recs on T/R/S. Pt was sent
home to initiate hospice care with to decide on further dialysis
as per patient's wishes.
# Diet: renal, neutropenic
# Prophylaxis: PPI, bowel regimen
# Access: dialysis port.
# Code: full
Medications on Admission:
Meds on admission:
Percocet PRN
ASA 81 qd
Bactrim DS qod
Pyrodoxine 100 qd
Vitamin E 400qd
Sevalamer 800 tid
Fentanyl patch 50 q72
Colace
Senna
Ambien prn
Levaquin 250 q24
Discharge Disposition:
Home With Service
Facility:
North Country Home Health and Hospice
Discharge Diagnosis:
Primary Diagnoses:
Respiratory Failure
Febrile Neutropenia
Altered Mental Status
.
Secondary Diagnoses:
Refractory Multiple Myeloma
ESRD on HD
Discharge Condition:
Stable to be discharged home with hospice care
Discharge Instructions:
.
Please take medications as below.
.
If you develop any complaints, please call your doctor or
primary oncologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]. If emergent please go to the
nearest emergency department
Followup Instructions:
Please call Dr. [**Last Name (STitle) 65636**] to schedule a follow up appointment as
needed; call [**0-0-**] to schedule that appointment.
ICD9 Codes: 486, 5119, 2760, 4589, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7228
} | Medical Text: Admission Date: [**2185-1-27**] Discharge Date: [**2185-5-23**]
Date of Birth: [**2185-1-27**] Sex: F
Service: NB
[**Doctor First Name 14880**] was born at 24-5/7 weeks gestation to a 27-year-old
gravida 4, para 0, now 1 woman. The mother's prenatal screens
were blood type B+, antibody negative, rubella immune, RPR
nonreactive. Hepatitis surface antigen negative. PPD
negative. HIV negative. Chlamydia and GC negative. Group B
strep unknown. This pregnancy was complicated by shortened
cervix and cervical dilatation with admission to [**Hospital3 **]
initially on [**2185-1-7**]. She was re-admitted one week prior to
delivery. On the day of delivery mother had a fever to 101.
She was treated with antibiotics, had progressive cervical
dilatation. The infant was in a footling breech presentation
and so had an emergency cesarean section under general
anesthesia. Infant emerged through foul smelling amniotic
fluid. Rupture of membranes occurred at the time of delivery.
Apgar's were 3 at 1 minute and 7 at 5 minutes.
The birth weight was 581 grams, the birth length 31.5 cm and
birth head circumference 22 cm.
PHYSICAL EXAMINATION: Admission physical examination revealed
a non-dysmorphic, extremely preterm infant, anterior fontanel
soft and flat. Eyelids fused, orally intubated, positive
subcostal and intercostal retractions. Breath sounds with
crackles. Heart with no murmur. Pulse is normal. Discolored
skin on the abdomen. Nondistended, no loops, no
hepatosplenomegaly. Normal female genitalia, patent anus.
Fowl smelling stool which was not meconium. No sacral dimple.
Hypotonic for age. Umbilical lies in place.
HOSPITAL COURSE BY SYSTEMS:
Respiratory status: [**Known lastname 59122**] was intubated in the delivery room,
received a course of surfactant, then successfully weaned
to nasopharyngeal continuous positive airway pressure on
day of life 57 and then weaned to nasal cannula oxygen on day
of life #74, and finally to room air 3 days prior to discharge.
She was treated with caffeine citrate
for apnea of prematurity from day of life #4 until day of
life #75. Her last episode of bradycardia occurred on
[**2185-4-26**]. She began treatment with Diuril for chronic lung
disease on day of life #40 and continues on that medication
at present. She has required intermittent doses of Lasix for
her chronic lung disease.
Cardiovascular: She required pressor support from day of life
#1 until day of life #4 and has remained normotensive since
that time. She was treated with Indocin on day of life 1 and
2 for clinical presentation of a patent ductus. Her murmur
persisted but follow-up echocardiogram showed a very small
patent ductus. On [**2185-3-18**] she presented with blood tinged
secretions from her endotracheal tube. An echocardiogram at
that time showed that the patent ductus was now a moderate
size with continuous left to right flow and she was treated
with another course of Indocin on [**2185-3-21**].
Follow-up echocardiogram on [**3-23**] showed no patent ductus
however, at that time it showed a pulmonary valve that was
mildly abnormal with no gradient across it. A follow-up
echocardiogram on [**3-24**] showed no patent ductus and no comment
was made on the pulmonary valve. She had been evaluated by
[**Hospital3 1810**] Cardiology, the plan is to follow this
clinically. If there is a development of a pulmonary ejection
murmur, they will re-evaluate her. At this time she does not
need any prophylaxis for subacute bacterial endocarditis.
On examination she has a Grade 1/6 systolic ejection murmur
at the left sternal border. She is pink and well perfused.
Fluid, electrolyte and nutrition status: At the time of
transfer her weight is 3160 grams, her length is 48 cm and
head circumference 35.5 cm. Enteral feeds were begun on day
of life #6 and reached full volume feeding after intermittent
stopped on day of life #21. She was increased to a maximum of
30 calories per ounce of breast milk or formula with added
ProMod. Since [**2185-5-4**] she has been on 24 calorie per ounce
breast milk made with 4 calories per ounce of Similac powder.
She is eating on an ad lib schedule with consistent weight
gain. She has required potassium chloride supplementation due
to her diuretic therapy. Her last set of electrolytes on
[**2185-5-16**] were sodium 135, potassium 5.3, chloride 99 and
bicarbonate 28.
Gastrointestinal: She was treated with phototherapy for
hyperbilirubinemia of prematurity from day of life 1 until
day of life 12. Her peak bilirubin on day of life 8 was total
3.7, direct 0.3. She is given prune juice daily for
constipation.
Hematology: Her blood type is B+, direct COOMBS negative. Her
last hematocrit on [**2185-5-16**] was hematocrit was 29.3 with a
reticulocyte count of 2.0% She has received five transfusions
of packed red blood cells during her NICU stay, the last one
on [**2185-3-20**].
Infectious disease status: She was started on Ampicillin and
Gentamicin at the time for sepsis risk factors. She completed
a 7 day course of the antibiotics for presumed sepsis. Her
blood and cerebrospinal fluid cultures from that time remain
negative. She remained off of antibiotics until day of life
17 when she was started on vancomycin and gentamicin for
clinical presentation of sepsis. The antibiotics were
discontinued after 48 hours when the blood cultures were
negative and the infant was clinically well. She has remained
off antibiotics since that time.
Neurology: Her first head ultrasound on [**1-28**] showed a
question of a germinal matrix hemorrhage. A follow-up on [**2-4**]
and [**2185-2-24**] were within normal limits. Head ultrasound on
[**2185-4-22**] again showed bilateral germinal matrix hemorrhage and
a follow-up on [**2185-5-12**] showed evolution of the bilateral
germinal matrix hemorrhages, no further evaluation is
planned.
Ophthalmology: Her eyes were last examined on [**2185-5-6**], she
has retinopathy of prematurity Stage II, zone 2, 3 o'clock
hour in the right eye and 4 o'clock hour on the left eye.
Follow-up examination will be performed as an outpatient with Dr.
[**Last Name (STitle) 36137**] on [**2185-5-25**] (this appointment has been made).
Psychosocial: Her parents have been very involved in the
infant's care throughout her NICU stay. She is discharged in
good condition. She is being transferred to [**Hospital3 18242**] for repair of her left inguinal hernia.
PRIMARY PEDIATRICIAN:
RECOMMENDATIONS: Feedings: 24 calorie per ounce breast milk,
4 calories per ounce made with Similac powder.
MEDICATIONS:
1. Potassium chloride supplementation 5 mEq 3 times a day
2. Prune juice one half tablespoon orally three times a day
3. Iron sulfate (25 mg per ml) 0.5 ml p.o. daily
4. Vi-Daylin 1 ml p.o. daily
5. Diuril 50 mg p.o. twice a day to provide 40 mg per kilo
per day
She has not yet had a car seat position screening test.
Her last State newborn screen was sent on [**2185-4-7**] and was
within normal limits.
She has received the following immunizations:
1. Hepatitis B vaccine #1 on [**2185-2-26**].
2. Pediarix on [**2185-4-7**].
3. HIB #1 on [**2185-4-7**].
4. Pneumococcal #1 on [**2185-4-10**].
RECOMMENDED IMMUNIZATIONS:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following
three criteria:
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with the following: Daycare
during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings.
3. Chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the childs life
immunization against influenza is recommended for
household contact and out of home caregivers.
FOLLOW UP:
1. Infant [**Hospital 702**] clinic at [**Hospital3 1810**].
2. [**Hospital6 **] of the [**Location (un) 2725**] Area Early
Intervention program. Telephone #[**Telephone/Fax (1) 44213**].
DISCHARGE DIAGNOSIS:
1. Status post extreme prematurity at 24-5/7 weeks gestation.
2. Status post respiratory distress syndrome.
3. Status post presumed sepsis.
4. Status post hyperbilirubinemia.
5. Anemia of prematurity.
6. Bronchopulmonary dysplasia
7. Retinopathy of prematurity.
8. Status post patent ductus arteriosus. s
9. Left inguinal hernia.
10. Umbilical hernia.
11. Bilateral germinal matrix hemorrhage.
12. Sepsis ruled out.
Reviewed By: DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-622
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2185-5-16**] 18:11:31
T: [**2185-5-16**] 19:23:29
Job#: [**Job Number 59123**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7229
} | Medical Text: Admission Date: [**2121-10-31**] Discharge Date: [**2121-11-1**]
Date of Birth: [**2040-7-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
abdominal pain and fever
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography
endotracheal intubation and extubation
History of Present Illness:
The patient is an 81 year old male with pmhx significant for
asthma, CBD stones s/p ERCP in [**2119**], anemia,
hypercholesterolemia and GERD initially transferred from [**Location (un) 21541**] hospital for ascending cholangitis and emergent ERCP who
presents s/p ERCP with O2 desaturation to 91% on RA.
.
Per wife, on [**10-28**], patient was sleeping and woke up shivering.
Temp at that time was 102. This has happened in the past when
the patient has PNA and the wife called the paramedics. He was
slightly nauseous before leaving for hospital and had one
episode of blood tinged vomit. Originally the pt went to [**Location (un) 21541**] ED and his presenting vital signs were T 101.1, P 131, BP
175/75, R 24, O2 sat 91% RA. He was noted to be dyspneic and
wheezing, abdomen nontender. He was given IVF,pan cultured and
found to have positive blood cultures w/ gram negative rods [**2-20**]
([**10-29**])-> ID to be pan-sensitive (CTX, quinolones, zosyn) e coli
in 1 out of 3 sets of blood, started on 3 g unasyn, 1 g
ceftriaxone, 500 azithromycin. The patient had abnl LFTs with
increased Tbili (6.4), Dbili (3.5) and AP (301) and left shift
on white count. RUQ US done and showed dilated intra and
extrahepatic bile ducts. GI consulted and thought sepsis [**2-20**]
biliary disease.His alk phos improved to 213 and t bili (4.5)
and d bili (2.7). He was transferred on [**10-31**] to [**Hospital1 18**] for ERCP.
.
During ERCP, patient was given reglan 12.5 mg, versed 4.5 mg,
fentanyl 175 mcg, 2 liters of D5 1/2 NS. Patient noted to be
very lethargic and was desatting. Patient thought to be
over-medicated and given narcan 40 mcg which did not help. He
was intubated for airway protection and transferred to ICU for
monitoring.
Past Medical History:
ascending cholangitis
Asthma
GERD
arthritis
hiatal hernia
anemia ? iron deficiency
high cholesterol
laminectomy [**3-24**]
Social History:
lives in [**Location 23638**] w/ wife; 2 children; smoked while in the navy
and quit 20 years ago; occasional etoh drink ([**1-20**] [**Doctor Last Name 6654**]/nite);
was a microbiologist
Family History:
father had bladder ca; daughter w/ breast cancer, Mother died
70s of CAD, brother died suddenly of MI at age 45
Physical Exam:
Upon arrival to the ICU:
VS: T P 72 BP 115/56 O2 100% on AC TV 450/14/90 % O2/PEEP 5
Gen:intubated, sedated
HEENT: pupil small and round but sluggish to reach, MMM
NEck: Supple, no JVD
CV:RRR, nl S1 and S2, no m/r/g
ABD:Soft, non-tender, non-distended, + bowel sounds
Resp: coarse breath sounds bilaterally
Ext:warm, +2 distal pulses, no edema
Neuro:moves ext, does not open eye or follow command
Pertinent Results:
[**2121-10-31**] 07:30PM WBC-5.0 RBC-4.31* HGB-12.2*# HCT-35.8*#
MCV-83# MCH-28.2# MCHC-34.0 RDW-17.9*
[**2121-10-31**] 07:30PM PLT COUNT-177
[**2121-10-31**] 07:30PM GLUCOSE-238* UREA N-8 CREAT-0.7 SODIUM-137
POTASSIUM-3.0* CHLORIDE-105 TOTAL CO2-24 ANION GAP-11
[**2121-10-31**] 07:30PM ALT(SGPT)-41* AST(SGOT)-48* ALK PHOS-257*
AMYLASE-29 TOT BILI-2.7*
[**2121-10-31**] 07:30PM LIPASE-22
.
[**2121-10-31**]: ERCP
1) Old spincherotomy seen in the major papilla with purulent
drainage. There was a periampullary diverticulum.
2) Cholangiogram showed moderate dilation of the biliary tree
wtih CBD measuring 12mm. There were multiple large CBD stones
largest measuring 10mm.
3) A 5cm by 10F Double pigtail biliary stent was placed in the
bile duct as the patient desaturated and the procedure was
terminated and was completed after endotracheal intubation.
Brief Hospital Course:
In brief, the patient is an 81 year old male w/ ascending
cholangitis [**2-22**] GNR bacteremia tranferred from OSH for ERCP now
s/p ERCP w/ stent and intubated for loss of airway.
.
1.) Respiratory distress - This is likely [**2-20**] to sedation
medication during the ERCP procedure. The patient was intubated
for airway protection. Following weaning of sedation the
patient was successfully extubated. By time of discharge he was
breathing comfortably on room air. He continued to receive his
home dose of inhalers.
.
2.) Ascending cholangitis - The patient underwent ERCP, biliary
stenting and bile stone removal. Blood cultures from the
outside hospital were positive for pan-sensitive e. coli. He
received IV antibiotics while in the hospital and will complete
a 1 week course of oral antibiotics following discharge. His
abdominal pain resolved. He will have a follow-up ERCP and
stent removal in [**4-24**] weeks.
.
3.) Asthma - Following successful extubation, the patient
received his home dose of inhalers.
.
4.) Anemia - This was of unclear etiology. There was no guaiac
positive stools and the patient has been on home iron. Iron
studies were pending at the time of discharge. These will be
follow-up by his primary physician.
.
5.) PPX - PPI, hep sc, replete lytes as needed
.
6.) FEN - initially was NPO while intubated. his diet was
advanced as tolerated by time of discharge.
.
7.) Access- [**Last Name (LF) **], [**First Name3 (LF) **] obtain another [**First Name3 (LF) **]
.
8.) Dispo - monitored in ICU while intubated post-procedure.
discharged to home to follow-up with PCP and GI.
.
9.) Code - FULL
.
10.) Communication - w/ wife [**Telephone/Fax (1) 56515**] and family
Medications on Admission:
prilosec OTC
iron 325 [**Hospital1 **]
advair 250/50 2 puff [**Hospital1 **]
MVI
Calcium
Discharge Medications:
1. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ascending Cholangitis
.
Secondary:
Asthma
GERD
Hiatal Hernia
Discharge Condition:
good. tolerating oral intake. afebrile. pain free
Discharge Instructions:
You have been evaluated and treated for an infection in your
bile ducts that was triggered by gall stones. A stent (small
artificial tube) was placed to keep the ducts open. This stent
will need to come out in [**4-24**] weeks.
.
You can resume your regular home medications.
.
You can eat a regular diet as you are able to tolerate.
.
Please take all of the prescribed antibiotic.
.
Please attend your recommended follow-up appointments as below.
.
If you develop any concerning symptoms, particularly fever to
greater than 100.5F, abdominal pain, yellowing of your eyes,
please call your primary physician.
Followup Instructions:
Please call your primary physician to schedule an appointment to
be seen within the next 1-2 weeks.
.
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2743**] office at ([**Telephone/Fax (1) 2306**] to
schedule a follow-up appointment. You should be seen in [**4-24**]
weeks to have an ERCP for stent removal.
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7230
} | Medical Text: Admission Date: [**2136-8-14**] Discharge Date: [**2136-8-21**]
Date of Birth: [**2064-3-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
Attempted temporary pacing wire placement (unsuccessful)
Foley catheter
History of Present Illness:
72 year old female with h/o severe ventricular dysfunction (EF
10%) secondary to polysubstance abuse and HIV (dx [**2116**] on [**Year (4 digits) 2775**],
last CD4 359), 2+ MR, on methadone maintenance who presents with
nausea, bradycardia, acute on chronic renal failure with
potassium of 6.0. Patient states she has been fatigued recently
but denies shortness of breath, chest pain, orthopnea and leg
swelling. On day of presentation to ED, she began vomiting,
non-bloody non-bilious.
.
Patient was recently admitted to [**Hospital1 18**] from [**Date range (1) 105348**]/07 with CHF
exacerbation, swan was placed that admission and she was
diuresed. Elevated troponin at the time thought secondary to
demand. She was started on amiodarone for runs of VTach and
continued on digoxin. She states she has been compliant with
her medications.
.
ED: sbp 80's, which is baseline. Given insulin, 1amp D50,
atropine, calcium gluconate 1g, sodium bicarbonate 50mEq for
potassium 6.0. Given ondansetron. EKG likely junctional brady
with retrograde p waves.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. She
denies recent fevers, chills or rigors. Other review of symptoms
negative aside from above.
.
In the ED, the patient was afebrile with SBP in the 80-90s. She
had nausea and was noted to have HR in the 30s junctional vs av
delay. Now being transferred to floor for further mgmt.
.
On arrival to the CCU, she was feeling tired (hadn't slept all
night) but no CP, shortness of breath, dizziness or LH.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. She
denies recent fevers, chills or rigors. Other review of symptoms
negative aside from above.
.
Cardiac review of systems is notable for absence of chest pain,
shortness of breath, palpitations, syncope or presyncope.
Past Medical History:
1. HIV- Diagnosed in [**2116**], has taken [**Year (4 digits) 2775**] therapy
intermittently. Stopped taking her pills three months ago
because stated she had foamy vomit every time she took them. CD4
274, VL<50 in [**12-10**]
2. CHF- EF 10% 7/07 followed by Dr. [**First Name (STitle) 437**]
3. HCV- VL >700K in [**12-9**], not a good candidate for interferon
therapy or liver biopsy per gi note in 04.
4. mild COPD- PFTs [**7-/2129**] showed a normal study
5. IVDU--last abuse heroin several days ago, skin popping
6. Arthritis
7. chronic pancreatitis
8. ventricular tachycardia
Social History:
Has 20 grandchildren, tobacco: [**4-8**] cig/day, 40 py
Heavy EtOH in past. States that last used heroin in the past few
days (skin popping) and also used cocaine in the last month.
Family History:
NC
Physical Exam:
VS: 96.2F HR 30 BP 86/50 RR 16 100%/2Ln.c.
Gen: Cachectic female 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, thin.
CV: PMI located in 7th intercostal space, midclavicular line.
Distant heart sounds, regular rhythm, normal S1, S2. [**3-13**]
holosystolic murmur at apex.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at right base,
left base clear.
Abd: Soft, ND, mild TTP epigastrium and RUQ with hepatomegaly.
No abdominal bruits.
Ext: no LE edema bilaterally.
Skin: Multiple well healed lesions from h/o drug abuse
Pulses:
Right: 1+ DP
Left: 1+ DP
Pertinent Results:
7/13/7. CXR. Stable severe cardiomegaly. New mild-to-moderate
pulmonary edema accompanied by small bilateral new pleural
effusion.
[**2136-8-14**]. Digoxin level 3.8
[**2136-8-16**]. Dig level 2.5
[**2136-8-17**]. Dig level 2.1
[**2136-8-18**]. Dig level 1.5
Brief Hospital Course:
72 yo female with severe ventricular dysfunction (EF 10%)
secondary to polysubstance abuse and HIV (last CD4 359) who
presented with bradycardia secondary to digoxin and amiodarone
toxicity.
.
# Rhythm: Found to be bradycardic to 30's in ED in setting of
digoxin toxicity with amiodarone and hyperkalemia contributing.
Patient had been started on amiodarone at her last
hospitalization due to runs of VTach. Pacer pads were placed
but she did not require transcutaneous pacing. An isoproterenol
drip was started which increased her Heart rates to 50's-60's
(although initially remained in junctional rhythm). Digoxin and
amiodarone were held. An attempt was made to place a temporary
pacing wire, but this attempt was unsuccessful because of
thrombosed veins. The isoprotenenol drip was stopped on [**8-18**].
Patient will not go home on amiodarone and will go home on
Digoxin 0.125 mg qod.
.
# Pump: EF 10% on last echo ([**2136-8-3**]). She appeared euvolemic
on admission so lasix was held. She developed increased
shortness of breath and CXR was consistent with pulmonary edema,
so patient was diuresed with lasix. A foley catheter was placed
to monitor accurate I/Os. Digoxin and ACEI were held. ACEI will
be held until she follows up in clinic with Dr. [**First Name (STitle) 437**].
# CAD: No evidence of active ischemia during admission. Normal
perfusion images in [**2133**].
# HIV: Last CD4 359 in 04/[**2136**]. Patient requested that her
[**Year (4 digits) 2775**] therapy be stopped as she felt that this made her
nauseated and gave her abdominal discomfort. Her PCP was
[**Name (NI) 653**] and made aware that the [**Name (NI) 2775**] was stopped. Her
bactrim prophylaxis was continued. She will follow-up with her
PCP [**2136-8-23**] to discuss further treatment options.
# Polysubstance abuse: Last use [**6-10**] mos PTA. Continued with
methadone 90mg.
# ARF on CRI: Baseline creatinine 1.3-1.5. Now ARF on CRI;
likely secondary to bradycardia and low EF in setting of digoxin
toxicity. Held lasix and ACEI initially. Creatine continues to
trend towards baseline with return of home lasix dose.
#) Hyperkalemia: likely [**3-9**] ARF on CRI. Held ACEI. Avoided
Calcium in setting of digoxin toxicity. Monitored frequent
electrolytes. Treated with kayxalate as needed. She will have
her potassium monitored on [**8-22**] at the rehab facility.
#) Anticoagulation: Patient started on coumadin given poor LV
function and risk of clot formation. Continued coumadin at
decreased dose with sub-therapeutic INR. Prior to discharge to
rehab, coumadin was increased to 5mg daily. Her INR will be
checked on [**8-22**] at rehab and coumadin will be adjusted by Dr.
[**First Name (STitle) 437**].
Medications on Admission:
1. Amiodarone 400mg [**Hospital1 **]
2. Digoxin 0.125 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY
3. Emtricitabine-Tenofovir 200-300 mg po daily
4. Furosemide 100mg po bid
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Methadone HCl 90 mg PO DAILY
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
9. Warfarin 2 mg PO HS
Discharge Medications:
1. Methadone 10 mg Tablet [**Hospital1 **]: Nine (9) Tablet PO DAILY (Daily).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet [**Last Name (STitle) **]: Five (5) Tablet PO BID (2 times
a day).
5. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every other
day: Start on Tuesday, [**2136-8-21**].
6. Coumadin 2.5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO once a day:
Please have your INR checked on [**2136-8-22**]. Results faxed to Dr.
[**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**].
7. Outpatient Lab Work
Please have your PT/PTT/INR as well as a chem 7 (electrolytes,
creatinine, BUN) checked on Wednesday, [**2136-8-22**]. Fax results to
Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] at ([**Telephone/Fax (1) 49261**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Digoxin toxicity resulting in bradycardia
Congestive heart failure
Coronary artery disease
Discharge Condition:
afebrile, comfortable on room air
Discharge Instructions:
Your foley catheter was removed just prior to discharge to
rehab. Please perform a voiding trial on the day of admission
to rehab.
.
Please stop taking Amiodarone and lisinopril. Please resume
taking digoxin 0.125 mg every other day starting on Tuesday,
[**2136-8-21**].
.
Please take coumadin at 5 mg daily. Your INR will be checked on
Wednesday, [**8-22**]. Results will be faxed to Dr.[**Name (NI) 3536**]
office.
.
Please resume the rest of the medications you were on prior to
admission, including lasix 100 mg twice per day.
Please call your primary physician or return to the emergency
room should you develop any of the following symptoms:
nausea/vomiting, chest pain, difficulty breathing, or any other
concerns.
Followup Instructions:
Please keep your appointment to see Dr. [**Last Name (STitle) **] on Thursday,
[**2136-8-23**] at 2:30 pm. Call [**Telephone/Fax (1) 3581**] if there is a problem with
this appointment. You should discuss restarting your HIV
medications at this appointment.
Please see DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] on [**2136-8-27**] at 3:30 PM. Call
[**Telephone/Fax (1) 3512**] if there is a problem with this appointment.
ICD9 Codes: 5849, 2767, 496, 4271, 4280, 4240, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7231
} | Medical Text: Admission Date: [**2170-6-26**] Discharge Date: [**2170-8-1**]
Date of Birth: [**2117-5-28**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycontin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Ascites and malnutrition.
Major Surgical or Invasive Procedure:
Intubation.
EGD x2 with variceal banding.
Diagnostic and therapeutic paracenteses x2.
History of Present Illness:
Mrs. [**Known lastname 84458**] is a very nice 53-year-old woman with HCV cirrhosis
and end-stage liver failure who presented after a recent
admission with weakness, abdominal pain, and malnutrition.
Patient was recently admitted [**6-16**] to [**6-20**] with fever of unclear
etiology, abdominal pain, all infectious work-up was negative
and patient was stable off broad spectrum antibiotics for >48
hours before D/C. Upon returning home, patient had continuous
bilateral epigastric pain, waxing and [**Doctor Last Name 688**] in severity,
associated with nausea and one episode of vomiting on the day
prior to admission. She took once baby dose of ibuprofen, which
helped. Patient had been unable to eat due to nausea, early
satiety and poor appetite. She has felt weak, using walker to
ambulate, and barely able to get out of bed for 4 days. This AM,
she felt lightheaded. She had "whooshing" sounds in her ears.
She presented to appt with Dr. [**Last Name (STitle) **], who was concerned about
her malnutrition and deconditioning.
.
Since admission she was noted to have one positive blood culture
[**6-26**] with coagulase negative staph. With no further positive
cultures, this was presumed to be a a contaminant. She was
treated Vancomycin / Metronidazole / Ceftriaxone on and off from
[**6-26**] - [**6-30**]. Over the next several days care focused on diuresis
with Lasix, nutritional support and pain control. On the day of
transfer to the MICU, patient became nauseated and vomited
approximately 800cc of BRB. Upon arrival the MICU she complains
of nausea and pain.
.
No fevers, +chills. No localized weakness/numbness/tingling. No
headaches/visual changes. No blood in stool or urine. No
dysuria. No cough, SOB.
Past Medical History:
- Chronic hepatitis C infection (genotype 1) with cirrhosis,
Child-[**Doctor Last Name 14477**] B
- Possible HCC with hypodense lesion on CT in [**4-/2170**] and
elevated AFP and CEA
- Portal hypertension, s/p banding of varices
- Chronic epigastric pain
- Chronic nausea
- Asthma
- Seasonal allergies
.
Past Surgical History:
- BSO
- tummy tuck
Social History:
Originally from [**First Name9 (NamePattern2) 8880**] [**Country **] and lives with husband and children.
Has been unemployed since [**2-11**] because of general weakness.
States, "I have no daily life," due to weakness and fatigue.
- Tobacco: Smoked age 19 to 35, 1 PPD, total of 15 pack years
- etOH: Denies, used to drink socially only
- Illicits: Denies, denies IVDU
Family History:
No family history of liver disease
Physical Exam:
VS - 98.3, 93, 108/61, 13, 97/RA
GENERAL - chronically ill-appearing in NAD, uncomfortable
HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, MM dry, OP clear
NECK - supple, no thyromegaly, JVD at 11cm
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, 2/6 SEM murmur at LUSB
ABDOMEN - distended, TTP at RUQ, unablet to appreciate
organmegaly given distension
EXTREMITIES - 2+ bilateral LE edema
SKIN - no rashes or lesions
NEURO - Awake, A&O x 3, CNs II-XII grossly intact, no asterixis
Brief Hospital Course:
Ms. [**Known lastname 84458**] is a 53 year-old transplant candidate with a history
of hepatitis C cirrhosis, possible HCC, portal hypertension s/p
variceal banding who presents with deconditioning/malnutrition
and abdominal pain.
# ESOPHAGEAL VARICES: Ms. [**Known lastname 84458**] had an episode of massive
hematemesis on [**7-7**] in the setting of bleeding esophageal
varices. She went immediately to the ICU were she was scoped
and banded. She had a repeat EGD the following AM with more
banding. Ms. [**Known lastname 84458**] was intubated for airway protection and
eventually stopped bleeding. She went for surveillence EGD on
[**7-20**] and an additional band was placed. Ms. [**Known lastname 84458**] was
maintained on nadolol, PPI, and sucralfate. When she was
received in the ICU on [**2170-7-27**], the patient was noted to have
bleeding from the oropharynx. Liver service scoped the patient
and was unable to stop bleeding. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was placed. The
following morning, on [**2170-7-28**], the patient underwent a TIPS
procedure, with a drop in gradient pressure from 13 to 5.
However, blood flow to the varices was not noted to decrease
post procedure. A paracentesis was also perfored by IR, with 4L
of bloody ascites removed. Albumin was provided to protect
against hepatorenal syndrome. Multiple units of pRBCs,
platelets, and FFP were given during procedure. LFTs, ammonia,
CBC, fibrinogen were followed closely. The esophageal balloon
was deflated before 24 hours, with a small amount of blood
expressed into the aspiration port upon deflation. Patient was
transfused in the ensuing days to keep Hct, INR, fibrinogen, and
platelets at acceptable levels. The gastric balloon was also
deflated eventually, while the [**Last Name (un) **] was left in place. The
[**Last Name (un) **] was removed by hepatology on [**2170-7-30**], after the
patient showed minimal bleeding from oropharnyx and ports.
# ALTERED MENTAL STATUS- Patient arrived to the ICU with
significant altered mental status. Wide differential including
hepatic encephalopathy, primary CNS, morphine, fluid shits from
pericentesis and transfusions, worsening uremia, infection,
among other causes. Most likely from worsening hepatic
encephalopathy perhaps coupled with primary CNS etiology given
CT findings, perhaps complicated by fluid shifts after
paracentesis and transfusions. Patient was unable to receive
treatment for possible hepatic encephalopathy during treatment
for esophageal bleed. Once off propofol, altered mental status
remained. Patient remained unresponsive, with increased
sluggishness of pupils. A CT of the head was performed on
[**2170-7-30**] initially was read as no acute process but showed
evidence of cerebral edema on final read. With progressive
brain edema and poor mental status, a family meeting was held
and decision was made to withdraw care once all family was
present. Patient was then terminally extubated.
# HEPATITIS C CIRRHOSIS: Ms. [**Known lastname 84458**] has HCV cirrhosis and
possible HCC. She was continued on rifaximin and lactulose.
Lasix and spironolactone were initially held for hyponatremia
and restarted when the sodium levels came up. The patient
arrived to the ICU with significant altered mental status,
presumably from hepatic encephalopathy. Esophageal varices
treated as above. Ascites removed after TAPs procedure and
again on [**2170-7-30**] with the help of IR. Both showed hemmorhagic
ascites. Lactulose and rifaximin were help while the [**Last Name (un) **]
was in place and the patient was being treated for esophageal
bleeding. The patient was on propofol while on mechanical
ventilation, which was decreased on [**2170-7-29**] to asses changes
in encephalopathy. Even off sedation, the patient was
significantly altered and unresponsive. Patient was given
albumin daily to protect from hepatorenal syndrome. Once the
[**Last Name (un) **] was removed, an OG was placed on [**2170-7-30**]. Patient
was seen and followed by transplant surgery and was awaiting
possible transplant throughout course.
.
# RESPIRATORY DISTRESS: Patient was intubated on [**2170-7-27**] and
most likely aspirated blood during that procedure. CXRs showed
bilateral pleural effusions and worsening physical exam.
Patient also had increasing WBCs. Patient was on antibiotic
converage for UTI that covered organisms for presumed aspiration
pneumonia. Patient remained intubated until she expired.
Medications on Admission:
(At time of transfer)
- Meropenem 500 mg IV Q8H Duration: 7 Days
day 1 = [**7-23**] (day 1 of 7 days)
- Midodrine 10 mg PO TID
- Multivitamins 1 TAB PO/NG DAILY
- Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
- Nadolol 10 mg PO DAILY
- Claritin *NF* 10 mg ORAL DAILY
- Octreotide Acetate 200 mcg SC Q8H
- Dextrose 50% 25 gm IV PRN hypoglycemia
- Ondansetron 4-8 mg IV Q8H:PRN nausea
- Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
- Pantoprazole 40 mg IV Q12H
- Ipratropium Bromide MDI 2 PUFF IH QID
- Rifaximin 400 mg PO/NG TID
- Lactulose 45 mL PO/NG TID titrate to 4 bowel movements/day.
- Simethicone 40-80 mg PO/NG TID
- Lactulose 30 mL PO/NG TID
- Lidocaine 5% Patch 1 PTCH TD DAILY
- Linezolid 600 mg PO/NG Q12H Day #1 is [**7-22**].
- Sucralfate 1 gm PO/NG QID
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary Arrest
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 5849, 5070, 2761, 5990, 5715, 311, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7232
} | Medical Text: Admission Date: [**2139-10-15**] Discharge Date: [**2139-10-21**]
Date of Birth: [**2085-2-5**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape / Ativan
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
tracheal stent placement
History of Present Illness:
This 54 yo woman with a history of obesity, asthma, anxiety,
kidney stones is transferred from [**Hospital3 **] after diagnosis of
MG (+ MUSK Ab) who is being admitted to the medical ICU
following respiratory decomposition after extubation following
placement of tracheal stent via elective rigid bronchoscopy.
She has had several recent decompositions from her myasthenia
over the past year, and most recently getting IVIG while
continuing on her cellcept, prednisone, amd pyridostigmine. She
has been recalcitrant to steroids in the past. She was last
admitted from [**2139-4-27**] - [**2139-5-26**] during which she had 3 tracheal
intubations (*Difficult airway/fiberscopic intubation) and
underwent plasmapheresis. She underwent trach/PEG placement on
[**2139-5-22**] by Dr. [**Last Name (STitle) **]. She was decanculated on [**2139-7-9**].
This morning, she had noted some increased tiredness and
diplopia,
She had tracheobronchomalacia on CT from the spring, and
underwent initial stent placement on [**2139-5-7**]. Y stent was
removed on [**2139-9-15**] and there was moderate granulation tissue
seen in the mainstem bronchi at that time. She was electively
admitted for Y-stent re-placement today, which occurred without
complication. She had cryotherapy to local granulation tissue.
After the extubation, the patient was noted to be hypoxic in the
PACU with O2 sats 70s-80s with mental status
change/unresponsiveness. She was on BiPap with improvement in
mental status and now weaned off to face tent.
Currently, she is complaining of severe headache mostly, which
has followed her General Anesthesia the last 3 procedures. Mild
dyspnea. She has some complaint of pain in her chest following
the stent, which she has had previously in same setting.
Past Medical History:
asthma
bronchitis
GERD
obesity
panic d/o
anxiety
s/p ccy
kidney stones
recent PNA with possible ards that improved on steroids
DMII, diet controlled
Social History:
No smoking, etoh, illicit drug use. Lives with son.
Family History:
Unknown
Physical Exam:
General Appearance: Well nourished, Overweight / Obese
Eyes / Conjunctiva: PERRL, EOM Full
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Wheezes : upper airway transmitted wheezing, Diminished: at
bases)
Abdominal: Soft, Non-tender, No(t) Distended
Extremities: Right: Absent, Left: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Not assessed, Tone:
Not assessed, UE [**3-28**] proxmially, [**4-27**] distally, LE [**4-27**] distally,
CN appear intact. No overt ptosis seen
Pertinent Results:
[**2139-10-21**] 05:05AM BLOOD WBC-9.4 RBC-5.05 Hgb-13.3 Hct-41.4 MCV-82
MCH-26.3* MCHC-32.1 RDW-14.8 Plt Ct-319
[**2139-10-15**] 08:42PM BLOOD Neuts-90.2* Lymphs-6.1* Monos-2.9 Eos-0.7
Baso-0.2
[**2139-10-21**] 05:05AM BLOOD PT-12.2 PTT-22.7 INR(PT)-1.0
[**2139-10-21**] 05:05AM BLOOD Glucose-143* UreaN-9 Creat-0.7 Na-145
K-3.5 Cl-97 HCO3-41* AnGap-11
[**2139-10-21**] 05:05AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.0
[**2139-10-20**] 07:14AM BLOOD Type-ART pO2-123* pCO2-75* pH-7.42
calTCO2-50* Base XS-20
[**2139-10-20**] 01:13AM BLOOD Lactate-1.2
Sputum [**10-19**]: HEAVY GROWTH OROPHARYNGEAL FLORA
C. diff negative [**2139-10-16**]
CXR: [**10-20**]
FINDINGS: In comparison with the study of [**10-19**], there is little
change.
Bibasilar atelectasis without evidence of acute pneumonia.
CT-head: [**10-19**]
IMPRESSION: Study limited by motion artifact. However, no
evidence of acute intracranial hemorrhage or mass effect.
Spirometry:
SPIROMETRY Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 1.31 2.76 47 1.33 48 +2
FEV1 1.03 2.05 50 1.00 49 -3
MMF 0.97 2.53 39 0.78 31 -20
FEV1/FVC 79 75 106 75 101 -5
Brief Hospital Course:
Assessment and Plan
54 yo woman with [**First Name9 (NamePattern2) 15099**] [**Last Name (un) 2902**] on cellcept, mestinon, and
prednisone, GERD, anxiety, admitted to MICU for respiratory
distress following extubation for Y-stent replacement. DDx for
resp failure includes hypercarbia, hypoventilation from MG, or
aspiration process
# Respiratory Failure:
The patient had an elective stent replacement on [**2139-10-15**]. She
required admission to the ICU s/p procedure, however, for
hypoxia (70's-80's) and somnalnace requiring mask ventilation
thought secondary either to neuromuscular weakness (in context
of MG) causing hypoventialtion vs. obstruciton and collapse in
setting of bronch findings above.
.
In the ICU, the patient was started on BIPAP. She was given a
Z-pak for possible sinusitis and started on Tessalon Perles,
Mucinex, and Nebulized saline to aid in secretion clearance. She
was placed on an Insulin SS for her diabetes. She continued her
outpatient MG regimen of Prednisone 20mg [**Hospital1 **], Mestinone 50mg q4h
and Cellcept 1000mg PO BID. She was followed by IP s/p Y-stent
placement. She required only 1L o2 by NC. She was
tachychardicinto the 150's while in the ICU; this was thought
2dary to anxiety. A neurology consult was requested; the
neurology team noted that the patient had not taken her
Pyridostigmine since the day before the procedure. They
additionally recommended infectious work-up in case infection
was triggering an exacerbation of MG. A Trial off BIPAP was
attempted on [**10-17**] but she failed, but the team was successful
in subsequent weaning such that on the day of transfer, she
required only 3 hours Bipap and was breathing 97% on 2L NC. She
did have new complaints suggestive for possible hospital aquired
PNA, and was started on Vancomycin but not Ceft/Zosyn.
Although her pCO2 was elevated, she was clinically stable and
thought to be stable for transfer from the ICU. She was briefly
transferred to the floor and then returned to the ICU with
hypertension and respiratory distress likely secondary to flash
pulmonary edema. She was stablized overnight and returned to
the floor. The patient was continued on nebs, but still
continued to have difficulty breathing and was not at her
baseline status. The patient continued to be increasingly
anxious to go home and decided the leave AMA. The patient
understood the risks, but felt that she stable enough to return
home. The patient was setup with follow-up appointments and
will return for an outpatient bronch in approx one week.
.
#) Myasthenia [**Last Name (un) **]
- Neurology consulted for possibility of MG component to
respiratory status, however given NIFS were -80 it was thought
that her MG was under control. She was continued on her
prednisone, mestinone, and cell cept. She had one episode of
diplopia that self-resolved.
#) Tracheomalacia
s/p Y stent
# Anxiety/panic d/o: The patient had continued anxiety during
her admission. She was continued on paxil 15 mg daily.
Additionally, the patient was treated with xanax 0.125mg prn.
# DM: stable, followed FSG and covered with RISS
.
#Tachycardia: Pt had sinus tachycardia and was started on 30mg
diltiazem. The patient was stable and her sinus tachycardia was
likely secondary to anxiety. She was not continued on diltiazam
upon discharge.
.
#Diarrhea: The patient had compliants of loose stools. The
patient states that these symptoms had occured for awhile prior
to admission. She stated it was well controlled by immodium
prior to admission. It was felt that her loose stools were
likely secondary to her Mestinon and she was restarted on
immodium.
.
#FEN:
- regular diet
- replete lytes PRN.
.
#ACCESS: PIV
.
#PPx: Heparin sub-q for DVT prophylaxis, bowel regimen, ppi,
.
#CODE: FULL.
.
#COMMUNICATION: Patient, sons: [**Name (NI) **], HCP ([**Telephone/Fax (1) 78744**],
[**Doctor Last Name **] (other son) ? [**0-0-**].
Medications on Admission:
ALENDRONATE 70 mg Tablet - qSun
FLONASE - 50 mcg Spray 2 sprays daily
OMEPRAZOLE - 40 mg [**Hospital1 **]
PAROXETINE HCL [PAXIL] - 15 mg daily
POTASSIUM CHLORIDE [K-DUR] - 20 mEq Tab Sust.Rel. [**Hospital1 **]
CALCIUM CARBONATE [CALCIUM 500] - 1 tab TID
DEXTROMETHORPHAN-GUAIFENESIN [MUCINEX DM] - 1,200 mg-60 mg Tab,
Multiphasic Release 12 hr - 1 Tab(s) by mouth twice a day
Compazine 5mg PO PRN
RISS
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
9. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten
(10) ML PO Q6H (every 6 hours) as needed.
10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week:
Sunday.
11. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2)
spary Nasal once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Hypercapneic respiratory failure
Secondary:
Bronchitis
GERD
obesity
panic d/o
anxiety
s/p ccy
kidney stones
DMII, diet controlled
tracheobronchomalacia s/p Y stent placement
Discharge Condition:
AGAINST MEDICAL ADVICE
Discharge Instructions:
YOU ARE LEAVING AGAINST MEDICAL ADVICE. The risks of leaving
were explained to you and you stated that you understood. You
were admitted to [**Hospital1 18**] for elective Y-stent replacement, but had
respiratory decompensation after the procedure. Your stay in
the ICU was complicated by continued respiratory distress,
hypertension and increased heart rate. You were stablized and
sent to the general medical floor for further management.
Please continue to take your medications as prescribed below.
Please follow-up with the appointments made below.
Please call your PCP or go to the ED if you experience worsening
shortness of breath, respiratory distress, cough, fevers,
chills, nausea, vomiting, diarrhea, chest pain or other
concerning symptoms.
Followup Instructions:
Interventional Pulm will call you regarding setting up an
outpatient bronchoscopy in 1 week. If you do not hear from them
in [**12-24**] days please call [**Telephone/Fax (1) 7769**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2139-10-29**] 11:15
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 2846**]
Date/Time:[**2139-12-8**] 10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9501**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2139-12-28**]
1:00
Completed by:[**2139-10-21**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7233
} | Medical Text: Admission Date: [**2188-5-14**] Discharge Date: [**2188-6-9**]
Date of Birth: [**2118-1-9**] Sex: M
Service: PODIATRY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18867**]
Chief Complaint:
Right heel necrotic gas gangrene
Major Surgical or Invasive Procedure:
[**5-14**] s/p R heel debridement
[**5-20**] s/p R angio
[**5-23**] s/p R AK [**Doctor Last Name **]-DP
[**5-29**] s/p R heel debridement & VAC
History of Present Illness:
The patient is a 70-year-old male who presented to the emergency
room with a chief complaint of a painful right heel with fevers
and chills. The patient is a
diabetic with previous history of ulceration. X-rays taken at
that time showed gas in the subcutaneous tissue. The patient was
taken to the operating room by Dr. [**Last Name (STitle) **].
Past Medical History:
HTN, DM, PVD, CABG '[**84**], creat 1.0-1.4, LVEF >55%, mild MR;
episodes of Wenckebach [**5-25**]
Social History:
N/A
Family History:
N/A
Physical Exam:
Gen: A&Ox3
CV: RRR
Pulm: CTA b/l
Abd: S/NT/ND, BS Present
LE:
Nonpalpable pedal pulses, cellulitis
Painful Right heel Abscess. The subcutaneous tissue was [**Doctor Last Name 352**],
necrotic, and foul-smelling in appearance with purulent
drainage. The entire soft tissue in this region appeared to
have been necrotic.
Pertinent Results:
[**2188-5-14**] 06:10AM GLUCOSE-475* UREA N-40* CREAT-1.3*
SODIUM-131* POTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-21* ANION
GAP-20
[**2188-5-14**] 06:10AM CALCIUM-8.7 PHOSPHATE-2.4* MAGNESIUM-1.7
IRON-12*
[**2188-5-14**] 06:10AM calTIBC-159* VIT B12-349 FOLATE-11.4
FERRITIN-606* TRF-122*
[**2188-5-14**] 06:10AM TSH-1.5
[**2188-5-14**] 06:10AM WBC-22.3* RBC-3.04* HGB-8.8* HCT-26.9* MCV-89
MCH-28.9 MCHC-32.6 RDW-13.5
[**2188-5-14**] 06:10AM PLT COUNT-216
[**2188-5-14**] 06:10AM PT-13.1 PTT-29.3 INR(PT)-1.1
[**2188-5-14**] 01:11AM COMMENTS-GREEN TOP
[**2188-5-14**] 01:11AM LACTATE-2.1*
[**2188-5-14**] 01:00AM GLUCOSE-421* UREA N-43* CREAT-1.4*
SODIUM-129* POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-24 ANION GAP-16
[**2188-5-14**] 01:00AM WBC-20.3*# RBC-3.09* HGB-9.1*# HCT-26.9*#
MCV-87# MCH-29.4 MCHC-33.8 RDW-13.6
[**2188-5-14**] 01:00AM NEUTS-90.6* LYMPHS-4.8* MONOS-4.5 EOS-0
BASOS-0
[**2188-5-14**] 01:00AM PLT COUNT-230
Brief Hospital Course:
1. Right Diabetic Foot Infection/Ulceration
70 yo M after presenting to ED c gas in tissue on x-ray was
taken to the OR immediately for debridement. The subcutaneous
tissue at this time was noted to be [**Doctor Last Name 352**], necrotic, and
foul-smelling in appearance with purulent drainage. The entire
soft tissue in this region appeared to have been necrotic. A
sterile probe was used to see where this purulence probed to.
The purulence probed laterally, and
a lateral incision was made. This wound was tracked laterally to
the lateral-most edge of the right heel. Medially, however, the
wound probed more proximally, and an incision was made which
extended beyond the medial-most border of the
calcaneus. A rongeur was then used to remove all devitalized
tissue from the wound.
At this time, it should be noted that the wound appeared
necrotic and foul-smelling with copious amounts of drainage. A
15 blade was used to further debulk the tissues that appeared
devitalized. A pulse irrigator was then used to irrigate the
wound. After the wound had been irrigated, it was packed open
with ortho solution-soaked gauze. This was then dressed with
sterile gauze, Kling, an abdominal pad, and
an Ace bandage. A vascular evaluation was obtained and
continuous Doppler ultrasonography and pulse volume recordings
were obtained, revealing normal inflow into the left lower
extremity with moderate right SFA and tibial disease. The
patient was therefore taken by vascular to the OR for a Right
below knee popliteal to anterior tibial bypass graft with
reversed saphenous vein graft. He was initially taken to the
VICU for recovery. After stabilized, he was transferred back to
floor status. Now after revascularization, he had an open wound
under his right heel that is extensive with exposed calcaneus.
At this point, an Incision and drainage of right foot abscess
and Partial calcanectomy right foot was performed. Afterwards,
this infection became stabilized and it was decided at that
point to apply a VAC dressing. VAC dressing and wound care was
performed for the duration of his hospital stay. He was
maintained on IV antibiotics that were tapered to his wound
cultures and was d/c'ed on IV Zosyn for broad coverage as he did
initially have gas gangrene. Plastics was also consulted for
flap/closure options and it was felt that there were no current
viable options until a longer period of VAC therapy. Pt
responded very well to VAC therapy and plastics plan was to cont
VAC for an additional 1-2 weeks with f/u with plastics as an
out-pt for future flap considerations after improved granulation
tissue. Pt will also f/u c Dr. [**Last Name (STitle) **] within one week. He
was sent to rehab with a PICC on Zosyn IV and VAC dressing
changes.
2. Peripheral Vascular Disease
A vascular evaluation was obtained and continuous Doppler
ultrasonography and pulse volume recordings were obtained,
revealing normal inflow into the left lower extremity with
moderate right SFA and tibial disease. The patient was therefore
taken by vascular to the OR for a Right below knee popliteal to
anterior tibial bypass graft with reversed saphenous vein graft.
He was initially taken to the VICU for recovery. After
stabilized, he was transferred back to floor status. He
recovered without complication from his bypass graft with
vascular service following.
3. Diabetes Mellitus Type 1
The patient presented with very labile blood glucose levels and
[**Last Name (un) **] was therefore consulted. His lantus was increased on
[**5-26**] due to hyperglycemia. On
[**5-31**] BG was 109 mg/dL in am and before lunch BG was 92 mg/dL.
[**6-1**] Low overnight. But pt preferred no changes to his regimen.
On [**6-2**]- his lantus was decreased to 30 for persistant am CBG
lows. His lantus was further decreased to 27 on [**6-5**] and then
on [**6-6**]-still decreased to 25 tonight. He remained stable.
4. HTN
The patient was maintained on his outpatient regimen as well as
a peri-op beta blocker. An Echo was obtained which showed an
LVEF >55%, mild MR. Pt had episodes of Wenckebach [**5-25**],
cardiology evaluated and felt there was no necessary
intervention. He had no other episodes or complications
throughout his hospital stay.
5. Chronic Renal Insufficiency
The pt remained at his baseline creatinine throughout his
hospital stay of [**12-29**].4.
Medications on Admission:
Alphagan gtt OS", lisinopril 20, Lopressor 50", HCTZ 25, Zocor
10, Lantus 34, B12, Fe, Soothe gtt OS
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
4. Zosyn 4.5 g Recon Soln Sig: One (1) Intravenous every eight
(8) hours for 2 weeks.
Disp:*2 weeks* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime.
Disp:*5 vials* Refills:*2*
8. Humalog 100 unit/mL Solution Sig: Per insulin sliding scale
sliding scale Subcutaneous per sliding scale: Please print out
sliding scale for rehab.
Disp:*2 vials* Refills:*2*
9. 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*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Lifecare of [**Location (un) 2199**]
Discharge Diagnosis:
[**5-14**] s/p R heel debridement
[**5-20**] s/p R angio
[**5-23**] s/p R AK [**Doctor Last Name **]-DP
[**5-29**] s/p R heel debridement & VAC
Discharge Condition:
Stable
Discharge Instructions:
Make and keep all follow up appointments.
Take all medication as prescribed.
PICC CARE per PICC Protocol
Zosyn IV through PICC Line
Non-weight bearing to right lower extremity
VAC Dressing to change every 3 days, keep at 125mmHg continuous
suction.
Followup Instructions:
1. Podiatric Surgery: Dr. [**Last Name (STitle) **] within one week of discharge
at [**Telephone/Fax (1) 543**]
2. Plastic Surgery: Dr. [**Last Name (STitle) **] [**Hospital1 18**]/Plastic Surgery
[**Location (un) 830**], 707E
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 20278**]
[**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**] DPM 48-121
Completed by:[**2188-6-6**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7234
} | Medical Text: Admission Date: [**2132-1-19**] Discharge Date: [**2132-2-4**]
Date of Birth: [**2057-5-9**] Sex: F
Service: PURPLE TEAM
CHIEF COMPLAINT: Abdominal pain, vomiting, abdominal
distention.
HISTORY OF PRESENT ILLNESS: The patient is a 74 year-old
female with a history of a radical hysterectomy, omentectomy,
ileocecectomy on [**2131-10-18**] who presented on [**2132-1-19**] with a
four day history of abdominal pain, one day history of
vomiting, and increased abdominal distention. Chest x-ray
showed free air under the diaphragm.
PAST MEDICAL HISTORY: Ovarian carcinoma status post radical
hysterectomy, omentectomy, ileocecectomy on [**2131-10-18**]. Status
post cholecystectomy, status post dilatation and curettage,
status post C section, depression.
MEDICATIONS ON ADMISSION: Risperdal, Glyburide 10 mg po q.d.
ALLERGIES: Penicillin.
SOCIAL HISTORY: She lives with her daughter.
LABORATORIES ON ADMISSION: Complete blood count, hematocrit
32.3, white cell count 2, platelets 111. Chem 7 sodium 124,
potassium 2.3, chloride 79, CO2 28, BUN 44, creatinine 2.4,
blood sugar 240. Arterial blood gases pH 7.46, PCO2 41, PO2
64, white count 30, basophils +4, lactate 2.3. Chest x-ray
revealed free air under the right diaphragm, superior and
mediastinal mass, bilateral atelectasis.
HOSPITAL COURSE: Ms. [**Known lastname **] was admitted directly to the
Intensive Care Unit for stabilization following which she was
taken the Operating Room on [**2132-1-19**]. The was operated on by
Dr. [**First Name (STitle) **] [**Name (STitle) **]. She underwent exploratory laporotomy with
lysis of adhesions, resection of leaking anastomosis, distal
ileum and hepatic flexure of colon and ileostomy and
mucofistula of transverse colon. She was transferred to the
Intensive Care Unit postoperatively. Her postoperative
course was complicated. She had a prolonged stay in the
Intensive Care Unit due to persistent acidosis requiring
vasopressors, acute renal failure, prolonged intubation. She
was extubated on [**2132-1-30**]. She was transferred out of the
Intensive Care Unit on [**2132-2-1**] and is ready for discharge to
rehab currently.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Awaiting discharge to rehab.
DISCHARGE DIAGNOSIS:
Status post exploratory laporotomy, lysis of adhesions,
resection of leaking anastomosis distal ileum and hepatic
flexure and ileostomy plus mucofistula on [**2132-1-19**].
MEDICATIONS ON DISCHARGE: 1. Nystatin powder to groin and
axilla b.i.d. 2. Epogen [**Numeric Identifier **] units subQ twice weekly
Monday and Thursday. 3. Heparin 5000 units subQ b.i.d. 4.
Lacrilube ointment to each eye q.i.d. 5. Lopressor 100 mg
per NG tube b.i.d. hold for systolic blood pressure less then
90, heart rate less then 60. 6. Hydralazine 10 mg per NG
tube q 6 hours hold for a blood pressure less then 100. 7.
Regular insulin sliding scale subQ. 8. Tylenol 650 mg per
NG tube q 4 to 6 hours prn. 9. Glyburide 10 mg per NG tube
q.a.m. 10. Risperdal per NG tube .5 mg q.a.m., 1.5 mg
q.p.m.
TREATMENT: Stoma therapy. Finger sticks q 6 hours with
regular insulin sliding scale, venodyne, incentive
spirometer.
DIET: Impact with fiber at 60 cc per hour via NG tube. Free
water boluses 250 cc q 4 hours by NG tube. Swallow study to
be repeated in two weeks.
FOLLOW UP: Follow up with Dr. [**Last Name (STitle) **], to call for
appointment in one to two weeks.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2132-2-4**] 09:49
T: [**2132-2-4**] 07:43
JOB#: [**Job Number 35753**]
ICD9 Codes: 2762, 5845, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7235
} | Medical Text: Admission Date: [**2198-5-20**] Discharge Date: [**2198-5-22**]
Date of Birth: [**2146-10-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Abdominal pain / nausea / vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51 yo F w/ a h/o DM II DM complicated by gastroparesis and
peripheral neuropathy with multiple hospitalizations / ER visits
for gastroparesis presents with her usual symptoms of epigastric
pain and tenderness, nausea and bilious vomiting x 24 hours.
Very poor PO intake over the past 1 day, 10 episodes of bilious,
non bloody, vomiting over the past 24 hours. Worsening until ED
visit, now since fluid and symptomatic treatment (pain control /
antiemetic) her symptoms have been improving. Her gastroparesis
symptoms last usually 2-7 days. She states that while vomiting
she had noticed some coughing afterwards and that she felt like
she was choking on her vomit at times.
.
She usually takes all of her medications at bedtime and vomited
up her medications last night, she therefore did not have her PO
antihypertensives.
.
She denies any headache, chest pain, shortness of breath, PND,
orthopnea. No fevers or chills. + cough as above, no dysuria.
.
In the ED her initial vital signs were HR 105 BP 208/101 which
increased to a peak of BP 240 / 123, O2 sat 97%. She received
ondansetron, morphine, metoprolol 5mg IV x2, hydralazine 20mg
IV, promethazine and was started on a labetalol drip. Her
labetalol drip was uptitrated to 3mg / hr and her BP came down
to 178 / 96. She was also given 3.8 liters of NS in the ED and
produced 200cc of urine.
Past Medical History:
# Type I diabetes, uncontrolled, complicated by gastroparesis
and peripheral neuropathy.
# Hypertension.
# Depression, with psychotic features per patient. Multiple
hospitalizations while living in [**Location (un) 5503**] up until 2 years
ago ("isolated myself"--now better since moving up to [**Location (un) 86**],
goes to meetings, therapy, etc), no hospitalizations since then.
# h/o Hepatitis B
# Hepatitis C
# Past history of IV heroin abuse, now sober, enrolled in NA/AA
for last 16 yrs
# Colon polyp - removed [**9-2**]; adenoma
Social History:
Lives with her two adult sons. [**Name (NI) **] smoked a pack a day for the
last 30 years; Agrees to nicotine patch in hospital. No
alcohol or other drugs for the last 16 years; attends NA/AA
meetings; before that, her drug of choice was injected heroin.
Family History:
Family History:
Father died of CHF-related causes in his 60s. Mother with "heart
problems" but still alive. +Family history of colon cancer.
Physical Exam:
Gen: Well nourished, NAD, overweight/obese
HEENT: PERRL, NCAT, MM dry
CV: Nl S1+S2, no m/r/g. R/L radial pulses present.
Resp: CTAB, symmetrical expansion.
Abd: Soft. Epigastric tenderness, referred tendereness to
epigastum from abd diffusely.
Pertinent Results:
[**2198-5-22**] 10:35AM BLOOD WBC-9.2 RBC-4.22 Hgb-12.0 Hct-36.3 MCV-86
MCH-28.5 MCHC-33.1 RDW-14.0 Plt Ct-197
[**2198-5-21**] 04:24AM BLOOD WBC-16.4* RBC-4.21 Hgb-11.7* Hct-35.5*
MCV-84 MCH-27.8 MCHC-33.0 RDW-13.8 Plt Ct-232
[**2198-5-20**] 12:15PM BLOOD WBC-13.5* RBC-4.94 Hgb-14.1 Hct-42.8
MCV-87 MCH-28.5 MCHC-33.0 RDW-14.1 Plt Ct-240
[**2198-5-20**] 12:15PM BLOOD Neuts-66.4 Lymphs-30.9 Monos-2.0 Eos-0.4
Baso-0.2
[**2198-5-20**] 12:15PM BLOOD PT-13.5* PTT-26.3 INR(PT)-1.2*
[**2198-5-21**] 04:24AM BLOOD Glucose-199* UreaN-9 Creat-0.7 Na-138
K-3.7 Cl-107 HCO3-22 AnGap-13
[**2198-5-20**] 12:15PM BLOOD Glucose-335* UreaN-7 Creat-0.8 Na-139
K-3.5 Cl-100 HCO3-27 AnGap-16
[**2198-5-20**] 12:15PM BLOOD ALT-24 AST-25 AlkPhos-116 TotBili-0.5
[**2198-5-20**] 12:15PM BLOOD Lipase-30
[**2198-5-21**] 04:24AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.3*
[**2198-5-20**] 11:29PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2198-5-20**] 11:29PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose->1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5
Leuks-NEG
[**2198-5-20**] 11:29PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-1
[**2198-5-20**] 11:29PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2198-5-20**] 11:29 pm URINE Source: CVS.
**FINAL REPORT [**2198-5-22**]**
URINE CULTURE (Final [**2198-5-22**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
CHEST (PORTABLE AP) Study Date of [**2198-5-20**] 10:05 PM
CLINICAL HISTORY: 51-year-old female with leukocytosis, coughing
and
vomiting. Evaluate for aspiration, pneumonia. AP chest
radiograph compared to [**2198-5-13**] [**Location (un) 381**] lung volumes,
however without consolidation, pneumothorax or pleural effusion.
The heart size is top normal, unchanged. Mediastinal and hilar
contours are within normal limits.
Brief Hospital Course:
1. Malignant Hypertension
- Initially managed in [**Hospital Unit Name 153**] with labatelol IV drip, with good
control
- Changed back to home PO regimen, which has maintained control
- Has follow up with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 4 days
2. Type 2 Diabetes Uncontrolled with Complications,
Gastroparesis
- Continue metoclopramide
- Glargine/Lispro ISS
- Moderate control in house
3. Leukocytosis
- Recurrent, and idiopathic
- Spontaneously resolved
- All cultures non-diagnostic
4. Depression
- Seroquel and Fluoxetine continued
5. Benign Positional Vertigo
- Meclazine
6. Obstructive Sleep Apnea
- CPAP was continued
Medications on Admission:
Aspirin 81 mg Daily
Docusate Sodium 100 mg Twice daily
Fluoxetine 60 mg Daily
Insulin Glargine 73 units at bedtime
Insulin Lispro Sliding scale
Lisinopril 40 mg daily
Metoclopramide 10 mg Four times daily
Metoprolol Succinate 50 mg Daily
Pravastatin 20 mg Daily
Triamterene-Hydrochlorothiazid 37.5-25 mg daily
Meclizine 12.5 mg every 8 hours as needed for dizziness
Quetiapine 600mg po every evening
Prilosec 20mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
4. Insulin Glargine 100 unit/mL Solution Sig: Sixty Three (63)
units Subcutaneous at bedtime.
5. Insulin Lispro 100 unit/mL Solution Sig: Sliding Scale Units
Subcutaneous ASDIR.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
11. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for vertigo.
12. Quetiapine 200 mg Tablet Sig: Three (3) Tablet PO QHS (once
a day (at bedtime)).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Malignant Hypertension
Type 2 Diabetes with complications
Gastroparesis
Depression
Benign Positional Vertigo
Obstructive Sleep Apnea
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital if you have fever/chills, headache,
inability to eat, chest pain, inability to take your medications
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] as previously scheduled [**Telephone/Fax (1) 3581**]
ICD9 Codes: 3572, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7236
} | Medical Text: Admission Date: [**2160-3-6**] Discharge Date: [**2160-3-16**]
Date of Birth: [**2080-4-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain & SOB
Major Surgical or Invasive Procedure:
[**2160-3-10**] Coronary artery bypass grafting x5, left internal
mammary artery grafting left anterior descending, reversed
saphenous vein graft to the marginal branch, ramus
intermedius branch, diagonal branch and posterior descending
coronary artery.Re-exploration [**2160-3-10**]
History of Present Illness:
79 y/o male with increasing frequency of angina, +ETT, referred
for cath which revealed 3vCAD
Past Medical History:
CAD
HTN
hypercholesterolemia
DM
Gout
PMR
Prostate Cancer (s/p XRT & hormones)
Social History:
retired firefighter
lives with wife
[**Name (NI) **]. ETOH
never smoked
Physical Exam:
unremarkable upon admission
Pertinent Results:
[**2160-3-16**] 05:10AM BLOOD WBC-7.0 RBC-2.96* Hgb-8.8* Hct-25.8*
MCV-87 MCH-29.7 MCHC-34.1 RDW-15.5 Plt Ct-182
[**2160-3-13**] 01:57AM BLOOD PT-13.6* PTT-28.2 INR(PT)-1.2*
[**2160-3-16**] 05:10AM BLOOD Glucose-74 UreaN-36* Creat-1.3* Na-141
K-4.3 Cl-105 HCO3-28 AnGap-12
PATIENT/TEST INFORMATION:
Indication: introp CABG. Evaluate Aortic Atheroma, Ventricular
function, Valvular function.
Height: (in) 60
Weight (lb): 84
BSA (m2): 1.29 m2
BP (mm Hg): 120/50
HR (bpm): 70
Status: Inpatient
Date/Time: [**2160-3-10**] at 09:24
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.2 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.9 cm
Left Ventricle - Fractional Shortening: 0.31 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%)
Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aorta - Arch: 2.8 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: *3.3 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: *2.1 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 18 mm Hg
Aortic Valve - Mean Gradient: 7 mm Hg
Aortic Valve - LVOT Peak Vel: 0.[**Age over 90 **] m/sec
Aortic Valve - LVOT VTI: 23
Aortic Valve - LVOT Diam: 2.1 cm
Aortic Valve - Valve Area: *1.8 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the
interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root.
Normal ascending aorta diameter. Focal calcifications in
ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Mildly dilated
descending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve
leaflets. Mild AS (AoVA 1.2-1.9cm2).
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
Conclusions:
Pre Bypass: There is mild symmetric left ventricular
hypertrophy. Overall left
ventricular systolic function is normal (LVEF>55%). Cannot
exclude focal
thinning of the basal inferior wall. Right ventricular chamber
size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level.
There are simple atheroma in the aortic arch. The descending
thoracic aorta is
mildly dilated. There are simple atheroma in the descending
thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are
moderately thickened. The non-coronary cusp is heavily calcified
and poorly
mobile. There is mild aortic valve stenosis (area 1.2-1.9cm2).
The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
Post Bypass: Patient is in sinus rhythm, on phenylepherine gtt
Preserved biventricular function with LVEF >55%. No change in
valves. Aortic
contours intact. Remaining exam is unchanged. All findings
disucssed with
surgeons at the time of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2160-3-12**] 16:09.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
admitted from [**Hospital6 5016**] with unstable angina on
[**2160-3-6**]. He had a carotid ultrasound, as well as other
pre-operative testing. He remained stable, and was taken tot he
OR on [**2160-3-11**] with Dr. [**Last Name (STitle) **]. He underwent CABG X 5
(LIMA>LAD, SVG>OM2, SVG>Diag & OM1, SVG>PDA. Post-op he was
taken to the CSRU. He had a significant amount of
post-operative bleeding despite correcting coagulation
parameters, and he was therefore taken back to the OR on the
night of surgery. A bleeding site was found and repaired. He
returned to the CSRU where he remained hemodynanically stable
with no further bleeding problems. [**Name (NI) **] was extubated and weaned
from vasoactive drips over the next 24 hours. He was
transferred to the telemetry floor on POD # 3, where he
progressed with pulmonary toilet and ambulation. A HIT screen
was sent due to thrombocytopenia, and it was negative. He
remained stable, and was discharged home on [**2160-3-16**]
Medications on Admission:
Allopurinol 100"
ASA 81'
HCTZ 25'
Avapro 300'
Metoprolol 50'
Lipitor 40'
Prandin 2"'
Toprol XL 50'
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*60 Tablet(s)* Refills:*2*
8. Repaglinide 0.5 mg Tablet Sig: Two (2) Tablet PO TIDAC (3
times a day (before meals)).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*4 1* Refills:*2*
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease, worsening angina, unstable angina.
OPERATION: Coronary artery bypass grafting x5, left internal
mammary artery grafting left anterior descending, reversed
saphenous vein graft to the marginal branch, ramus
intermedius branch, diagonal branch and posterior descending
coronary artery.
Discharge Condition:
good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**3-20**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 10775**] in [**1-19**] weeks.
Local cardiologist, Dr.[**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] [**Telephone/Fax (1) 5424**] in [**1-19**]
weeks.
Completed by:[**2160-3-17**]
ICD9 Codes: 4111, 2875, 4019, 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7237
} | Medical Text: Admission Date: [**2141-3-9**] Discharge Date: [**2141-3-13**]
Date of Birth: [**2087-3-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
coronary artery disease s/p coronary artery bypass graft x3 (
LIMA-LAD, SVG diag and OM)
History of Present Illness:
History of Present Illness: 53 year old man with a history of
hyperlipidemia and hypertension with complaints of non-radiating
exertional chest pain for the last 6 weeks underwent stress test
today. Pt. complained of chest pain [**2141-7-3**] during the stress
test
and had [**Street Address(2) **] elevations in lead V1-V4 and [**Street Address(2) 4793**] V5. EKG
returned to [**Location 213**] after test. Mr. [**Known lastname **] has been chest pain
free since
the test. He underwent cardiac catheterization in [**2133**] for (+)
stress test which showed 40% stenosis of the mid-LAD coronary
artery. He underwent a cardiac catheterization
which showed 3 vessel coranonary artery disease and taken for
cardiacrevascularization on [**2141-3-9**]
Past Medical History:
hypertension, hyperlipidemia
Social History:
Married, two children. Works full time as mechanical engineer.
Social history: Significant for current tobacco use -[**1-28**] ppd x
35
years. There is
no history of alcohol abuse.
Family History:
mother has coronary disease
Physical Exam:
Physical Exam
Pulse:72 Resp: O2 sat:
B/P Right:176/110 Left: 181/100 98% RA
Height:6'2" Weight:260#
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 [] Superficial veins bilaterally
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 37844**] (Complete)
Done [**2141-3-9**] at 1:35:00 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2087-3-7**]
Age (years): 54 M Hgt (in): 73
BP (mm Hg): 115/62 Wgt (lb): 260
HR (bpm): 70 BSA (m2): 2.41 m2
Indication: Chest pain. Coronary artery disease. Left
ventricular function.
ICD-9 Codes: 786.05, 786.51, 424.0
Test Information
Date/Time: [**2141-3-9**] at 13:35 Interpret MD: [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15426**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW001-0:00 Machine: AW5
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 4.9 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.3 cm
Left Ventricle - Fractional Shortening: 0.48 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 85 ml/beat
Left Ventricle - Cardiac Output: 5.95 L/min
Left Ventricle - Cardiac Index: 2.47 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 7 < 15
Aorta - Annulus: 2.9 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 6 mm Hg < 20 mm Hg
Aortic Valve - LVOT VTI: 16
Aortic Valve - LVOT diam: 2.6 cm
Aortic Valve - Valve Area: 3.5 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 1.00
Tricuspid Valve - Peak Velocity: 2.0 m/sec
TR Gradient (+ RA = PASP): >= 18 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic 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. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-bypass:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. 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. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a trivial/physiologic pericardial effusion.
Post-bypass:
The patient is not receiving inotropic support post-CPB.
Biventricular systolic function is preserved. All other findings
are consistent with pre-bypass findings. The aorta is intact
post-decannulation. All findings discussed with the surgeon.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2141-3-9**] 17:08
.
Brief Hospital Course:
Mr [**Known lastname **] was admitted on [**2141-3-9**] and taken to the Operating room
for Coronary artery bypass graft x3, left internal mammary
artery to the left anterior descending artery and saphenous vein
grafts to the diagonal and obtuse marginal.
2. Endoscopic harvesting of the long saphenous vein. See
operative note for details.
Post operatively he reamined intubated and was admitted to the
ICU for invasive hemodynamic monitoring. He awoke neurologically
intact and was weaned from the ventilator and extubated. He
statin therpay and betablockers were resumed and was gently
diuresed toward his pre-operative weight. His chest tubes and
pacing wires were removed per protocol. On POD#1 he was
transferred for the ICU to the stepdown unit. He was evaluated
by physical therapy for strength and conditioning and was
cleared for discharge to home on POD#4 by DR. [**Last Name (STitle) **].
Medications on Admission:
atenolol 12.5 daily, imdur 30 daily,Simvastatin 40 daily, ASA 81
daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
coronary artery disease, hypertension, hyperlipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Discharge Instructions: Please shower daily including washing
incisions gently with mild soap, no baths or swimming, and look
at your incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Recommended Follow-up:Please call to schedule appointments
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3357**] in [**1-28**] weeks
Cardiologist Dr. [**Last Name (STitle) 911**] in [**1-28**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2141-3-13**]
ICD9 Codes: 412, 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7238
} | Medical Text: Admission Date: [**2109-7-16**] Discharge Date: [**2109-7-26**]
Date of Birth: [**2041-2-25**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 68-year-old male
patient with a past medical history of hyperthyroidism,
hypercholesterolemia, borderline hypertension, and diabetes,
who presented with worsening exertional chest pain. He
states he has been having intermittent chest pain, however on
the night prior to admission, he had 10/10 chest pain
radiating to his neck with diaphoresis that dissipated with
aspirin and some rest. He presented to the Emergency
Department.
PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2.
Borderline hypertension. 3. Diet-controlled diabetes
mellitus. 4. Hypothyroidism.
PAST SURGICAL HISTORY: Total knee replacement seven years
ago.
MEDICATIONS ON ADMISSION: 1. Levoxyl 150 mg p.o. q.d. 2.
Viagra 100 mg p.o. p.r.n. 3. Aspirin, occasional.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is married, smoked one pack of
cigarettes per day for 20 years but quit 30 years ago, and
rare ETOH intake.
HOSPITAL COURSE: The patient was subsequently admitted to
the cardiology service and was taken to cardiac
catheterization, which revealed three-vessel coronary artery
disease, as well as a left ventricular ejection fraction of
45%. Cardiothoracic surgery consultation was obtained at
that time. The patient subsequently had persistent chest
pain on medical management and was taken back to the Cardiac
Catheterization Laboratory for placement of intra-aortic
balloon pump. This was done on [**2109-7-17**]. The patient was
then admitted to the coronary care unit, remained on an
intra-aortic balloon pump, and was taken to the operating
room on [**2109-7-18**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], where he underwent
coronary artery bypass grafting x 4. He had a left internal
mammary artery to the left anterior descending coronary
artery, saphenous vein graft to the posterior descending
coronary artery, saphenous vein to the obtuse marginal and
saphenous vein to the diagonal. Postoperatively the patient
was transported from the operating room to the cardiac
surgery recovery unit in stable condition. He was in normal
sinus rhythm with a heart rate in the 80s. He was on
propofol, Neo-Synephrine and IV insulin drips. On the night
of surgery the patient was weaned from mechanical ventilation
and subsequently extubated to a nasal cannula without any
difficulty. He remains on IV nitroglycerin drip. His other
drips had been discontinued.
On the morning of postoperative day one, it was noted that
his intra-aortic balloon pump had blood in the tubing and was
removed emergently at the bedside in the cardiac surgery
recovery unit with no difficulty. On postoperative day two
the patient was noted to be in atrial flutter with a
ventricular response of about 150. The patient had no
symptoms or complaints at the time. He had been on oral
Lopressor at that time and was given IV Lopressor without any
decrease in his ventricular heart rate. For that reason he
was started on IV diltiazem drip at 15 mg per hour. There
was still a fair amount of difficulty controlling his rate.
He remained on diltiazem drip until the morning of
postoperative day three, when he was placed on IV amiodarone,
however he remained in atrial flutter with a ventricular rate
of about 100. The patient remained in the cardiac surgery
recovery unit and on postoperative day four, was still in
atrial flutter, remained on amiodarone. His diltiazem drip
had been restarted and was remaining at 15 mg an hour. At
that time he was begun on IV heparin since he had remained in
atrial flutter for approximately 36 hours at that time, and
Coumadin was initiated.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Clinic consultation was obtained also on
postoperative day four, since the patient had a questionable
history of diabetes mellitus, but had never received any
treatment for such. He did require a fair amount of insulin
infusion in his postoperative course in the cardiac surgery
recovery unit. He was initially started by the [**Hospital **] Clinic
on NPH Insulin b.i.d. with sliding scale of Regular Insulin.
On postoperative day five, [**2109-7-23**], the patient remained in
atrial flutter with variable ventricular response, anywhere
from 100 to 150 per minute. His room air oxygen saturation
was 96%. His blood pressure was 140s/60s, and was otherwise
hemodynamically stable. The patient received an extra IV
dose of amiodarone that morning and was electrically
cardioverted in the cardiac surgery recovery unit, using 150
joules and one shock that converted him to normal sinus
rhythm in the 70s at that time. The patient tolerated the
procedure well and had not had any subsequent atrial
fibrillation since the time of his cardioversion on
postoperative day five. The patient was converted from IV
amiodarone to oral amiodarone. He was subsequently
transferred out of the cardiac surgery recovery unit to the
telemetry floor on postoperative day six, [**2109-7-24**], and has
remained in good condition since that time. The patient's
epicardial pacing wires were removed. He was continued on
diuretics, beta blockers and amiodarone. The patient was
also started on Coumadin, which has been increased. His
heparin infusion had been discontinued when his INR was 1.8.
He is in good condition today on postoperative day eight and
ready to be discharged home.
CONDITION ON DISCHARGE: Good.
DISPOSITION: He is to be discharged home with visiting nurse
to follow up for postoperative wound checks, vital signs
monitoring, Coumadin teaching and diabetes teaching as well.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. b.i.d. x 7 days.
2. Potassium chloride 20 mEq p.o. b.i.d. x 7 days.
3. Coumadin 2 mg p.o. today, [**2109-7-27**], [**2109-7-28**] and he is to
have an INR checked on [**2109-7-29**], Coumadin subsequently to be
dosed by Dr.[**Name (NI) 5786**] office with a target INR of 2 to 2.5.
4. Colace 100 mg p.o. b.i.d.
5. Aspirin 81 mg p.o. q.d.
6. Percocet 5/325, one p.o. q. 4 hours p.r.n. pain.
7. Protonix 40 mg p.o. q.d.
8. Synthroid 150 mcg p.o. q.d.
9. Metformin 500 mg p.o. b.i.d.
10. Lopressor 50 mg p.o. b.i.d.
11. Amiodarone 400 mg p.o. q.d. x 1 month then to be dosed
per Dr.[**Name (NI) 5786**] recommendations.
FOLLOW-UP PLANS: The patient is to follow up with Dr. [**First Name4 (NamePattern1) 919**]
[**Last Name (NamePattern1) 911**] within the next two weeks. He is to call his assistant
for an appointment at [**Telephone/Fax (1) 920**]. The patient is to follow
up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], cardiac surgeon, in six weeks.
The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], his
primary care physician. [**Name10 (NameIs) **] patient is also to follow up
with the [**Hospital **] Clinic as previously instructed by the [**Hospital **]
Clinic.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting.
2. Atrial fibrillation status post cardioversion.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2109-7-26**] 13:26
T: [**2109-7-26**] 13:54
JOB#: [**Job Number 107130**]
ICD9 Codes: 4111, 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7239
} | Medical Text: Admission Date: [**2132-2-27**] Discharge Date: [**2132-3-3**]
Date of Birth: [**2132-2-27**] Sex: F
Service: NEONATAL
HISTORY OF PRESENT ILLNESS: [**Known lastname 52756**] [**Known lastname 52757**] is the former
2.96 kilogram product of a 39-4/7 weeks gestation pregnancy
born to a Gravida 1, Para 0, now 1 woman. The pregnancy was
achieved with in [**Last Name (un) 5153**] fertilization assistance. The mother
received her initial obstetrical care at [**Hospital **] Hospital.
Prenatal ultrasounds showed development of polyhydramnios and
micrognathia and she was referred to the [**Hospital1 346**] for further work-up and management.
A subsequent magnetic resonance imaging test confirmed the
findings consistent with [**Location (un) 4597**]-[**Doctor First Name **] sequence polyhydramnios
and a cleft palate. The esophageal anatomy appeared normal.
Other significant maternal history notable for Synthroid use
for hypothyroidism. She also experienced a motor vehicle
accident in [**2131-10-24**] while pregnant and had evidence
of a fetal maternal bleed with a Kleihauer-Betke test
positive at 0.5%.
On the day of delivery, the mother was in spontaneous labor
and proceeded to normal spontaneous vaginal delivery. The
infant emerged crying and vigorous. She required blow-by O2.
Apgars were nine at one minute and nine at five minutes. She
was shown to the parents and admitted to the Neonatal
Intensive Care Unit.
PRENATAL SCREENS: Blood type A positive, antibody negative,
hepatitis B surface antigen negative. RPR nonreactive.
Group beta Streptococcus status unknown.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit weight was 2.96 kilograms which was 25th
percentile; length was 51 centimeters which is 75th
percentile; head circumference 34 centimeters which is 50th
percentile. Head, Ears, Eyes, Nose and Throat: Anterior
fontanel open and flat. Symmetric facies. U-shaped
posterior cleft palate; micrognathia. Airway appears
normal; glossoptosis. Chest with lungs clear and equal
bilaterally. Cardiovascular is regular rate and rhythm
without murmur; normal S1 and S2 with good pulses throughout.
