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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7300
} | Medical Text: Admission Date: [**2166-12-30**] Discharge Date: [**2167-1-9**]
Date of Birth: [**2109-11-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Benadryl
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
right flank pain
Major Surgical or Invasive Procedure:
CABGx4(LIMA-LAD,SVG-OM, SVG-PVL, SVG-Diag)[**1-1**]
History of Present Illness:
57 yo F admitted to [**Hospital3 **] with right flank pain, had
chest pain prior to dialysis and ruled in for MI. Transferred to
[**Hospital1 18**] cath lab.
Past Medical History:
HTN, ^chol, ESRD/HD(polycystic KD), PAFib, Anxiety, Gout, +tob
Tonsillectomy, Tubal [**Last Name (LF) **], [**First Name3 (LF) **] tumor removal
Social History:
works as stay at home mom
+ tobacco - 1.5 ppd x 30 years
denies etoh
lives with husband and son
Family History:
mother deceased from MI at 44
Physical Exam:
Admission:
VS HR 76 RR 22 BP 218/83
NAD
Rt subclavian tunneled cath
Lungs CTAB
RRR 2/6 systolic murmur
Abdomen soft/NT/ND, obese
Extrem warm, trace edema
Varicosities none
Neuro grossly intact
Discharge:
VS T98.2 HR 68SR BP 155/84 RR 18 O2sat 94% RA
Gen NAD
Neuro A&Ox3, nonfocal exam
Pulm Decreased Left base, otherwise clear. Rt subclav tunnel
line
CV RRR, no M/R/G. Sternum stable, incision CDI
Abdm soft, NT/ND/+BS
Ext warm, 2+ pedal edema
Pertinent Results:
[**2166-12-30**] 10:05PM PLT COUNT-145*
[**2166-12-30**] 02:30PM GLUCOSE-149* UREA N-31* CREAT-5.5*#
SODIUM-131* POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-20* ANION GAP-17
[**2166-12-30**] 02:30PM ALT(SGPT)-13 AST(SGOT)-13 CK(CPK)-23* ALK
PHOS-70 AMYLASE-90 TOT BILI-0.6
[**2166-12-30**] 02:30PM CK-MB-NotDone cTropnT-0.53*
[**2166-12-30**] 02:30PM ALBUMIN-3.6
[**2166-12-30**] 02:30PM %HbA1c-5.3
[**2166-12-30**] 02:30PM WBC-7.4 RBC-2.93*# HGB-8.8* HCT-25.8* MCV-88#
MCH-29.9 MCHC-34.0 RDW-17.6*
[**2166-12-30**] 02:30PM PT-28.9* PTT-77.9* INR(PT)-2.9*
[**2167-1-9**] 06:30AM BLOOD WBC-7.9 RBC-3.21* Hgb-9.6* Hct-28.8*
MCV-90 MCH-29.9 MCHC-33.3 RDW-17.6* Plt Ct-246
[**2167-1-9**] 06:30AM BLOOD Plt Ct-246
[**2167-1-4**] 02:50AM BLOOD PT-12.3 PTT-25.9 INR(PT)-1.0
[**2167-1-9**] 06:30AM BLOOD Glucose-105 UreaN-34* Creat-5.6* Na-134
K-4.1 Cl-96 HCO3-25 AnGap-17
[**2166-12-30**] 02:30PM BLOOD ALT-13 AST-13 CK(CPK)-23* AlkPhos-70
Amylase-90 TotBili-0.6
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2167-1-8**] 8:24 AM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
57 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
eval for pleural effusions
INDICATION: 57-year-old status post CABG.
COMPARISON: [**2167-1-2**].
PA AND LATERAL CHEST: The patient is status post median
sternotomy and CABG. A right subclavian hemodialysis catheter
terminates in the distal SVC. Moderate degree of cardiomegaly
appears unchanged. Mediastinal and hilar contours are stable.
There is slight increased size of a moderate left and small
right pleural effusion. There is improved aeration at the left
lung base. No pneumothorax is identified. Mild degenerative
changes are noted in the mid thoracic spine.
IMPRESSION: Slight interval increase in a moderate left and
small right pleural effusion. Improving left basilar
atelectasis.
DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 30530**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 30531**] (Complete)
Done [**2167-1-1**] at 9:37:47 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2109-11-1**]
Age (years): 57 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG
ICD-9 Codes: 402.90, 786.05, 786.51, 799.02, 440.0, 424.0
Test Information
Date/Time: [**2167-1-1**] at 09:37 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 #: 2008AW1-: Machine: [**Pager number 30532**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *4.7 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Aortic Valve - Valve Area: 3.2 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. The lateral wall of the LV is hypokinetic. The
remaining left ventricular segments contract normally. Right
ventricular chamber size and free wall motion are normal. 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 leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Post bypass: Good RV systolic fxn. The lateral LV wall shows
some improved systolic fxn. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2167-1-1**] 16:04
Brief Hospital Course:
Cardiac cath showed 3VD. She was transferred to the CCU for
hypertensive urgency and was weaned from her hydralazine,
nipride and nicardipine. She was continued on argatroban instead
of heparin for concern of HIT, and she was seen by hematology.