Abdomen is soft, no gross anomalies or abnormal masses,
positive bowel sounds. Extremities intact and within normal
limits. Hips stable. Neurological is appropriate; no gross
motor defect. Appropriate tone and reflexes.
HOSPITAL COURSE BY SYSTEMS AND PERTINENT LABORATORY DATA:
1. RESPIRATORY: [**Known lastname 52756**] has been able to maintain adequate
saturation in room air. She is predominantly positioned
prone due to her known airway anomalies. At the time of
transfer, she is breathing comfortably 40 to 60 times a
minute. She does have a sternal pectus with some mild
intercostal retractions.
2. CARDIOVASCULAR: [**Known lastname 52756**] has maintained normal heart
rates and blood pressures. No murmurs have been noted.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Enteral feeds were
started at the day of birth. She has been exclusively
nasogastric fed per the orders of the Craniofacial team. She
is currently on pumped breast milk by gavage, 140 cc per kilo
per day. She has had adequate urine and stool output. Recent
weight is 2840 grams.
4. INFECTIOUS DISEASE: No issues.
5. GASTROINTESTINAL: As noted, only nasogastric feedings
have been administered.
6. NEUROLOGY: Except for a shrill cry, no neurological
abnormalities have been noted. Sensory, Audiology and
Hearing Screen has not yet been performed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Transfer to [**Hospital3 1810**] for
tongue, lip adhesion surgery.
Primary pediatrician eventually to be Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], care
of [**Hospital **] Hospital, [**Last Name (un) **], [**Hospital1 **], [**Numeric Identifier 52758**]; phone number [**Telephone/Fax (1) 52178**]. The attending surgeon from
the [**Hospital3 1810**] for the Craniofacial Team is Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 40701**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding by nasogastric tube, breast milk or Enfamil 20 or
n.p.o. per orders of Anesthesia.
2. No medications.
3. Car seat position screening not performed.
4. State newborn screen was sent on [**2132-3-1**], with no
notification of abnormal results to date.
5. Immunizations: Hepatitis B vaccine was administered on
[**2132-3-1**].
6. Hearing screening - A full diagnostic ABR should be
performed at [**Hospital3 1810**].
DISCHARGE DIAGNOSES:
1. [**Location (un) 4597**]-[**Doctor First Name **] sequence - cleft palate and severe
micrognathia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern1) 52554**]
MEDQUIST36
D: [**2132-3-2**] 17:23
T: [**2132-3-2**] 18:00
JOB#: [**Job Number 52759**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7240
} | Medical Text: Admission Date: [**2111-7-27**] Discharge Date: [**2111-8-4**]
Date of Birth: [**2046-4-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath and palpitations
Major Surgical or Invasive Procedure:
[**2111-7-31**] PROCEDURE:
1. Coronary artery bypass grafting times one with a
saphenous vein graft to the posterior descending artery.
2. Left-sided Maze procedure with left atrial appendage
resection.
3. Mitral valve replacement with a 31-mm St. [**Male First Name (un) 923**]
mechanical valve, reference number [**Serial Number 82733**].
History of Present Illness:
65 year-old woman with HTN, HL, COPD/asthma, rheumatic heart
disease who comes with Paroxysmal Atrial Fibrillation and
shortness of breath. She was in her prior state of health until
9 days prior to admission when she noted to be very tired, with
worsening shortness of breath. She had seen her PCP 3 days prior
and full evaluation was normal. 7 days ago she noted irregular
palpitations up to 120-130 beats per minute, that worsened her
shortness of breath even further. She recalls taking all her
medications, no changes in her diet, fever, chills, rigors,
diarrhea or signs of infection. Her weight was at her baseline
of 160 lbs. She increased her lasix from 20 to 40 without
improvement in her symptoms. She continued to deteriorate until
[**2111-7-23**] when she was admitted to [**Hospital3 **] with Atrial
Fibrillation at 130s and SOB. Her initial BP was 90/60 with HR
130s. She was started on diltiazem infusion, which worsened
hypotension, but controlled atrial fibrillation. She was
admitted to the ICU and eventually she was switched to diltiazem
orally and was started on amiodarone. For unclear reasons she
received steroids, whcih worsened her AFib (per patient's
report). She was transfered to [**Hospital1 18**] for further cardiac work up
and Cardiac surgery evaluation.
Past Medical History:
H/o rheumatic heart disease at age 7
CAD with cath on [**5-28**] showing 90% R-PDA
Mild AS
Moderate MS with LA size 6.1 cm X 7.9 cm, Wedge of 20 on cath
[**5-28**] and MVA of 1.87 with gradieng of 7 mmHg.
Pulmonary hypertension, severe: at rest 64/39/44 on cath
Hypertension
Hyperlipidemia
COPD/asthmatic bronchitis
Heart murmur
Asthma
Allergies
Social History:
Lives with:husband
She works as administrative assistant.
She currently does not smoke, but quit >30 Y ago; she has h/o 15
pack-years. She denies any current alcohol intake, which worsens
her AFib.
She denies any illegal substance use.
G2P2C0A0. In menopause.
Family History:
Mother diagnosed with MI and CAD in her mid 50s and died with
CHF in her 60s. Father was alcoholic and died of lung cancer.
Older brother, who is healthy.
Physical Exam:
Admission Physical Exam
Pulse:116 Resp:21 O2 sat: 95%2L
B/P Right: 81/45
Height: 5'6" Weight: 79KG
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur II/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] + bowel
sounds [x]
Extremities: Warm [x], well-perfused [x] Edema +1 Varicosities
0
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
Admission:
[**2111-7-27**] 07:42PM PT-49.7* PTT-34.0 INR(PT)-5.4*
[**2111-7-27**] 07:42PM PLT COUNT-142*
[**2111-7-27**] 07:42PM WBC-17.2* RBC-3.41* HGB-10.3* HCT-30.2*
MCV-89 MCH-30.2 MCHC-34.1 RDW-17.0*
[**2111-7-27**] 07:42PM TSH-1.5
[**2111-7-27**] 07:42PM CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-2.5
IRON-36
[**2111-7-27**] 07:42PM proBNP-4514*
[**2111-7-27**] 07:42PM GLUCOSE-143* UREA N-47* CREAT-1.3*
SODIUM-131* POTASSIUM-5.3* CHLORIDE-97 TOTAL CO2-26 ANION GAP-13
[**2111-7-28**] 10:42PM BLOOD CK-MB-3 cTropnT-<0.01
[**2111-7-30**] 06:03AM BLOOD %HbA1c-6.0* eAG-126*
[**2111-7-30**] 06:03AM BLOOD Triglyc-91 HDL-41 CHOL/HD-2.8 LDLcalc-57
[**2111-7-30**] 06:03AM BLOOD ALT-36 AST-20 LD(LDH)-264* AlkPhos-58
TotBili-0.5
[**2111-7-28**] 10:42PM BLOOD CK(CPK)-38
Discharge:
[**2111-8-4**] 04:50AM BLOOD WBC-10.6 RBC-3.38* Hgb-10.2* Hct-29.4*
MCV-87 MCH-30.3 MCHC-34.8 RDW-16.6* Plt Ct-149*
[**2111-8-4**] 04:50AM BLOOD Plt Ct-149*
[**2111-8-4**] 04:50AM BLOOD PT-21.5* INR(PT)-2.0*
[**2111-8-4**] 04:50AM BLOOD Glucose-101* UreaN-26* Creat-0.5 Na-133
K-4.4 Cl-95* HCO3-32 AnGap-10
Radiology Report CHEST (PORTABLE AP) Study Date of [**2111-8-3**] 9:19
AM
[**Hospital 93**] MEDICAL CONDITION: 65 yo woman s/p cabg/mvr and ct
removal
REASON FOR THIS EXAMINATION: r/o ptx
COMPARISONS: Chest x-ray from [**2111-8-2**].
FINDINGS:
The right apical pneumothorax is significantly diminished in
size when
compared to [**2111-8-2**] study. No left pneumothorax is
present. A linear opacity in the left mid lung is again
visualized which is the site of previous chest tube placement.
This may represent atelectasis or a small hematoma. Small
bilateral pleural effusions are unchanged in appearance.
Hilar and mediastinal silhouettes appear stable. The cardiac
contours and the replaced mitral valve are stable. The bony
structures appear unremarkable.
IMPRESSION:
1. The right apical pneumothorax is significantly diminished in
size when
compared to [**2111-8-2**] study.
2. Small bilateral pleural effusions, stable.
3. A linear opacity at the left mid lung, correstponds to the
site of
previous left chest tube placement, likely atelectasis or
hematoma, unchanged.
The study and the report were reviewed by the staff radiologist.
DR. [**Last Name (STitle) 3889**] [**Name (STitle) 3890**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Date/Time: [**2111-7-31**] at 12:41 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Echocardiographic Measurements
Left Atrium - Long Axis Dimension: *6.4 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Aorta - Annulus: 1.9 cm <= 3.0 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 12 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 1.7 cm
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 2.3 m/sec
Mitral Valve - Mean Gradient: 11 mm Hg
Mitral Valve - Pressure Half Time: 284 ms
Mitral Valve - MVA (P [**12-20**] T): 0.8 cm2
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast
in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection
velocity.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Moderate (2+) AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Characteristic rheumatic deformity of the mitral valve leaflets
with fused commissures and tethering of leaflet motion. Severe
mitral annular calcification. Severe valvular MS (MVA <1.0cm2).
Severe (4+) MR.
TRICUSPID VALVE: Moderate to severe [3+] TR. Eccentric TR jet.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Mild PR.
PERICARDIUM: Very small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The rhythm appears to be atrial fibrillation.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PREBYPASS:
The left atrium is markedly dilated. No spontaneous echo
contrast is seen in the body of the left atrium or left atrial
appendage.
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 three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Moderate (2+) aortic
regurgitation is seen.
The mitral valve leaflets are severely thickened/deformed. The
mitral valve shows characteristic rheumatic deformity. There is
severe mitral annular calcification. There is severe valvular
mitral stenosis (area <1.0cm2). Severe (4+) mitral regurgitation
is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. The
tricuspid regurgitation jet is eccentric and may be
underestimated.
There is a very small pericardial effusion.
There are bilateral pleural effusions.
POSTBYPASS:
The patient is A paced and is on epinephrine and phenylephrine
drips.
Left ventricular function remains normal.
The left atrial appendage has been resected.
There is a new well-seated mechanical mitral valve prosthesis in
an anti-anatomical position. There is no evidence of stenosis in
the mechanical valve (MVA 2.44 cm2 with a peak gradient of 3
mmHg). There are washing jets at either end of the mitral valve
with no evidence of regurgitation.
The aortic valve, which was not replaced, continues to be
stenotic, but aortic valve area is now 0.9 cm2 (at a cardiac
output of 4.5 L/min, which is increased from the prebypass
cardiac output of 2.0-2.5 L/min). At a cardiac output of 5.6
L/min, the aortic valve area is 1.1 cm2. The valve area is 1.23
cm2 by planimetry. Peak gradient is 26 mmHg and mean gradient is
14 mmHg.
Tricuspid regurgitation continues to be moderate-to-severe (3+).
Aortic contours are normal.
Dr. [**Last Name (STitle) **] was informed of the results at the time of the study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
Radiology Report CAROTID SERIES COMPLETE Study Date of [**2111-7-30**]
2:45 PM
[**Hospital 93**] MEDICAL CONDITION: 65 yo woman with mitral stenosis,
pulm HTN.
REASON FOR THIS EXAMINATION: pre-op for mitral valve
replacement
BILATERAL CAROTID ULTRASOUND: Grayscale and color
ultrasonography was
performed of the right and left CCA, ICA, ECA, and vertebral
arteries.
Grayscale imaging demonstrates heterogeneous plaque within the
proximal right ICA and to a lesser degree in the left ICA.
Antegrade flow is seen within the vertebral arteries
bilaterally. The following velocity measurements were obtained:
RIGHT: Proximal ICA 40/21 cm/sec, mid ICA 41/16 cm/sec, distal
ICA 55/28
cm/sec, CCA 60/16 cm/sec, ECA 67 cm/sec, and vertebral artery 33
cm/sec.
Right ICA/CCA ratio is 0.9.
LEFT: Proximal ICA 55/15 cm/sec, mid ICA 44/17 cm/sec, distal
ICA 30/14
cm/sec, CCA 55/20 cm/sec, ECA 62 cm/sec, and vertebral artery 33
cm/sec. Left ICA/CCA ratio is 1.0.
IMPRESSION: Findings are consistent with less than 40% stenosis
bilaterally.
DR. [**First Name8 (NamePattern2) 5650**] [**Name (STitle) **]
Brief Hospital Course:
Transferred from [**Hospital3 **] for w/u and management of
congestive heart failure and new onset atrial fibrillation. Echo
at that time revealed moderate to severe mitral regurgitation,
moderate to severe tricuspid regurgitation, mild aortic
insufficiency, and at least moderate pulmonary hypertension.
Cardiac surgery was consulted for possible mitral valve
replacement. After usual cardiac surgery w/u patient was brought
to the operating room on [**7-31**]. Please see operative report for
details. In summary she had: Coronary artery bypass grafting
times one with a
saphenous vein graft to the posterior descending artery.
Left-sided Maze procedure with left atrial appendage resection.
Mitral valve replacement with a 31-mm St. [**Male First Name (un) 923**]
mechanical valve, reference number [**Serial Number 82733**]. Her bypass time
was 110 minutes with a crossclamp of 97 minutes. She tolerated
the operation well and post-operatively was transferred to the
cardiac surgey ICU in stable condition. She remained
hemodynamically stable in the immediate post-op period, awoke
neurologically intact and was extubated. All tubes lines and
drains were removed per cardiac surgery protocols. She was ready
for transfer from the ICU to the stepdown floor on POD1 however
there were no beds available and her actual transfer did not
occur until POD3. She worked with physical therapy to increase
her activity level.
She was started on Coumadin for her mechanical valve and dose
was titrated to acheive target INR of 2.5-3.5.
The remainder of her hospital course was uneventful. On POD# 4
she was cleared by Dr.[**Last Name (STitle) **] for discharge to [**Hospital 599**] Rehabilitation
with anticipated length of stay less than 30 days. All follow up
appointments were advised.
Medications on Admission:
Lisiopril 20 mg Daily
Simvastatin 80 mg Daily
Aspirin 325 mg Daily
NS 3 ml Flush
Carvedilol 6.25 [**Hospital1 **]
Amiodarone 400 mg TID
Diltiazem 30 mg QID
Protonix 40 mg PO Daily
Lasix 40 mg Daily
Advair 250/50 IH [**Hospital1 **]
Coumadin BEING HELD
Tylenol 325 mg PO Q4 hrs PRN pain
Atropine 1 mg X1 PRN
Milk of Magnesia PO PRn
Lidocaine IV x2 PRN
Nitroglycerin 0.4 mg SL PRn CP
Ambien 5 mg PO QHS PRN
Ativan 0.5 mg PO Q6 hrs PRN
Xopenex 0.63 mg IH Q4 hrs
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg QD x7 days then 200mg QD.
Disp:*35 Tablet(s)* Refills:*2*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): 1 puff
[**Hospital1 **].
Disp:*1 Disk with Device(s)* Refills:*0*
5. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**3-24**]
hours as needed for pain/fever.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
11. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): Target INR 2.5-3.5.
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
16. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses.
17. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
[**2111-7-31**]: s/p Coronary artery bypass grafting times
one/Left-sided Maze with left atrial appendage resection/Mitral
valve replacement
Past Medical History:
Hypertension
Dyslipidemia
Diabetes
Chronic diastolic CHF
h/o Rheumatic Heart Disease (AS/MS)
COPD/Asthmatic bronchitis
Asthma
Past Surgical History:
s/p tubal ligation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions: Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
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 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
**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:
***INR draw for Mechanical Mitral Valve- INR goal=2.5-3.5
Dr.[**Last Name (STitle) 1637**] will follow INR/Coumadin dosing.#[**Telephone/Fax (1) 14655**]
You are scheduled for the following appointments
Surgeon: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1504**]) on [**9-2**] @1:30PM
Please call to schedule appointments with your:
PCP/Cardiologist Dr [**Last Name (STitle) **],[**First Name3 (LF) 1575**] J. [**Telephone/Fax (1) 14655**] in [**12-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2111-8-4**]
ICD9 Codes: 5849, 2761, 4280, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7241
} | Medical Text: Admission Date: [**2121-12-7**] Discharge Date: [**2121-12-12**]
Date of Birth: [**2041-5-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Lidocaine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Acute mental status change
Major Surgical or Invasive Procedure:
Chest tube placement
Right internal jugular central venous line placement
History of Present Illness:
80 year-old lady with history of dementia presents as
transfer to medicine service. The patient was admitted to the
CV-ICU on the night of [**2121-12-7**] because she had a central line
placed in her left subclavian artery at an outside hospital.
This was complicated by a left-sided hemopneumothorax for which
a
chest tube was placed at the outside hospital. The only other
active medical issues upon transfer was the patient's recurrent
acute on chronic renal failure and a recurrent UTI. The patient
had an INR of 4.3 and HCT of 23 upon transfer to [**Hospital1 18**]. The
goal
upon admission to the vascular service was to transfuse her and
correct her INR. The subclavian line would be pulled at the
bedside [**2121-12-8**].
Past Medical History:
A Fib, Dementia, HTN, Hypercholesterolemia, s/p CVA with
hemiparesis, Anxiety disorder, depression, frequent UTIs, PNA,
rib fractures, s/p R hip fracture, hydronephrosis, congenital
UPJ
obstruction
[**Doctor First Name **] Hx: s/p R total hip replacement x 2
Social History:
Lives at [**Hospital1 11851**] NH; no ETOH, DNR/DNI
Family History:
Noncontributory
Physical Exam:
Transfer exam
VS: T 94.7 (Ax), HR 73, BP 108/53, RR 20, 94% 3L
GEN: Anxious, communicates with groans
NECK: supple, no bruits
LUNGS: rhonchi B/L, wheezes B/L, no air leak on chest tube
CV: irregularly irregular, nl S1 and S2
ABD: Soft, NT, ND
EXT: L arm without any sign of ischemia, no c/c/e of LE, right
foot slightly cooler than left, 2+ radial and 1+ ulnar on left
VASC:
Fem [**Doctor Last Name **] PT DP
R 2+ 2+ D D
L 2+ 2+ D 2+
Discharge Exam
VS 97/97.2 155/70 70 20 98%RA
Gen: NAD
HEENT: MMM, OP clear, neck supple
CV: Irregular S1+S2, no m/r/g
Lungs: CTAB anteriorly
Abd: S/NT/ND +bs
Ext: no c/c/e
Neuro: Oriented x1 (person). Continues to have echolalia
although improved from yesterday.
Pertinent Results:
[**2121-12-12**] 07:35AM BLOOD WBC-10.1 RBC-3.55* Hgb-10.5* Hct-30.3*
MCV-85 MCH-29.5 MCHC-34.6 RDW-15.1 Plt Ct-277
[**2121-12-11**] 07:00AM BLOOD WBC-10.2 RBC-3.43* Hgb-10.1* Hct-28.5*
MCV-83 MCH-29.4 MCHC-35.4* RDW-15.1 Plt Ct-306
[**2121-12-10**] 07:07AM BLOOD WBC-12.1* RBC-3.84*# Hgb-11.4*#
Hct-32.2*# MCV-84 MCH-29.6 MCHC-35.3* RDW-15.4 Plt Ct-360
[**2121-12-9**] 02:08AM BLOOD WBC-8.9 RBC-2.92* Hgb-8.6* Hct-24.5*
MCV-84 MCH-29.3 MCHC-34.9 RDW-15.1 Plt Ct-274
[**2121-12-8**] 04:18PM BLOOD Hct-24.8*
[**2121-12-8**] 04:58AM BLOOD WBC-9.8 RBC-3.26* Hgb-9.7* Hct-27.6*
MCV-85 MCH-29.9 MCHC-35.3* RDW-14.9 Plt Ct-261
[**2121-12-7**] 08:46PM BLOOD WBC-8.8 RBC-3.09* Hgb-8.9* Hct-26.3*
MCV-85 MCH-28.8 MCHC-33.8 RDW-15.1 Plt Ct-286
[**2121-12-7**] 08:46PM BLOOD Neuts-84.6* Lymphs-14.6* Monos-0.6* Eos-0
Baso-0.1
[**2121-12-7**] 08:46PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+
[**2121-12-12**] 07:35AM BLOOD Plt Ct-277
[**2121-12-12**] 07:35AM BLOOD PT-13.2 PTT-24.6 INR(PT)-1.1
[**2121-12-12**] 07:35AM BLOOD Glucose-87 UreaN-44* Creat-1.1 Na-148*
K-3.3 Cl-113* HCO3-27 AnGap-11
[**2121-12-12**] 07:35AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.5*
[**2121-12-10**] 07:07AM BLOOD VitB12-1495*
[**2121-12-10**] 07:07AM BLOOD TSH-1.2
[**2121-12-7**] 09:20PM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-53* pH-7.24*
calTCO2-24 Base XS--5
CTH
1. No evidence of acute intracranial hemorrhage. Hypoattenuation
involving
the left basal ganglia extending into the corona radiata may
represent sequela
of previously stated remote CVA, however, interposed acute
component cannot be
entirely excluded. MRI may be obtained for further evaluation to
exclude
underlying acute component as discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
at the time of
dictation.
2. Minimal sinus disease as described above.
3. Right subinsular cortical infarct, old.
NOTE ADDED AT ATTENDING REVIEW: The changes noted above
involving the left
thalamus, caudate body, internal capsule and periventricular
white matter
appear to reflect old infarction, perhaps with old hemorrhage.
There is no
evidence of recent infarction. However, in the setting of
chronic infarction further ischemic injury in the same
distribution can be difficult to detect with non contrast CT.
CXR ([**2121-12-10**])
Probable persistent tiny left apical pneumothorax although
difficult to discern from overlying rib shadows.
Brief Hospital Course:
80 year old female with AF, dementia, HLP, CVA with residual
hemiparesis, anxiety/depression, and congenital UPJ obstruction
transferred from OSH for left subclavian arterial line placement
and presumed UTI.
1. UTI:Patient has history of frequent UTIs with multiple
admissions in the past year to OSH. She also currently has a
chronic indwelling FC, increasing her risk of UTI. She has been
treated with IV ciprofloxacin since being admitted to the OSH.
Repeated urine cultures during admission were contaminated.
Patient was initially treated with ciprofloxacin, but given past
history of E.coli resistant to quinolones. Urinalysis at outside
hospital performed without urine culture. Patient was converted
to ceftriaxone, which she tolerated well even with reported
history of PCN allergy. On discharge, she was coverted to
cefpodoxime and instructed to complete a total of 7 days on
ceftriaxone/cefpodoxime.
2. Anemia: Patient was transfused a total of 2u PRBC during
admission at [**Hospital1 18**]. Although unclear, it appears as if she was
also transfused 2u PRBC at OSH. On discharge, her hct was
stable.
3. Left subclavian arterial line placement: Upon transfer,
subclavian arterial line was removed and a chest tube was placed
on the left for her hemopneumothorax. On hospital day 3 her
chest tube was removed without adverse events. Of note, a
follow-up CXR after chest tube removal demonstrated a small
residual pneumonthorax.
4. Acute mental status change: Most likely multifactorial due to
UTI, hospitalization, and medications including morphine and
ativan that the patient received while in the ICU. The patient
at [**Hospital1 11851**] has also been receiving remeron, ativan, and
trazadone, which were discontinued. The patient appeared to have
mild improvement in her delirium during her admission. Of note,
a non-contrast CT head was performed during her admission that
did not demonstrate an acute intracranial process.
5. Acute on chronic renal failure: Likely secondary to
intravascular volume depletion. Patient received IVF during her
admisison and on discharge, her creatinine was at baseline at
1.1.
6. Afib: Patient was initially admitted on atenolol 100 mg po
bid. Given her acute on chronic renal failure, she was
transitioned to metoprolol 50 mg po bid. After her hematocrit
was stabilized, she was restarted on coumadin. She will need to
have her INR monitored with a goal of [**2-9**].
7. Hypertension: Beta blocker changed to metoprolol as above.
Amlodipine 5 mg daily was added for additional blood pressure
control.
8. Steroids: The patient was admitted to [**Hospital1 18**] one prednisone,
which was continued during her admission. On discharge, she was
instructed to continue with 10 mg daily prednisone. Although
unclear as to the reason for her steroid use, it appears as if
she was on a scheduled taper at [**Hospital1 11851**] of prednisone. She
was instructed on discharge to follow-up with her physician at
[**Name9 (PRE) 11851**] or her PCP with regard to prednisone taper.
Medications on Admission:
Coumadin 2 qd, Lasix 40 qd, MVI 1 qd, KDur 20
mEq qd, Atenolol 100 [**Hospital1 **], Remeron 30 qhs, Prednisone 10 qd,
Cipro
500 [**Hospital1 **] (started [**12-5**]), Forastor probiotic 250 [**Hospital1 **], Tylenol 650
q 4 prn, Dulcolax prn, MOM prn, Trazodone 25 qhs prn, Ativan 0.5
mg q4 prn, Duonebs prn
Discharge Medications:
1. Vantin 200 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO once
a day.
3. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1)
Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
9. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Primary
- UTI
- Anemia
Secondary
A Fib, Dementia, HTN, Hypercholesterolemia, s/p CVA with
hemiparesis, Anxiety disorder, depression, frequent UTIs, PNA,
rib fractures, s/p R hip fracture, hydronephrosis, congenital
UPJ
obstruction
Discharge Condition:
Patient was discharged in stable condition.
Discharge Instructions:
1. You were admitted for a urinary tract infection, which was
treated with antibiotics. You will need to continue these
antibiotics as an outpatient. The instructions for this
medication are:
Cefpodoxime 200 mg by mouth twice daily for 5 days (STOP ON
[**2121-12-17**])
2. You were also admitted for a subclavian arterial line
placement. You received a blood transfusion while admitted. On
discharge your hematocrit was stable.
3. Unless otherwise indicated, please resume all of your
medications as take prior to admission. It is very important
that you take your medications as prescribed. You were admitted
on prednisone, which was continued during your admission. You
will need to follow-up with your PCP or [**Name9 (PRE) 11851**] physician with
regard to prednisone taper.
4. You will need to have you INR checked on Monday, [**12-15**] with a
goal INR of [**2-9**]. You will need to have regular INR checks with
your coumadin adjusted as necessary by your doctor [**First Name (Titles) **] [**Last Name (Titles) 11851**].
5. It is very important that you make all of your doctor's
appointments.
6. If you develop chest pain, shortness of breath, or other
concerning symptoms, please call your PCP or go to your local
Emergency Department immediately.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] 2 weeks. You can schedule an
appointment by calling [**Telephone/Fax (1) 6019**].
Completed by:[**2121-12-13**]
ICD9 Codes: 5990, 5849, 2760, 2930, 2851, 5859, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7242
} | Medical Text: Admission Date: [**2197-9-21**] Discharge Date: [**2197-10-4**]
Date of Birth: [**2160-11-21**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Found unresponsive in service man-hole while working
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 87242**] is a 36-year-old man transferred from [**Hospital3 4107**]
after being found unresponsive. He is now medically stable after
he was recovered from a man-hole with two episodes concerning
for seizure.
***
Mr. [**Known lastname 87242**] is a sanitation worker with no known past medical
history. He was found unresponsive and reportedly not breathing
in a service-hole while working today. The crew had seen his
feet poking out of the service-hole. He had been away from his
team for 15-20 minutes. His brother, on the same crew, felt
dizzy and lightheaded when recovering the patient, as did his
cousin - also on the crew. The patient was reportedly not
breathing, but spontaneously started taking deep breaths when
out of the manhole. He also exhaled yellowish foam. He had a
pulse. Testing equipment that the workmen had revealed low
oxygen tension in the man hole, but no sign of toxic gases (per
his brother). It is unclear which gases were tested. His color
was 'green' per his brother, definitely not red. EMS came and
gave the patient Narcan without effect, given pin-point
pupils. His vital signs were stable and pO2 on initial blood gas
in the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was 86 mmHg. He was rigid in the ED. He had
clonic movements of his arms with rightward head deviation.
Dilantin 1g was given along with Ativan. He became more lucid
following this, apparently behaving as if he recognized his
family, but still unable to follow commands per Dr. [**Last Name (STitle) **], but
following some instruction [**First Name8 (NamePattern2) **] [**Hospital1 **] notes. He had yet another
episode of right-[**Hospital1 **] head deviation and clonic movements, so a
further 500 mg of Dilantin was loaded and more Ativan given.
Vital signs were stable and urinary toxicology was negative. CT
head was performed without evidence of ventricular effacement or
bleed. He was taken to the [**Hospital1 **] ICU. He was never intubated.
He was apparently awake, continuing to demonstrate shaking
movements and talking. Apparently is feeling 'sick'.
On arrival at [**Hospital1 18**], the patient was combative and given a
further 2 mg of Ativan. Upon interview, he opened eyes to voice.
Followed simple motor commands and made some simple responses,
but was easily confused. The patient recalls going into the
man-hole, but thinks that there was someone with him. He thinks
he was in there for 5 minutes before passing out, but cannot
recall this happening. He does not recall becoming lightheaded
or dizzy. Per his girlfriend he had a head cold last week, but
was recovering.
Past Medical History:
None
Social History:
The patient does not smoke, drinks beer socially, not everyday.
Denies illicit drug use. The patient lives in [**Location 7168**] with his
fiancee/girlfriend.
Family History:
No history of seizure or other neurologic disorder. His father
says that his family is healthy.
Physical Exam:
Exam on admission:
Vital Signs
Afebrile, HR 93, BP 110/61 (73), SpO2 97%
GCS 12
- Verbal [**3-24**], Motor [**6-25**], Eye Opening [**3-23**] = 12.
General Observations and Appearance
Well-appearing man of normal BMI, eyes closed, no spontaneous
movement. Clippered chest hair.
General Physical Exam
Head - Size appears within normal limits, symmetric, no
exostoses
nor tenderness.
Eyes - Some blood on sclera at medial aspect of [**Doctor First Name 2281**] on right.
ENT/OP - MMM and tongue surface normally papillated. Tongue of
normal size/muscle bulk.
Neck - No bruits, pulses normal, no LAD, supple, normal
appearance.
Chest/Thorax/Breasts - CTA, RR, good air entry, no dysmorphic
features.
Cardiovascular - RRR, normal PMI, normal s1 s2, no M/R/G.
Peripheral pulses normal.
Abdomen - No scars, stigmata of liver disease, soft, non-tender,
no masses nor organomegaly.
Spine - Normal curvatures, non-tender, no dimpling or unusual
hair growth.
Extremities - No deformities, nor contractures. No clubbing,
cyanosis nor edema. No arthropathy. Normal digits. No palmar
erythema.
Skin - Neither greasy nor dry, no spider angiomas, no tattoos,
scars other markings.
Hair and Nails - Normal appearances.
Mental Status
Patient with eyes closed, then at time of exam had just been
combative. Patient was re-directable. Simple expressions.
Movements with clonus and clumsy. Tried to take off nasal
cannula. Speech was dysarthric and scanning, short phrases.
He was able to open eyes, lift arms and legs to command.
Could not register three words after six trials and had to ask
what question was.
Cranial Nerves
No blink to threat. Could not identify how many fingers were
being held up nor did he look at the hand. Large saccades to
command in all direction - EOM full. Pupillary reaction to light
normal on left, with good concensus in right pupil. Sluggish on
left with sluggish concensual reaction on left. No hippus. Jaw
opening was symmetric and facial sensation appeared to be intact
with patient saying "No" each time his face was touched. Facial
expressions were strong and symmetric. Hearing was grossly
intact. Soft palate symmetric at rest and with elevation.
Apparently normal salivation and swallowing. No dysphonia.
Shoulder shrug and head appeared strong, but difficult to have
patient execute commands with perseverance. Tongue bulk and
movements normal and symmetric.
Tone was normal in upper and lower limbs. No spasticity.
Superimposed tremor on all movements, worse near target, with
significant dysmetria on finding nose with index finger of
either hand.
Power and Muscle Bulk normal. Strength excellent - difficult to
control when combative. Able to lift all limbs. Difficult to
evaluate strength movement by movement given mental status.
Reflexes ( left ; right )
Biceps ( ++ ; ++ )
Triceps ( ++ ; ++ )
Brachioradialis ( ++ ; ++ )
Quadriceps ( ++ ; ++ )
Plantar flexors ( ++ ; ++ )
Plantar responses ( up ; down )
Sensation - Not tested.
Pertinent Results:
[**2197-9-21**] 07:22PM PT-13.5* PTT-23.6 INR(PT)-1.2*
[**2197-9-21**] 07:22PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2197-9-21**] 07:22PM OSMOLAL-295
[**2197-9-21**] 07:22PM ALBUMIN-4.1 CALCIUM-7.7* PHOSPHATE-2.6*
MAGNESIUM-1.7
[**2197-9-21**] 07:22PM CK-MB-7 cTropnT-LESS THAN
[**2197-9-21**] 07:22PM ALT(SGPT)-61* AST(SGOT)-64* LD(LDH)-328*
CK(CPK)-797* ALK PHOS-59 TOT BILI-0.5
[**2197-9-21**] 07:22PM GLUCOSE-108* UREA N-11 CREAT-0.9 SODIUM-139
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-20* ANION GAP-16
[**2197-9-21**] 08:30PM PLT COUNT-206
[**2197-9-21**] 08:30PM WBC-12.2* RBC-4.30* HGB-12.3* HCT-36.0*
MCV-84 MCH-28.5 MCHC-34.0 RDW-13.8
[**2197-9-21**] 09:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
RADIOLOGY:
CT from OSH reviewed and shows possible swelling of brain
parenchyma.
No blood/masses/lesions.
Brain MRI [**2197-9-22**] (on initial presentation):
FINDINGS: The diffusion images demonstrate no evidence of
restricted
diffusion to indicate acute infarct. There is no evidence of
restricted
diffusion seen in the basal ganglia or in the cortex. The
ventricles and extra-axial spaces are normal in size. There is
no evidence of midline shift, mass effect, or hydrocephalus
seen. There are no focal abnormalities identified. The
suprasellar and craniocervical regions
are normal on the sagittal images.
IMPRESSION: No evidence of acute infarct, mass effect, or
hydrocephalus
CXR on admission [**9-21**]
Portable AP chest radiograph was reviewed with no prior studies
available for comparison.Some degree of cardiomegaly is
suspected with the cardiac silhouette being approximately 60%
compared to the chest diameter, although it may be related to
portable character of the study. Mediastinum is unremarkable.
Lungs are essentially clear. Correlation with echocardiography
is suggested.
ECG on arrival [**9-21**]
Sinus rhythm. Right inferior axis. Early R wave progression with
ST segment elevation in lead V1. Inferior Q waves at this age -
consider left posterior hemiblock versus inferior myocardial
infarction. No previous tracing available for comparison.
Clinical correlation is suggested.
EEG on [**2197-9-23**]
Normal EEG in the waking and drowsy states. No focal or
epileptiform features were seen.
Repeat MRI [**2197-9-29**] (eight days after presentation):
Restricted diffusion in the cortical distribution of both
frontal and parietal lobes is suggestive of hypoxic brain
injury. Restricted diffusion in both occipital lobes also could
be secondary to hypoxic injury with likely acute wallerian
degeneration in the splenium of corpus callosum. These findings
are new since the previous MRI of [**2197-9-22**].
Brief Hospital Course:
Mr. [**Known lastname 87242**] is a 36-year old man presenting with confusion,
intention tremor, dysmetria, amnesia, blindness, probable
seizures. Numerous etiologies are possible, but it does appear
that the patient was hypoxic and not breathing when found. The
cause of this is unclear, but may include gas/hypoxic exposure.
The cerebellar signs and amnesia, fit well with well-known
vulnerability of Purkinje neurons and the hippocampus to hypoxia
and carbon monoxide poisoning. Hypoxia may have been the cause
of this presentation, or the consequence of respiratory arrest
or seizure. These possibilities seem much less likely.
Mr. [**Known lastname 87242**] had an unremarkable head CT scan. He was admitted to
the ICU where he had a full laboratory evaluation which was
unrevealing as to the cause of unresponsiveness. He was loaded
with Dilantin prior to arrival at [**Hospital1 18**] for two likely seizure
events which was continued. He had an initial brain MRI which
was normal, and an initial EEG which was normal. He continued
on Dilantin. His combativeness, agitation, and confusion
improved. He was transferred to the neuromedicine floor, stroke
service, for further management.
While on the floor, Mr. [**Known lastname 87242**] had continued difficulty, most
notably with vision.
He had an ophthalmology evaluation and was not found to have any
abnormalities on formal ophthalmologic examination. Visual
evoked potentials were attempted twice, and were uninterpretable
due to inability for patient to focus on the screen. The cause
of Mr. [**Known lastname 87243**] blindness was not initially apparent, and there
was some suggestion of a conversion reaction given normal
imaging and depression and anxiety symptoms. However, repeat
brain MRI on [**2197-9-29**], showed restricted diffusion in the
cortical distribution of both frontal and parietal lobes,
suggestive of hypoxic brain injury, as well as restricted
diffusion in both occipital lobes with likely acute wallerian
degeneration in the splenium of corpus callosum. He has been
diagnosed with cortical blindness secondary to injury of
occipital lobes. Additionally, Mr. [**Known lastname 87242**] has evidence of
inattention, apraxia, limb ataxia, and likely inattention to his
left side, all due to his hypoxic brain injury. Mr. [**Known lastname 87242**] has
been evaluated by physical and occupational therapy, and
rehabilitation has been recommended.
Mr. [**Known lastname 87242**] was given Ativan for anxiety and agitation, and then
was started on Seroquel for insomnia, anxiety, and agitation.
He was also treated for intermittent headache and nausea. At
the time of discharge to rehab, he did not endorse depressive
symptoms or suicidal ideation, and was cleared from a psychiatry
perspective for medical rehabilitation. Psychiatry follow up is
recommended.
He remained HDS with stably impaired MS and stable exam findings
until discharge to an acute Rehabilitation facility on [**2197-10-4**].
He will follow up in clinic with one of our Cognitive/Behavioral
Neurology attending physicians, Dr. [**First Name (STitle) **] (appointment made
as written below).
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Fever or pain.
2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia, anxiety.
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
9. Ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
11. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Hypoxic brain injury
2. Suicidal Ideation, now resolved
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 hospitalized at [**Hospital1 18**] after a likely hypoxic event.
You initially had difficulties with confusion, memory,
coordination, and vision. You had a laboratory evaluation which
was normal. Your head CT scan and initial brain MRI did not
show abnormalities or evidence of injury, however you had a
repeat brain MRI 8 days later, on [**2197-9-29**] which did show
evidence of hypoxic brain injury, especially in the vision areas
of the occipital region of your brain. This explains your
current vision problems as well as your difficulty thinking and
using your hands appropriately. Your ophthalmology examination
was normal, and a repeat ophthalmology examination is
recommended. After you have another ophthalmology appointment,
your paperwork for registration with [**State 350**] services for
the blind can be completed.
During your hospitalization, you had anxiety and depressed mood,
as well as suicidal thoughts. You were followed by the
psychiatry service, who initially recommended inpatient
psychiatric care, however, your mood has improved and therefore
you do not require this.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2197-10-6**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2197-11-16**] 3:00
Completed by:[**2197-10-4**]
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7243
} | Medical Text: Admission Date: [**2128-6-24**] Discharge Date: [**2128-7-10**]
Date of Birth: [**2078-2-19**] Sex: M
Service: SURGERY
Allergies:
Cymbalta / Morphine / Nortriptyline
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Placement of a 34-French Malecot catheter via the stoma to
facilitate drainage of stool.
Placement of VAC.
History of Present Illness:
50M s/p anal squamous ca treated w/ chemoradiation w. subsequent
anal stricture requiring sigmoid colectomy, end colostomy,
mucous fistula. s/p colostomy resite, parastomal hernia repair
w/ biomesh, component separation, completion sigmoidectomy c/b
perforated ostomy and dehisc/fistula. Now is admitted via the ED
with complaints of fever 103F.
Past Medical History:
PMH: anal SCC, anal stricture, large abdominal hernia, chronic
abdominal pain, CAD, PVD, ?OSA, HTN, hypercholesterolemia
vitamin D deficiency
PSH: sigmoid colectomy and dilatation, 2 LLE stents,
Social History:
originally from [**Country 3400**]
lives with wife, no children
quit tobacco 2 months ago, previously 1 ppd x 2 years
no EtOH in 14 years
Family History:
noncontributory
Physical Exam:
VS:
GA: alert and oriented, no acute distress
CVS: normal S1, S2, no murmurs
Resp: CTAB
[**Last Name (un) **]: soft, tender at ostomy site and skin bridge between
midline incision and ostomy site, wound vac in place
Ext: warm, minimal edema
Pertinent Results:
[**2128-6-24**] 04:42PM GLUCOSE-107* UREA N-5* CREAT-0.7 SODIUM-135
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15
[**2128-6-24**] 04:42PM WBC-12.0* RBC-3.77* HGB-9.4* HCT-29.4*
MCV-78* MCH-24.9* MCHC-32.0 RDW-15.2
[**2128-6-24**] 04:42PM NEUTS-76.1* LYMPHS-16.3* MONOS-5.6 EOS-1.9
BASOS-0.2
[**2128-6-24**] 04:42PM PLT COUNT-480*
[**2128-6-24**] 04:42PM PT-13.9* PTT-21.3* INR(PT)-1.2*
[**2128-6-25**] 09:53PM BLOOD WBC-13.3* RBC-3.83* Hgb-9.4* Hct-30.3*
MCV-79* MCH-24.6* MCHC-31.1 RDW-14.9 Plt Ct-442*
[**2128-7-1**] 05:13AM BLOOD WBC-11.1* RBC-3.34* Hgb-8.4* Hct-26.4*#
MCV-79* MCH-25.0* MCHC-31.7 RDW-15.0 Plt Ct-410
[**2128-7-2**] 05:45AM BLOOD WBC-9.6 RBC-3.32* Hgb-8.5* Hct-26.4*
MCV-80* MCH-25.7* MCHC-32.2 RDW-15.3 Plt Ct-452*
Brief Hospital Course:
Mr. [**Known lastname 73917**] was admitted [**2128-6-25**] for fever of 103F. On admission
blood cultures and urine cultures were taken. WBC was mildly
elevated to 12.0. His home wound vac was removed as it was
dysfunctional. On [**2128-6-25**] Mr. [**Known lastname 73917**] was triggered for rigors
and shaking. It was noted that his ostomy was leaking into a
pocket within his superficial abdominal soft tissues. He was
promptly taken to the OR for washout of his abdominal wall,
placement of a malencot drain to prevent stricture of his
ostomy, and vac placement (@50mmHg). Immediately
post-operatively patient was transferred to the ICU for
monitoring and pain control. His Creatinine was elevated to
2.2. Renal US was normal and revealed no hydronephrosis.
Patient was transferred to the floor on [**2128-6-27**]. Pain service
was consulted for management of his pain and weaning of his
methadone therapy. Patient returned to OR on [**2128-6-29**] for
washout of his abdominal wound. Post-operatively he desaturated
to 83% in PACU. This resolved with BIPAP and he spontaneously
recovered. On [**2128-7-1**] patient was transfused 2 units for a hct
of 20.8. Post-transfusion hct was 26.4. Mr. [**Known lastname 73918**] diet was
advanced to full liquids which he tolerated well. He was
started on a methadone taper per pain service which involved
decreasing his methadone dose by 5mg per day every 5 days
divided over 3 doses. At discharge he was tolerating a soft
diet and his pain was managed with methadone to be tapered per
chronic pain service plan listed above.
Medications on Admission:
Cilostazol 100'', Plavix 75', VitD2 50,000 uqwk, Nexium 40',
Mehadone 20''prn, lopressor 100'', Roxicet 5mgq6h, colace, MVI
Discharge Medications:
1. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO bid ().
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for pain.
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
Disp:*2 Patch Weekly(s)* Refills:*0*
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q 8H (Every 8 Hours) as needed for constipation.
10. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day) for 7 days.
Disp:*63 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Perforated Ostomy and Wound Dehisence
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 fever as a result of an
infection that was in your blood. You were treated with
antibiotics during your admission which has treated this fever.
You have not had a fever for many days and you are now ready to
return home. It is important that when you return home you work
closely with the visiting nursing team and follow their
instruction. The VAC sponge dressing will be changed every 3
days as previously ordered. There is a small area that drains a
small amount of stool that stains the white sponge only a small
amount, the VNA will know about this, it is our hope that this
will stop over time and this connection will close. If you note
that the stool has increased or you have increasing pain call
the office or if severe got ot the emergency room. Watch for
signs and symptoms of worsening infection such as fever,
increased pain, fast heart rate, or green/white drainage in the
surgical wound. The ostomy appliance should be changed with
these dressing changes. Monitor the output in the ostomy
appliance, it should be thin stool and should not be more than
1500ml daily, if the output is above this amount or below 500cc
please call Dr.[**Name (NI) 3377**] office. You will take a medication to
make your stool thin three times daily. Please adhere to the
soft diet taught to you by nutrition services and the surgical
NP. It is very important that the stool is thin so it will pass
through the drain in your stoma and not tract through into the
wound. Please keep yourself well hydrated. Your diet should
include soft foods, full liquids, and ensure. Soft foods such
as: scrambled eggs, couscous, mashed potato, nothing very high
in fiber. If you notice that the stool is to thick, or output
from the ostomy decreases call Dr. [**Last Name (STitle) 4488**] office, if you have
increased pain, develop a fever, are nauseated, or begin to
vomit please come to the emergency room. As you improve your
diet will be advanced by Dr. [**Last Name (STitle) 4488**] team.
You have a follow up appointment currently with the Chronic Pain
Clinic as described below. Please keep this appointment. The
goal is that you will continue to decrease the amount of
methadone you are taking daily. Your medications will continue
as given in the hospital. Please make a follow-up appointment
with your primary care provider to remove your medications. Take
these medications as precribed.
Followup Instructions:
Please make an appointment to be seen with Dr. [**Last Name (STitle) 1120**] to be seen
in [**1-24**] weeks. Call ([**Telephone/Fax (1) 3378**] to make an appointment.
Provider: [**Name10 (NameIs) 1089**] [**Name11 (NameIs) 1090**], MD Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2128-7-14**]
2:20
Completed by:[**2128-7-10**]
ICD9 Codes: 5845, 486, 4019, 4439, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7244
} | Medical Text: Admission Date: [**2157-6-1**] Discharge Date: [**2157-6-3**]
Date of Birth: [**2081-5-20**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: This is a 76-year-old gentleman
with history of aortic valve replacement, mitral valve
replacement both bioprosthetic valve, status post 1 vessel
CABG for 3 vessel coronary artery disease back in [**2144**], who
presents to [**Hospital1 18**] [**Hospital6 3872**] for further
evaluation and treatment of his coronary artery disease,
severe mitral regurgitation. The patient recently presented
to his cardiologist, Dr. [**First Name (STitle) 1075**], with gradually worsening
shortness of breath with exertion over the last 12 months,
more significantly over the last 2 to 3 months. The patient
previously has been able to walk "three telephone poles "
distance before dyspnea. Now, the patient reports that he
gets dyspneic with less than one-half of that distance. The
patient also reports that he feels winded after 1 to 5
stairs. He denies history of chest pain, paroxysmal
nocturnal dyspnea, orthopnea, lower extremity edema,
palpitations, syncope or lightheadedness.
REVIEW OF SYSTEMS: On further review of systems, he denies
recent illness, injury, no recent fevers, chills, nausea,
vomiting, diarrhea, melena, hematochezia, dysuria, hematuria,
rash or headache. Cardiac catheterization at [**Hospital6 31672**] on [**2157-5-24**], showed three-vessel coronary
artery disease, distal LAD with tapered occlusion, (left
circumflex 90 percent, AV groove, occluded OM, OM-SVG, 85
percent at proximal RCA). In addition, a cardiac
catheterization showed left ventricular dysfunction at 25
percent with global hypokinesis and apical akinesis,
dysfunctional bioprosthetic mitral valve replacement with
moderate to severe regurgitation and moderate mitral
stenosis. The catheterization did reveal that the aortic
valve replacement was functional and there was trace aortic
insufficiency. The patient was referred to [**Hospital1 18**] for further
treatment. On the day of admission, [**2157-6-1**], the patient
had cardiac catheterization done here, which showed SVG to OM
totally occluded, RCA with severe disease, right atrial
pressure of 17, pulmonary catheter wedge pressure 36/65/37;
pulmonary artery pressure 85/32; cardiac index 2.54;
peripheral vascular distance at 346. A pulmonary artery
catheter was placed in the cardiac cath lab after the patient
had two stents deployed in his right coronary artery.
Postcatheterization on arrival to the coronary intensive care
unit, the patient was feeling well without complaints.
PAST MEDICAL HISTORY: Ischemic coronary artery disease.
Mitral stenosis, status post mitral valve replacement in
[**2149**]. Aortic stenosis, status post aortic valve replacement,
both bioprosthetic valves.
Paroxysmal atrial fibrillation.
Hypertension.
Pneumonia.
Status post right hip replacement.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] is a
retired truck driver. He worked with Budweiser Horses. A
Korean War veteran. He was stationed in [**Country 2784**] during the
war. He never smoked. He has never drunken a beer in his
life, no other alcohol use. No history of illicit drug use.
His cardiologist is Dr. [**First Name (STitle) 1075**].
FAMILY HISTORY: No early coronary artery disease.
OUTPATIENT MEDICATIONS:
1. Aldactone 25 q.d.
2. Lasix 20 mg p.o. b.i.d.
3. Coumadin 3 mg q.d., except Wednesday, the patient takes 4
mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Atenolol 50 mg q.a.m., 25 mg q.p.m.
6. Zantac 150 mg b.i.d.
7. KCl 10 mEq q.d.
PHYSICAL EXAMINATION: On admission, temperature 97.4, heart
rate 62, blood pressure 116/47, respiratory rate 20, oxygen
saturation 98 percent on room air, weight 88.3 kg. In
general, he is in no apparent distress, calm. HEENT:
Sclerae anicteric. Pupils equal, round, and reactive to
light and accommodation. Extraocular muscles intact
bilaterally. Mucous membranes moist. Oropharynx: Clear.
Neck: Supple. JVD approximately 10 to 11 cm at 45 degree
angle. Cardiovascular: Regular rate and rhythm. Normal S1,
loud S2, 2/6 systolic ejection murmur, audible throughout,
loudest at apex. No rubs or gallops noted. Chest: Clear to
auscultation bilaterally, anteriorly good aeration. Abdomen:
Obese, soft, nontender, and nondistended. Normoactive bowel
sounds. No pulsatile masses or hepatosplenomegaly.
Extremities: Cool, dry, 1 plus pedal pulses bilaterally. No
clubbing, cyanosis or edema. Left groin site clean, dry, and
intact without hematoma, oozing or bruit.
LABORATORY DATA: Labs on admission, CBC, white count 9.3,
hematocrit 41, platelets 196,000. Chem-7, sodium 141,
potassium 5.2, hemolyzed chloride 105, BUN 26, bicarbonate
40, creatinine 1.6, calcium 10, INR 1.1. EKG on admission,
sinus bradycardiac 53 beats per minute, normal axis, PR
interval prolonged at 320 ms, QRS 166 ms, left bundle-branch
block. Old left atrial enlargement.
[**Last Name (STitle) 56412**]SPITAL COURSE: This 76-year-old man status post
bioprosthetic AVR and MVR now status post catheter since the
RCA, three-vessel disease, elevated pulmonary artery pressure
secondary to severe mitral regurgitation was admitted for
trial of vasodilators and diuresis, in hopes of optimization
of clinical status for consideration of mitral valve
replacement by Dr. [**Last Name (Prefixes) **].
Pu[**Last Name (STitle) **]y artery hypertension, mitral valve regurgitation:
The patient was started on a trial of Nipride, which the
patient tolerated well with significant reduction of his
pulmonary artery pressures. The initial upon readings for
pulmonary artery pressure 85/32 with a mean of 48, which
reduced to pulmonary artery pressure of 34/12 with a mean of
20 after nitroprusside. The patient's SVR also decreased
significantly from 1008 to 744 on the Nipride. His pulmonary
vascular resistance also decreased significantly from 346 to
160 on Nipride. His pulmonary capillary wedge pressure
decreased from 37 to 15 on Nipride. The patient tolerated
the trial of Nipride well. However, the patient's systolic
blood pressure did drop somewhat with the Nipride drip, which
was held secondary to hypotension after 12 hours of Nipride
therapy. After discussion with the patient, the decision was
made to transition the patient from Nipride to nesiritide for
conservative afterload reduction until mitral valve
replacement. The patient was diuresed significantly with
nesiritide and Lasix. The team felt that the patient was
diuresed to euvolemia given that his creatinine increased from
1.4 to 1.9 on the day of discharge. Discussion was held with
the patient and his wife as well as with Dr. [**Last Name (Prefixes) **]
regarding whether or not to keep the patient inpatient until
mitral valve replacement could be done or readmit the patient
to optimize his medical condition for possible surgery at a
later date. The
patient preferred to go home given that Dr. [**Last Name (Prefixes) **]
cannot do his mitral valve replacement until next week.
Therefore, the patient was discharged home on his
home medications with one change. The patient's atenolol was
felt to be too high of a dose for the patient. He was noted
to be hypotensive to a map of 55 to 60 and the heart rate in
the 50s on this atenolol dose of 50 mg q.a.m. and 25 q.h.s.
Therefore, the atenolol dose was decreased to 25 mg b.i.d.
The patient was advised that he felt dizzy or lightheaded
that he should discontinue his p.m. atenolol dose after
talking with his cardiologist, Dr. [**First Name (STitle) 1075**].
DISCHARGE DIAGNOSES: Congestive heart failure.
Severe mitral valve regurgitation.
Hypertension.
Paroxysmal atrial fibrillation.
Reversible pulmonary artery hypertension.
DISCHARGE CONDITION: Stable.
DI[**Last Name (STitle) 408**]E MEDICATIONS:
1. Plavix 75 mg p.o. q.d.
2. Spironolactone 25 mg p.o. q.d.
3. Aspirin buffered 325 mg p.o. q.d.
4. Lipitor 40 mg p.o. q.d.
5. Atenolol 25 mg p.o. b.i.d., hold if lightheaded.
6. Valsartan 320 mg p.o. q.h.s.
7. Zantac 150 p.o. b.i.d.
8. Coumadin 3 mg p.o. q.h.s. The patient's was told to
contact Dr. [**Last Name (Prefixes) **] regarding when to discontinue the
Coumadin prior to mitral valve replacement.
9. Lasix 20 mg p.o. b.i.d.
DI[**Last Name (STitle) 408**]E FOLLOW UP: The patient will be contact[**Name (NI) **] by Dr. [**Last Name (Prefixes) **] for mitral valve replacement surgery. He will be
called to schedule a follow up appointment likely next week.
He is advised if he has any chest pain, shortness of breath,
lightheadedness or dizziness, he should call his primary care
physician or his cardiologist, Dr. [**First Name (STitle) 1075**], for further advise.
He is advised that if he does not hear from Dr. [**Last Name (Prefixes) **]
next Tuesday that he should call Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office to
inquire about an appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 13600**]
Dictated By:[**Last Name (NamePattern1) 10641**]
MEDQUIST36
D: [**2157-6-3**] 14:13:21
T: [**2157-6-3**] 22:00:53
Job#: [**Job Number 47715**]
ICD9 Codes: 4111, 4019, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7245
} | Medical Text: Admission Date: [**2120-3-26**] Discharge Date: [**2120-4-12**]
Date of Birth: [**2063-1-23**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 26411**]
Chief Complaint:
s/p motorcycle crash
Major Surgical or Invasive Procedure:
[**2120-3-26**]: I&D right open tibia fracture, with closed reduction,
external fixation, and VAC placement
[**2120-3-29**]: I&D right open tibia fracture with IM nail, removal of
external fixator, and VAC placement
[**2120-4-1**]: I&D right open tibia fracture with VAC change
[**2120-4-3**]: 1. Partial excision bone right tibia.
2. Debridement open fracture down to bone.
3. Debridement and washout including skin, soft tissue, muscle
and bone right lower extremity.
4. Preparation of recipient site for subsequent coverage.
5. Free microvascular rectus abdominis muscle flap from the
right abdomen to the right lower extremity.
6. Split-thickness skin grafting greater than 100 cm2 right
lower extremity.
History of Present Illness:
Mr. [**Known lastname **] is a 57 year old man who was involved in a
motorcycle crash on [**2120-3-26**]. He was taken to [**Hospital 8641**] Hospital and
was found to have an open right tibia fracture and was
transferred to the [**Hospital1 18**] for further evaluation and care.
Past Medical History:
Denies
Brief Hospital Course:
Mr. [**Known lastname **] presented to the [**Hospital1 18**] on [**2120-3-26**] via transfer from
[**Hospital 8641**] Hospital with a right open tibia fracture. He was
evaluated by the orthopaedic surgery department and taken to the
operating room and underwent an I&D of his right open tibia with
external fixator placement and VAC placement. On [**2120-3-28**] he was
transfused with 2 units of packed red blood cells due to acute
blood loss anemia. On [**2120-3-29**] he returned to the operating room
and underwent a right tibia I&D with tibial nail placement, and
VAC change. He was also transfused with 2 units of packed red
blood cells due to acute blood loss anemia. Plastic surgery was
consulted to help with wound closure. On [**2120-3-30**] he was
transfused with 1 unit of packed red blood cells due to acute
blood loss anemia. On [**2120-3-31**] he was again transfused with 1
unit of packed red blood cells due to actue blood loss anemia.
On [**2120-4-1**] he returned to the operating room and underwent an
I&D of his right tibia with VAC change. That same day he also
had an angiogram to evaluate perfusion of the leg given the
significant soft tissue avulsion and loss in this area. The
angiogram showed the anterior tibial as well as peroneal
arteries. However, the posterior tibial artery was injured
approximately 2 cm after its takeoff of the tibioperoneal trunk.
Given these findings and the large anterior wound, it was felt
that a rectus free flap would be required to restore soft tissue
coverage at this area. The patient thus returned again to the OR
on [**2120-4-3**] for further debridement and washout of that site, a
free microvascular rectus abdominis muscle flap from the right
abdomen to the right lower extremity, and skin grafting.
The rest of his hospital stay was uneventful with his lab data
and vitals signs within normal limits and his pain controlled.
He is being discharged today in stable condition.
Medications on Admission:
Denies
Discharge Medications:
1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous once a day for 30 days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: Do not exceed 12/day.
4. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1122**] Center - [**Hospital1 3597**]
Discharge Diagnosis:
s/p motorcycle crash
Right open tibia fracture
Acute blood loss anemia
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:
Continue to be non-weight bearing on your right leg
.
Continue your Lovenox injections as instructed
.
Please take all your medication as prescribed
.
Right lower extremity dangle schedule:
[**2120-4-12**] Dangle 10 minutes 3x/day
[**2120-4-13**] Dangle 15 minutes 3x/day
[**2120-4-14**] Dangle 15 minutes 3x/day
[**2120-4-15**] Dangle 20 minutes 3x/day
[**2030-4-16**] Dangle 20 minutes 3x/day
[**2120-4-17**] Dangle 25 minutes 3x/day
[**2120-4-18**] Dangle 25 minutes 3x/day
[**2120-4-19**] Dangle 30 minutes 3x/day
[**2120-4-20**] Dangle 30 minutes 3x/day
.
-Elevate your right leg as much as possible and maintain it in
your splint.
-Please keep your right leg dry when you shower/bathe.
- If your right leg begins to worsen after discharge home with
an acute increase in swelling or pain, please call Dr. [**Name (NI) 83165**] office.
- Please leave your right thigh skin graft donor site as is
(with drying xeroforms in place)
- Your right lower leg flap site dressing should be changed once
daily. Apply xeroform, fluffs and wrap with kerlix and then
wrap in ACE wrap and re-apply splint.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
.
Medications:
* Resume your regular medications unless instructed otherwise.
* You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
* Take prescription pain medications for pain not relieved by
tylenol.
* Take Colace, 100 mg by mouth 2 times per day, while taking the
prescription pain medication to prevent constipation. You may
use a different over-the-counter stool softerner if you wish.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopedics, in 2
weeks. Please call [**Telephone/Fax (1) 1228**] to schedule that appointment
with Dr. [**Last Name (STitle) **].
.
Please follow up with Dr. [**Last Name (STitle) 23606**] (Plastic Surgery)in 7 days:
Call ([**Telephone/Fax (1) 26412**] to make an appointment for next week.
Completed by:[**2120-4-12**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7246
} | Medical Text: Admission Date: [**2180-1-12**] Discharge Date: [**2180-1-29**]
Date of Birth: [**2111-10-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Sudden onset headache
Major Surgical or Invasive Procedure:
[**2180-1-12**]: Diagnostic angiogram x2
[**2180-1-12**]: L crani for aneurysm clipping and clot evac
[**2180-1-12**]: placement of external ventricular drain
[**2180-1-25**]: PEG placement
History of Present Illness:
Dr [**Known lastname 85007**] is 69 y/o male with PMH of Hyperlipidemia, Asthma and
TIA. In the last week he has been complaining of URI symptoms
and was recently started on Zithromycin. He was in his usual
state of health this evening he had a few instances of word
finding difficulty around 1800 on [**1-11**] then at [**2199**] c/o "massive
headache" and went and layed down. His wife was unable to arouse
him at 2230 and called 911. He went to [**Hospital6 **] and
started to vomit and was lethargic though would open eyes and
follow commands. He was intubated to protect his airway. He was
transferred to [**Hospital1 18**] for further management.
Past Medical History:
Hyperlipidemia, Asthma, TIA ([**10-10**])Being treated for URI prior
to admission
Social History:
Psychiatrist at [**Hospital 8**] Hospital
Family History:
No known family hx of anuerysms. Mother died of pulmonary issue
and father killed in [**Name (NI) 8751**]
Physical Exam:
On Admission:
O: T: BP:105/44 HR:68 R 16 O2Sats 100%
Gen: Intubated on Propofol, off Propofol for 10 minutes when
examined.
HEENT: Pupils:[**4-2**] EOMs unable to test
Neck: In collar.
Does not open eyes to voice or pain
Questionable following of command on left foot
+ Gag, + cough, + corneals
Spontaneously moving both right arm and leg with appears full
strength
No withdrawl to pain on right upper extremity and minimal
withdrawl of left leg to pain though spontaneous moves toes
Toes upgoing bilaterally
On Discharge:
oriented to self, follows commands with LUE, withdraws to
noxious LLE, RUE and RLE plegic, answers yes or no questions,
EOMS intact with some prompting, eyes open to voice
Pertinent Results:
Labs on Admission:
[**2180-1-12**] 01:40AM BLOOD WBC-24.5* RBC-3.62* Hgb-11.0* Hct-32.9*
MCV-91 MCH-30.3 MCHC-33.4 RDW-12.9 Plt Ct-706*
[**2180-1-12**] 01:40AM BLOOD Neuts-88.5* Lymphs-6.2* Monos-4.8 Eos-0.3
Baso-0.2
[**2180-1-12**] 01:40AM BLOOD PT-13.5* PTT-24.2 INR(PT)-1.2*
[**2180-1-12**] 01:40AM BLOOD Fibrino-528*
[**2180-1-12**] 01:40AM BLOOD UreaN-21* Creat-1.1
[**2180-1-12**] 01:40AM BLOOD ALT-19 AST-33 LD(LDH)-235 AlkPhos-75
TotBili-0.5
[**2180-1-12**] 01:40AM BLOOD Lipase-51
[**2180-1-12**] 07:27PM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.5 Mg-2.0
[**2180-1-12**] 07:27PM BLOOD Phenyto-10.6
[**2180-1-12**] 01:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CT/A Head [**1-12**]:
CT HEAD: There has been interval increase in diffuse
subarachnoid hemorrhage within the frontal, temporal, and
parietal lobes, left greater than right, and extending within
the sylvian fissures. There is a new large intraparenchymal
hemorrhage in the left temporal lobe, measuring 6.5 cm
anteroposterior x 3.1 cm transverse with associated surrounding
hypodensity. There is new mass effect upon the entire left
lateral ventricle with approximately 6 mm midline shift to the
right. There is effacement of the frontal and occipital horns of
the left lateral ventricle. Additional note is made of
intraventricular blood products layering within the occipital
horns, unchanged. There is evidence of
left uncal herniation and transfalcine herniation. No acute
territorial
infarction is identified. Incidental note is made of a mucus
retention cyst within the left maxillary sinus. The remaining
paranasal sinuses and mastoid air cells are well aerated.
CTA HEAD: The patient is intubated. The vertebrobasilar system
is
unremarkable. There is a 3 mm aneurysm at the left M3 segment.
There is a 1.5 mm left posterior communicating artery aneurysm
and a 2.1 mm anterior
communicating artery aneurysm. No additional aneurysms are
identified. The
intracranial internal carotid, anterior, middle, and posterior
cerebral
arteries demonstrate a normal course and caliber without
evidence of high-
grade stenosis, occlusion, or arteriovenous malformation.
IMPRESSION:
1. Interval development of a large left intraparenchymal
hemorrhage with new mass effect, rightward midline shift, left
uncal herniation, and tranfalcine herniation. Interval increase
in diffuse subarachnoid hemorrhage with intraventricular
extension.
2. 3 mm left M3 aneurysm, 2 mm anterior communicating artery
aneurysm, and
1.5 mm left posterior communicating artery aneurysm.
CT Head [**1-12**](Post-op):
FINDINGS: The patient is status post left frontal craniotomy
with surgical
staples seen in the scalp. Expected pneumocephalus and gas
within the
operative site is seen. High-density material in the left M2/3
region likely represents clips. Rightward shift is 5 mm, similar
to prior. Intraparenchymal and diffuse subarachnoid hemorrhage
appears grossly similar. Slightly more hemorrhaging material
layers in the occipital horns. Effacement of the left lateral
ventricle and overlying sulci appear similar to prior. Mastoid
air cells are clear. Visualized paranasal sinuses demonstrate
mild ethmoidal sinus mucosal thickening.
IMPRESSION: Status post left craniotomy, clot evacuation and
aneurysm
clipping with expected postoperative changes including
pneumocephalus. Overall similar rightward midline shift,
intraparenchymal and diffuse subarachnoid hemorrhage.
Brief Hospital Course:
Patient was transferred to [**Hospital1 18**] from [**Hospital6 2561**] on
[**2180-1-12**] s/p experiencing word finding difficulties and severe
sudden onset headache which caused him to lie down and be
unarousable by his wife. Upon arrival he underwent cerebral
angiogram, followed by Left craniotomy for Left MCA aneurysm
clipping with placement of subgaleal [**Last Name (un) 86529**] [**Location (un) 1662**] drain, and
then returned to the interventional neuroradiology suite for
another angiogram.
On [**2180-1-13**] he began to display posturing so an EVD was placed on
the right side. on [**1-14**] his exam remained stable and his
subgaleal JP drain was removed. Also a right subclavian central
line was placed by the surgical ICU team.
On [**1-14**], subgaleal drain was removed and patient was febrile to
102. Cultures have been sent. C. diff was also sent.On [**1-19**],
patient was observed to be febrile overnight to 101.4, cultures
have been sent and results from cultures on [**1-14**] were negative.
His EVD continues to be raised to 20 and open. Patient opens his
eyes spontaneously, R hemiplegia, no commands, but spontaneous
with L side.
He remaine din the ICU. On [**1-18**] a CTA was performed and stroke
neurology service was consulted for prognosis. There was a
family meeting. His c. diff sample was resulted as negative. On
[**1-20**] the EVD was clamped. The patient was attempting to follow
commands. He exhibited receptive aphasia.
On [**1-21**], the patient's family was agreeable to extubation and he
was made DNI. He surprisingly did well s/p extubation, as he had
spontaneous eye opening, purposeful movement with his L upper
extremity, and questionable command following. The family spent
the day of [**1-23**] deciding what level of care and intervention
they wanted for Mr. [**Known lastname 85007**] which was full care but DNR/DNI.
They have agreed to have a PEG placed. It was placed on [**2180-1-25**].
Tube feedings were started and were tappered up to goal. He is
maintained NPO otherwise. It was also noted that day that his
plt count bumped to 1.4 million. Heme onc was contact[**Name (NI) **] for
recommendations. Dr. [**Last Name (STitle) 4613**] recommended starting Hydrea at 250mg
daily with close monitoring of cbc with diff to be drawn q
monday/friday - they would like to see him back in the clinic in
[**12-4**] weeks after discharge.
On [**2180-1-27**] he was lethargic but afebrile. WBC bumped from
12->20->16. CT scan of the brain was done and is stable. CXR
demonstrates new left lower lobe pneumonia c/w aspiration. He
was started on antibiotics.
On [**1-29**] his exam remained unchanged and he was transferred to
[**Hospital3 **] for continuing care
Medications on Admission:
Lipitor
Discharge Medications:
1. Outpatient Lab Work
Q MONDAY AND FRIDAY
CBC WITH DIFF
PLEASE CALL 6[**Telephone/Fax (1) 86530**] TO PROVIDE RESULTS
THANK YOU
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 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. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for severe pain.
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. Hydroxyurea 500 mg Capsule Sig: 0.5 Capsule PO DAILY
(Daily): Follow CBC with diff on Monday and Friday.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
13. Hydromorphone (PF) 1 mg/mL Syringe Sig: .125 mg Injection
Q4H (every 4 hours) as needed for pain.
14. Cefepime 2 gram Recon Soln Sig: Two (2) grams Intravenous
Q12H (every 12 hours).
15. Ciprofloxacin 400 mg/40 mL Solution Sig: Four Hundred (400)
mg Intravenous Q12H (every 12 hours).
16. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: midline.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
atraumatic subarachnoid hemorrhage
dysphagia
respiratory failure
obstructive hydrocephalus
ventricular tachycardia
aphasia
right hemiparesis
thrombocytosis
atrial fibrillation
aspiration pneumonia
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
[**Name10 (NameIs) **]
Usually no special [**Name10 (NameIs) **] is prescribed after a craniotomy. A
normal well balanced [**Name10 (NameIs) **] is recommended for recovery, and you
should resume any specially prescribed [**Name10 (NameIs) **] you were eating
before your surgery.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast, as well
as a CTA of the head.
YOU MUST FOLLOW UP IN THE [**Hospital **] CLINIC WITHIN 1-2 WEEKS OF
DISCHARGE FROM THE [**Hospital1 18**]. PLS CALL [**Telephone/Fax (1) 6946**] TO SCHEDULE AN
APPOINTMENT.
Completed by:[**2180-1-29**]
ICD9 Codes: 5070, 4271, 5185, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7247
} | Medical Text: Admission Date: [**2108-12-30**] Discharge Date: [**2109-1-4**]
Date of Birth: [**2023-5-14**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
CC: weakness/Low Hct
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85-year-old female with The patient is a 85 yo F with a PMHx
significant for CHF, CAD, MV disease s/p replacement on
warfarin, afib presents with weakness, nausea/vomiting x1 and
large hematocrit drop.
.
The patient was in her usual state of health until roughly a few
months prior to presentation. At that time she developed dyspnea
on exertion that has been getting progressively worse. 1 week
prior to presentation the patient noted intermittent nausea.
Since that time she has a decreased oral intake. The day of
admission she had nausea, emesis x1 and diffuse weakness. At
that time she presented to [**Hospital1 18**] EW. The patient denies blood in
emesis or stool. The emesis appeared like cottage cheese, which
was what she had for dinner. She denies SOB at rest,
lightheadedness, chest pain, palpitations, epistaxis, hematuria,
back pain or other sypmtoms. Of note, she has not had any recent
change in medication.
.
In the EW, initial vitals were: T 97.2, HR 58, BP 108/61, RR 19,
SaO2 97% RA. Given her initial complaints of weakness and
shortness of breath the patient was given 325mg ASA and EKG was
done and negative. Hct very low so concern of GIB. Guaiac
negative. NGL initially negative but then turn positive with
bright red blood. Cleared with 800cc fluid. GI consulted who
recommended ICU admit for potential GIB. CTAP without RP bleed.
NGL pulled. Patient started on pantoprazole ggt. The patient
became hypotensive with systolic blood pressures in 90s. The
patient was given 2L NS and 2u pRBCs. The patient was
transferred to floor with HR 74, BP 125/83, RR 17, SaO2 97%RA.
.
Currently, the patient feels well and is without symptoms. She
denies any intermittent nausea, vomiting, bowel movement or
other symptoms.
.
Review of systems: + weakness, nausea, vomiting, DOE, chronic R
leg swelling. Last colonoscopy [**2090**].
Past Medical History:
Past Medical History (per OMR):
1. Diabetes mellitus
2. Hypertension
3. Hyperlipidemia
4. Osteoarthritis
5. Osteoporosis
6. Congestive heart failureEF 45%
7. Depression
8. Spinal stenosis
9. Obesity
10. Mitral valvular disease s/p replacement ([**2090**]; INR goal [**1-3**])
11. Left foot drop in [**6-/2103**]
12. Renal insufficiency
13. Vitamin D deficiency
14. Leg edema
15. Falls
16. Atrial fibrillation
17. ? Interstitial lung disease
Social History:
Patient currently resides at the [**Hospital3 **] [**Hospital3 **]
center. She worked at the [**Hospital **] Hospital for 26 years as a
secretary for the maintenance department. She never married and
does not have any children. Her closest living relative is her
younger cousin in [**Name (NI) **]. She has an approximate 10 year smoking
history, quitting at age 29. She drinks alcohol rarely and does
not use illicit drugs.
Family History:
Significant for an MI in her mother at age [**Age over 90 **]. She otherwise did
not have siblings and does not know her father's medical
history.
Physical Exam:
VS: Temp: 97.6 BP: 132/60 HR: 77 RR: 14 O2sat: 98% RA
GEN: pleasant, elderly, comfortable, NAD
HEENT: PERRL, anicteric, MMM, op without lesions, poor
dentition, no supraclavicular or cervical lymphadenopathy, low
jvd
NECK: no thyromegaly or thyroid nodules
RESP: Bibasilar crackles, no wheezes, good air movement, no
accessory muscle use
CV: RR, nl rate, mechanical valve apex
ABD: soft, obese, nontender, nondistended, +b/s, no organomegaly
EXT: WWP, right leg edema > left leg edema (chronic), dry skin,
no cyanosis or clubbing
SKIN: dry skin, rash in groin and under breasts
NEURO: Cn II-XII grossly intact.
RECTAL: per EW, guaiac neg brown stool
Pertinent Results:
ADMISSION LABS:
.
Brief Hospital Course:
85-year-old female with CHF, CAD, AFib, MVR on warfarin with
nausea/vomiting x1 and large hematocrit drop of unclear
etiology.
.
# Low hematocrit: large hematocrit drop from baseline 33 last in
[**Month (only) **] to 18 on presentation. She denied frank hematemesis or
BRBPR on time of presentation and she was guiac negative. NGT
lavage was done, initially negative, then returned BRB, cleared
with 800cc of fluid. INR on presentation was 5.4. SBPs at this
time came down to 90s, from 110s. CT Scan showed no evidence of
RP bleed. Patient was started on IV PPI gtt and admitted to the
MICU. On arrival to the unit, she was given 2L NS and 2 units
PRBCs. Hcts were then stable at 27-29 for remainder of
admission. GI was consulted, and patient refused inpatient
EGD/colonoscopy. She was extensively described the benefits of
these studies in her setting and was made aware of the risks of
not doing these studies, yet still refused. It was determined
that she will get a virtual colonoscopy as an outpatient, and
possibly an Upper GI series. She was discharged on PO BID PPI
and with GI follow-up.
.
# Mitral valve disease s/p mechanical MV replacement:
supratherapeutic INR on admission > 5. Coumadin restarted at 3
mg once a day when INR returned < 3. INR 1.9, will be bridged
on Loveox injections once a day until INR > 2.5.
.
# Acute on chronic renal insufficiency: Baseline creatinine
1.5-1.6. Was elevated to > 2, now back to baseline at time of
discharge, like pre-renal etiology from hypovolemia.
.
# Chronic congestive heart failure: DOE and pulmonary edema on
CXR, based on patient's symptoms at baseline, likely Stage III.
Now back on metoprolol, aspirin, olmesartan. Will continue to
hold lasix until tomorrow AM as patient not clinically
decompensating currently.
.
#. Hypernatremia: Na maxed out at 151. Likely secondary to
decreased PO intake as patient had been NPO for several days.
She has started a full diet since. She was given 1 L D5W, Na
returned to 143 the next day, and remained normal for rest of
admission.
.
# Leg swelling: Appears chronic. R>L. LENI in EW. Negative for
DVT. Chronic venous stasis dermatitis seems stable.
.
# DM2: Insulin sliding scale while renal function unstable.
Outpatient regimen of glipizide started today.
Medications on Admission:
1. Acetaminophen ER 650mg PO q8H
2. Alendronate 70mg PO qWeekly
3. Amiodarone 200mg PO daily
4. Aspirin 81mg PO daily
5. Benicar 20mg PO daily
6. MVI daily
7. Diabetic tussin EX PO q4H prn
8. Fexofenadine 60mg PO daily
9. Fluoxetine 60mg PO daily
10. Glipizide 15mg PO AM, 10mg PO HS
12. Nystatin powder [**Hospital1 **]
13. Pravastatin 80mg PO daily
14. Warfarin 3mg PO daily
15. Docusate 100mg PO daily
16. Oxycodone/acetaminophen 5/325mg PO prn
17. Albuterol 90mcg 2 puffs q4-6 prn
18. Lasix 40 mg [**Hospital1 **]
Discharge Medications:
1. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
2. glipizide 10 mg Tablet Sig: 1.5 Tablets PO qAM.
3. glipizide 10 mg Tablet Sig: One (1) Tablet PO every evening.
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day.
6. Diabetic Tussin DM 10-100 mg/5 mL Liquid Sig: Two (2)
teaspoons PO every four (4) hours as needed for cough.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Endocet 5-325 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
9. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
10. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO twice
a day as needed for constipation.
11. acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours: 2 tabs every morning,1 tab in afternoon, t tab at
bedtime.
12. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
On Saturday.
13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
14. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
15. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. benzonatate 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
17. multivitamin Tablet Sig: One (1) Tablet PO once a day.
18. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day.
19. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
20. fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day.
21. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
22. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q24H
(every 24 hours).
Disp:*5 syringes* Refills:*1*
23. Outpatient Lab Work
Pleas check INR on Monday [**1-7**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
GI Bleed, likely lower eitology
Congestive heart failure
Mechanic Mitral valve on coumadin, initially with
supratherapeutic INR, now subtherapeutic.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital because of low blood counts
secondary to a bleed in you stomach. You were transfused blood
and your blood counts recovered. Because of the bleed, it was
recommended that you have an endoscopy and colonoscopy. You
refused these studies, and agreed that you were aware of the
risks of not performing these studies. You will see the GI
doctors in about a month for possible non-invasive imaging if
your stomach and intestines. Because of the bleed, your
coumadin was also held. In order to "bridge" you to therapeutic
levels, you will have to get once daily injections of another
blood thinner called Lovenox until your INR is high enough.
Visiting nurses will help you with this. You should get your
INR checked on Monday [**2109-1-6**].
.
We made the following changes to your medications:
ADDED lovenox once a day
ADDED Pantoprazole 40 mg once a day
DECREASED Lasix dose to 40mg once a day, pending weights may
need to increase dosage back to 40mg PO BID.
Continue coumadin at 3mg PO daily until next INR check.
.
It was a pleasure taking care of you during your hospital stay.
.
A visiting nurse will help to weigh yourself every morning, and
will [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
Followup Instructions:
Department: GERONTOLOGY
When: THURSDAY [**2109-1-10**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Urine culture pending at the time of discharge.
Patient will need follow up virtual colonoscopy arranged
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2109-1-16**] at 9:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5789, 5849, 2760, 2851, 4280, 5859, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7248
} | Medical Text: Admission Date: [**2194-7-21**] Discharge Date: [**2194-7-26**]
Date of Birth: [**2125-4-28**] 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:
[**2194-7-21**] Coronary Artery Bypass Graft x 3 (Left internal mammary
artery > left anterior descending, Saphenous vein graft > obtuse
marginal, Saphenous vein graft > right coronary artery)
History of Present Illness:
69 year old gentleman with history of coronary artery disease
which was originally diagnosed in [**2173-2-25**] by
catheterization following a positive stress test. He has been
managed medically since that time and has done well. More
recently he has developed exertional chest pain and dyspnea
prompting a repeat stress test which was positive for ischemia.
A cardiac catheterization revealed an occluded right coronary
artery and a 99% left anterior descending artery stenosis. Given
the severity of his disease, he has been referred for surgical
evaluation.
Past Medical History:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Benign prostatic hypertrophy
Blind left eye from accident
2nd and 3rd digit on right hand amputated in machine accident
s/p Eye and right hand surgery for above injuries
Social History:
Lives with: Wife in [**Name2 (NI) 745**]
Occupation: Semi-retired
Tobacco: Denies
ETOH: [**3-28**] week
Family History:
Father died of MI at 56
Physical Exam:
Pulse: 66 Resp: 18 O2 sat: 96%
B/P Right: 120/66 Left: 115/69
Height: 5'4" Weight: 165 lbs
General: Well-developed male in NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA/EOMI on right (blind on left)
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 -
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:
[**2194-7-21**] Echo: PRE-CPB: 1. The left atrium is normal in size. The
left atrial appendage emptying velocity is depressed (<0.2m/s).
No thrombus is seen in the left atrial appendage. 2. No atrial
septal defect is seen by 2D or color Doppler.3. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with inferior
hypokinesis. 4. Right ventricular chamber size and free wall
motion are normal. 5. There are simple atheroma in the
descending thoracic aorta. 6. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. 7. Mild (1+) mitral
regurgitation is seen. Mild MAC is seen. POST-CPB: On infusion
of phenylephrine. A pacing for slow sinus rhythm. Preserved
biventricular systolic function with LVEF = 60%. MR, AI remain
1+. Aortic contour is normal post decannulation.
[**2194-7-26**] 06:45AM BLOOD WBC-4.2 RBC-3.71* Hgb-10.8* Hct-32.7*
MCV-88 MCH-29.1 MCHC-33.0 RDW-13.3 Plt Ct-121*
[**2194-7-26**] 06:45AM BLOOD PT-17.2* INR(PT)-1.5*
[**2194-7-26**] 06:45AM BLOOD Glucose-106* UreaN-29* Creat-1.2 Na-141
K-4.8 Cl-105 HCO3-29 AnGap-12
Brief Hospital Course:
He was admitted same day surgery and was brought to the
operating room for coronary artery bypass graft surgery. See
operative report for further details. He received cefazolin for
perioperative antibiotics and was transferred to the intensive
care unit for post operative management. That evening he was
weaned from sedation, awoke neurologically intact, and was
extubated without complications. On post operative day one he
was started on beta blockers and diuretics. He continued to do
well and was transferred to the floor. That evening he developed
atrial fibrillation and was treated with intravenous Lopressor
and amiodarone. He was then placed on amiodarone drip due to
persistent atrial fibrillation. He continued in atrial
fibrillation and received one bolus of diltiazem with no
response, beta blockers were continued to be increased and on
post operative day two he converted to normal sinus rhythm. His
Foley was removed and he was able to void post removal but then
had high residual and it was reinserted. He continued with the
Foley until post operative day four, at which time it was
removed and he had no further difficulties. His chest tubes and
wires were removed per protocol. He had further episodes of
atrial fibrillation that were treated with amiodarone and
titrating up beta blockers, and he was started on Coumadin for
anticoagulation. He was in sinus rhythm for more than
forty-eight hours prior to discharge. On post operative day five
he was ready for discharge home with services. All follow-up
appointments were advised.
Medications on Admission:
Atenolol 50mg twice daily
Lipitor 80mg daily
Tamsulosin 0.4mg daily
Aspirin 325mg daily
Multivitamin
Vitamin B complex
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): Take 400mg TID for 7 days. Then 400mg [**Hospital1 **] for 7 days.
Then 200mg [**Hospital1 **] x 7 days. Finally 200mg dialy until stopped by
cardiologist.
Disp:*100 Tablet(s)* Refills:*1*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*2*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 10 days.
Disp:*20 Tablet Extended Release(s)* Refills:*2*
11. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: take
two tablets (4mg total) daily or as directed by the office of
Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*2*
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Post operative Atrial Fibrillation
Past medical history:
Hypertension
Hyperlipidemia
Benign prostatic hypertrophy
Blind left eye
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet as needed
Sternal Incision - healing well, no erythema or drainage
Left Leg EVH - healing well, no erythema or drainage
No Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2194-7-30**] at
10:30
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2194-8-14**] at 1:30 pm
Cardiologist Dr. [**First Name4 (NamePattern1) 21976**] [**Last Name (NamePattern1) 11679**] on [**8-25**] at 2:00 pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 30837**] in [**4-29**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2.0-2.5
First draw on [**2194-7-29**]
Results to Dr [**Last Name (STitle) **] phone [**Telephone/Fax (1) 30837**] fax [**Telephone/Fax (1) 30838**]
Please check monday, wednesday, and friday for two weeks and
then decrease as instructed by Dr [**Last Name (STitle) **]
Completed by:[**2194-7-26**]
ICD9 Codes: 4111, 9971, 2875, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7249
} | Medical Text: Admission Date: [**2125-7-31**] Discharge Date: [**2125-8-17**]
Date of Birth: [**2050-3-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Dilaudid / Heparin Agents
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath, s/p NSTEMI at [**Hospital1 **]
Major Surgical or Invasive Procedure:
[**2125-8-6**] AVR(tissue)/CABGx1(SVG->PDA)
[**2125-8-4**] dental extractions
History of Present Illness:
75 year old male with known aortic stenosis was admitted to
[**Hospital **] Hospital with shortness of breath. He was at home and
was he was feeling short of breath and his wife checked his
oxygen level, which was in the 90's on 2.5L
of oxygen and gave him 40mg of Predinsone. After a little bit he
seemed to be breathing more labored and she called EMT and he
was brought to [**Hospital1 **]. In the ED he was found to have elevated
troponins. He was admitted and cathed the next day. He was
transferred to [**Hospital1 18**] for surgical evaluation.
Past Medical History:
COPD
CAD s/p MI with 2 stents placed [**2116**]
Diabetes Mellitus
Hypertension
Depression
Asthma
Hyperlipidemia
CVA resulting in short-term memory impairment [**2120**]
Peripheral vascular disease
h/o lung mass in left upper lobe which is being followed by
serial CT scans
Paroxysmal Atrial Fibrillation-not on coumadin
Esophageal Carcinoma
BPH
Aortic Stenosis
Congestive Heart Failure
Pacemaker placed [**6-/2125**] (for sick sinus syndrome)
Iron deficiency anemia
Achilles rupture-not repaired
Anxiety
H/O GI bleed ischemic Colitis
Gout
EtOH abuse
fatty liver by US [**2123**]
Past Surgical History:
s/p Esophagectomy with gastric pull through in [**2108**] w/ pre-op
chemotherapy and radiation therapy (at [**Hospital1 112**])
Left shoulder surgery
Angioplasty to right femoral artery [**2122**]
Unsuccessful angioplasty of the right superficial femoral artery
[**2122**]
s/p pacer placement [**6-/2125**]
s/p bilat cataract surgery
s/p dialation of GE junction [**3-/2124**] for stricture
Past Cardiac Procedures:
Dual Chamber Pacemaker placed [**2125-6-25**] model:
LAD stent placed [**2116**] at [**Hospital1 1774**]
LAD stent placed [**2122**] at [**Hospital1 1774**]
s/p MI with 2 stents placed [**2122**]
Social History:
Race:caucasian
Last Dental Exam:
Lives with:wife
Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 112394**]
Occupation:retired quality assurance worker
Cigarettes: Smoked no [] yes [x] Hx:quit 20 years ago, 90-100
pack year history(3PPD)
Other Tobacco use:
ETOH: < 1 drink/week [] [**2-6**] drinks/week [x] >8 drinks/week []1
beer per night-much less than previous
Illicit drug use-denies
Family History:
non-contributory
Physical Exam:
Pulse:67 AV paced Resp:14 O2 sat:96% on 3 L NC
B/P Right:137/86 Left:
Height:5'7" Weight:88 kgs
General:
Skin: Dry [x] intact [x]
HEENT: pupils unequal-L4-5mm reactive, R2-3mm reactive EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest:increased AP diameter, Lungs rales bilat R>L, decreased
at
bases[]
Heart: RRR [x] Irregular [] Murmur [] grade [**3-6**] harsh SEM
radiating to carotids______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] brown discoloration to
anterior LE consistent with venous stasis Edema [] none_____
Varicosities: None [x]
Neuro: awake, alert, oriented to self, place, knows year but not
date, president, not why he's in the hospital. many
difficulties
with recall of both short and long term events; grip strength
equal upper and knee flextion/extension equal lower extremities
Pulses:
Femoral Right:1+ Left:1+
DP Right:doppLeft:dopp
PT [**Name (NI) 167**]:doppLeft:dopp
Radial Right:1+ Left:1+
Carotid Bruit Right:murmur radiating Left:
murmur radiating
Pertinent Results:
ECHO:[**2125-8-8**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size is
normal. An aortic valve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal transvalvular
gradients. No 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
puomonary artery systolic pressure could not be quantified.
There is an anterior fat pad.
IMPRESSION: Very suboptimal image quality. Norrmally functioning
aortic valve bioprosthesis. Grossly normal left ventricular
cavity size and global systolic function.
.
[**2125-8-16**] 07:50AM BLOOD WBC-6.1 RBC-2.95* Hgb-9.8* Hct-30.8*
MCV-104* MCH-33.2* MCHC-31.8 RDW-18.9* Plt Ct-95*
[**2125-8-15**] 03:41AM BLOOD WBC-6.2 RBC-3.02* Hgb-10.1* Hct-31.0*
MCV-103* MCH-33.5* MCHC-32.5 RDW-18.5* Plt Ct-69*
[**2125-8-14**] 03:03AM BLOOD WBC-5.4 RBC-2.65* Hgb-9.0* Hct-27.3*
MCV-103* MCH-33.9* MCHC-33.0 RDW-18.6* Plt Ct-57*
[**2125-8-17**] 05:30AM BLOOD PT-24.4* INR(PT)-2.3*
[**2125-8-16**] 07:50AM BLOOD PT-34.0* INR(PT)-3.3*
[**2125-8-15**] 03:41AM BLOOD PT-32.8* PTT-37.2* INR(PT)-3.2*
[**2125-8-14**] 12:26PM BLOOD PT-35.1* INR(PT)-3.4*
[**2125-8-14**] 03:03AM BLOOD PT-31.3* PTT-36.2 INR(PT)-3.0*
[**2125-8-13**] 02:49AM BLOOD PT-18.2* PTT-31.9 INR(PT)-1.7*
[**2125-8-12**] 02:24AM BLOOD PT-17.7* PTT-32.6 INR(PT)-1.7*
[**2125-8-11**] 02:44AM BLOOD PT-23.3* PTT-46.0* INR(PT)-2.2*
[**2125-8-10**] 04:56PM BLOOD PT-33.9* PTT-66.0* INR(PT)-3.3*
[**2125-8-16**] 07:50AM BLOOD Glucose-91 UreaN-14 Creat-0.6 Na-135
K-4.7 Cl-99 HCO3-27 AnGap-14
[**2125-8-15**] 03:41AM BLOOD Glucose-104* UreaN-10 Creat-0.5 Na-133
K-3.9 Cl-97 HCO3-28 AnGap-12
[**2125-8-14**] 12:26PM BLOOD UreaN-12 Creat-0.6 Na-130* K-4.3 Cl-97
HCO3-26 AnGap-11
[**2125-8-14**] 03:03AM BLOOD Glucose-80 UreaN-14 Creat-0.6 Na-132*
K-4.1 Cl-97 HCO3-32 AnGap-7*
Brief Hospital Course:
Mr. [**Known lastname 33668**] was admitted to [**Hospital1 18**] from [**Hospital **] Hospital where he
was diagnosed with an NSTEMI. He underwent a plavix load for a
cardiac cath showing single vessel disease and aortic stenosis
and was transferred to [**Hospital1 18**] for evaluation of surgical
revascularization. He underwent a thorough pre-op work up. He
was found to have several teeth requiring extraction prior to
surgery and on HD#3 he was taken to the operating room for
dental extractions of teeth #22, 23, 24, 25, 26, 27. He was
also found to have significant left ICA stenosis and a vascular
surgery consul was obtained from Dr. [**Last Name (STitle) 1391**]. Mr. [**Known lastname 33668**] will
require a carotid endarterectomy one month after cardiac
surgery. On HD# 5 he was taken to the operating room again
where he underwent Coronary artery bypass grafting x1 with the
saphenous vein graft to the posterior descending artery, Aortic
valve replacement with a [**Street Address(2) 6158**]. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**] tissue valve,
serial #[**Serial Number 112395**], reference number [**Serial Number 112396**].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He was
hemodynamically labile in the immediate post-operative period
requiring pressor and inotropic support. Over the ensuing
post-operative days he was weaned from intropes and pressors and
was extubated. Post extubation he had lot to secretions and
tenious respiratory status. He received aggressive pulmoanry
toileting and avoided reintubation. He was also aggressively
diuresed. His BUN/creat remained stable. His CT's were removed
wihtout difficulty. He was very confused and at times combative,
he was started on seroquel but became too sedate and was
eventually restarted on all his preopertaive psych meds. He
remains pleasantly confused but nonfocal. He was
thrombocytopenic and was HIT negative x2. He was started on
coumadin low dose for pre-op and post-op afib.
Beta blocker was initiated and the patient was diuresed towards
his preoperative weight. The patient was transferred to the
telemetry floor on POD# 8 for further recovery. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 11 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to Ledgewood in [**Hospital1 **] in good condition with appropriate
follow up instructions.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientAtrius.
1. Albuterol-Ipratropium [**1-1**] PUFF IH Q4H
2. Aspirin 325 mg PO DAILY
3. BuPROPion 200 mg PO DAILY
4. Citalopram 40 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Digoxin 0.125 mg PO DAILY
7. Diltiazem Extended-Release 180 mg PO DAILY
8. Furosemide 20 mg IV BID
9. Heparin 5000 UNIT SC TID
10. NPH 10 Units Breakfast
NPH 10 Units Bedtime
11. MethylPREDNISolone Sodium Succ 40 mg IV Q 12H
12. Metoprolol Tartrate 25 mg PO BID
13. Pravastatin 40 mg PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. Mucinex *NF* (guaiFENesin) 600 mg Oral [**Hospital1 **]
Discharge Medications:
1. Albuterol-Ipratropium 2 PUFF IH Q6H
2. Aspirin EC 81 mg PO DAILY
if extubated
3. BuPROPion (Sustained Release) 200 mg PO QAM
4. Citalopram 40 mg PO DAILY
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
6. Metoprolol Tartrate 25 mg PO BID
7. Mucinex *NF* (guaiFENesin) 600 mg Oral [**Hospital1 **] Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
8. Pantoprazole 40 mg PO Q24H
9. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
10. Bisacodyl 10 mg PR HS:PRN constipation
11. Captopril 12.5 mg PO TID
12. Clonazepam 0.5 mg PO QHS
13. Docusate Sodium 100 mg PO BID
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
15. FoLIC Acid 1 mg PO DAILY
16. Lactulose 30 mL PO TID
17. Potassium Chloride 20 mEq PO BID
Hold for K >4.5
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
19. Thiamine 100 mg PO DAILY
20. Warfarin MD to order daily dose PO DAILY
21. Furosemide 40 mg PO DAILY Duration: 10 Days
22. Pravastatin 80 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5682**] Rehabilitation and Skilled Nursing Center - [**Hospital1 **]
Discharge Diagnosis:
COPD
CAD s/p MI with 2 stents placed [**2116**]
Diabetes Mellitus
Hypertension
Depression
Asthma
Hyperlipidemia
CVA resulting in short-term memory impairment [**2120**]
Peripheral vascular disease
h/o lung mass in left upper lobe which is being followed by
serial CT scans
Paroxysmal Atrial Fibrillation-not on coumadin
Esophageal Carcinoma
BPH
Aortic Stenosis
Congestive Heart Failure
Pacemaker placed [**6-/2125**] (for sick sinus syndrome)
Iron deficiency anemia
Achilles rupture-not repaired
Anxiety
H/O GI bleed ischemic Colitis
Gout
EtOH abuse
fatty liver by US [**2123**]
Past Surgical History:
s/p Esophagectomy with gastric pull through in [**2108**] w/ pre-op
chemotherapy and radiation therapy (at [**Hospital1 112**])
Left shoulder surgery
Angioplasty to right femoral artery [**2122**]
Unsuccessful angioplasty of the right superficial femoral artery
[**2122**]
s/p pacer placement [**6-/2125**]
s/p bilat cataract surgery
s/p dialation of GE junction [**3-/2124**] for stricture
Past Cardiac Procedures:
Dual Chamber Pacemaker placed [**2125-6-25**] model:
LAD stent placed [**2116**] at [**Hospital1 1774**]
LAD stent placed [**2122**] at [**Hospital1 1774**]
s/p MI with 2 stents placed [**2122**]
Discharge Condition:
Alert and oriented x2 nonfocal
Ambulating with 4 person assist
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage. 1+ lower ext
Edema. Multiple ecchymotic areas
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) **] MD Phone: [**Telephone/Fax (1) 170**] Date/Time:[**2125-9-13**] 1:15
Cardiologist: Dr [**Last Name (STitle) 28181**] [**Name (STitle) 81956**] [**2125-9-5**] @ 3:00pm
Vascular surgeon: Dr. [**Last Name (STitle) 1391**] [**Telephone/Fax (1) 1393**] -needs carotid
endarterectomy
[**9-12**] at 10:45 Am [**Last Name (NamePattern1) **] [**Hospital Unit Name 17173**]
Please call to schedule appointments with your
Primary Care Dr. ,[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 79695**] in [**4-5**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? afib/stroke
Goal INR [**2-2**]
First draw [**2125-8-18**]
Coumadin follow up to be arranged upon discharge from rehab
Completed by:[**2125-8-17**]
ICD9 Codes: 2930, 2875, 4280, 5990, 2851, 496, 412, 4019, 2724, 4439, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7250
} | Medical Text: Admission Date: [**2119-6-18**] Discharge Date: [**2119-6-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 82 yo male with hx of CHF (EF 55% 3+MR), afib,
DMII, and recent MRSA PNA who presents with dyspnea. Pt has
multiple recent hospitalizations the most significant of which
was [**Date range (3) 15221**] during which he suffered an SDH which was
surgically evacuated, liver failure from dilantin toxicity, ARF
due to CHF and pneumonia treated with a course of levofloxacin.
He was readmitted [**Date range (1) 15222**] for mental status changes and
hypoxia requiring intubation for airway protection. BNP was in
the 30,000's and he was found to have a RML infiltrate on CT and
MRSA in his sputum and treated with a 10 day course of
vancomycin which he completed on [**2119-5-27**]. He was also breifly
hospitalized [**Date range (1) 15223**] for apneic episodes at rehab with confusion
thought to be due to [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations secondary to CHF
exacerbation. He represented to the ED yesterday with confusion
and found to have hypokalemia, ARF, and FS of 60 with mental
status improved with correction of these disturbances. CXR was
read as clear by ED staff but final read showed new left sided
effusion and bilateral infiltrates concerning for CHF but head
CT was unchanged.
He now presents from rehab after being started on levofloxacin
since [**6-16**] for fever and suspected UTI and PNA . In the ED he
was found to be hypoxic suspectedly due to CHF with concomitant
PNA. He was given a dose of lasix 40mg IV with vancomycin and
started on BIPAP since the patient was DNR/DNI and appeared to
have difficult work of breathing with hypercarbia on ABG despite
normal O2 sats on 4L NC.
Past Medical History:
1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2. 3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine. No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia
12. ?progressive dementia
Social History:
Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards).
Family History:
no Alzhemer's or Parkinson's
Physical Exam:
Admission:
T 99.8 HR 85 BP 135/55 RR 30 O2 sat 95% 4L NC
HEENT-PERRL, MM dry, elevated JVP to ear but pt breathing
forcefully, no ant or post cerv LAD
Hrt-RRR nS1 soft S2 [**2-27**] SM at apex, [**2-27**] diastolic murmur at LUSB
Lungs-bronchial BS at left lung base and dullness to percussion
at bases bilat, no crackles, mild diffuse end expiratory wheeze
Abdomen-soft NT, ND, no organomeg, NABS
Extrem-2+ rad and dp pulses, 2+ pitting edema
Neuro-noncompliant with exam, moving all extrem well, arousable
but agitated and appropriate
Skin-left forearm abrasion 1/2cm
Pertinent Results:
Admission labs:
[**2119-6-17**] 05:45PM BLOOD WBC-4.9 RBC-3.55* Hgb-10.2* Hct-30.8*
MCV-87 MCH-28.8 MCHC-33.2 RDW-17.9* Plt Ct-150
[**2119-6-17**] 05:45PM BLOOD Neuts-50.8 Lymphs-40.1 Monos-7.6 Eos-1.3
Baso-0.3
[**2119-6-17**] 05:45PM BLOOD Hypochr-1+ Anisocy-1+ Microcy-1+
[**2119-6-17**] 05:45PM BLOOD PT-14.3* PTT-26.2 INR(PT)-1.3*
[**2119-6-17**] 05:45PM BLOOD Glucose-79 UreaN-27* Creat-1.5* Na-145
K-3.1* Cl-102 HCO3-33* AnGap-13
[**2119-6-17**] 05:45PM BLOOD ALT-14 AST-21 CK(CPK)-37* AlkPhos-70
Amylase-47 TotBili-0.8
[**2119-6-17**] 05:53PM BLOOD Lactate-1.8
Other labs:
[**2119-6-17**] 06:11PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2119-6-17**] 06:11PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2119-6-17**] 06:11PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-<1
[**2119-6-17**] 05:45PM BLOOD cTropnT-0.04*
[**2119-6-18**] 03:10PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2119-6-17**] 05:45PM BLOOD Lipase-22
[**2119-6-19**] 05:30AM BLOOD %HbA1c-5.1 [Hgb]-DONE [A1c]-DONE
[**2119-6-19**] 05:30AM BLOOD TSH-1.9
[**2119-6-18**] 04:41PM BLOOD Type-ART Rates-/30 pO2-81* pCO2-50*
pH-7.45 calHCO3-36* Base XS-8 Intubat-NOT INTUBA
[**2119-6-19**] 08:06AM BLOOD Type-ART Temp-37.3 pO2-106* pCO2-53*
pH-7.43 calHCO3-36* Base XS-8 Intubat-NOT INTUBA
[**2119-6-18**] 03:34PM BLOOD Lactate-2.1*
[**2119-6-19**] 08:06AM BLOOD Lactate-1.2
[**2119-6-19**] 02:39PM PLEURAL WBC-60* RBC-1295* Polys-3* Lymphs-62*
Monos-28* Eos-2* Meso-1* Macro-4*
[**2119-6-19**] 02:39PM PLEURAL TotProt-2.2 LD(LDH)-105
[**2119-6-19**] Pleural fluid show no maligant cells
Discharge Labs:
[**2119-6-23**] 06:15AM BLOOD WBC-6.3 RBC-3.49* Hgb-10.3* Hct-29.8*
MCV-86 MCH-29.6 MCHC-34.6 RDW-17.0* Plt Ct-147*
[**2119-6-23**] 06:15AM BLOOD Glucose-94 UreaN-23* Creat-1.2 Na-139
K-3.6 Cl-98 HCO3-31 AnGap-14
[**2119-6-23**] 06:15AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9
Echocardiogram ([**2119-6-19**]) The left atrium is moderately dilated.
The right atrium is markedly 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 aortic root is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild to moderate ([**12-26**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. At least
moderate(2+) mitral regurgitation is seen (view suboptimal). The
mitral regurgitation jet is eccentric. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2119-4-3**], there is no
significant change.
Radiology
CXR ([**2119-6-19**]) -bilat effusion worse on left, patchy opacity in
RLL but no clear focal infiltrate
Brief Hospital Course:
The patient is 82 yo male with hx of CHF (EF 55% 3+MR), afib,
DMII, and recent MRSA PNA who presents with dyspnea. His
hospital course on this admission is as follows:
1. Confusion-Appears to be a delirium with waxing and [**Doctor Last Name 688**]
mental status due to acute illness. We treated his agitation
with zyprexa prn and it completely cleared with diuresis,
improvement in potassium levels and better glucose control.
2. Fever-He had a positive UA at rehab but repeat UA and culture
were negative. There was no clear infiltrate on CXR although he
was presumed to be at risk for aspiration PNA with altered
mental status along with hypoxia. He had been recently treated
with vancomycin for PNA and levofloxacin for UTI along with
watery diarrhea raised concern for Cdiff colitis since he has a
known history of colitis on sulfasalazine in past. He was
initially broadly covered with Vancomycin for recent MRSA PNA,
levofloxacin to cover aspiration PNA with flagyl for C.
difficile. He was never febrile while in hospital with no
elevated WBC or for left shift so antibiotics except for flagyl
was stopped on HD2. Flagyl was then stopped on HD3 after Cdiff
toxin assay was negative x3.
3. Hypoxia-Pt was thought to be at risk for aspiration PNA as
above. Bilateral effusions with LE edema and elevated JVP raised
concern for CHF. Wheeze on exam was likely cardiac wheeze. ECG
showed no acute changes suggestive ischemia or infarct with CE
stable for >24 since his ED visit on the day prior to admission.
Pt had known chronic hypercarbia which were thought to be
related to effusions causing hypoventilation. He required bipap
intermittently over the first night of admission and was
diuresed approximately 2-3 liters over the first 48 hours of
hospitalization. Repeat TTE showed now change in ventricular
function. Left sided thoracentesis was performed due to risk of
parapneumonic effusion and 2L were removed and found to be
transudative and no evidence of malignant cells. We initially
held on his ACE-I due to ARF and afterload reduced with Imdur
and hyralazine. Once patient's condition was stabilized, and
transferred from the MICU to the medicine floor, we d/c his
hydralazine, and started him on lisinopril 5mg PO, which is his
home dose. In additon, we weaned him gradually off supplemental
O2 to up 90% on 2L at the time of the discharge, which is his
baseline.
4. Hypokalemia-Due to poor PO intake and diuresis. Mental status
had been poor in past in the setting of hypokalemia. Initially,
we replete him aggressively and required >120mEq of KCL per day
to maintain serum potassium levels >3.6, then daily potassium
check and supplement as needed. As he was total body potassium
depleted he will likely need standing KCl supplementation with
close monitoring at rehab.
5. Subdural hematoma-Remained stable on head CT from ED visit on
the day prior to admission. His MS continued to improve with
correction of metabolic derangements so no repeat head CT was
performed. We continued Keppra for seizure prophylaxis.
6. AAA-ascending; measured >5cm in [**11-27**] & pt refused surgical
intervention at that time although no hypotension or back pain
to suggest dissection at this time.
7. Acute on CRI-Likely due to CHF and poor perfusion. Creatinine
returned to baseline after he was adequately diuresed.
8. Paroxysmal Afib- We continue metoprolol for rate control
despite acute CHF exacerbation as he needs longer ventricular
filling times due to valvular dysfunction. We did not initiate
anticoagulation with warfarin given recent subdural hematoma and
h/o frequent falls.
9. DM2-Given his recent weight loss we suspected that his
hyupoglycemia was due to loss of insulin resistence and
continued glyburide use. He remained hypoglycemic during the
first 48 hours of hospitaliztion with FS in the 60's requiring
multiple amps of D50. His hemaglobin A1c was 5.1 suggesting no
insulin resistance so glybride should be held indefinitely.
10. Anemia-iron studies were most c/w chronic dz (ferritin 86).
Hct remained stable. We continued ferrous sulfate.
11. Hypothyroidism-He was clinically euthyroid. We continued
synthroid and rechecked TSH which was found to be WNL.
12. Depression-remained stable. Continue celexa.
13. Communication-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (5) 15224**]
14. Nutrition and Diet-on low salt, cardiac, diabetic and renal
diet.
15. Activity-Assist out of bed, PT consults
16. Code- Full code which was reversed by the patient from
DNI/DNR during this admission, but needs to be addressed
further.
Medications on Admission:
Protonix 40 mg daily
ferrous sulfate 325 mg daily
furosemide 40 mg daily
Keppra 250 mg twice daily
Celexa 10 mg daily
vitamin C 250 mg daily
levothyroxine 25 mcg daily
lisinopril 5 mg daily
glyburide 2.5 mg daily
potassium chloride 20 mg once Monday, Wednesday, Friday
metoprolol 50 mg twice daily
RISS
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. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
CHF excerbation
pneumonia
Secondary Diagnosis:
2 + mitral regurgitation and significant AR [**3-30**]
Atrial fibrillation-off coumadin due to liver coagulopathy and
falls
Ascending aortic aneurysm (not interested in surgery)
Type 2 diabetes
Gout
Hypertension
GERD
chronic renal insufficiency
h/o Asbestosis
Recent B12 and Fe def. anemia
Subdural hematoma s/p evacuation in [**2119-4-12**]
recent MRSA peumonia ([**4-29**])
Discharge Condition:
Patient is discharged in good condition, experiencing no
symptoms of shortness of breath, chest pain, dizziness, O2 sat
up 90% on 2L, which is his baseline.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
If you experience any chest pain, shortness of breath,
dizziness, or other concerning symptoms, please seek medical
attention immediately
Followup Instructions:
Please follow up with your primary care doctor: Dr [**Last Name (STitle) 3649**]
([**Telephone/Fax (1) 3070**]) within one week of discharge, in addition to the
following appointments.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2119-7-3**] 4:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2119-6-23**]
ICD9 Codes: 5070, 5849, 2768, 5119, 5859, 2749, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7251
} | Medical Text: Admission Date: [**2140-3-6**] Discharge Date: [**2140-3-13**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Placement of percutaneous cholecystostomy tube
History of Present Illness:
[**Age over 90 **] year old male who presents with 3 days of abdominal pain
which has gotten progressively gotten worse. He has had 2 days
of vomiting clear liquid and feeling nauseated. He denies
fever/chills or night sweats. He had a bowel movement this
morning. No diarrhea. He had a cholecystostomy tube placed in
[**2137**] for a similar episode.
Past Medical History:
# Hypertension
# Osteopenia [**3-8**] steriod use
# Diabetes mellitus Type 2
# Diabetic peripheral neuropathy
# Hypercholesterolemia
# Osteoarthritis
# Hemorrhoids
# Peripheral vascular disease
# Chronic left hip pain
# Cataracts
# Onychodystrophy
# Mitral regurgitation
# Giant cell temporal arteritis
Social History:
# Personal: [**Location 7972**], speaks Portuguese. Lives with wife.
Independent in ADLs, but walks with a cane.
# Substance use: No h/o ETOH, tobacco, or recreational drug use.
Family History:
Noncontributory
Physical Exam:
In ED:
Vital Signs: T 97 HR 73 BP 180/82 18 100
General: No Acute distress
Lungs: Clear to auscultation bilaterally
Cardiac: Regular rate and rhythm
Abdomen: Soft, tender in the right upper quadrant, no guarding,
nondistended
Rectal: Normal tone, no gross blood, guaiac negative
Pertinent Results:
[**2140-3-6**] 12:55AM WBC-9.2# RBC-3.84* HGB-10.9* HCT-33.9* MCV-88
MCH-28.3 MCHC-32.1 RDW-15.5
[**2140-3-6**] 12:55AM NEUTS-65.4 LYMPHS-24.5 MONOS-9.4 EOS-0.3
BASOS-0.3
[**2140-3-6**] 12:55AM PT-14.6* PTT-30.5 INR(PT)-1.3*
[**2140-3-6**] 12:55AM LIPASE-40 GGT-115*
[**2140-3-6**] 12:55AM ALT(SGPT)-35 AST(SGOT)-45* ALK PHOS-193* TOT
BILI-0.5
[**2140-3-6**] 12:55AM GLUCOSE-108* UREA N-29* CREAT-1.5* SODIUM-138
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-21* ANION GAP-20
[**2140-3-6**] 01:02AM LACTATE-2.9*
Liver/Gallbladder U/S: Distended gallbladder with
pericholecystic fluid and gallbladder wall thickening measuring
up to 8 mm and sludge ball with findings highly concerning for
acute cholecystitis.
CTAP: 1. Distended gallbladder with surrounding pericholecystic
fluid and
gallbladder wall enhancement and surrounding stranding that is
highly
concerning for acute cholecystitis that can be confirmed with
ultrasound as clinically indicated. 2. Prostatic enlargement
measuring up to 5.2 cm in transverse dimension. 3. Extensive
atherosclerotic disease and plaque involving the abdominal aorta
and all of its major branches. 4. Right inguinal hernia
containing fat and loop of small bowel without associated
obstruction.
Brief Hospital Course:
Mr. [**Known lastname 25456**] was admitted with acute cholecystitis and underwent
percutaneous cholecystostomy tube placement. Because of his
advanced age and other medical comorbidities, he was admitted to
the surgical ICU and placed on IV antibiotics and had placement
of a right internal jugular central line for fluid and
medication delivery and monitoring. As he improved, he was
transferred to the floor and his diet was slowly advanced as
tolerated. Cultures from PTC drain grew gram negative rods and
gram positive rods. When sensitivities were finalized
antibiotics were narrowed to Ciprofloxacin. Patient remained
afebrile with normal viatal signs prior to discharge.
Medications on Admission:
Albuterol, ASA 325, Metoprolol 50'', metop XL 200', Prednisone 5
mg ', Lisinopril 40', Amlodipine 5', Gabapentin 300',
Alendronate 35mg Q Fri, Lipitor 40', GLipizide 5', HCTZ 25',
Metformin 500', Ca+ D 500-200, colace, senna, protonix 40',
tylenol
Discharge Medications:
1. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale per sliding scale Injection ASDIR (AS DIRECTED).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
11. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times
a day) as needed for constipation.
12. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*7 Tablet(s)* Refills:*0*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day:
Until gout flare resolves.
Disp:*14 Tablet(s)* Refills:*0*
16. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for gout for 3 days.
17. 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*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
acute cholecystitis
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 experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-13**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Please call Dr.[**Name (NI) 2829**] office at ([**Telephone/Fax (1) 2363**] on Monday [**3-14**] in order to schedule a follow up appointment.
Please follow up with your primary care provider within two
weeks of discharge.
ICD9 Codes: 4019, 3572, 2720, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7252
} | Medical Text: Admission Date: [**2200-9-23**] Discharge Date: [**2200-10-7**]
Date of Birth: Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 30-year-old
female who was admitted for a diagnostic cerebral angiogram
after her mother was found to have a cerebral aneurysm. On
diagnostic angiogram, the patient was found to have a left
ophthalmic internal carotid artery aneurysm with a daughter
aneurysm. The patient was brought back to her room and
remained in the hospital to have a later clipping of the
aneurysm.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Seasonal allergies.
2. Depression.
3. Status post cholecystectomy in [**2194-6-24**].
4. Status post tonsillectomy and adenoidectomy in [**2176**].
ALLERGIES: The patient has significant drug allergies to
MORPHINE, CECLOR, CELEXA, SULFA DRUGS, CLARITIN, PAPER TAPE,
CROMOLYN EYEDROPS, TRANSPARENT DRESSING, and
GENORA BIRTH CONTROL PILLS.
MEDICATIONS ON ADMISSION: (Medications on admission
included)
1. [**Doctor First Name **].
2. Lo/Ovral.
3. Fluoxetine 20 mg by mouth once per day.
BRIEF SUMMARY OF HOSPITAL COURSE: The risks and benefits of
a craniotomy were explained to the patient, and she was
brought to the operating room on [**2200-9-24**] where she
underwent a clipping of the left ophthalmic artery aneurysm.
Postoperatively, her vital signs revealed a temperature of
97.3 degrees Fahrenheit, her blood pressure was 127/52, her
heart rate was 99, and her respiratory rate was 14, and her
oxygen saturation was 97%. She was intubated on propofol.
She awoke easily and was following commands. Her pupils were
3 mm to 2 mm. Her grasp was full. Her iliopsoas were [**4-28**].
Her postoperative hematocrit was 31. The patient was
extubated a few hour postoperatively and did well overnight.
She was monitored in the Surgical Intensive Care Unit. She
was started on Protonix and Decadron 4 mg intravenously q.6h.
She was also started on Dilantin and clindamycin. Heparin
was started in the morning.
On her first postoperative day, she was alert, awake, and
oriented times three. Her face was symmetric. She grips
were full. The iliopsoas were full. Her sodium was found to
be 131 which was repleted. She had a repeat angiogram on
[**2200-9-26**] which showed a stable clipping of her
aneurysm. Postoperatively from that procedure, she had good
pedal pulses. There was no hematoma at the groin site. Her
vital signs were stable, and she remained neurologically
intact.
On [**9-27**], she was transferred from the Intensive Care
Unit to the regular surgical floor. Her Decadron was
decreased, and her Dilantin level was only 1.2. She received
a by mouth bolus.
On [**2200-9-28**] the patient did complain of some mild
heaviness on the left side of her head. Her hearing was
intact. She could hear a telephone tone bilaterally. She
had full comprehension. Her laboratories were within normal
limits. She was out of bed and tolerating a regular diet.
She was assessed by the Physical Therapy Service who felt she
was cleared to go home and just a need for assistance with
her endurance.
On [**2200-9-30**] the patient was alert, awake, and oriented
times three. She did continue to complain of some headaches.
DISCHARGE DISPOSITION: The patient was discharged home
neurologically stable with instructions to keep her incision
dry until the staples were removed. No heavy lifting or
strenuous exercise. Recommended followup wit Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**]
in two to three weeks.
MEDICATIONS ON DISCHARGE: (She had the following
medications)
1. Dilantin extended release 100 mg by mouth three times per
day.
2. Percocet 5/325-mg tablets one to two tablets by mouth
q.4-6h. as needed.
3. Prozac 20-mg tablets two tablets by mouth every day.
4. Protonix 40 mg by mouth once per day.
5. Decadron 2-mg tablets two tablets by mouth twice per day
for one day and then 2 mg by mouth twice per day for one day
and then 1 mg by mouth every day and then discontinue.
DISCHARGE STATUS: The patient's discharge status was to
home.
CONDITION AT DISCHARGE: The patient was neurologically
intact.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2200-12-4**] 11:56
T: [**2200-12-6**] 05:20
JOB#: [**Job Number 32466**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7253
} | Medical Text: Admission Date: [**2137-9-18**] Discharge Date: [**2137-10-21**]
Date of Birth: [**2058-9-23**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Biliary colic
Major Surgical or Invasive Procedure:
laproscopic cholecystectomy, ERCP with sphincterotomy, repair of
duodenal perforation
History of Present Illness:
The patient is a 78-year-old female who was admitted under the
care of Dr. [**Last Name (STitle) 468**] on [**9-18**] following an ERCP procedure.
During a sphincterotomy and common bile duct extraction by Dr.
[**Last Name (STitle) **], a duodenal perforation became apparent.
Past Medical History:
biliary colic
Social History:
none
Family History:
none
Physical Exam:
General- no apparent distress
Lungs: clear to ascultation bilaterally
Heart: regular rate and rhythum, normal S1S2
Gastrointestinal: soft, diffusely tender, mildly distended
Neurologic: alert and oriented X3
Pertinent Results:
[**2137-9-19**] 12:32AM BLOOD WBC-19.4* RBC-5.18 Hgb-16.3* Hct-46.7
MCV-90 MCH-31.4 MCHC-34.8 RDW-13.2 Plt Ct-243
[**2137-9-21**] 10:30AM BLOOD WBC-14.4* RBC-4.50 Hgb-13.8 Hct-41.2
MCV-92 MCH-30.6 MCHC-33.4 RDW-13.9 Plt Ct-247
[**2137-9-24**] 04:44PM BLOOD WBC-12.4* RBC-4.08* Hgb-12.4 Hct-36.4
MCV-89 MCH-30.5 MCHC-34.1 RDW-13.8 Plt Ct-276
[**2137-9-25**] 06:35AM BLOOD WBC-14.3* RBC-3.96* Hgb-11.8* Hct-35.3*
MCV-89 MCH-29.9 MCHC-33.5 RDW-14.0 Plt Ct-266
[**2137-9-30**] 12:30AM BLOOD WBC-11.9* RBC-3.30* Hgb-10.0* Hct-29.6*
MCV-90 MCH-30.2 MCHC-33.8 RDW-14.0 Plt Ct-380
[**2137-10-3**] 04:53AM BLOOD WBC-9.4 RBC-3.28* Hgb-9.7* Hct-29.3*
MCV-89 MCH-29.6 MCHC-33.2 RDW-13.8 Plt Ct-438
[**2137-10-8**] 06:00AM BLOOD WBC-9.4 RBC-3.15* Hgb-9.3* Hct-28.3*
MCV-90 MCH-29.6 MCHC-33.0 RDW-14.3 Plt Ct-400
[**2137-10-14**] 08:40AM BLOOD WBC-7.7 RBC-3.03* Hgb-8.9* Hct-27.1*
MCV-89 MCH-29.3 MCHC-32.9 RDW-15.4 Plt Ct-411
[**2137-10-21**] 08:30AM BLOOD WBC-4.5 RBC-3.24* Hgb-9.6* Hct-29.6*
MCV-91 MCH-29.6 MCHC-32.3 RDW-16.0* Plt Ct-215
[**2137-9-29**] 04:00PM BLOOD Neuts-87.8* Bands-0 Lymphs-6.8* Monos-4.4
Eos-0.9 Baso-0
[**2137-10-11**] 05:55AM BLOOD Neuts-78.8* Lymphs-11.7* Monos-2.7
Eos-6.6* Baso-0.3
[**2137-9-24**] 04:44PM BLOOD PT-13.3 PTT-28.2 INR(PT)-1.2
[**2137-9-28**] 04:55AM BLOOD Plt Ct-355
[**2137-9-28**] 02:40PM BLOOD PT-15.5* INR(PT)-1.6
[**2137-9-30**] 12:30AM BLOOD Plt Ct-380
[**2137-9-30**] 02:36PM BLOOD PT-12.8 PTT-31.0 INR(PT)-1.1
[**2137-10-2**] 10:20PM BLOOD Plt Ct-426
[**2137-10-15**] 05:35AM BLOOD Plt Ct-340
[**2137-10-21**] 08:30AM BLOOD Plt Ct-215
[**2137-9-19**] 12:32AM BLOOD Glucose-128* UreaN-9 Creat-0.5 Na-134
K-3.6 Cl-96 HCO3-24 AnGap-18
[**2137-9-19**] 06:05AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-132*
K-3.6 Cl-95* HCO3-23 AnGap-18
[**2137-9-26**] 06:00AM BLOOD Glucose-88 UreaN-8 Creat-0.5 Na-137 K-4.2
Cl-101 HCO3-27 AnGap-13
[**2137-10-2**] 02:58AM BLOOD Glucose-138* UreaN-7 Creat-0.4 Na-131*
K-3.7 Cl-100 HCO3-26 AnGap-9
[**2137-10-5**] 06:00AM BLOOD Glucose-164* UreaN-9 Creat-0.4 Na-133
K-4.6 Cl-98 HCO3-30 AnGap-10
[**2137-10-10**] 08:13AM BLOOD Glucose-122* UreaN-12 Creat-0.5 Na-133
K-3.2* Cl-100 HCO3-27 AnGap-9
[**2137-10-13**] 06:40AM BLOOD Glucose-683* UreaN-11 Creat-0.6 Na-112*
K-3.4 Cl-87* HCO3-22 AnGap-6*
[**2137-10-17**] 12:50AM BLOOD Na-131* K-3.6 Cl-98
[**2137-10-21**] 08:30AM BLOOD Glucose-105 UreaN-14 Creat-0.6 Na-134
K-3.5 Cl-97 HCO3-31 AnGap-10
[**2137-9-19**] 12:32AM BLOOD ALT-58* AST-32 AlkPhos-121* Amylase-66
TotBili-0.9
[**2137-9-19**] 06:05AM BLOOD ALT-53* AST-30 AlkPhos-116 Amylase-62
TotBili-0.9
[**2137-9-29**] 04:58AM BLOOD Amylase-35
[**2137-10-13**] 06:40AM BLOOD ALT-18 AST-22 LD(LDH)-185 AlkPhos-174*
Amylase-81 TotBili-0.4
[**2137-10-14**] 08:40AM BLOOD ALT-20 AST-22 AlkPhos-188* Amylase-76
TotBili-0.5
[**2137-10-17**] 05:47AM BLOOD AST-33
[**2137-10-21**] 08:30AM BLOOD ALT-28 AST-35 LD(LDH)-167 AlkPhos-286*
Amylase-44 TotBili-0.4
[**2137-9-19**] 12:32AM BLOOD Calcium-8.8 Phos-2.3* Mg-1.5*
[**2137-9-29**] 04:58AM BLOOD Calcium-7.5* Phos-2.3*
[**2137-10-1**] 05:14PM BLOOD Calcium-6.7* Phos-2.7 Mg-1.8
[**2137-10-5**] 06:00AM BLOOD Calcium-7.6* Phos-3.1 Mg-1.9
[**2137-10-11**] 12:35PM BLOOD Calcium-7.5* Phos-2.2* Mg-1.8
[**2137-10-21**] 08:30AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.7
[**2137-9-23**] 09:12AM BLOOD Type-ART pO2-60* pCO2-36 pH-7.49*
calHCO3-28 Base XS-4
[**2137-10-1**] 01:33AM BLOOD Type-ART pO2-91 pCO2-35 pH-7.44
calHCO3-25 Base XS-0
[**2137-10-3**] 05:19AM BLOOD Type-ART Temp-38.2 pO2-66* pCO2-37
pH-7.47* calHCO3-28 Base XS-3 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
Brief Hospital Course:
The patient is a 78 year old female who was admitted to the care
of Dr. [**Last Name (STitle) 468**] after she had an ERPC with sphincterotomy that
resulted in a perforated duodenum. A CT scan from the date of
her admission showed bilateral pleural effusions and
retroperitoneal free air. The patient was treated
conservatively at first, with serial examinations, pain
medications, and intravenous fliuds, as well as Levofloxacin and
Flagyl intravenously and a nasogastric tube for decompression.
On hospital day five, the patient was doing well clinically and
her NG tube was discontinued and her diet was advanced slowly.
A repeat CT scan from [**9-23**] demonstrated new large bilateral
pleural effusions, small non-specific pulmonary nodules in the
right middle lobe, and persistent retroperitoneal free air,
consistent with known duodenal perforation, as well as interval
development of large amount of retroperitoneal fluid, as well as
fluid in the root of the mesentery. A repeat CT scan on [**9-26**]
demonstrated a large, mainly fluid-attenuating collection in the
right retroperitoneum extending from the lateral paraduodenal
and hepatorenal fossa to the anterior right pelvis. In addition,
there were multiple air locules in the paraduodenal component in
keeping with recent local perforation. These collections have
not shown interval size change. Also, there were moderate right
basal pleural effusion that had shown some interval reduction in
size. Also, there was a possible 3 mm nonobstructing gallstone
in the distal end of the CBD with no intrahepatic biliary
dilatation. On [**9-30**], the patient underwent an exploratory
laparotomy with retroperitoneal exploration and debridement,
exploration of lesser sac, drainage of lesser sac and
retroperitoneum, gastrostomy tube placement, jejunostomy tube
placement, and colotomy with primary repair for aspiration of
colon. This was done for retroperiotnela sepsis. The patient
then spent four days in the surgical intensive care unit. She
was started on tube feeds and total perenteral nutrition during
that time period. Cultures from her abscess grew out
enterococcus, coagulase negative Staphylococcus, and [**Female First Name (un) 564**]
Albicans. She was started Vancomycin and Fluconazole in
addition to her previous antibiotic regime. The patient
continued to spike fevers however. A CT scan from [**10-7**]
deonstrated marked interval reduction in the size of the right
posterior abdominal/right retroperitoneal collections, small
residual collections along the right posterior
abdomen/retroperitoneum and in the small bowel mesentry to the
left of midline, moderate right basilar smaller left basilar
pleural effusion with posterior bibasilar atelectasis, more
marked on the right side,unchanged in the interval. A CT from
[**10-14**] demonstrated interval regression in the size of the right
pararenal and retroperitoneal fluid-attenuating collections. In
addition, there was moderate right basal pleural effusion has
shown some interval reduction in size. Posterior bibasilar
atelectasis and a small effusion at the left base were
unchanged. The remainder of her hospital course was uneventful
except for continuous spiking of fevers of unknown origin.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO DAILY (Daily).
6. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for Hyponatremia.
7. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
8. Loperamide 1 mg/5 mL Liquid Sig: One (1) PO BID (2 times a
day).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
11. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
12. Prochlorperazine 10 mg IV Q6H:PRN nausea
13. Fluconazole 200 mg IV Q24H
14. 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
15. Morphine Sulfate 2 mg IV Q2H:PRN
16. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
17. Vancomycin HCl 1000 mg IV Q 12H Start: [**2137-10-2**]
18. Pantoprazole 40 mg IV Q24H
19. Piperacillin-Tazobactam Na 4.5 gm IV Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
duodenal perforation, biliary colic, choledocholithiasis
Discharge Condition:
good, but spiking fevers of unclear origin despite thouough
work-up
Discharge Instructions:
-Please follow up with Dr [**Last Name (STitle) **] in two weeks
-Swallow evaluation before seeing Dr [**Last Name (STitle) **]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2137-11-19**] 10:30
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks
Completed by:[**2137-10-21**]
ICD9 Codes: 5119, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7254
} | Medical Text: Admission Date: [**2197-1-26**] Discharge Date: [**2197-2-3**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
female with C4 to C5 plate displacement. She is status post
C4-C5 vertebrectomy with harmed cage and symphysis plate from
[**2196-12-26**]. She is readmitted now for repositioning
of the plate which has slipped and a posterior fusion.
PAST MEDICAL HISTORY: She has a past medical history of
cervical stenosis, lumbar stenosis, rheumatic fever, heart
murmur, pulmonary edema, hypertension, status post
appendectomy, status post carotid endarterectomy on the
right, carpal tunnel release, osteoarthritis and gout.
ALLERGIES: She has an allergy to shellfish and tuna fish.
PHYSICAL EXAMINATION: On physical examination her blood
pressure was 142/60. Temperature was 97.7. Heartrate was
75. Saturations were 96% on room air. She is a pleasant
woman in no acute distress. Head, eyes, ears, nose and
throat reveal pupils are equal and reactive. She has a
well-healed neck incision. She has no lymphadenopathy.
Chest is clear to auscultation bilaterally. Cardiac, S1 and
S2 with no murmur, rub or gallop. Abdomen is distended with
positive bowel sounds. Extremities, no cyanosis, clubbing or
edema. Neurologically she is awake and alert. Cranial
nerves II through XII are intact. Motor strength is [**6-4**] in
all muscle groups with the exception of the right deltoid
which was 4-/5. Reflexes are 2 to 3+ in the lower
extremities. She has positive sustained clonus in bilateral
ankles and sensation is intact to light touch.
HOSPITAL COURSE: She is admitted for preoperative
displacement of cervical disc. On [**2197-1-27**]. The
patient underwent C6 corpectomy, C2 to C3 anterior cervical
diskectomy, harmed cage fusion C3 to C7, plate for C2 to C7
and IMPG placement with no intraoperative complications.
Postoperatively she was monitored in the Surgical Intensive
Care Unit. Her vital signs remained stable. She was awake,
alert, and moving all extremities with good strength, biceps
[**4-4**], triceps [**3-7**], finger extension was [**4-4**] and wrist
extension [**4-4**] bilaterally, immediately postoperatively.
Lower extremity strength was 4+ to [**6-4**]. The patient was
extubated on [**2197-1-29**] with transfer to the regular
floor where she has remained neurologically stable. She did
have an episode of congestive heart failure on [**2197-2-1**] and was given Lasix times two. Chest x-ray confirmed
left lateral to posterior basal atelectasis on the right side
and minimal atelectasis on the left side and no other
significant pulmonary cardiopulmonary abnormalities were
detected although the patient did respond well to diuretics
and currently is breathing at a rate of 20 with saturations
of 96 to 98% on room air. The patient also had video swallow
study which confirms a small amount of aspiration with thin
liquids. The patient is allowed a soft moist, pureed diet
and thickened liquids to nectar consistent with crushed
pills. She has been out of bed ambulating to the chair and
is being followed by physical therapy and occupational
therapy. She has also had difficulty with voiding. She has
a Foley catheter in place that should stay in for one to two
weeks and follow up with Urology for a voiding trial at that
time.
MEDICATIONS ON DISCHARGE:
1. Allopurinol 300 mg p.o. q. day
2. Atenolol 75 mg p.o. q. day
3. Lasix 40 mg p.o. q. day
4. Norvasc 2.5 mg p.o. q. day
5. Isordil 20 mg p.o. b.i.d.
6. Zantac 150 mg p.o. b.i.d.
7. Lopressor 25 mg p.o. b.i.d.
8. Percocet 1 to 2 tablets p.o. q. 3 hours prn for pain
9. Dulcolax one p.r. q. day prn
10. Captopril 50 cc p.o. t.i.d.
11. Colace 100 mg p.o. b.i.d.
12. Senokot one tablet p.o. q.h.s.
CONDITION AT DISCHARGE: Stable.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 1327**] in one
week's time for staple removal in his office.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2197-2-3**] 22:26
T: [**2197-2-4**] 07:55
JOB#: [**Job Number 36204**]
ICD9 Codes: 4280, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7255
} | Medical Text: Admission Date: [**2137-1-11**] Discharge Date: [**2137-1-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
This is an 85 yo male with h/o AVR (mechanical valve), Afib, AAA
5.9 cm not surgical candidate, admitted to [**Hospital1 1474**] for painless
jaundice. He had an ERCP with was unsuccessful at OSH,
therefore he was sent here for repeat ERCP and evaluation. He
had a stent removed, biopsies of a suspicious lesion, and new
stent placed. During the procedure, he became intermittently
hypotensive, with SBP in the 80s, requiring fluid boluses and
800 mcg of phenylephrine. He received Versed 2 mg, Propofol 100
mg, and fentanyl 75 mcg during the procedure. He received 800
mL of LR during the procedure. Post ERCP, he was in the
holding area, noted to be hypotensive to low 90s, and with a
concerning "wide complex rhythm". [**Hospital Unit Name 153**] was called to evaluate
and monitor the patient prior to transfer back to [**Hospital1 1474**]. At
the time of evaluation, the patient only complained of some
abdominal soreness, denied chest pain, SOB, lightheadedness, or
dizziness. SBP had already improved to 112/68. His rhythm was
V-paced. Cardiology was also at bedside to evaluate.
.
ROS: The patient denies any fevers, chills, weight change,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, cough, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, or rash.
Past Medical History:
1) Asthma
2) Mechanical AVR on coumadin- currently held and on lovenox
3) Atrial Fibrillation s/p PPM
4) AAA 5.9 cm not surgical candidate
5) Anemia
6) Hyperlipidemia
7) Depression
8) ? seizure d/o
Social History:
lives at home with a roommate. denies ETOH or smoking.
Family History:
NC
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
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:
[**2137-1-11**] 03:20PM GLUCOSE-126* UREA N-14 CREAT-0.7 SODIUM-140
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14
[**2137-1-11**] 03:20PM ALT(SGPT)-102* AST(SGOT)-175* LD(LDH)-212
CK(CPK)-17* ALK PHOS-451* AMYLASE-49 TOT BILI-13.6*
[**2137-1-11**] 03:20PM LIPASE-28
[**2137-1-11**] 03:20PM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-3.0
MAGNESIUM-2.4 CHOLEST-227*
[**2137-1-11**] 03:20PM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-3.0
MAGNESIUM-2.4 CHOLEST-227*
[**2137-1-11**] 03:20PM TRIGLYCER-156* HDL CHOL-13 CHOL/HDL-17.5
LDL(CALC)-183*
[**2137-1-11**] 03:20PM WBC-5.4 RBC-2.72* HGB-9.9* HCT-29.3* MCV-108*
MCH-36.4* MCHC-33.7 RDW-16.6*
[**2137-1-11**] 03:20PM NEUTS-69 BANDS-1 LYMPHS-15* MONOS-9 EOS-2
BASOS-2 ATYPS-0 METAS-0 MYELOS-2*
[**2137-1-11**] 03:20PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-OCCASIONAL
ERCP [**2137-1-11**]:
Impression: A plastic stent placed in the biliary duct was found
in the major papilla. The stent was removed with a snare and
sent for cytology.
Evidence of a previous sphincterotomy was noted in the major
papilla.
Cannulation of the biliary duct was successful contrast medium
was injected resulting in complete opacification.
A single smooth stricture that was 35mm long was seen at the mid
CBD extending to the hilum. There was moderate post-obstructive
dilation.
A 10FR by 250cm SPYGLASS Choledochoscope was introduced into the
bile duct with success. The mucosa appeared irregular and
friable, suspicious for a malignant process. Three cold forceps
biopsy were taken from the stricture through the SPYGLASS
choledochoscope for histology.
A 10cm by 10FRmm Cotton [**Doctor Last Name **] biliary stent was placed
successfully using a 10FR stent introducer kit. Excellent bile
drainage was achieved
Otherwise normal ercp to second part of the duodenum
PLAN: Return to outside hospital under Dr. [**Last Name (STitle) 35828**] [**Name (STitle) **] care
Follow for response/complications
Please call if develops jaundice, black stools, fever, or
abdominal pain
juices today when awake, alert, and at baseline
Follow-up cytology results
Follow-up biopsy results
If malignancy confirmed will arrange ERCP and metal stent
insertion with Dr [**Last Name (STitle) **]
ECG [**2137-1-11**]: Multiple ECGs available for evaluation and telemtry
strip. Baseline underlying rhythm Atrial fibrillation. Some
ECG are V-paced. Difficult to determine whether there are any
ischemic changes on v-paced beats, but no obvious ST segment
changes. rate in 90s-100. Tele strip shows afib, then
subsequent likely V-paced rhythm.
Brief Hospital Course:
Assessment: This is a 85 year-old male with a history of
mechanical AVR, atrial fibrillation, AAA, who is transferred to
the [**Hospital Unit Name 153**] s/p ERCP c/b hypotension and concern for "wide complex"
rhythm.
# Hypotension: Patient's hypotension was thought to be
secondary to sedation and possibly volume depletion. He
underwent a rule-out for myocardial infarction that was
negative. He was given a 500cc normal saline bolus and his
blood pressure remained stable during his hospital stay. He did
not require vasopressors.
# Hypoxia: Patient had an oxygen requirement of 4L that was
thought to be secondary to pulmonary edema. He will likely need
gentle diuresis upon arrival at [**Hospital1 1474**] to help reduce his
oxygen requirement. Subjectively, he was not complaining of
shortness of breath.
# Ventricular-paced rhythm/AFIB: Patient has a history of afib
with V-paced rhythm. He did not complain of chest pain and also
ruled out for myocardial infarction. He was restarted on
lovenox after his ERCP on [**1-11**] at [**Hospital1 18**].
# Painless Jaundice: Patient underwent a repeat ERCP on the
evening of [**2137-1-11**] at [**Hospital1 18**]. A plastic stent placed in the
biliary duct was found in the major papilla. The stent was
removed with a snare and sent for cytology. Evidence of a
previous sphincterotomy was noted in the major papilla.
Cannulation of the biliary duct was successful. A single smooth
stricture that was 35mm long was seen at the mid CBD extending
to the hilum. There was moderate post-obstructive dilation. A
10FR by 250cm SPYGLASS Choledochoscope was introduced into the
bile duct with success.
The mucosa appeared irregular and friable, suspicious for a
malignant process.
Three cold forceps biopsy were taken from the stricture through
the SPYGLASS choledochoscope for histology. A 10cm by 10FRmm
Cotton [**Doctor Last Name **] biliary stent was placed successfully using a 10FR
stent introducer kit. Excellent bile drainage was achieved.
Otherwise normal ercp to second part of the duodenum. He should
return to [**Hospital1 1474**] under Dr. [**Last Name (STitle) 35828**] [**Name (STitle) **] care and his cytology
results should be followed-up.
# Mechanical AVR: Patient was restarted on lovenox after
discussion with the ERCP fellow.
# C. diff: Patient had diarrhea and his stool was positive for
c. diff. He was started on po flagyl.
Medications on Admission:
Albuterol 90 mcg 2 puffs IH q4H PRN
Enoxaparin 80 mcg [**Hospital1 **]
Finasteride 5 mg daily
Folic Acid 1 mg daily
Pantoprazole 40 mg daily
Phenytoin 200 mg QAM and 300 mg QHS
Simvastatin 80 mg QHS
Terazosin 5 mg daily
Discharge Medications:
1. Influen Tr-Split [**2135**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ASDIR (AS DIRECTED).
2. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
ASDIR ML Injection ASDIR (AS DIRECTED).
3. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) MG
Subcutaneous Q12H (every 12 hours).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO QAM (once a day (in the morning)).
9. Phenytoin 50 mg Tablet, Chewable Sig: Six (6) Tablet,
Chewable PO QHS (once a day (at bedtime)).
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
C. diff colitis
Hypotension
.
Secondary:
Abdominal aortic aneurysm
Aortic valve repair
Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of low blood pressure. Your blood
pressure has remained stable while you were an inpatient here.
We also performed an ERCP and we replaced the stent that was
placed in your bile duct at [**Hospital1 1474**]. We also took a biopsy of
some of the tissue. While you were here, we also diagnosed you
with C. diff, an infection of the bowel. To treat you for this,
we gave you antibiotics.
Followup Instructions:
Per primary team at [**Hospital 1474**] Hospital
Completed by:[**2137-1-13**]
ICD9 Codes: 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7256
} | Medical Text: Admission Date: [**2134-1-26**] Discharge Date: [**2134-2-8**]
Date of Birth: [**2063-11-12**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: This is a 70 year old male with upper
gastrointestinal bleed and alcohol withdrawal, transferred to
[**Hospital1 69**] at the request of family
and intubated on transfer for airway protection.
HISTORY OF PRESENT ILLNESS: The patient presented to [**Hospital3 **] Medical Center by the family with concern for three
to four days of multiple falls due to worsening balance, gait
abnormality, intermittent slurred speech and word finding
difficulties and expressive aphasia. The patient stated he
"didn't feel right". The patient denied any head trauma,
loss of consciousness, dizziness. Cardiac and neurologic
review of systems are negative, although the family noted a
recent change in his personality and increased alcohol
consumption. In addition, the patient noted black stool
times one week, cough productive of yellow sputum times three
days. The patient's vital signs were normal in the Emergency
Department. His laboratories were notable for a hematocrit
of 26.0, potassium 5.6, blood urea nitrogen 61, creatinine
1.5. Chest x-ray showed a 7.0 centimeter lesion in the
posterior right upper lobe, thought to be a rounded mass
versus collapsed lung distal to an endobronchial lesion.
Head CT showed multiple small calcified ring enhancing
lesions, with the differential diagnoses of metastases,
syssarcosis or abscesses.
For the patient's lung and brain masses, the patient was
started on intravenous Dilantin on the advice of neurology,
and a chest CT was ordered.
With regards to his upper gastrointestinal bleed, his
hematocrit dropped from 26.0 to 22.0 in the first night with
occult blood positive stool. Gastric lavage was negative.
Upper endoscopy showed superficial linear erosions in the
lower third of the esophagus, mild nonerosive gastritis and
duodenitis with no erosions or bleeding. He continued to
have orthostatic hypotension. He received a total of three
units of packed red blood cells, and then was transferred to
the Intensive Care Unit. His hematocrit was stable since the
evening of [**2134-1-24**]. The plan was to repeat the colonoscopy
after his alcohol withdrawal had resolved.
For his alcohol withdrawal, he was started on Oxazepam
protocol and given multivitamin Thiamine and Folate. He
became agitated on [**2134-1-23**], requiring posy and restraints.
On [**2134-1-24**], he became hypertensive to 210/130, requiring
control with Nitroglycerin paste and Clonidine. He was
transferred to [**Hospital1 69**] at the
request of the family. In order to stabilize for transfer,
he required sedation with Propofol and consequent
endotracheal intubation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Peripheral vascular disease.
3. Nephrolithiasis.
4. Hiatal hernia.
5. Tobacco abuse.
6. Alcohol abuse.
7. High cholesterol.
8. Seasonal allergies.
9. Colonic tubular adenoma, status post colonoscopy in
[**2131-2-27**].
OUTPATIENT MEDICATIONS:
1. Lisinopril 40 mg p.o. once daily.
2. Simvastatin 40 mg p.o. once daily.
3. Fexofenadine.
4. Aspirin 325 mg p.o. once daily.
5. Potassium Chloride 20 meq p.o. once daily.
6. Multivitamin.
7. Folate.
TRANSFER MEDICATIONS:
1. Protonix 40 mg intravenous twice a day.
2. Gatifloxacin 40 mg intravenous once daily.
3. Dilantin 100 mg intravenous three times a day.
4. Diltiazem 7.5 mg intravenous four times a day.
5. Diazepam 10 mg intravenous q2hours and 10 mg intravenous
q2hours p.r.n.
6. Clonidine 0.1 mg patch.
7. Propofol drip.
8. Nitroglycerin paste two inches.
9. Haldol 2 to 4 mg intravenous q2-3hours.
SOCIAL HISTORY: The patient is a retired rocket scientist,
currently a part-time teacher at [**University/College 5130**] [**Location (un) **]. On
admission to [**Hospital3 **] Medical Center, he admitted to
drinking twenty shots of vodka per day, Cage questionnaire
was positive. The patient has a significant smoking history
of three packs per day times twenty to forty years.
PHYSICAL EXAMINATION: Vital signs revealed temperature 98.8,
pulse 73, blood pressure 111/palpable. In general, the
patient is an intubated elderly male who occasionally
struggles against restraints. Possible mild palmar erythema
but no spider nevi or caput medusa. Head, eyes, ears, nose
and throat - pink conjunctiva, no icterus, pupils are equal,
round, and reactive to light and accommodation. The neck
revels seven centimeter jugular venous distention above the
right atrium. Cor - regular rate and rhythm with physiologic
splitting of S2. The lungs are clear to auscultation
bilaterally. The abdomen is positive bowel sounds, soft,
nondistended, no flank dullness or fluid wave. Liver
palpable two centimeters below the right costal margin.
Extremities - good peripheral pulses, no cyanosis, clubbing
or edema.
LABORATORY DATA: White blood cell count 7.6, hematocrit
32.1, platelets 259,000. Prothrombin time 13.8, INR 1.3,
partial thromboplastin time 30.1. Sedimentation rate 55.
Sodium 140, potassium 3.9, chloride 107, bicarbonate 22,
blood urea nitrogen 11, creatinine 0.8, glucose 114, ALT 10,
AST 18, alkaline phosphatase 78, total bilirubin 0.6, albumin
3.0, calcium 8.0, phosphorus 3.4, magnesium 1.8.
CT of the brain with and without contrast revealed hyperdense
edema in both temporal lobes. Hyperdensity in superior left
parietal lobe. Small areas of calcification in the right
temporal lobe and bilateral frontal and parietal lobes.
HOSPITAL COURSE: In short, this is a 70 year old male with
new brain lesions, apparent lung mass with endobronchial
obstruction, ETOH withdrawal requiring deep Propofol sedation
and endotracheal intubation for interhospital transfer.
1. Oncology - As already noted, the patient was noted to
have right upper lobe endobronchial mass on chest x-ray
concerning for carcinoma, especially given the findings of
what appeared to be multiple brain metastases no head CT. CT
of the chest, abdomen and pelvis revealed a large right upper
lobe mass, two liver lesions in the right lobe, pancreatic
mass in the body of the pancreas, read as principal lung
neoplasm, with metastatic foci. Head CT from [**2134-1-26**],
showed metastatic lesions in the frontal, parietal and
temporal lobes, with moderate edema, minimal mass effect and
some calcification. The patient received bronchoscopy. The
pathology on the bronchoscopy was consistent with nonsmall
cell lung cancer. Given these imaging findings and the
patient's changed mental status, he was given a very poor
prognosis with his Stage IV nonsmall cell lung cancer. The
patient was seen by oncology. He was also seen by radiation
oncology. There was general agreement that head radiation
therapy would be the initial starting point for palliative
treatment. However, because the family was able to
communicate with the patient and actually saw some
improvement in his mental status over the past several weeks,
especially since extubation, they decided to hold off on head
radiation therapy, understanding that radiation therapy while
it could provide further improvement in his mental status, it
could also have negative effect too. Instead, the patient
was kept on Dexamethasone which was eventually tapered down
to 4 mg four times a day.
2. Mental status changes - Once the patient was extubated, he
initially was still quite somnolent, giving only one word
answers. Over the period of about one week, however, the
patient became much more alert. He was always oriented to
person, some times to place, but this was variable. He was
never oriented to time and his attention was severely
impaired. The patient's mental status changes most probably
can be attributed to his multiple brain metastases, however,
it is odd that the patient did not show any focal signs even
with a greatly limited neurologic examination. Other sources
of mental status change included high Ativan load with poor
clearing, effect of Dilantin, Wernicke's syndrome. There is
also concern for carcinomatosis meningitis, however, given
that the patient was improving, this was not worked up. The
patient's Dilantin was stopped, but his steroids were
continued. Head magnetic resonance scan on [**2134-1-31**], showed
multiple foci of enhancement, edema in both cerebral
hemispheres, posterior fossa consistent with metastatic
disease, no hydrocephalus, mass shift, hemorrhage or left
meningeal enhancement that might suggest meningitis. Once
again, the family held off on head radiation therapy given
the patient's improving mental status. They were willing to
give it a try, however, should his mental status deteriorate.
3. Alcohol withdrawal - The patient did not show any sign of
withdrawal once he was extubated. He was kept on Clonidine
at 0.5 mg p.o. twice a day.
4. Gastrointestinal bleed - The patient's hematocrit was
noted to decrease from 30.7 to 27.5 on [**2134-1-31**]. However,
the patient did not overtly pass any blood, and his
hematocrit remained stable.
5. FEN - Initially once he was extubated, the patient had a
nasogastric tube. He received swallowing evaluation with
nasogastric tube in place and was noted to be a silent
aspirator. However, once the nasogastric was removed, repeat
video swallowing study revealed that he, in fact, was not
aspirating. The patient was kept on aspiration precautions
given his waxing and [**Doctor Last Name 688**] mental status. He was kept on
pureed solids and thin liquids with one to one supervision.
6. Psychiatric - The patient was noted to have reversed
sleep/wake cycles. He was asleep most of the day but was up
a lot of the night trying to get out of bed. For this
reason, he required a sitter which further complicated his
disposition planning. The patient was written for low dose
Ambien at night as needed to help him sleep.
CONDITION ON DISCHARGE: Fair.
MEDICATIONS ON DISCHARGE:
1. Regular insulin sliding scale.
2. Protonix 40 mg p.o. once daily.
3. Folate 1 mg p.o. once daily.
4. Thiamine 100 mg p.o. once daily.
5. Multivitamin one tablet p.o. once daily.
6. Lisinopril 40 mg p.o. once daily.
7. Clonidine 0.5 mg p.o. twice a day.
8. Dexamethasone 4 mg p.o. four times a day.
9. Lopressor 25 mg p.o. twice a day.
10. Ambien 5 mg p.o. q.h.s. p.r.n. insomnia.
DISCHARGE INSTRUCTIONS: At this point in time, it is unclear
which facility the patient will be going to. The family does
not feel that they can handle the patient on their own. The
patient will likely go to Hospice care.
DISCHARGE DIAGNOSES:
1. Metastatic nonsmall cell lung cancer.
2. Mental status changes, likely secondary to brain
metastases.
3. Alcohol withdrawal.
4. Gastrointestinal bleed.
5. Hypertension.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2134-2-6**] 23:10
T: [**2134-2-7**] 09:41
JOB#: [**Job Number **]
ICD9 Codes: 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7257
} | Medical Text: Admission Date: [**2204-6-26**] Discharge Date: [**2204-7-4**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Doctor First Name 7926**]
Chief Complaint:
Hypotension, tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a [**Age over 90 **] yo Russian speaking M with hx of TIA, A fib,
HTN, HL, Ao stenosis (valve area 1.2cm) who presents from [**Hospital **]
rehab with SOB and hypotension in the setting of rapid A fib.
Per records, patient c/o chest pain at 7pm at [**Hospital 100**] Rehab and
nitropatch was put on temporarily. One hour later, metoprolol
25mg given and at 9pm, HR found to be in 120s and irregular. At
11pm, HR persistently in 120s and BP at 94/59. Was then sent to
the ED for evaluation.
In the ED, initial VS were: 98.4 84 95/63 14 98%. The patient
was mentating well, no real complaints. Labs were notable for
Na 130 (chronically low, last 120 at discharge), Hct 34.7 (at
baseline), trop 0.03. CXR was notable for
Gave 2L IVF.
On arrival to the MICU,
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:
1. Hypertension
2. ?CAD, negative MIBI [**8-25**], EF>55% 8/09
3. History of anemia
4. Zoster and postherpetic neuralgia ([**2197**]) - seen by [**Hospital **] clinic
5. History of peptic ulcer disease, H. pylori + - unsure if he
has been treated in past; reports being following by Dr. [**First Name (STitle) 452**] in
[**Hospital **] clinic
6. Aortic stenosis (area 1.2cm [**7-26**] echo)
7. s/p TURP
8. Chronic bilateral rotator cuff tears
9. Chronic bronchitis
10. Hyponatremia attributed to SIADH (BL Na 125-131)
11. Chronic bilateral rotator cuff tears with a secondary
degenerative joint disease, especially in his left shoulder
12. s/p septic joint [**2201**]
Social History:
A retired engineer and does not recall any exposures to
chemicals, dust, or fumes. Currently lives alone. He quit
smoking in [**2151**].
Family History:
Parents were killed by the Nazis. His grandparents died of
strokes. His GF had complicated foot ulcer.
Physical Exam:
On admission:
Vitals: T: 100.8 (Rectal) BP: 110/77 P: 124 R: 21 O2: 97%RA
General: Alert, speaking in Russian
[**Year (4 digits) 4459**]: MMM
Neck: supple, JVP not elevated, no LAD
CV: irregular rhythm, regular rate, 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, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
On discharge:
Vitals: T: 97.8 BP 117-135/65-83 HR 90-100s (on tele) R: 22 O2:
95%RA
I/Os: [**Telephone/Fax (1) 68768**], weight 60.1kg (59.9kg yesterday)
General: Alert, hard of hearing and blind, able to understand
and speak some English
[**Telephone/Fax (1) 4459**]: MMM
Neck: supple, JVP 1/3 of the way up the neck
CV: irregular rhythm, regular rate, harsh 2/6 systolic murmur at
right upper sternal border
Lungs: Expiratory wheezing and coarse breath sounds b/l in all
lung fields, no rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, trace pitting edema to
calves bilaterally
Skin: raised, dark, round marking on left lower leg
Neuro: grossly intact
Pertinent Results:
[**2204-7-3**] 07:03AM [**Month/Day/Year 3143**] WBC-9.5 RBC-3.45* Hgb-10.3* Hct-30.5*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.2 Plt Ct-243
[**2204-7-2**] 04:50AM [**Month/Day/Year 3143**] WBC-11.6* RBC-3.68* Hgb-10.5* Hct-32.6*
MCV-89 MCH-28.6 MCHC-32.3 RDW-13.7 Plt Ct-276
[**2204-7-1**] 06:37AM [**Month/Day/Year 3143**] WBC-10.0 RBC-3.43* Hgb-10.1* Hct-30.3*
MCV-88 MCH-29.5 MCHC-33.4 RDW-13.8 Plt Ct-252
[**2204-7-2**] 04:50AM [**Month/Day/Year 3143**] Neuts-55.4 Lymphs-34.8 Monos-7.1 Eos-2.5
Baso-0.3
[**2204-6-26**] 12:40AM [**Month/Day/Year 3143**] Neuts-56.1 Lymphs-34.9 Monos-5.4 Eos-3.0
Baso-0.7
[**2204-7-3**] 07:03AM [**Month/Day/Year 3143**] Plt Ct-243
[**2204-7-2**] 04:50AM [**Month/Day/Year 3143**] Plt Ct-276
[**2204-6-26**] 07:00AM [**Month/Day/Year 3143**] PT-10.2 PTT-27.3 INR(PT)-0.9
[**2204-7-3**] 07:03AM [**Month/Day/Year 3143**] Glucose-83 UreaN-22* Creat-0.7 Na-131*
K-4.5 Cl-97 HCO3-25 AnGap-14
[**2204-7-2**] 03:15PM [**Month/Day/Year 3143**] Glucose-81 UreaN-23* Creat-0.8 Na-132*
K-4.9 Cl-98 HCO3-28 AnGap-11
[**2204-7-2**] 04:50AM [**Month/Day/Year 3143**] Glucose-86 UreaN-26* Creat-0.8 Na-132*
K-5.4* Cl-97 HCO3-26 AnGap-14
[**2204-6-30**] 05:25AM [**Month/Day/Year 3143**] Glucose-80 UreaN-26* Creat-0.9 Na-130*
K-4.6 Cl-96 HCO3-24 AnGap-15
[**2204-6-26**] 07:00AM [**Month/Day/Year 3143**] ALT-16 AST-18 LD(LDH)-183 CK(CPK)-62
AlkPhos-78 TotBili-0.5
[**2204-6-26**] 07:00AM [**Month/Day/Year 3143**] CK-MB-4 cTropnT-0.03*
[**2204-6-26**] 12:40AM [**Month/Day/Year 3143**] cTropnT-0.03*
[**2204-7-3**] 07:03AM [**Month/Day/Year 3143**] Mg-2.1
[**2204-7-3**] 07:03AM [**Month/Day/Year 3143**] Digoxin-0.6*
[**2204-7-2**] 04:50AM [**Month/Day/Year 3143**] Digoxin-0.5*
[**2204-7-1**] 06:37AM [**Month/Day/Year 3143**] Digoxin-0.9
[**2204-6-29**] 06:24AM [**Month/Day/Year 3143**] Digoxin-1.6
Cardiology:
EKG: A fib with RVR, HR in 120s
Radiology:
CXR: heart size normal. tortuous aorta. engorged pulmonary
vessels with some interstitial edema
Brief Hospital Course:
[**Age over 90 **]M with history of severe aortic stenosis, chronic hyponatremia
[**1-19**] SIADH, came from [**Hospital 100**] rehab who presented with afib with
rvr, chest pain, and hypotension.
.
Acute Diagnoses:
.
#Afib with rvr: unclear whether this is new onset as
cardiologist does not recall formally diagnosing with atrial
fibrillation. Upon admission, EKG showed atrial fibrillation
with rvr, rate in 120s. [**Month (only) 116**] have been related to ischemia and/or
aortic stenosis; but cardiac workup was negative. Also
considered COPD and hypothyroidism as cause; TSH within normal
limits and CXR unremarkable. Last echo in [**2-/2203**] and EF>55% and
valve area 1.0-1.2cm2. CHADS2 score is 4; Dr. [**Last Name (STitle) 171**]
(cardiology) notified and recommended not anticoagulating, but
continuing aspirin, and doing a repeat TTE. TTE showed aortic
valve area to be unchanged at 1.2, preserved EF>55%. Pt rate
controlled with metoprolol 25mg TID on hospital day 1 which
brought down heart rate to high 90s. Cardiology recommended
digoxin 0.5mg PO for 2 days followed by digoxin level before
administering third dose. On hospital day 2, patient's SBP
80-90s and HR 110-120, still in Afib. Due to concern over the
thickness of pt's left ventricle, digoxin was held and rate
control was tried with Metoprolol only. Over the [**Hospital **] hospital
course, his heart rates could not be adequately controled with
Metoprolol alone. Therefore pt was restarted on digoxin .125mg
to help with rate control.
.
#Hypotension: Pt had nitropatch on day of admission after
complaing of chest pain. Nitropatch could have been part of the
the cause of hypotension, where duration of action is 10-12hrs
for transdermal route. Patient's BP was persistently low on
first hospital day, SBP~90. Tachycardia resolved with
metoprolol, but unfortunately worsened the patient's hypotension
as low as to the high 70s SBP. Patient placed on digoxin on
[**2204-6-27**] for two day course.
.
Chronic Diagnoses:
#Chronic hyponatremia: Has a sodium baseline 125-131 due to
SIADH. Sodium was 130 on admission and remained stable.
.
#Chronic bronchitis: No shortness of breath or worsening cough
during hospital course, remained on home regimen of albuterol
and Advair diskus.
.
#Back pain from spinal stenosis: Pt remained on home regimen of
lidocaine patch and gabapentin 300mg PO daily. Has [**7-5**] appt
with pain clinic at [**Hospital **] hospital.
.
#HTN: At the [**Hospital 100**] Rehab facility, was on valsartan and
metoprolol. Valsartan was held during hospital course as BP
remained low, SBP in 80s- low 100s.
.
Transitional issues:
-Has [**7-5**] appt with pain clinic at [**Hospital1 18**].
-Pt is to have Digoxin level rechecked by Dr.[**Name (NI) 5103**] office,
his outpatient cardiologist at his appointment on FRIDAY [**7-6**],[**2203**] at 9:00 AM.