She continued on dialysis. HIT was negative and she was taken to
the operating room on [**1-1**] where she underwent a CABG x 4. She
was transferred to the ICU in stable condition. She was
extubated on POD #1. She was given 48 hours of vanocmycin as she
was in the hospital preoperatively. She was transfused. She was
transferred to the floor on POD #3. She continued on HD M-W-F.
She was ready for discharge home on POD8
HD is set up at [**Location (un) **] Dialysis Center.
Medications on Admission:
Lipitor 80', ASA 81', Imdur 120' Lopressor 75", Renegal 400''',
Nephrocap 1', Diazepam 2.5 Q8/prn, PhosLo 667 QMon/Wed,
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO resume preop schedule
as needed.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
CAD s/p CABG
HTN, ^chol, ESRD/HD(polycystic KD), PAFib, Anxiety, Gout, +tob
Tonsillectomy, Tubal [**Last Name (LF) **], [**First Name3 (LF) **] tumor removal
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 4469**] 2 weeks
Dr. [**Last Name (STitle) 10543**] 2 weeks
Completed by:[**2167-1-9**]
ICD9 Codes: 5856, 2875, 2767, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7301
} | Medical Text: Admission Date: [**2138-7-25**] Discharge Date: [**2138-9-4**]
Date of Birth: [**2072-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
Tracheostomy
Intubation
R Thoracentesis (x2)
Central Line Placement
PICC Line Placement
HD line placement
Hemodialysis (CVVH)
PEG Placement
History of Present Illness:
61 year old man, PMH of DM type II, with recent hospital
admission ([**5-22**]) for enterococcal bacteremia and aortitis,
presented to OSH on [**2138-7-22**] complaining of 6 weeks of back pain
and bowel incontinence. Patient said onset of severe back pain
began approximately 6 weeks ago in lower right side, worse with
sitting or standing. If attempted to stand, he experience pain
shooting up his back. He last walked approximately 6 weeks ago.
The pain has been stable, not worsening. He reports mild
improvement. He is now able to roll in bed. Yesterday patient
was unable to turn his head to the side. That has since
resolved.
.
Two weeks ago, patient developed bowel incontinence. He can not
sense when he is going. He has loss of stool approximately
3-4x/day. Also reports decreased urine output with no leakage or
dribbling. Patient feels he is dehydrated.
He decided to go to the hospital when after attempting to get
out of bed he felt very dizzy and "things went black." Also
became concerned about his decreased urine output.
.
At OSH: MRI was notable for an L2-L3 epidural abscess. Notable
findings at the OSH include ampicillin sensitive enterococcal
bacteremia, CT scan findings of possible aortitis and a right
pleural effusion. He was started on ampicillin and gentamycin,
and transferred to [**Hospital1 18**] for surgical evaluation. Pt was started
on flagyl for diarrhea.
.
Mr. [**Known lastname 6228**] is a 6xyo male with DM, CAD recently s/p NSTEMI with
EF 20-30%, PVD, hypoalbuminemia and COPD initially transferred
from OSH for management of C5-6 and L2/L3 osteomyelitis and
enterococcal bacteremia.
.
Past Medical History:
1.CAD, NSTEMI [**5-22**] refused Cath
-complicated by cardiomyopathy, with EF =45%
-negative stress test [**11/2137**]
- ECHO in [**5-/2138**] with reported paradoxical motion of LV apex,
hypokinesis of septum and anterior wall infarct ischemia.
2.Diabetes Mellitus Type II
3.Peripheral vascular disease
-s/p left great toe ampuation
4.History of enterococcal bacteremia
-Admitted to [**Hospital **] hospital with this earlier in [**5-22**].
Received ampicillin and gentamycin, and there was suspicion for
aortitis vs infected clot. Patient left AMA on linezolid after
refusing vascular surgery intervention.