Medications on Admission:
Tylenol 650mg q6h
Albuterol inhaler 90mcg/act hventolin inhaler, 2puff twice a day
Aspirin EC 81mg once daily
Bisacodyl 20mg once daily PO
Chlorhexidine mouthwash 15ml twice a day swish and spit
Codeine sulf 20mg q6h
Docusate sodium 100mg twice a day
Fluticasone propionate 1 spray every 12hrs both nostrils
Fluticasone/Salmeterol (Advair 100/50) 1 puff every 12 h
Gabapentin 300mg once daily
Lactulose syrup 10gm once daily
Lidocaine patch 5% 1 daily
Menthol/Camphor 1 apply twice a day
Metoprolol tartrate 25mg twice a day
Mupirocin 2% apply twice a day
Pravastatin 40mg every evening
Ranitidine 300mg twice a day
Senna 17.2mg twice a day
Valsartan 40mg twice a day
Vit A/Vit C/Vit E/Zinc/Copper
PRNs: meclizine
Discharge Medications:
1. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO BID:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
7. Gabapentin 300 mg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD DAILY
9. Meclizine 25 mg PO Q12H:PRN nausea
10. Senna 1 TAB PO BID
11. Simvastatin 20 mg PO QHS
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
13. Digoxin 0.125 mg PO DAILY
14. Albuterol Inhaler 2 PUFF IH [**Hospital1 **]
15. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
16. Metoprolol Tartrate 50 mg PO TID
Hold for HR<60 or SBP < 95
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
Primary:
-Atrial Fibrillation with Rapid Ventricular Response
-Hypotension
-Chest Pain
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 68759**],
It was our pleasure taking care of you at the [**Hospital1 18**].
You were admitted to the [**Hospital1 69**]
from [**Hospital 100**] Rehab facility for low [**Hospital **] pressure after having
chest pain. Your pulse was also found to be very high, and
irregular- something we call atrial fibrillation. Your heart
rate was controlled with medication and your condition improved.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2204-7-6**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2859, 4019, 4241, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7258
} | Medical Text: Admission Date: [**2112-11-23**] Discharge Date: [**2112-12-4**]
Date of Birth: [**2063-7-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Demerol
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
altered mental status; respiratory symptoms
Major Surgical or Invasive Procedure:
Mechanical Ventilation
Arterial Line
Central Venous Line
History of Present Illness:
49F with HCV/EtOH cirrhosis on transplant list initially
presented to OSH after a fall and L hip pain. As per report,
the L hip film was negative. Patient was transferred after she
was noticed to have tachypnea, elevated white count, and change
in mental status, that and the fact that she is followed by Dr.
[**Last Name (STitle) 497**]. As per OSH notes, she was alert and cooperative on
morning of transfer. While in our ED, she was anxious and given
Valium. She was also given CTX/Vancomycin/Zosyn in our ED and
given 400 cc NS prior to transfer to the floor.
Patient is not orientated and is unable to provide a history
Past Medical History:
# HCV and EtOH cirrhosis - diagnosed in the fall of [**2111**] after
an acute episode liver decompensation (ascites, lower extremity
edema, low albumin, and increased INR).
# hypertension,
# migraines
# history of a dissecting pseudoaneurysm in the internal carotid
artery, which was treated with Plavix for 6 months. Her most
recent MRI in [**2109**] was normal
Social History:
Lives with dog on [**Location (un) **]. Has not had a drink of etoh in
sevearal months. Has never smoked. Uses no illegal drugs. Has
a remote history of cocaine use. Employed as a waitress.
Family History:
Father died of heart disease. Pt denies any other illnesses in
her family.
Physical Exam:
Tcurrent: 36.4 ??????C (97.5 ??????F)
HR: 108 (108 - 109) bpm
BP: 126/46(62) {108/46(61) - 126/47(62)} mmHg
RR: 23 (23 - 28) insp/min
SpO2: 96%
Wgt (current): 73 kg (admission): 73 kg
Physical Examination
General Appearance: No(t) Diaphoretic, tachypneic
Eyes / Conjunctiva: Pupils dilated, anicteric sclera, bilateral
horizontal nystagmus
Head, Ears, Nose, Throat: dry MM
Cardiovascular: (S1: Normal), (S2: Normal), tachycardic
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : @ Right base)
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: Absent, Left: Absent
Skin: Warm
Neurologic: Responds to: Noxious stimuli, Oriented (to):
nothing,
Pertinent Results:
HEMATOLOGY
[**2112-11-23**] 01:42PM BLOOD WBC-24.7*# RBC-4.80# Hgb-13.1#
Hct-38.9#Plt Ct-107*
[**2112-12-3**] 08:06PM BLOOD WBC-29.9* Hct-21.0* Plt Ct-67
[**2112-11-23**] 01:42PM BLOOD Neuts-88* Bands-6* Lymphs-1* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2112-11-24**] 05:16AM BLOOD Neuts-95* Bands-0 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-2*
[**2112-11-26**] 03:33AM BLOOD Neuts-82* Bands-6* Lymphs-8* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* NRBC-1*
COAGULATION
[**2112-11-23**] 01:42PM BLOOD PT-26.4* PTT-60.3* INR(PT)-2.6*
[**2112-11-23**] 08:25PM BLOOD PT-29.4* PTT-57.8* INR(PT)-3.0*
[**2112-11-24**] 05:16AM BLOOD PT-37.8* PTT-66.1* INR(PT)-4.1*
[**2112-11-24**] 05:55PM BLOOD PT-20.7* PTT-43.2* INR(PT)-1.9*
[**2112-11-25**] 12:51PM BLOOD PT-35.5* PTT-47.6* INR(PT)-3.8*
[**2112-11-25**] 09:53PM BLOOD PT-44.4* PTT-61.7* INR(PT)-4.9*
[**2112-11-26**] 03:33AM BLOOD PT-51.5* PTT-66.4* INR(PT)-5.9*
[**2112-11-26**] 09:09AM BLOOD PT-49.5* PTT-65.5* INR(PT)-5.6*
[**2112-11-26**] 08:07PM BLOOD PT-26.9* PTT-47.9* INR(PT)-2.7*
[**2112-11-27**] 02:25PM BLOOD PT-24.7* PTT-43.3* INR(PT)-2.4*
[**2112-11-28**] 09:40PM BLOOD PT-54.9* PTT-74.7* INR(PT)-6.4*
[**2112-12-2**] 09:33PM BLOOD PT-37.8* PTT-115.8* INR(PT)-4.1*
[**2112-12-3**] 05:00AM BLOOD PT-84.8* PTT-150* INR(PT)-13.4*
[**2112-12-3**] 12:36PM BLOOD PT-43.5* PTT-128.5* INR(PT)-5.4*
[**2112-12-3**] 08:06PM BLOOD PT-36.0* PTT-79.8* INR(PT)-3.8*
[**2112-12-4**] 03:59AM BLOOD PT-71.8* PTT-142.4* INR(PT)-10.7*
FIBRINOGEN
[**2112-11-24**] 05:16AM BLOOD Fibrino-132*
[**2112-11-27**] 08:29PM BLOOD Fibrino-87*
[**2112-11-28**] 09:40PM BLOOD Fibrino-60*
[**2112-11-29**] 04:16AM BLOOD Fibrino-67*
[**2112-11-30**] 02:28AM BLOOD Fibrino-77*
[**2112-11-30**] 09:16AM BLOOD Fibrino-118*#
[**2112-11-30**] 04:04PM BLOOD Fibrino-85*
CHEMISTRY
[**2112-11-23**] Glucose-63* UreaN-39* Creat-2.2*# Na-126* K-2.8* Cl-93*
HCO3-13*
[**2112-11-23**] Glucose-60* UreaN-38* Creat-1.8* Na-129* K-3.1* Cl-97
HCO3-14*
[**2112-12-3**] Glucose-132* UreaN-7 Creat-1.3* Na-128* K-3.3 Cl-85*
HCO3-20*
[**2112-12-4**] Glucose-116* UreaN-7 Creat-0.6 Na-129* K-3.4 Cl-86*
HCO3-18*
LIVER
In summary, the patient had an increase in her LFTs throughout
the early admission peaking around [**11-26**], though she continued
to have synthetic dysfunction as noted by her indirect
bilirubinemia, coagulopathy, hypoglycemia.
[**2112-11-23**] 01:42PM ALT-17 AST-60* AlkPhos-254* TotBili-2.8*
[**2112-11-24**] 05:16AM ALT-15 AST-51* LD(LDH)-359* AlkPhos-187*
TotBili-3.2*
[**2112-11-25**] 03:26AM ALT-22 AST-100* AlkPhos-138* TotBili-4.7*
[**2112-11-26**] 03:33AM ALT-69* AST-553* LD(LDH)-1496* AlkPhos-139*
TotBili-7.2* DirBili-4.0* IndBili-3.2
[**2112-11-26**] 03:06PM ALT-257* AST-2637* LD(LDH)-3560* AlkPhos-156*
TotBili-8.4*
[**2112-11-27**] 05:08AM ALT-194* AST-1746* LD(LDH)-2469* AlkPhos-139*
TotBili-9.4*
[**2112-11-28**] 03:21AM ALT-139* AST-896* LD(LDH)-1152* AlkPhos-139*
TotBili-14.1*
[**2112-11-28**] 09:40PM ALT-90* AST-533* LD(LDH)-614* AlkPhos-131*
TotBili-16.8*
[**2112-11-29**] 04:16AM ALT-80* AST-442* LD(LDH)-559* AlkPhos-131*
TotBili-18.4* DirBili-7.8* IndBili-10.6
[**2112-12-3**] 03:57AM ALT-28 AST-112* AlkPhos-116 TotBili-32.0*
DirBili-16.0* IndBili-16.0
[**2112-12-4**] 03:59AM AlkPhos-113 TotBili-33.3*
[**2112-11-23**] 01:42PM Ammonia-64*
[**2112-11-28**] 03:56PM Cortsol-13.2
[**2112-11-23**] 09:29PM Type-ART pO2-89 pCO2-22* pH-7.42 calTCO2-15*
Base XS--7
[**2112-11-24**] 01:17AM Type-ART pO2-73* pCO2-23* pH-7.40 calTCO2-15*
Base XS--7
[**2112-11-23**] Radiology CT C-SPINE W/O CONTRAST
1. No fracture identified.
2. Straightening of the normal cervical lordosis could be due to
presence of cervical collar.
3. Multilevel degenerative changes. In the setting of trauma,
cannot exclude ligamentous injury and would recommend MRI to
exclude possible ligamentous injury if clinical concern
warrants.
4. Large right-sided layering pleural effusion.
[**2112-11-23**] Radiology CHEST (PORTABLE AP)
There is a right basal effusion with atelectasis in the right
lower lobe.
Left lung is clear. Cardiomediastinal silhouette is
unremarkable. Follow up is recommended to ensure clearance of
the effusion and re-expansion of the right lower lobe.
[**2112-11-23**] Radiology DUPLEX DOP ABD/PEL LIMI
1. No portal vein thrombosis.
2. Small ascites with no pocket large enough to mark for
paracentesis.
3. Large right pleural effusion.
4. Gallbladder distention without wall thickening,
pericholecystic fluid,
or cholelithiasis.
5. Cirrhotic liver with limited evaluation for focal lesion as
described.
[**2112-11-23**] Radiology CT HEAD W/O CONTRAST
1. No intracranial hemorrhage.
2. Air-fluid level within the right maxillary sinus and mucosal
thickening
of the ethmoid, sphenoid and frontal sinus. These changes likely
represent
sinus disease, however, in the setting of trauma, cannot exclude
an occult
fracture. If the mechanism of injury suggests fracture, would
recommend
dedicated sinus CT to further evaluate.
[**2112-12-1**] Radiology DUPLEX DOPP ABD/PEL POR
1. Patency and appropriate directional flow of the visualized
portal and
hepatic venous branches, with limitations described above.
2. Splenomegaly.
3. Ascites.
4. Sludge in the gallbladder.
Thoracentesis on [**11-25**] was transudative with negative culture
The patient had alpha strep in her urine on admission; all other
cultures from blood, mini-BAL, sputum did not grow.
Brief Hospital Course:
SEPSIS,
The patient was admitted with respiratory distress and preceding
symptoms of a respiratory tract infection. She was broadly
covered with vancomycin, azithromycin, and ceftriaxone/later
changed to Zosyn covering possible SBP. She intermittently
required support with vasoactive agents, building more of a
dependence as her course progressed. Her initial CT scan had
question of sinusitis, and chest film had pneumonia vs
atelectasis at her right lung base. Culture remained negative,
including mini-BAL performed by respiratory. She received
albumin ongoing to ?SBP as well as hepatorenal syndrome as
described below. With the progression of her liver failure her
body was unable to mount an adequate immunologic response
ARDS
She was intubated for respiratory distress and developed an ARDS
pattern on her chest films. She was ventilated using ARDSnet
protocols. Her PEEP was increased to improve oxygenation and an
esophageal balloon was inserted for better estimation of
transpleural pressures. She had constant modifications in her
PEEP and FiO2 although it was extremely difficult to oxygentate
and ventilate her as her body retained more fluid. It was also
thought that she may have contracted a ventilator associated
pneumonia and her antibiotic treatment was changed to cover
possible organisms.
MULTIORGAN FAILURE
LIVER FAILURE
The patient developed progressive and severe liver failure
losing synthetic function as manifested by hyperbilirubinemia,
coagulopathy requiring intermittent plasma transfusion and
cryoprecipitate transfusion, as well as profound hypoglycemia
due to impaired gluconeogenesis requiring boluses of dextrose
and and a continuous dextrose infusion. She was seen by the
Hepatology Service and was removed from the transplant list
given active infection. She was followed daily by the
Hepatology Service and she was treated with Midodrine,
Octreotide and Albumin for presumed Hepatorenal Syndrome,
although diagnostic studies were not entirely consistent with
this diagnosis.
ACUTE RENAL FAILURE
The patient had progressive renal failure becoming anuric on
hospital day 2 thought to be hepatorenal syndrome vs ATN. She
was started on continuous renal replacement therapy using CVVH.
Even in the setting of CVVH she was retaining large amounts of
fluid and her kidney function never recovered.
Medications on Admission:
Almotriptan Malate 12.5 mg qd
Fiorinal 50-325-40 mg Capsule Oral
Furosemide 60 mg PO DAILY
Lactulose
Paxil CR 37.5 daily
Rifaximin 600 daily
Maxalt Oral
Spironolactone 200 daily
Ferrous Sulfate 325 daily
1Pyridoxine 50 mg daily.
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Sepsis, septic shock
2. Acute Respiratory Distress Syndrome
3. Liver Failure
4. Acute Renal Failure, Hepatorenal Syndrome Type I
5. Hepatitis C Virus
6. Cirrhosis
7. Hypertension
Discharge Condition:
Expired
Completed by:[**2112-12-5**]
ICD9 Codes: 0389, 486, 2762, 5849, 5715, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7259
} | Medical Text: Admission Date: [**2169-9-26**] Discharge Date: [**2169-10-1**]
Service: NEUROSURGERY
Allergies:
Codeine / Oxycodone / Thioridazine / Tolmetin / Egg
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fall with SDH and traumatic SAH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **]yo W with a history of hypertension, hyperlipidemia,
ischemic stroke s/p TPA in [**2163**], dementia and lower extremity
edema who sustained in the early morning hours of [**2169-9-26**].
Per her daughter, she was in her
USOH last night and was doing well. Her daughter heard her
mother
fall down the stairs in the early morning hours, and found her
flat on her back. There was no eye fluttering activity, shaking
of her extremities or any other features to suggest seizure. EMS
was immediately called. On arrival, she was noted to have
problems with [**Name2 (NI) 56971**] and was given morphine and zofran for
symptomatic relief.
ROS: not obtained from patient, per daughter, no recent sick
symptoms, no recent fever or weight loss, no change in
medications, no anticoagulation
Past Medical History:
- Hypertension
- Dementia (unspecified)
- Hypercholesterolemia
- History of ischemic stroke [**2163**] s/p TPA, no residual deficits
- "Leg swelling", treated with lower extremity compression
stockings
- Urinary incontinence s/p sling procedure ([**2163**]).
Social History:
No alcohol, tobacco or drugs. Per daughter, she is "allergic to
cigarette smoke". Currently, the daughter reports that the
patient has "dementia". She does speak, but it is often
difficult to comprehend and nonsensical. She does
walk with a cane or walker, but sometimes she may walk by
herself. She does need help bathing. She does not manage her own
finances, etc.
Family History:
Family History: Mother died of cancer at 42, father with
dementia
Physical Exam:
On Admission:
Vitals: AF, 142/62, 97%, 12, 62
General: Elderly frail woman, eyes closed, opens eyes to calling
her name
HEENT: Tender region of swelling over the occipital scalp
without
open laceration or bleeding
Neck: C-spine stabilized with C-collar, difficult to examine. No
gross thyroid enlargement or adenopathy
Pulmonary: Lungs CTA anteriorly
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted, positive
bowel sounds
Extremities:warm and well perfused, 2+ nonpitting edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: GCS 14 (E4M4V6). Awake, but poorly
communicative.
Eyes are closed at baseline. Grimaces to pain and turning her
head. Only whispers few words if any, "I'm cold", "I'm feeling
better". Language, praxis, naming, memory is difficult to
assess.
Speech is minimal. Follows some commands intermittently.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. VFF not assessed.
III, IV and VI: EOM are intact and full, no nystagmus
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric. Grimace is
symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone. No tremor.
- Upper extremities are antigravity
- Lower extremities withdraw to babinski testing, poor effort
for
formal strength testing.
- Sensory: Grossly intact to light touch
-DTRs: Diffusely arefleix
-Plantar response: Toes are up bilaterally
-Coordination/Gait: not tested
Pertinent Results:
[**2169-9-26**] 08:03PM GLUCOSE-152* UREA N-21* CREAT-1.2* SODIUM-141
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14
[**2169-9-26**] 08:03PM CK(CPK)-108
[**2169-9-26**] 08:03PM CK-MB-2 cTropnT-<0.01
[**2169-9-26**] 08:03PM CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-2.0
[**2169-9-26**] 05:37AM PLT COUNT-278
[**2169-9-26**] 05:37AM PT-11.2 PTT-20.9* INR(PT)-0.9
[**2169-9-26**] 05:37AM WBC-13.9* RBC-4.20 HGB-13.2 HCT-39.8 MCV-95
MCH-31.4 MCHC-33.1 RDW-12.7
[**2169-9-26**] 05:37AM GLUCOSE-165* LACTATE-2.9* NA+-143 K+-3.9
CL--103 TCO2-25
[**2169-9-26**] 05:37AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2169-9-26**] 06:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2169-9-26**]: Chest Xray: There is bibasilar atelectasis with no
focal opacification concerning for pneumonia. There are no
pleural effusions or pneumothorax. The cardiomediastinal and
hilar contours are unremarkable demonstrating tortuosity of the
thoracic aorta with atherosclerotic calcification. Accounting
for technique, the heart is mildly enlarged. Pulmonary
vascularity is normal. The trauma board overlies the film and
obscures fine detail. There is a moderate hiatal hernia.
Incidentally noted is a bone island within the left scapula.
[**2169-9-26**]: CT head IMPRESSION:
1. Multicompartmental hemorrhage with a smaller area of
extraaxial hemorrhage demonstrated adjacent to the right
cerebellar hemisphere, immediately adjacent to a fracture,
left-sided frontal and temporal subarachnoid hemorrhage and
subdural hemorrhage layering along the tentorium and adjacent to
the cerebellar hemispheres.
2. Large mixed density cephalohematoma involving the posterior
occiput.
3. Minimally displaced fracture involving the left aspect of the
occipital
bone extending through the foramen magnum.
4. Minimally displaced fracture of the clivus as better depicted
on concurrent CT of the cervical spine.
[**2169-9-26**]: CT cervical spine: IMPRESSION:
1. Mildly displaced (C-spine 1 to 2 mm) complex occipital bone
fracture
extending along the right aspect of the occipital bone
inferiorly.
2. Minimally displaced fracture of the clivus.
3. No cervical spine fracture or malalignment.
4. Multilevel degenerative changes, most prominent at the level
of C5-C6
[**2169-9-26**] CT Chest/Abdomen/Pelvis IMPRESSION:
1. No evidence of traumatic injury within the chest, abdomen or
pelvis.
2. Right inguinal hernia containing nonobstructed small bowel.
3. Moderate-to-large hiatal hernia.
4. Non-specific periesophageal prominent lymph node with a
hiatal hernia and mild esophageal wall thickening. When
clinically appropriate, follow-up barium esophagram or endoscopy
is suggested, or alternatively CT follow-up could be considered
as a possible alterative in [**2-5**] months.
5. Incompletely characterized hyperenhancing 11mm liver lesion
in segment II for which MRI can be performed or alternatively
follow-up CT in [**2-5**] months as clinically indicated.
[**2169-9-26**] repeat CT head: There is no new intracranial
hemorrhage. There is no increased mass effect or evidence of
infarct. Right occipital fracture extending to the foramen
magnum with associated overlying soft tissue contusion is
redemonstrated.
[**2169-9-28**] LENI's: IMPRESSION: No evidence of deep vein thrombosis
in either leg.
Brief Hospital Course:
Mrs. [**Known lastname 83147**] was admitted to the ICU on the neurosurgery service
for Q1 hour neurochecks and SBP control less than 140. Repeat
Head CT demonstrated stable intracranial hemorrhages, no new
bleeding. CT torso was negative for trauma.
Neurologically the patient remained stable on [**9-27**]. She had an
episode of chest pain in the late morning. An EKG was performed
which was stable. The patient also required an increased O2
requirement at this time.
On [**9-28**] the patient was still requiring increased supplemental
O2. CE's were sent and negative. A CTA was requested to rule out
PE, but put on hold due to patient's renal status and inability
to receive anticoagulation. A D-dimer revealed was elevated
however given history of trauma no further interventin was
recommended per ICU. A family meeting was held on [**9-28**] to
discuss her current O2 requirements. Family confirmed DNR/DNI
but wanted to think about comfort measures.
On [**9-29**], family had another family meeting and it was decided
to make her comfort measures only. She remained in the ICU until
[**10-1**] AM when she was transferred to the floor. At 14:45 a
family friend (hospitalist at [**Hospital1 18**]) was visiting the patients
family when they noticed that she had stopped breathing. This
was confirmed with auscultation.
Report of Death Paperwork was completed.
Medications on Admission:
Atenolol
Lisionpril
Aggrenox
Simvastatin
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Right cerebellar contusion
Left Frontotemporal traumatic Subarachnoid and subdural
hemorrhages
Right occipital skull fracture
Respiratory Failure
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2169-10-1**]
ICD9 Codes: 2720, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7260
} | Medical Text: Admission Date: [**2121-9-30**] Discharge Date: [**2121-9-30**]
Date of Birth: [**2061-5-27**] Sex: M
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
hypoxia after ERCP
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
60 yo M with h/o HTN here for elective ERCP this am for
resection of an ampullary adenoma. After sedation with Versed
3.5, Fentanyl 75, and Phenergen 25 pt was noted to be apneic
with an O2 sat of 77%. Bag ventilation was initiated with an
increase in his sats to 100%. He was given Narcan 400 mcg IM and
Flumazanil 200 mg IV. He is currently sleeping with a O2 sat of
100% on a NRB. His BP and pulse were maintained throughout.
Past Medical History:
- HTN
- Barrett's esophagous
- hypercholesterolemia
Social History:
Married
Family History:
non-contributory
Physical Exam:
Tc 95.0 BP 141/68 HR 55 RR 8 Sat 100% 2L NC
Gen: snoring, appears comfortable
HENNT: dried blood in mouth, anicteric
Neck: large, no LAD
CV: Regular, brady, nl S1S2, No M/R/G
Lungs: anteriorly upper airway coarse breath sounds
Abd: soft, NT/ND, +BS
Ext: no edema, strong DP/PT pulses bilaterally
Neuro: sleeping but easily arousable, moving all extremities
Pertinent Results:
[**2121-9-30**] 07:30AM BLOOD WBC-6.7 RBC-4.70 Hgb-14.3 Hct-42.2 MCV-90
MCH-30.4 MCHC-33.9 RDW-13.6 Plt Ct-251
[**2121-9-30**] 07:30AM BLOOD PT-11.9 INR(PT)-1.0
[**2121-9-30**] 07:30AM BLOOD Glucose-112* UreaN-21* Creat-1.2 Na-142
K-5.1 Cl-104 HCO3-26 AnGap-17
[**2121-9-30**] 07:30AM BLOOD ALT-26 AST-47* AlkPhos-76 Amylase-111*
TotBili-1.0 DirBili-0.1 IndBili-0.9
[**2121-9-30**] 07:30AM BLOOD Lipase-41
[**2121-9-30**] 07:30AM BLOOD Albumin-4.7 Calcium-9.0 Phos-3.6 Mg-2.5
Brief Hospital Course:
# Apnea/Hypoxia secondary to sedation. Improved with
administration of Flumazinal and Narcan. Pt may have sleep apnea
as well. He was monitored in ICU, and did well and was
saturating 96% on room air. He was not somnolent. GI had raised
the possibility of sleep apnea, and an appointment was made for
him to follow-up in the sleep clinic at [**Hospital1 18**] to further
evaluate apnea.
.
# HTN: Patient was instructed to restart home BP meds when he
returns home.
.
# Ampullary adenoma. Resection not completed given hypoxia. Pt
will f/u with Dr. [**Last Name (STitle) **] as an outpatient.
.
# FEN. Regular diet.
.
# Code: Presumed full.
.
# Communication: Wife
Medications on Admission:
- Atenolol
- Lipitor
- Protonix
- Lisinopril
- ASA 81 mg daily (stopped 2 days ago)
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoxia after sedation for an elective ERCP
Discharge Condition:
Stable
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience shortness of breath or have any other
concerns.
Please resume all your home medications.
Followup Instructions:
The following appointment has been made for you in the Sleep
Clinic located on [**Hospital Ward Name 23**] 8:
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] NP/DR [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**].
Date/Time:[**2121-10-15**] 10:30AM. Please arrive 15 minutes early. The
location is the [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 860**] Building, room B23.
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-2**] weeks.
Please follow up with Dr. [**Last Name (STitle) **] regarding rescheduling your
ERCP.
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7261
} | Medical Text: Admission Date: [**2125-3-30**] Discharge Date: [**2125-4-26**]
Date of Birth: Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 55 year old male with
a history of hypertension, unspecified heart problems, who
recently immigrated from [**Country 4812**] six weeks ago, who
presented to the Emergency Room with chest pain in the
setting of cough. The patient, again, immigrated from
[**Country 4812**] six months ago. Over the past six months, he has
been experiencing a dry cough; at baseline he does have some
chest discomfort as well and it seems that this pain is
exertional; however, over the last several weeks, he has
begun to have a pleuritic sharp chest pain with radiation to
the back, worse again when he coughs.
On a trip to [**Location (un) **] two weeks prior to admission, he did
complain of a similar pain and presented to a local hospital.
All the details of that hospitalization are unclear. [**Name2 (NI) **] did
leave the hospital pain free. The patient again came back to
the US several days ago and on the date of admission he was
in a car with his daughter when he experienced retrosternal
discomfort once again with radiation to the back. Per the
daughter, he looked pale and diaphoretic and for this reason,
he was brought to the Emergency Room.
He denies any history of syphilis, heart murmur, scarlet
fever, Strep-throat or rheumatic fever. He does take some
medicines for his cough but does not know what they are.
In the Emergency Room, he was noted to have a significant
diastolic murmur. His blood pressure was elevated in the 200
to 100 range similar bilaterally. Chest x-ray noted a large
widened mediastinum and the patient was initially placed on
labetalol and then a Nipride drip for blood pressure control.
Chest CT scan was performed which showed a large thoracic
aneurysm but no evidence of dissection, and the patient was
admitted to Coronary Care Unit for aggressive blood pressure
control.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Question of angina.
3. History of negative PPD six months ago.
MEDICATIONS:
1. Labetalol 200 twice a day.
2. Zestril over the last week.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is of Ethiopian origin,
recently immigrated to the US six years ago. No tobacco or
alcohol.
PHYSICAL EXAMINATION: On examination, temperature 97.3 F.;
heart rate 70; respiratory rate 18; blood pressure was
180/60; saturation of 95% on room air. In general, this is an
middle aged male in no acute distress. HEENT: Pupils
reactive. Oropharynx clear. Mucous membranes were moist.
Neck was supple. Jugular venous pressure was not visualized.
No carotid bruits. Chest was clear to auscultation
bilaterally. Cardiac: S1, S2 normal. There was a III/VI
diastolic murmur at the right upper sternal border. Abdomen
was benign, soft, good bowel sounds, no palpable masses.
Extremities with no edema. Neurologically intact. Good
motor and sensory in all extremities. Cranial nerves intact.
Toes downgoing bilaterally. Deep tendon reflexes symmetric.
LABORATORY: Initial laboratory data was notable for a white
blood cell count of 7.5, hematocrit of 39.3, platelets of 259
with 13% eosinophilia. SMA7 was notable for a creatinine of
1.3. CK was 110; initial coagulation studies within normal
limits. Initial EKG showed normal sinus rhythm, left
ventricular hypertrophy, left atrial abnormality.
Chest x-ray revealed a large aneurysmal mass abutting the
left hilar area. CT scan of the chest showed a 6.6 by 6.7
centimeter large oblong descending thoracic aneurysm
compressing the left upper lobe bronchus with no evidence of
dissection, no lung masses or infiltrates.
HOSPITAL COURSE:
1. LARGE THORACIC ANEURYSM: The patient was admitted with a
new diagnosis of a large thoracic aortic aneurysm without any
evidence of dissection on initial chest CT scan. The
patient's blood pressure was aggressively managed with
Nipride drip and labetalol and eventually was transitioned
over to a PR regimen.
CT Surgery was consulted initially, however, initially they
wanted a cardiac catheterization and an echocardiogram prior
to surgery, however, they did feel that the surgery was
needed urgently. However, due to an episode of hemoptysis
that the patient had in-house, they deferred surgery until
the patient had a bronchoscopy and was further stabilized.
Due to multiple other complications during the hospital
course, the patient's surgery was deferred and to be done
when the patient stabilized. The patient was eventually
discharged to return for an elective surgical resection.
During the hospitalization, the patient had no evidence of
dissection or any catastrophic effects of aneurysm.
2. HEMOPTYSIS: The patient was initially presenting with an
aneurysm that had abutted the left upper lobe bronchus.
During the hospitalization, the patient had episodes of
hemoptysis. Bronchoscopy which was performed showed blood
trickling from the left upper lobe bronchus, but did not
reveal any discrete masses or lesions. The question of
fistula was entertained. The patient, however, was intubated
electively due to recurrent hemoptysis for airway protection,
however was able to be extubated eventually and discharged.
No further hemoptysis was noted after extubation.
3. AORTIC INSUFFICIENCY: The patient with a loud diastolic
murmur. A 2D echocardiogram revealed a three plus aortic
insufficiency. Cardiac catheterization revealed no coronary
disease. The plan was to replace the aortic valve at the
time of aneurysm repair.
4. PNEUMONIA: The patient developed a Hemophilus influenzae
pneumonia while on the ventilator. The patient was treated
with a prolonged course of Levaquin for his pneumonia with
improvement.
5. STAPHYLOCOCCUS COAGULASE NEGATIVE LINE SEPSIS: The
patient developed Staphylococcus coagulase negative
bacteremia in the setting of peripheral line. The patient's
line was removed and the patient was treated with a prolonged
course of intravenous Vancomycin with clearance of subsequent
blood cultures.
6. MYOCLONIC JERKS: The patient with myoclonic jerks
interrupted he setting of infection and medication. He was
seen by Neurology who recommended an EEG which did not show
any evidence of epileptiform features. The myoclonus
resolved with treatment of the infection.
DISCHARGE DIAGNOSES:
1. Large thoracic aortic aneurysm with communication to left
upper lobe bronchus.
2. Hemoptysis secondary to a question of aortobronchus
fistula.
3. Aortic insufficiency.
4. Hemophilus influenzae pneumonia.
5. Staphylococcus line sepsis.
6. Hypertension.
DISCHARGE MEDICATIONS:
1. Protonix 40 q. day.
2. Hydralazine 100 p.o. four times a day.
3. Zestril 40 p.o. q. day.
4. Procardia XL 90 p.o. q. day.
5. Lopressor 100 p.o. three times a day.
DISPOSITION: The patient was discharged on [**2125-4-26**].
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] in CT
Surgery for an elective admission for thoracic aortic
aneurysm repair and possible aortic valve repair.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-463
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2126-8-1**] 09:32
T: [**2126-8-4**] 20:52
JOB#: [**Job Number 39010**]
ICD9 Codes: 4280, 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7262
} | Medical Text: Admission Date: [**2121-8-25**] Discharge Date: [**2121-9-1**]
Date of Birth: [**2068-6-13**] Sex: F
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy - [**2121-8-26**]
Upper GI endoscopy - [**2121-8-25**]
History of Present Illness:
This patient is a 53 year old female who presents with GIB. Pt
diagnosed with "large" ulcer 1.5 years ago for which the patient
is taking sulcralfate and protonix. Pt was in usual state of
health until a few days ago, felt very tired. Today fainted
while knocking on the door to use bathroom in her home. Pt felt
acute need to have bowel movement. She felt very lightheaded
with extensive sweating and cold. The husband saw her (before
she falls down on the floor from a semi-standing position) and
lost consciousness for about 2 mins per husband. [**Name (NI) **] head trauma
during this fall. Then she awoke on the floor. No jerky
movements witnessed by husband, no urine or stool incontinence
or tongue biting. Husband called 911. Husband saw toilet, he
stated there was "blood on the toilet." she was brought to OSH
and had 2 large dark bloody bowel movements. Her Hct there was
28. She received there IV protonix, and her vitals were BP
(120's-150's/70's-80's with HR of 60's-80's). No black stools.
No new abdominal pain except for her baseline epigastric pain
since bypass surgery. She had no blood transfusions at the OSH.
Pt has chronic abdominal pain, which she says is the same today.
No fevers, chills, bloody emesis. Pt has vomiting daily, but
states there is no change today since her bypass in [**2117**].
.
In the ED inital vitals were T 100 HR 84 BP 134/62 RR 16 Sat
100% 2L NC. Exam was notable for DRE with melena and flecks of
red blood. NG lavage was attempted x6 but could not be tolerated
by the patient [**1-1**] gagging. GI was consulted and recommended
admission to the MICU and EGD tonight. She became tachycardic to
the low 100s in the setting of attempted NG placement. 2 large
bore IVs were placed. Pantoprazole gtt was started. VS on
transfer to ICU were: T 100,BP 143/70 ,HR 103,RR 16, Sat% 99 2L
NC.
.
On arrival to [**Hospital Unit Name 153**], did not report chest pain, SOB, cough.
Denied abdominal pain, nausea or vomiting.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, 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. Denies diarrhea, constipation.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
obesity, HTN, hypothyroid, TAH, ventral hernia repair w mesh,
lap gastric bypass, lap CCY
Social History:
Denies EtOH, tobacco, or drug use. Lives with husband.
Family History:
Father had CABG twice in his 40's and 60's. Also he had stomach
aneurysm. No FH of cancer.
Physical Exam:
Admission Physical Exam:
VS: BP 154/69 HR 95 RR 13 S 99%RA
General: Alert, oriented x 3, no acute distress, looks tired
HEENT: Sclera anicteric, no conjuctival pallor, MM relatively
dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no rubs, gallops.
2/6 systolic murmur best heard at right mid-sternal border
Abdomen: soft, non-distended, mildly tender at epigastric
region, bowel sounds present, no rebound tenderness or guarding,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical Exam:
VS: T 97.3 HR 70 BP 128/76 RR 18 O2 97 %RA
General: NAD, A&Ox3
Cardiac: RRR
Lungs: CTA Bilaterally
Abdomen: Soft, non-distended, minimal tenderness to palpation
epigastric region, no rebound tenderness or guarding
Ext: No edema
Pertinent Results:
Admission Labs:
[**2121-8-25**] 03:55PM BLOOD WBC-8.6# RBC-3.34* Hgb-9.8* Hct-28.0*
MCV-84 MCH-29.3 MCHC-35.0 RDW-14.0 Plt Ct-277
[**2121-8-25**] 03:55PM BLOOD Neuts-77.1* Lymphs-19.9 Monos-2.7 Eos-0.1
Baso-0.2
[**2121-8-26**] 04:27AM BLOOD PT-12.4 PTT-21.1* INR(PT)-1.0
[**2121-8-25**] 03:55PM BLOOD Glucose-117* UreaN-19 Creat-0.6 Na-143
K-4.2 Cl-110* HCO3-27 AnGap-10
[**2121-8-25**] 03:55PM BLOOD ALT-17 AST-17 AlkPhos-58 TotBili-0.2
[**2121-8-25**] 03:55PM BLOOD Phos-3.3 Mg-1.9
Discharge Labs:
[**2121-9-1**] 06:10AM BLOOD WBC-7.1 RBC-4.23 Hgb-12.6 Hct-35.8*
MCV-85 MCH-29.7 MCHC-35.1* RDW-14.9 Plt Ct-218
[**2121-8-31**] 06:35AM BLOOD WBC-6.9 RBC-4.22 Hgb-12.4 Hct-35.0*
MCV-83 MCH-29.3 MCHC-35.4* RDW-14.8 Plt Ct-238
[**2121-8-27**] 04:00PM BLOOD calTIBC-395 VitB12-1378* Folate-GREATER
TH Ferritn-77 TRF-304 TSH-0.38 PTH-44 VITAMIN B1-PND VITAMIN D
[**12-24**] DIHYDROXY-PND
CTA Abdomen/Pelvis - [**2121-8-26**]:
IMPRESSION:
1. No evidence of active arterial or venous gastrointestinal
hemorrhage.
There is clinical concern for GI bleeding persists, a tagged red
cell scan may be considered.
2. Sigmoid diverticulosis without evidence of diverticulitis.
3. Right lower quadrant and right inguinal prominent lymph
nodes, but not
pathologic by size criteria; correlate clinically.
EGD - [**2121-8-25**]: There was no blood or active bleeding.
Impression: Abnormal mucosa in the esophagus. Suction (NG)
trauma in teh esophagus. Ulcers in the GJ anastomosis.
Friability and granularity in the gastric pouch compatible with
gastritis. Otherwise normal EGD to jejunum
Colonoscopy - [**2121-8-26**]: No bleeding or potential culprit lesion
was identified.
Impression: Normal mucosa in the sigmoid, ascending, distal and
proximal ascending colon. Diverticulosis of the sigmoid colon.
Otherwise normal sigmoidoscopy to proximal transverse colon
Brief Hospital Course:
Ms. [**Known lastname 109051**] was transferred to the Emergency Department from
and OSH on [**2121-8-25**] following a syncopal event at home
associated with bloody bowel movements and a hematocrit of 28.0.
Upon arrival to [**Hospital1 18**], the patient's DRE revealed melena with
specks of blood; her hematocrit level was noted to be 28.0. NGT
lavage was attempted, but unsuccessful in the Emergency
Department. A protonix gtt was initiated and the patient was
transferred to the Intensive Care Unit for ongoing management.
Neuro: The patient was alert and oriented throughout her
hospitalization. The patient has chronic pain issues related to
marginal ulcerations, which are managed on an out-patient basis
by the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic. Therefore, the Chronic Pain Service
was consulted, who recommended continued treatment with po
tramadol; pain was well controlled on this regimen.
Additionally, Dr. [**First Name (STitle) 74316**], patient's provider at [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**]
Clinic, advised discharge to home on tramadol with a
prescription for a one month supply of medication; she will
follow-up as an out-patient upon return from [**State 108**].
CV/Pulm: The patient remained stable from a cardiovascular
standpoint; she was mildly tachycardic upon admission, which
resolved following blood transfusion. The patient remained
stable from a pulmonary standpoint; vital signs were routinely
monitored.
GI/GU/FEN: Given the reported melena and flecks of red blood,
UGI bleed was thought to be the most likely cause. An EGD was
done but did not show a source of active bleed. A CTA was done
which was signicant for diverticuli. She underwent a flexible
sigmoidoscopy. They were able to visualize to the ascending
colon but were unable to find the source of bleeding. The
patient was initially started on a PPI gtt which was later
transitioned to pantoprazole IV bid and then to a po regimen of
prilosec and carafate. She received 4 units of PRBCs given hct
drop to a nadir of 21. GI believed the source of her bleed to be
diverticulosis, however she does have marginal ulcers and she
may have a duodenal ulcer that could not be evaluated by EGD due
to the anatomy of her post operative GI tract. The patient's
hcts were stable on the floor and she was informed of the
warning signs of a GI bleed and to return to the hospital
immediately if any were to occur. She was discharged on a PPI
and carafate and will have a colonoscopy performed on [**2121-9-3**] to
further evaluate her diverticuli; her hematocrit level will be
rechecked at this time. Also, she will follow up with Dr. [**Last Name (STitle) **]
on [**2121-9-5**]. The patient is planning to go to [**Location (un) 5944**], FL after
her appointment with Dr. [**Last Name (STitle) **] for an indefinate period of time.
Dr. [**Last Name (STitle) **], Bariatric Surgery at [**Hospital 5944**] [**Hospital3 **] was
contact[**Name (NI) **] and will be sent a copy of her pertinent medical
records in the event that she needs care while in [**Location (un) 5944**].
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
Prophylaxis: [**Last Name (un) **] dyne boots were used during this stay; she was
encouraged to ambulate.
Social work: The patient reported an increased level of stress
the day prior to admission due to financial issues. Also, the
patient's social situation is complicated by an impending
separation and concern over the abusive nature of her
relationship with her husband. She stated that she feels safe
at home and was seen by psychiatry and social work (please refer
to OMR notes) who believed she was safe for discharge to home;
the patient declined consultation by the domestic violence
service. She is currently declining outpatient social work
follow-up due to plans to travel to [**State 108**]; multiple
alternative means of stress reduction were offered and
outpatient social work was encouraged.
At the time of discharge to home, the patient had stable vital
signs. She remained alert and oriented with well controlled
pain. Her hematocrit level remained stable at 35.8 and stools
were guaiac negative. She will have her hematocrit level
rechecked prior to her follow-up appointment on [**2121-9-6**]. The
patient was tolerating a stage 4 bariatic diet, but will
maintain a stage 3 diet at home and begin colonoscopy
preparation as directed by gastroenterology. Also, she will
continue taking omeprazole and sucralfate. The patient received
extensive discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
atenolol 50 mg [**Hospital1 **]
levothyroxine 50 mcg QD
tramadol 50 mg 2 tab 4 times a day (she is taking 5 tab per day)
calcium-vitamin K-D3 (dosage uncertain)
multivitamin with minerals QD
sucralfate 1 gram QID
protonix
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*240 Tablet(s)* Refills:*0*
5. atenolol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
CBC
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleeding
Marginal ulcer
Diverticulosis
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 after passing out in your
bathroom. You were found to have a gastrointestinal bleed,
which was treated with blood transfusions, intravenous
pantoprazole and carafate. You underwent an endoscopy and a
colonoscopy, which could not definitively identify the source of
your bleeding.
If you feel lightheaded or dizzy or you have black, tarry, or
bloody vomit or stool, you should go directly to the Emergency
Room.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid driving or
operating heavy machinery while taking pain medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] (ST-3) GI ROOMS Date/Time:[**2121-9-3**] 1:00 pm
Provider: [**Name10 (NameIs) 16385**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2121-9-3**] 1:00 pm
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 2723**]
Date/Time:[**2121-9-5**] 3:15 pm
If you have any acute issues while in [**Location (un) 5944**], Fl you should go to
[**Hospital 5944**] [**Hospital3 **], and request Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Bariatric
Surgical Director, he has been faxed your pertinent medical
records and is aware that you will be there. If you have issues
or concerns while in [**Location (un) 5944**], you should call his office at ([**Telephone/Fax (1) 109923**]. You can always call Dr.[**Name (NI) 78793**] office at ([**Telephone/Fax (1) 25898**].
Completed by:[**2121-9-1**]
ICD9 Codes: 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7263
} | Medical Text: Admission Date: [**2133-9-27**] Discharge Date: [**2133-9-29**]
Date of Birth: [**2103-5-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Inapsine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fulminant hepatic failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
30y/o M with HIV presented to [**Hospital 11485**] Hospital on AM of
admission with nausea/vomiting x2 days, abdominal pain. 5 days
PTA, pt felt that his ears were blocked with decreased hearing.
Went to PCP 3 days PTA, who diagnosed him with swimmer's ear and
asthma given his wheezing. He was given a nebulizer and a Rx
for his ears and an inhaler; pt did not fill prescription. Pt's
partner left town; pt states he felt worse the following day.
By 2 days PTA, pt was confused, with slurred speech and
inappropriate responses to questions. Called ambulance to come
to the hospital.
Pt's partner states that pt has not been receiving pain meds for
his BKA and amputated toes, as he was told this was phantom pain
and he was instructed to take Tylenol. For the past 5 years,
pt's partner has been buying him a bottle of 50 tablets weekly.
More recently, pt's partner has been finding empty bottles of
tylenol, as well. 2 days PTA, also found 2 empty bottles of
aspirin.
Over the past few years, pt has been more depressed due to BKA
and decreased functionality. Has lost a few jobs. Pt's partner
feels that he is not suicidal. In addition, pt has not taken
HAART during the last few days.
At [**Name (NI) 11485**], pt's labs were notable for INR 10.6, lactate 16.1,
anion gap 38. RUQ ultrasound revealed gallstones. Pt was given
8 units FFP, 2 doses mucomyst. He was intubated, sedated, and
paralyzed, and eventually required levophed prior to his
transfer. In addition, he had an episode of coffee-ground
emesis during intubation, and his Hct dropped from 54 to 36. In
addition, he was noted to be hypoglycemic into the 30s, which
responded with D50.
Past Medical History:
1. HIV - CD4 count 600s about 6 months ago, VL ~60,000
2. s/p BKA in setting of sepsis/renal failure thought to be [**3-4**]
brown recluse
3. Burkitt's lymphoma - [**2127**], s/p chemo, thought to be in
remission
Social History:
Pt has partner of >10 years. + tobacco, more recently, up to
about 2ppd, total duration 14 years. No alcohol. Occasional
MJ, more in the last few years. Does office work, has been
working temp jobs recently.
Family History:
DM2 - father, PGM
no liver disease
Physical Exam:
VS: 99.5 127/46 133 30 95% AC 450x30/15/1.0
Gen: intubated, sedated, paralyzed
HEENT: pupils dilated, reactive to light; mild chemosis; ear
canals with blood and erythema bilaterally, difficult to
visualize tympanic membranes
Neck: no cervical LAD
CV: tachycardic, regular, nl S1/S2, no murmurs appreciated
Pulm: coarse breath sounds bilaterally, monophonic whistle at L
base; no diffuse wheezes
Abd: soft, mildly distended, +hepatomegaly to about 4
fingerbreadths below the costal margin and fullness detected in
midline; + BS, no other masses
Ext: warm, 2+ distal pulse in LLE; RLE with BKA; stigmata of
skin graft on L anterior leg; toe amputations on LLE; no
splinter hemorrhages noted
Neuro: sedated, paralyzed - could not assess further
Pertinent Results:
Admission labs:
CBC:
WBC-8.1 RBC-3.82* HGB-13.7* HCT-39.3* MCV-103* MCH-36.0*
MCHC-34.9 RDW-14.7
NEUTS-90.3* BANDS-0 LYMPHS-8.9* MONOS-0.8* EOS-0 BASOS-0
PLT SMR-NORMAL PLT COUNT-63*
coags:
PT-23.7* PTT-38.0* INR(PT)-3.7
electrolytes:
GLUCOSE-152* UREA N-21* CREAT-1.3* SODIUM-145 POTASSIUM-3.6
CHLORIDE-111* TOTAL CO2-19* ANION GAP-19
ALBUMIN-3.5 CALCIUM-8.0* PHOSPHATE-5.1* MAGNESIUM-1.9
LFTs:
ALT(SGPT)-4833* AST(SGOT)-4359* LD(LDH)-6600* ALK PHOS-164*
AMYLASE-216* TOT BILI-3.4* LIPASE-344*
ABG:
7.09 63/81 on AC 450x30/15/1.0
CXR: bilateral airspace disease, no effusions, R IJ and NG tube
in proper place
.................
CT Head [**2133-9-28**]
Reason: BLOWN RT PUPIL, ? HERNIATION
[**Hospital 93**] MEDICAL CONDITION:
30 year old man with blown pupil
REASON FOR THIS EXAMINATION:
Herniation
CONTRAINDICATIONS for IV CONTRAST: None.
PROCEDURE: CT HEAD WITHOUT CONTRAST.
INDICATION: 30-year-old male with fulminant hepatic failure and
blown pupil. Question herniation.
TECHNIQUE: Non-contrast CT of the head was performed.
CT OF THE HEAD WITHOUT CONTRAST: There is global hypodensity of
the brain parenchyma with loss of [**Doctor Last Name 352**]-white matter
differentiation, as well as diffuse effacement of the sulci and
basilar CSF spaces. Increased density is also noted within the
basal cistern spaces. There is no shift of the normally midline
structures, or CT evidence of brain herniation. There is a focus
of encephalomalacia within the right occipital lobe from likely
prior traumatic or ischemic insult. Bone window show no
suspicious lesions. Mucosal sinus soft tissue thickening is seen
within the imaged portions of the maxillary, ethmoid, and
sphenoid sinuses. This is likely secondary to the patient's
intubation.
IMPRESSION:
1. Global edematous swelling of the brain parenchyma with loss
of the [**Doctor Last Name 352**]- white differentiation. Findings could relate to a
global hypoxic/ischemic event with secondary diffuse infarction.
However, this could represent diffuse swelling without
infarction in a patient with fulminant hepatic faliure, in which
case return to normal is possible.
2. Increased density of the basilar cistern spaces, which may be
artifactual in appearance given the adjacent low density of the
brain parenchyma. However, the possibility of subarachnoid blood
or meningeal infection cannot be excluded. Recommend correlation
with CSF fluid sampling if clinically appropriate.
....................
[**2133-9-28**]
RUQ US
IMPRESSION:
1. Normal son[**Name (NI) 493**] appearance of the liver.
2. Cholelithiasis. Edematous gallbladder wall. These findings
are frequently seen in patients with liver failure and
hypoalbuminemia. The gallbladder is not abnormally distended.
3. Mild splenomegaly.
...................
Brief Hospital Course:
A/P: 30y/o M with HIV presents with fulminant hepatic failure
after tylenol overdose.
.
# Respiratory failure/ARDS - Likely etiology was
multifactorial, including fulminant hepatic failure, possible
aspiration, PNA, shock. Pt remained intubated and paralytics
were removed but the patient was unable to remain synchronized
with the ventilator so these were restarted. Maintained on low
tidal volume strategy with HOB elevated. Pt had borderline
acceptable oxygenation and ventilation and required high levels
of PEEP and FIO2 to maintain O2 sats. Ceftazidime for poss
Pseudomonal ear infx as below, azithromycin, and vancomycin for
empiric coverage of pneumonia given bilateral opacities were
started. Bronch was planned for when patient was stable.
However, the patient clinically worsened. He was noted to have
a blown pupil and CT Head was done which showed diffuse brain
edema, poor [**Doctor Last Name 352**]/white matter differentiation, and new stroke.
With such poor prognosis d/t fulminant hepatic failure with
resultand increased intracranial pressure and elevated INR, bolt
was not placed. The patient was DNR and a family discussion was
had with mother and partner where it was decided to removed
endotracheal tube in setting of poor prognosis. The patient had
a respiratory arrest approx 20 minutes after ETT was removed.
He was pronounced dead at 0030 on [**2133-9-29**]
# Fulminant hepatic failure - Likely cause was tylenol
hepatotoxicity. HAART could also have contribution, as
efavirenz can cause transaminitis, and Combivir can cause
hepatomegaly, hyperbilirubinemia, transaminitis, and
hyperamylasemia. Liver team was involved who recommended FFP PRN
and Vit K daily. Initially full workup was planned with [**Doctor First Name **],
AMA, hep serologies, HCV, alpha antitrypsin. Liver transplant
team was contact[**Name (NI) **] but the patient was not deemed a candidate
d/t HIV status. RUQ ultrasound with Dopplers performed which
excluded vascular causes of FHF. Supportive treatment was
maintained but the patient continued to decline and developed
increased intracranial pressure as above.
.
# Upper GI bleed - Pt with coffee ground emesis at OSH, but
presented with stable Hct and this remained stable. Likely
cause d/t coagulopathy in setting of liver failure. [**Hospital1 **] IV PPI
given, 2 large bore IV's, typed and crossed. Did not continue
to bleed, so no EGD was done.
.
# HIV - HAART held, as some meds may have contributed to
hepatotoxicity.
.
# Otitis externa - pt with bilateral ear bleeding, difficult to
visualize TMs; appeared that pt had erythematous ear canals.
Plan was for further workup by ENT, but this did not happen
before death.
.
# Acidosis - Respiratory acidosis, anion gap metabolic acidosis
due to lactate and renal failure. Supported intravascular
volume, treated infection with above antibiotic regimen.
.
# Acute renal failure - Pt with Cr 0.5 at OSH, presented to
[**Hospital1 18**] at 1.3 here. Likely was d/t tylenol toxicity and
hypoperfusion in setting of hypotension.
.
# Code - DNR
.
# Communication: partner [**Name (NI) **] ([**Telephone/Fax (1) 62907**] (home) - HCP
mom [**Name (NI) 2894**] ([**Telephone/Fax (1) 62908**]
Medications on Admission:
sustiva 600mg po qHS
combivir 150mg/300mg po bid
tylenol
Discharge Medications:
In-hospital medications:
Acetylcysteine (IV) 4900 mg IV Q4H
Ceftazidime 2g IV Q 8H
Vancomycin HCl 1000 mg IV Q 12H
Azithromycin 500 mg IV Q24H
Midazolam HCl 0.5-2 mg/hr IV DRIP INFUSION
Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION
Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO titrate
to MAP > 60
Pantoprazole 40 mg IV Q12H
Vitamin K 10mg SC daily x3 days
Discharge Disposition:
Expired
Discharge Diagnosis:
Fulminant hepatic failure d/t tylenol toxicity
ARDS
Renal failure
Coagulopathy
Increased intracranial pressure
Discharge Condition:
Deceased
Discharge Instructions:
Deceased. No autopsy desired by family.
ICD9 Codes: 5849, 431, 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7264
} | Medical Text: Admission Date: [**2139-8-26**] Discharge Date: [**2139-8-27**]
Date of Birth: [**2078-11-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
Hemodialysis.
History of Present Illness:
The patient is a 60 yo man with h/o ESRD on HD, ESLD [**3-16**] HepC,
seizure d/o, who presented to the ED with bradycardia. The
patient states that he was in his normal state of health until
three days ago, when he began to develop increased shortness of
breath. He stated that he felt subjective fevers at home;
however, he never documented a fever. He normally has HD on
M/W/F, but he rescheduled today's HD session for tomorrow. This
afternoon, the patient began to feel weak and dizzy at home and
found that his pulse was significantly slower (30s-40s). He has
experienced a similar situation approximately 3 times over the
past year, so he presented to the ED for further workup and
evaluation.
In the ED, the patient's VS were T 97.9 BP 164/75 P 37 O2 96% on
RA. His pulse was persistently in the 30s-40s. He complained of
lightheadedness and dizziness, but no CP. ECG showed junctional
rhythm with retrograde P waves. Trop is at baseline. Labs were
drawn which showed a K of 6.7. He was given Calcium gluconate,
Kayexelate, D50, Sodium Bicarbonate, and insulin, and his ECG
converted to sinus bigeminy. He then became increasingly
hypertensive to 220/130s and reportedly complained of active
chest pain. He was given NTG SL, which did not alleviate his
pain, and he was then started on a nitro gtt. EKG at this time
showed ST depressions in V4-V6. He was then transferred to the
CCU for emergent HD and further observation.
On arrival to the CCU, the patient states that he does not
currently feel any chest pain and he solely felt "chest
pressure" in the ED, which was not concerning to him.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. Epilepsy: began in childhood w/ generalized tonic-clonic
seizures. previously treated with phenobarbitol, mysoline,
depakote, dilantin, trileptal, tegretol, keppra; most recently
Keppra + Lamictal. usual seizure characterized by confusion,
disorientation, rare generalized tonic-clonic, followed by Dr.
[**First Name (STitle) 437**]
2. ESRD on HD; due to idiopathic glomerulonephritis, s/p failed
renal Tx x 2
3. Hypertension
4. Hypothyroidism
5. Peripheral [**First Name (STitle) 1106**] disease s/p stenting of bilateral common
iliac arteries
6. ESLD [**3-16**] Hepatitis C, on liver xplant list, followed by [**Doctor Last Name 497**]
7. CHF - systolic w/ EF 45% and diastolic dysfunction (echo
[**12/2135**])
8. h/o SVT/AVNRT s/p ablation
9. h/o MRSA line infection
10. h/o VRE infection
11. ? amyloid masses b/l shoulders
Social History:
Lives at [**Hospital3 **] facility on Mission [**Doctor Last Name **] called
[**Hospital1 **] at [**Hospital1 1426**], on disability, has two sons. smokes 1ppd x
40 yrs, no etoh, drugs.
.
Family History:
Mother with breast CA; father alive with CAD & CHF; sons
healthy.
Physical Exam:
VS: T 95.4, BP 185/92 HR 72 RR 16 O2 sat 91% on 4L
GENERAL: Middle aged man, cantankerous, in NAD. AAO x3.
Depressed affect.
[**Hospital1 4459**]: PERRL, EOMI. Oropharynx clear and without exudate.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP of 13 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Occasional S3. No m/r/g. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar rales to
mid-way up lung.
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: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2139-8-26**] 10:04PM K+-5.6*
[**2139-8-26**] 07:00PM K+-6.8*
[**2139-8-26**] 06:50PM GLUCOSE-94 UREA N-56* CREAT-7.8* SODIUM-137
POTASSIUM-6.7* CHLORIDE-97 TOTAL CO2-24 ANION GAP-23*
[**2139-8-26**] 06:50PM CK(CPK)-57
[**2139-8-26**] 06:50PM cTropnT-0.05*
[**2139-8-26**] 06:50PM WBC-5.8 RBC-3.98* HGB-10.5* HCT-33.3* MCV-84
MCH-26.5* MCHC-31.6 RDW-21.0*
[**2139-8-26**] 06:50PM NEUTS-53 BANDS-0 LYMPHS-34 MONOS-12* EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2139-8-26**] 06:50PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-2+ POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL
OVALOCYT-2+ TEARDROP-1+
[**2139-8-26**] 06:50PM PLT COUNT-223
Chest Portable (AP)
Comparison is made with prior study performed a day earlier.
Mild-to-moderate cardiomegaly is unchanged. Moderate pulmonary
edema has
improved. Aeration in the bases of the lungs has also improved.
There is no evidence of pneumothorax. Small right pleural
effusion is more conspicuous on today's exam. Central venous
catheter is in a standard position.
Brief Hospital Course:
The patient is a 60 yo man with h/o End Stage Renal Disease on
hemodialysis, Hepatits C cirrhosis, and Seizure disorder, who
presents with bradycardia and hypertensive emergency in the
setting of a missed HD session.
# Bradycardia: The patient presented with symptomatic junctional
bradycardia with a long QT and a rate of 30s-40s. His K on
admission was 6.7 Emergent HD was performed in the CCU, with an
output of 2.5 liters. After the procedure, the potassium
decreased to 4.7. He was monitored on telemetry and did not have
any further episodes of bradycardia. It is likely that the
patient was hyperkalemic because he missed a session of
hemodialysis the morning prior to admission. His hyperkalemia
was the etiology behind his bradycardia. He is advised to make
all of his hemodialysis appointments.
# Hypertensive Urgency/Emergency: The patient's BP in the ED
increased to 230s/130. He had concomitant chest pain, and there
was concern for ACS. His EKG during this episode did not show
ischemic changes, but a chronic strain pattern seen with chronic
severe hypertension. The patient was given Nitroglycerin SL and
was started on a nitroglycerin drip, which decreased his BP and
relieved his CP. The patient has a history of labile BPs, and
this current episode is most likely related to his fluid
overload.
After the nitro drip was weaned down, the patient was restarted
on his home medications of lisinopril, clonidine, metoprolol,
and nifedipine. He is to follow up closely with his nephrologist
and primary doctor for further managment.
# Pneumonia: Patient complained of a new productive cough and
subjective fever. On chest xray it appeared that an infiltrate
was forming. Since the patient is at high risk for infection on
hemodialysis, he was started on a five day course of
Azithromycin for community acquried pneumonia. He is to
follow-up with his primary care doctor next week and have a
repeat chest x-ray in [**3-17**] weeks.
# End Stage Renal Disase: The patient has a history of ESRD, for
which he receives hemodialysis on M/W/F. He received HD
overnight and 2.5 liters were taken off. He remained
hemodynamically stable throughout and his potassium decreased to
a normal level. He is to continue follow-up with his
nephrologist next week.
# HepC Cirrhosis: The patient has a history of HepC cirrhosis,
and he recently took himself off of the [**Date Range **] list. His
liver function appeared stable throughout this admission. He is
currently taking Rifaximin 200 mg TID, he is to continue this
medication and follow up with his PCP for further management.
# Seizures: The patient has a history of epilepsy, for which he
takes Lamotrigine, Phenytoin, and Keppra daily. The patient did
not have a seizure during this hospital stay, and appears stable
on his medication. He is to continue these medications and
follow-up with his Neurologist for futher management.
Medications on Admission:
B-Complex with Vitamin C daily
Cinacalcet 90 mg daily
Clonidine 0.1 mg [**Hospital1 **]
Clopidogrel 75 mg daily
Lamotrigine 250 mg [**Hospital1 **]
Lansoprazole 30 mg daily
Lisinopril 20 mg daily
Metoprolol Tartrate 50 mg TID
Rifaximin 200 mg TID
Aspirin 81 mg daily
Phenytoin Sodium Extended 200 mg [**Hospital1 **]
Levetiracetam 375 mg [**Hospital1 **]
Levetiracetam 250 mg after HD
Calcium Carbonate 500 mg qid prn
Nifedipine 60 mg Sustained Release TID
Discharge Medications:
1. Clonidine 0.1 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
2. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Rifaximin 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
5. Lamotrigine 100 mg Tablet [**Hospital1 **]: 2.5 Tablets PO BID (2 times a
day).
6. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
7. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Phenytoin Sodium Extended 100 mg Capsule [**Hospital1 **]: Two (2) Capsule
PO BID (2 times a day).
9. Levetiracetam 250 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2 times
a day).
10. Keppra 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO As directed: To
be taken three times weekly after hemodialysis.
11. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: Two (2)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
12. Nifedipine 60 mg Tablet Sustained Release [**Hospital1 **]: One (1)
Tablet Sustained Release PO TID (3 times a day).
13. Azithromycin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H
(every 24 hours) for 4 days: Start [**2139-8-28**], [**Month/Day/Year 2974**] morning.
Disp:*4 Tablet(s)* Refills:*0*
14. B Complex Plus Vitamin C Oral
15. Cinacalcet 30 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Bradycardia, community acquired pneumonia, end stage
renal disease requiring dialysis
Secondary: Hypertension, Hypothyroidism, Peripheral [**Month/Day/Year 1106**]
disease s/p stenting of bilateral common iliac arteries, End
stage liver disease secondary to Hepatitis C, CHF systolic with
EF 45% and diastolic dysfunction, Seizures
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted after developing shortness of breath, cough
and then chest pain. This was in the setting of missing a
hemodialysis session. You were found to have slow heart rate
(bradycardia) and electrolyte abnormalities due to missing
dialysis. You were also found to have pneumonia.
Given your severe reaction from missing hemodialysis, you must
attend every session or risk life threatening medical
consequences.
Please take all medications as prescribed.
- In addition to your regular medications, you have been
started on a 5 day course of antibiotics for your pneumonia.
You must pick this medication up from the pharmacy upon
discharge.
- You were previously on a medication called Lansoprazole.
This medication interacts with your Clopidogrel, please discuss
changing it to a different medication at your next primary care
visit. You have not been discharged on this medication given
this interaction.
- You were found to have low calcium. Given this, you should
increase your Calcium Carbonate (Tums) intake to 2 tabs (1000 mg
total) four times daily.
Please keep all outpatient appointments.
Your next hemodialysis appointment is at [**Location (un) **] [**Location (un) **]
tomorrow [**Location (un) 2974**] at 11am. Please keep this appointment.
Seek medical advice if you develop fever, chills, difficulty
breathing, chest pain, persistent productive cough, abdominal
pain, weakness, lightheadedness or any other symptom that is
concerning for you.
Followup Instructions:
You have an appointment scheduled with [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 93901**], NP, who
works with Dr. [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) 4321**] at the same office in Jamaice Plain.
This appointment is [**2139-9-2**] at 11:00 AM. You should discuss
your hospitalization and pneumonia symptoms at this appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2139-8-28**] 8:40
Your next dialysis session is [**2139-8-28**] at 11AM at [**Location (un) **]
[**Location (un) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 486, 5856, 4280, 5715, 2767, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7265
} | Medical Text: Admission Date: [**2148-2-28**] Discharge Date: [**2148-3-28**]
Date of Birth: [**2106-1-28**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Adhesive Bandage / Dicloxacillin
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Cirrhosis on [**Male First Name (un) **] list s/p aborted trx due to pulmonary
HTN.
Major Surgical or Invasive Procedure:
Right heart catheterization x2
Paracenteses x2
Intubation
History of Present Illness:
Mr. [**Known lastname 19420**] is a 41 year-old man, well known to this service,
with history of cirrhosis secondary to EtOH + HCV, pulmonary
HTN, severe ascites, and recurrent encephalopathy, now being
transferred from the SICU s/p aborted liver trx due to elevation
in pulmonary pressures to 52/25 (mean 36).
.
Mr. [**Known lastname 19420**] was recently admitted from [**2-11**] to [**2147-2-22**] to medicine
service for pancreatitis presumed secondary to gallstones. ERCP
was not performed during that admission as he improved and it
was felt that since he was doing well, the risks outweighed the
benefits. Since d/c, he did well, but did present to ED on [**2-26**]
with abdominal pain and distended abdomen from worsening
ascites. 6L paracentesis was performed and he was given 75 g of
albumin. Of note, creatinine at that visit was 1.8, up from 1.2
from recent discharge. He has been maintained on lasix 20 qd,
aldactone 50 qd. On this admission, his creatinine was noted to
be 2.2, which rose to 2.4, but is now down to 1.8 s/p IVFs.
Past Medical History:
- HCV and EtOH cirrhosis on [**Month/Day (4) **] list
- h/o SBP early [**7-27**] on Cipro prophylaxis
- Grade II esophageal varices
- Recurrent hepatic encephalopathy on vegetarian diet
- Pulmonary HTN
- Hypothyroidism
- Anxiety disorder
- H/o EtOH abuse, IVDU
- Osteoporosis of hip and spine per pt
- Anemia w/ hx of guaiac positive stool.
- Pulmonary HTN
Social History:
He lives with his mother. [**Name (NI) **] quit smoking [**5-28**], was smoking
[**12-23**] ppd. Quit drinking EtOH 11 years ago. Prior remote hx of IVD
as teen. No current drug use.
Family History:
Mother with DM and HTN. Father with rheumatic heart disease.
Physical Exam:
T 98.2, BP 95/64, HR 74, RR 20, satting 97% RA
Gen: Pleasant, conversant, NAD.
HEENT: Sclera icteric
Pulm: Clear to auscultation bilaterally
CV: RRR. No m/r/g.
Abd: Very distended and firm with ascites. No pain.
Ext: 3+ edema bilaterally lower extremities.
Neuro: No asterixis.
Pertinent Results:
Labs at Admission:
[**2148-2-28**] 03:00AM BLOOD WBC-8.3 RBC-2.18* Hgb-6.9* Hct-21.1*
MCV-97 MCH-31.5 MCHC-32.6 RDW-20.0* Plt Ct-80*
[**2148-2-28**] 03:00AM BLOOD Neuts-82.5* Lymphs-8.1* Monos-6.7 Eos-2.7
Baso-0
[**2148-2-28**] 03:00AM BLOOD PT-24.2* PTT-58.5* INR(PT)-2.4*
[**2148-2-28**] 03:00AM BLOOD Glucose-97 UreaN-37* Creat-2.2* Na-126*
K-3.7 Cl-96 HCO3-17* AnGap-17
[**2148-2-28**] 03:00AM BLOOD ALT-16 AST-54* AlkPhos-149* Amylase-108*
TotBili-15.1*
[**2148-2-28**] 03:00AM BLOOD Albumin-3.2* Calcium-8.5 Phos-4.3# Mg-2.2
Iron-92
Brief Hospital Course:
42 year-old man well known to our service, with history of
cirrhosis secondary to EtOH + HCV, pulmonary HTN, severe
ascites, and recurrent encephalopathy, s/p transfer from SICU
post aborted liver trx due to elevation in pulmonary pressures,
then transferred to MICU for diuresis on Lasix gtt. He is now
transferred to back to [**Doctor Last Name 3271**] [**Doctor Last Name 679**] following 13L fluid removal
for further medical management.
.
# New leukocytosis: Pt with large bump in WBC toward end of
stay, downtrending on day of discharge. Unclear etiology, as has
remained afebrile and clinically feels well. C.Diff negative,
multiple therapeutic taps negative for SBP. No cultures negative
to date.
.
# Elevated PAPm: Repeat right heart cath on [**3-11**] (after
diuresis) showed mean PA pressure of 52 with wedge pressure in
high 20s. Following MICU admission with Swann in place for
diuresis, PAPm is much improved now s/p diuresis on Lasix gtt.
BNP is also improving. His length of stay fluid balance in the
MICU is -13.5L, and his PCWP/PAPm has improved to 15/29 (from
28/52). As PAPm has improved significantly following diuresis
with concomittant improvement in PCWP, it is possible that fluid
overload may be contributing more to elevated PAPm than
pulmonary hypertension.
Off Lasix gtt, negative fluid balance was difficult to obtain,
and pt was placed on increasing doses of IV then eventually PO
diuretics to achieve improved UOP. Increases doses were limited
by rising Cr. Pt was finally dicharged on Spironolactone 200mg
PO qam, 100mg PO qpm, and Lasix 200mg PO qam, 100mg PO qpm, with
goal I/O negative -1L. Per outpt pulmonologist Dr.[**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **],
resumed home Iloprost while inpatient. Pt is now re-listed on
liver [**Last Name (NamePattern1) **] list (pt aware) in setting of improved
pulmonary hypertension.
.
# Cirrhosis: MELD score was previously 34-36, which led to
attempted liver [**Last Name (NamePattern1) **]. Now s/p diuresis for elevated
pulmonary pressure. Cirrhosis has been c/b ascites,
encephalopathy and SBP. No asterixis at present. Pt has had 3
therapeutic [**Doctor First Name 4397**] thus far- [**3-1**] (6L off), [**3-5**] (5L off), [**3-14**]
(6L off), [**3-21**] (~5.5L.), [**3-26**] (~4L). MELD score at discharge
stable at 33. Pt was continued on Lactulose 30ml PO QID,
Rifaximin 200mg PO TID for hx hepatic encephalopathy. Continue
Ciprofloxacin 250mg PO q24 for SBP prophylaxis. Continue
Ursodiol 600mg PO QAM for elevated bilirubin/pruritis. On Lasix
and Spironolactone. Pt is now re-listed on liver [**Month/Day (4) **] list
(pt aware) as PAPm now improved to <35 (actual 29). Nadolol held
given borderline pressures, re-consider as outpt.
.
# Acute renal failure: This was thought to be secondary to
volume overload +/- HRS at time of transfer from SICU. In MICU,
Cr improved significantly, down to 1.2 from 2 with diuresis,
suggesting improved renal perfusion. On floor, Cr likely
bumping with diuresis, has been stable between 1.8-2.2. Pt was
discharged on high doses of Spironolactone/Lasix as above. Also
continue Midodrine 7.6mg PO TID for renal perfusion; holding
Octreotide d/t concern this might further elevate pulmonary
arterial pressures.
.
# Hypothyroid: stable. Last TSH [**2147-12-29**] wnl. Continue outpatient
Synthroid 88mcg PO qday.
.
# Anemia: normocytic; felt to be due primarily to marrow
suppression. S/p transfusion 1U PRBCs [**3-1**], [**3-5**], and [**3-8**]; 2U
PRBCs on [**3-10**]. Pt was guiaic positive on [**3-10**] and [**3-11**], hapto
<20, LDH WNL, retic count 2.4. Patient with h/o diverticulosis
per [**2142**] colonoscopy.
Crit has been stable in mid-20s.
- Trend daily crits
- Consider repeat colonoscopy as outpt
- Transfuse if hct<21 or actively bleeding
.
# Hand/leg cramping: Thought to be related to increasing doses
of diuretics. Magnesium was increased with some benefit. Pain
was controlled with Codeine 15-30mg PO q12 PRN cramping/pain. Pt
was discharged with a limited prescription.
.
# FEN: Pt had previously had a Dobhoff, which clogged [**3-9**], and
was removed [**3-10**]. Now tolerating POs, but per nutrition will not
get adequate intake given liver disease and low
protein/vegetarian diet. Dobhoff replaced again [**3-21**], as pt
inadvertantly had it pulled out. Additionally, pt accidentally
pulled Dobhoff out 10inches toward end of stay while sleeping.
Replaced by GI fellow, with bridle now in place. Likely not
post-pyloric but adequate. On fluid restriction 1200ml d/t
concern of volume overload. On Mag, Zinc, Vit D.
.
# Proph: Pneumoboots, compression stockings, PPI, Lactulose
scheduled
# Code: FULL
# Dispo: home with services.
Medications on Admission:
1. Ciprofloxacin 250 mg qday
2. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID
3. Levothyroxine 88 mcg qday
4. Nadolol 10 mg qday
5. Omeprazole 20 mg qday
6. Rifaximin 200 mg tid
7. Zinc Sulfate 220 mg [**Hospital1 **]
8. Furosemide 20 mg qday
9. Spironolactone 25 mg qday
10. Ursodiol 600 mg qAM, 300 mg qPM
12. Acidophilus Oral
13. Iloprost Inhalation
14. Magnesium Oral
15. Calcium Oral
16. Cholecalciferol (Vitamin D3) Oral
17. White Petrolatum-Mineral Oil Ophthalmic
Discharge Medications:
1. Outpatient Lab Work
Please have INR, Total bilirubin, Creatinine, Sodium, Albumin
checked daily in am, starting on Thursday, [**3-28**]
2. Tube Feeds
Pt requires tube feeds below as nutritional status is poor in
setting of liver disease. PO intake alone is inadequate.
.
Nutren 2.0 Full strength;
Starting rate: 30 ml/hr; Advance rate by 10 ml q4h Goal rate: 30
ml/hr
Hold feeding for residual >= : 100 ml
Flush w/ 30 ml water q4h
Other instructions: No residuals with post pyloric feeding tube
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
[**Month/Day (4) **]:*1 bottle* Refills:*1*
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
[**Month/Day (4) **]:*30 Tablet, Chewable(s)* Refills:*1*
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO Q AM ().
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
[**Month/Day (4) **]:*30 Tablet(s)* Refills:*2*
13. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
14. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO QID (4 times
a day): Titrate to >6 BM daily.
15. Iloprost 10 mcg/mL Solution for Nebulization Sig: 2.5 MLs
Inhalation 6 times per day ().
16. Tube Feed Supplies
Pump, pole, backpack, 60cc syringes, feeding bags
Quantity sufficient for 1 month with 11 refills
17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)).
[**Month/Day (4) **]:*60 Tablet(s)* Refills:*2*
19. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO QPM
(once a day (in the evening)).
20. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO QPM (once a day
(in the evening)).
[**Month/Day (4) **]:*90 Tablet(s)* Refills:*1*
21. Furosemide 40 mg Tablet Sig: Five (5) Tablet PO QAM (once a
day (in the morning)).
[**Month/Day (4) **]:*150 Tablet(s)* Refills:*1*
22. Codeine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO twice a day
as needed for pain for 7 days.
[**Month/Day (4) **]:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary:
Cirrhosis secondary to alcohol use and Hepatitic C infection
Pulmonary hypertension
Recurrent hepatic encephalopathy
Recurrent ascites secondary to liver disease
Secondary:
Hypothyroidism
Anxiety
Discharge Condition:
hemodynamically stable, afebrile, satting well on RA, AOx3
Discharge Instructions:
You were admitted for possible liver transplantation. While you
in the OR, you were found to have elevated pressure in your
pulmonary system, and your [**Month/Day (4) **] was put on hold
temporarily. These pressures improved with diuresis, and you
were placed back on the [**Month/Day (4) **] list. You are still on the
[**Month/Day (4) **] list and should continue to be adherent to your
medication regimen and follow up with your appointments.
.
The following changes have been made to your medications:
INCREASE Lasix to 200mg PO every morning, 100mg PO every evening
INCREASE Spironolactone to 200mg PO every morning, 100mg PO
every evening
DECREASE Ursodiol to 600mg PO every morning only
INCREASE Magnesium oxide to 200mg PO twice daily
CONTINUE Simethicone 40-80mg PO 4 times daily as needed for gas
or bloating
CONTINUE Miconazole powder as needed for itching
CONTINUE Midodrine 7.5mg PO three times daily
CONTINUE Codeine 15-30ml PO twice daily AS NEEDED for
breakthrough pain x 1 week
You can use Tylenol 325-650mg PO AS NEEDED for pain also, just
limit your total daily dose to 2000mg maximum.
.
If you experience any fever, chills, abdominal pain, worsening
swelling, nausea, vomiting, diarrhea, shortness of breath, or
ED.
Followup Instructions:
MD: [**First Name8 (NamePattern2) 2943**] [**Doctor Last Name 696**]
Specialty: Liver
Date and time: [**2148-3-29**] at 1pm
Location: [**Hospital Ward Name 517**] [**Last Name (NamePattern1) 439**] [**Hospital Ward Name **] Bldg
Phone number: [**Telephone/Fax (1) 2422**]
Completed by:[**2148-4-15**]
ICD9 Codes: 5849, 2761, 4168, 4280, 2449, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7266
} | Medical Text: Admission Date: [**2194-12-19**] Discharge Date: [**2194-12-31**]
Date of Birth: [**2194-12-19**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Known lastname 64891**] was delivered at 35-6/7
weeks gestation with a birth weight of 3520 grams and was
admitted to the newborn intensive care nursery from Labor and
Delivery for management of respiratory distress.
Mother is a 39-year-old Gravida 1, Para 0 now 1 mother with
estimated date of delivery [**2195-1-19**]. Prenatal screens
included blood type O+, antibody screen negative, hepatitis B
surface antigen negative, RPR nonreactive, rubella immune and
group B strep unknown.
Her prenatal course was notable for in [**Last Name (un) 5153**] fertilization
pregnancy with normal 1st trimester ultrasound and recurrent
HSV outbreaks during the pregnancy with an outbreak 1 day
prior to delivery. Infant was delivered by cesarean section
due to HSV. Membranes were ruptured at delivery. No maternal
fever. Apgar scores were 8 at 1 minute and 8 at 5 minutes.
The baby delivered respiratory distress around 10 minutes of
age and was transferred to the newborn intensive care for
evaluation and management.
PHYSICAL EXAMINATION ON ADMISSION: Weight 3520 grams
(greater than 90th percentile); length 19 inches (50th-75th
percentile); head circumference 34.5 cm (greater than 90th
percentile). Anterior fontanel open, flat. Infant active with
moderate respiratory distress, nasal flaring and grunting.
Normal S1, S2. No heart murmur. All breath sounds distant,
equal. Abdomen: Soft, nontender, nondistended. Extremities:
Well perfused. Tone appropriate for gestational age. Testes
descended bilaterally. Patent anus. Spine intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Chest x-
ray and clinical course consistent with respiratory distress
syndrome. Received 1 dose of surfactant and was extubated on
day of life 1 to nasal CPAP. [**Doctor First Name **] weaned off CPAP on day of
life 4. He required supplemental oxygen via nasal cannula
then weaned to room air on day of life 9 ([**2194-12-28**]).
He has remained in room air since with comfortable work of
breathing. Respiratory rate is in the 30s-60s.
Cardiovascular: Has been hemodynamically stable throughout
hospital stay with heart rates ranging from 130s-160s. No
murmur. Recent blood pressure 75/37 with a mean of 51.
Fluids, electrolytes, nutrition: Remains NPO until day of
life 4 when enteral feeds were started. He advanced to full
feeds on day of life 5. At discharge he is ad lib. breast
feeding when mother is here. Bottle feeding expressed breast
milk when mother is not here and feeding well. Discharge
weight 3200 grams.
GI: Peak bilirubin was a total of 13.8, direct 0.4 on day of
life 5. He was treated with a bilirubin blanket for 2 days.
His bilirubin has come down with the most recent bilirubin on
[**2193-12-30**], with a total 10.5, direct 0.3.
Hematology: Hematocrit on admission 54%.
Infectious disease: A CBC and blood culture were drawn on
admission due to respiratory distress. He received 48 hours
of ampicillin and gentamicin. The blood culture was negative.
CBC was benign.
Neurology: Exam age appropriate.
Sensory: Hearing screening was performed with automated
auditory brainstem responses and passed both ears.
CONDITION AT DISCHARGE: A 12-day-old infant now 37-4/7 weeks
postmenstrual age.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 55565**] at [**Hospital 932**]
Pediatrics. Telephone number: [**Telephone/Fax (1) 42011**].
CARE RECOMMENDATIONS:
1. Feeds ad lib. demand breast feeding.
2. Medications: Tri-Vi-[**Male First Name (un) **] 1 ml orally daily.
3. Ferrous sulfate (25 mg/ml) 0.3 ml orally daily.
4. Carseat pending.
5. State newborn screen. Initial screen showed a slightly
elevated 170H. A repeat newborn screen was done on
[**12-27**] and is pending.
IMMUNIZATIONS RECEIVED: Received hepatitis B immunization on
[**2194-12-27**].
NEWBORN SCREEN: Initially sent on [**2194-12-22**] was noted to have a
17-OH-Progesterone/Adrenal Hyperplasia (CAH) level that was
minimally elevated 52.8 ng/ml (normal less than 50 ng/ml). A
repeat was sent [**2195-12-27**] with normal results teh
17-OH-Progesterone/Adrenal Hyperplasia (CAH) was less than 13.5
ng/ml (normal less than than 50 ng/ml).
FOLLOW-UP APPOINTMENTS: Parents have appointment at
pediatrician's office on [**2194-12-31**].
DISCHARGE DIAGNOSES:
1. Prematurity at 35-6/7 weeks.
2. Large for gestational age.
3. Respiratory distress syndrome, resolved.
4. Perinatal sepsis ruled out.
5. Physiologic jaundice.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2194-12-30**] 14:27:10
T: [**2194-12-30**] 15:45:46
Job#: [**Job Number 64892**]
ICD9 Codes: 769, 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7267
} | Medical Text: Admission Date: [**2163-12-24**] Discharge Date: [**2164-1-5**]
Date of Birth: [**2101-8-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
acute mitral regurg
Major Surgical or Invasive Procedure:
[**2163-12-26**] MVR (onx 25mm/33mm)
History of Present Illness:
62yo man with hx of asthma and mitral regurg comes in from OSH
with acute mitral regurgitation. Three months ago, he had
several weeks of a cough, treated with inhalers with
improvement. Then two days ago, he experienced CP, PND, and
orthopnea. This persisted. Last night, he had severe orthopnea
and had increasing fatigue so his wife brought him to OSH around
5am on [**12-24**].
.
At OSH, initial EKG showed sinus tachy, nl axis, nl intervals.
Peaked T waves V3-V4. CXR showed pulm edema. Received lasix 20
IV in ED. Then hypotensive so required NS bolus. Developed
resp distress so started BiPAP and solumedrol 150 IV. Received
another 20 IV lasix but BP dropped so received 1000 NS bolus.
To ICU: O2 sat remained low 80s% on 100% NRB. Intubated at
12:15pm w AC 500/16 100% PEEP 5. O2 sats remained 90-93%.
Sedated with propofol and fentanyl. No pressors were started.
.
Echo per report showed MV prolapse with likely acute flail
leaflet ? chordae rupture.
.
Patient transferred here urgently and went directly to cath lab.
Initial BP 80s/60. Tachycardic to 120. IABP placed and SBP
improved to the 90s, MAP at 65. Coronaries were examined and
were clean. Swan placed with wedge of 31 (with steep V waves),
RA 9, RV 64/19, PA 70/30 (51). TEE showed posterior mitral
leaflet flail and severe MR. Cardiac surgery consulted. The
IABP site on right was bleeding so it was resited to left groin.
MAPs dropped and cardiac index 1.55 so periph dopa started with
good response.
.
Also received lasix 40mg IV with approx 1L UOP in cath lab.
Creatinine increased from 1.4 to 1.8 then stabilized at 1.7.
ABGs here were 7.23/56/86 so RR increased. Then 7.31/43/138
then 7.26/48/97 w lactate 1.4 so Vt increased and Peep
increased.
Past Medical History:
Asthma
hernia repair
Mitral regurg: per wife, pt had systolic murmur noted on pre-job
physical years ago and has not had an echo or further workup
Social History:
married with wife. [**Name (NI) **] [**Name2 (NI) **] or etoh. works at a bakery.
functionally, very high functioning with good exercise
tolerance.
Family History:
No CAD or known structural heart disease
Father with parkinson's and stroke
Physical Exam:
VS: 97.3 HR 102 Cuff pressure 95/65, [**Month (only) **] [**Last Name (un) 6043**] 103, assist
systole 90, PAP 51/43 (mean 47)
Dopa at 4
AC 600/22 FiO2 80% Peep 12
GEN: sedate but arousable to voice.
NEURO: opens eyes on request. Squeezes bilat hands and moves
feet on request.
HEENT: pupils pinpoint but equally reactive. MMM
CARDS: JVP 8-10 but diff to assess. Palpable thrill. Tachy,
regular. [**5-29**] holosystolic murmur at apex with heave.
RESP: crackles at based. on respirator
ABD: BS+ NT ND, holosystolic murmur heard at epigastrium. soft.
no rebound
EXT: no edema. 2+ DP and PT both feet (assessed by me and
intern). Groin sites: right with small 2x2 hematoma, no bruit.
left with art and venous lines.
ACCESS: Right IJ CVL (OSH line), left arterial balloon pump
groin, left venous swan.
PULSES: as above
Pertinent Results:
[**2164-1-5**] 06:45AM BLOOD WBC-13.9* RBC-3.93* Hgb-11.6* Hct-34.9*
MCV-89 MCH-29.4 MCHC-33.1 RDW-13.8 Plt Ct-887*#
[**2163-12-24**] 06:00PM BLOOD WBC-21.4* RBC-4.50* Hgb-14.2 Hct-41.8
MCV-93 MCH-31.5 MCHC-33.9 RDW-13.3 Plt Ct-387
[**2164-1-5**] 06:45AM BLOOD Plt Ct-887*#
[**2164-1-5**] 06:45AM BLOOD PT-29.2* PTT-146.7* INR(PT)-3.1*
[**2164-1-4**] 06:30AM BLOOD PT-21.5* PTT-94.4* INR(PT)-2.0*
[**2164-1-3**] 01:10PM BLOOD PT-17.4* PTT-45.7* INR(PT)-1.6*
[**2164-1-3**] 10:40AM BLOOD PT-17.7* INR(PT)-1.6*
[**2164-1-2**] 09:18PM BLOOD PT-16.2* PTT-31.5 INR(PT)-1.5*
[**2164-1-5**] 06:45AM BLOOD Glucose-108* UreaN-21* Creat-1.2 Na-139
K-4.7 Cl-101 HCO3-26 AnGap-17
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 75295**], [**Known firstname 251**] [**Hospital1 18**] [**Numeric Identifier 75296**] (Complete)
Done [**2163-12-26**] at 10:08:04 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2101-8-17**]
Age (years): 62 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Cardiogenic shock for MVR.
ICD-9 Codes: 428.0, 786.05, 799.02, 424.1, 424.0
Test Information
Date/Time: [**2163-12-26**] at 10:08 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 #: 2007AW-:1 Machine: [**Pager number 30532**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe
(4+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: No 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
This was a focused study on patient in shock, with IABP, for
urgent MVR.
Pre-Bypass: No spontaneous echo contrast is seen in the left
atrial appendage. There is moderate global right ventricular
free wall hypokinesis. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The aortic valve leaflets are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Severe (4+) mitral
regurgitation is seen. There is no pericardial effusion.
Post Bypass: Patient is on Milrinone. Well-seated and
functioning mitral prosthesis. No leak, no MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta
intact. RV systolic fxn is good. LV is globally mildly
depressed.
Brief Hospital Course:
He was taken to the operating room on [**2163-12-26**] where he
underwent an MVR. He was transferred to the ICU in critical but
stable condition on milrinone, neo and propofol. He
inadvertently pulled out his own balloon pump but remained
stable. He was extubate on POD #1. He was given 48 hours of
perop vancomycin because he was in the hospital preoperatively.
He was transfused for HCT 22. He was started on coumadin for his
mechanical valve. He was pancultured for elevated wbc and
started on Zosyn for presumed aspiration pneumonia. He
initially failed swallow evaluation and was seen by ENT for
question of pharyhgeal pouch seen on video swallow. He was
transferred to the floor on POD #5. He passed repeat swallow
evaluation. He remained on heparin gtt awaiting a therapeutic
INR, and was ready for discharge home on POD # 10. He completed
a one week course of zosyn. His wife spoke with Dr. [**Last Name (STitle) **]
office who has agreed to follow his coumadin, doses and
discharge info were faxed there.
Medications on Admission:
Beclomethasone
Advair
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
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:*0*
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses: Check INR [**1-6**] with results to Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
MR now s/p MVR
acute systolic heart failure
Asthma
Discharge Condition:
good.
Discharge Instructions:
Calll with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week,
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Coumadin to be followed by Dr. [**Last Name (STitle) **], have INR checked
[**1-6**].
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) **] 2 weeks and for coumadin follow up
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2164-1-5**]
ICD9 Codes: 4240, 5849, 5070, 4280, 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7268
} | Medical Text: Admission Date: [**2188-7-16**] Discharge Date: [**2188-7-23**]
Date of Birth: [**2144-6-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
"groggyness," confusion, and HA s/p gemzar infusion 1 day prior
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patinet is a 44 y/o male w/ hx of metastatic renal cell
cancer currently Sutent and Gemzar C5D9 who presenting to clinic
after D8 Gemzar w/ fatigue, headache, and confusion. the
patient reports a history of headaches, lethargy, and N/V
following chemotherpay. This headache recurred early this
morning as the patient awoke at 4am. He took one Percocet and
went back to sleep in addition to his normal nightly
percocet/ativan for sleep. He then awoke at 9am confused with
word finding difficulties. His wife noticed he was confused as
if "half awake, half asleep, as if he was in the middle of a
dream." His reports that this "fog" has improved, but not to
baseline. He was with a hyperkalemia of 5.5 on yesterday's lab,
which persists today.
He is denying any worsening or change in quality of the
headache,
nausea, vomiting, fever, chills, vision changes, weakness, or
recent falls. He is able to walk without difficulty. No chest
pain, shortness of breath, abdominal pain, diarrhea, melena, or
brbpr. He denies muscle pain, decreease in motor strength,
sensory abnormalities. No bloot noted in urine, no worsening of
baseline edema. Current ECOG: 2.
Past Medical History:
Presented with low grade fevers,
night sweats, and microscopic hematuria. CT scan on
[**2187-10-30**] which revealed a large L renal mass measuring 9.7 x
8.7 x 12 cm. They also noted enlarged lymph nodes and very
small bilateral pulmonary nodules reported as probable
metastatic lesions. He underwent a debulking nephrectomy,
regional lymph node dissection on [**2187-11-16**]. He was started on
the dendritic cell fusion vaccine on [**2-6**] but had a poor
response. He was then started on Sutent & Gemzar on [**2188-4-8**]
Protocol # 04-385.
Social History:
He is married with 3 children. Employed as a lawyer at a
pharmaceutical company. He denies tobacco, alcohol, or IVDA.
Family History:
Sister with [**Name (NI) 4522**] disease. No other history of
gastrointestinal diseases.
Physical Exam:
GEN: Alert, oriented x 3. Appears chronically ill.
HEENT: anicteric, OP clear, moist MM
NECK: supple without cervical, supraclavicular, infraclavicular,
lympadenopathy
CV: reg rate, S1,S2, no MRG
PULM: CTAB
ABD:soft, non-tender, nondistended, No HSM
EXT: 2+ pitting edema to mid-thigh
Skin: pale, follicular eruption on face
Neuro: Cranial nerves II-XII intact, No abnml in coordination,
gait, fine motor activity, or strength. Neg Romberg. No
dysdyadikenisis, FTK intact. 30/30 mini-mental.
Pertinent Results:
[**2188-7-16**] 11:58AM UREA N-23* CREAT-2.0* SODIUM-135
POTASSIUM-5.5* CHLORIDE-113* TOTAL CO2-16* ANION GAP-12
[**2188-7-16**] 11:58AM ALT(SGPT)-64* AST(SGOT)-63* LD(LDH)-370*
CK(CPK)-101 ALK PHOS-202* TOT BILI-0.2 DIR BILI-0.1 INDIR
BIL-0.1
[**2188-7-16**] 11:58AM WBC-4.1 RBC-3.48* HGB-11.3* HCT-34.0* MCV-98
MCH-32.6* MCHC-33.3 RDW-23.4*
[**2188-7-16**] 11:58AM NEUTS-85.3* BANDS-0 LYMPHS-11.7* MONOS-1.3*
EOS-0.7 BASOS-0.9
[**2188-7-16**] 11:58AM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL
TARGET-1+ BURR-OCCASIONAL TEARDROP-1+
[**2188-7-16**] 11:58AM PLT SMR-LOW PLT COUNT-108*
[**2188-7-16**] 11:58AM GRAN CT-3490
[**2188-7-15**] 11:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2188-7-15**] 11:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2188-7-15**] 11:30AM URINE RBC-2 WBC-6* BACTERIA-NONE YEAST-NONE
EPI-0
[**2188-7-15**] 09:27AM GLUCOSE-136* UREA N-17 CREAT-2.1* SODIUM-135
POTASSIUM-5.5* CHLORIDE-111* TOTAL CO2-19* ANION GAP-11
[**2188-7-15**] 09:27AM estGFR-Using this
[**2188-7-15**] 09:27AM ALT(SGPT)-77* AST(SGOT)-71* LD(LDH)-373*
CK(CPK)-122 ALK PHOS-231* AMYLASE-78 TOT BILI-0.2 DIR BILI-0.1
INDIR BIL-0.1
[**2188-7-15**] 09:27AM LIPASE-23
[**2188-7-15**] 09:27AM ALBUMIN-1.8* CALCIUM-7.8* PHOSPHATE-4.2
MAGNESIUM-2.8* URIC ACID-5.0
[**2188-7-15**] 09:27AM WBC-3.7* RBC-3.60* HGB-11.6* HCT-35.6*
MCV-99* MCH-32.1* MCHC-32.5 RDW-22.7*
[**2188-7-15**] 09:27AM NEUTS-63.0 LYMPHS-29.0 MONOS-2.5 EOS-3.9
BASOS-1.7
[**2188-7-15**] 09:27AM PT-12.4 PTT-27.9 INR(PT)-1.1
.
IMAGING
[**7-16**] MRI HEAD W AND W/OUT CONTRAST: IMPRESSION:
1. Multiple areas of FLAIR hyperintensity in bilateral frontal,
parietal, temporal and occipital white matter, predominantly in
the frontal and parietal lobes, with some restricted diffusion;
no mass effect or enhancement. This could most likely represent
changes associated with reversible leukoencephalopathy or
progressive multifocal leukoencephalopathy. Superimposed
ischemic or infarction changes can be present given the
restricted diffusion on the diffusion-weighted sequences.
2. Metastasis is unlikely given the lack of enhancement.
.
[**2188-7-16**] CT HEAD W/O CONTRAST
Bilateral white matter hypodense areas in parietal and
occipital, and in left frontal white matter. These may represent
associated metastatic lesions versus other white matter changes
like reversible leukoencephalopathy. Infarction is unlikely
given the appearance of the hypodense areas which suggest
vasogenic edema.
However, accurate assessment is limited due to the lack of IV
contrast.
Pt. needs MRI scan of the brain with IV gadolinium, for more
accurate assessment.
.
[**2188-7-18**] CT HEAD W/O CONTRAST
1. There is no significant interval change from prior exam.
There is no evidence of hemorrhage, hydrocephalus, mass effect,
or large vascular territory infarction.
2. Again seen are hypodense areas in the left frontal, bilateral
parietal, and bilateral occipital white matter. There is no
change to the appearance of these regions. These are
inadequately evaluated on the non-contrast CT study.
.
[**2188-7-18**] Neurophysiology EEG
This is an abnormal portable EEG due to intermittent right
frontocentral slowing as well as intermittent generalized
slowing in the
setting of a slow and disorganized background. The first finding
suggests an area of subcortical dysfunction in the right
frontocentral
region. The other is consistent with a moderate encephalopathy,
suggestive of diffuse or deeper midline dysfunction.
Medications,
metabolic disturbances, infections and anoxia are among the
common
causes of encephalopathy. There were no clearly epileptiform
features
noted however.
.
[**2188-7-19**] Radiology RENAL U.S. PORT
Examination was markedly limited due to patient's altered mental
status. Specifically, patient was unable to hold breath during
the examination.
The right kidney measures 11.7 cm, and was grossly normal in
son[**Name (NI) 493**] appearance, without evidence of large solid mass,
stone, or hydronephrosis.
Limited examination of the left renal fossa was unremarkable.
IMPRESSION: Unremarkable son[**Name (NI) 493**] appearance of the right
kidney.
.
[**2188-7-21**] Radiology MR HEAD W & W/O CONTRAST
Confluent symmetric foci of T2 prolongation in the posterior
brain, predominantly in the posterior brain white matter,
including the posterior aspects of the frontal lobe and much of
the parietal and occipital lobes, and another focus in the left
frontal periventricular white matter, are unchanged. There is no
enhancement or mass effect associated with these lesions. There
is slight restricted diffusion noted, corresponding to the
areas, however, not significantly changed since last
examination. No hemorrhage, edema, or infarction are identified.
The ventricles and sulci are normal in configuration. No
abnormal enhancement after contrast administration is seen. Mild
mucosal thickening of the left maxillary, right frontal, and
scattered ethmoid air cells are seen.
IMPRESSION: Multiple areas of FLAIR and T2 prolongation in a
pattern similar to the [**2188-7-16**] examination, most likely
representing posterior reversible leukoencephalopathy, without
significant change.
.
[**2188-7-18**] Radiology CHEST (PORTABLE AP)
A left retrocardiac opacity could represent early pneumonia.
Recommend correlation with dedicated PA and lateral films. There
are no pleural effusions. The cardiomediastinal silhouette is
normal. Surgical clips are again noted in the left upper
abdomen.
IMPRESSION: Possible early pneumonia in retrocardiac region.
Correlation with dedicated PA and lateral film is recommended.
.
[**2188-7-21**] Radiology CHEST (PORTABLE AP)
The heart size is mildly enlarged but stable. The mediastinal
contours are unremarkable. The left lower lobe retrocardiac
consolidation markedly increased in the meantime interval and
might represent combination of atelectasis and pneumonia. Small
left pleural effusion is noted. The rest of the lung is
unremarkable. The clips of left nephrectomy are demonstrated.
IMPRESSION: Rapid development of left lower lobe retrocardiac
consolidation consistent with atelectasis and/or pneumonia.
.
[**2188-7-15**] Cardiology ECG Normal sinus rhythm. Flat T waves in
lead aVL. No diagnostic abnormality. Compared to the previous
tracing of [**2188-5-20**] no significant change.
.
[**2188-7-18**] Cardiology ECG Baseline artifact
Sinus rhythm Probable normal ECG, although baseline artifact
makes assessment difficult. Since previous tracing of the same
date, probably no significant change
Brief Hospital Course:
#) Mental status changes: At the time of admission the patient
had a significant improvement of mentation compared to morning
of presentation, and belief was that was neither narcotic
induced confusion or secondary to metabolic derangments. Over
the course of the second day of admission, the patient showed a
worsening level of mentation throughout the day, with
progressive deterioration such that the patient displayed
deficts with each portion of mini-mental exam. MRI hyperintense
lesions of FLAIR c/w leukoencephalopathy w/ areas of
questionable stroke. Neurology was consulted, who gave
diagnosis of reversible posterior leukoencephalopathy, most
likely secondary to patient's hypertension (sbp of 160s) vs.
chemotherapy induced. Given findings of CT/MRI, past sutent use
with known side effects, cause is likely reversible posterior
leukoencephalopathy from Sutent toxicity. Their recommendations
were for tight blood pressure control. Throughout the night,
the patient showed worsened mentation and a questionable
seizure. Blood pressures were too difficult to control on floor
and there was concern over mental status/ability to tolerate
POs, so he was admitted to ICU on [**7-18**]. (Pt failed IV
hydralazine x 10mg in ICU and IV diltiazem/ lopressor on floor.
EEG results showing moderate encephalopathy suggestive of
subcortical dysfunction. Pt was started on Nitro and esmolol gtt
for BP control, with goals SBPs 120-130. Over the first few days
in the ICU the patient had waxing [**Doctor Last Name 688**] mental status, was
intermittently extremely agitated, requiring 1:1 sitter, 4-point
restraints and increasing doses of zyprexa. By [**7-20**] and [**7-21**]
with improved BP control, and off pressor drips, the patient's
MS greatly improved and now has clear sensorium and asking
appropriate, in-depth questions. MRI [**7-21**] showed no significant
change per official read (possible improvement per Neuro). Was
transferred back to floor [**7-22**]. Patient was observed for an
additional two days, and ultimatly discharged to home.
.
#)HTN: Pt w/o hx of htn, may be [**1-4**] to sutent. Was started on
night of admission on 25mg of metoprolol TID. On the floor was
switched to dilt, and was titrating up w/ decrease of sbp to
140s, but pt unable to tolerate PO medication [**1-4**] to difficulty
swallowing. Pt failed IV hydralazine x 10mg in ICU and IV
diltiazem/ lopressor on floor and was transferred to the MICU as
above for better BP control. Was started on nitro and esmolol
drip and was weaned to only po metoprolol by [**7-21**]. He was also
duiresed with IV lasix 60mg daily. Patient was discharged on
metoprolol 25mg TID, and as sutent clears system, intention to
titrate down as tolerated if BP decreases.
#) Hyperkalemia: Patient presented with a potassium of 5.5 on
admission, unclear etiology. Given acidosis, kayexalate was
held, and patient was initially treated with IV HCO3. The
patient had serial EKGs with no abnormalities. Despite a small
improvement, patient had worsened potassium of 5.7, and
kayexalate was given. In the ICU he was treated with 60mg IV
lasix daily and his hyperkalemia resolved. K+ of 4.1 at time of
discharge.
#) Metabolic acidosis: Again, unclear etiology. Pt shows
worsened renal fxn based off Cr at 2.3, which has been trending
upwards for the last month. Non-gap metabolic acidosis with
urine lytes consistent with type I or IV RTA, likely secondary
to ARF.
.
# ARF: Pt with past baseline Cr 1.5. Bumped to 2.4 and
hyperkalemic, but trending downwards to 1.7 at time of
discharge. No clear insult, though may be related to
medication/chemo, worsening malignancy, or possibly related to
hypertension (which could explain improvement with better BP
control). Obstructive cause ruled out by renal US, cortisol
normal making mets to adenals less likely cause. No recent
antibiotics and no urine eos to suggest interstitial nephritis.
FeUrea 52%, non-suggestive of prerenal etiology. Making good
urine with lasix. Avoided ACEI given ARF.
.
# Leukocytosis/pancytopenia: On the floor, WBC was trending
upwards in setting of recent Neulasta, now trending down. No
current signs of infection, though CXR with possible
retrocardiac opacity. Cultures NGTD. Likely [**1-4**] to chemo as
other cell lines down as well. Baseline Hct around 30. HCT and
platelets continue to trend downwards. Likely related to
inflammation and malignancy or secondary to chemo per onc. No
signs of active bleeding. Has fluctuated in past in relation to
chemo treatments. Coag wnl arguing against DIC/consumptive
process/hemolysis.
.
Transaminitis: Appears relatively chronic and stable over last
few months. Past US without liver pathology or thrombosis.
Thought to be related to sutent. Currently asymptomatic by exam
with normal bili.
.
Glucosuria:
Glucosuria on U/A, and elevated serum values recently, fasting
glucose in 80s.
Medications on Admission:
VB12
Iron
MVI
Ativan 1mg qhs/ qdinner
percocet 5mg qhs
lasix PRN
Discharge Medications:
1. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Posterior Leukoencehalopathy
Hytertensive emergency
Acute Renaly Failure
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after admission for
change in mental status. MRI was consistent with a condition
known as posterior leukoencephalopathy, which is most likely
caused by the sutent chemotherapy. You were also found to be
hypertensive, which also can be a cause of this neurologic
condition. Your sutent was held and tight blood pressure
control was targeted. In order to achieve this control, you
were admitted to the ICU. Over the course of a week, your
mentation returned to [**Location 213**] and BP control has been achieved on
oral medications. You are being discahrged on this medication,
and the decision to continue sutent to be discussed with your
primary oncologist as an outpatient.
You were also noted to have electolyte abnormalities and
evidence of acute renal failure on admission. These
abnormalities have resolved, and it your kidney function is
improving toward your baseline. These should be followed in to
assessed as an outpatient for continued improvement.
Your blood counts have additionally fell over the course of
this admission, believed to be secondary to the gemzar dose you
had received. You were given a blood transfusion and neupogen
to bolster these numbers. These too should be followed as
outpatient.
You are being discharged on hypertensive medications, which
may be able to be stopped now that sutent has been withdrawn.
You blood pressure should be followed as an outpatient.
If you develop severe headache, nasua/vomiting, increased
confusion, dizziness call your doctor.
Followup Instructions:
Provider: [**Name Initial (NameIs) 455**] 6-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2188-7-29**] 9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10645**] Call to schedule
appointment
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
ICD9 Codes: 5849, 2767, 2762, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7269
} | Medical Text: Admission Date: [**2150-10-8**] Discharge Date: [**2150-10-25**]
Date of Birth: [**2079-4-9**] Sex: M
Service: CARDTHOR S
DIAGNOSIS: Coronary artery disease for coronary artery
bypass graft.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 71 year old
gentleman with a history of stable mild exertional angina
since the early [**2116**]. He has been medically managed through
the years and has been tolerating management well. He
describes his symptoms as mild pressure across the chest
which resolved with rest. He walks approximately four miles
each day as well.
On [**2150-8-26**], he had a stress test and developed
angina after four minutes, showing [**Street Address(2) 31707**]
depressions in leads V4 through V6. Follow-up imaging
revealed a mild to moderate sized reversible anteroseptal and
antero-apical defect. His ejection fraction was noted to be
48% at the time.
Subsequently he underwent cardiac catheterization at the [**Hospital1 1444**] on [**2150-10-6**], which
revealed left ventricular ejection fraction of 55% with a
mitral regurgitation. He was also shown to have 80% stenosis
of the proximal right coronary artery, 100% stenosis of the
distal right coronary artery, 50% stenosis of the left main
artery, 100% stenosis of the mid left anterior descending,
80% stenosis of the proximal circumflex.
He was admitted on the same day for a coronary artery bypass
graft.
PAST MEDICAL HISTORY:
1. Coronary artery disease times 30 years.
2. Hypertension.
3. Hypercholesterolemia.
4. Noninsulin dependent diabetes mellitus.
5. Moderate chronic obstructive pulmonary disease.
6. Status post repair of triple aneurysm in [**2148-5-10**].
7. Status post suprapubic prostatectomy.
MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Diltiazem 180 mg p.o. q. day.
3. Lipitor 10 mg p.o. q. h.s.
4. Glucotrol XL 2.5 mg p.o. q. day.
5. Lisinopril 5 mg p.o. q. day.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: His family history is unremarkable except
for a small history of cerebrovascular accidents.
SOCIAL HISTORY: He currently lives at home with his wife.
[**Name (NI) **] had admitted to smoking heavily with a 90 pack year
smoking history, but quit 14 years prior. He rarely drinks
any alcohol.
PHYSICAL EXAMINATION: On physical examination when he was
admitted, he was afebrile with stable vital signs. He had
full extraocular movements and his pupils were equal and
reactive and he had no palpable cervical nodes. His neck was
supple with no lymphadenopathy. His carotids were two plus
bilaterally with no bruits. His lungs were clear to
auscultation. He had an irregular pulse and normal heart
sounds with no murmurs. His abdominal examination was
benign. His abdomen was nontender to palpation with normal
bowel sounds and no palpable masses. He had good peripheral
pulses with warm extremities. He had no peripheral edema.
HOSPITAL COURSE: He was admitted to the hospital on [**2150-10-6**], for a coronary artery bypass graft. On [**2150-10-8**], he was taken to the Operating Room for a coronary
artery bypass graft times four. He had his left internal
mammary artery grafted to the left anterior descending;
saphenous vein graft to the diagonal and obtuse marginal, and
the saphenous vein graft to the patent ductus arteriosus. He
was placed under general anesthesia and intubated for the
procedure. He tolerated the procedure well and recovered
without complications.
Postoperatively he did well. He remained neurologically
intact and his Neo-Synephrine was weaned. On postoperative
day four, he experienced an episode of atrial fibrillation.
He was started on an amiodarone drip after a bolus and then
converted to 400 mg p.o. twice a day. He converted back to
sinus rhythm.
He experienced some agitation while in the Intensive Care
Unit and became suddenly confused and belligerent. He became
paranoid and refused certain treatments. Psychiatry was
called for consultation and the diagnosis of postoperative
delirium was made. He was started on Haldol 2 mg p.o. three
times a day p.r.n. and he continued to improve.
On postoperative day six, he was started on Lopressor 25 mg
p.o. twice a day.
On postoperative day seven, he was noted to have some
subcutaneous emphysema and air leak in the mediastinal tube
was noted. The right chest tube was removed on postoperative
day eight but he persisted in having an air leak.
Ultimately, he had three chest tubes placed, one mediastinal
and two additional chest tubes. He continued to have an air
leak.
Cardiology was consulted for his postoperative paroxysmal
atrial fibrillation in which he developed significant pauses
while on metoprolol, amiodarone and Haldol. They felt that
his intrinsic sinus node function was okay. They suggested
resuming his metoprolol 25 mg p.o. twice a day, holding the
amiodarone, and then anti-coagulating him if atrial
fibrillation persisted. If this was required, they would
follow-up after the chest tubes were removed for replacement.
He continued to have some episodes of supraventricular
tachycardia which the Electrophysiology fellow thought was
atrial flutter. During one of these episodes, a 12 lead EKG
was obtained which was suggestive of atrial flutter. The
plan from Cardiology was then to ablate him once the chest
tubes were removed.
He remained in the unit on postoperative day 15 with a
persistent leak. Both chest tubes and his mediastinal tubes
were clamped on postoperative day 15 and then one chest tube
was removed on hospital day 15. His air leak has gradually
been decreasing as well as the subcutaneous emphysema.
On postoperative day 16, he was transferred to the floor. He
was doing well with stable vital signs and in sinus rhythm.
His remaining chest tube on the right was removed and his
mediastinal tube was converted to a Heimlich valve with a
Foley bag attachment. That evening, he had a short period of
atrial fibrillation in which he spontaneously converted back
to sinus rhythm.
He has currently been more than 24 hours without an
arrhythmia. He is stable with normal vital signs. He has
been ambulating with assistance and tolerating his p.o.
intake well. He has had bowel movements. His air leak has
continuously been improving.
He is finally stable for discharge home with follow-up
Physical Therapy. He is to follow-up with Dr. [**Last Name (STitle) 1537**] in four
weeks. He has been told to follow-up with his primary care
physician and his Cardiologist in one to two weeks. He has
been advised not to lift weights greater than ten pounds for
three months. He was advised not to drive for one month or
while on pain medications.
DISCHARGE MEDICATIONS:
1. Metoprolol 12.5 mg p.o. twice a day.
2. Lasix 20 mg p.o. twice a day times seven days.
3. Potassium chloride 20 mEq p.o. twice a day times seven
days.
4. Colace 100 mg p.o. twice a day.
5. Enteric-coated aspirin 325 mg p.o. q. day.
6. Percocet 5/325 mg one to two tablets p.o. q. four to six
hours for pain p.r.n.
7. Glipizide 2.5 mg, one tablet p.o. q. day.
8. Lipitor 10 mg tablet p.o. q. day.
9. Haldol 1 mg p.o. three times a day p.r.n.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 50046**]
MEDQUIST36
D: [**2150-10-24**] 18:09
T: [**2150-10-24**] 18:26
JOB#: [**Job Number 50047**]
ICD9 Codes: 496, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7270
} | Medical Text: Admission Date: [**2145-7-10**] Discharge Date: [**2145-7-14**]
Date of Birth: [**2088-9-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Hypotension at dialysis
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
56 year-old male with HCV cirrhosis, ESRD on HD, recent
hypotension in the setting of large-volume paracentesis or
dialysis presenting with hypotension to 56/32 15 minutes into
dialysis the day of admission. The patient states he was "a
little dizzy" at the time, however, denied presyncope, chest
pain, shortness of breath, palpitations. The patient also
complained of the gradual onset of sharp LUQ pain, nonradiating,
after being placed in Trendelenberg. The pain resolved when
taken out of Trendelenberg. He denied fevers, chills, sweats,
nausea, vomiting, hematemesis, change in [**4-14**] BM/day on
lactulose, melena, recent hematochezia - he had one episode of
BRBPR only with wiping a few weeks prior. He was given 1L NS and
transferred to the ED for further evaluation.
.
In the ED, initial VS: T 97.8 HR 110 BP 91/53 RR 20 SaO2 98%RA.
Blood pressure subsequently dropped to 74/45. EKG unchanged from
prior. Chest x-ray showed question LLL pneumonia. Abdominal CT
showed ascites but was otherwise negative for acute pathology.
The patient received 4L NS with improvement in SBP to 90-100s. A
therapeutic paracentesis was attempted but unsuccessful. The
patient was given zosyn.
.
Currently, the patient has no complaints.
.
ROS: As above. Denies headache, vision changes, rhinorrhea,
congestion, pharyngitis, cough, myalgias. Patient is anuric.
Review of systems otherwise negative in detail.
Past Medical History:
1. Hepatitis C and alcoholic cirrhosis:
- Complicated by encephalopathy, portal HTN w/ portal
hypertensive gastropathy, grade I varices, and ascites requiring
q2-3weekly paracentesis
- Followed at the [**Hospital3 2358**] for liver transplantation
- Also followed by Dr. [**Name (NI) **]
2. ESRD:
- On HD T/Th/Sa
- Followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Hospital1 3494**]
3. Hypertension/Hypotension
- The patient had several anti-hypertensives discontinued as the
patient easily becomes hypotensive with dialysis
4. History of IVDU
5. Neuropathy
6. Osteoarthritis
7. Seizures:
- Patient with a history of two seizures - once in [**2141-4-11**],
seizure in the setting of new diagnosis of renal failure,
pneumonia, and alcohol use, second seizure in [**10-18**] with
generalized tonic-clonic seizure while at HD
- MRI in [**10-18**] remarkable for localized area of encephalomalacia
secondary to trauma
- EEG in [**10-18**] unremarkable
8. Tobacco Abuse
9. Type 2 Diabetes Mellitus:
- Not taking medication currently
- Presented with DKA in [**2144**]
- Followed at [**Last Name (un) **]
Social History:
Lives on his own. Currently unemployed. Smokes [**2-12**] pack per day.
History of alcohol abuse in the past, non recently. History of
IVDU, none recently.
Family History:
Non-contributory
Physical Exam:
On admission-
.
GENERAL: Alert, NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. OP clear. MMM.
NECK: Supple, no LAD.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally. No dullness to
percussion or egophony in the LLL.
ABDOMEN: NABS. Mildly distended, bulging flanks, shifting
dullness. No tenderness to palpation.
EXTREMITIES: Trace edema b/l, 2+ dorsalis pedis/posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: AAOx3. CN 2-12 are intact. Normal strength in all four
extremities. No asterixis.
Pertinent Results:
===========
Micro
===========
Blood culture 5/30x2 - No growth to date at time of discharge
.
===========
Labs
===========
[**2145-7-10**] 07:40AM BLOOD WBC-7.1 RBC-4.00* Hgb-12.9* Hct-39.3*
MCV-98 MCH-32.2* MCHC-32.7 RDW-19.6* Plt Ct-155#
[**2145-7-11**] 01:10AM BLOOD WBC-6.6 RBC-3.53* Hgb-11.3* Hct-35.0*
MCV-99* MCH-32.2* MCHC-32.5 RDW-20.5* Plt Ct-71*
[**2145-7-12**] 04:55AM BLOOD WBC-7.0 RBC-3.64* Hgb-11.6* Hct-36.0*
MCV-99* MCH-31.8 MCHC-32.2 RDW-20.7* Plt Ct-72*
[**2145-7-14**] 04:50AM BLOOD WBC-7.5 RBC-3.66* Hgb-11.7* Hct-36.2*
MCV-99* MCH-31.9 MCHC-32.3 RDW-19.2* Plt Ct-78*
[**2145-7-10**] 08:54AM BLOOD Glucose-93 UreaN-23* Creat-8.5*# Na-141
K-3.1* Cl-110* HCO3-16* AnGap-18
[**2145-7-11**] 01:10AM BLOOD Glucose-92 UreaN-34* Creat-12.9*# Na-137
K-4.1 Cl-99 HCO3-22 AnGap-20
[**2145-7-12**] 04:55AM BLOOD Glucose-83 UreaN-48* Creat-15.9*# Na-142
K-4.2 Cl-103 HCO3-19* AnGap-24*
[**2145-7-13**] 04:55AM BLOOD Glucose-87 UreaN-30* Creat-12.0*# Na-144
K-3.4 Cl-104 HCO3-25 AnGap-18
[**2145-7-14**] 04:50AM BLOOD Glucose-77 UreaN-35* Creat-13.8*# Na-141
K-3.5 Cl-102 HCO3-22 AnGap-21*
[**2145-7-10**] 08:54AM BLOOD ALT-29 AST-70* AlkPhos-131* TotBili-2.3*
[**2145-7-11**] 01:10AM BLOOD ALT-40 AST-82* AlkPhos-192* TotBili-2.9*
[**2145-7-13**] 04:55AM BLOOD ALT-35 AST-71* AlkPhos-159* TotBili-3.3*
[**2145-7-14**] 04:50AM BLOOD ALT-40 AST-82* AlkPhos-208* TotBili-2.9*
[**2145-7-10**] 08:55AM BLOOD Ammonia-162*
.
===========
Radiology
===========
RUQ u/s [**7-12**] -
Cirrhotic liver with a moderate amount of ascites. Patent portal
vein.
.
CT Abdomen and pelvis [**7-10**]
1. Nodular liver compatible with underlying cirrhosis. There is
moderate
ascites.
2. No evidence for bowel obstruction or bowel ischemia. There is
a single
non-specific loop of mildly prominent fecalized small bowel in
the left lower
quadrant, which demonstrates normal mucosal enhancement and no
distinct
transition points.
3. Atrophic kidneys compatible with underlying renal disease.
4. Atherosclerotic disease of the abdominal aorta with
aneurysmal dilatation.
.
CXR [**7-11**]
PA AND LATERAL VIEWS. Comparison with [**2145-7-10**]. The lungs now
appear clear.
The heart is normal in size. Mediastinal structures are
otherwise
unremarkable. The bony thorax is grossly intact. A possible
focal area of
increased density at the left base is no longer identified.
IMPRESSION: Clear lungs.
Brief Hospital Course:
# Hypotension: The patient has a recent history of hypotension
as an outpatient thought due to fluid shifts or aggressive fluid
removal during dialysis or large-volume paracentesis. His
episode on admission may be due to hypovolemia or fluid shifts.
SBP was back to 90-100s, which is his baseline per HD records
after 5L NS, without evidence of fluid overload. Also on the
differential is infection, with possible sources spontaneous
bacterial peritonitis versus pneumonia. The patient remains
afebrile and without leukocytosis, however. Culture data
remained negative. Hematocrit was down from baseline, however,
the patient denies gastrointestinal bleeding. Weight now 102.6
kg from recorded dry weight 95 kg (recent post-HD weight 99.2
kg). Patient was treated transiently with vancomycin and zosyn
which were stopped after 3 days and patient remained afebrile.
He was discharged without antibiotics.
.
# Abdominal pain: Resolved. Unclear etiology - may be due to
reversible ischemia in the setting of hypotension as positional.
CT abdomen negative for acute pathology. Was treated with zosyn
for potential SBP, but since pain resolved this felt to be an
unlikely culprit.
.
# Metabolic acidosis: The patient has a chronic metabolic
acidosis likely due to renal failure, as well as lactic acidosis
with baseline lactate 2.1-2.7, likely due to liver disease.
.
# Anemia: Macrocytic. Recent hematocrit mid-to-high 30s, now 30
on admission. No evidence of active bleeding. Baseline anemia
likely due to underlying liver and renal disease. Last EGD
[**5-/2144**] with only grade I varices. Initial ED laboratories were
likely laboratory error. Hct was stable and patient did not
require any transfusions while in house.
.
# HCV and EtOH cirrhosis: Complicated by encephalopathy, portal
HTN with portal hypertensive gastropathy, grade I varices, and
ascites requiring q2-3 weekly paracentesis. INR was elevated
from recent baseline, however, other liver function tests
stable. RUQ u/s was unchanged, with comparable ascites and
cirrhosis. Patient is on the transplant list through [**Hospital1 3343**]
.
# ESRD: Continued on HD while in house.
.
Medications on Admission:
Pregabalin 75 mg PO DAILY on HD days and 50 mg DAILY on non-HD
days
Lactulose 30 ML PO BID
Paricalcitol 1 mcg IV QHD
Epoetin Alfa 10,000 unit SC QHD
B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
Calcium Acetate 1337 mg PO TID W/MEALS
Folic acid 0.8 mg PO DAILY
Oxycodone 5 mg Q12H:PRN pain
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO 4X/WEEK
([**Doctor First Name **],MO,WE,FR).
4. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO 3X/WEEK
(TU,TH,SA).
5. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q6H
(every 6 hours): Please increase or reduce dose as needed to
ensure 3 bowel movements daily.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection QHD.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypotension with dialysis
Hepatic Encephalopathy
.
Secondary:
End stage liver disease [**3-15**] hepatitis C cirrhosis
End stage kidney disease on dialysis [**3-15**] diabetes
Discharge Condition:
vitals signs stable, afebrile
Discharge Instructions:
You were admitted because of low blood pressure with dialysis.
We treated you with IV fluids and antibiotics and your blood
pressure improved. We also treated you for confusion thought
secondary to your liver failure. Your confusion improved with
lacutlose. Your antibiotics were stopped because your blood
cultures did not reveal an infection.
.
Please continue to follow at the [**Hospital3 **] for possible
transplant.
.
If you develop any of the following, chest pain, shortness of
breath, cough, fever, chills, nausea, vomiting, diarrhea,
headache, confusion or dizziness, please call your primary care
doctor or go to your local emergency room.
[**Hospital3 **] yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Please follow up with Dr. [**Last Name (NamePattern4) **], MD
Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2145-7-14**] 9:10
.
Please follow up with Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2145-10-25**] 1:25
.
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2146-2-21**] 1:00
.
Please follow up with Dr. [**First Name (STitle) 1382**] [**Name (STitle) 1383**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2145-7-19**] 10:10
.
Please follow up with Dr. [**Last Name (STitle) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2977**]
Date/Time:[**2145-7-26**] 11:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2145-7-15**]
ICD9 Codes: 5856, 2762, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7271
} | Medical Text: Admission Date: [**2175-12-20**] Discharge Date: [**2176-1-11**]
Date of Birth: [**2115-8-12**] Sex: M
Service: SURGERY
Allergies:
Ceclor
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
s/p exploratory laporotomy, left hemi-colectomy and transverse
colostomy on [**2175-12-20**]
History of Present Illness:
60 y/o M with ESLD, EtOHic cirrhosis, p/w jaundice, abd pain,
and n/v the day prior to presentation. T was 102.6 in ED. [**12-22**]
loose stools c lactulose the day before, and denies F/C @ home.
Tolerating POs, denies dysuria, or abd pain like this in past.
Pain began peri-umbilical intermittently q 3-4hours, though it
has presently resolved. Pt has also noticed slight increase in
abdominal girth.
Past Medical History:
1) EtOH Cirrhosis: Has abused EtOH x 40 years. Hospitalized at
[**Hospital3 **] for worsening jaundice and ascites.
2) Gout
3) Hyperkalemia
4) Depression, seen by [**Location (un) 583**] Mental Health
Social History:
Lives with wife who is involved in his care. 10 quarts of
Beer/day with occasional binges or larger amounts. States that
he had not had a drink in 2 months (this is confirmed by his
wife). [**11-20**] ppd cigarettes. No IVDU. No recreational drug use.
Family History:
Mother: TB (details unknown)
Brother: Esophageal carcinoma, EtOH Abuse
Father: laryngeal ca, EtOH Abuse
Physical Exam:
Tm102.6 Tc98.1 Hr91 Bp85/32 to 102/52 RR16 SaO2100%
NAD AAOX3 ill in appearance, jaundiced
icteric sclera
RRR, LCTAb/l
Decreased bs, protuberant abdomen, soft, +TTP in RLQ only, no
rebound or guarding
rectal: hypotone, guiac negative
Pertinent Results:
[**2175-12-19**] 10:00PM PT-22.4* PTT-43.8* INR(PT)-2.2*
[**2175-12-19**] 10:00PM PLT SMR-LOW PLT COUNT-104*
[**2175-12-19**] 10:00PM NEUTS-78.3* BANDS-0 LYMPHS-15.7* MONOS-4.4
EOS-1.1 BASOS-0.4
[**2175-12-19**] 10:00PM WBC-4.1 RBC-2.65* HGB-9.6* HCT-27.4* MCV-103*
MCH-36.2* MCHC-35.1* RDW-16.1*
[**2175-12-19**] 10:00PM ACETONE-NEG
[**2175-12-19**] 10:00PM LIPASE-30
[**2175-12-19**] 10:00PM ALT(SGPT)-11 AST(SGOT)-35 ALK PHOS-148*
AMYLASE-39 TOT BILI-9.4* DIR BILI-3.7* INDIR BIL-5.7
[**2175-12-19**] 10:00PM GLUCOSE-100 UREA N-16 CREAT-1.4* SODIUM-132*
POTASSIUM-3.2* CHLORIDE-93* TOTAL CO2-27 ANION GAP-15
[**2175-12-19**] 10:06PM LACTATE-4.7*
Brief Hospital Course:
Pt was admitted to the transplant service where a CT showed a
cirrhotic liver, splenomegaly, a diffusely thickened colon,
small amount of ascites. He was started on broad spectrum
antibiotics. Serial exams revealed worsening abd pain and pt
had ? of a perforated diverticulum and free air on imaging, so
pt was taken to the OR where diffuse pan colitis free air and
colonic diverticulosis was found. An expolatory laporotomy,
left hemicolectomy, and transverse colostomy was performed.
Post operatively, the pt was taken to the SICU where he remained
intubated until POD 8. His operatively placed drains had output
of over 1500cc/day, and although he was transferred to the floor
on POD 9, he had to be sent back to the ICU on POD 14 in order
to float a swan and better manage his volume status. He stayed
in the ICU until POD 16 when his outputs had tapered. He was
transferred to the floor where his drains were removed and
stiches were placed to close the JP site. Pt remained stable
and was dischared to rehab on post op day 21.
Medications on Admission:
rifaximin, aldactone, lasix, remeron, protonix, nadolol,
lactulose, MVI, folate
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
2. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO q 4-6hrs prn.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
5. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Insulin SS
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
71-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
60M s/p ex lap & L colectomy/transverse colostomy [**12-20**]
PMH: ESLD, MELD 30, h/o encephalopathy, grade 1 varices [**8-22**];
gout, depression
Discharge Condition:
stable
Discharge Instructions:
Patient is to call Transplant surgery immediately at
[**Telephone/Fax (1) 673**] if any fevers, chills, nausea, vomiting, increase
abdominal pain. Call Transplant surgery if any incdrease
leaking or fluid leak from suture sites, or around the ostomy,
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2176-1-17**]
11:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2176-3-18**] 11:50
Completed by:[**2176-1-11**]
ICD9 Codes: 2875, 2768, 4280, 2859, 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7272
} | Medical Text: Unit No: [**Numeric Identifier 64075**]
Admission Date: [**2135-6-22**]
Discharge Date: [**2135-7-2**]
Date of Birth: [**2115-1-22**]
Sex: M
Service: TRA
CHIEF COMPLAINT: Status post suicide attempt. Fall
approximately 40 to 50 feet.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 55087**] is an unfortunate
gentleman who attempted suicide after a jump from
approximately 40 to 50 feet from a bridge. There was a
suicide note and there had been prior suicide attempts. Per
EMS report the patient was found unresponsive and initially
had no blood pressure. He was intubated at an outside
hospital with multiple extremity fractures. En route to [**Doctor First Name **]-
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **], he remained tachycardic but
blood pressure remained intact.
PAST MEDICAL HISTORY: None available.
PAST SURGICAL HISTORY: No incisions seen. No history
available.
MEDICATIONS AT HOME: Unknown.
ALLERGIES: Unknown.
PHYSICAL EXAMINATION: Mr. [**Known lastname 55087**] presented to the emergency
department with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 3. He is intubated
and unresponsive.
HEENT: Pupils are noted to be 1 mm and reactive. There is
bilateral hemotympany. No evidence of any bony stepoffs or
malformation in the cervical spine.
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR: Normal.
PELVIS: Wrapped.
RECTAL: Negative.
There is a gross femoral deformity. Right and left lower
extremities are splinted and wrapped.
LABORATORY DATA: White blood cell count 12.1, hematocrit 36,
platelet count 101, sodium 138, potassium 5.4, chloride 109,
CO2 25, BUN 15, creatinine 0.5, glucose 225, _______ noted
to be 4.2.
After stabilization in the emergency department the patient
was transferred to the trauma intensive care unit. There he
was started on Dilantin per neurosurgery recommendations.
Within the intensive care he stabilized. The patient's CT
findings were reviewed with neurosurgery. This finding
included diffuse arachnoid hemorrhage, bilateral small
cortical hemorrhages, anterior fontanel and posterior
temporal lobes with arachnoid blood. ICP ____ was placed by
neurosurgery which showed an opening pressure of 60. Body CT
showed left hemithorax bilaterally. There is a moderate
amount of retroperitoneal blood also noted on the CT scan.
Following this finding bilateral chest tubes were placed by
the trauma service. While there are no focal findings on the
CT scan, the patient's persistent unresponsiveness to [**Location (un) 2611**]
coma scale of 3 indicated a potentially grave prognosis for
the patient.
Over the next several days, multiple attempts were made to
lighten the patient's sedation to off and adequate
neurological examination and wean from ventilation. During
the sedation, weaning episodes, the patient demonstrated no
consistent discernible neurologic reflexes. Corneal reflex
was absent wholly. Gag reflex was found at times, and
decorticate posturing was seen consistently. As the
patient's overall prognosis continued to worsen, attention
had to be turned towards potential repair of his orthopedic
fractures. This ultimately became a decision for the family
to make. After several discussions with the patient's mother
and uncle during which many members from both sides of the
family were present, a decision was made to not pursue more
aggressive care. On multiple occasions the patient was made
ready for the operating room for orthopedic repair, however
the family would waver and decide not to pursue more
aggressive intervention.
After final family meeting the patient's family agreed to
extubate the patient. On further request the patient was
evaluated by the [**Location (un) 511**] organ bank for possible organ
donation but was ultimately declined. On [**2135-7-4**], on
hospital day 13, per the mother's mother and uncle's request
a final decision was made to extubate the patient and make
CMOs necessary. This was performed according to the risk and
the patient's expiratory rate thereafter.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 9178**]
MEDQUIST36
D: [**2135-7-28**] 14:06:51
T: [**2135-7-29**] 02:55:50
Job#: [**Job Number 64076**]
ICD9 Codes: 5180, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7273
} | Medical Text: Admission Date: [**2195-4-28**] Discharge Date: [**2195-5-3**]
Date of Birth: [**2115-2-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis
History of Present Illness:
This patient is an 80 y/o M with history of decompensated ETOH
cirrhosis, DMII, recent [**Hospital 21340**] nursing home resident, who presents
with fever and hypotenstion is admitted with sepsis, probable
sbp.
The patient was noted to have a fever at the nursing home
([**Hospital 21341**] Rehab and nursing care) last night, and again this
afternoon. He was initially given tylenol 650mg. He was noted to
have minimal urine output and borderline low BP, and increased
confusion, so was transferred to the ER for further evaluation.
In the abulance, he was noted to be in some respiratory
distress, requiring O2, and had about 30 seconds of
unresponsiveness. Per patients son, he has been coughing more
frequently during the past week.
In the ED, initial vs were: T 101.5 P 91 BP 113/97 R 30 O2 sat
88% on nrb. Patient was given ceftriaxone, zosyn and vancomycin
for emperic treatment for SBP and ?cellulitis. He was given 3L
NS and started on phenylephrine for sbps persistently in the 60s
despite fluids. He is DNR/DNI. There was difficulty with blood
draws secondary to coagulpathy (likely [**12-23**] liver failure), so an
IJ was placed. tylenol given
On the floor, patient remains confused, but interactive. He
denies fevers, chills, shortness of breath.
.
Review of sytems: Difficult to obtain given patient confusion.
details as above.
Past Medical History:
ETOH cirrhosis with recurrent ascites, hx of SBP and
encephalopathy
Alcoholic cirrhosis
Portal vein thrombosis
Babesiosis [**2192**]
SBP [**1-26**]
Glaucoma
Iron deficiency anemia
Chronic delirium
Afib not on warfarin [**12-23**] fall risk
Hyponatremia
Barretts esophagus
Social History:
Previously drank heavily until the past few years, no alcohol in
the past year. Per family, smoked cigars for many years, no
cigarettes. No drug use. Married. Lives at nursing home. Four
children very involved in his care. Per son, he generally
recognizes family members, but is not oriented. does not always
make sense. Has been getting worse over last few months.
Family History:
Son reports that patient's brother had history of [**Name (NI) 13808**] and
recently passed away at age 82.
Physical Exam:
Vitals: T: 96 BP: 85/56 P: 115 R: 18 O2: 97% on NRB
General: Alert, confused
HEENT: dry mucous membranes
Neck: supple, JVP flat, right IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: irregularly irregular, no murmurs, rubs, gallops
Abdomen: ascites, fluid wave, shifting dullness
GU: foley
Ext: warm, 2+ pulses, 4+ pitting edema
Skin: arms dry, many skin tears
Pertinent Results:
Laboratory Data
[**2195-4-28**] 08:35PM BLOOD WBC-4.8# RBC-3.12*# Hgb-9.2* Hct-27.1*
MCV-87 MCH-29.4 MCHC-33.8 RDW-15.5 Plt Ct-164#
[**2195-4-29**] 01:40AM BLOOD WBC-8.2# RBC-3.22* Hgb-9.9* Hct-28.3*
MCV-88 MCH-30.7 MCHC-34.9 RDW-15.3 Plt Ct-180
[**2195-4-30**] 04:23AM BLOOD WBC-20.8*# RBC-3.16* Hgb-9.5* Hct-27.9*
MCV-88 MCH-29.9 MCHC-33.9 RDW-15.4 Plt Ct-147*
[**2195-4-30**] 02:28PM BLOOD WBC-17.6* RBC-2.91* Hgb-8.5* Hct-25.4*
MCV-87 MCH-29.3 MCHC-33.5 RDW-15.1 Plt Ct-89*
[**2195-5-1**] 04:04AM BLOOD WBC-19.2* RBC-2.73* Hgb-8.0* Hct-24.1*
MCV-88 MCH-29.5 MCHC-33.4 RDW-15.3 Plt Ct-63*
[**2195-4-28**] 05:35PM BLOOD Neuts-59 Bands-38* Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2195-4-28**] 08:35PM BLOOD Neuts-43* Bands-45* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-8* Myelos-0 NRBC-1*
[**2195-4-28**] 07:37PM BLOOD PT-28.1* PTT-66.0* INR(PT)-2.8*
[**2195-4-30**] 04:23AM BLOOD PT-23.5* PTT-59.9* INR(PT)-2.2*
[**2195-5-2**] 03:57AM BLOOD PT-21.2* PTT-51.0* INR(PT)-2.0*
[**2195-4-29**] 01:40AM BLOOD Fibrino-259
[**2195-4-30**] 04:23AM BLOOD Fibrino-362
[**2195-4-30**] 04:23AM BLOOD FDP-40-80*
[**2195-4-28**] 05:35PM BLOOD Glucose-47* UreaN-11 Creat-0.6 Na-140
K-1.8* Cl-122* HCO3-10* AnGap-10
[**2195-4-28**] 08:35PM BLOOD Glucose-106* UreaN-26* Creat-1.9*#
Na-125* K-3.9 Cl-94* HCO3-19* AnGap-16
[**2195-4-29**] 01:40AM BLOOD Glucose-69* UreaN-26* Creat-2.0* Na-127*
K-4.3 Cl-97 HCO3-15* AnGap-19
[**2195-4-29**] 08:24PM BLOOD Glucose-98 UreaN-28* Creat-2.2* Na-125*
K-4.4 Cl-91* HCO3-16* AnGap-22*
[**2195-4-30**] 04:23AM BLOOD Glucose-114* UreaN-29* Creat-2.3* Na-120*
K-4.5 Cl-90* HCO3-16* AnGap-19
[**2195-4-30**] 02:28PM BLOOD Glucose-111* UreaN-31* Creat-2.3* Na-120*
K-4.1 Cl-91* HCO3-18* AnGap-15
[**2195-5-1**] 04:04AM BLOOD Glucose-142* UreaN-33* Creat-2.3* Na-122*
K-3.8 Cl-89* HCO3-18* AnGap-19
[**2195-5-2**] 03:57AM BLOOD Glucose-143* UreaN-38* Creat-2.4* Na-119*
K-4.0 Cl-93* HCO3-18* AnGap-12
[**2195-4-28**] 05:35PM BLOOD ALT-6 AST-11 AlkPhos-32* TotBili-1.0
[**2195-4-29**] 01:40AM BLOOD ALT-18 AST-39 LD(LDH)-185 AlkPhos-73
TotBili-2.6*
[**2195-4-30**] 02:28PM BLOOD ALT-24 AST-59* LD(LDH)-155 AlkPhos-46
TotBili-3.6*
[**2195-5-1**] 04:04AM BLOOD ALT-26 AST-54* LD(LDH)-167 AlkPhos-46
TotBili-4.0*
[**2195-4-28**] 05:35PM BLOOD Lipase-5
[**2195-4-28**] 08:35PM BLOOD Albumin-2.1* Calcium-8.0* Phos-3.0#
Mg-1.9
[**2195-5-2**] 03:57AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9
[**2195-4-29**] 01:40AM BLOOD Cortsol-132.0*
[**2195-4-29**] 02:00AM BLOOD Type-ART pO2-76* pCO2-24* pH-7.41
calTCO2-16* Base XS--6
[**2195-5-1**] 02:47PM BLOOD Type-ART Temp-36.9 O2 Flow-3 pO2-105
pCO2-29* pH-7.41 calTCO2-19* Base XS--4 Intubat-NOT INTUBA
[**2195-4-28**] 05:35PM BLOOD Lactate-3.1*
[**2195-4-29**] 09:30AM BLOOD Lactate-8.2*
[**2195-4-30**] 04:56AM BLOOD Lactate-5.8*
[**2195-5-1**] 02:47PM BLOOD Lactate-3.5*
.
Microbiology Data
[**2195-4-28**] 5:35 pm BLOOD CULTURE
**FINAL REPORT [**2195-5-4**]**
Blood Culture, Routine (Final [**2195-5-4**]):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2195-4-29**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier 21342**] [**2195-4-29**] AT 1345.
.
[**2195-4-28**] 11:45 pm PERITONEAL FLUID
**FINAL REPORT [**2195-5-3**]**
GRAM STAIN (Final [**2195-4-29**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2195-5-2**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1425, [**2195-4-30**].
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2195-5-3**]): NO ANAEROBES ISOLATED.
.
Imaging
[**2195-4-29**] Abdominal Ultrasound
IMPRESSION:
1. Son[**Name (NI) 493**] features consistent with cirrhosis; no apparent
thrombosis of the intrahepatic portal vein.
2. Extrahepatic portal vein not visualized. If evaluation of the
extra-hepatic PV is clinically indicated consider MRI or CT.
Brief Hospital Course:
Mr. [**Known lastname **] is an 80 year old man with EtOH cirrhosis, previous
history of SBP, and dementia who presented with septic shock
from SBP.
Septic Shock: Mr. [**Known lastname **] presented with fevers and altered
mental status. He was found to have Pseudomonas in blood and
peritoneal cultures. He was initially placed on vancomycin,
ciprofloxacin, and zosyn. He had a central line placed in the
emergency department. He was initiated on three pressors to
maintain his blood pressures. He was initially resuscitated with
normal saline and then albumin. His fluid resucitation was
balanced with his respiratory status as Mr. [**Known lastname 515**] family was
clear that he did not wish to be intubated. His vasopressin was
turned off because of worsening hyponatremia. However, he
continued to require two pressors.
Acute Kidney Injury: During the hospital course Mr. [**Known lastname **]
developed worsening renal failure thought to be related to ATN
or possibly hepatorenal. He eventually became oliguric.
Alchoholic Cirrhosis: RUQ ultrasound consistent with cirrhosis.
He was treated with octreotide and pressors.
Hypervolemic hyponatremia: Following admission Mr. [**Known lastname **] had a
rapid decline in his serum sodium. His fluid balance was
carefully monitored. His sodium stabilized.
Atrial fibrillation with RVR: He was not on warfarin at home
given frequent falls. Not on rate control either.
Goals of Care: On admission the family was very clear that Mr.
[**Known lastname 515**] code status was DNR/DNI. As his prognosis worsened and
his ability to interact with his family declined, the family
wished to pursue comfort measures. His pressors and antibiotics
were stopped and aggressive care was withdrawn. He was treated
with morphine and ativan as needed, and passed away on [**5-3**] with
his family at the bedside. His PCP was notified of the events.
Autopsy was declined.
.
Medications on Admission:
2grams Sodium three times daily (with 2L fluid restriction)
Tyelnol PRN
Multivitamin
Timolol 0.5% 1 drop each eye twice daily
Seroquel 25mg twice daily standing, and PRN for agitation
Rifaximin 400mg three times daily
Lactulose 30mL three times daily
Spironolactone 25mg three times daily
Lasix 80mg three times daily
Midodrine 10mg three times daily
Aluminum Hydroxide 20mL every 4 hours as needed
MOM
[**Name (NI) 21343**] DM as needed
Bisacodyl as needed
Humalog sliding scale
Prilosec 20mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2195-5-5**]
ICD9 Codes: 5845, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7274
} | Medical Text: Admission Date: [**2183-6-18**] Discharge Date: [**2183-7-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
86 y/o M s/p fall from standing- pt. transferred from OSH
w/films demonstrating SAH and hemorrhagic contusions bilaterally
Major Surgical or Invasive Procedure:
Intubated in the ED
trach/peg placement
History of Present Illness:
86 y/o M w/history of dementia fell from standing earlier on day
of admission. +LOC. Pt. brought in by Med Flight after eval at
OSH showing SAH. On arrival pt. w/GCS of 15. Pt. with acute
decompensation in trauma bay to GCS of 10 and electively
intubated.
Past Medical History:
- HTN
- diabetes
- dementia
Social History:
unknown
Family History:
unknown
Physical Exam:
Admission PHYSICAL EXAM:
BP: 101/58 HR: 59
Gen: WD/WN, comfortable, NAD
HEENT: unable to assess, bleeding abrasion on left forehead
Neck: in C-collar
Lungs: CTA bilaterally, no w/c/r
Cardiac: RRR. S1/S2.
Abd: Soft, BS+, nd
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: intubated and sedated, follows commands but does
not open eyes to instruction
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: unable to assess
V, VII: unable to assess.
VIII: unable to assess.
IX, X: intubated unable to assess.
[**Doctor First Name 81**]: unable to assess
XII: unable to assess
Motor: will move all extremities, Vec from ED wearing off
Discharge EXAM:
Gen: NAD
HEENT: NCAT, neck somewhat stiff (tone is increased throughout)
Lungs: diffuse rhonchi
Cardiac: RRR. S1/S2.
Abd: Soft, BS+, nd
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: occasional spont eye opening, grimace to sternal
rub, non verbal, does not follow commands
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: no obvious droop
V, VII: unable to assess.
VIII: unable to assess.
IX, X: gag present
[**Doctor First Name 81**]: unable to assess
XII: unable to assess
Motor: moves extremities intermittently. Sometimes withdraws to
pain
Pertinent Results:
[**2183-6-24**] 03:20AM BLOOD WBC-10.5 RBC-2.60* Hgb-8.7* Hct-24.6*
MCV-95 MCH-33.3* MCHC-35.1* RDW-13.1 Plt Ct-173
[**2183-6-24**] 03:20AM BLOOD Plt Ct-173
[**2183-6-24**] 03:20AM BLOOD PT-13.2* PTT-33.1 INR(PT)-1.2*
[**2183-6-18**] 04:33PM BLOOD Fibrino-448*
[**2183-6-24**] 03:20AM BLOOD Glucose-198* UreaN-37* Creat-1.5* Na-136
K-4.1 Cl-104 HCO3-25 AnGap-11
[**2183-6-18**] 04:33PM BLOOD ALT-13 AST-18 AlkPhos-72 Amylase-55
TotBili-0.5
[**2183-6-24**] 03:20AM BLOOD Calcium-7.2* Phos-3.5 Mg-2.4
[**2183-6-24**] 03:20AM BLOOD Vanco-11.7*
[**2183-6-22**] 01:55AM BLOOD Phenyto-13.0
[**2183-6-18**] 04:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
EKG:[**2183-6-19**]: NSR at around 60, nl axis, nl intervals, no ST-T
changes. No previous for comparision
.
Radiologic: Head CT [**6-18**]: Bilateral hemorrhagic contusions and
subarachnoid blood, most significant along the left frontal and
left temporal areas. Fractures of the left maxillary sinus are
identified, but would be better assessed by dedicated
sinus CT. Opacified right mastoid air cells may also belie
subtle base of skull fractures in the trauma setting despite the
lack of an identifiable fracture lines, and clinical correlation
is recommended.
.
Repeat Head CT [**6-18**]: 1. Bilateral subarachnoid hemorrhage,
slightly increased, and left temporal and frontal contusions,
not significantly changed, compared to the recent study.
2. Disproportionate prominence of the lateral and third
ventricles c/w cortical sulci, raising possibility of underlying
communicating hydrocephalus (doubt obstructive, as no
intraventricular hemorrhage).
2. Fracture of the left maxillary sinus lateral wall, with blood
in that sinus, as well as the left zygomatic arch.
3. Probable acute-on-longstanding inflammatory disease in the
right mastoid process and middle ear; review of bone algorithm
images from previous head/maxillofacial/cervical CT studies
demonstrates no definite temporal bone or other skull base
fracture.
.
MRI head [**6-20**]: No evidence of diffuse axonal injury. Left
frontal and temporal and small right frontal subarachnoid
hemorrhages, corresponding with prior CT.
.
EEG [**2183-6-26**]: IMPRESSION: Abnormal portable EEG due to the slow
and disorganized background and bursts of generalized slowing.
These findings indicate a widespread encephalopathic condition
affecting both cortical and subcortical structures. Medications,
metabolic disturbances, and infection are among the most common
causes. Trauma and raised pressure are also possible causes. No
prominent lateralized findings were evident to correlate with
the history of subdural hematoma. There were no epileptiform
features.
.
CT sinus [**6-18**]: Air-fluid level with hemorrhage in the left
maxillary sinus, with minimally displaced fracture of the
posterior wall of the left maxillary sinus. No displacement of
intra-orbital content.
.
Portable Chest [**6-25**]: Tracheostomy and percutaneous gastrostomy
in standard positions. Slightly worsened left basilar
atelectasis, aspiration, or pneumonia. Probable small bilateral
layering pleural effusions.
.
[**7-4**] CXR: Patient is status post tracheostomy. The
cardiomediastinal silhouette is unchanged. There is a
persistent left lower lobe consolidation. This is unchanged
appearance compared to the prior
examination. There is a small left pleural effusion. The right
lung is clear.
.
[**7-3**]: No DVT on bilat LENI's.
.
[**7-3**]: Abd US: This exam is limited secondary to patient
unresponsiveness. The visualized liver demonstrates normal
echogenicity with no focal lesions identified. The gallbladder
is unremarkable. The common duct is not dilated. There is
appropriate forward portal venous flow. The right kidney
measures 9.5 cm. The left kidney measures 8.9 cm. There is no
evidence of hydronephrosis, masses, or stones. The pancreas and
aorta are not well visualized.
Brief Hospital Course:
Pt. was transferred to the [**Hospital1 18**] ED after evaluation in an OSH.
At the OSH the pt. was found to have SAH s/p a fall from
standing and down about 4 stairs. The pt. was brought by
[**Location (un) **] to the [**Hospital1 18**] ED where he was immediately transferred
to the trauma bay. There he reportedly had a GCS of 15 before
acutely decompensating to a GCS of 10 for which he was
electively intubated. The pt. underwent CT scan on admission
that confirmed the presence of SAH. The pt. was then admitted
to the trauma ICU for care.
Neuro: The pt. underwent serial head CT scans over the first 24
hours of his hospitalization. They were stable, showing only
slight increase in the amount of bleed the pt. had suffered. On
HD 3 the pt. underwent an MRI that was negative for diffuse
axonal injury. The pt.'s exam remained relatively unchanged
from the day of admit during which his pupils were equal and
reactive, he localizes with his left upper extremity and will
withdraw bilateral lower extremities. He is intermittently awake
and will open his eyes intermittently spontaneously. No verbal
response. He was put on phenytoin for seizure prophylaxis but
developed a transaminitis. Dilantin was changed to Keppra and
the transaminitis resolved over a matter of days. He has had no
seizure activity.
Resp: Pt. was intubated electively in the ED because of acute
decompensation. He remained on the ventilator until HD8 - at
which time he underwent a trach. Moreover, he began spiking
fevers on HD 4 and at that time CXR showed slight patchy
infiltrates. By HD 7 the pt continued spiking fevers
occasionally and the patchy infiltrates had organized in the LLL
suggesting a pneumonia. He received a one week course of
antibiotics and was able to wean down to a trach mask at the
time of discharge. He then developed a second fever and grew
stenotrophomonas on sputum. ID was consulted and suggested a 14
day course of bactrim and levoquin, which he is currently on at
the time of discharge. He is sating well on 35% trach mask but
requires frequent suctioning for clear/white secretions. He has
a good cough.
Cardiac: Pt. was initially hemodynamically stable. On HD [**4-30**]
the pt. had a few episodes of SBP in the 80s. At that time the
pt. was also being given lasix and it was believed that he had
become hypovolemic. His pressure rose with fluid and a CVL was
placed to better assess his volume status. He did stablize and
at the time of discharge he did not have any cardiac issues.
GI/FEN: The pt. was started on tube feeds after receiving his
PEG and tolerated tube feeds at goal during his hospitalization.
He was found to have low serum sodium levels and was started on
salt tabs. Sodiums were followed and improved, salt tablet
taper begun. At the time of discharge he is not on any salt.
Endo: He did have elevated serum glucoses. Medicine recommended
insulin doses and these were adjusted as needed.
GU: no issues. The pt initially had a foley but this was
discontinued in the days prior to discharge. He does have a
stage II decubitous ulcer that should be dressed per wound care
recs - see discharge paperwork.
ID: Pt. started on abx because of intermittent fevers early in
his hospital course. Sputum cultures demonstrated gram positive
cocci and gram negative rods. He was given a week of vancomycin
and zosyn. An infectious disease consult was called for his
intermittent fevers despite antibiotics. They recommended
switching his dilantin to keppra to r/o drug fever as above.
Repeat sputum revealed Stenotrophomonas on [**6-28**] and
bactrim/levoquin were initiated for a planned 14 day course (to
end on [**7-19**]). The pt defervesced. He developed a LGF to 100.1
the day prior to discharge - no source is identified. His WBC
have been elevated to [**1-11**] since his admission to [**Hospital1 18**]. This
has not changed. He has a neutrophil predominence but has no
bandemia. He has a known healing sinus fracture, a sacral
decubitus ulcer, white/clear sputum (and is on treatment for
stenotrophomonas), and gout as below. Also in the fever
differential is SAH itself.
GOUT: His knee was found to be edematous and was tapped on [**7-4**]
and fluid was consistent with gout. Culture negative. The pt is
currently finishing a steroid taper for gout. Allopurinol could
be started at a dose of 100-300 per day but should be delayed
until mid-[**Month (only) 205**] as it should not be started during an acute
flare.
Dispo: acute rehab
The patient is full code per the wishes of his appointed
guardian (his son).
The patient did receive heparin sq at this hospitalization.
Medications on Admission:
- metformin
- lopressor
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 days.
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: start on [**7-13**].
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days: until [**7-19**].
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 8 days: until [**7-19**].
13. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed for fever < 101.4.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Eight (28) units Subcutaneous twice a day: before breakfast and
before dinner.
15. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection qid ac: Sliding Scale:
0-150 - 0 units
151-200 - 2 units
201-250 - 4 units
251-300 - 6 units
301-350 - 8 units
351-400 - 10 units.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
bilateral subarachnoid hemorrhage with contusions
transaminitis from dilantin - resolving off dilantin
pneumonia
hypertension
Discharge Condition:
Neurologically stable
Discharge Instructions:
Please come to the emergency room if you have fever >101.4,
nausea or vomiting, shortness of breath, or any other symptoms
concerning to you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**2-28**] weeks. Call his office
at [**Telephone/Fax (1) 2992**] for an appointment.
Will need an outpatient CT head mid-[**Month (only) 205**]. Call Dr.[**Name (NI) 9034**]
office to set up.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2183-7-15**]
ICD9 Codes: 5185, 486, 5849, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7275
} | Medical Text: Admission Date: [**2112-9-25**] Discharge Date: [**2112-10-4**]
Date of Birth: [**2046-9-9**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Glipizide / Ciprofloxacin / Bactrim / Soriatane /
Potassium Chloride / Bupropion / Calcium Channel Blocking
Agents-Benzothiazepines / atenolol
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Left IJ central catheter
Right arterial line
History of Present Illness:
Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] is a 66 year-old woman with history of diastolic
CHF, Stage 1A NSCLC, COPD, presenting to the emergency room with
cough and dyspnea. Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] has frequent dyspnea at
baseline, but over the past four days patient had noted
increased shortness of breath and ocugh. She was supposed to
have an endoscopy done last Thursday but it was cancelled
because she was complaining of cough and dyspnea and anesthesia
was not available for the procedure. She has been taking her
home dose of toresemide, but has noted decreasing urine output
over the past day. She has not been eating or drinking as much
at home as she typically does. Denies fevers or chills. This
morning her daughter noted that she had a low grade fever of 100
and seemed more confused. FS was 119 at that time. She was also
complaining of worsened dyspnea, so she called 911.
Of note patient was last hospitalized in either [**Month (only) 205**] or [**Month (only) 216**],
but has not been hospitalized in the last month. Her daughter,
who she lives with, has also been sick at home over the past
week and also has a bad cough.
In the ED, initial VS were: 99.6 68 126/59 28 100%
Non-Rebreather. On arrival exam was significant for b/l wheezing
and the patient was slightly confused. Labs were significant for
creatinine of 1.9 (baseline 0.6 - 1), troponin 0.05, BNP 3247
(last was 900 in [**2112-6-12**]), leukocytosis to 11.6. ABG was
7.3/56/69 - last ABG in [**11/2111**] was 7.44/38/66. CXR with low
lung volumes, known-stable RLL mass, and concern for right
mid-lung pneumonia. Patient required BiPAP while in the ED. In
the ED patient received albuterol and ipratripium nebs,
nitroglycerin 0.4 mg SL x1, methylprednisolone 125 mg IV x1,
azithromycin 500 mg IV x1, and ceftriaxone 1 gram IV x1.
On arrival to the MICU, patient is on BiPAP. She is lethargic,
but opens her eyes to her name. Patient nods that her breathing
feels better on the BiPAP. She denies any pain.
Past Medical History:
s/p Left Lower Lobectomy ([**10/2110**]) for mass - Pathology returned
as a 2.0 cm undifferentiated large cell carcinoma, pT1aN0Mx, neg
nodes clear margins, stage 1a. Currently followed by thoracic
surgery for spiculated RLL lesion, which has increased in size
and is concerning for malignancy.
- Diastolic CHF (also with mild MR, AS)
- A. Fib on coumadin
- Cirrhosis (likely [**1-14**] NASH vs. congestive hepatopathy)
- DMII c/w peripheral neuropathy
- pansenitive e.coli uti
- c. diff currently on fidaxomicin
- COPD
- Chronic venous insuffiency LE cellulitis
- depression
- anemia baseline hct 28.7
- HLD
- Gastritis
- Nephrolithiasis
- Psoriasis
- History of choleycystectomy
- Obesity
- Osteoporosis
- Hypercholesterolemia
Social History:
Lives with daughter. Retired file clerk in a law office. Current
smoker 1 to 1.5 ppd (60 pack year history). No alcohol or
illicits. Ambulates with a cane because walker doesn't fit well
in hallways.
Family History:
+fh for diabetes, no FH for malignances
Physical Exam:
Admission Physical Exam
Vitals: T: 100.8 BP: 110/51 P: 71 R: 14 O2: 100% on BiPAP (30%
FiO2)
General: Lethargic, but arousable to voice, on BiPAP
HEENT: Sclera anicteric, PERRL, psoriasis on scalp
Neck: supple, unable to assess JVP 2/2 habitus
CV: Regular rate and rhythm, S1, S2, no murmurs appreciated
Lungs: Diffuse rhonchi anteriorly, no rales or wheezes.
Abdomen: obses, soft, non-tender, non-distended, bowel sounds
present
GU: foley catheter in place
Ext: erythema of lower extremity b/l likely consistent with
chronic venous stasis changes, 1+ pedal edema, 1+ DP pulses,
Neuro: Lethargic, arousable to voice, follows simple commands,
PERRLA, reflexes symmetric, asterixis
Discharge Physical Exam
Vitals: wt 77.3kg 98.7, 138/70, 69, 19, 96%2L
General: NAD, sitting up in bed in NAD
HEENT: Sclera anicteric, PERRL, psoriasis on scalp,
subconjunctival hemorrhage obscuring white of the eye on the
left, not into the [**Doctor First Name 2281**] at all
Neck: supple, JVD 5cm above the clavicle
CV: RRR, III/VI SEM at the base and II/VI holosystolic murmur in
the mitral area
Lungs: Crackles [**12-16**] way up the bases bilaterally
Abdomen: obsese, soft, non-tender, non-distended, bowel sounds
present
GU: foley catheter in place draining clear yellow urine
Ext: erythema of lower extremity b/l likely consistent with
chronic venous stasis changes, 1+ LE edema up to knees, 1+ DP
pulses,
Neuro: AAOx3. no asterixis, tongue fasiculations
Pertinent Results:
Admission Labs:
[**2112-9-25**] 09:20AM BLOOD WBC-11.6* RBC-3.87* Hgb-9.4* Hct-30.8*
MCV-80* MCH-24.4* MCHC-30.6* RDW-17.4* Plt Ct-158
[**2112-9-25**] 09:20AM BLOOD Neuts-79.4* Lymphs-14.4* Monos-5.0
Eos-0.9 Baso-0.3
[**2112-9-25**] 09:20AM BLOOD PT-17.0* PTT-27.5 INR(PT)-1.6*
[**2112-9-25**] 09:20AM BLOOD Glucose-111* UreaN-51* Creat-1.9* Na-142
K-4.3 Cl-103 HCO3-27 AnGap-16
[**2112-9-25**] 09:20AM BLOOD ALT-22 AST-36 CK(CPK)-43 AlkPhos-133*
TotBili-0.5
[**2112-9-25**] 09:20AM BLOOD CK-MB-3 proBNP-3247*
[**2112-9-26**] 05:27AM BLOOD Calcium-8.3* Phos-5.6*# Mg-1.9
[**2112-9-25**] 05:10PM BLOOD Ammonia-25
[**2112-9-25**] 09:42AM BLOOD Type-[**Last Name (un) **] pO2-49* pCO2-61* pH-7.27*
calTCO2-29 Base XS-0 Comment-GREEN TOP
[**2112-9-25**] 09:42AM BLOOD Lactate-1.5
Discharge labs:
[**2112-10-4**] 06:55AM BLOOD WBC-10.8 RBC-4.07* Hgb-9.5* Hct-31.3*
MCV-77* MCH-23.4* MCHC-30.4* RDW-17.3* Plt Ct-88*
[**2112-10-4**] 06:55AM BLOOD PT-30.4* PTT-36.7* INR(PT)-2.8*
[**2112-10-4**] 06:55AM BLOOD Glucose-130* UreaN-15 Creat-0.7 Na-142
K-3.1* Cl-98 HCO3-42* AnGap-5*
[**2112-10-4**] 06:55AM BLOOD Calcium-9.3 Phos-2.7 Mg-1.9
Urine studies
[**2112-9-25**] 10:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2112-9-25**] 10:15AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2112-9-25**] 10:15AM URINE RBC-0 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
[**2112-9-25**] 10:15AM URINE CastHy-260*
Micro:
[**2112-9-25**] 7:03 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2112-10-2**]**
GRAM STAIN (Final [**2112-9-25**]):
[**10-6**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2112-9-30**]):
RARE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 1 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
LEGIONELLA CULTURE (Final [**2112-10-2**]): NO LEGIONELLA
ISOLATED.