5. HTN
6. h/o osteomyelitis
7. COPD, not on steroids, per pt never intubated
8. L great toe amputation [**2-/2138**]
Social History:
Retired electrician, lives with wife. 100 pkyr tobacco hx, prior
ETOH use 6pk/day (quit 6mos ago), no illicit drug use
Family History:
Sister Diabetes [**Name2 (NI) 6229**] deceased at age 65
Physical Exam:
at micu admission
VITALS: T 94.4 BP 103/66 HR 86 O2Sat 95%RA
*
PHYSICAL EXAM
Gen: Elderly male lying in bad in moderate distress with
movement
HEENT: EOMI, PEERL, anicteric, oropharynx clear
NECK: supple, no [**Doctor First Name **],
CHEST: poor air movement, diffuse wheezes throughout
Back: No vertebral tenderness, R paraspinal tenderness at T8
CV: RRR, S1S2, no m/r/g
Abd: protuberant, tympanitic, nontender, distended, + BS
Ext: L foot s/p great toe amputation, flaking, red skin with
partial thickness ulcer on L foot
Scrotal Edema
Neuro: CN II-XII intact, B/L UE 5/5 strength, B/L hip flexors
[**3-20**] limited by pain, Dorsi/plantar flexion [**4-19**], Sensation
saddle-decreased but present,
Pertinent Results:
Initial MRI L Spine: Findings indicative of discitis and
osteomyelitis at L2-3 and L4-5 level. Inflammatory changes
posterior to the thecal sac at L2-3 level could be due to
phlegmon or a small epidural abscess. Inflammatory changes are
also seen involving the right psoas muscle and posterior
musculature at L4-5 level. Epidural enhancing soft tissues due
to phlegmon are also seen. Examination is limited and for better
evaluation if clinically indicated, a repeat study with proper
sedation is recommended.
.
MRI C/T/L spine [**2138-7-27**]: Discitis and osteomyelitis at C5-C6
level. No overt change in the extent of discitis and
osteomyelitis at L4-L5 level, incompletely assessed at L2-L3
level. Probable pelvic fluid, incompletely assessed.
.
TTE [**7-22**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF= 20-30 %) secondary to severe
hypokinesis of the anterior septum and anterior free wall,
moderate hypokinesis of the inferior septum and lateral wall,
and extensive apical akinesis. There is no ventricular septal
defect. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. There are filamentous strands on
the aortic leaflets consistent with Lambl's excresences (normal
variant), although small vegetations cannot be excluded with
certainty. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. No mass or vegetation is seen on
the mitral valve. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined. No
vegetation/mass is seen on the pulmonic valve. There is a small
to moderate sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
Brief Hospital Course:
Mr. [**Known lastname 6228**] is a 66yo male with DM, CAD recently s/p NSTEMI with
EF 20-30%, PVD, hypoalbuminemia and COPD initially transferred
from OSH for management of C5-6 and L2/L3 osteomyelitis and
enterococcal bacteremia.
His hospital course is summarized as follows:
He was initially followed on the medical floor for medical
management of his MI and bacteremia but then transferred to the
MICU on [**7-29**] when he became hypoxemic with an associated
respiratory acidosis. In the MICU, patient was diuresed.
Initially Abx extended to vanco/zosyn/amp/gent for presumed PNA.
However CXR more consistent with worsening CHF and pleural
effusion. PICC was placed for longterm antibiotic therapy.
.
Pt was called out to floor on [**2138-7-31**]. On the floor, he
initially was stable then on [**8-2**] became more SOB. CXR revealed
moderate R pleural effusion as well as worsening CHF. Diuresis
with Lasix plus albumin with minimal response.
.
On [**8-3**], he was transferred to MICU for closer monitoring for
SOB.
MICU PROBLEM BASED COURSE SINCE [**8-3**]:
.
1. Respiratory Failure: Pt was initially intubated for
respiratory distress with subsequent multiple failed planned and
self-extubations throughout MICU course. His respiratory
failure was likely secondary to large pleural effusions [**1-17**] CHF
(EF 10-15%). Hypoalbuminemia due to nephrotic syndrom also
playing large role as pt reaccumulated fluid s/p thoracentesis
and additionally, he has underlying COPD. On [**8-9**] extubated, R
Thoracentesis removed 2L fluid. CXR improved following but
clinical scenario without change. Pt refused re-intubation
overnight. Worsening gas on bipap. Pleural fluid labs:
transudate. On [**8-10**] Reintubated (pt w/ barely adequate O2 resp
function on BiPap). On [**8-13**] Pt self-extubated and [**8-14**]
re-intubated secondary to increasing hypoxia, hypercarbia. On
[**8-20**] extubated x1hr to speak with wife but was briefly
hypotensive with reintubation, requiring levophed.
On [**8-23**] pt extubated himself, agreed to reintubation. [**8-26**] R
Thoracentesis removed 1.8 L, stopped due to hypotension
requiring levophed temporarily. On [**8-27**] Trach placed by IP and
respiratory status remained stable through remaining hospital
course. He is able to breath off the vent for 8-10 hours on some
days, but then tires and requires to be replaced on the vent.
.