Blood cultures x 2 [**2112-9-25**]- NEGATIVE
Urine culture [**2112-9-25**]- NEGATIVE
Brief Hospital Course:
Ms. [**Last Name (Titles) **]. [**Doctor Last Name **] is a 66 yo female with h/o diastolic CHF, COPD,
Stage 1a NSCLC (and new concerning RLL lesion), presenting with
dyspnea, wheezing and altered mental status who was admitted
with RML pnuemonia who required intubation secondary to altered
mental status and worsening hypercarbia who was found to have an
MSSA pneumonia, and had CHF exacerbation requiring diuresis who
was improved respiratory and mental status at the time of
discharge to rehab.
#Right middle lobe MSS pneumonia- patient was admitted with
cough and new CXR finding of infiltrat in the right middle lobe.
She required intubation for hypercarbic respiratory failure and
altered mental status and was extubated after 24 hour with no
further respiratory decompensation. Pt was started on
Ceftriaxone and azithromycin on admission and completed a 5 day
course of this. During this time her sputum culture grew out
MSSA and the patient was treatd with IV vancomycin from
[**Date range (1) 87529**] (the course was abridged by 1 day [**1-14**]
thrombocytopenia that there was concern was secondary to the
vancomycin. She was treated with vancomycin even after
sensisitivies came back given her penicillin and fluroquinolone
allergy, and current Cdiff infection did not want to treat with
clindamycin. After hte patient was called out of the ICU she
had no further fevers and a nonproductive cough and had no
episodes of respitaory distress. She continued to require oxygen
around 98% on 2L NC.
#CHF decompensation- on admission the patient had evidence fo
volume overload with an elevated BNP concerning for CHF
exacerbation, gvein her underlying pneumonia she was not
initially diuresed. After transfer to the floor she was diuresed
agressively and responded well to 80mg IV lasix 1-2x/day. Her
weight at the time of discharge is 77.3kg. She has some mild
edema in her lower extremitis on discharge and will likely still
require continued diuresis at home. She normally takes 80mg of
po torsemide as an outpatient. Given that she put out 3L to this
when given inpatient and developed a contraction alkalsois with
it was decided to decrease the dose of her torsemide to 40mg po
qday and her outpatient providers can assess if this should be
uptitrated once she resumes her regular home food. She was
briefly off of her ACEI given acute renal failure and low blood
pressures and this was restarted at 1/2 of her home dose at the
time of discharge. She developed chronic hypokalemia in the
setting of diuresis and was started on standing potassium
supplements.
-discharge wt 77.3kg
-decreased po torsemide from 80mg to 40mg once a day
-decreased enalapril from 20mg to 10 mg once a day
-patient has follow-up with Dr. [**First Name (STitle) 437**]
[**Name (STitle) **] will need repeat CHEM 7 checked on [**10-6**] to assess for
electrolyte abnormalities and assess specifically for her bicarb
elevation (was 42 at the time of discharge)
# Altered mental status: Likely multifactorial - likely in
setting of hypercarbia/COPD vs, pneumonia/acute infection vs.
metabolic derangements from renal failure. While the patient
has a history of cirrhosis she had no signs of encephalopathy on
exam and never had asterxis. After transfer onto the floor she
continued to be altered and her antidepressives were held and
then restarted prior to her discharge. She had a nonfocal exam
and had a negative head CT. She was awake and A+Ox3 at the time
of discharge.
# Acute renal failure: Pt presented with elevated BUN/ Cr
(59/1.9). This was likely secondary to intravascular depletion
and she had many hyalnie casts on her admission UA which was
consistent with this. This resolved to baseline and Cr was 0.7
on discharge.
#Thrombocytopenia- patient devloped thrombocytopenia during her
admission downt o 70 at the lowest and was increasing to 88 at
the time of discharge. On review of her medicaitons that she was
receiving inhouse she was getting vancomycin and it is likely
that the combination of vancomycin and her acute infection lead
to this. She was NOT on heaprin during this admission as she is
on warfarin for afib.
-Patient will need platelet count checked in two weeks after
discharge to assure that it is improving or sooner if she has
petichiae or concerns for bleeding
#Afib on warfarin- patient was continued on her warfarin while
inhouse. Per records she was taking 6.5mg of warfarin as an
outpatient, this was decreased to 4 and then when cymbalta was
restarted increased to supratherapeutic levels and it was held x
1 day and restarted on the day of discharge to 3mg.
-she will need her INR checked on [**10-6**] and warfarin dose
adjusted then.
# Recurrent c. diff: Patient has had difficult to treat c. diff
despite long taper of vancomycin and is now on fidaxomicin on
admission. She was asymptomatic during her admission. She was
followed by ID as an outpatient. Given that she was on
antibiotics throughout the ocurse of her hospital stay her
fidaxomicin was continued. She will need to complete a 10 day
course started on [**10-4**] as this was the planned course prior to
her admission
-will continue fidaxamicin until [**2112-10-13**]
# DM: During her admission her NPH was held and she was kept on
a sliding scale and her metformin was held. As she started to
take in more PO her blood sugars were remaining elevated. She
NPH wa restarted at a lower dose on [**10-3**] with improved control.
Would recommend that the outpatient providers uptitrate as
needed and will be the ones to decide whether or not to restart
the metformin as an outpatient.
-stopped metformin
-lowered NPH dose 56U down to 25 U [**Hospital1 **]
-Patient was discharged with a sliding scale
# Psoriasis: Continued clobetasol 0.05% ointment.
# Depression: Patient originally had her antidepresents held
during her altered mental status and these were restarted prior
to her discharge. She continued to have very low energy,
decreased appetitte and felt depressed while here. She was seen
by social work while inpatient and they recommend that she
follow-up with social work in [**Company 191**]
-recommend f/u with the [**Company 191**] social worker.
-mirtazapine was decreased from 30mg to 7.5 during this
admission due to exessive sleepiness initially (could be
reuptitrated as an outpatient)
#GERD: Continued pantoprazole 40 mg po daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
apply to affected area
2. Duloxetine 20 mg PO DAILY
3. Enalapril Maleate 20 mg PO DAILY
4. fidaxomicin *NF* 200 mg Oral [**Hospital1 **]
planned through [**9-30**]
5. NPH 52 Units Breakfast
NPH 56 Units Bedtime
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Nadolol 20 mg PO BID
8. Mirtazapine 30 mg PO HS
9. Omeprazole 40 mg PO DAILY
10. Pregabalin 150 mg PO BID
11. Torsemide 80 mg PO DAILY
12. Warfarin 6.5 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
15. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Duloxetine 20 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
4. NPH 25 Units Breakfast
NPH 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Mirtazapine 7.5 mg PO HS
6. Nadolol 20 mg PO BID
7. Omeprazole 40 mg PO DAILY
8. Potassium Chloride 40 mEq PO DAILY Duration: 1 Doses
Hold for K >5
9. Enalapril Maleate 10 mg PO DAILY
10. fidaxomicin *NF* 200 mg Oral [**Hospital1 **]
planned through [**2112-10-13**]
11. Torsemide 40 mg PO DAILY
12. Pregabalin 150 mg PO BID
13. Warfarin 3 mg PO DAILY
14. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
apply to affected area
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
16. Senna 1 TAB PO BID:PRN Constipation
17. Ipratropium Bromide Neb 1 NEB IH Q6H
18. Docusate Sodium 100 mg PO BID
19. Acetaminophen 650 mg PO Q6H:PRN pain
do not exceed 3g in 24 hour
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] at [**Location (un) 1821**]
Discharge Diagnosis:
MSSA pneumonia
decompensated dCHF
Acute kidney injury
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],
It was a pleasure taking care of you while you were here at
[**Hospital1 18**]. You were admitted to the hospital when you were
confused. You were found to have a pneumonia and were in the ICU
where you were intubated for a day and then improved your
breathing status. You completed a course of antibiotics for your
pneumonia. You were also having worsening heart failure in the
setting of this and required more fluid removal with IV lasix to
help your breathing.
It will be important to monitor your weight daily after you
leave.
Followup Instructions:
You should have a follow-up appointment scheduled with your PCP
for when you get out of rehab.
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2112-10-11**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9661**], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: TUESDAY [**2112-10-11**] at 9:00 AM
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2112-10-11**] at 8:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 2762, 2760, 2724, 311, 3572, 2720, 3051, 4280, 2875, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7276
} | Medical Text: Admission Date: [**2157-9-1**] Discharge Date: [**2157-9-12**]
Date of Birth: [**2157-9-1**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 38329**] [**Known lastname **] is the 2390
gm product of a 34 [**2-3**] week twin gestation born to a 29 year old
gravida 5, para 4, now 6 woman whose past obstetrical history
deliveries in [**2148**] and [**2151**] and a 34 week gestation infant in
[**2155**].
PAST MEDICAL HISTORY: Non-contributory; she is not on any
medications.
PRENATAL SCREENS: A positive, antibody negative, hepatitis
Group B Streptococcus unknown. Pregnancy history reveals
diamniotic/dichorionic twin gestation, antepartum course was
unremarkable until preterm contractions several days prior to
delivery. Ultrasound on [**3-1**] and [**8-16**], normal and
consistent with dates. Proceeded to cesarean section under
epidural spinal anesthesia, ruptured membranes at delivery
yielding clear amniotic fluid. No maternal fever or fetal
tachycardia, antepartum antibiotics administered four hours
prior to delivery. The infant emerged with minimal
respiratory effort. Orally and nasally bulb suctioned for
copious clear secretions, dried and tactile
stimulation provided, positive pressure ventilation provided
for one to two minutes for ongoing inconsistent respiratory
effort and central cyanosis. Infant began to cry by
approximately 3 minutes of age and was pink on free flow
oxygen with minimal distress by 5 minutes. Apgars were 5 at
1 minute and 8 at 5 minutes, transferred to the Newborn
Intensive Care Unit for management of prematurity.
HOSPITAL COURSE:
Respiratory - [**Known lastname 38329**] has been stable on room
air throughout her hospital course and has had no apnea
of prematurity.
Cardiovascular - She has been cardiovascularly stable
throughout her hospital course.
Fluids, electrolytes and nutrition - Birthweight was 2390 g,
50th to 75th percentile for gestational age, length was 46.5
cm, 50th to 75th percentile for gestational age, head
circumference 32.5 cm 50th to 75th percentile. She was
initially started on 60 cc/kg/day of D10/W. Enteral feedings
were initiated on day of life #1. She is currently ad lib
feeding Enfamil 24 calories per ounce, demonstrating good weight
gain and intake. Weight at discharge is 2265 grams and
increasing from a nadir of 2195g on [**2165-9-5**].
Gastrointestinal - Peak bilirubin was on day of life #4,
10.1/0.3. The infant has not required any phototherapy; her most
recent bilirubin was down to 9.3/0.3 on [**9-7**]. She is
demonstrating normal stooling patterns.
Hematology - Hematocrit on admission was 37.8; she has not
required any blood transfusions during this hospital course.
Infectious disease - Complete blood count and blood culture
were obtained on admission. Complete blood count was
negative. Blood culture remained negative at 48 hours of age,
Ampicillin and Gentamicin were discontinued at that time.
She has not required any further interventions for sepsis.
Neurological - Neurological exam has been within normal limits.
Sensory - Hearing screen was performed with automated
auditory brain stem responses, and the infant passed in both
in both ears.
Psychosocial - A social worker has been involved with this
family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home
PRIMARY CARE PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 38699**], [**Location (un) 669**]
Comprehensive Community Health Center, telephone [**Telephone/Fax (1) **].
CARE RECOMMENDATIONS:
Continue ad lib feedings Enfamil 24 calorie per ounce, monitor
growth and development.
Carseat position screening has been performed and the
infant passed carseat position screening, 90 minute screen.
State newborn screens have been sent per protocol.
Immunizations received: the infant has received hepatitis
B vaccine on [**2157-9-4**] and also received Synagis.
Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: A. Born at less than 32 weeks; B. Born between
32 and 35 weeks with plans for daycare during respiratory
syncytial virus season, with a smoker in the household or
with preschool siblings; or C. With chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSES:
1. Prematurity, 34 3/7 weeks.
2. Status post sepsis evaluation with antibiotics.
3. Hyperbilirubinemia, resolved.
4. Twin #2.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 36532**]
Dictated By:[**Last Name (NamePattern1) 43911**]
MEDQUIST36
D: [**2157-9-11**] 17:54
T: [**2157-9-11**] 18:11
JOB#: [**Job Number 44632**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7277
} | Medical Text: Admission Date: [**2184-2-9**] Discharge Date: [**2184-2-14**]
Date of Birth: [**2133-11-12**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14197**]
Chief Complaint:
Right thigh pain
Major Surgical or Invasive Procedure:
1. Radical resection of right thigh mass
2. Prophylactic internal fixation right femur with an 11 hole DC
plate
3. Exposure of superficial femoral and profunda arteries with a
separate medial thigh incision by Vascular surgery
History of Present Illness:
The patient is a 50-year-old gentleman who presented with a
large mass in his right anterior thigh 2-3 months ago. It was
extremely painful. He was evaluated and found to have a large
mass deep in his quadriceps adjacent to the bone. Biopsy of this
showed elements of sarcoma and carcinoma intermixed and he also
was found to have pulmonary metastases. He has medullary
carcinoma of the thyroid. He underwent treatment with
preoperative radiation and chemotherapy as the radiosensitizer
but the mass got even larger and unfortunately his pulmonary
metastases increased in size and number. It was recommended that
he consider chemotherapy for his pulmonary mets but he strongly
desired to have this thigh mass removed first and therefore he
was brought to the operating room today for that procedure.
Past Medical History:
Patient developed small R thigh pain/mass in [**7-5**] which was felt
to be was bursitis but as the mass enlarged the area was more
painful which prompted another ER evaluation and MRI confirming
presence of this mass in the R thigh. Patient was originally
seen at [**Hospital 1263**] Hospital. CT guided biopsy on [**2183-10-24**] was
consistent with carcinoma with spindle and epithelial morphology
focally CK positive and TTF-1 positive. The patient also
underwent U/S guided biopsy of a thyroid nodule which showed
atypical cells but not clearly malignant. Further imaging with
PET and CT demonstrates a R thyroid lobe mass, scattered small
pulm nodules, mildly FDG avid region in the L adrenal gland and
L psoas muscle and a 20cm R thigh mass in the region of the
femur without bony involvement or FDG uptake within the
skeleton.
Social History:
Was living with niece temporarily. Unemployed, former
bricklayer. Former smoker, quit within past year.
Family History:
Unknown, as he is adopted.
Physical Exam:
NAD, alert
RLE: [**Last Name (un) 938**]/DF/PF intact, SILT over tib/sp/dp, palpable DP
incision c/d/i, benign
Pertinent Results:
Hgb [**2184-2-13**]: 9.1 (stable)
Brief Hospital Course:
Patient was admitted for the above listed surgery, tolerated it
well. Complication was a broken screw at the distal end of the
DC plate. EBL: 1000cc. While in the PACU the patient became
tachycardic and hypotensive with low UOP, his thigh incision was
draining bloody fluid (300cc in 2 hours). His dressing was
reinforced and his heart rate was controlled with medication.
He was transferred to the ICU o/n. The tachycardia and
hypotension were secondary to hypovolemia, he was transfused a
total of 4 units pRBC's (Hgb 7.7) o/n. His heart trended down,
his UOP increased and his BP normalized. Of note he was started
on Hydrocortisone in the ICU secondary to a low random cortisol
(0.6). He was transferred to the floor on POD 1 in stable
condition. He was started in SSI secondary to elevated blood
sugar secondary to the steroid. Hydrocortisone was discontinued
on POD 2 after discussion with endocrine. His BP remained
stable. His blood sugar normalized after the steroid was
discontinued. His Hgb trended up following the initial
transfusion, but on POD 2 the Hgb was 8.4 and he was transfused
2 units pRBC's. His Hgb trended up to 9.1 where it remained
stable.
At discharge he was voiding spontaneously, tolerating PO diet,
and pain was controlled. He was cleared for safe discharge to
rehab by PT. He was afebrile and hemodynamically stable at
discharge.
Medications on Admission:
COLACE 50 mg--
MS CONTIN 100 mg--1 tablet(s) by mouth twice daily
Morphine 30 mg--1 tablet(s) by mouth [**4-4**] as needed for pain
PROTONIX 40 mg--1 tablet(s) by mouth daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
4. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO QHS (once a day
(at bedtime)) as needed for insomnia.
5. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed.
6. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
once a day.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Right thigh carcinoma/sarcoma
Discharge Condition:
Stable
Discharge Instructions:
1. Lovenox daily for 4 weeks.
2. Weight bearing as tolerated right lower extremity.
3. [**Doctor Last Name **] brace for comfort when ambulating.
4. R knee ROM as tolerated.
5. You may shower, no bathing. Pat incision dry when finished.
6. Daily dressing changes with dry sterile guaze. [**Month (only) 116**] wrap with
an ACE bandage.
Physical Therapy:
1. Weight bearing as tolerated right lower extremity.
2. [**Doctor Last Name **] brace for comfort when ambulating.
3. R knee PROM and AROM as tolerated.
Treatments Frequency:
Dry sterile dressing changes to right thigh incisions changed
daily
Followup Instructions:
Follow up in [**Hospital Ward Name 23**] [**Location (un) **] with Dr [**Last Name (STitle) **] in 2 weeks with
AP and Lat X-ray of the right femur.
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7278
} | Medical Text: Admission Date: [**2185-5-5**] Discharge Date: [**2185-5-14**]
Date of Birth: [**2105-12-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 year-old right-handed man with a past medical
history significant for alzheimer's disease,
hypercholesterolemia, and hypothyroidism who was found at around
4:30pm this evening to be behaving oddly. Though he has moderate
alzheimer's at baseline he clearly was acting differently. He
was
clearly more agitated. He was found at one point in the bathroom
folding and unfolding towels. He did this with a napkin and a
handkerchief as well. He was much more fidgety than normal. The
patient's wife called her daughter who phoned their Neurologist.
A decision was made to call EMS and have the patient brought to
[**Hospital **] hospital. Blood pressure there was 149/78 There a CT
scan
showed a right frontal hemorrhage. The white blood cell count
was
slightly elevated at 10.8. The patient was transferred here for
neurosurgical intervention.
Past Medical History:
Hypothyroidism
Hypercholesterolemia
Alzheimer's Dementia
Social History:
Lives with wife. [**Name (NI) **] a daughter in neighborhood.
[**Name2 (NI) **] smoking or drugs. Drinks a glass of red wine every evening.
Functioned minimally with advanced dementia, but was
conversation and pleasant. Needed prompting and cueing for most
ADLs, and needed help with dressing and personal hygiene. When
put in chair with book/newspaper he would read happily. Was able
to join family on small outings.
Family History:
NC
Physical Exam:
Vitals: T:97.9 P:78 R:19 BP:133/68 SaO2:100%
General: Eyes closed. Arrousable. NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA anteriorly.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Eyes closed. Opens to his name if repeated
loudly
and often. Variably following commands. Didn't open and close
right hand to command. Did close his eyes to command. Didn't
open
his eyes to command. Wasn't able to tell where he was. Correctly
identified his wife as "[**Name2 (NI) **]" when I asked him who she was.
He
doesn't move his limbs to command, but he does keep them up.
-Cranial Nerves: Olfaction not tested. Pupils equal at 1mm and
minimally reactive. Unable to obtain fundoscopic exam. Corneal
reflex intact bilaterally. No facial droop. Patient actively
opposed eye opening. He was able to hear my questions.
-Motor: All four limbs are antigravity. The patient does not
comply with a formal motor test. He can keep both arms up for 10
seconds and both legs up for 5 seconds.
-Sensory: Intact to noxious stimuli in the upper and lower
extremities bilaterally.
-Coordination: Nt tesed.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
C5 C7 C6 L4 S1
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was extensor bilaterally.
-Gait: In no condition to test
Pertinent Results:
MRI [**5-5**]
Again demonstrated is a large right frontal intraparenchymal
hemorrhage, measuring approximately 5.5 cm x 5 cm, not
significantly changed in size from three hours prior. This
lesion demonstrates mostly T2 hyperintensity and T1
isointensity, compatible with an acute hemorrhage. There is
associated mass effect on the frontal [**Doctor Last Name 534**] of the right lateral
ventricle with mild subfalcine herniation, not significantly
changed.
Additionally, a moderate amount of layering intraventricular
hemorrhage within the occipital horns of the lateral ventricles
is stable. Thre is no evidence of hydrocephalus. On
gradient-echo sequences, scattered punctate foci of
susceptibility are seen within the sulci, likely reflecting
blood products from a small amount of associated subarachnoid
hemorrhage.
No definite enhancement is seen within the right frontal region
to suggest a large mass or vascular malformation. However, given
the relatively large size of this, assessment is somewhat
limited. Additionally, there is no evidence of an acute infarct
within any particular vascular territory. No convincing evidence
of amyloid angiopathy is identified. Minimal mucosal thickening
of the ethmoidal sinuses is seen. No abnormal enhancement is
identified after contrast administration.
IMPRESSION:
1. Large right frontal intraparenchymal hemorrhage, with
associated subarachnoid and intraventricular hemorrhage. Overall
size and appearance is largely unchanged from three hours prior.
2. Mild leftward subfalcine herniation and effacement of the
right frontal [**Doctor Last Name 534**] and lateral ventricle is not changed.
3. No definite evidence of underlying mass, vascular
malformation, or infarct. No convincing evidence of amyloid
angiopathy. However, due to the large size of this hemorrhage,
assessment is limited for an underlying lesion, and a followup
study after resolution of acute symptoms is recommended to
exclude any underlying mass or vascular malformation.
CT [**5-5**]
Again is noted a large right frontal intraparenchymal
hemorrhage, slightly larger than the study conducted at 3:00
a.m. this morning. There is associated subarachnoid hemorrhage,
comparable to the prior study. Unchanged bilateral
intraventricular extension is again noted. There is extensive
vasogenic edema surrounding the hemorrhage causing mass effect
and effacement of the frontal and occipital horns of the lateral
ventricle. There is a 4.9 mm leftward subfalcine herniation
compared to prior 4.4 mm. There is no uncal or downward
transtentorial herniation. There is diffuse global atrophy,
unchanged. There are no acute major vascular territorial
infarcts or obvious masses. There is no hydrocephalus. No other
interval changes are noted.
IMPRESSION:
1. Slight interval increase in the right frontal
intraparenchymal and bilateral subarachnoid hemorrhage.
2. Stable intraventricular hemorrhage and minimal leftward
subfalcine herniation.
CT [**5-6**]
Again is noted a large right frontal intraparenchymal
hemorrhage, slightly larger than the study conducted at 3:00
a.m. this morning. There is associated subarachnoid hemorrhage,
comparable to the prior study. Unchanged bilateral
intraventricular extension is again noted. There is extensive
vasogenic edema surrounding the hemorrhage causing mass effect
and effacement of the frontal and occipital horns of the lateral
ventricle. There is a 4.9 mm leftward subfalcine herniation
compared to prior 4.4 mm. There is no uncal or downward
transtentorial herniation. There is diffuse global atrophy,
unchanged. There are no acute major vascular territorial
infarcts or obvious masses. There is no hydrocephalus. No other
interval changes are noted.
IMPRESSION:
1. Slight interval increase in the right frontal
intraparenchymal and bilateral subarachnoid hemorrhage.
2. Stable intraventricular hemorrhage and minimal leftward
subfalcine herniation.
CT [**5-10**]
The large right intraparenchymal hemorrhage with associated
edema, mass effect and effacement of the right frontal [**Doctor Last Name 534**] of
the lateral ventricle have shown expected evolution from prior
study without any evidence of new hemorrhage or infarct. The
4-mm leftward midline shift is unchanged. The diffuse
subarachnoid blood within the cortical sulci is similar,
although the confluent area in the left parietal lobe is less
apparent. There is slightly less blood within the occipital
horns of lateral ventricles than on prior. The mild
ventriculomegaly and dilated temporal horns is similar to prior.
There is new opacification of the left sphenoid sinus. The
mastoid air cells are normal. There are no fractures.
IMPRESSION:
1. Expected evolution of right intraparenchymal hemorrhage and
diffuse subarachnoid hemorrhage and intraventricular blood
without evidence of new infarct or intracranial hemorrhage.
2. Persistent midline shift.
3. No change in the mild ventriculomegaly.
Brief Hospital Course:
The patient was admitted to the ICU. Neurosurgery was consulted
but no intervention. Repeat CT next day no interval change. Exam
remained poor. Transferred to floor. Patient became febrile, no
focus found, CXR read as possible infiltrate around L
hemidiaphragm but no change after 3 days of ABx, no white count,
no labored breathing so likely central fever. Exam remained
extremely poor and patient deteriorated slowly over 9 day stay,
despite stable vital signs and only mild fever, with no evidence
of systemic infection. EEG negative for seizures, did show mild
to moderate encephalopathy, consistent with exam. 3rd CT scan on
[**5-10**] showed further blossoming of R parietal contusion,
entrapment of ventricles with balooning, large R frontal
evolution of bleed.
Towards the 2nd half of hospitalization, daily conversations
were held with family. Grim prognosis was stressed, given age,
extensive frontal lobe involvement, deterioration during
hospital stay, and perhaps most importantly his pre-morbid
advanced dementia.
The patient has expressed clearly that he wanted no supportive
measures in absence of a meaningful life, and the family has
respected his wishes after the prognosis became more evident
over time. First they chose not to give him a PEG tube, and with
continued lack of recovery quite understandingbly made him CMO.
Medications on Admission:
Asa 81 qd
Namenda 10mg [**Hospital1 **]
Aricept 10mg daily
Levothyroxine 112mcg daily
Simvastatin 20 daily
Vit E 1200 IU daily
Ginko 120mg daily
Discharge Medications:
Scopolamine patch
Morphine drip PRN at discretion of hospice medical team
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Intracranial hemorrhage
Discharge Condition:
comfort measures only
Discharge Instructions:
You will be transferred to a hospice facility. You have had a
large R frontal and a smaller L parietal bleed.
Followup Instructions:
none
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2185-5-13**]
ICD9 Codes: 486, 2720, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7279
} | Medical Text: Admission Date: [**2159-10-22**] Discharge Date: [**2159-10-29**]
Date of Birth: [**2097-9-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Amiodarone
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
intubation
CVL placement
History of Present Illness:
This is a 62 yom with history of CAD s/p CABG x 5 in [**2144**], UGIB,
Chronic Systolic CHF (EF 20%), hx of VT s/p PPM/ICD in [**2144**],
Afib on Coumadin, Hyperlipidemia who presents from home with
weakness x 10 days. Patient reports feeling increasing weakness
over this time, +dry cough as well. He denies any worsening SOB
but does report some worsening orthopnea and PND. He sleeps with
two pillows at baseline and this has not increased over this
time frame. He denies any worsening DOE or pedal edema. He
weighs himself every 2 days and has not noted any increase in
weight. Last wednesday he, reports 2 episodes of ICD firing when
he was getting out of the bathtub. He denies any syncope, fall,
chest pain, N/V or diaphoresis during this event. He denies any
recent fevers, chills, SOB, chest pain, N/V, abdominal pain,
diarrhea, hematochezia, melena, dysuria or hematuria. Patient
reports +anuria over the past week, states he has not urintated
in 7 days. He took double his dose of lasix over the weekend
given his anuria but did not have any urine output.
.
Of note, patient has been in the hospital twice over the past
two months. He was hospitalized from [**8-24**] - [**8-27**] for a CHF
exacerbation. He presented to the hospital with SOB and found to
have a lactate of 13.7. Sepsis was a concern but not infectious
source was found. CXR was done and showed +pulmonary edema, he
was diuresed over the course of his hospitalization and his
lactate trended down to normal. LFT were also noted to be
elevated with peak AST of 2094 and peak ALT 711 with Tbili peak
of 5.2 and INR of 4.7. This was thought to be [**1-1**] congestive
hepatopathy. Lorazepam, clonazepam, simvastatin, midodrine, and
zolpidem were also discontinued at that time out of concern for
causing hepatic damage. He was again hospitalized from
[**Date range (1) 31933**] for ICD firing. On the morning of [**9-15**] he went into
afib with RVR and a CODE BLUE was called, he was intubated and
shocked and started on amiodarone. He was extubated successfully
and went home on Amiodarone as well as low dose digoxin.
.
Per the wife, patient visited his podiatrist on friday and a
small pocket of fluid was opened which was thought to be
non-infectious, however, Cipro 750mg daily was started. Wife
also reports decreased UOP over the weekend and +SOB on friday
so Lasix was increased from 40mg to 60mg with no increase in UOP
noted.
.
In the ED, initial VS: Temp 96.5, HR 117 afib, BP 86/53, RR 28,
99% 2L NC. He was given Levoflox 750mg IV x 1, Flagyl 500mg IV x
1, Vanco was ordered but not given. He received 1.5L IVF. EP was
consulted and interrogated his pacer. He was noted to have afib
with RVR on friday, no episodes of Vtach.
Past Medical History:
Coronary Artery Disease s/p 5 vessel CABG in [**2144**]
Anterior MI [**2144**]
Large UGIB in [**2154**] thought to be secondary to a combination of
gastritis, nsaids, and coumadin (required intubation and
tracheostomy secondary to MRSA ventilator associated pneumonia)
Chronic systolic heart failure (EF 20% by last echocardiogram)
History of VT s/p BiV pacer and ICD placement in [**2144**] now s/p
multiple device changes most recently in [**2157**].
Left hip arthritis
Hyperlipidimia
Hypothyroidism
Atrial Fibrillation (not on anticoagulation secondary to GI
bleeding)
Osteomyelolitis on L foot
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
-CABG: Five vessel CABG in [**2144**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: [**Company 1543**] Concerto biventricular ICD placed in
[**2158-3-30**]. He has three leads. The RV lead is a [**Company 1543**] 6943
implanted [**2150-9-18**]. The atrial lead is a Guidant 4464
also implanted in [**2150-8-30**]. His LV lead is a [**Company 1543**] 4193
implanted in [**2153-7-30**] and the ICD device was implanted in
[**2158-3-30**].
Social History:
Lives at home with his wife, has two sons. Denies any EtOH,
tobacco or illicit drug use
Family History:
father who died of MI at 61
Physical Exam:
Vitals - T: BP: HR: RR: 02 sat:
GENERAL: NAD, lying in bed comfortably
HEENT: NCAT, EOMI, PERRLA
CARDIAC: +S1/S2, no M/R/G, irregular rhythm, irregular rate
LUNG: mild dry crackles in bilateral bases, no ronchi, no
wheezing
ABDOMEN: +BS, soft, NT/ND, no hepatosplenomegaly
EXT: no C/C/E, +dopplerable bilateral pedal pulses, +venous
stasis changes LLL > RLE, +blanching erythma LLE, +2 clean bases
ulcers on superior anterior portion of left foot, no exudate/pus
noted
DERM: no rashes
Pertinent Results:
[**2159-10-22**] 07:07AM BLOOD WBC-14.3*# RBC-4.33* Hgb-10.4* Hct-37.6*
MCV-87# MCH-24.0* MCHC-27.7*# RDW-19.3* Plt Ct-320#
[**2159-10-29**] 03:04AM BLOOD WBC-13.1* RBC-4.32* Hgb-10.4* Hct-35.1*
MCV-81* MCH-24.1* MCHC-29.6* RDW-20.1* Plt Ct-148*
[**2159-10-29**] 03:04AM BLOOD PT-33.1* PTT-51.3* INR(PT)-3.4*
[**2159-10-24**] 03:30AM BLOOD PT-71.7* PTT-56.1* INR(PT)-8.4*
[**2159-10-22**] 07:07AM BLOOD Glucose-20* UreaN-27* Creat-1.8* Na-131*
K-4.7 Cl-92* HCO3-11* AnGap-33*
[**2159-10-25**] 04:03AM BLOOD Glucose-62* UreaN-42* Creat-1.7* Na-128*
K-4.6 Cl-93* HCO3-20* AnGap-20
[**2159-10-29**] 03:04AM BLOOD Glucose-118* UreaN-47* Creat-2.4* Na-128*
K-4.8 Cl-97 HCO3-22 AnGap-14
[**2159-10-22**] 07:07AM BLOOD ALT-170* AST-616* CK(CPK)-103
AlkPhos-177* TotBili-4.8* DirBili-3.3* IndBili-1.5
[**2159-10-24**] 03:30AM BLOOD ALT-394* AST-1250* LD(LDH)-610*
AlkPhos-153* TotBili-4.1*
[**2159-10-29**] 03:04AM BLOOD ALT-349* AST-595* AlkPhos-144*
TotBili-15.2*
[**2159-10-22**] 07:07AM BLOOD CK-MB-7 proBNP-5108*
[**2159-10-22**] 07:07AM BLOOD cTropnT-0.08*
[**2159-10-22**] 02:53PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2159-10-23**] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2159-10-23**] 05:22PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2159-10-29**] 03:04AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.5
[**2159-10-29**] 07:39AM BLOOD Vanco-28.0*
[**2159-10-26**] 02:58AM BLOOD Cortsol-29.1*
[**2159-10-26**] 02:58AM BLOOD Digoxin-0.6*
[**2159-10-29**] 03:09AM BLOOD Type-ART pO2-152* pCO2-38 pH-7.38
calTCO2-23 Base XS--1
.
Echo:
The left atrium is markedly dilated. The right atrium is
markedly dilated. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is severely depressed (LVEF<20%). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. No mass or vegetation is seen on the
mitral valve. Moderate (2+) mitral regurgitation is seen. Severe
[4+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: No valvular vegetations seen (reasonable-quality
study). No intracardiac or significant transpulmonary shunting
seen. Dilated left ventricle with severe global systolic
dysfunction. Dilated right ventricle with moderate global
systolic dysfunction. Moderate mitral regurgitation. Severe
tricuspid regurgitation. At least moderate pulmonary
hypertension.
.
Liver US:
IMPRESSION:
1. Limited study from obscuration of marked gastric distention.
Incomplete
assessment of the gallbladder.
2. Moderate amount of ascites.
3. Unchanged diffusely echogenic liver, may be from fatty
deposition or
congestive hepatopathy, however more advanced liver disease such
as cirrhosis
or fibrosis cannot be excluded.
4. Abnormal periodicity of the hepatopetal portal venous flow,
unchanged.
Brief Hospital Course:
62 yom with history of CAD s/p CABG x 5 in [**2144**], UGIB, Chronic
Systolic CHF (EF 20%), hx of VT s/p PPM/ICD in [**2144**], Afib on
Coumadin, Hyperlipidemia who presents from home with weakness x
10 days found to have sepsis. See below for discussion of each
problem.
.
# Sepsis: Mr. [**Known lastname 31930**] presents with lactate of 11.9, Afib with
RVR to 140s and leukocytosis of 14.3 all consistent with sepsis.
He is also c/o of cough over the past week. Patient has history
of MRSA PNA requiring intubation in the past, CXR with ?LLL
infiltrate. will treat broadly at this time as there is no clear
source. Urinalysis negative. Blood Cx, Urine Cx drawn. Grew
GCPs and meropenem was started. He required pressors and was
unable to be weaned. Evenutally his family decided on DNR and
then to stop escalation of care and he passed away while still
requiring pressors.
.
# Transaminitis: Unclear etiology at this time but may be
related to sepsis and mild shock liver as lactate 11.9. CT done
and shows no biliary cause. Serum tox negative for acetaminohen,
patient denies EtOH use. Patient had similar presentation in
[**7-/2159**] which was thought [**1-1**] shock liver/hypotension.
?Amiodarone related. Had multiple ultrasounds while admitted
without clear cause and was thought to be from shock liver. His
bili was 15 prior to his death.
.
# ARF: Likely related to sepsis, BUN/Cr less than 20, so more
likely related to ATN. will treat with IVF and trend. Initially
given IVFs given sepsis but then was diuresed. No HD needed as
escalation of care was not wanted by the family.
.
# Afib with RVR: Currently, patient is in Afib with normal rate
s/p fluids. Currently not on Coumadin, but INR elevated, likely
[**1-1**] liver dysfunction. We held amiodarone given hepatitis. He
had tachycardia and hypotension while febrile. Attempted to
control fever with tylenol and cooling blanket but were unable
to decrease heart rate in the setting of afib and sepsis.
.
# ICD firing: per patient, ICD fired x 2. EP consulted in ED and
pacer interrogated, no Vtach noted, patient has been in afib
with RVR over the weekend. EP followed along and ICD was turned
off.
.
# Chronic CHF: Patient with history of chronic CHF. Had echo
showing worsening function during sepsis. He continued to make
good urine output through his course until the final day, and
was not aggressively diuresed due to his low BPs. We tried to
avoid excess IVFs, though.
.
# Respiratory Failure: was intubated during admission for
respiratory failure with possible LLL infiltrate, although LE
wound was likely the cause of his sepsis. Unable to be weaned
off the ventilator during his admission.
.
# CAD s/p CABG: No signs of MI at this time, CK flat and Trop
0.[**4-6**] be related to ARF. Not on BB, ACE-I as outpatient.
.
# He passed away after his family was informed of his poor
prognosis and his worsening liver failure and unchanging
hemodynamics despite treatment with pressors and antibiotics.
He became tachycardic and more hypotensive while febrile and
pressors were not uptritrated and he passed away.
Medications on Admission:
Midodrine 5mg PO TID
Levothyroxine 50mcg PO DAILY
Bupropion HCl 50mg PO BID
Amiodarone 400 mg PO DAILY
Furosemide 40mg PO DAILY
Digoxin 125mcg PO EVERY OTHER DAY
Simvastatin 40mg PO DAILY
Spironolactone 25mg PO BID
Citalopram 10 mg PO DAILY
Ativan 2mg PO qHS PRN insomnia
Ambien 10mg PO qHS PRN insomnia
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis
systolic heart failure
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2160-2-1**]
ICD9 Codes: 5845, 4271, 2761, 2762, 4280, 412, 2449, 2724, 311, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7280
} | Medical Text: Admission Date: [**2178-12-15**] Discharge Date: [**2178-12-22**]
Date of Birth: [**2110-3-24**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents / Amiodarone
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
HYPOTENSION IN SETTING OF RP BLEED
Major Surgical or Invasive Procedure:
Midline placement
History of Present Illness:
Mr. [**Known lastname **] is a 68 yo M w/ PMH CAD s/p CABG x4 in [**2163**], CHF
(EF-20%), VT s/p ablation and ICD in [**2-16**], HIT, who presented to
an OSH [**2178-12-12**] with hypotension and shock. Of note, he had been
at [**Hospital1 18**] [**10-16**] for infected ICD wire (likely originating from
foot infection), resulting in ICD wire removal. He was d/c'd to
rehab for planned 6 wk course of vanco (to be completed
[**2178-12-13**]). He presented to the OSH from rehab after the sudden
onset of L flank pain with SBP 50s. He was also hypoxic,
requiring NRB. On abd CT at the OSH, he was found to have an
enlarging L sided RP hematoma orginating from L kidney. Of note,
he had received one dose of fondaparinux on admission for his
h/o HIT. He initially required pressors, which were weaned off
[**12-14**]. He received 11U PRBCs, 3U FFP, 10mg Vit K x2, DDAVP
22.5mg. He was seen by urology at OSH, who recommended
conservative treatment for RP bleed.
.
He was also felt to have infection/sepsis contributing to his
hypotension, with lactate 8.0, and was started on vanco and
imipenem on admission. He was found to have GPC in clusters
growing from his PICC line, and this was removed. In addition,
coccyx wound cultures grew out acinetobacter, sensitive only to
aminoglycosides. The patient had WBC of 14.9 with L shift, no
fever noted. The patient also presented with plts of 174K which
trended down to 34K, so his mexiletine was discontinued as a
possible source of thrombocytopenia.
.
He was transferred to [**Hospital1 18**] on [**2178-12-15**]. Vancomycin was continued
for GPC PICC line infection, but other abx were discontinued. He
was also found to have a pneumonia, and was started on
ciprofloxacin. He has received 4U PRBC here, as well as 1U
platelets. His [**Date Range **] was resumed, after discussion with EP.
His [**Date Range **] dose was also increased to 40mg daily, due to a
gout flare.
.
ROS: Currently, denies CP, SOB, cough, F/C, back/flank pain, abd
pain, N/V, diarrhea, dysuria, dizziness.
Past Medical History:
Past Medical History:
1)CAD s/p CABG CABG [**2163**] (LIMA->LAD, SVG->D->OM2 jump graft,
SVG->LPDA)
- cath([**2177-1-31**]: patent LIMA->LAD, patent SVG->diagonal and OM2.
Occluded SVG-> L PDA.
- Underwent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2->proximal and distal left circumflex/PVA
2)HTN
3)Hyperlipidemia
4)s/p VT ablation and ICD implantation [**2-16**]
5)COPD
6)Gout
7)chronic LLE ulcers
8)PVD/claudication
- s/p right external iliac artery stent [**8-/2176**]
- complicated by LUE hematoma, ? nerve injury;
- s/p right to left fem-fem bypass grafting in [**2178-5-11**]
9)spinal stenosis
- s/p back surgery
[**82**])bilateral renal masses
11)s/p L inguinal hernia repair
12)s/p cataract surgery
Social History:
Single, lives alone. Has visiting nurse service. Active smoker
of 10 cigarettes per day. Has smoked 1-2 packs per day for [**10-25**]
years. Denies ETOH. Retired construction worker.
Family History:
Non-contributory
Physical Exam:
VS: Temp: 97.6 BP: 130/82 HR: 102 RR: 18 O2sat: 100% on RA
Gen: chronically ill appearing, appears comfortable. NAD at
rest.
HEENT: anicteric, MMM, OP clear
Neck: no JVD
CV: RRR, II/VI SEM at LUSB
Lungs: Minimal bibasilar crackles, L>R.
Ab: +BS, slightly firm, mild tenderness on L side, no guarding
or rebound. Faint ecchymosis visible on L side.
Extrem: R wrist and elbow with discomfort on active and passive
ROM. Diffuse tophi. L foot with healing ulcer, no erythema or
discharge. 2+ pitting edema b/l. 1+ DP pulses.
Back: 5x6 cm sacral decubitus ulcer, no active pus or
surrounding cellulitis.
Pertinent Results:
Admission Labs:
[**2178-12-15**] 10:58PM PT-13.4* PTT-36.7* INR(PT)-1.2*
[**2178-12-15**] 10:58PM PLT SMR-LOW PLT COUNT-93*#
[**2178-12-15**] 10:58PM NEUTS-96.7* BANDS-0 LYMPHS-1.7* MONOS-1.5*
EOS-0.1 BASOS-0
[**2178-12-15**] 10:58PM WBC-9.0 RBC-2.67* HGB-8.5* HCT-23.6* MCV-88
MCH-31.9 MCHC-36.1* RDW-17.4*
[**2178-12-15**] 10:58PM ALBUMIN-3.2* CALCIUM-7.7* PHOSPHATE-7.2*#
MAGNESIUM-2.0
[**2178-12-15**] 10:58PM ALT(SGPT)-27 AST(SGOT)-31 LD(LDH)-377* ALK
PHOS-129* TOT BILI-1.1
[**2178-12-15**] 10:58PM estGFR-Using this
[**2178-12-15**] 10:58PM GLUCOSE-72 UREA N-62* CREAT-2.1* SODIUM-137
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-15* ANION GAP-22*
.
Discharge Labs:
[**2178-12-22**] 06:25AM BLOOD WBC-6.5 RBC-3.21* Hgb-9.9* Hct-29.5*
MCV-92 MCH-30.8 MCHC-33.6 RDW-17.0* Plt Ct-100*
[**2178-12-22**] 06:25AM BLOOD Glucose-83 UreaN-76* Creat-1.6* Na-137
K-4.0 Cl-107 HCO3-20* AnGap-14
.
Micro:
[**2178-12-16**] 1:04 am CATHETER TIP-IV Source: right sc presept
cath.
**FINAL REPORT [**2178-12-18**]**
WOUND CULTURE (Final [**2178-12-18**]): No significant growth.
.
Imaging:
MRI Abdomen [**12-16**]:
FINDINGS: There is a large, approximately 30 cm in craniocaudad
dimension, perinephric hematoma that extends retroperitoneally
into the pelvis. This retroperitoneal collection displaces the
left kidney superiorly. There is a subcapsular component of this
large perinephric hematoma. No active extravasation is
visualized at the time of the examination. There was a delayed
nephrogram to the left kidney, however the arterial and venous
flow is preserved. Coronal reconstructions suggest that the left
kidney is intact. There is no history of trauma, this finding
may be secondary to rupture of a complicated cyst or bleeding
from lipid poor angiomyolipoma with coagulation deficiencies
causing excessive bleeding. On the prior examination of
[**2178-11-4**], no definitive angiomyolipoma was seen.
Post simple and hemorrhagic cysts are visualized within the
right kidney. Limited visualization of the adrenal glands, liver
and pancreas are unremarkable. There has been interval
development of multiple tiny subcapsular non-enhancing foci
within the spleen, which are not seen on the prior examination.
Question residual from infection in this patient with history of
MRSA bacteremia.
Multiplanar 2D and 3D reformations as well as subtraction images
were essential in demonstrating multiple perspectives for this
dynamic series.
IMPRESSION:
1. Large perinephric hematoma extending into the pelvis with
contiguity with the left kidney. In the absence of trauma, this
may be a complication of a ruptured cyst versus a bleeding lipid
poor angiomyolipoma. [**Date Range **] flow to the left kidney is
preserved and the left kidney appears intact on coronal
reformatted images.
2. New tiny foci seen in the subcapsular aspect of the spleen,
suggesting residual of prior infection in this patient with
history of MRSA bacteremia.
.
Renal US [**12-16**]:
IMPRESSION:
1. Edematous and distended left kidney without evidence of
Doppler flow, could be secondary to ischemia, i.e., venous
obstruction as a result of the hematoma. Further evaluation with
MRI is recommended.
2. Multiple right renal cysts with echogenic parenchyma
representing parenchymal disease.
3. Small ascites and right pleural effusion.
.
CXR PA/LAT [**12-22**]:
PA and lateral radiograph. Comparison [**11-10**] and [**2178-12-16**], as well as CT [**2176-9-4**].
Left lower lobe consolidation and effusion are unchanged. There
may be minimal atelectasis in the medial right lung base.
Mediastinal contours are stable. Calcification in the
interventricular septum and the myocardial left ventricular apex
are noted on the lateral view. Pulmonary vasculature is stable
and within normal limits.
There is an old healed right posterior seventh rib fracture.
IMPRESSION: No change in left lower lobe pleural effusion and
consolidation.
Brief Hospital Course:
Retroperitoneal Bleed: The patient was initially hypotense
requiring aggressive volume resusitation. The patient's Hct on
admission was 23. He was given a total of 11 units PRBCs as
well as 5 units of FFP. Renal US demonstrated an edematous and
distended left kidney. MRI abdomen showed a perinephric
hematoma with perserved [**Year (4 digits) 1106**] flow to the kidney, as well as
renal cysts. His cysts were thought the likely cause of the
bleed. Urology was consulted and recommended supportive care.
His Hct stabilized to 28-30. They recommended repeat imaging
with a MR urogram as an outpatient as long as remains clinically
stable. He will need follow up with urology as an outpatient,
and urgent evaluation if becomes clinically unstable.
.
MRSA Line Infection: Prior to admission, the patient had a
positive blood culture from his previous PICC line which grew
MRSA one day prior to completing course of vanco for MRSA
bacteremia, though other blood cultures were negative. Follow
up blood cultures here were negative. However, the patient was
continued on vanco. ID was consulted to determine proper course
of vanco. Although it was uncertain if he did in fact have a
line infection vs. a contaminant, they recommended to continue
vanco to complete a 14 day course starting [**12-13**]. A midline
catheter was placed on [**12-22**]. He should take vanco through
[**12-27**].
.
Pneumonia: The patient was thought to have a left lower lobe
pneumonia. The patient was given a 7 day course of cipro. He
remained afebrile with a normal WBC count, satting 100% on room
air. A repeat CXR did show persistent infiltrate. He was
clinically asymptomatic however. A repeat CXR in [**1-12**] weeks or
as symptoms dictate are needed to confirm resolution of his
pneumonia.
.
Thrombocytopenia: The patient was thrombocytopenic on admission.
His thrombocytopenia was thought secondary to multiple PRBCs
given. He did not receive any heparin products here. His
platelet count remained stable between 90-110. His platelet
count will need periodic monitoring. He is NOT TO RECEIVE
HEPARIN PRODUCTS.
.
Gout: The patient has known severe tophaceous gout. His
allopurinol and colchicine were held prior to admission. The
patient experienced an acute flare, mostly localized to his
right wrist. Because of his ARF, he was not given colchicine or
NSAIDS. Instead, he was given [**Date Range 2768**] 40mg with good result.
He continued 40mg x 4 days. His [**Date Range 2768**] was switched to
30mg on [**12-22**]. He should continue his [**Month/Year (2) **] taper as
follows, and restart his allopurinol as an outpatient at the
discretion of his PCP: [**Name10 (NameIs) 2768**] taper - [**2185-12-22**] 30mg,
[**2087-12-23**] 20mg, [**2090-12-25**] 10mg, [**2093-12-28**] 5mg then stop.
.
Acute Renal Failure: His ARF was thought likely due to ATN and
pre-renal azotemia from his hypotension. His creatinine
improved during admission to near his baseline. It was 1.6 on
discharge. His renal function will need to be followed for
resolution.
.
History of VTach: Continued on mexilitene without complications.
.
CHF: His metoprolol and lisinopril and statin were restarted
prior to discharge. His ASA and [**Month/Day/Year **] were held. They can be
restarted once the patient is more stable. He should also have
a repeat ECHO to assess his heart function.
.
Chronic Anemia: His Epoetin was continued at 4000 units SC q
MWF, as well as his ferrous sulphate.
.
Metabolic Acidosis: He initially had an acidosis secondary to an
elevated lactate. Once his lactate normalized, he continued to
have a non AG acidosis thought likely to his ARF. His acidosis
improved throughout his admission.
.
Sacral Wound: Patient will need pressure relief from his wound,
repositioning q2hrs prn. Wound care recommended cleansing with
commercial cleanser, patting dry, applying no-sting barrier wipe
to periwound tissue, applying aquacel sheet to ulcer, covering
with dry gauze and ABD, securing with mefix tape.
.
Foot Ulcer: Patient was seen by podiatry. Recommended aquacel
for 1st MPJ but not necessary for dorsal wound. Recommended
slightly moist environment for wounds. Can have partial weight
bearing, heel touch. Pt should f/u with Dr. [**First Name (STitle) 3209**] 1 week from
D/C [**Telephone/Fax (1) 543**]
.
Code: FULL for this admission
Medications on Admission:
Allopurinol 200mg PO qDay
Ambien 5mg PO qHS
Ascriptin 325mg PO qDay
Colchicine 0.6mg PO qDay
Flonase 50mcg/act nasal 2 sprays qDay
[**Telephone/Fax (1) 11573**] 40mg PO TID
Lisinopril 5mg PO qDay
[**Telephone/Fax (1) 105360**] 150mg PO BID
Oxycontin 40mg [**Hospital1 **]
Percocet 5-325 PO 1-2 Tabs q6hrs prn
Plavix 75mg PO qDay
Pravachol 40mg PO qDay
Senna
Sotalol 120mg PO BID
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
10. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Pravastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
15. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
16. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
17. [**Hospital1 2768**] 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): for dates [**12-22**] - [**12-23**].
18. [**Month/Year (2) 2768**] 10 mg Tablet Sig: Two (2) Tablet PO once a day:
for dates [**12-24**] - [**12-25**].
19. [**Month/Year (2) 2768**] 10 mg Tablet Sig: One (1) Tablet PO once a day:
for dates [**12-26**] - [**12-28**].
20. [**Month/Year (2) 2768**] 5 mg Tablet Sig: One (1) Tablet PO once a day:
for dates [**12-29**]- [**12-31**] THEN STOP AFTER [**12-31**].
21. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
22. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y
(750) Milligrams Intravenous q24 hours: Please take through
[**12-27**] to complete 14 day course.
23. Insulin sliding scale
Regular or Humalog insulin sliding scale at your discretion fo
hyperglycemia
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
Retroperitoneal bleed
MRSA line infection
Gout flare
.
Secondary Diagnoses:
Pneumonia
Thrombocytopenia
Anemia
Congestive Heart Failure
Acute Renal Failure
Hyperkalemia
SacralDecubitus Ulcer
Foot Ulcer
Heparin Induced Thrombocytopenia
Hypertension
Chronic Obstructive Pulmonary Disease
Discharge Condition:
stable, eatings solids easily
Discharge Instructions:
Pt has normal oxygen saturation on room air, with well
controlled blood pressure and heart rate. Patient will need to
continue Vancomycin until [**2178-12-27**] per recommendation of
infectious disease consult team.
Followup Instructions:
1)Mr. [**Known lastname **] has an appointment for an MRI of his kidneys on
[**1-8**] at 11:15 am on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building at
[**Hospital3 **], at [**Location (un) **]. He must be npo for 4 hours
prior, may take his meds. Per case management NO
PRE-AUTHORIZATION IS NEEDED given that patient's insurance is
medicare primary.
2)Pt has a follow up appointment with the Urologist Dr. [**First Name (STitle) **] on
Tuesday [**1-12**] at 11:15am, located at [**Hospital Ward Name 23**] Building [**Location (un) **] Please call [**Telephone/Fax (1) 6317**] if you need to cancel.
3) Follow up appointment with infectious disease [**1-26**] at
11:00am at [**Last Name (NamePattern1) 439**] [**Hospital 1422**] Clinic.
.
Patient has a podiatry appointment with Dr. [**First Name (STitle) 3209**] on Tuesday [**1-26**] at 10AM in the Dept of Podiatry at [**Hospital1 18**]
.
Please have patient follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**] in [**2-14**] weeks.
[**Telephone/Fax (1) 3070**]
ICD9 Codes: 486, 496, 4280, 5845, 2762, 5859, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7281
} | Medical Text: Admission Date: [**2179-4-7**] Discharge Date: [**2179-4-12**]
Date of Birth: [**2118-3-18**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 61 year old man with history of embolic CVA in 92
who complained of headache upon arrival to [**Hospital1 **] for
Pt for his RLE. He was uncooperative and they transfered him to
[**Hospital1 18**]. CT head showed larhe Left IPH/SDH and Neurosurgery was
consulted. He reports headache and fatigue. He has no nausea,
emesis.
Past Medical History:
AVR/MVR on coumadin, HTN, prev embolic stroke 92 with speach
disturbance, R knee surgery with chronic pain in PT. ETOH abuse
in past, Hep C, endocarditis, CHF, CVD
Social History:
He is a left handed married man who works at Stop and
Shop. Prior ETOH abuse, no tobacco
Family History:
NC
Physical Exam:
O: 99.1 68 127/71 16 100%
pt arrives via ems from [**Location (un) 2274**] with c/o HA sudden onset 12:20 when
pt went for PT appt - pt states + loss of vision to right eye -
pt with Hx CVA in past with residual of a limp - pt took 1
percocet of his own and revieved 0.5mg IV [Completed by [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 79636**]]
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-17**] EOMs intact
Neuro:
Mental status: sleepy, awakes to voice, cooperative with exam,
normal
affect.
Orientation: Oriented to person, hospital, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-19**] throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Handedness Left
On Dishcarge:he is pleasant and cooperative, PERRL, face
symmetric, no drift, motor is full, sensory intact, AOX3
Pertinent Results:
[**4-7**] NCHCT
1. Extensive intra- and extra-axial hemorrhage within the left
cerebral
hemisphere causing subfalcine herniation 7 mm to the right and
suggestion of impending downward transtentorial herniation.
[**4-8**] CT/CTA
1. Stable extent of left-sided subdural hematoma and
fronto-parieto-occipital hemorrhages with significant mass
effect and midline shift. In the presence of marked
hypointensity within the left corona radiata, concomitant
infarct is not excluded.
2. There is no evidence of cerebral aneurysm or vascular
malformation. CTA
neck is unremarkable.
[**4-9**] NCHCT - No short interval change of multicompartmental
hemorrhage since one day prior. No increased mass effect or new
hemorrhage.
[**4-11**] NCHCT - 1. Known left parietooccipital parenchymal
hemorrhage and left hemispheric subdural hematoma, similar to
the prior study of [**2179-4-9**]. No new hemorrhage.
2. The ventricles and sulci are mildly enlarged, consistent with
involutional changes.
Brief Hospital Course:
Pt was admitted to the neurosurgery service on [**4-7**]. He was
given FFP and profiline nine to reverse his elevated INR. His
SBP was controlled to SBP less than 140 and he was transferred
to the ICU. He had a CTA head to evaluate for malformation and
this was negative. A repeat CTH on [**4-8**] was stable and showed no
increase in hemorrhage. On [**4-8**] his HCT was 23 and he was given
2 units of PRBC and his HCT increased to 27.8. He remained
neurologically stable and another repeat CT head showed no
change.
On [**4-10**], patient intact on exam, he remains hypertensive on
cardiene gtt. Blood pressure was liberalized to SBP<160 and
cardiene gtt is being weaned and his oral medication increased.
On [**4-11**] a repeat Head Ct was obtained which demonstrated no
significant cahnge of left SDH and intraparenchymal hemorrhage.
No significant shift. on [**4-12**], he was evaluated by PT and was
cleared for discharge home in stable condition and will
follow-up accordingly.
Medications on Admission:
coumadin 2.5 mg, 2 and [**2-18**] daily.
Triamterene-Hydrochlorothiazide
37.5/25 1 CAP PO DAILY, Carvedilol 25, [**2-15**] [**Hospital1 **] **dose
uncertain,
Enalapril Maleate 20 mg PO/NG po QD. FoLIC Acid 1 mg po Q24H,
Discharge Medications:
1. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
2. carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
3. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*1*
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q8H (every 8 hours) as needed for headache.
Disp:*80 Tablet(s)* Refills:*0*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural hematoma
hypertension
Pyrexia
AVR/MVR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in _2___weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
- Please follow up with your PCP upon discharge from hospital
Completed by:[**2179-4-12**]
ICD9 Codes: 431, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7282
} | Medical Text: Admission Date: [**2186-1-22**] Discharge Date: [**2186-1-29**]
Service: MEDICINE
This is an incomplete discharge summary, please see discharge
addendum for completion of the [**Hospital 228**] hospital course,
discharge diagnoses and discharge medications.
HISTORY OF PRESENT ILLNESS: The patient is an 80 year-old
female with a past medical history significant for chronic
diarrhea since colon resection for a colon cancer in [**2179**]
with a resultant chronic hypokalemia and hypocalcemia for
which she is on oral supplementation. She has multiple
histories to [**Hospital3 **] in the past for metabolic
abnormalities, which required intravenous supplementation.
She now presents with complaints of intermittent nausea,
vomiting, diarrhea for at least one week. She admits to
discontinuing her potassium and calcium supplements
approximately one and a half weeks ago, because of
gastrointestinal upset. Her daughter reports that this
probably is a form of secondary gain since the patient cares
for her demented husband. She denies any fevers or chills,
headache, chest pain, shortness of breath, abdominal pain,
urinary symptoms. She also complains of weakness and
decreased oral intake with a weight loss over the last two
years.
On admission in the Emergency Room the patient was found to
be severely hypokalemic with a potassium of 1.6, calcium 5.2,
magnesium level of 0.6, bicarbonate level of 12, and an anion
gap of 21. The patient received 1 liter of normal saline,
potassium chloride intravenous 40 milliequivalents, 2 grams
of calcium gluconate intravenous and 2 grams of magnesium
sulfate intravenous. Central access was obtained.
PAST MEDICAL HISTORY:
1. Breast cancer in [**2173**].
2. Colon cancer in [**2179**] status post resection with resultant
chronic diarrhea since the surgery.
3. Diverticulitis.
4. Hypothyroidism.
ALLERGIES: Penicillin, morphine sulfate.
MEDICATIONS: 1. Synthroid 150 micrograms po q day. 2.
Potassium 8 milliequivalents two tabs b.i.d. 3. Calcium
supplementation. 4. Multivitamin.
SOCIAL HISTORY: No tobacco, no alcohol use. The patient
lives and cares for her demented husband.
PHYSICAL EXAMINATION: In general, the patient was conversing
well in no acute distress, alert and awake. Temperature
97.1. Heart rate 90. Blood pressure 133/79. Respiratory
rate 18. Oxygen saturation 94% on room air. HEENT pupils
are equal, round and reactive to light. Extraocular
movements intact. Normocephalic, atraumatic. Cardiovascular
irregularly irregular, normal S1 and S2 without murmurs, rubs
or gallops. Lungs clear to auscultation bilaterally.
Abdomen soft, nontender, nondistended. Normoactive bowel
sounds. Extremities no clubbing, cyanosis or edema.
Neurological alert and oriented times three with cranial
nerves II through XII intact. Strength 4 out of 5 in upper
and lower extremities.
LABORATORY: White blood cell count 15.5 with a differential
of 91 neutrophils, 4 bands, 4 lymphocytes, 1 monocytes, 0
eosinophils. Hematocrit 37.0, platelets 396, sodium 140,
potassium 1.2, chloride 107, bicarbonate of 12, BUN 75,
creatinine 9.6, glucose 102. Calcium 5.2 with a free calcium
of 0.93 with phosphorus of 6.0, magnesium of 0.6. TSH 11,
albumin 3.3. Urinalysis yellow, clear, no leukocyte esterase
or nitrates, large blood, 30 protein, 0 to 2 red blood cells,
0 to 2 white blood cells, moderate bacteria, 0 to 2
epithelial cells. Urine creatinine 61, urine sodium 47, FENA
5.28%. Spun urine revealed muddy brown casts. Arterial
blood gas 7.19, 24, 150. Renal ultrasound small kidneys
without evidence of hydronephrosis. Head CT no evidence of
intracranial hemorrhage. Chest x-ray no congestive heart
failure, no pneumonia or fusions, moderate cardiomegaly.
Electrocardiogram normal sinus rhythm at 91 beats per minute
with frequent premature ventricular contractions, left axis
deviation, normal intervals, nonspecific ST and T wave
changes, QT interval was noted to be 438.
HOSPITAL COURSE: 1. Renal: The patient's profound
electrolyte abnormalities were likely secondary to the
patient's not taking her oral supplementation as well as
severe volume depletion. The evidence of muddy brown casts
as well as elevated BUN and creatinine indicated that the
patient had acute tubular necrosis, which was likely
secondary to hypovolemia and poor renal perfusion. The
patient was also noted to have a primary metabolic acidosis
secondary to her diarrhea and her renal failure with a
compensatory respiratory alkalosis. The renal team was
consulted and repletion of potassium, calcium and magnesium
was initially performed intravenously in the Medical
Intensive Care Unit. The patient was also started on
bicarbonate repletion once her potassium was above 3.0. The
patient was also given gentle intravenous fluids and on
[**2186-1-25**] the patient was transferred from the Medical
Intensive Care Unit to the medicine team. At that time the
patient was started on oral potassium supplements, Tums for
calcium supplementation and oral sodium bicarb tablets. By
this time the patient did not require any standing magnesium
supplementation and was only repleted on a prn basis. The
patient's BUN and creatinine continued to improve during her
hospital stay with her BUN and creatinine at the time of this
dictation being 44 and 6.0 respectively. At this time there
is no indication for hemodialysis, however, the Renal Service
is following and assessing this decision on a daily basis.
In addition, the patient had a good urine output during her
hospital course.
2. Gastrointestinal: The patient was noted to have an
elevated amylase and lipase level of amylase levels in the
200s and lipase level in the 600s on [**2186-1-24**]. It was
thought that this chemical pancreatitis was probably
secondary to volume depletion and poor perfusion of the
pancrease. The patient did not clinically have any signs of
pancreatitis such as nausea, vomiting, abdominal pain when
the pancreatitis was discovered by elevated amylase and
lipase levels. The patient was placed on a low fat diet.
Enzymes were followed and there was no treatment indicated at
this time since the pancreatitis was likely secondary from
ischemia from hypotension and hyperperfusion. The GI Service
was consulted for the patient's chronic diarrhea, which is
likely multifactorial. Possible causes included lactose
intolerance as well as a short colon. There possibly is a
malabsorption element as well. Stool studies were sent,
which did not reveal an infectious etiology nor was there any
evidence to suggest inflammatory bowel disease. Currently a
stool fat is pending at this time as well as stool
electrolytes and osms. Metamucil as well as Lomotil was
added to help with the diarrhea. In addition, a right upper
quadrant ultrasound was obtained to further evaluate the
patient's pancreatitis, which was completely unremarkable.
3. Hematology: The patient's hematocrit was noted to be 21
to 22 upon transfer from the Medical Intensive Care Unit.
The patient's stools were guaiaced and were negative. The
patient's iron studies were consistent with anemia of chronic
disease. It was thought that the patient's anemia was likely
secondary to her acute renal failure. As a result the
patient was transfused 2 units of packed red blood cells with
appropriate increase in her hematocrit to 30 to 31. In
addition, the patient was started on Epogen 3000 units subQ
b.i.d.
This is an incomplete discharge summary. Please see
discharge addendums for completion of the [**Hospital 228**] hospital
course, discharge diagnoses and discharge medications.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 14486**]
MEDQUIST36
D: [**2186-1-29**] 04:27
T: [**2186-2-1**] 09:22
JOB#: [**Job Number 14487**]
ICD9 Codes: 5845, 2765, 2762, 2768, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7283
} | Medical Text: Admission Date: [**2196-4-26**] Discharge Date: [**2196-5-3**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83 year-old
male with prostate cancer recently hospitalized with
pneumonia who presents with fatigue. Since his
hospitalization he has been up and down per his family. Over
the last two days he has grown more fatigued per his
daughter. [**Name (NI) **] has gone three months without a transfusion and
often appears fatigue when he is due for a transfusion. His
po has decreased and he has not been sleeping at night. He
occasionally uses Ativan with resultant hypersomnolence and
confusion per his family. No reports of fevers, chills,
diarrhea, abdominal pain. He has pain when coughing from a
possible rib fracture sustained during a fall. Today he is
quite confused. Physical therapist saw him at home thought
he had deteriorated so his family brought him to see Dr.
[**Last Name (STitle) **] and this patient was admitted from clinic.
PAST MEDICAL HISTORY: Prostate cancer hormone refractory,
congestive heart failure, peptic ulcer disease, degenerative
joint disease, anemia transfusion dependent.
HOME MEDICATIONS: Renagel 800 t.i.d., Colace 100 b.i.d.,
hydrocortisone 20 b.i.d., Benzonatate 100 t.i.d.,
Ketoconazole 400 b.i.d., Toprol 25 b.i.d., Levaquin 250
b.i.d., Trazodone 50 q.h.s., Duragesic patch 15 micrograms
per hour q 32 hours, Percocet prn, Lasix 20 mg times one.
ALLERGIES: Ultram.
PHYSICAL EXAMINATION: Temperature 98. Heart rate 91. Blood
pressure 164/64. Respirations 24. O2 sat 97%. General, the
patient was alert, weak, chronically ill appearing. HEENT
ecchymosis over the left face. Tongue midline. Thorax clear
to auscultation bilaterally. Cardiac regular rate and
rhythm. Abdomen positive bowel sounds, nontender,
nondistended. Extremities no pitting edema. Neurological in
general, the patient was alert, but disoriented. Speech was
fluent. Cranial nerves II through XII are intact. Motor 5
out of 5 throughout upper and lower extremities.
LABORATORY: White blood cell count 2.8, hematocrit 25.3,
platelets 27.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2196-4-26**]. He was transfused to correct his anemia. The
patient was admitted to the Medicine Service. All narcotics
and sedatives were held. A CT scan was performed to evaluate
an old subdural hematoma sustained after a fall. Chest x-ray
was performed, which was negative. His Ketoconazole was
stopped. The patient was introduced to the neurosurgery
service for the purpose of draining his subdural hematoma. A
neurological checks q one hour were recommended. His
platelets were transfused to maintain platelets up above 100.
On [**2196-4-28**] a subdural drain was placed to allow drainage of
the subdural hematoma. Drainage was successful and the
patient continued to improve. On [**2196-4-30**] the drain was
removed. On [**2196-5-1**] the patient was discharged to the
regular floor where he received physical therapy and a
regular diet. He did well with both and physical therapy
recommended that the patient be allowed to go home with 24
hour supervision.
On [**2196-5-3**] the patient is being discharged to home. He will
have 24 hour supervision provided by his wife and daughter.
[**Name (NI) **] will also be sent home with VNA to provide home safety
evaluation checks, neurological checks, cardiopulmonary
checks and gait training. The patient is to follow up with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1327**] in about one week for suture removal. The
patient is being discharged on Tylenol #3 for pain, Renagel
800 mg po t.i.d., Colace 100 mg po b.i.d., Hydrocortisone 20
mg po b.i.d. po, Toprol 25 mg po q 12, Trazodone 50 mg po
q.h.s. po, Duragesic patch 50 micrograms per hour q 72 hours,
Ranitidine 150 mg po q day. The patient is being discharged
in stable condition. He may observe a regular diet and ad
lib activity.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern4) 5919**]
MEDQUIST36
D: [**2196-5-3**] 12:05
T: [**2196-5-4**] 08:09
JOB#: [**Job Number 45925**]
ICD9 Codes: 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7284
} | Medical Text: Admission Date: [**2196-3-4**] Discharge Date: [**2196-5-3**]
Date of Birth: [**2144-10-19**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
More frequent seizures
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
This is a 51yo male patient with a h/o cerebral palsy, mental
retardation, grand mal seizures now presents with drowsiness and
increasingly frequent seizures complicated by a recent h/o
cough, dyspnea, bradycardia, and hypothermia.
In [**1-/2196**], developed a cough and drowsiness unaccompanied by
fevers, chills, or SOB, recieved Azithromycin and initially
improved. However, sometime after, his caretaker noticed he was
more drowsy, was drooling, had "congested" breathing sounds, and
the seizures were more frequent than the baseline [**3-17**]/month with
occasional myoclonic jerks. Apart from a transient diarrhea
which resolved after empiric Azithro, she reports that there are
no changes in his urine or stool.
EMS was called for dyspnea and on the way to the [**Hospital1 18**], he had
an episode of bradycardia to 39 for which he received 0.5mg of
Atropine, but he was not hypotensive. In the ED, he had a grand
mal seizure with extremities shaking x4 x1.5min and recieved
Ativan 1mg. He also had an episode of hypothermia T=89 and was
placed under a "bair hugger", received Ceftriaxone and Levoquin
for ?PNA or sepsis. He was also found with QT-prolongation and
AV-block on EKG in the ED.
He was admitted to the MICU, he was found with rhythmic right
shoulder jerks and a rolled back right eye and received Ativan
1mg - after which he went to sleep. Neurology was consulted for
AED mgmt, sz mgmt and altered mental status
Review of Systems: As above
Past Medical History:
Cerebral palsy, mental retardation, seizures, LE edema (thought
to be secondary to veinous insufficiency), seasonal allergies,
contact dermatitis in groin treated with hydrocortisone
Social History:
Patient lives with caregiver [**Name (NI) 123**] [**Telephone/Fax (1) 93387**] in a regular
home. No immediate family. He has been living with [**Female First Name (un) 123**] for 18
years. He is total care. He goes to group activities. Patient
is able to sit up. He is incontinent of urine and stool.
Guardian: [**Name (NI) **] [**Name (NI) 93388**] is patient's guardian, contact #'s:
[**Telephone/Fax (1) 93389**], [**Telephone/Fax (1) 93390**]. No discussions about code status
previously.
Family History:
His aunt passed away 3 years ago from lung CA. Both parents are
dead. Mother died of heart condition.
Physical Exam:
PHYSICAL EXAM: Vitals: Tcurr=97.7... Tmax=100.2 Lowest T = 89..
BP=117/65... HR=83... RR=20... O2=
GENERAL: Lying on the bed and did not appear to be in acute
distress
HEENT: No meningismus. Normocephalic, atraumatic. No
conjunctival pallor. No scleral icterus. Left eye enucleated.
Some difficulty turning his head to the right.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Expiratory tracheo-bronchial sounds - heard most at the
neck.
EXTREMITIES: Pitting 4+ b/l pedal edema, 2+ dorsalis pedis
pulses b/l, but could not appreciate posterior tibial pulses.
SKIN: No evidence of abscess on his back or perianal area. The
was a rash in the left postrio-medial thigh.
NEURO:
#. Mental Status: Arousable to voice, responds to voice and
occasionally follows simple comands (e.g. "Look at me"). He was
not-verbal.
- Pupillary exam (CN 2 & 3): Left eye not seen. Right pupil
sluggishly reactive to light (from 2 to 1.5mm). Appeared able
to focus right eye on examiner and not let it rove
- Oculocephalic Reflex (CN 3, 6, & 8): Present in right eye,
but was a delayed with prominent sacchades
- Corneal Reflex (CN 5 & 7): Present in right eye
- Gag reflex (CN 9 & 10): Good gag reflex observed during
oropharyngeal suction
- CN 3: Able to open eyelid opening; vertical nystagmus
observed when right eye not moving.
- CN 5 (V1/V2/V3): Frowns to painful pinch in all 3 divisions
b/l
- CN 11: good lateral head rotation and neck flexion.
#.Motor: No fasiculations or tremor noted. Asterixis not tested.
Right wrist appeared more rigid than the left. Rhythmic
contractions of the right supraspinatus muscle observed. Moving
UE (deltoids, biceps, triceps, wrist extensors, finger flexors
and extensors b/l) and LE (anterior tibial, knee flexors,
adductors and abductors) away from pain. Also moving LE
(especially anterior tibial) as a general response to pain in
any part of the body.
#. Sensation: Grimaces to pain in face b/l.Not responsive to
pain in C8-T2 b/l. See Motor exam above.
#. Reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
#. Coordination: Deferred
#. Gait: Deferred
Pertinent Results:
Recent STUDIES:
[**2196-3-5**] CT NECK W/CONTRAST: Minimal fullness of the right
peritonsillar region, without discrete abscess or mass. Minimal
paranasal sinus mucosal thickening.
[**2196-3-4**] CT HEAD W/O CONTRAST: Again noted is diffuse atrophy of
the brain parenchyma with prominence ventricles and sulci
essentially unchanged from prior studies. There is severe
atrophy
of the cerebellum, out of proportion to the cerebral atrophy.
There is no hemorrhage, acute large vascular territory infarct,
shift of midline structures or mass effect present. No fractures
are present and the visualized paranasal sinuses and mastoid air
cells are well aerated. There is a left pthisis bulbi.
[**2196-3-4**] CXR: There are low lung volumes limiting evaluation.
The
visualized lungs show no effusions or pneumothorax. There is
bibasilar atelactasis, unchanged. The cardiomediastinal
silhouette appears unremarkable. The osseous structures are
intact
Brief Hospital Course:
[**Known firstname **] [**Known lastname 26010**] is a 51 year old man with a history of mental
retardation, cerebral palsy and epilepsy who presented with
likely sepsis with hypothermia, bradycardia and increased
seizure frequency.
NEURO:
The patient had a dilantin level of 28 and Carbamazepin level of
3. His increased seizure frequency was felt to be realted to
toxic dilantin levels and infection. Over the course of this
hospitalization, his medications where redosed multiple times
and it was unclear what his home medications had been as there
where discrepencies in his record. He was monitored on LTM
while in the ICU and until his medications where stable and
seizure frequency decreased. His last seizure was on [**4-18**].
Since that time he came of off LTM and continued to do well with
no further seizures. He was started on a low dose lamicatal to
be titrated slowly up as an outpatient. From a neurological
standpoint his seiuzures have returned to baseline and he is
ready for discharge.
[**Known firstname **] was evaluated by physical therapy and felt to benefit
from rehabilitation.
ID:
There was initially no souce of infection identified on
admission. Blood cultures grew Coagulase negative staph in [**4-17**]
bottles. TTE was without evidence of no clear vegitations.
Although the blood cultures where felt to be a contaminant. He
was treated with a course of vancomycin emperically after
discussion with ID. All subsequent cultures after [**3-8**] where
negative.
PULM:
The patient was noted to have episodes of apnea while sleeping.
He may warrent evaluation for sleep apnea.
Social:
The patient was ready for discharge but had an extended hospital
stay secondary as he needed to go to rehab however the proper
guardianship was not in place. This needed to be established by
court order. Once this was done he was discharged to rehab.
Medications on Admission:
Medications - Prescription
CARBAMAZEPINE [TEGRETOL XR] - 200 mg Tablet Sustained Release
12hr - 1 Tablet(s) by mouth 2/day
CHUX - - case/9 as needed
FEXOFENADINE - 60 mg Tablet - 1 Tablet(s) by mouth twice a day
as
needed for rhinitis, sneezing
HELMET - - HARD SHELL HELMET WITH A FACE BAR dx: Seizures use
as directed to prevent injury
HYDROCORTISONE - 2.5 % Cream - Apply to areas of redness twice a
day as needed for (not open areas) It the rash worsens please
stop using cream and call the office
LEVETIRACETAM [KEPPRA] - 500 mg Tablet - 1 Tablet(s) by mouth
6/day - No Substitution
PHENYTOIN SODIUM EXTENDED [DILANTIN KAPSEAL] - 100 mg Capsule -
1
Capsule(s) by mouth 2/day No subst. Brand name medically
necessary - No Substitution
TIMOLOL MALEATE [TIMOPTIC-XE] - 0.5 % Gel Forming Solution - 1
drop right eye q AM
Medications - OTC
BACITRACIN - 500 unit/gram Ointment - apply once daily to area
CARBAMIDE PEROXIDE - 6.5 % Drops - one dropper full in each ear
daily as needed for ear wax
.
ALLERGIES: NKDA
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) 4542**] Nursing & Rehab
Discharge Diagnosis:
Suspected sepsis with hypothermia
Increased seizure frequency
Discharge Condition:
Returned to baseline:
Severe mental retardation, minimal interaction, vocabulary of 1
to 3 words
All extremities move against gravity and appear stronger but
difficult to assess due to inability to cooperate
Discharge Instructions:
You were admitted following an episode of hypothermia, suspected
sepsis, and increased seizure frequency. You were observed in
the medical ICU for 6 days, with multiple rounds of viral and
bacterial cultures. No causative organism was ever found. You
were treated with broadspectrum antibiotics throughout this
period. You had blood cultures positive for coag negative strep,
which is most consistent with contamination and not a true
positive finding. Regardless, you received sufficient
vancomycin to cover this organism in the unlikely event that it
represented a true infection.
During this period of suspected sepsis your seizure frequency
was noted to be higher than baseline. We have adjusted your
anti-seizure medications during the hospitalization. You have
been very stable and your last seziures was [**2196-4-18**]. You are
currently stable on the medications as follows:
Carbamazepine 400mg/600mg am/pm
Keppra 1500mg/2000mg am/pm
Phenytoin 150mg/100mg am/pm
and you were started on Lamictal 25mg [**Hospital1 **]
which will be increased by 25mg every week until you
are on a dose of 150mg [**Hospital1 **]
Please make all follow up appointments. If you have an increase
in seizure frequency please ensure the patient's doctor is
notified.
Completed by:[**2196-5-3**]
ICD9 Codes: 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7285
} | Medical Text: Admission Date: [**2127-3-4**] Discharge Date: [**2127-3-19**]
Date of Birth: [**2084-12-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
found down, unresponsive
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
42 F (name is [**Name (NI) 402**] [**Name (NI) **]) w/ no known PMHx, on no known
medications, BIBA EMS to OSH ([**Location (un) **]-[**Doctor First Name **]) after being found
down in her apartment. Per report, pt has a neighbour who checks
on her from time to time, and as she did not answer the door
today ([**3-3**] at 08:00), neighbour became concerned and called
911.
.
EMS found her unresponsive, lying face down in pool of dark
black bloody emesis in an unkempt household with empty bottle of
methadone next to her. Per report she was barely responsive and
barely breathing. She was given Narcan without response.
Intubation was attempted in the field but was unsuccessful. She
was ambu-bagged the entire way to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital ED.
There she was hypotensive w/ SBPs to 60s and tachycardic to
140s. She was intubated for airway protection with etomidate/
succinylcholine as she continued to cough up copious amounts of
coffee-ground emesis. Stools were also noted to be guaiac
positive and brown. Pt was noted to be febrile up to 102 F and
had CXR concerning for R-sided aspiration PNA, for which
treatment with vanc/zosyn was initiated.
.
She was medflighted to [**Hospital1 18**] ED for tertiary care
In the [**Name (NI) **] pt was given 200ml NS w/ levophed, 250 D5W w/ 80mg
protonix, 500ml NS w/ vancomycin, and additional 2.5 L NS.
.
Initial ABG: 7.09/73/76
ABG upon intubation 7.17/ 64/57 on AC 500x16 PEEP 5 FiO2 100%
Past Medical History:
- Polysubstance abuse, opioid dependence
- Hep C, Cirrhosis, last VL [**6-27**] - 683K, unknown genotype.
- Knee arthritis b/l
Social History:
Takes care of her elderly parents with whom she lives.
Cigarettes: [ ] never [ ] ex-smoker [X] [**1-19**] cigarettes per
day
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs: none
Occupation: unemployed
Marital Status: [ ] Married [X] Single
Lives: [ ] Alone [X] w/ family [ ] Other:
Family History:
Diverticulitis and colon surgery in mother. [**Name (NI) **] father has
dementia. One of her nieces has gall bladder disease.
Physical Exam:
ON ADMISSION:
VS: afebrile HR 110s BP 106/60, SaO2 100% on AC 500x16, PEEP 5,
FiO2 100%, Ht 5'8 Wt 113 kg
GEN: ill-appearing obese caucasian F intubated, sedated but
opening eyes to commands
HEENT: PERRLA, no scleral icterus, marked B/L periorbital edema
CV: tachycardic, no murmurs appreciated
LUNGS: coarse ventilated BS anteriorly
ABD: +BS soft does not seem tender
EXT: b/l LE edema, anasarca
NEURO: intubated, sedated but responsive to eye opening
At discharge:
VS: SpO2 93% on 3L NC and 70% tent mask or one 5L NC alone at
times
GEN: awake, alert F in NAD, answering questions appropriately,
fully oriented
HEENT: no periorbital edema
CV: slightly fast but regular, II/VI holosystolic murmur
LUNGS: scattered insp crackles, worst at R apex and L base, no
wheezes
ABD: +BS, soft, NT, ND
EXT: 2+ pitting edema b/l to below knee
Pertinent Results:
ADMISSION LABS:
[**2127-3-4**] 02:15AM WBC-8.4 RBC-3.45* HGB-11.8* HCT-35.3*
MCV-102* MCH-34.1* MCHC-33.3 RDW-15.4
[**2127-3-4**] 02:15AM NEUTS-77* BANDS-4 LYMPHS-9* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2127-3-4**] 02:15AM HYPOCHROM-1+ ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
[**2127-3-4**] 02:15AM PLT COUNT-103*
[**2127-3-4**] 02:15AM PT-20.9* PTT-41.6* INR(PT)-1.9*
[**2127-3-4**] 02:15AM GLUCOSE-79 UREA N-13 CREAT-0.9 SODIUM-143
POTASSIUM-3.0* CHLORIDE-110* TOTAL CO2-21* ANION GAP-15
[**2127-3-4**] 02:15AM CK(CPK)-1646*
[**2127-3-4**] 02:15AM CK-MB-31* MB INDX-1.9
[**2127-3-4**] 02:15AM cTropnT-0.60*
[**2127-3-4**] 02:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-3-4**] 02:15AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2127-3-4**] 02:21AM TYPE-ART PO2-76* PCO2-73* PH-7.09* TOTAL
CO2-23 BASE XS--9 COMMENTS-GREEN TOP
[**2127-3-4**] 02:21AM GLUCOSE-73 LACTATE-6.7* K+-3.1*
Pertinent Labs:
[**2127-3-14**] 05:02AM BLOOD VitB12-1774* Folate-16.0
[**2127-3-4**] 05:40AM BLOOD TSH-1.1
[**2127-3-5**] 02:46AM BLOOD AMA-NEGATIVE
[**2127-3-5**] 02:46AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2127-3-11**] 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES- Negative
for Heparin PF4 Antibody Test by [**Doctor First Name **]
MICRO:
[**2127-3-4**] 9:59 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2127-3-8**]**
GRAM STAIN (Final [**2127-3-4**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2127-3-8**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
Sensitivity testing confirmed by Sensititre.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
ERYTHROMYCIN AND OXACILLIN Sensitivity testing
confirmed by
Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>16 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2127-3-6**] Blood Culture, Routine (Final [**2127-3-12**]): NO GROWTH.
[**2127-3-6**] Blood Culture, Routine (Final [**2127-3-12**]): NO GROWTH.
[**2127-3-6**] 7:59 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2127-3-8**]**
GRAM STAIN (Final [**2127-3-6**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2127-3-8**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
[**2127-3-9**] 12:05 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2127-3-11**]**
GRAM STAIN (Final [**2127-3-9**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2127-3-11**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
[**2127-3-9**] Blood Culture, Routine (Final [**2127-3-15**]): NO GROWTH.
[**2127-3-9**] Blood Culture, Routine (Final [**2127-3-15**]): NO GROWTH.
[**2127-3-9**] URINE CULTURE (Final [**2127-3-10**]): NO GROWTH.
STUDIES:
[**2127-3-4**] CXR: Global right lung consolidation, probable
pneumonia, conceivably hemorrhage. Volume loss suggests some
bronchial compromise. CT recommended when feasible. ET tube
terminates 3 cm above carina appropriately.
[**2127-3-4**] CT HEAD: 1. No evidence of acute intracranial
abnormalities. 2. Extensive right scalp hematoma and right
facial subcutaneous edema.
[**2127-3-4**] ABD U/S: 1. Cirrhotic liver with reversal of flow within
the main and left portal veins. The right portal vein was not
assessed on this portable exam, which was also slightly limited.
2. Splenomegaly with trace ascites. 3. Gallbladder sludge with
mild gallbladder wall edema and pericholecystic fluid, likely
due to underlying liver disease.
[**2127-3-12**] TTE: Normal biventricular cavity sizes with preserved
regional and excellent/hyperdynamic biventricular systolic
function. Mild pulmonary artery systolic hypertension.
[**2127-3-14**] CXR: A right-sided PICC line tip is again seen at the
brachiocephalic/SVC junction. Diffuse opacity within the right
hemithorax
continues to worsen with decreased aeration of the right lung
base.
Multifocal opacities on the left are unchanged. There is no
pneumothorax.
Discharge Labs:
WBC=4.4
Hct=26.5
PLT=106
INR=1.7
K=4.1
Na=132
Cr=0.7
Phos=2.6
Tbili=1.7
AST=91
Rest of labs wnl
Brief Hospital Course:
42 F w/ h/o HCV cirrhosis found down in pool of bloody emesis w/
empty methadone bottle w/ sepsis and lactic acidosis [**2-19**]
aspiration PNA from decreased alertness.
.
#. RESPIRATORY FAILURE- Patient's respiratory failure was
attributed to aspiration pneumonia/pneumonitis in the setting of
altered mental status and methadone overdose (though of note did
not awaken with narcan). She was intubated on admission to the
MICU on AC ventilation. She was started on vanc/unasyn for
aspiration pneumonia coverage and sputum culture was sent.
Initial sputum culture grew MRSA. Patient continued on
antibiotic treatment but mental status, significant secretions,
and volume overload precluded weaning from vent. She was started
on diuresis with lasix IV (LOS balance was over 10 liters
positive at one point), requiring a drip for effective removal
of volume. Repeat sputum cultures were sent when patient spiked
temperature and had worsened CXR. Antibiotics were broadened to
vancomycin and zosyn, and when sputum grew out pseudomonas cipro
was added for double coverage. Patient was called out to the
floor with a plan for an 8 day course of antibiotics from day of
positive pseudomonal culture for VAP. Patient was successfully
extubated on [**2127-3-13**] and called out to the floor on [**3-15**] for
further management. She completed her course of antibiotics on
[**3-18**] and PICC line was discontinued. She was briefly given IV
acetazolamide to attempt to correct her alkalosis with minimal
improvement. Her oxygen requirement at time of discharge was 3L
NC and 70% face tent or 5L NC alone at times, with SpO2 around
93%. Persistent O2 requirement is likely mostly due to post-ARDS
syndrome and may take time to recover. However, she does not
appear significantly volume overloaded and she was discharged on
a diuretic regimen of furosemide 40mg PO daily and
spironolactone 50mg daily for a goal of net even. This may need
to be adjusted at the facility.
.
# Hypokalemia: Pt was persistently hypokalemic at time of
transfer out of the MICU. She was continually repleted and then
placed on standing 40mEq daily. She was also started on
spironolactone 50mg daily. She should have K checked relatively
frequently after discharge until level normalizes and she no
longer requires repletion. Standing KCl may need to be reduced
as well should she become hypperkalemic.
.
# RUQ Pain: the patient reported RUQ pain that started approx 2
months prior to admission. This was well controlled during
admission.RUQ ultrasound showed Gallbladder sludge with mild
gallbladder wall edema and pericholecystic
fluid, likely due to underlying liver disease. However, she
would benefit from further workup for this including ruling out
malignancy and gallstone disease.
.
# Hyponatremia: Pt [**Name (NI) **] was 138 throughout most of admission but
trended down to 132 at time of discharge. THis was attributed to
diuresis, incl. with acetazolamide. She should have sodium level
checked on Friday, [**3-21**] along with potassium and phosphate.
.
#. SHOCK- Patient presented with shock which was attributed to
distributive (septic) from RLL PNA/pneumonitis. Lactate was 6.7
on admission. She was started on levophed in the ED and this was
continued with NS boluses as well. Antibiotics, initially
vanc/zosyn, then vanc/unasyn were continued. She was gradually
weaned off levophed. Blood cultures were negative.
.
#. [**Name (NI) 32707**] Pt reportedly found down in pool of black bloody emesis
and had + NGT lavage. Etiologies could include gastritis, PUD,
AVMs. Patient had RUQ U/S with dopplers which showed cirrhotic
liver with reversal of flow within the main and left portal
veins. Patient has a history of portal hypertensive gastropathy.
Her hematocrits remained stable and she did not require any
blood transfusions in the MICU. She was continued on an IV PPI
until tolerating POs and then transitioned to once a day PO PPI,
which she should remain on per hepatology recs. She will benefit
from an EGD as an outpatient to assess for varices given her
known liver disease. [**Hospital1 18**] Hepatology will attempt to contact pt
with appointment time. Hct was stable at 26.4 at time of
discharge.
.
#. Altered mental status- Unclear etiology- believed to be
secondary to methadone overdose, lactic acidosis, and overall
septic picture. She was gradually weaned off of her sedation and
required zyprexa which was transitioned to seroquel to manage
her agitation. She was seen by psychiatry around the time of her
extubation, who felt that her overdose was not a suicide attempt
and thus she did not require a 1:1 sitter. They recommended
tapering her clonazepam given her history of dependence and
detox 1 year prior- she was on 0.5 mg qHS (to be continued for 2
days and then stopped) when she was called out to the floor.
Benzos were stopped prior to discharge and quetiapine should
continue to be weaned if possible until no longer taking
(currently on 25mg QHS). Psychiatry continued to believe she was
not a threat to herself or others.
.
#. Thrombocytopenia- Patient's platelets dropped during
admission. HIT antibody was sent and negative. Thrombocytopenia
was attributed to liver disease. No active bleeding.
.
#. Liver disease: The patient has known HepC. This is likely
contributing to her elevated INR, low PLT count, and peripheral
edema. She will be followed by hepatology post-discharge.
.
.
# Outstanding issues:
-monitor K closely and adjust standing KCl and spironolactone
prn
-monitor Na closely until normalizes
-adjust furosemide and spironolactone for goal of net even
-wean oxygen requirement as tolerated
-wean quetiapine to off if possible
-stop sc heparin once ambulating
-aggressive PT
-f/u with hepatology as outpt for EGD to r/o varices
-workup RUQ pain x 2 months, including r/o malignancy
-pt will need PCP at time of discharge from facility-may call
[**Telephone/Fax (1) 250**]
Medications on Admission:
None
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
12. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for Rash.
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
1. Respiratory Failure
2. Aspiration Pneumonia
3. Septic Shock
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after you were found down at
home. You were intubated and in shock. You were started on IV
antibiotics and given a large amount of IV fluids. You also had
evidence of an upper gastrointestinal bleed. Your breathing
function improved and you were extubated. You completed a course
of antibiotics. You also had issues with your electrolytes which
need to be monitored closely for now. Psychiatry also evaluated
you and felt that you were not a threat to yourself or others.
You will also need your blood counts checked and your diuretics
adjusted as needed.
.
Some of your medications were changed during this admission:
START spironolactone
START furosemide
START pantoprazole
START docusate
START senna as needed
START polyethylene glycol as needed
START heparin
START folic acid
START multivitamin
START quetiapine
START thiamine
.
Some of these medications may be removed prior to your discharge
from the facility you are being transferred to.
Followup Instructions:
If you don't have a primary care physician, [**Name10 (NameIs) **] should call
[**Telephone/Fax (1) 250**] to set up an appointment for a new one.
.
Location: [**Hospital1 18**]-DIVISION OF GASTROENTEROLOGY/LIVER CENTER
Address: [**Doctor First Name **] STE 8E, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2422**]
*Someone from this department will contact you to schedule an
appointment. You should see follow up with a doctor within 2
weeks.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 0389, 5070, 2762, 2930, 2851, 2761, 5715, 2875, 2768, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7286
} | Medical Text: Admission Date: [**2167-8-15**] Discharge Date: [**2167-8-18**]
Date of Birth: [**2108-2-20**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Hypotension, Blood Bowel Movement
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 74741**] is a 59 year old female with medical history
significant for esophageal CA diagnosed in [**2167-4-14**] who now
presents with acute dyspnea and large bloody BM. The patient was
initially seen at OSH with Hct of 17 on presentation and SBP in
the 80s. The patient was resuscitated with 2U PRBCs and 2.5L NS
and transferred to [**Hospital1 18**] for ongoing management. On arrival to
the [**Hospital1 18**] ED the patient was with repeat Hct of 24 with SBP of
130 but still tachycardic. The patient was given a 3rd unit of
blood on arrival. GI and surgery have been contact[**Name (NI) **]. GI will
see patient in the MICU. The patient additionally had a CTA of
the chest performed given concern that the patient's
mediastinal/esophageal mass may have resulted in aortic
fistulization, this was ruled out by CTA. An NG lavagae has not
been performed given concern for Esophageal CA.
.
Patient denies any use of NSAIDS, aspirin, or alcohol. She has
been receiving chemotherapy and radiation starting this month
for the tumor. She has also been receiving dexamethasone as part
of her regimen. Patient denies any abdominal pain, and has not
been taking any antacid medications.
.
Past Medical History:
Esophageal CA - diagnosed [**2167-4-14**]. Started on cisplatin/5-FU
with daily XRT in early [**2167-7-15**]. Patient had a J-tube placed
for feeding that has at times come out and has required
hospitalization for replacement.
Social History:
Smokes [**12-16**] ppd. former ETOH
Family History:
Noncontributory
Physical Exam:
Vitals: 99.5, 105, 122/50, 67, 20, 100% on RA
GEN:Mild distress secondary to leg pain, chronically
ill-appearing, no diaphoresis
HEENT: EOMI, pale conjunctiva, MMM, OP clear
NECK: No JVD
COR: Tachycardic, regular rhythm, no M/G/R
PULM: Scattered rhonchi
ABD:Soft, NT, ND, J-tube site with surrounding brownish
discoloration of dressing. +BS
EXT: Warm, well-perfused, no calf tenderness
NEURO: A&O x 3, moves all 4 extremities
SKIN: Pale, no ecchymoses
Pertinent Results:
[**2167-8-15**] 08:29PM GLUCOSE-78 UREA N-31* CREAT-0.4 SODIUM-138
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-24 ANION GAP-10
[**2167-8-15**] 08:29PM GLUCOSE-78 UREA N-31* CREAT-0.4 SODIUM-138
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-24 ANION GAP-10
[**2167-8-15**] 08:29PM CALCIUM-7.2* PHOSPHATE-3.0 MAGNESIUM-1.9
[**2167-8-15**] 08:29PM WBC-6.2# RBC-2.90* HGB-9.1* HCT-25.2* MCV-87
MCH-31.5 MCHC-36.2* RDW-15.9*
[**2167-8-15**] 08:29PM PLT COUNT-138*
[**2167-8-15**] 08:29PM PT-11.2 PTT-22.0 INR(PT)-0.9
[**2167-8-15**] 01:45PM HCT-29.6*
[**2167-8-15**] 06:05AM HGB-8.3* calcHCT-25
[**2167-8-15**] 06:00AM GLUCOSE-74 UREA N-48* CREAT-0.4 SODIUM-140
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-21* ANION GAP-13
[**2167-8-15**] 06:00AM estGFR-Using this
[**2167-8-15**] 06:00AM WBC-13.9* RBC-2.73* HGB-8.5* HCT-24.1* MCV-88
MCH-31.0 MCHC-35.1* RDW-15.4
[**2167-8-15**] 06:00AM NEUTS-81* BANDS-12* LYMPHS-2* MONOS-2 EOS-1
BASOS-0 ATYPS-0 METAS-1* MYELOS-1* NUC RBCS-1*
[**2167-8-15**] 06:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-OCCASIONAL
TEARDROP-1+
[**2167-8-15**] 06:00AM PLT SMR-NORMAL PLT COUNT-156
[**2167-8-15**] 06:00AM PT-11.6 PTT-20.8* INR(PT)-1.0
/GJ TUBE CHECK PORT [**2167-8-18**] 10:06 AM
G/GJ TUBE CHECK PORT
Reason: Please check placement
Contrast: CONRAY
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with esophageal cancer
REASON FOR THIS EXAMINATION:
Please check placement
INDICATION: Esophageal cancer. Check tube placement.
COMPARISON: AXR [**2167-8-17**].
FINDINGS: Initial scout radiograph demonstrates previously
administered contrast in loops of small and large bowel. After
instillation of Gastrografin through the J-tube, there is
opacification of a loop of small bowel. No extraluminal contrast
is identified.
IMPRESSION: Satisfactory positioning of J-tube.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2167-8-15**] 5:58 AM
CTA CHEST W&W/O C&RECONS, NON-
Reason: eval for bleed
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with esophageal CA, 5cm mass in upper thorax,
with GIB from OSH, BP 60s initially, now 130s on 2nd liter of
PRBC.
REASON FOR THIS EXAMINATION:
eval for bleed
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 59-year-old female with esophageal cancer, also with GI
bleeding and initially hypotensive with concern for erosion into
the great vessels of the mediastinum.
COMPARISON: No prior study at this institution.
TECHNIQUE: MDCT axial images of the thorax pre- and post- rapid
bolus of 100 ml Optiray IV contrast per the CT angiogram
protocol with coronal and sagittal reformats.
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There is irregular
wall thickening of the mid thoracic esophagus concerning for
tumor, which involves an approximately 6 cm long segment. While
the portion of the esophagus that is involved with the mass
closely abuts the aorta and trachea, there is no evidence of
invasion of these structures. The heart and great vessels of the
chest opacify well. There is no evidence of central pulmonary
embolism. There is no pathologic mediastinal lymphadenopathy
identified.
There is scarring at the lung apices. There are mild background
centrilobular emphysematous changes. There is a tiny calcified
granuloma of the right middle lobe measuring 3 mm. There is no
pleural or pericardial effusion and no pneumothorax. Limited
evaluation of the upper abdomen demonstrates no significant
abnormality.
BONE WINDOWS: No suspicious osteolytic or osteoblastic lesions
are identified.
IMPRESSION:
1. Irregular wall thickening involving a 6 cm long segment of
mid thoracic esophagus concerning for esophageal neoplasm. While
the involved segment of the esophagus abuts the aorta, there is
no evidence of erosion into the aorta.
2. Emphysema
Brief Hospital Course:
Pt was treated for her GI bleed which was thought to be
secondary to XRT, chemotherapy, or dexamethasone therapy for her
esophageal mass. Pt was seen by GI who felt that the mass was
too friable and given her recent endoscopy at the OSH where they
couldn't pass the scope past the mass, another endoscopy wasn't
warrented at the time. Surgery was consulted but felt the pt did
not have a need for surgical intervention. Pt monitored with
serial Hcts, large bore IVs were placed, and started on
Pantoprazole 40mg IV BID. While pt was in house, she also had
her J-tube re-evulated twice for concerns of positioning. Both
gastrofin studies showed good positioning.
Pt was monitored for 48 hours, was stable throughout entire
course, and discharged home on a PPI.
Medications on Admission:
1. Albuterol PRN
2. Amitriptyline 10mg qdaily
3. Dexamethasone 2mg [**Hospital1 **]
4. Lorazepam 1mg qdaily
5. Diltiazem 50mg daily
6. Eth-Oxydose 1ml q8 hours via J-tube
7. Fentanyl 25mcg q72H
8. furosemide 20mg qdaily
9. Potassium chloride
10. Promethazine 25mg qdaily with meals for nausea
Discharge Medications:
1. Albuterol PRN
2. Amitriptyline 10mg qdaily
3. Dexamethasone 2mg [**Hospital1 **]
4. Lorazepam 1mg qdaily
5. Diltiazem 50mg daily
6. Eth-Oxydose 1ml q8 hours via J-tube
7. Fentanyl 25mcg q72H
8. furosemide 20mg qdaily
9. Potassium chloride
10. Promethazine 25mg qdaily with meals for nausea
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI Bleed
Discharge Condition:
stable
Discharge Instructions:
Pt will need to follow up with oncology this week and her
surgeon that placed the J-tube in the next few days.
Followup Instructions:
General surgery for J-tube
Oncology
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7287
} | Medical Text: Admission Date: [**2175-6-26**] Discharge Date: [**2175-7-17**]
Date of Birth: [**2102-11-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Central line placement (right IJ)
History of Present Illness:
72 year-old female with past medical hx of Lung CA s/p
lobectomy, CHF, presented from OSH w/resp distress. She was
found at home in the morning of admission sitting on the couch,
short of breath, right-sided "slouching", hypertensive to
225/110, tachycardic to 110-120s, unresponsive, incontinent of
urine/stool. At OSH was saturating 70% on 12L NC and so was
intubated. Head CT was negative at OSH. She receiving rocephin,
lasix, bumex, lactulose, neomycin. Also received
succinylcholine, fentanyl, and versed peri-intubation.
*
In our ED, she received lasix 60 IV x1 with minimal response,
placed on propofol, and had a CT of her abdomen due to a
distended abdomen. On ROS, family noted PND, chart noted pt w/hx
URI, recent steroids use. Pt's family reports increased cough,
URI symptoms, dizziness, increased sputum. Has multiple URIs,
allergies, recent azithro < 2 weeks ago, prednisone < 1 month
ago.
Past Medical History:
1. Lung CA s/p lobectomy
2. CHF
3. Asthma
4. CRI
5. Liver hemangioma
6. Anemia
7. COPD
8. Hyperlipidemia
9. Hypothyroidism
10. Gastritis
11. Depression
12. HTN
Social History:
married, lives with husband/son, 35 pack yrs, no etoh
Pertinent Results:
CT abdomen: Large mass replacing most of the right lobe of the
liver and a second smaller hypodense lesion in the left lobe of
the liver that are incompletely characterized on this
noncontrast study. Fat-containing right-sided abdominal wall
hernia. Bilateral pleural effusions with bibasilar lung
opacities with possible interlobular septal thickening
consistent with CHF/fluid overload. Air bronchograms present in
the right basilar opacity raise the possibility of a
superimposed infectious process.
MRI abdomen:
1) Giant cavernous hemangioma of the right lobe of the liver
measuring 27.2 x 21.3 x 21.1 cm. A second smaller hemangioma is
seen within the medial segment of the left lobe, measuring 2.3 x
2.5 x 3.1 cm. The hepatic venous and portal venous vasculature
is patent.
2) Bilateral pleural effusions.
3) Lower anterior abdominal wall fat-containing hernia.
Brief Hospital Course:
ICU Course:
Active problems on admssion included 1)hypercarbic respiratory
failure, 2)oliguric acute renal failure, 3)large liver mass seen
on the abdominal CT, 4)intermittent supraventricular
tachycardia, 5)Hypotension. In terms of respiratory failure, pt
was intubated and was treated for pneumonia, COPD exacerbation,
and +/-CHF. CXR on admission showed bilateral retrocardiac
opacity and later showed RUL opacity. Sputum culture from [**6-26**]
grew MRSA. She was started on Vanc/Levo/Flagyl for empiric
coverage. She was initially given Lasix 100 mg IV for a concern
for CHF from pulmonary edema seen on CXR but was later thought
unlikely since her CVP was only 10. She was also started on
steroids for COPD exacerbation. In the ICU, there was
difficulty extubating secondary to her agitated MS, but was
successfully extubated on [**2175-7-5**]. She was able to maintain
mid-90's on room air. In terms of ARF, she presented with Cr of
2.3-2.8 and became oliguric and peaked at 3.5. Renal was
consulted whose impression was oligurid renal failure->ATN from
hypoperfusion +[**Last Name (un) **]. Her urine output picked up and now making
adequate urine. Her Creatinine normalized to 2.8. In terms of
22 cm liver mass seen on the abdominal CT, liver team was
consulted. She has a hx of liver hemangioma and this is likely
the expansion of the hemangioma. The family and the team
decided to not pursue with any surgical procedure. She had
episodes of SVT to 140's with hypotension to SBP 80's on [**2175-6-29**]
of what appears as AVNRT. She was started on Diltiazem and has
been adequately rate controlled. In terms of hypotension, she
had intermittent episodes of hypotension which appears to be
positional, likely from the liver compressing on IVC?. This in
addition to the systemic illness may have worsened her renal
failure on admission. Or she may have had episodes of AVNRT
with hypotension prior to admission to have caused the renal
insult.
Floor Course by problems:
.
1)Respiratory failure: Patient likely had MRSA PNA +/- COPD
exacerbation. She completed a 14 day course of Vanc which was
dosed by level as she was in oliguric renal failure/ATN. Pt got
Albuterol/fluticasone and a very short course of steroid taper
for the possible COPD exacerbation. She was stable on room air
from pulmonary stand point prior to discharge.
.
2)Renal failure: Pt had ischemic ATN in the ICU from presumed
hypoperfusion episode. She was followed by Renal. Later, she
started to make adequate urine, and her creatinine eventually
came down to 2.7 which is where it stabilized. Per her PCP, [**Name10 (NameIs) **]
baseline PCP [**Last Name (NamePattern4) **] 2.0 in [**2175-3-28**]. Cr 2.7 is likely her new
baseline per renal. She also developed hypernatremia which was
corrected with IV D5W to correct the free water deficit. She
also develop metabolic acidosis and was supplemented by sodium
bicarb. She was continued on Calcitriol and Sevelamer. Her
Epogen dose was increased to 5000 unit qMWF from 3000 unit.
.
3)Altered MS: Pt was very agitated, confused, and at times
disruptive pulling out her lines. Her mental status waxed and
wane. Her delirium was thought likely from toxic metabolic
etiology secondary to combination of hypothyroid, ICU delirium,
steroid use, hypernatremia, and acute infection. She was
initially kept NPO due to aspiration risk from mental status
change. She got tubefeed in the ICU and PPN on the floor. She
initially required frequent PRN Haldol and Zydis for agitation.
However, on [**7-11**] her MS returned to baseline. She passed
swallow evaluation and was able to tolerate po diet with normal
consistency and thin liquids.
.
4)Hypertension: She was continued on po metorprol and
Hydralazine for BP control. When she was NPO, she got the IV
version.
.
5)Tacchycardia: Pt had episodes of supraventricular tachycardia,
likely AVNRT, in the ICU which was controlled with Diltiazem
then was switched to metoprolol. On the floor, she again had an
episode of SVT for 1 hr which was finally broke with IV
Diltiazem. Her EKG and rhythm strips were reviewed by the EP
team who recommended medical management at this time with a
beta-blocker. She will follow up with her PCP/Cardiologist Dr.
[**Last Name (STitle) **] regarding this. If she continues to have AVNRT
despite maximal medical treatment, elective ablation should be
considered.
.
6)Anemia: Pt has anemia of what appears as chronic illness/renal
disease. She was intitially on Epogen 3000 unit qMWF, but was
later switched to 4000 unit and then to 5000 unit qMWF by renal.
She had a very slow decline in Hct and got a total of 4 units
of PRBC during the hospitalization (2 units in the ICU, 2 units
on the floor). Hct prior to discharge after the transfusion was
stable at 28-29. She needs to have her Hct checked frequently.
If she continues to have a decline in Hct despite increased
Epogen dose, she would need an outpatient EGD + colonoscopy to
rule out GI bleed.
.
7)Liver mass: Pt with known history of giant liver hemangioma
that was has followed as outpatient. The CT and MRI of abdomen
again demonstrated giant mass that appears as hemangioma. AFP
value was normal. Spoke with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and plan is
to follow closely as outpatient.
.
8)Hypothyroid: Her TSH was elevated, and her free T4 was low as
well. Her synthroid dose was increased to 50 mcg qd.
Medications on Admission:
Norvasc 5, serevent, flovent, synthroid 0.88, meclizine,
procrit, xanax 0.25 tid, darvocet, effexor, lipitor 20, cozaar
150, benicar 40, prednisone < 1 month ago, nebulizers
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
3. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK
([**Doctor First Name **],TU,TH).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours) as needed.
7. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
11. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Epoetin Alfa 10,000 unit/mL Solution Sig: 5000 (5000) unit
Injection QMOWEFR (Monday -Wednesday-Friday).
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
15. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Hydralazine 25 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Primary:
1)MRSA Pneumonia
2)COPD exacerbation
3)Acute renal failure
4)Delirium
5)Metabolic acidosis
Secondary:
1)Giant liver hemangioma
2)Asthma
3)Chronic renal insufficiency
4)Anemia
5)Gastritis
6)Depression
7)Hypertension
Discharge Condition:
Hemodynamically stable, able to take PO, mental status back to
baseline.
Discharge Instructions:
Please take all of the medications as directed. Please seek
medical attention if you develop fever, chills, chest pain,
palpitation, shortness of breath, cough, confusion, nausea,
vomiting, or any other concerning symptoms. Please follow up
with Dr. [**Last Name (STitle) **] within 1-2 weeks.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] within 1-2 weeks.
Completed by:[**2175-7-17**]
ICD9 Codes: 4280, 5845, 2760, 2930, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7288
} | Medical Text: Admission Date: [**2162-3-4**] Discharge Date: [**2162-3-25**]
Date of Birth: [**2093-7-29**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Neurontin / Cyclosporine / Methotrexate And
Derivatives / Levofloxacin
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2162-3-5**] Exploratory Laparotomy, Lysis of Adhesions, resection
of small bowel with anastomosis x 1.
[**2162-3-18**] PICC line placement
History of Present Illness:
68M with a history of recurrent SBOs requiring multiple
rounds of enterolysis presented to [**Hospital3 **]recently
admitted on [**Month (only) 1096**] with acute cholecystitis. Due to his
multiple co morbidities he underwent percutaneous
cholecystostomy
tube on [**2161-10-20**]. Patient developed hypotension and oxygen
desaturation with septic shock. As the cholecystotomy tube was
no
longer draining, patient went to the OR and underwent an open
subtotal cholecystectomy [**2161-10-22**]. On [**2161-10-29**] he underwent an
[**Date Range **] with sphincterotomy and stenting of the cystic duct
secondary to a leak at the cystic duct stump.
Patient presented today to [**Date Range **] for stent removal, but was noted
to have worsening abdominal distension over several days, with
no BMs x 3-4 days, and several episodes of N/V, so was sent to
the ED. Patient complains of 2 weeks of mild abdominal pain,
worsening during the past week in the upper abdomen mostly on
the
LUQ, associated with worsening constipation (last BM 3 days ago
after mag citrate). Had been passing flatus until yesterday, but
none noted today.
ROS:
(+) per HPI
(-) Denies fevers chills, night sweats, unexplained weight loss,
fatigue/malaise/lethargy, changes in appetite, trouble with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
hematemesis, melena, BRBPR, dysphagia, chest pain, shortness of
breath, cough, edema, urinary frequency, urgency
Past Medical History:
PMH: multiple epsiodes of SBO, GERD, Barrets esophagous, CAD,
CHF, MIx2, stroke, Hypertension, hyperlipidemia, OSA on BiPAP,
asthma, COPD, gastroparesis, h/o GI bleed, stroke in [**2154**],
polymyalgia rheumatica, polyarthralgia, chronic neck pain
PSH: splenectomy, bowel resection x2, lysis of adhesions x10
Social History:
Single. Never married. No children. Denies tobacco use,
drinks
occasionally.
Family History:
Father died at 85 with throat cancer and CAD. Mother died at 73
of MI
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Vitals: 97.9 76 133/106 18 100% RA
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, severely distended, moderately tender to palpation on
upper abdomen. No rebound or guarding, no palpable masses.
Severe
scarring of the abdominal wall. Right subcostal incision mostly
healed, with a very small open area on the medial aspect, pasked
with a small gauze.
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
White Blood Cells 12.4* Red Blood Cells 2.91* LAB
Hemoglobin 8.2* Hematocrit 24.7*
MCV 85 82 - 98 fL
MCH 28.1 27 - 32 pg
MCHC 33.1 31 - 35 %
RDW 16.7* 10.5 - 15.5 %
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 542*
Glucose 80 Urea Nitrogen 17 Creat 0.6 Sodium 138
Potassium 4.2 Chloride 109* 96 - 108 mEq/L
Bicarbonate 23 22 - 32 mEq/L
Anion Gap 10 8 - 20 mEq/L
Albumin 2.5* 3.5 - 5.2 g/dL
Calcium, Total 8.0* 8.4 - 10.3 mg/dL
Phosphate 3.2 2.7 - 4.5 mg/dL
Magnesium 1.9 1.6 - 2.6 mg/dL
IMAGING:
[**3-4**] CT Abd/pelvis: Sequelae of multiple small bowel surgeries,
w/early or partial SBO. Distal migration of CBD stent into
duodenum.
[**2162-3-14**] CT abd/pelvis:
IMPRESSION:
1. No extraluminal contrast to suggest large anastomotic leak.
Intraperitoneal gas and fluid with stranding of the small bowel
mesentery is likely post-surgical. A mid abdominal incision
remains open and packed.
2. Similar appearance of fluid collection in the left anterior
abdomen, which
is better appreciated on the contrast-enhanced study of earlier
today.
[**2162-3-18**]
IMPRESSION:
1. Extensive occlusive deep vein thrombosis extending from the
left common
femoral vein to the left popliteal vein.
2. No right-sided DVT.
[**2162-3-18**]
IMPRESSION:
1. Enterocutaneous fistula from the mid jejunum through to the
anterior
abdominal wall with contrast also pooling within a likely
intra-abdominal
fluid collection.
2. Area of caliber change with multiple not as fully distendable
bowel loops in the right lower quadrant beyond a persistent
discrete, although no angulated, point of distinct caliber
change; this confirms the impression that there may be mild
partial obstruction due to an adhesion beyond the point of
fistulization.
Brief Hospital Course:
He was admitted to the Acute Care Surgery service and taken to
the operating room on [**3-5**] for exploratory laparotomy with
extensive lysis of adhesions (> 8 hours) and
small-bowel resection x1 with primary anastomosis.
Intraoperatively he developed atrial fibrillation at surgical
hour 8 and received amiodarone load. He was transferred to SICU
post-op intubated and vented for hemodynamic monitoring and
further management. He was weaned and extubated on [**3-7**]
successfully. He remained hemodynamically stable and was
transferred to the regular surgical floor for ongoing care.
Once transferred to the floor he progressed slowly. He was given
a diet and began working with Physical and Occupational therapy.
On [**3-14**] he was noted with enterocutaneous fistula requiring that
a wound VAC be placed over the wound. The drainage output from
this was initially high; a NG tube was placed as well also
initially with high output. The decision was made to place a
PICC and initiate TPN.
On [**3-18**] he was noted with left calf swelling and tenderness. He
underwent a ultrasound which revealed extensive occlusive deep
vein thrombosis extending from the left common femoral vein to
the left popliteal vein bu no right-sided DVT. A Heparin drip
was started and his PTT was followed closely.
His NG was clamped on [**3-22**] for 6 hours with no residual and no
increase in his fistula output. The NG was removed and there has
not been any increase in the fistula drainage since its removal.
On [**3-22**] Coumadin was started with the Heparin drip being
continued as a bridge. He received 5 days of Coumadin, doses
being increased every 2 days. His INR did not increase. It was
felt that he was most likely not absorbing the Coumadin and the
decision was made to stop the Heparin drip and initiate
therapeutic Lovenox - he is currently receiving 80 mg every 12
hours. As the fistula heals restarting Coumadin should be
revisited as he will require long term anticoagulation therapy.
He has remained NPO allowing for fistula healing and will
continue on the TPN in the meantime. He will need to follow up
at least every 2 weeks in the Acute Care Clinic for wound and
fistula evaluation.
He has been recommended for acute rehab after hospital discharge
for ongoing care.
Medications on Admission:
Advair 250-50mcg 2 puffs [**Hospital1 **], Albuterol INH PRN, Amitriptyline
75mg QPM, Aspirin 81mg daily, Carvedilol 6.25 [**Hospital1 **], Calcitriol
0.25mcg QMWF, Ciclopirox 8% daily, Coumadin 2mg (hasnt taken for
2 days), Cyclobenzaprine 10mg [**Hospital1 **], Furosemide 40mg QD, Vicodin
PRN pain, Hyoscyamine 0.125mg daily, Isosorbide (Imdur) 30mg
daily, Nitroglycerin 0.4mg PRN, Omeprazole 40mg QD, Ondansetron
4mg PRN, Miralax 17g [**Hospital1 **], Potassium Chloride 40mg [**Hospital1 **],
Pravastatin 40mg daily (N), Sucralfate 1g TID, MVI
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for SOB.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may rpt q 5 min x3 doses.
4. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) MG
Subcutaneous Q12H (every 12 hours).
5. Metoprolol Tartrate 5 mg IV Q6H
while NPO. Hold SBP <100 or HR <55
6. insulin regular human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for per sliding scale.
7. Pantoprazole 40 mg IV Q24H
8. 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.
9. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
10. Heparin Flush (10 units/ml) 1 mL IV DAILY
11. Dilaudid (PF) 1 mg/mL Solution Sig: 0.5-1 MG Injection every
4-6 hours as needed for pain.
12. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-15**]
Tablet, Delayed Release (E.C.)s PO once a day as needed for
constipation.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
15. Ondansetron 4 mg IV Q8H:PRN nausea
16. TPN SEE ATTACHED
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Small bowel obstruction
Enterocutaneous fistula
Deep vein thrombosis - left lower extremity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with a small bowel obstruction
requiring an operation to remove the obstruction. Your surgery
was complicated by a wound fistula that has interferred with
progressing you to being able to eat. You are being given
intravenous nutrition called TPN that is being administered
through the specialized IV called a PICC line. Once the fistula
heals foods will be re-introduced.
You also developed a blood clot in the veins in your left leg
and initially was started on Heparin which is a blood thinner.
Blood clots can commonly develop in people who have undergone
major surgery and are not able to be very mobile. You are
continuing to be treated with blood thinners called Lovenox
which is an injection that is gien 2x/day. You were tired on
Coumadin which is a pill form blood thinner but because of your
medical condition your intestines were not able to absorb this
medication and that is why you were changed to Lovenox.
Followup Instructions:
Follow up in [**11-15**] weks in Acute Care Surgery Clinic; call
[**Telephone/Fax (1) 600**] for an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2162-4-14**]
ICD9 Codes: 2762, 412, 4280, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7289
} | Medical Text: Admission Date: [**2138-12-26**] Discharge Date: [**2139-1-1**]
Date of Birth: [**2083-1-14**] Sex: M
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
unresponsiveness, respiratory distress
Major Surgical or Invasive Procedure:
Picc line placement
History of Present Illness:
Mr. [**Known lastname 4401**] is a 55 year old man with history of COPD on 3L home
O2, hypertension, diabetes, history of stroke, hypertension, IV
drug use on chronic methadone, history of pancreatitis, history
of PE with IVC ([**2137**]) who was admitted to [**Hospital1 18**] on [**2138-12-27**] for
unresponsiveness and respiratory failure. He was found minimally
responsive at his long-term facility and brought to the ED,
where his O2sat was 71% on 3L NC. He was febrile to 101.6F in
the ED. He was initially given 2mg Narcan and placed on BiPap
with improvement in respiratory status. His respiratory rate
increased after the Narcan. CXR was performed which demonstrated
a RUL pneumonia. He received CTX, Flagyl, and Vancomycin. During
his stay in the ED, he became unresponsive at which time ABG was
7.10/168/356/56; he was again given Narcan with improvement. He
was then transferred to the MICU after moderate improvement.
.
In the MICU, he was initially treated with BiPAP and he was
continued on vancomycin and zosyn for his RUL pneumonia. He
received nebs and prednisone. His Utox was negative except for
opiates. He came off of BiPAP, was stabilized on 3LNC, afebrile,
and breathing comfortably, and was called out to the general
medical floor. His ABG improved to 7.37/77/153/46 at the time of
transfer.
.
Over the preceding days, patient required between 3-6LNC with O2
sats 89-91%. On the morning of transfer, his oxygen saturation
was noted to be low, between 70-mid 80s. He was given a
nebulizer treatment, after which he transiently improved. At
that time he was A+Ox3. A CXR was performed which was showed
improvement in RUL infiltrate. He then became more sedated and
was given 0.4mg ov Narcan with no improvement. At that time, ABG
showed 7.43/70/64/15. His saturation increased on a venti mask
(up to 96% sat), then trended down to 84%. Again, he recovered
spontaneously. He was then noted to be increasingly somnolent
and transiently unresponsive (with no movement and unrousable to
sternal rub); ABG at that time was 7.50/54/83/44. Patient was
then transferred to the MICU.
.
Upon arrival to the MICU, the patient is mentating without
difficulty. Alert and oriented x3. States he does not understand
why he needs to be in intensive care. He does remember having
low oxygen this morning but does not remember being unresponsive
or frequent attempted arousals. O2 sat is 86-91% on 6L O2. He
denies any chest pain, pleuritic chest discomfort, palpitations,
leg pain, cough, shortness of breath, diarrhea, constipation. He
does feel like his breathing is somewhat more difficult than at
home. He notes that he typically only wears his oxygen at night.
Past Medical History:
# Chronic obstructive pulmonary disease: On home O2
# Diabetes: [**3-7**] pancreatic surgery
# Hypertension
# Chronic pancreatitis, s/p Whipple
# Hepatitis C
# Peptic ulcer disease
# Anemia
# History of PE with IVC filter ([**3-/2137**])
# Possible CVA ([**2122**]): Reports he was comatose for two weeks and
has had memory problems since
# Seizure disorder
# Previous substance abuse
# Depression
Social History:
Lives in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] retirement home. Brother and sister in
area. Originally from [**State 531**]. Former laborer. Previous alcohol
abuse, quit 13 years ago. Previous smoker 2 pks a day, duration
unknown, quit 2-3 years ago. Previous heroin abuse
Family History:
Unknown
Physical Exam:
PE: T: 98.7 BP: 138/79 HR: 93 RR: 14 O2 91% 6LNC
Gen: Pleasant, comfortable, no respiratory distress
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD, No JVD.
CV: RRR. Distant heart sounds. No appreciable murmurs, rubs or
[**Last Name (un) 549**]
LUNGS: Decreased breath sounds throughout but symmetric bilat.
Bilat wheezes
ABD: NABS. Healed midline surgical incision. Soft, ND. TTP in
epigastrum w/o rebound or guarding. No rigidity.
EXT: WWP, No clubbing. No edema. 2+ DP pulses BL
SKIN: No rashes/lesions.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Resting
tremor in LUE. Moving all extremities. Gait assessment deferred
Pertinent Results:
STUDIES:
.
ECG [**2138-12-29**]: NSR @ 88. LAD. Nl intervals. LAFB. Delayed RW
progression. Early repolarization changes in inf leads. Compared
to prior, no [**Month/Day/Year 65**] change.
.
CXR [**2138-12-29**]: writers read: improved consolidation in RUL.
.
CXR [**2138-12-28**]: There is interval improvement of the consolidation
within the right upper lobe. There is some atelectasis of the
right base. The cardiac silhouette and mediastinum is within
normal limits.
.
CXR [**2138-12-26**]: Right upper lobe pneumonia. Repeat radiography
following appropriate therapy recommended to document
resolution.
.
ECHO [**2138-12-5**]: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). There is borderline right
ventricular hypertrophy. Right ventricular chamber size and free
wall motion are normal. The aortic root is moderately dilated at
the sinus level. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined (probably at least
mildly elevated but Doppler measurements were technically
suboptimal). There is a trivial/physiologic pericardial
effusion.
Brief Hospital Course:
Mr. [**Known lastname 4401**] is a 55yoM with history of COPD on 3L home O2, DM,
HTN, chronic methadone use admitted with altered MS found to
have hypercapnea and pneumonia. The patient was initially
admitted to the MICU, then transferred to the floor. In the
MICU, he was initially treated with BiPAP and he was continued
on vancomycin and zosyn for his RUL pneumonia. He received nebs
and prednisone. His Utox was negative except for opiates. He
came off of BiPAP, was stabilized on 3LNC, afebrile, and
breathing comfortably, and was called out to the general medical
floor. His ABG improved to 7.37/77/153/46 at the time of
transfer.
.
Over the preceding days, patient required between 3-6LNC with O2
sats 89-91%. On the morning of transfer, his oxygen saturation
was noted to be low, between 70-mid 80s. He was given a
nebulizer treatment, after which he transiently improved. At
that time he was A+Ox3. A CXR was performed which was showed
improvement in RUL infiltrate. He then became more sedated and
was given 0.4mg ov Narcan with no improvement. At that time, ABG
showed 7.43/70/64/15. His saturation increased on a venti mask
(up to 96% sat), then trended down to 84%. Again, he recovered
spontaneously. He was then noted to be increasingly somnolent
and transiently unresponsive (with no movement and unrousable to
sternal rub); ABG at that time was 7.50/54/83/44. Patient was
then transferred back to the MICU.
.
Upon arrival to the MICU, the patient was mentating without
difficulty. Alert and oriented x3. O2 sat is 86-91% on 6L O2.
After further improvement in his respiratory status, he was
transferred back out the the floor on 3-4L O2.
Hospital Course by problem:
# altered mental status: waxing and [**Doctor Last Name 688**] on floor. Ddx
includes med induced, hypercarbia, seizure, infection,
toxic-metabolic encephalopathy. Patient was back to MS baseline
at time of admission to the MICU. Not clearly related to CO2 and
did not have evidence of worsening CO2 rentention from baseline.
Suspect significant contribution of psychoactive medications
including methadone, gabapentin, zyprexa, theophylline. Should
also consider seizure given question of seizure disorder
although no post ictal period and no obvious evidence of seizure
clinically. No evidence to suggest active infection either.
Intially methadone, zyprexa, gabapentin were held -> improved MS
with holding these medications. These medications have all been
resumed at time of discharge. A theophylline level was checked
and found to be subtherapeutic. His U/A was unremarkable. His
LFTs and pancreatic enzymes were found to be unremarkable.
.
# hypoxia: pt has a home O2 requirement but significantly
increased O2 requirement at presentation. Ddx includes
hypoventilation, PE, mucous plugging, pneumonia, V/Q mismatch
from COPD, CHF, cardiac ischemia. Hypoventilation could be
explained by altered MS [**First Name (Titles) **] [**Last Name (Titles) 72587**] despite improved MS.
Pneumonia appears improved on CXR. No evidence of collapse on
CXR to suggest mucous plugging. No evidence of CHF on exam or
CXR. Pt was ruled out for MI and no ischemic changes on ECG. PE
ruled out by CTA. O2 sats were maintained between 88-92% to
avoid CO2 retention.
# COPD: Pt has a baseline O2 requirement, ~ 3L O2 via nasal
cannula. Likely exacerbated by pneumonia. Pt was continued on
albuterol, spiriva, flovent and theophylline. Patient was given
prednisone and is now on a taper, currently day 2 of prednisone
20mg. He will continue for 3 additional days and then taper to
prednisone 10mg qday x 5 days.
# RUL Pneumonia - Initially thought to be a possible aspiration
PNA given unresponsiveness. Suspect some contribution of
pneumonitis given rapid resolution on CXR. No sputum Cx
available as dry cough. Afebrile without white count currently.
Treated with vancomycin and zosyn, now day [**8-16**]. Patient has a
PICC line in place for IV antibiotics.
.
# Diabetes: secondary to pancreatic resection. On NPH and ISS.
NPH was uptitrated while on prednisone, also patient with many
dietary indiscretions while in-house resulting in elevated BS.
Will discharge patient on NPH 15mg [**Hospital1 **] and sliding scale
insulin. As prednisone is tapered and stricter diet is resumed,
the patient will likely require less insulin.
.
# Hypertension: Patient was admitted off antihypertensives but
home regimen was supposed to consist of lisinopril 60mg daily,
HCTZ 25mg daily, clonidine patch 0.2mg daily, toprol XL 25mg
daily. Home regime was slowly re-initiated and patient is
discharged on his home regiment.
# Chronic abdominal pain: unclear etiology. Likely secondary to
abdominal surgery. Abdomen soft. Seems to be at patients
baseline. Pancreatic enzyme supplements continued.
.
# History of PE: Unclear circumstances but had IVC filter
placed, reportedly in 2/[**2137**]. IVC filtered confirmed by
abdominal CT. Had been on coumadin but was d/c'ed following
admission [**6-8**]. CTA w/o evidence of new PE. Patient received
subq heparin throughout this hospitalization.
.
# Hepatitis C. No active issues.
.
# Peptic ulcer disease. Not currently active. Continue PPI.
.
# Seizure disorder: Keppra continued throughout hospitalization.
Patient did not have an EEG.
# Previous IVDU on methadone - Patient has some nonspecific
aches/pains but no clear e/o withdrawal. Home dose Methadone 5
mg PO tid. Patient was restarted on his home dose of methadone
the day before discharge.
.
# Depression. No active issues. Continued buproprion,
citalopram.
The patient was evaluated by physical therapy and will be
discharged to a rehab bed at the [**Hospital3 1186**] with physical
therapy. He was discharged on hospital day #7 in stable
condition.
.
Medications on Admission:
Albuterol Nebs Q2H PRN
Fluticasone 2 puff INH [**Hospital1 **]
Buproprion 150mg PO BID
Citalopram 40mg daily
Olanzapine 5mg QHS
Levetiracetam 500mg TID
Ferrous Sulfate 325mg [**Hospital1 **]
Gabapentin 300mg [**Hospital1 **], 600mg QHS
Memantine 5mg daily
Methadone 5mg TID
Acetaminophen 325mg Q6H PRN
Colace 100mg [**Hospital1 **]
Dulcolax PRN
Amylase-Lipase-Protease 20,000-4,500,25,000 capsule TID with
meals
Theophylline 80mg/15mL [**Hospital1 **]
Insulin NPH 10 units QD
Tiotropium 18mcg one cap INH daily
Ipratropium 0.02% INH Q6H
Prilosec 20mg daily
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Bupropion 75 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day).
3. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
4. Levetiracetam 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day).
5. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Ferrous Sulfate 325 (65) mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) [**Hospital1 **]: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
10. Theophylline 80 mg/15 mL Elixir [**Hospital1 **]: One (1) PO BID (2
times a day).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
Inhalation Q4H (every 4 hours).
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
inhalation Inhalation Q2H (every 2 hours) as needed.
14. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY
(Daily).
15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Last Name (STitle) **]:
One (1) Cap Inhalation DAILY (Daily).
16. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain, [**Last Name (STitle) **].
17. Ibuprofen 400 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q8H (every 8
hours) as needed.
18. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed.
19. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 3 days.
20. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
21. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
22. Methadone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
23. Gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
24. Gabapentin 300 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO HS (at
bedtime).
25. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
26. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
[**Last Name (STitle) **]: One (1) Intravenous Q8H (every 8 hours) for 7 days.
27. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q 12H (Every 12 Hours) for 7 days.
28. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
29. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
30. Zyprexa 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO qHS.
31. Clonidine 0.2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
32. insulin
Humalog Insulin Sliding Scale per sliding scale provided.
NPH 15mg [**Hospital1 **] (breakfast/dinner)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Pneumonia
COPD exacerbation
Diabetes
Secondary:
HTN
Chronic pancreatitis
HCV
PUD
Anemia
h/o PE with IVC filter
Seizure d/o
h/o substance abuse
Depression
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] > 100.4, shortness of breath,
chest pain, inability to tolerate food/liquids.
Followup Instructions:
1. Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She will see you at your
long term care facility.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
ICD9 Codes: 5070, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7290
} | Medical Text: Admission Date: [**2176-3-10**] Discharge Date: [**2176-3-27**]
Date of Birth: [**2129-3-28**] Sex: F
Service: MEDICINE
Allergies:
Lamictal
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
Endotracheal intubation and ventilation
History of Present Illness:
46 yo female with med hx of depression, suicide attempt, COPD,
admitted to [**Hospital3 **] [**3-9**] after being found minimallly
responsive by neighbor. She reported slipping on the ice
multiple times during the past snow storm, and reported left arm
pain and bilat LE pain. She denied CP, CT, or SOB but reported
general malaise. She took increasing doses of both trazadone and
Klonopin overnight due to insomnia from discomfort which is her
last memory. On arrival EMS found empty pill bottles of
seroquel, percocet, and trazodone and OD was suspected. In the
ED at OSH VS were stable but ABG revealed resp acidosis and they
decided to intubate her for airway protection. She was given
activated charcoal for suspected ingestion. Labs revealed an
elevated WBC 17 so she was started on ceftriaxone and
zithromycin for possible PNA. CT head also revealed a rt
parietal hypodensity. LFT revealed a transamiinitis thought to
be due to APAP so NAC was started although tox screen negative
for tylenol but positive for amphetamines. She was transferred
to [**Hospital1 18**] on [**3-10**] where she remained intubated. In regards to
transaminitis hepatology saw the pt and recomended NAC and RUQ
U/S which revealed cirrhosis. Transaminases continued to trend
down without further intervention. Parietal hypodensity on CT
was evaluated by nuerology who recommended BP control and ASA.
Pt also had an NSTEMI on admission with trop .32 but heparin gtt
held due to parietal lesion which on [**3-14**] MRI showed slight
hemorrhagic transformation. She continued to spike fevers
despite above antibiotics so on [**3-15**] vancomycin started for
possible endocarditis and TTE showed a severly depressed EF
20-30% but no valvular lesions. CTPA was obtained to rule out PE
as source and blood, sputum and urine cultures were neg. On
admission creat mildly elevated and had high CK's suggestive of
rhabdomylosis but this resolved with IV hydration. CT thorax
showed bullae and pt had autopeep on the ventilator so was
started on IV solumedrol which was weaned to oral prednisone
after extubation. Pt was extubated on [**3-17**] and VS remained
stable. Due to neck pain which was possibly chronic ortho spine
was consulted and afte MRI spine revealed possible ligamentous
injury they recommended C-spine use until follow-up in clinic.
Psychiatry was called once pt extubated and recommended 1:1
sitter and she was called out to the floor for further medical
management.
Past Medical History:
1. Depression s/p prior suicide attempt
2. h/o ?alc hep
3. s/p CCY and ERCP with sphincototomy
4. h/o esophagitis (-HIV in '[**64**])
5. B12 deficiency macrocytic anemia
6. sciatica
7. infertility with ?PCOS (hirsutism), but conveived with IVF
Social History:
Tobacco, but unclear level of use. History of multiple drug
abuse - including amphetamine, opiates.
Family History:
Non contributory
Pertinent Results:
[**2176-3-10**] 10:22PM TYPE-MIX PH-7.36
[**2176-3-10**] 10:22PM LACTATE-2.5*
[**2176-3-10**] 10:22PM freeCa-1.18
[**2176-3-10**] 07:54PM GLUCOSE-102 UREA N-13 CREAT-0.7 SODIUM-144
POTASSIUM-3.4 CHLORIDE-108 TOTAL CO2-27 ANION GAP-12
[**2176-3-10**] 07:54PM ALT(SGPT)-1130* AST(SGOT)-1524* CK(CPK)-604*
TOT BILI-0.5
[**2176-3-10**] 07:54PM CK-MB-6 cTropnT-0.17*
[**2176-3-10**] 07:54PM CALCIUM-8.7 PHOSPHATE-1.9* MAGNESIUM-1.8
[**2176-3-10**] 07:54PM WBC-12.8* RBC-3.69* HGB-12.1 HCT-37.0
MCV-100* MCH-32.9* MCHC-32.8 RDW-15.4
[**2176-3-10**] 07:54PM PLT COUNT-108*
[**2176-3-10**] 07:54PM PT-15.5* PTT-31.2 INR(PT)-1.5
[**2176-3-10**] 04:19PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2176-3-10**] 04:19PM URINE RBC-[**4-6**]* WBC-0 BACTERIA-FEW YEAST-OCC
EPI-0-2
[**2176-3-10**] 04:18PM GLUCOSE-162* UREA N-15 CREAT-0.8 SODIUM-145
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-29 ANION GAP-14
[**2176-3-10**] 04:18PM ALT(SGPT)-1212* AST(SGOT)-[**2181**]* LD(LDH)-1711*
ALK PHOS-64
[**2176-3-10**] 04:18PM WBC-11.8* RBC-3.83* HGB-12.7 HCT-38.2
MCV-100* MCH-33.1* MCHC-33.1 RDW-15.5
[**2176-3-10**] 04:18PM PLT COUNT-109*
[**2176-3-10**] 04:18PM PT-16.4* PTT-32.9 INR(PT)-1.7
[**2176-3-10**] 04:18PM SED RATE-6
[**2176-3-10**] 02:51PM TYPE-ART PO2-128* PCO2-33* PH-7.45 TOTAL
CO2-24 BASE XS-0
[**2176-3-10**] 02:38PM GLUCOSE-122* UREA N-15 CREAT-0.7 SODIUM-143
POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-23 ANION GAP-13
[**2176-3-10**] 02:38PM CK(CPK)-750*
[**2176-3-10**] 02:38PM CK-MB-8 cTropnT-0.20*
[**2176-3-10**] 02:38PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2176-3-10**] 02:38PM HCV Ab-NEGATIVE
[**2176-3-10**] 12:00PM ALT(SGPT)-1113* AST(SGOT)-2300* LD(LDH)-[**2113**]*
ALK PHOS-46
[**2176-3-10**] 12:00PM HCT-34.0*
[**2176-3-10**] 12:00PM PT-17.9* PTT-37.9* INR(PT)-2.0
[**2176-3-10**] 09:05AM GLUCOSE-105 UREA N-17 CREAT-1.0 SODIUM-144
POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-23 ANION GAP-14
[**2176-3-10**] 09:05AM ALT(SGPT)-1612* AST(SGOT)-3635* CK(CPK)-956*
ALK PHOS-65 TOT BILI-0.4
[**2176-3-10**] 09:05AM CK-MB-11* MB INDX-1.2 cTropnT-0.32*
[**2176-3-10**] 09:05AM ALBUMIN-3.0* CALCIUM-7.4* PHOSPHATE-0.9*
MAGNESIUM-2.2
[**2176-3-10**] 09:05AM WBC-13.9* RBC-4.13* HGB-13.4 HCT-40.8 MCV-99*
MCH-32.5* MCHC-32.8 RDW-15.5
[**2176-3-10**] 09:05AM PLT COUNT-121*
[**2176-3-10**] 04:20AM GLUCOSE-135* UREA N-19 CREAT-0.8 SODIUM-142
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-20* ANION GAP-14
[**2176-3-10**] 04:20AM CK(CPK)-1177*
[**2176-3-10**] 04:20AM PLT COUNT-147*
[**2176-3-10**] 04:20AM PT-21.7* INR(PT)-3.0
[**2176-3-10**] 04:20AM FIBRINOGE-244 D-DIMER-2814*
[**2176-3-10**] 04:08AM GLUCOSE-134* LACTATE-3.5* NA+-136 K+-4.1
CL--109 TCO2-22
[**2176-3-10**] 04:08AM freeCa-1.10*
[**2176-3-9**] 11:53PM TYPE-ART TEMP-38.2 RATES-/14 TIDAL VOL-600
O2-100 PO2-222* PCO2-50* PH-7.31* TOTAL CO2-26 BASE XS--1
AADO2-381 REQ O2-74 INTUBATED-INTUBATED VENT-CONTROLLED
[**2176-3-9**] 10:00PM URINE HOURS-RANDOM
[**2176-3-9**] 10:00PM URINE HOURS-RANDOM
[**2176-3-9**] 10:00PM URINE HOURS-RANDOM
[**2176-3-9**] 10:00PM URINE UCG-NEG
[**2176-3-9**] 10:00PM URINE GR HOLD-HOLD
[**2176-3-9**] 10:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2176-3-9**] 10:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2176-3-9**] 10:00PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2176-3-9**] 10:00PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
[**2176-3-9**] 10:00PM URINE GRANULAR-0-2
[**2176-3-9**] 09:59PM LACTATE-3.2*
[**2176-3-9**] 09:50PM ALT(SGPT)-2757* AST(SGOT)-8611* CK(CPK)-1758*
ALK PHOS-83 AMYLASE-135* TOT BILI-0.7
[**2176-3-9**] 09:50PM ALBUMIN-3.9
[**2176-3-9**] 09:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2176-3-9**] 09:50PM WBC-20.8* RBC-5.10 HGB-17.1* HCT-52.5*
MCV-103* MCH-33.6* MCHC-32.6 RDW-14.9
[**2176-3-9**] 09:50PM PLT COUNT-133*
[**2176-3-9**] 09:50PM PT-19.8* PTT-32.3 INR(PT)-2.5
MR HEAD W/O CONTRAST [**2176-3-14**] 10:42 AM
There is an area of restricted diffusion within the right
parietal lobe. There is susceptibility within the same region on
gradient-echo images and increased T2 signal. No new areas of
restricted diffusion are seen. There is no significant mass
effect, shift of normally midline structures or hydrocephalus.
There are multiple air-fluid levels and mucosal thickening
within the maxillary and sphenoid sinuses.
There is no hemodynamically significant stenosis or aneurysmal
dilatation of the visualized vasculature.
Brief Hospital Course:
46F who presented with fulminant hepatitis status post likely
acetaminophen overdose (including narcotics and amphetamines)
with history of depression and suicide attempts.
CVA-PT had no residual deficits on peripheral neuro exam. CT
head read suggested old infarct although MR head more consistent
with mild hemmorhage. MRA head showed no stenosis in ant or post
circulation and no afib as risk for cardiac thrombus and no
thrombus seen on TTE with repeat showing normal EF and no
thrombus. Carotid U/S was neg but likely source was LV thrombus
post MI although difficult to interpret repeat TTE results. We
controlled her BP with ACE-I which were titrated as blood
pressure tolerated and added ASA 325mg for MI prophylaxis. No
need for anticoagulation at this time per Neurology and
Cardiology consulatation given her recovery in LVEF and risk fo
hemmorrhage due to poor med compliance as an outpt. Pt is
medically clear from a neurological standpoint at this time with
plan for only ASA 325mg qd and outpatient follow-up with
Neurology which will be handled by her PCP.
CAD-large hypokinetic areas on TTE suggest large infarct and ECG
suggested evolving anteroseptal MI although repeat TTE shows
normal EF. We continue ASA as above, Lisinopril now at 10mg and
B blocker at 25mg qd due to normal BP's. Pt with borderline LDL
panel prior to staring statin so cont on 10mg qd. Pt had small
residual effusion on CXR although no further need for diuresis
with pt having adequate O2 sats on room air. Per cardiology pt
will need elective low intesity stress test in 6 weeks, but with
new TTE results prognosis is much better. Pt is medically clear
from a cardiac standpoint to DC home.
Hepatitis-LFT's trended back to normal limits with only NAC.
Most likely drug induced with multiple inciting factors
including APAP in percocet, trazadone, klonopin. Antismooth
muscle Ab pos suggetive of autoimmune hep although [**Doctor First Name **] neg. IgG
and Igm at normal levels, [**Doctor First Name **] neg, hepatitis A,B,C serologies
neg. Unclear what etiology of nodularity of liver on RUQ in pt
who refuses EtOH use and Hep serologies neg.
Elevated WBC-Now normalized and pt afebrile. [**Month (only) 116**] be due to
demargination from steroid use although previous fevers suggest
other etiology. She did not complete a course of any of her
antibiotics although fevers resolved while in MICU. Pt had
increasing sputum production and fevers which have resovled
since starting levofloxacin and will continue [**9-11**] day course of
levofloxacin for PNA with CXR from yesterday clear.
Ingestion -?suicide attempt although pt's ability to make good
decisions is questionable at baseline. Psychiatry is following
and recommended 1:1 sitter and now report that she will need an
inpatient psychiatry stay. Will consult with BEST team regarding
placement.
Anxiety-Started Klonopin as above so stopped ativan. Pt out of
window of withdrawal at this point. Holding on seroquel and
trazadone per psychiatry.
Hip pain-Pain regimen as an outpt included 150mg MS contin [**Hospital1 **]
with percocet for breakthrough as confirmed with PCP DR [**Last Name (STitle) 26909**]
[**Telephone/Fax (1) 35930**]. Pt seen by pain clinic at [**Hospital1 2025**] but not since [**2172**].
Hip films suggest no fracture and read on MRI is no pathology on
side of pain. Pain well controlled on current regimen of MS
contin 60mg tid and 15mg of IR for breakthrough with neurontin
for possible neuropathic component as recommended by pain
consult and now on tylenol.
C-spine-Neck pain appears to be chronic although MRI Cspine
suggestive of possible bone bruising involving C5 spinous
process with contusion of the ligaments attached to the spinous
process and posterior soft tissue swelling. Orthospine consulted
and recommended f/u flexion and extension films which we were
neg so C-collar removed. Pt will have orthopedic follow-up as an
outpt.
COPD-Pt has long smoking hx and cont wheeze on PE. Pt on
steroids for >1wk so will need slower taper now at 5 mg
prednisone qd but will discontinue tomorrow. Cont ipratropium
and albuterol nebs with MDI's but all as prn. Pt CXR of severe
COPD and likely has baseline low O2 sats but is not tachypneic.
PCP is aware and will schedule pulmonary follow-up as an
outpatient.
Anemia-Iron studies suggest anemia of chronic disease. B12 and
folate normal. Hct stable so no acute need for workup including
bone marrow biopsy
Medications on Admission:
Seroquel 100mg qhs
trazadone 200mg qhs
percocet T q4-6h
MS Contin 60mg q4h
Advair Discus
Calcium
Klonopin 0.5mg qid
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 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 for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Morphine Sulfate 30 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO Q8H (every 8 hours).
Disp:*180 Tablet Sustained Release(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*3 vials* Refills:*0*
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Rt parietal stroke
Anteroseptal myocardial infarction
Medication overdose
Discharge Condition:
Stable
Discharge Instructions:
If you experience any chest pain, chest tightess, shortness of
breath, increasing cough, fever, chills, weakness or loss of
sensation, feeling as if you want to hurt yourself or others you
should call your, but if he/she is not available you should go
to the nearest emergency room. You were also started on some new
medications while you were in hospital which you should take as
prescribed. We changed your pain medication regimen and you
should take the new regimen and disregard old prescriptions. Dr.
[**Last Name (STitle) 26909**] is aware of these changes and will work with you
regarding a new pain management plan.
Followup Instructions:
You have a scheduled appointment with Dr. [**Last Name (STitle) 26909**] at
[**Telephone/Fax (1) 35930**] on Wed [**4-10**] at 11am for post hospitalization
follow-up. While in the hospital you were evaluated by the
cardiology team regarding your myocardial infarct(heart attack)
and recommend that your primary care doctor refer you to a
cardiologist in your area for follow-up which he is aware of.
You should also follow-up with a local Neurologist regarding
your stroke and an Orthopedic doctor regarding your neck injury.
ICD9 Codes: 486, 4280, 496, 2875, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7291
} | Medical Text: Admission Date: Discharge Date: [**2185-6-2**]
Date of Birth: [**2185-6-2**] Sex: F
Service: NEONATOLOGY
HISTORY: [**First Name8 (NamePattern2) 9110**] [**Known lastname **] is a 35 week, 2,070 gram infant,
delivered by scheduled Cesarean section for prenatal
diagnosis of a cloacal anomaly and longstanding severe
oligohydramnios, admitted to the Neonatal Intensive Care Unit
with respiratory distress and hypoxia. Mom is a 32 year-old,
Gravida I, Para 0 now I, with unremarkable prenatal screens
including blood type AB positive, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive and
Rubella immune. Group beta strep status unknown. Estimated
date of confinement [**2185-7-7**].
Prenatal diagnosis by ultrasound and MRI showed a cloacal
anomaly with multiple tubular cystic structures in the
abdomen, (presumed bowel, question bladder), kidneys normal,
ureters and bladder not seen. Tethered spinal cord. Severe
longstanding oligohydramnios. No other structural anomalies
on full fetal ultrasound (specifically, cardiac [**Doctor Last Name 1754**] and
outflow tracts noted to be structurally normal). Followed in
the Advanced [**Hospital **] Care Center at [**Hospital3 1810**] by Dr.
[**Last Name (STitle) 38447**] (General Surgery) and Dr. [**Last Name (STitle) 45267**] (Urology).
The baby was delivered via Cesarean section on the morning of
[**6-2**] at 35 weeks gestation due to concern for increasing
risk of cord accident and increasing gestational age with
severe oligohydramnios. [**Doctor First Name 9110**] emerged with a spontaneous
cry. She received stimulation, suction and blow-by oxygen.
Apgar's were seven at one minute and seven at five minutes of
age. Progressive respiratory distress and poor perfusion
with increasing cyanosis despite blow-by oxygen. The baby
was intubated shortly upon arrival to the Newborn Intensive
Care Unit.
PHYSICAL EXAMINATION: Weight 2,070 grams on admission.
Temperature 95.9 rectally. Heart rate 170. Respiratory rate
40. Oxygen saturation 66 percent with blow-by oxygen. Blood
pressure 96/66 with a mean arterial pressure of 84. Infant
with low tone and activity, dusky. Anterior fontanel open
and flat. Mild dysmorphism/deformation consistent with oligo
(ears, lower limbs). Lungs poorly aerated with spontaneous
and positive pressure ventilation. Heart: Regular rate and
rhythm without murmur. Abdomen: Nondistended, soft, no
hepatosplenomegaly or masses. Hips stable. Genitourinary:
Female with cloacal opening only. No urethral meatus or
anus. Passing what appears to be mix of urine/stool which is
watery and brownish-yellow in color. Spine straight with
defects. Minimal gluteal musculature (noted by surgical
resident to signify likely higher level gastrointestinal
obstruction).
HOSPITAL COURSE:
1. Respiratory: [**Doctor First Name 9110**] initially required very high
inspiratory pressures with conventional and manual
ventilation. Radiographs showed very poor lung excursion and
completely opacified lung fields with somewhat bell- shaped
thorax. After Surfactant administration, the infant was
transitioned to hi-fi ventilation, following which there was a
brief period of moderate stability, during which FI02 was
weaned to 50 percent on HFOV ventilation. There was a sudden
desaturation to 45 percent with radiographic evidence of left
tension pneumothorax. Needle thoracentesis was performed
yielding 30 ml of air, following which a thoracostomy tube was
placed. Continued desaturation to 50 to 70 percent,
responsive only partially to manual ventilation with peak
inspiratory pressures of 50 cm of water and high rates. Blood
gas showed mixed metabolic and respiratory acidosis. She
received two sodium bicarbonate boluses but follow up pH was
still only 6.95. Gradual further deterioration in oxygen
saturations despite aggressive ventilation, with eventual
onset of bradycardia. The chest tube was removed and
replaced, yielding continuous air but minimal improvement in
saturation. At time of decision with parents to discontinue
intensive cardiorespiratory support, her oxygen saturation was
17 percent on 100 percent FI02 with a heart rate of 55.
2. Cardiovascular: Infant had a normal cardiac examination.
Three normal saline boluses were given for poor perfusion.
Blood pressure remained normal throughout until terminal
bradycardiac event.
3. Fluids, electrolytes and nutrition: A UAC and a UVC were
placed and maintenance dextrose solution running. Initial
blood glucose of 43 but progressively hyperglycemic. No urine
output noted during course. No bladder palpable. As above,
severe metabolic acidosis, refractory to bicarbonate
administration.
4. Central nervous system: Infant initially neurologically
appropriate with normal neurologic examination. The infant
received several Fentanyl boluses followed by two Pavulon
doses to facilitate ventilation and comfort.
5. Infectious Disease: CBC with differential and blood
culture were drawn upon admission to the Newborn Intensive
Care Unit. White blood cell count was 18.9 with 26 percent
polys and 0 percent bands. Broad spectrum antibiotic therapy
was started at that time.
6. Hematology: Platelet count on admission to the Neonatal
Intensive Care Unit was 233 with a hematocrit of 54. No blood
products were administered and no apparent bleeding diathesis
was noted.
7. Social: Parents were updated throughout the afternoon.
Although parents spoke English, neonatology did make use of
the services of interpreters in the family and from [**Hospital1 1444**] for discussions regarding the
later direction of care decision. Initially, [**Doctor First Name 55970**]
parents asked that all appropriate interventions be undertaken
on her behalf. As the degree of pulmonary hypoplasia became
evident, and the respiratory status worsened progressively,
there was discussion regarding the minimal probability that she
was going to respond to the therapies available. They held her
and then expressed their preferences with the team to discontinue
intensive cardiorespiratory support and proceed with comfort
measures. The endotracheal tube was removed and [**Doctor First Name 9110**] was
pronounced dead shortly after at 5:51 in the evening of [**6-2**].
Parents declined a postmortem examination.
DISCHARGE DIAGNOSES:
1. Prematurity at 35 weeks gestation.
2. Presumed pulmonary hypoplasia.
3. Cloacal anomaly.
REVIEWED BY: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], MD [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 55971**]
MEDQUIST36
D: [**2185-6-16**] 17:11:31
T: [**2185-6-16**] 17:55:44
Job#: [**Job Number 55972**]
ICD9 Codes: 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7292
} | Medical Text: Admission Date: [**2186-5-15**] Discharge Date: [**2186-5-17**]
Date of Birth: [**2119-10-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 66 y/o F with a PMHx of IDDM x17 years (last HgA1c
10.0% in [**3-9**]), COPD, hypothyroidism, Bipolar d/o here with
nausea, vomiting, elevated BS to >600s at home. Pt states that
starting 3-4 days ago, she started developing worsening elevated
BS that didn't register on her glucometer, coupled with
progressive nausea, and several episodes of vomiting. Pt states
that this is similar to her previous episodes of DKA for which
she was admitted to the [**Hospital1 2025**] in [**1-/2186**] and [**Hospital1 18**] in 04/[**2185**]. Pt
denies noncompliance with her insulin, stating that she takes
her Lantus 30 qhs, with her Humalog SS as needed. She denies
any recent CP, SOB, DOE, or any other symptoms. Does admit to
polyuria, but denies any odynophagia, change in her chronic
cough, increased sputum, diarrhea, dysuria, or any other
symptoms.
.
In the [**Name (NI) **], pt's VSS were T96.2, HR98, BP99/47, RR18, 97%RA. Pt
had an ABG of 7.18[28[132. Pt received 5L NS, 8u regular
Insulin IV, placed on Insulin gtt. R femoral cordis was placed
under sterile technique. Lactate was 3.73.
.
Past Medical History:
DM X 17 years- insulin dependent, last Hgb A1c 9.5% in [**1-9**]
COPD
thyroiditis/ hypothyroidism
Manic Depressive
Social History:
Quit working 2 years ago, previously secretary. Lives w/
husband who has dementia, 3 kids nearby. 52 pack year smoking
history, no ETOH x 15 years. No illicits
Family History:
non-contributory
Physical Exam:
VS: HR92 BP80/49 RR24 o2sat:100%RA FS 384
GEN: Lying in bed, breathing comfortably, in NAD
HEENT: Anicteric sclera. PERRL. EOMi.
NECK: No elev JVP
CV: RRR. No murmurs.
RESP: Moving air throughout all fields. +exp wheezes, prolonged
expiration.
ABD: Soft. NTND. +BS. No TTP. No rebound/guarding.
EXT: No edema bilat.
NEURO: AAOx3.
Pertinent Results:
EKG: NSR 94. Nml axis. Nml intervals. +LAA. TWI in V1, old.
No ST or TW changes. Good R wave progression.
Brief Hospital Course:
A/P: 66 y/o F with a PMHx of IDDM x17 years (last HgA1c 10.0% in
[**3-9**]), COPD, hypothyroidism, Bipolar d/o here with DKA
.
#DKA
Patient with recurrent episodes of DKA over the past several
months, presenting again with DKA. Etiology unclear at this
point; ? viral gastroenteritis vs noncompliance with
medications. WBC elevated with left shift but no clear
localizing signs or sx's. Blood cx's x2, urine cx P. Pt
received 10u regular Insulin IV in the ED, placed on Insulin gtt
prior to transfer to the ICU. She was given NS IVF hydration,
which was transitioned to D5 1/2 NS once her glucose had
declined under 250. On HD#2 she was tolerating PO diet, and was
transitioned to her Insulin SS. The [**Last Name (un) **] was consulted to
assist with improved outpatient regimen and compliance as an
outpatient. Patient was discharged on her home regimen and
encouraged to be compliant with f/u appts with [**Name8 (MD) **] NP in 1 week
and her endocrinologist in 3 weeks after discharge.
Medications on Admission:
Lithium 300 [**Hospital1 **]
Ativan 2 qhs
ASA 325
Mevacor 20
Lantus 30units qhs
Humalog SS
Lisinopril
Lopressor 25 [**Hospital1 **]
Discharge Medications:
1. Lantus 100 unit/mL Cartridge Sig: Twenty Five (25) units
Subcutaneous with dinner.
Disp:*qs units* Refills:*2*
2. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Mevacor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*0*
7. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Humalog 100 unit/mL Cartridge Sig: as per your home sliding
scale units Subcutaneous three times a day.
Disp:*qs units* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Discharge Condition:
stable to be discharged home
Discharge Instructions:
Follow up with appointments as below.
.
Please take medications as directed below. Take 25 units of
Lantus Insulin tonight at dinner, then continuing taking it at
bedtime starting tomorrow night ([**5-18**]).
.
If develop nausea, vomiting, elevated blood sugars, fevers, or
any other symptoms, please call Dr. [**Last Name (STitle) **] or report to the
nearest ER.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 39750**] to schedule a follow up
appointment.
.
Please call the [**Last Name (un) **] at [**Telephone/Fax (1) 2384**] to schedule a follow up
appointment with a nurse educator next week and with Dr.
[**First Name (STitle) **] in the next month.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2186-5-24**]
ICD9 Codes: 496, 5849, 2449, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7293
} | Medical Text: Admission Date: [**2133-2-11**] Discharge Date: [**2133-2-17**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
54 yo F with history of DMI, severe gastroparesis, HTN, Grave's
Disease and Hep C, who presents with DKA for the 3rd time in 2
months. The patient was last admitted from [**Date range (1) **] with DKA,
and was found to have a pan-sensitive enterococcus UTI. The
patient states that she started to note diffuse abdominal pain
yesterday, typical of her diabetic gastroparesis. She describes
this pain as crampy and sharp, coming in waves. She has vomited
>10 times with bilious emesis. She describes mild mylagias, but
no cough, rhinorrhea, sore throat, dysuria, vaginal discharge,
diarrhea, headache, BRBPR, or shortness of breath. She describes
a chest pain in her lower left chest wall that has been constant
over the past day and accompanying her abdominal pain. She
denies drinking alcohol. She states she has been taking her
insulin as prescribed.
In the ED, the pts vitals were: Tm 98.1 HR 130-150 BP
116-160/72-83 R 24-30 Sat 100% 2 LNC. She was noted to have FS
in the critical range with +urine ketones, and an anion gap of
37. She was given Reglan 10 mg IV x1, 10 U SC insulin, 7 U IV
insulin, and then a 5U/hr gtt. She received 3L of NS and a R
femoral line was placed. CXR was negative for infiltrate, and UA
appeared clean.
Past Medical History:
1. DM Type 1: Years w/ DM: 5 Age of Diag: 48 Year Diag: [**2127**]
Several episodes of DKA (last one in [**2129**]), managed on 36U
Lantus plus HISS
2. Diabetic polyneuropathy
3. Hypertension
4. Grave's disease s/p RAI [**2129**]
5. Reactive airway disease
6. Seronegative arthritis, followed in rheumatology
7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
never been on antiviral therapy, acquired via blood transfusion
during surgery in [**2110**]
8. GERD
9. Migraines
10.Bilateral knee arthroscopy in [**5-24**]
11.s/p TAH and pelvic floor surgery with bladder lift
12.Depression
13. Obesity
14. Bone spurs in feet
Social History:
No smoking/EtOH/drugs. Lives at home with 2 daughters. [**Name (NI) **] lives
downstairs. Does not work.
Family History:
Mother: died of colon cancer
Long h/o DM-2
Physical Exam:
Physical Exam:
VS: Temp: 99.5 BP: 167/71 HR: 137 RR: 18 O2sat 100% RA
GEN: pleasant, fatigued, [**Name (NI) **] bilious fluid on initial exam
[**Name (NI) 4459**]: [**Name (NI) 2994**], EOMI, anicteric, dry MM, op without lesions
NECK: Flat jvd, supple, no LAD
RESP: CTA b/l with good air movement throughout
CV: Tachy but regular, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, diffusely tender but no rebound or
guarding, no masses. Neg [**Doctor Last Name 515**].
EXT: no c/c/e, warm, 1+ bilateral dp/pt pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Moves all extremities.
.
On discharge, patient was afebrile with stable vital signs. Her
physical exam remain largely unchanged with the following
exceptions. She was no longer [**Doctor Last Name **] or tachycardic. She
continued to have diffuse mild abdominal pain, without rebound
or guarding.
Pertinent Results:
[**2133-2-11**] 11:50AM
BLOOD WBC-6.5# RBC-4.41# Hgb-13.4# Hct-40.4# MCV-92 MCH-30.4
MCHC-33.1 RDW-12.9 Plt Ct-479*#
[**2133-2-11**] 11:50AM BLOOD Neuts-93* Bands-0 Lymphs-6* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2133-2-11**] 11:50AM BLOOD Glucose-681* UreaN-35* Creat-1.5* Na-132*
K-5.9* Cl-87* HCO3-8* AnGap-43*
[**2133-2-11**] 11:50AM BLOOD ALT-23 AST-34 AlkPhos-115 TotBili-0.7
[**2133-2-11**] 03:20PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2133-2-11**] 09:18PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2133-2-12**] 06:01AM BLOOD CK-MB-5 cTropnT-<0.01
[**2133-2-11**] 11:50AM BLOOD Calcium-10.9* Phos-7.0*# Mg-2.1
[**2133-2-11**] 06:23PM BLOOD %HbA1c-11.0*
[**2133-2-11**] 03:20PM BLOOD TSH-LESS THAN
[**2133-2-11**] 03:20PM BLOOD Free T4-2.3*
[**2133-2-12**] 01:15PM BLOOD T3-89
[**2133-2-11**] 05:38PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2133-2-11**] 09:18PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
.
[**2133-2-11**]. KUB. IMPRESSION: No radiographic evidence for
obstruction.
[**2133-2-11**]. CXR. IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
In summary, Ms. [**Known lastname 18741**] is a 54 year old female with type 1 DM
complicated gastroparesis and neuropathy, HTN, HCV, admitted to
MICU with DKA in setting of gastroparesis flare.
.
Diabetic Ketoacidosis: Patient intially presented with DKA and
AG of 37. Patient had gastroparesis flare and unclear if she
was less compliant with her insulin. Infectious workup was
unrevealing. Patient was treated with IVF, insulin drip with
D5W, and antiemetics. Patient was transitioned from insulin
drip to glargine with insulin sliding scale. She was
transferred to the floor once her gap closed. On the floor, she
continued to use glargine and a humalog sliding scale. She was
followed by [**Last Name (un) **] while in house and will follow up with them
on the [**Last Name (un) 766**] after discharge.
.
Type I DM: Patient was diagnosed with Type 1 diabetes 6 years
ago. She was found most recently to have a HgA1C of 11.0. She
has had multiple recent admission for DKA and her diabetes is
complicated by peripheral neuropathy and gastroparesis. She was
initially on an insulin drip but then trasitioned to glargine
and sliding scale. She was followed by [**Last Name (un) **] and will follow
up.
.
Gastroparesis: Patient complains of nausea, [**Last Name (un) **] and
abdominal pain due to gastroparesis. Gastric emptying study in
[**1-26**] showed markedly delayed gastric emptying and esophageal
stasis. She was started on hyocyamine SL, an anticholinergic
that causes GI smooth muscle relaxation. She was started on
standing tylenol with PRN NSAIDS and oxycodone. She was
continued on standing reglan. She was treated with zofran as
needed for nausea.
.
Peripheral neuropathy: Patient reported severe leg pain due to
peripheral neuropathy. She was continued on gabapentin and
amytriptyline. She was also placed on standing tylenol with PRN
NSAIDS and oxycodone for pain control.
.
Grave's Disease: Patient has history of [**Doctor Last Name 933**] disease s/p
radioablation. Patient's TSH has alternated from being
suppressed and being elevated over the past year. On admission,
TSH was found to be undetectable with elevated free T4 but
normal T3. It was difficult to interpret these result in the
setting of acute illness. There was concern for medication
noncompliance at home. She was continued on methimazole at 15
mg [**Hospital1 **] and started on propanolol to inhibit convesion of T4 to
T3. She did not appear thyrotoxic on exam. She was followed by
endocrine. She will need outpatient radioablation as she is
refusing surgery. She will need her TFTs checked as an
outpatient. She will needs outpatient opthalmology follow-up.
Her outpatient physician at [**Name9 (PRE) **] who follows her thyroid was
made aware.
.
Depression: Patient is on amitryptyline at home, however serum
tox was negative for TCAs on admission, suggesting that patient
is either noncompliant or was unable to tolerate it due to
gastroparesis/DKA. Patient's utox also positive for Benzos
though patients was not known to be prescribed benzos. She was
followed by social work because there was concern that an
unstable home environment contributed her her multiple
admissions. Social work filled out paperwork for the patient to
obtain "The Ride" so she is able to get to her appointments.
.
Asthma: Albuterol was initially held due to hyperkalemia. She
was continued on home fluticasone, montelukast.
.
CAD: Patient had negative stress in [**2131**] and normal echo with EF
of 60-70% in [**2129**]. However, she is at risk for cardiac events
given her severe and poorly controlled diabetes. She was
continued on aspirin and statin.
.
Seronegative arthritis: Patient has a history of arthritis with
normal rheumatoid factor. She was continued on sulfasalazine.
.
Anemia: Patient admitted with Hct of 40 which fell to 25 in
setting of aggressive IVF hydration. It remains difficult to
determine her baseline hematocrit given that patient is
frequently admitted for dehydration in setting of DKA and then
agressively resucitated causing Hct to be hemoconcentrated and
then diluted. Colonoscopy in [**2-26**] showed only internal
hemorrhoids. Anemia is likely from chronic disease and dilution
from IVF. Labs on discharge appear consistent with iron
deficiency anemia. The patient will need outpatient follow up
for her anemia.
.
HCV: LFTs were checked and found to be within normal limits.
No history of antiviral medications.
.
Urinary tract infection: The patient was found to have a coag
positive staph UTI while in the hospital. She was discharged to
complete a course of antibiotics. VNA will obtain a repeat UA
and culture to check that her urine has cleared of infection.
These results will be faxed to her primary care doctor.
.
Communication: HCP daughter [**Name (NI) **] [**Name (NI) 18741**] [**Telephone/Fax (1) 102661**], cell
[**Telephone/Fax (1) 102663**].
Medications on Admission:
Trazodone 100 mg PO HS (at bedtime) as needed for insomnia.
Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for sob, wheezing.
Flovent
Amitriptyline 25 mg PO HS (at bedtime).
Gabapentin 300 mg qP Q12H
Aspirin 81 mg Tablet, PO DAILY (Daily).
Methimazole 10 mg PO TID
Metoclopramide 10 mg PO QIDACHS
Montelukast 10 mg PO DAILY
Hexavitamin PO DAILY
Pantoprazole 40 mg PO Q24H
Salmeterol 50 mcg/Dose Disk Q12H
Simvastatin 10 mg PO DAILY
Sulfasalazine 500 mg PO TID
Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO q6H PRN
Hyoscyamine Sulfate 0.375 mg Tablet, SL [**Hospital1 **]
Losartan 50 mg PO DAILY
Lantus 20 Units [**Hospital1 **]
HISS
Flexeril 10 mg TID prn
Zelnorm 6mg 1 tab PO TID
?valium
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. Methimazole 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
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 TID (3
times a day).
12. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: Three
(3) Tablet, Sublingual Sublingual [**Hospital1 **] (2 times a day).
13. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*1*
16. Lidocaine HCl 2 % Solution Sig: 1-2 MLs Mucous membrane TID
(3 times a day) as needed.
Disp:*20 ML(s)* Refills:*0*
17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*2 Tablet(s)* Refills:*0*
18. Glargine
Please take your glargine 16 units with breakfast and 18 units
with dinner.
19. Insulin Sliding Scale
Please continue your Humalog (insulin) sliding scale as
instructed on the worksheet.
20. Outpatient Lab Work
Please check TSH, free T4, and T3.
Please check Urinalysis and urine culture.
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
Diabetic Ketoacidosis
Gastroparesis
Diabetes Mellitus type 1 complicated by peripheral neuropathy
.
Secondary:
Hypertension
[**Doctor Last Name 933**] Disease
Hepatitis C
Reactive Airway Disease
Seronegative Arthritis
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted with Diabetic ketoacidosis and Gastroparesis.
You were restarted on your Glargine and Humalog sliding scale
doses. You were seen by the [**Last Name (un) **] and the endocrine service and
will need to follow up in clinic on [**2133-2-23**].
.
Please schedule a follow-up appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 58216**]
[**Name (STitle) 7537**] within the next 2 weeks. You will have a follow-up
urinalysis with your VNA, and the results will be faxed to your
PCP.
.
Please check your fingersticks prior to each meal and prior to
bedtime, record these numbers and bring them when you see your
doctors. If you have a low blood sugar or feel symptomatic
(lightheaded, dizzy, sweaty), please take some juice and recheck
your sugars 15 minutes later, if still low please call your
doctor immediately. If your glucose is greater than 400, please
call your doctor immediately.
.
If you develop any of the following concerning symptoms, such as
fevers, chills, nausea, [**Name (STitle) **], diarrhea, excessive sweating,
increasing abdominal pain, chest pain, increasing thirst and
urinary frequency, please call your doctor or come to the
Emergency Department.
.
Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. Please take
all your medications as prescribed. You were started on a new
medication called propranolol for your [**Doctor Last Name 933**] disease. Your
methimazole dose was changed from 10 mg three times a day to 15
mg twice a day. Please finish your course of antibiotics
Bactrim DS. You will complete your course tomorrow.
Followup Instructions:
Gastroenterology Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2133-2-25**] 1:00
.
Hepatology Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2133-6-16**] 11:00
.
[**Last Name (un) **] Diabetes Center Provider: [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:
[**Telephone/Fax (1) 2384**] Date/Time:[**2133-2-23**] 11:00am
.
Please schedule a follow-up appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 58216**]
[**Name (STitle) 7537**] within the next 2 weeks. The phone number is
[**Telephone/Fax (1) 58261**].
ICD9 Codes: 5849, 5990, 3572, 4019, 2767, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7294
} | Medical Text: Admission Date: [**2183-2-17**] Discharge Date: [**2183-2-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
[**Age over 90 **]year old male with h/o dementia, HOH, CAD s/p CABG, s/p PPM,
recent L hip fx s/p THA (fall) sent to [**Hospital1 18**] from [**Hospital1 **] [**Location (un) 16824**] after being found down this am. Pt not able to provide
history so history per ER records and daughter who is in
[**Name (NI) 108**]. Found on floor this am, no witnessed fall. Second fall
in past week. Per rehab, not communicative since arrival there,
very hard of hearing. Per daughter, has not recovered since
surgery, previously was communicating and walking around
independently as of the New Years until his fall and fracture.
Son-in-law and [**Name2 (NI) **] saw pt 3days ago and thought he
looked "terrible". No report of fevers/chills at [**Hospital1 1501**].
In ER, imaging w/o acute traumatic injury. Seen by ortho,
nothing to do and did not feel wound was infected. Found to be
in ARF [**3-10**] dehydration with Na 155, Creat 2.5 Got 2L IVF. Foley
placed. At some point, O2 sats decreased to 80%RA and HR
increased to 105 (Admitting MD NOT notified of this change) and
he was placed on O2. Recieved Vanc for possible wound infection
and levo for foul urine (UA negative). Also recieved ativan 1mg
IV for agitation and was placed in soft restraints. By time of
arrival to floor, pt is lying in bed, moaning insensibly,
opening his eyes to voice but not following commands.
ROS: unable to obtain given patient's current mental status
Past Medical History:
DJD
CAD s/p 4vCABG 25years ago, no h/o CHF (?ICM)
AV PPM for 2nd deg AVB [**2179**]
BPH
Alzheimer's dementia
Deaf-hard of hearing
L hip fx s/p bipolar hemiarthroplasty [**2182-2-7**] (fem neck fracture
s/p fall)
dyslipidemia
DM-new dx
depression
Hemmerhoids
nephrolithiasis
Social History:
Recently living at [**Hospital3 **] dementia unit (The Falls in
[**Location (un) 745**]) since [**1-13**] (independent living before that-->moved [**3-10**]
worsening dementia), then had fall with fracture and hip
surgery, now getting rehab at [**Hospital1 **] [**Location (un) 55**] since [**2182-2-10**].
No active tobacco, etoh. Pt is unable to provide further social
history regarding past use. wife died 2.5years ago and pt has
been depressed since.
Family History:
patient is unable to provide any family history at this time and
this is noncontributory given his age
Physical Exam:
On Presentation Per Admission Note:
Vitals: 98.0, 94/64, 108, 18, 97% 2L NC
General: Patient is an elderly male, moaning and calling out
intermittently. Patient opens eyes to yelling, does not follow
commands. Moving all limbs to painful stimuli. Patient yells out
when touching any part of body
HEENT: NCAT. Pupils 2-3mm bilaterally.
OP: MM very dry appearing
Neck: JVP appears 5-6 cm
Chest: Difficult to appreciate over moaning. Relatively clear
anterior
Cor: Irregular, II/VI systolic murmur at LUSB
Abd: Obese, soft. + BS. No guarding with exam
Rectal: Normal tone, large soft brown stool in rectal vault,
guaiac negative
Back: No sacral decubitus ulcer
Ext:
Left Hip with 10-12cm linear surgical wound with staples in
place, mild erythema surrounding wound. No obvious fluctuance or
induration
Pertinent Results:
ADMISSION LABS:
CBC: WBC 19.5 with 87%N HGB 8.8, HCT 26.7 MCV 93 per OSH
records: HCT 31.2 on [**2-10**] (post-op on discharge)
INR 1.3
Trop 2.2
Lactate 3.6-->2.9
Chem: Na 155, K 3.4, Cl 114, Bicarb 24, BUN 89, Creat 2.5
(baseline 0.8)
Ca, Mag, Phos wnl
CK 281
UA: [**7-16**] wbc, trace LE, no bacteria
UCx pending
IMAGING:
pCXR [**2183-2-17**]: IMPRESSION: No acute abnormality. Tortuous
thoracic aorta.
EKG: ?wavy baseline (afib vs NSR) with LBBB
Bilateral hips radiographs total of five views [**2183-2-17**]:
COMPARISON: No prior comparison available.
FINDINGS: There is no evidence of acute fracture or dislocation.
The left hip arthroplasty hardware is seen without evidence of
hardware complications. Surgical staples are seen projected onto
the left lateral pelvis. The visualized portion of the lower
lumbar is unremarkable. The sacroiliac joints are grossly
intact. There are degenerative changes of the hips with marginal
osteophytosis on both sides, right slightly more prominent than
left. There is underlying vascular calcification.
IMPRESSION: No acute fracture or dislocation. Uncomplicated
appearance of the left hip arthroplasty.
CT Head w/o contrast [**2-17**]:
IMPRESSION: No acute intracranial hemorrhage or fracture.
CT c-spine w/o contrast [**2-17**]:
IMPRESSION:
No acute fracture or malalignment of the cervical spine.
Multilevel
degenerative changes as noted, with a prominent posterior
osteophyte at the level of C5-C6.
RIGHT HUMERUS, TWO VIEWS. RIGHT SHOULDER, TWO VIEWS. RIGHT HAND,
THREE
VIEWS [**2183-2-20**]:
RIGHT SHOULDER: Probable diffuse osteopenia. No fracture or
dislocation
detected involving the right shoulder. A pacemaker type device
is noted.
RIGHT HUMERUS, TWO VIEWS: No fracture is detected involving the
right
humerus. If there is high clinical concern for an elbow injury,
then
dedicated views would be recommended. No obvious elbow
derangement is
detected on these views.
RIGHT HAND, THREE VIEWS: There is diffuse osteopenia. There is
background
osteoarthritis, including narrowing and subluxation at several
MTP joint.
There is diffuse soft tissue swelling. The AP view raises the
question of
slight deformity at the base of the fifth metatarsal -- the
possibility of an occult fracture at the base of the fifth
metatarsal cannot be entirely
excluded. Otherwise, no fracture is detected involving the right
hand.
IMPRESSION:
1. Moderately-severe diffuse osteopenia.
2. Prominent soft tissue swelling about the hand.
3. Subtle deformity base of right fifth metacarpal bone raising
question of a possible occult fracture. Is there point
tenderness in this location? If symptoms persist, consider
followup x-ray in [**6-12**] days to assess for changes about a
potential occult fracture.
4. No fracture or dislocation involving the right shoulder. No
fracture
detected involving the right humerus.
TTE [**2183-2-19**]:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Overall left ventricular
systolic function is mildly depressed (LVEF= 45-50 %) with
infero-lateral hypokinesis. There is no ventricular septal
defect. 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. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
[**2183-2-17**] 8:46 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2183-2-23**]**
Blood Culture, Routine (Final [**2183-2-23**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final [**2183-2-18**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2183-2-18**] @ 9:10 P.M..
[**2183-2-18**] 9:21 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # 265-4109W [**2183-2-17**].
Anaerobic Bottle Gram Stain (Final [**2183-2-20**]):
GRAM POSITIVE COCCI IN CLUSTERS.
CXR [**2183-2-19**]:
FINDINGS: Interval placement of left-sided PICC with tip at the
low
SVC/cavoatrial junction. Transvenous pacing leads in standard
positions.
This is a technically limited evaluation secondary to rotation.
The lungs are
grossly unchanged from prior examination. The cardiac and
mediastinal
contours are stable.
: Interval placement of left PICC with tip ending at low
SVC/cavoatrial junction.
.
Hip Xray [**2183-2-24**]
IMPRESSION
INDINGS: Compared to [**2183-2-17**], there has been little
interval change
in the appearance of a patient status post left
hemiarthroplasty. Allowing
for marked positional differences between two studies, there has
been no
change in the position of the hardware. Joint space narrowing
related to
degenerative change in the right hip. Vascular calcifications
are present.
Sacroiliac joints appear normal. The pubic symphysis is normal.
The sacrum
is obscured by overlying bowel gas.
IMPRESSION: Stable appearance of left hemiarthroplasty without
dislocation.
.
LLE Ultrasound [**2183-2-26**]: No DVT
Brief Hospital Course:
[**Age over 90 **] year old male with history of reported dementia, heard of
hearing, CAD s/p CABG, Afib s/p PPM who recently was admitted to
[**Hospital6 **] for a left hip fracture after fall,
who was found down at his NH. He was initially admitted to the
floor but was found to be intermittently hypotensive and
hypernatremic with a sodium of 160 and was transferred to the
ICU for more acute management. Hypernatremia was treated with
D5W and resolved. The patient was initially continued on
vanc/zosyn for broad spectrum coverage pending culture data.
Patient also had elevated CK/troponins. Initally treated with
heparin gtt which was d/c'ed as on re-evaluation the patient's
troponin elevation was likely secondary to ARF.
The patient was transferred from the ICU to the medicine service
on [**2-20**].
# MRSA Bacteremia: Pt's blood cultures on [**2-17**] noted to grow
MRSA x 2 bottles, culture and blood culture on [**2-18**] also grew
MRSA. Unclear as to the source of the bacteremia, pt did
recently undergo hip replacement however his left hip did not
show any gross evidence of infection, no pnuemonia had been
noted on chest x-rays. Pt was started on Vancomycin on [**2-17**]. Pt
was also started on Zosyn however given the results if the
positive blood cultures it was d/c'd on day #3. TTE did not
reveal any evidence of endocarditis. On [**2-22**], an extensive
discussion was held with the patient's daughter and son
regarding goals of care. The patient's son and daughter did not
want any invasive procedures such as a TEE, IR-aspiration of
fluid around the patient's hip or explantation of the patient's
pacemaker. Given the potential for endocarditis, osteomyelitis,
and pacemaker infection, a 6 week course of Vancomycin was
agreed upon. The patient has a high possibility of becoming
reinfected after his antibiotics are stopped given that he has
hardware in place. While on Vanc, the pt will need weekly
troughs, CBC, and creatinine checked. Due to trough of 6.0 on
Vanc 1 gm daily, Vanc was increased to 1 gram twice daily. His
trough was 19.6, so dose was decreased on day of discharge to
750 mg twice daily (will receive his first dose of this after
discharge). He needs a repeat Vanc trough the AM prior to his
[**2-28**] dose. Goal trough close to 15.
.
# Delirium on underlying mdoerate Alzheimers dementia) [**Doctor Last Name **]
and waxing with multiple etiologies contributing. The patient
had recent hip operation, bacteremia, various hospitalizations
contributing. At times he yells "help,help" and at other times
he is more somnolent and does not answer questions. His delirium
will likely take weeks to resolve. He was followed by geriatrics
consult here. They recommended not restarting his ativan and not
to restart him on paxil (given its anticholinergic properties).
The patient also would benefit from long term placement as prior
to several months ago he had been living independently and he
has now had a significant decline in function. Suspect pt will
not return to his baseline. Pt had been living in an [**Hospital 4382**] facility prior to recent hip fracture. At time of
discharge, pt was more interactive, eating (with 1:1
assistance), but confused and does not know where he is.
.
# Hypotension: The patient was hypotensive on the floor,
possible contribution of hypovolemia and preseptic physiology
given MRSA bacteremia. This resolved with IV fluids. His
atenolol has been restarted, but not his cardizem or imdur.
.
# Hypernatremia - Secondary to free water deficit, calculated at
5.6 liters. Treated with D5W and it resolved. The patient is at
risk for dehydration and readmission for hypernatremia in the
future given his poor po intake. If he is admitted for
dehydration, then PEG placement for fluid purposes will need to
be discussed. At this time, pts family would like to minimize
invasive procedures and defer discussion of PEG placement unless
absolutely necessary.
.
# Acute Renal Failure: Secondary to significant hypovolemia.
Improved with volume resuscitation, good urine output.
Creatinine back to 0.7 at discharge.
.
# Hypoxia, transient: Unclear actual oxygen requirement on the
floor. O2 sat confirmed 97% on 2L NC with ABG on floor prior to
ICU transfer. Repeat CXR without obvious infiltrate or volume
overload. Patient satted well on room air at discharge.
.
# S/p recent left hip fracture - Incision appears c/d/i, but
again, concern for underlying hardware infection/osteo based on
MRSA bacteremia and recent surgery. Pain control with
tylenol/oxyocodone as needed. Staples were removed. Pt will need
to continue lovenox until [**3-11**]. As noted above, pts family does
not want any invasive work up for osteomyelitis diagnosis. Of
note, due to LLE swelling day of discharge, obtained LE
ultrasound which showed no evidence of DVT.
.
# Urinary Retention: After removal of his foley, pt was noted
to have urinary retention. Initially he was straight cathed
every 6 hours, but this began to become traumatic with blood
clots. A foley was replaced. UA negative for infection. Not
receiving any offending medications (not receiving morphine). Pt
has not been receiving his terazosin, which may be contributing
to his retention. After he had his speech and swallow eval,
terazosin was restarted. He should have a voiding trial in 1
week after discharge, which should be enough time for his
terazosin to take effect.
.
# CAD: Initially held BP meds given hypotension. Continued ASA
and statin. Atenolol was restarted once taking po meds. Imdur
can be restarted if pt has room with his BP.
.
# Atrial fibrillation s/p PCM: Continued on ASA, no coumadin
given fall risk. Restarted atenolol once taking po. Cardizem
held and can be restarted if pt becomes hypertensive or
tachycardic.
.
# Diabetes Mellitus II, controlled, without complications: On
sliding scale insulin with lantus 5 U started on day of
discharge. As pt eats more, he likely will have more long acting
insulin needs.
.
# Hard of hearing: Pt can only hear with headphones/microphone.
.
# Hypocalcemia/Hypophosphatemia: Likely Vitamin D depletion.
Given Vit D 50,000 U x1. Would give another dose weekly for 3
more weeks and then daily repletion with [**Telephone/Fax (1) 106706**] U a day.
.
# HTN, benign: Initially held BP meds in setting of hypotension.
Atenolol was restarted once taking po and BP was improved.
Cardizem 120 mg daily and imdur 30 mg daily still on hold given
borderline low blood pressure (systolic in 100s). Cardizem can
be restarted as well as imdur if BP tolerates.
.
# Anemia: Hct was 23-25 while here. B12/folate WNL. Likely
anemia of chronic disease. Pt does have OB+ stool, but brown
loose on exam. He received a PRBC transfusion on [**2-25**]. Hct rose
to 26.1 prior to discharge.
.
# FEN: Per speech and swallow-pt can take soft solids, nectar
thick liquidis, crushed meds, 1:1 supervision; repeat swallow
eval in [**3-12**] weeks at rehab.
.
# Proph: Lovenox SC bid for 1 month following hip fracture (Day
1 approx [**2-8**])
.
# ACCESS: PICC
.
# Code: DNR/DNI, no pressor support or feeding tube placement.
Transfer to ICU OK, but no invasive procedure.
.
# Communication: Daughter [**Name (NI) **] [**Name2 (NI) **] in [**State **]: [**Telephone/Fax (1) 106707**] cell: [**Telephone/Fax (1) 106708**], son-in law: [**Telephone/Fax (1) 106709**] (home),
[**Telephone/Fax (1) 106710**] (cell)
.
Medications on Admission:
per [**Hospital1 1501**] list:
simva 20
ASA 81 chew
ISMN 30mg qd
cardizem CD 120 qd
atenolol 25mg qd
lovenox 30mg qd, plan for 4weeks
terazosin 2mg qhs
paxil 20mg qd
SSI-regular insulin
ativan 0.5mg [**Hospital1 **] prn
tylenol prn
oxycodone 5mg q4prn
vicodin 5/500 prn
colace [**Hospital1 **], dulocolax 10mg qd prn, mOM prn, [**Name2 (NI) **] enema prn
MVI c minerals
ground diet with thin liquids and diabetic supplements
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours): STOP AFTER [**2183-3-11**].
2. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED): For FS of: 150-199 give 2 U,
200-249 give 4 U, 250-299 give 6 U, 300-349 give 8 U, 350-400
give 10 U.
3. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week for 3 doses: First dose to be given [**3-4**] Tuesday.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
10. 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.
11. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Vancomycin 750 mg IV Q 12H
Day #1 [**2183-2-17**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Delirium
MRSA bacteremia
Hypernatremia
Dehydration
Acute urinary retention
Acute renal failure
Discharge Condition:
stable
Discharge Instructions:
You were admitted with delirium (altered mental status), and
found to be dehydrated with high sodium levels. You also were
noted to have acute renal failure which has resolved. You were
found to have a bacteria growing in your blood called MRSA.
.
You will need to complete 6 weeks of antibiotics to cover for
potential infection of your hip as well as your pacemaker. On
discussion with your family, it was decided not to further
pursue a TEE (echocardiogram of your heart by doing a procedure
down your esophagus) or to pursue aspiration of your left hip.
It is possible this antibiotic course will not clear your
infection.
.
Due to retention of urine while holding your terazosin, we had
to place a foley.
.
Your cardizem and imdur have not been restarted yet.
.
Call your doctor or return to the ER for any worsening
confusion, fever, worsening hip pain, chest pain, shortness of
breath, or any other concerning findings.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 104493**] [**Hospital 1411**] medical
Group-[**Telephone/Fax (1) 8506**] after discharge from rehab. Fax:
[**Telephone/Fax (1) 8512**], [**Location (un) 58062**], [**Location (un) 1411**], [**Numeric Identifier 9310**].
.
ICD9 Codes: 5849, 2930, 2760, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7295
} | Medical Text: Admission Date: [**2148-12-8**] Discharge Date: [**2148-12-31**]
Date of Birth: [**2083-12-3**] Sex: M
Service: MEDICINE
Allergies:
Nsaids
Attending:[**Doctor First Name 2080**]
Chief Complaint:
s/p fall, left humeral fracture
Major Surgical or Invasive Procedure:
Central line placement (Left IJ)
History of Present Illness:
65yo male with h/o ESRD on HD, CHF (EF 35%), diabetes, who
presented to OSH s/p mechanical fall. States that he was in his
usual state of health yesterday until he fell after dinner. He
dropped his silverware and went to pick it up, and then fell
over. Denies any CP, SOB, LH, or dizziness before or after
event. Denies head trauma or LOC. Event was unwitnessed however
wife was in other room and came immediately when she heard the
patient fall. Patient was taken to OSH ED by EMS and was found
to have comminuted left humeral fracture. Patient then
transferred to [**Hospital1 18**] for further evaluation.
.
In ED initial VS were 97 70 100/50 18 93% on RA. Ortho
consulted, however surgical intervention was not necessary.
Patient was given IV pain medications and IV zofran. Noted to
have BP in 80s. HCT noted to be 28 and trended down to 26,
however there was no evidence of bleeding. Patient noted to have
potassium of 5.7. Dialysis team aware, and patient taken for
dialysis. Of note, patient had SBP in 60s at dialysis.
.
On encounter in dialysis, patient appeared comfortable at rest,
however was in tremendous pain on movement. Patient denied any
CP or SOB, dizziness, or lightheadedness. On admission to floor,
patient triggered for hypotension.
ROS:
(+) Per HPI, endorses about 170lb weight loss over 1 year
(-) Denies fever, chills and night sweats. Denies headache,
sinus tenderness, rhinorrhea or congestion. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
Diastolic heart failure
Hypertension
ESRD on HD
Morbid obesity
Afib and h/o tachy-brady syndrome s/p pacemaker placement
Diabetes Mellitus
DVT
CVA left frontal [**2136**] - L hemiparesis
Sleep apnea
Restrictive lung disease (thought [**2-20**] body habitus)
Gout
Chronic back pain
Hx of Subarachnoid hemorrhage
Social History:
Married. Works as real estate developer. No tobacco or illicit
drug use. Rare EtOH use, one drink every 2 weeks.
Family History:
Mother deceased secondary to MI age 77, Father deceased
secondary to complications from renal disease.
Physical Exam:
Admission Exam
VS 100.1 64/d 70
GEN: AAOx3, chronically ill appearing, no acute distress
HEENT: EOMI, PERRL, no epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, right tunneled line without erythema or purulence
or tenderness
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: crackles b/l without wheezes
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/ +1 edema b/l, dressing over left elbow with stained
blood, pain in the left humerus.
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Patellar DTR +1.
Plantar reflex downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Labs:
[**2148-12-8**] 04:45AM BLOOD WBC-17.4*# RBC-2.82*# Hgb-9.7* Hct-28.5*
MCV-101* MCH-34.5*# MCHC-34.1 RDW-14.7 Plt Ct-382
[**2148-12-8**] 04:45AM BLOOD Neuts-90.4* Lymphs-6.6* Monos-2.2 Eos-0.6
Baso-0.2
[**2148-12-8**] 04:45AM BLOOD PT-21.6* PTT-31.9 INR(PT)-2.0*
[**2148-12-8**] 04:45AM BLOOD Glucose-195* UreaN-49* Creat-4.7* Na-137
K-5.7* Cl-97 HCO3-29 AnGap-17
[**2148-12-8**] 04:45AM BLOOD VitB12-1012* Folate-14.1
.
Other Labs:
[**2148-12-8**] 05:00PM BLOOD CK(CPK)-37*
[**2148-12-8**] 10:05PM BLOOD ALT-17 AST-21 LD(LDH)-120 CK(CPK)-45*
AlkPhos-75 TotBili-0.2
[**2148-12-9**] 05:06AM BLOOD CK(CPK)-65
[**2148-12-8**] 05:00PM BLOOD CK-MB-2 cTropnT-0.10*
[**2148-12-8**] 10:05PM BLOOD CK-MB-2 cTropnT-0.11*
[**2148-12-9**] 05:06AM BLOOD CK-MB-2 cTropnT-0.13*
[**2148-12-9**] 05:06AM BLOOD Cortsol-25.9*
[**2148-12-9**] 05:06AM BLOOD Digoxin-0.9
[**2148-12-9**] 12:21AM BLOOD Lactate-1.6
.
Discharge Labs:
.
Microbiology:
[**2148-12-8**] Blood cultures: pending, no growth to date
[**2148-12-8**] Urine culture: negative
[**2148-12-9**] Blood culture: pending, no growth to date
.
Imaging:
[**2148-12-8**] EKG: One hundred percent A-V paced. Compared to the
previous tracing of [**2148-1-29**] no diagnostic interval change.
.
[**2148-12-8**] Left Humerus X-ray: Three views of the left shoulder
are slightly limited, though were the best obtainable given the
patient's level of discomfort per the performing radiographic
technologist. Note is made of a subtrochanteric left humeral
fracture with some impaction of the humeral shaft into the
humeral head. There is no evidence of dislocation of the humeral
head. There is no other fracture or dislocation. A cardiac
pacing device is partially imaged
.
[**2148-12-8**] CXR: Moderate right pleural effusion largely fissural
has increased since [**9-17**]. Small left pleural effusion is
unchanged. Right middle lobe is atelectatic, and moderate
cardiac silhouette has increased in size, and there is greater
pulmonary vascularity, but no edema. Transvenous right atrial
and ventricular pacer leads are unchanged in their respective
positions. As before, the dialysis catheter ends in the right
atrium. No pneumothorax. There is no good evidence for
pneumonia.
.
[**2148-12-8**] CXR: There is interval development of new bibasilar
opacities consistent with newly developed aspiration given the
short interval. Asymmetric pulmonary edema would be another
possibility although less likely. The patient is rotated.
Within the limitations of the differences in the position of the
patient, no change in pleural effusion. The cardiomediastinal
silhouette is unchanged.
.
[**12-30**] Shoulder X-ray:
FINDINGS: Central venous access catheter incompletely evaluated.
Dual-lead
pacemaker present. The visualized left lung and ribs are
unremarkable. Joint
space narrowing of the AC joint. No dislocation. Again seen is
the proximal
left humerus fracture of the surgical neck, which extends into
the humeral
head, including the greater tuberosity. There is no significant
change in
healing or alignment. No new fractures.
IMPRESSION: No interval change in left proximal humerus
fracture, as above.
.
[**2148-12-10**] CT Chest w/Contrast:
1. No evidence of hemothorax.
2. Multifocal acute consolidation, most likely bacterial in
nature.
3. Associated mild pulmonary edema.
Brief Hospital Course:
65yo male with DM, ESRD on HD, CHF EF 35%, tachy/brady syndrome
s/p PPM placement, afib on coumadin, CVA w/left sided weakness
who presented s/p fall, was found to have comminuted humerus
fracture, and with hospital course complicated with persistent
hypotension.
.
#. Comminuted Left Humerus Fracture: Patient initially presented
s/p mechanical fall, and was found to have left humerus
fracture. Patient seen by ortho, who do not plan to surgically
intervene at this time. They reccommended conservative
(non-operative) management at this time such as sling and pain
control. Patient also seen by acute pain service, for additional
recommendations regarding pain control. Patient will need to
wear arm in sling/collar, and follow-up with ortho for
re-evaluation, he should schedule this appointment in early-mid
[**Month (only) 404**]. Had follow up X-ray of his fracture shortly before
discharge which showed no change. His pain was controlled with
oxycontin 20mg [**Hospital1 **], tramadol PRN and dilaudid 2-4mg prn. He
usually required only 2-4mg dilaudid a day.
**Team asked patient and rehab to coordinate the follow up appt
with Ortho within 1 month of discharge (mid [**Month (only) 404**]).
.
#. Hypotension: Patient's initial hypotension requiring MICU
admission felt to be due to sepsis, likely secondary to
multifocal pneumonia (HCAP) given CT chest findings. Was on
vancomycin and cefepime for empiric coverage of HCAP, completed
8 day course on [**12-15**]. He then persisted to have hyptension
averaging 70-90 every day and occasionally dropping to 55. He
was afebrile, mentating well, with negative blood cultures. All
anti-hypertensives were stopped. This hypotension was thought to
be multifactorial: fluid shifts during HD, autonomic neuropathy,
chronic CHF, and narcotics. He was sent back to the MICU for
several days to receive CVVH to remove 11kg of fluid. Back on
the floor, he continued to be hypotensive (more so in the
evenings where he would be in the 60s) and he was given albumin
12.5g. If the albumin failed to increase his pressures, he was
given midodrine 5mg. If neither albumin nor midodrine improved
BP to the goal of 70s, he was given 250-500cc NS IVF bolus. His
fluid intake was restricted to 1500cc/day.
**Note: His BP ranges from 70-90s throughout hospitalization. At
night, they frequently fell to 60s. When they are in the
60s-->try albumin 12.5 g once-->if BP still <70s then try
midodrine 5mg once-->if BP still <70s try NS 250-500cc bolus.
Goal BP should be 70s. Pt's organs appear well perfused and he
mentates well at these pressures.
**If pt is mentating well and afebrile, then the hypotension is
unlikely concerning. However, if he does spike a fever of has
altered mental status, then this would need further evaluation
and workup.
.
#. Anemia, multifactorial: 10 point drop in HCT since [**42**]/[**2148**].
Was transfused 2 units PRBCs earlier in his hospitalization.
Etiology of anemia unclear, and it is likely multifactorial:
anemia in setting of ESRD, anemia of chronic inflammation, and
marrow suppression in setting of acute illness as potential
causes. HCT stabalized in the 26 range and pt was asymptomatic.
.
#. ESRD on HD: At home, patient has HD T/Th/Sun (noctural
dialysis over 8 hr stretches which he tolerates well). During
this hospitalization he was given CVVH in the unit to remove
fluid and then daily HD/UF. He alternated: 3 days a week he
would get HD and the alternating 3 days a week he would get
Ultrafiltration with no clearance. He was also given albumin 25g
during HD to improve pressures. Occasionally he was give
midodrine 5-10mg on HD days to improve pressures, if needed. He
was continued on neprhocaps and sevelamer. Pt would likely
benefit from nocturnal HD since his pressures seem well
controlled when he has a longer stretch of slow dialysis versus
boluses 3 times a week. When he eventually goes home, he will
resume nocturnal HD.
**At rehab, he will likely need 3 days of HD (monday, wednesday,
friday) for 4 hours each session. His last HD session was
[**2148-12-30**] and last Ultrafiltration session was [**2148-12-31**]. The
next session will be [**2149-1-1**].
**If pt building up fluid and not near his dry weight, would
reccommend 3 days of UF on non-dialysis days alternating the 3
days of HD. (Ex: HD->UF->HD->UF...)
**He might need albumin 12.5-25.0g (of 25% solution) on days of
dialysis to improve pressures.
**He might benefit from midodrine 5-10mg on days of dialysis to
improve pressures.
**He received HD on Monday [**12-30**], the day of discharge, and
tolerated it well with 25g of albumin and midodrine 10mg.
.
#. Acute on chronic Systolic heart failure (LVEF 35%): Patient
developed pulmonary edema earlier in the hospitalization, in
setting of volume resusictation for hypotension. Pts heart
failure likely contibuting to his hypotension. Lisinopril and
metoprolol were discontinued in the setting of hypotension.
.
#. Afib and h/o tachy-brady syndrome s/p pacemaker: Pt found to
mainly be in normal sinus rhythem. He was given coumadin 1-3mg
daily for goal INR [**2-21**]. Metoprolol was stopped in setting of
hypotension. He was continued on digoxin. INR at time of
discharge was 2.4 and he was written for 2mg daily (up from 1mg
daily the few days prior).
.
#. Hypertension at home: Stopped his home lisinopril and
metoprolol in setting of hypotension. [**Month (only) 116**] resume outpatient, per
cardiologist, if tolerated.
.
#Constipation: Was given aggressive bowel regimen for several
days, including several enemas. He had several small bm and one
medium bm day before discharge. He gets daily colace TID, daily
senna. Prunes are effective. Lactulose PO is also effective. He
was given fleet and soap suds enemas as well as manual
dis-impaction. Pt very concerned about his bowel movements and
wants to make sure if it still addressed at rehab.
**Please continue daily aggressive bowel regimen with patient.
This is very important to him.
.
#. Diabetes Mellitus: Monitored FSBS QID, continued FISS.
Diabetic diet.
.
#. Gout: Continued allopurinol 100mg every other day (renally
dosed).
.
#. h/o CVA with residual left weakness: Continued ASA, statin.
Medications on Admission:
Albuterol 2 puffs Q6H
Allopurinol 150 mg daily
Amiodarone 400 mg daily
Astelin NS 137 mcg 2 sprays [**Hospital1 **]
Bumetanide 4 mg [**Hospital1 **]
Colace 100 mg TID
Warfarin (1, 2.5, 2.5, or 5 mg as directed by coumadin clinic)
Flexiril 10 mg at 3pm, 11pm
Digoxin 125 mcg ([**1-20**] tab QMWFSat)
ASA 325 mg daily
Flovent 2 puffs Q12H
Insulin NPH 34 units QAM and 45 units QPM
Insulin HISS
Lisinopril 2.5 mg QMWFSat
Multivitamin
Metoprolol succinate 50 mg daily
Metrolotion topical
Miralax 17gm daily
Oxybutynin 10mg daily
Percocet 7/500mg 1 tab Q3Pm/Q11pm
Pantoprazole 40 mg daily
Renagel 2400 mg TID
Senna 2 tabs QHS
Simvastatin 40 mg QHS
Spironolactone 25 mg daily (temporarily off)
Tylenol 1500 mg Q3PM/Q11pm
Vitamin D 1000 units daily
Zinc sulfate 220 mg daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO once a day.
2. MetroLotion Topical
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO QMOWEFR (Monday
-Wednesday-Friday).
11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
15. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain.
17. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for breakthrough pain: First try Tramadol. If
no relief, then try Dilaudid.
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): take standing.
19. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to left shoulder 12 hrs on and 12 hrs off every day.
21. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to right shoulder. 12 hrs on and 12 hours off every day.
22. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
23. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
24. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
25. lactulose 10 gram/15 mL Solution Sig: 1000 (1000) MLs PO
ONCE A DAY PRN () as needed for constipation.
26. midodrine 5 mg Tablet Sig: One (1) Tablet PO DAILY PRN DAY
OF DIALYSIS OR SBP<70 () as needed for BP<70: If BP<70, first
try albumin 12.5g (of 25% solution), then try midodrine 5mg.
27. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
28. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain: First try tramadol for breakthrough pain. If
no relief, then try dilaudid.
29. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal [**Hospital1 **] (2 times a day).
30. warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Goal INR [**2-21**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary Diagnoses:
Left humerus fracture
Sepsis
Pneumonia
Hypotension NOS
Secondary Diagnoses:
Systolic congestive heart failure
Anemia
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:
Mr. [**Last Name (Titles) 20197**],
It was a pleasure taking care of you during your stay at [**Hospital1 18**].
You initially presented to the hospital after falling and
fracturing your left shoulder. The orthopedic doctors saw [**Name5 (PTitle) **],
but did not feel you needed surgery. You will need to follow-up
with them in clinic.
While you were here, you had a pneumonia and completed a course
of antibiotics.
You were also found to have low blood pressure. After carefully
watching you for several weeks, it became clear that your new
baseline blood pressure is in the 70-90s range. You tolerated
these pressures very well and remeained asymptomatic. Your low
blood pressure was attributed to several causes: your chronic
heart failure, narcotics, fluid shifts during dialysis and
autonomic neuropathy. Your blood pressure was often improved
after giving you albumin, midodrine and/or fluids.
You were also found to be anemic, and you received a blood
transfusion. Your blood counts remained stable after the
transfusion.
We made the following changes to your medications:
For gout,
-DECREASED allopurinol dose to 100mg every other day
For pain,
-STOPPED your home percocet
-STARTED Oxycontin 20mg twice a day (a long acting narcotic)
- STARTED dilaudid (a shorter-acting pain medication)
- STARTED Tramadol (another short acting medication)
For your low blood pressure,
-STOPPED metoprolol (because your blood pressure was very low)
-STOPPED Lisinopril (because of your low blood pressures)
- STOPPED Spironolactone (because of your low blood pressures)
-STOPPED Bumetanide
-Changed Digoxin 125 ([**1-20**] tab) M,W,F, Sat--> M,W,F (no longer
taking on saturdays)
.
Please continue to take your other medications. Please follow
up with your primary care doctor shortly after leaving rehab.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
-Schedule an appt with your primary care doctor within 1 week of
discharge
**Department: ORTHOPEDICS
When: CALL TO SCHEDULE AN APPOINTMENT WITHIN 1 MONTH ([**Month (only) 404**],
[**2149**])
[**Telephone/Fax (1) 1228**]
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2149-2-19**] at 3:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9091**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 0389, 486, 5856, 4280, 2859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7296
} | Medical Text: Admission Date: [**2123-4-8**] Discharge Date: [**2123-4-22**]
Date of Birth: [**2045-11-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Meningioma causing inability to walk.
Major Surgical or Invasive Procedure:
Angiogram.
Craniotomy for meningioma resection.
History of Present Illness:
This is a 77 yo RH woman who's primary language is Russian, who
presents after obtaining and MRI at OS facility showing
worsening swelling, enlarging tumor.
She was diagnosed with a parasagittal meningioma in [**2115**], and
underwent cyberknife radiosurgery from [**2122-10-19**] to [**2122-10-23**]. She
was maintained on dexamethasone, but this was weaned off in [**Month (only) **].
[**2122**]. Her dex treatment was complicated by steroid myopathy as
outlined by Dr. [**Last Name (STitle) 724**]. (I do not see any EMG/NCS report in our
system). Over the past several months patient has noticed
progressive worsening of her gait requiring a walker. Over the
past two weeks has barely been able to ambulate at all, has had
increased frequency of falls (most recently last night when
getting up to go to the BR during the night, no LOC). She has
trouble lifting the legs, right worse than left, and some
dragging of the right foot. She does have troubles with her arms
- she had a left rotator cuff tear and has lots of pain in the
left shoulder for the past 2-3 months. She denies headache,
nausea, vomiting. She denies urinary or bowel incontinence. She
complains of nonrhythmic shaking of the RUE, that is somewhat
suppressible but not entirely, not thought to be seizures per
Dr. [**Last Name (STitle) 724**]. The shaking fluctuates, and has been present for the
past 6 months or so, and currently is not "that severe" (appears
to be a low amplitude tremor). Yesterday she had some teeth
pulled (and will need stitches out in 7 days) but otherwise she
has been in good health.
She obtained MRI brain today, and it showed increasing size of
tumor, thus she was told to come to the ED for admission. After
discussion with Dr. [**Last Name (STitle) 724**], it seems as though she does better
when on dex, but then worsens the steroid myopathy. When off
dex, her gait/leg weakness worsens. She is now at a point where
she and family are considering surgery.
Past Medical History:
Parasagittal meningioma as above
HTN
Glaucoma
Right wrist fracture
Recent dental tooth extraction
Left rotator cuff repair
Pelvic prolapse repair
Cataract extraction
Social History:
Originally from [**Location (un) 3156**], lives w/husband (who recently had a
mild stroke) in [**Location (un) **]; one son, no [**Name2 (NI) **]/etoh/drugs. Not
working, no prior career.
Family History:
No illnesses per patient
Physical Exam:
VITALS: 68, 132/79, 14, 98%RA
GEN: obese elderly woman laying in stretcher, NAD
SKIN: multiple bruises on her legs
HEENT: NC/AT, anicteric sclera, mmm
NECK: supple
CHEST: normal respiratory pattern, CTA bilat
CV: regular rate and rhythm with+ systolic murmur
ABD: soft, nontender, nondistended, +BS, no HSM
EXTREM: left leg is swollen (recent US [**2-22**] shows no clot)
NEURO:
Mental status:
Patient is alert, awake, pleasant affect.
Oriented to person, place, time.
Good attention - does well with MOYB but is a bit slow. Has
some trouble following commands mostly due to language barrier.
Is able to follow 2 step commands. Language is fluent with good
comprehension, repetition, no dysarthria.
No apraxia, no neglect. Able to calculate, no left/right
mismatch.
Cranial Nerves:
I: deferred
II: Visual fields: mildly constricted in all fields.
Fundoscopic exam: no papilledema. Pupils: 4->2 mm, consensual
constriction to light.
III, IV, VI: EOMS full, gaze conjugate. No nystagmus or
ptosis.
V: facial sensation intact over V1/2/3 to light touch and pin
prick.
VII: symmetric face
VIII: hearing decreased to finger rubs
IX, X: Symmetric elevation of palate.
[**Doctor First Name 81**]: unable to test due to pain
XII: tongue midline without atrophy or fasciculations.
Sensory: Has decreased proprioception right big toe to only
large movements, decreased vibration right toe only as well.
Decreased pin over the swollen area in the left ankle/calf. No
sensory level anteriorly. No extinction to double simultaneous
stimulation.
Motor:
Diffuse muscle wasting, slightly increased tone bilateral legs
with some paratonia. No fasciculations. Unable to test drift
due to shoulder pain left. Mild postural tremor RUE (or so it
appears as it gets worse with posture). No asterixis. Strength:
Neck flexor weakness, neck extensors are full.
weakness is greatest in the proximal legs, right worse than
left, and right foot drop. Also weak proximal right arm. Left
arm limited by weakness.
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF Toe
RT: 4 4+ 5 5 5 4 5 3 5 4? 3 5 x
LEFT: x x x 5 5 4+ 5 4 5 4? 4 4 x
x = untestable, due to pain
? = some give way, some inability to fully understand the
command.
Reflexes:
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 2 2 2 2 0 down
LEFT: 2 2 2 2 0 down
Coordination:
Normal finger-to-nose, heel-to-shin not tested, normal RAMs.
Gait: not tested patient refused.
Pertinent Results:
[**2123-4-8**] 04:50PM BLOOD WBC-9.9 RBC-4.15* Hgb-12.4 Hct-37.3
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.8 Plt Ct-377
[**2123-4-8**] 04:50PM BLOOD Neuts-65.5 Lymphs-28.9 Monos-4.5 Eos-0.8
Baso-0.2
[**2123-4-8**] 04:50PM BLOOD PT-12.1 PTT-19.2* INR(PT)-1.0
[**2123-4-9**] 06:58AM BLOOD Glucose-113* UreaN-21* Creat-0.9 Na-143
K-3.8 Cl-108 HCO3-23 AnGap-16
[**2123-4-9**] 06:58AM BLOOD ALT-14 AST-18
[**2123-4-9**] 06:58AM BLOOD Calcium-9.0 Phos-5.5* Mg-1.9
[**2123-4-9**] 06:58AM BLOOD TSH-0.87
-----
Shoulder X-ray: IMPRESSION: Probable neuropathic joint of the
left shoulder
-----
CXR: Normal
-----
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 104045**],[**Known firstname **] [**2045-11-7**] 77 Female [**Numeric Identifier 104046**]
[**Numeric Identifier 104047**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd
SPECIMEN SUBMITTED: Bifrontal tumor biopsy, left side tumor
nodule, parasagittal tumor resection
Procedure date Tissue received Report Date Diagnosed
by
[**2123-4-15**] [**2123-4-15**] [**2123-4-16**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/jtj??????
************This report contains an addendum***********
PRELIMINARY DIAGNOSIS:
#1, BIFRONTAL TUMOR BIOPSY (including intraoperative smear #1):
MENINGIOMA with prominent nucleoli, sheeting, and nuclear
pleomorphism.
See note.
#2, LEFT TUMOR NODULE (including intraoperative smear #2 and
frozen section #2):
Await processing. Final diagnosis to be issued in an addendum.
#3, PARASAGITTAL MASS RESECTION:
Await processing. Final diagnosis to be issued in an addendum.
NOTE: Although the sample in part 1 has some atypical features,
formal grading of the meningioma awaits permanent sections on
the remaining submitted material. The final diagnosis will be
issued in an addendum.
FINAL DIAGNOSIS:
#1, BIFRONTAL TUMOR BIOPSY (including intraoperative smear #1):
MENINGIOMA with prominent nucleoli and nuclear pleomorphism.
#2, LEFT TUMOR NODULE (including intraoperative smear #2):
MENINGIOMA with prominent nucleoli, spindle cell component,
recent/early organizing geographic necrosis, and nuclear
pleomorphism.
#3, PARASAGITTAL MASS RESECTION:
MENINGIOMA with spindle cell and transitional components,
prominent nucleoli, focal edema, and nuclear pleomorphism.
NOTE:
This tumor has several worrisome features, including its
prominent nucleoli and nuclear pleomorphism. In many fields in
the third specimen, the tumor consists of a spindle-cell
neoplasm, reminiscent of a solitary fibrous tumor. These fields
are interrupted by areas of diagnostic transitional meningioma
histology. In some regions, the spindle cells have anaplastic
nuclei, although in most areas they are bland. The transitional
component becomes hypercellular focally and shows prominent
nucleoli and pleomorphism, although mitotic figures remain rare.
Brain is present in one block but no brain invasion is
identified.
Because this tumor had previously been treated with both
radiation and embolization, it can no longer be accurately
graded by formal WHO criteria. Some high-grade features could be
a result of either the tumor grade or the effects of treatment.
The paucity of mitotic figures may not reflect this tumor's
actual growth potential because of these effects. However, the
focal hypercellularity and pleomorphism, together with the
prominent nucleoli, suggest this tumor may be biologically more
aggressive than a grade I meningioma.
Additional immunoperoxidase studies are pending; the results
will be issued in an immunoperoxidase addendum.
Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/jtj??????
Date: [**2123-4-21**]
Clinical: Bilateral meningioma. Status post CyberKnife radiation
therapy ([**2122-10-20**]) and embolization ([**2123-4-14**]).
Gross:
The specimen is received in three parts labeled with the
patient's name, "[**Known lastname **], [**Known firstname **]" and the medical record number.
Part 1 is further labeled "bifrontal tumor, frozen section". The
specimen is received fresh in the OR. A small portion is used to
prepare an intraoperative smear. The intraoperative diagnosis by
Dr. [**First Name (STitle) 122**] reads:
"Bifrontal tumor (smear):
Meningioma with prominent nucleoli and pleomorphism (some
atypical features).
Final diagnosis pending permanent sections".
The specimen consists of multiple small pieces of soft tan-pink
tissue measuring 1.0 x 0.4 x 0.3 cm in aggregate. The specimen
is submitted entirely in A.
Part 2 is additionally labeled "left side tumor nodule" and
consists of a firm tan white lobulated soft tissue mass
measuring 2.3 x 1.4 x 1.0 cm. Representative sections are
submitted for smear and frozen section. The intraoperative
diagnosis by Dr. [**First Name (STitle) 122**] reads:
"#2, Left side tumor nodule (smear #2, FS#2):
Consistent with meningioma with necrosis.
Final diagnosis pending permanent section."
The specimen is represented as follows: B = frozen section
remnant, C = additional representative sections.
Part 3 is additionally labeled "parasagittal tumor" and consists
of a firm tan pink lobulated soft tissue mass measuring 4.8 x
2.9 x 2.5 cm. The specimen is serially sectioned to reveal both
smooth tan white glistening and tan white focally fibrotic and
hemorrhagic appearing cut surfaces. The specimen is represented
in D-G.
Brief Hospital Course:
77 yo RH female with h/o HTN, glaucoma, and known parasagittal
meningioma s/p cyberknife 5 months ago who returned after an MRI
showed growth of tumor. She has clinically had much more
difficulty walking and has had several falls as a result. This
is likely due to her tumor and edema. She is not a risk free
candidate for surgery given the location of her tumor and its
proximity to the superior sagittal sinus. She was severely
impaired by the tumor at this point however, so her options were
limited. The neurosurgery team met with the patient and her
family and discussed the significant risk associated with this
procedure. They understood and decided to go forward with the
surgery after some consideration.
She was initially given dexamethasone given the swelling of the
tumor, however, this was not continued in the hospital due to
concern that it might impair healing and increase her chances of
infection with surgery.
She was continued on her home dose of Keppra 125 mg [**Hospital1 **] which
she is on for "dizziness" per prior clinic notes. Her Avapro and
diamox were also continued at her home doses. Her Lasix was
stopped, but her nadolol was continued. This is because her BP
was on the low side and we preferred to have her on a
beta-blocker peri-operatively.
In preparation for the procedure, she had an cerebral angiogram
(arteriogram and venogram) by Dr [**Last Name (STitle) **] on [**2123-4-14**] for tumor
vasculature embolization, they were able to embolize 60-70% of
the vasculature. She is taken to operating room for right
craniotomy for resection of parasagittal meningioma on [**2123-4-15**]
under general anesthesia. She was transferred to neurosurgery
thereafter. She transferred to neuro ICU for close hemodynamic
and neurologic monitoring. There no intra operative
complications occurred. Estimated blood loss during surgery is
500cc.
She remained intubated on postoperative day one, she had a
episode of seizure on postoperative day, in addition to Keppra,
added dilantin, on postop day one Keppra increased to 1000 mg
[**Hospital1 **] ultimately to 1500 [**Hospital1 **] for adequate seizure coverage.
Postoperative Head CT revealed status post large parafalx
meningioma removal with minimal postoperative hemorrhage is
present. Postoperative intracranial air and vasogenic edema is
unchanged. Neurologically she is opening her eyes to voice, able
squeeze on the left upper extremity, no movement on the right
upper and bilateral lower extremities to command or noxious
stimuli on postop day one.
Patient kept on high dose dexamethasone postoperatively due to
vasogenic edema, and kept on 100% FiO2 for postop pneumocephalus
for 24 hours . Postoperative MRI suggests status post resection
of parasagittal meningioma with small area of residual
enhancement is seen in the left parasagittal region. Blood
products are seen at the surgical site with several venous
collaterals secondary to resection of superior sagittal sinus.
No acute infarct is seen.
She successfully extubated on [**4-16**].
Patient started moving(able to wiggle) her left upper and lower
extremities to command on [**2123-4-18**] am left was stronger than
right side, and was more alert. Dr [**Last Name (STitle) 724**] seen her while
inpatient, she will be seen again in brain tumor clinic 2 weeks
from surgery, will be remain on dexamethasone 4mg a day until
then.
Patient developed worsening edema of both hands bilaterally [**4-19**]
and her fluid balance was positive 1-2L.Her IVF stopped and
started on Lasix for diuresis with improvement of edema and
achieved evolumia. Noted to have decreased urine output
overnight and appeared dry, was then restarted on IV fluids with
adequate urine output.
On exam on [**4-20**] was noted to have persistent UE edema localized
to both hands. Moving all four extremities- can grip and move
arm a few inches on left UE, finger movement only on R unable to
grip. Withdraws to pain Right LE, moves Left LE voluntarily.
Patient reports normal sensation x4. Persistent Left UE focal
motor seizure most notable at shoulder and hand. Alert and
oriented x 2 (did not know the year "199?"). Continued on Keppra
1500 mg [**Hospital1 **] and Phenytoin 100 TID. Weaning Dexamethasone to goal
of 4mg daily maintenance dose until seen in Brain tumor clinic.
Her official pathology result is MENINGIOMA with spindle cell
and transitional component(see details in pertinent result
section in this summary).
She has been seen by PT/OT daily basis, felt to be she needs
acute rehabilitation.
Patient discharged to rehab with follow up and discharge
instructions.
Medications on Admission:
avapro 150mg daily
diamox 250 daily
keppra 125 [**Hospital1 **]
colace 100 [**Hospital1 **]
timolol gtt
zofran prn
protonix [**Hospital1 **]
?detrol?
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Nadolol 20 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.
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Injection TID (3 times a day).
8. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days: last dose 5/9.
13. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): start [**4-27**] continue until seen in Brain tumor clinic.
14. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Parasaggital meningioma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Monitor insicion site for drainage, redness, or sweling. Report
any fever greater than 101.5, or any other neurologic symptoms
that may be concerning.
Followup Instructions:
Follow up in Brain tumor clinic on [**2123-5-10**] at 15:00. Brain tumor
clinic phone number is [**Telephone/Fax (1) 1844**].
Sture removal in Dr[**Name (NI) 9034**] office on [**2123-4-28**] at 09:00. Dr [**Doctor Last Name **] office number is [**Telephone/Fax (1) 2731**].
Completed by:[**2123-4-22**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7297
} | Medical Text: Admission Date: [**2128-10-3**] Discharge Date: [**2128-10-6**]
Date of Birth: [**2128-10-3**] Sex: M
Service: NEONATOLOGY
DATE OF TRANSFER: [**2128-10-6**].
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 50835**] is a 4595
gram 37 and [**2-3**] week EGA male infant born by spontaneous
vaginal delivery to a 36 year old gravida III, para 0-I.
Pregnancy complicated by mild pregnancy induced hypertension
and gestational diabetes mellitus. The baby delivered by
cesarean section for macrosomia and the infant emerged with
good cry, Apgar nine at one minute and nine at five minutes.
In Newborn Nursery noted to have blue hard testicle.
PRENATAL SCREENS: The mother is O positive, antibody
negative, RPR nonreactive, GSB unknown.
PHYSICAL EXAMINATION: Large for gestational age pink, well
perfused nondysmorphic male, anterior fontanelle flat,
positive red reflex, palate intact and clear. Breath sounds
normal, S1 and S2, no murmur. Pulses full. Abdomen is soft,
no hepatosplenomegaly. Normal phallus, right testicle blue,
swollen and firm and left testicle normal to palpation. Anus
patent. No click. The patient moves all extremities, normal
tone and reflexes.
HOSPITAL COURSE:
1. The infant had a urology consultation and was transferred
to [**Hospital3 1810**] for ultrasound and exploration.
Ultrasound confirmed absence of blood flow to the right
testicle. The baby was transferred to the operating room for
right orchiectomy and left orchidopexy, both without
complication under general anesthesia. The infant returned
extubated and with an uneventful postoperative course. He
rquired supplemental O2 for several days after extubation.
2. Respiratory - The infant required nasal cannula oxygen
until [**2128-10-5**], when he transitioned to room air at 5:00 p.m.
This was thought to be related to retained fetal lung fluid
and/or recovery from anesthesia. The baby is currently in
room air with bilateral breath sounds that are clear and
equal with no respiratory distress. Baseline respiratory
rate is in the 30s to 50s.
3. Cardiovascular - The baby has had no murmur with baseline
heart rate in the 90s to 120s. Blood pressure has been
stable and he has had no cardiovascular issues.
4. Fluids, electrolytes and nutrition - The baby was made
NPO, and received maintenance intravenous fluid, returned
from the operating room once awake, begin ad lib feeding and
is ad lib breast feeding without incident. The baby is
voiding and stooling.
5. Genitourinary - The incision line is healing and Dr.
[**Last Name (STitle) **] is the surgeon who performed the orchiectomy with plan
for follow-up in one month, telephone [**Telephone/Fax (1) 50836**]. Mother
will call for a follow-up appointment. They have been in
touch with Dr. [**Last Name (STitle) **] directly.
6. Gastrointestinal - The infant has exhibited some
physiologic jaundice. Peak bilirubin on [**2128-10-6**], was
19/0.4. The baby was placed under two spot lights and a
blanket. Repeat bilirubin at 4:00 p.m. on [**2128-10-6**], after
being under triple phototherapy was 16.2/0.3, 15.9. The
patient was then placed under double phototherapy with the
plan to transfer to Newborn Nursery where they will obtain
another bilirubin on [**2128-10-7**], a.m.
7. Hematology - The baby did not require any blood products
during this admission and has had no hematocrit drawn.
8. Infectious disease - There were no infectious disease
issues. The infant has not received any antibiotics.
9. Neurology - The baby is appropriate for gestational age.
10. Sensory - Audiology screening has not been performed at
the time of this dictation.
11. Ophthalmology - Examination is not indicated. The baby
is greater than 32 weeks.
12. Psychosocial - Mother and her partner [**Name (NI) 29633**] have been
visiting and were appropriately concerned about a trip to the
operating room and look forward to transitioning home.
CONDITION AT TIME OF TRANSFER: Stable.
DISCHARGE DISPOSITION: To Newborn Nursery.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6537**], [**Telephone/Fax (1) 50837**].
DISCHARGE INSTRUCTIONS:
1. Feedings at discharge - Continue ad lib breast feeding.
Parents are informed the baby should have six to eight wet
diapers within a 24 hour period and may need to supplement
with formula if not adequate output.
2. Medications - None at the time of transfer.
3. Immunizations Received - None at the time of transfer.
4. State Newborn Screen - To be done in Newborn Nursery.
5. Immunizations Recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants
who meet any of the following three criteria:
a. Born at less than 32 weeks.
b. Born between 32 and 35 weeks with plans for Day Care
during RSV season, with a smoker in the household or with
preschool siblings.
c. With chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
FOLLOW-UP APPOINTMENTS: With primary pediatrician per
routine. With Dr. [**Last Name (STitle) **], urology, at [**Hospital3 1810**] in
one month as stated above.
DISCHARGE DIAGNOSES:
1. Status post testicular right torsion with surgical
repair.
2. Hyperbilirubinemia.
3. Mild respiratory distress, probably transient tachypnea
of the newborn.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 36251**]
MEDQUIST36
D: [**2128-10-6**] 19:06
T: [**2128-10-6**] 20:12
JOB#: [**Job Number 50838**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7298
} | Medical Text: Admission Date: [**2145-7-7**] Discharge Date: [**2145-7-10**]
Date of Birth: [**2066-8-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
Esophagoduodenoscopy.
History of Present Illness:
78 year-old man with history of DM2, NASH/cirrhosis, known
esophogeal varices, and no prior GI bleeds presents with coffee
ground emesis. Per his son, he has been doing well and was in
his USOH until this morning when, after taking his medications
with some tomato juice, he had sudden onset of coffee-ground
emesis with dark blood. EMS was called and he was brought to the
ED. Upon arrival, initial VS were 98.5 115/52 85 20 98%RA and
had repeated episode of coffee-ground emesis. An NG lavage was
performed and after aspiration of coffee grounds and dark red
blood, his gastric contents cleared with 500cc NS. He was also
noted to have a melanotic bowel movement. He was started on an
octreotide and PPI drip and given 2L IVF and ciprofloxacin 400
mg IV x 1. Because his initial K+ was 6.7, he was also given
calcium gluconate, insulin, and dextrose. Liver was consulted
and he was admited for urgent scoping. He remained
hemodynamically stable while in the ED.
.
On arrival to the MICU, his VS remained stable and he was
comfortable with no complaints. Recent history is notable for
the absence of fevers, chills, sick contacts, nausea, vomiting,
diarrhea, CP, and SOB.
.
While in the ICU, he had an EGD that showed some esophageal
varices. Three bands were placed during the scope. He never
received a transfusion. He had some melena during the day, but
again, his Hct stayed stable around 27-28. His IV PPI was
switched from a gtt to [**Hospital1 **], his diet was advanced. He was never
hemodynamically unstable.
.
Currently, he is feeling well. He continues to have some melena.
He is tolerating a real diet now, no nausea or vomitting or
abdominal pain. He does not feel lightheaded or dizzy when
sitting up of transferring from the bed to the commode.
.
Past Medical History:
1. DM type 2
2. HTN
3. NASH: cirrhosis c/b mild encephalopathy and ascites
4. h/o nonocclusive portal vein thrombosis: [**2137**]
5. Esophogeal varices (grade 2, last EGD [**6-2**])
6. dCHF (LVEF 55% IN [**12-4**])
7. Depression
8. Obesity/OSA: not on CPAP
9. Diastolic CHF, LVEF >70% 2/06
10. Wenckebach AV block s/p pacemaker
11. Hypercholesterolemia
12. s/p laminectomy L3-L4, L4-L5, L5-S1 and exploration of the
left
L5-S1 disc space on [**2142-1-16**] by Dr [**Last Name (STitle) 739**] for treatment of
lumbar stenosis with radiculopathy
13. Psoriasis
Social History:
Retired sixth grade teacher. Lives with his wife and son. Smoked
2ppd, quit 8 years ago per his report; has at least a 100
pack-year history. Previously a social drinker, no alcohol use
since diagnosed with NASH.
Family History:
No history of liver disease of blood clotting or bleeding
diathesis.
Physical Exam:
T 98.6, BP 133/43, HR 90 (paced), R 19, 92% on RA
Gen: NAD
HEENT: anicteric, EOMI, PERRL, OP clear w/ dry MM, no JVD
CV: reg s1/S2, [**1-1**] SM
Pulm: symmetric to percussion, soft expiratory wheezes b/l, some
mild bibasilar crakcles
Abd: obese, +BS, soft, non-tender, ND; no spider angiomas or
caput medusae
Ext: warm, 2+ DP B/L, 2+ LE edema b/l
Neuro: a/o x 3, CN 2-12 intact, [**3-30**] UE/LE strength
.
Pertinent Results:
EKG [**2145-7-7**]: ventricularly paced, rate 83 bpm
.
CXR [**2145-7-7**] (my read): poor quality study, poor inspiratory
effort, no clear infiltrates
.
EGD [**2145-7-7**]:
Esophagus: Protruding Lesions 3 cords of grade II varices were
seen starting at 30 cm from the incisors in the gastroesophageal
junction and lower third of the esophagus. No blood in esophagus
or stomach or duodenum. Two red linear erosions on one varix. 3
bands were successfully placed.
.
Stomach: Mucosa: Granularity, erythema, congestion, petechiae
and nodularity of the mucosa were noted in the fundus and
stomach body. These findings are compatible with moderate portal
hypertensive gastropathy.
.
Duodenum: Normal duodenum.
.
Impression: Varices at the gastroesophageal junction and lower
third of the esophagus (ligation); Granularity, erythema,
congestion, petechiae and nodularity in the fundus and stomach
body compatible with moderate portal hypertensive gastropathy;
Otherwise normal EGD to second part of the duodenum
.
ADMISSION LABS:
[**2145-7-7**] 02:45PM BLOOD WBC-7.8 RBC-3.46* Hgb-10.8* Hct-34.1*
MCV-99* MCH-31.2 MCHC-31.6 RDW-13.8 Plt Ct-152
[**2145-7-7**] 02:45PM BLOOD Neuts-89* Bands-0 Lymphs-6* Monos-3 Eos-1
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2145-7-7**] 02:45PM BLOOD PT-16.1* PTT-23.4 INR(PT)-1.4*
[**2145-7-7**] 02:45PM BLOOD Glucose-252* UreaN-64* Creat-1.6* Na-137
K-6.7* Cl-105 HCO3-27 AnGap-12
[**2145-7-7**] 02:45PM BLOOD ALT-37 AST-58* AlkPhos-134* TotBili-1.0
[**2145-7-7**] 07:20PM BLOOD Calcium-9.1 Phos-2.5* Mg-1.8
[**2145-7-7**] 02:39PM BLOOD K-6.2*
[**2145-7-7**] 02:39PM BLOOD Hgb-11.7* calcHCT-35
DISCHARGE LABS:
[**2145-7-10**] 07:40AM BLOOD WBC-6.1 RBC-3.02* Hgb-9.4* Hct-29.9*
MCV-99* MCH-31.3 MCHC-31.6 RDW-14.3 Plt Ct-120*
[**2145-7-10**] 07:40AM BLOOD PT-15.5* PTT-29.2 INR(PT)-1.4*
[**2145-7-10**] 07:40AM BLOOD ALT-30 AST-34 LD(LDH)-243 AlkPhos-95
TotBili-1.0
[**2145-7-10**] 07:40AM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.5 Mg-1.7
Brief Hospital Course:
75 year-old man with history of DM2, NASH/cirrhosis, known
esophogeal varices, and no prior GI bleeds presents with coffee
ground emesis on [**7-7**], admitted to MICU for management of upper
GI bleed, s/p scope with 3 bands placed. Hemodynamically stable
with no hct drops.
.
# GI bleed: Likely source of bleeding is esophogeal varices or
portal gastropathy though no active bleeding seen on endoscopy.
Status post ligation of varices with evidence of some erosion.
Hematocrit is stable at 29 down from baseline of 40 with no
evidence of continued blood loss. No evidence of significant
coagulopathy. Patient did not need blood transfusion. He was
initially placed on octriotide drip which was D/c post banding.
Patient has done well and is stable to go home. He will need a
repeat EGD in 4 weeks to check on the varices
-Cipro 500mg twice daily until [**2145-7-11**] for SBP ppx due to GI
bleed for total of 5 days
-Sulcralfate 1gm four times per day until [**2145-7-19**]
-Started on pantoprazole 40mg twice daily
-stopped ASA because of the bleeding
.
# NASH/cirrhosis: He is followed by Dr. [**Last Name (STitle) 497**]. He has esophogeal
varices as described above. No evidence of encephalopathy.
- restarted lasix on day prior to discharge at 80mg Qday since
pt c/o SOB when walking to the bathroom
- Holding spironolactone for now, would restart once creat
started to trend down. He was sent home on Aldactone 100 mg
Qday.
- continue rifaxamin
.
# Chronic kidney disease: sl increase in Creatinine to 1.9 from
his baseline of 1.6. He will need to have outpatient follow-up.
- renally dose meds
- renal diet
- restarted the lasix and on spirolactone as noted above
.
# Diastolic heart failure: Appears well compensated currently
though reports dyspnea on exertion at home. He had improving
pleural effusions on cxray. Initially holding lasix and
spirolactone due to increase in creatine which was restarted
prior to him being discharge. Continue on lasix 80mg Qday and
spirolactone 100mg Qday as noted above.
.
# Hyperkalemia: Had potassium of 6.7 on presentation and history
of modestly elevated potassium, with multiple measurements > 6.
No EKG changes and s/p calcium gluconate/insuline in ED. Has
improved s/p kayexcelate, unclear why so high as no new renal
failure. K was 4.4 at time of discharge.
.
.
# DM type 2: controlled w/ lantus and insulin sliding scale.
- insulin SS
- holding aspirin in setting of bleed, would not restart for a
while as is only preventative and does not have known CAD.
.
# FEN: on regular diabetic diet tolerating well
.
# Prophylaxis: pneumoboots, PPI
.
# CODE: Full code, discussed with patient
.
# Communication: Son, [**Name (NI) **] [**Name (NI) 58007**] [**Telephone/Fax (1) 110922**] (h)
.
Medications on Admission:
Medications at home:
Aldactone 100mg po daily
Insulin: Lantus 32u sq at bedtime; regular insulin sliding scale
Lasix 80 mg po qd
Paroxetine 20mg po daily
Welchol 625mg tabs, 3 tablets [**Hospital1 **]
?Ranitidine 150mg po [**Hospital1 **]
Vitamin D 1000u qd
Aspirin 81 po daily
Rifaxamin 600 mg [**Hospital1 **]
.
Medications on Transfer:
Octreotide gtt
Protonix 40 mg IV BID
Sulcralfate 1 gm PO QID
Cipro 400 mg IV q12hr
Rifaximin 600 mg [**Hospital1 **]
Insulin sliding scale
Paroxetine 20 mg daily
* holding aspirin, aldactone, lasix for now
.
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 9 days: until [**7-19**].
Disp:*36 Tablet(s)* Refills:*0*
2. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
3. Paroxetine HCl 20 mg 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 Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: until [**7-11**].
Disp:*3 Tablet(s)* Refills:*0*
6. Lantus 100 unit/mL Cartridge Sig: Thirty Two (32) units
Subcutaneous at bedtime.
7. Insulin Regular Human 100 unit/mL Cartridge Sig: As directed
Injection four times a day: Per sliding scale.
8. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. Aldactone 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. WelChol 625 mg Tablet Sig: Three (3) Tablet PO twice a day.
11. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary: UGI bleed
esophageal varices
NASH cirrhosis
Secondary:
Diastolic CHF
HTN
DM type II
Discharge Condition:
Vitals stable, no further bleeding.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for coffee ground emesis. You had an
endoscopy where they banded 3 of your esophageal varices. We
also started you on some medications to proctect you from
further bleeding or having an infection. You did well and did
not need to have a blood transfusion.
We have made the following changes to your medications:
-Cipro 500mg twice daily until [**2145-7-11**]
-Sulcralfate 1gm four times per day until [**2145-7-19**]
-Started on pantoprazole 40mg twice daily
-stopped ASA because of the bleeding
Please make sure to follow-up with your doctor's appointments as
listed below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Call your doctor or come to the emergency room if you vomit any
coffee ground fluid, if you have tar black stools or bloody
stools, chesp pain, worsening shortness of breath, temperature >
101.3, chills, or for any other concerns:
Followup Instructions:
Follow-up with your PCP in the next 1-2 weeks.
Please keep the following appointment:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2145-8-13**] 3:40
You will also need a repeat EGD in 4 weeks to check on the
varices.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
ICD9 Codes: 5715, 4280, 5859, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7299
} | Medical Text: Admission Date: [**2143-10-29**] Discharge Date: [**2143-11-11**]
Date of Birth: [**2068-2-3**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 75-year-old white male has
a history of coronary artery disease, chronic renal
insufficiency, and anemia, and had been complaining of
shortness of breath. He presents to an outside hospital in
pulmonary edema. He denied chest pain. He had a 68% sat on
room air, and his respiratory rate was 38. He received
Lopressor, Lasix, nitroglycerin drip, and Heparin drip, and
was intubated. His EKG revealed ST depressions in V4 through
V6, and he is transferred here to [**Hospital1 190**] for further management.
PAST MEDICAL HISTORY:
1. History of anemia.
2. History of peripheral vascular disease.
3. History of coronary artery disease; he had a positive
stress test in [**March 2143**] and had a cardiac catheterization in
[**2138**], and an echocardiogram in [**3-25**] which revealed
concentric left ventricular hypertrophy, normal left
ventricular size and function with an EF of 60%, moderate
aortic insufficiency, a thickened mitral valve with
mild-to-moderate MR, LA enlargement, and moderate pulmonary
hypertension.
4. He also has a history of chronic renal insufficiency with
a baseline creatinine of 2.4 to 2.6.
5. Hypertension.
6. History of necrotic kidney and only has one kidney.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Xalatan.
2. Cardura 1 mg p.o. q.d.
3. Hydrochlorothiazide 12.5 mg q Monday.......... Friday.
4. Norvasc 10 mg p.o. q.d.
5. Nitroglycerin prn.
6. Aspirin 325 mg p.o. q.d.
7. Imdur 60 mg p.o. q.d.
8. Lipitor 20 mg p.o. q.d.
9. Folate 2 mg p.o. q.d.
10. Vasotec 20 mg p.o. b.i.d.
11. Nadolol 120 mg p.o. q.d.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION: On physical exam, he is an elderly
white male intubated. His temperature was 99.8, heart rate
75, blood pressure 136/60. O2 saturation was 88% on 100%
FIO2, 15 of PEEP, and 16 of IMV. Neck was supple, full range
of motion, and no lymphadenopathy, thyromegaly. Carotids are
2+ and equal bilaterally without bruits. Lungs had coarse
breath sounds diffusely up to the mid chest. Cardiovascular
examination: Regular, rate, and rhythm, normal S1, S2, no
murmurs, rubs, or gallops. Abdomen is soft and nontender
with positive bowel sounds, no masses or hepatosplenomegaly.
Extremities had 1+ bilateral pitting edema. Neurologic
examination: He was sedated.
He was admitted to the CCU and he was diuresed. Renal was
consulted. They recommended holding his ACE inhibitor. He
ruled in for a MI with a peak troponin of 3.24, peak CPK of
934 with 37% MB. He was diuresed with Lasix drip and he was
started on CVVH as a therapy prior to cardiac
catheterization.
On [**10-31**], he underwent cardiac catheterization which revealed
a 70% distal left main stenosis, 80% ostial proximal left
anterior descending artery stenosis, 70% long proximal left
circumflex stenosis, and a 90% OM-3 stenosis. RCA had a
proximal occlusion.
Dr[**Last Name (Prefixes) 4558**] was consulted, and the patient was continued
on CVVH. The patient continued to improve, was extubated.
His creatinine was up to 3.3 and came back down to 2.4 with
CVVH. He was transferred to the floor on [**11-2**],
hospital day four, and continued to progress and on [**11-5**], he
underwent a CABG x3 with PDA endarterectomy. He had a
saphenous vein graft to the PDA to the distal LAD and a LIMA
to the diagonal with a cross clamp time was 99 minutes.
Total bypass time was 117 minutes. He was transferred to the
CSRU in stable condition, and was only on propofol.
He was extubated postoperative night and his creatinine was
2.8 on postoperative day #1. He had good urine output. He
was A-paced for blood pressure support. His creatinine on
postoperative day two went up to 3.6, and we continued to
monitor this.
On postoperative day three, it came down to 3.6, and he was
transferred to the floor in stable condition. He was started
on Plavix immediately postoperatively for his endarterectomy
and chest tubes D/C'd on postoperative day #2. He continued
to progress. Had his epicardial pacing wires D/C'd on
postoperative day #4, and Renal continued to follow him. His
creatinine remained around 3, and on postoperative day #6, he
was discharged to home in stable condition.
LABORATORIES ON DISCHARGE: Hematocrit is 28.8, white count
7,300, platelets 357. Sodium 134, potassium 4.8, chloride
98, CO2 26, BUN 79, creatinine 3.0, blood sugar 107.
MEDICATIONS ON DISCHARGE:
1. Percocet 1-2 tablets p.o. q.4-6h. prn pain.
2. Plavix 75 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Imdur 30 mg p.o. q.d.
5. Iron 150 mg p.o. q.d.
6. Vitamin C 500 mg p.o. b.i.d.
7. Epogen 5,000 units subQ two times a week.
8. Calcium 1334 mg p.o. t.i.d. with meals.
9. Lipitor 20 mg p.o. q.d.
10. Eyedrops one drop O.U. q.h.s.
11. Lopressor 50 mg p.o. b.i.d.
12. Lasix 40 mg p.o. b.i.d.
FO[**Last Name (STitle) **]P INSTRUCTIONS: He will be followed by Dr. [**First Name (STitle) **] in
[**1-24**] weeks and Dr. [**Last Name (STitle) **], his renal doctor in one week, and
an appointment with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3116**]
MEDQUIST36
D: [**2143-11-11**] 13:07
T: [**2143-11-11**] 13:10
JOB#: [**Job Number 50327**]
ICD9 Codes: 4280, 5849, 2859, 4439 |
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