2. Hypotension: Pt originally presented hypotensive: Thought
most likely cardiogenic shock, although he did have many reasons
to be septic (osteomyelitis, TV vegetation, retropharyngeal
fluid collection). Pt started on levophed [**8-3**]. remained
pressor dependant despite negative cultures since [**8-3**]. Tried
dobutamine trial ~[**8-6**] and [**8-11**] , pt failed (became hypotensive,
tachycardic). Attempted vasopressin [**8-12**] w/ goal of levophed
wean: unsuccessful. D/ced vasopressin [**8-15**]. Also considered
component of hypovolemic shock given depleted intravascular
status w/ hypoalbuminemia, pt transfused to HCT 30 ([**2061-8-12**]) w/o
improvement in pressor requirement (continued levophed
requirement). Considered adrenal insufficiency, stim test on :
cosyntropin stim normall originally, normal on repeat [**8-14**]. On
[**8-19**]-started Hydrocort trial: 100mg IV x1; allowed successful
wean off levophed. Continued steroids w/ 6 day tapering course,
finished [**8-25**]. [**Date range (1) 6230**] while on steroids pt w/ stable BP. The
pt had 2L dialyzed off on [**8-24**] and pt with hypotension w/ sbp 70
overnight responsive to 750 cc bolus. On [**8-26**], temporary
hypotensive episode requiring levophed due to 1.8L volume
removal thoracentesis. [**8-29**] pt hypotensive when in chair,
standing valium decreased to 2.5 TID (from 5), and
hydrocortisone restarted at 50 q 6. Given hypotension, the
fentanyl patch and valium were d/c'd and Fludrocortisone 0.2mg
daily was started for orthostasis. Pt BP has thus been stable.
.
3. Anxiety / depression: Patient intermittently angry,
attempting to lash out at nurses and making rude, offensive
statements. Evaluated by psychiatry given pt refused HD and
unclear if he is competent to make any decisions. -Unclear if
pts current "anger" is part of his pre-morbid personality vs
delirium. Zyprexa started [**8-21**], Started SSRI, celexa [**8-25**], using
standing valium to wean from midazolam drip s/p trach. After
psych evaluation began Haldol 5mg IV BID, then held Celexa in
setting of poor renal function. On D/C haldol 5mg TID has been
working well and soothing his agitation.
.
4. Tracheitis: pt w/ thick secretions decreasing. sputum w/ +
growth for Kleibsiella oxtocea, enterobacter cloacae on [**8-13**],
both sensitive to cefepime. [**8-18**] and [**8-25**] sputum remains + for
gram - rods. Continue cefepime (had started cefepime and vanco
[**8-13**], changed temporarily to ceftriaxone for better gram -
coverage prior to sensitivites, reverted back to cefepime
[**8-18**])through [**9-2**] for 15d course
.
5. Renal Failure: F: likely prerenal F, as pt w/ hypotension and
pressor requirement. Pt also w/ diabetic nephropathy. total
protein 3207g=nephrotic syndrome. Hypoalbuminemia playing large
role in cardiovascular compromise as pt third spacing tremendous
amount of fluid (+8L prior to CVVH, now +7L on intermittent HD).
CVVH used as temprorary bridge for volume removal. clinical
condition did not improve. CVVH stopped as was not considered to
be permanent solution given ICU requirement. renal plan for
renal biopsy when/if pt stable to determine if any aspect of
nephrotic dz would be steroid responsive. After successful
levophed wean pt attempted on HD trials: trials of intermittent
HD successful thus far, pt has tolerated fluid removal and
remained hemodynamically stable.
.
6. Pleural effusion: reaccumulated w/i 48 hrs s/p thoracentesis
on [**8-9**], quick reaccumulation suspected to be related to
hypoalbuminemia. Likely contributing to pts resp distress. c/s
IP to discuss feasability of successful pleurodesis: IP does not
believe procedure would be successful. IP performed
thoracentesis on [**8-26**], removed 1.8 L on [**8-26**], stopped fluid
removal secondary to hypotensive episode.
.
7. Vertebral osteo: osteomyelitis at L2-3, L4-5, C5-6.
[**7-27**]: MRI total spine [**7-27**]: retropharyngeal fluid collection at
level of C1-C5; may be pre-vertebral as opposed to
retropharyngeal,adjacent to C5-6 vertebrae w/ appearance c/w
osteomyleitis. [**8-6**]: MRI neck: improved retropharyngeal fluid
collection. Continued appearance of edematous and enhancing C5
vertebral body and C [**4-20**] interval disc space. Ortho spine
evaluated and no concern for fluid collection itself
compromising vital structures; therefore no need surgical
intervention. Treatment continues wtih ampicillin for
osteomyelitis.
.
8. Endocarditis: TEE [**8-15**] confirms large TV vegetation, +AV
vegetation. Continue ampicillin x8 weeks.
.
9. Enterococcus bacteremia per OSH (E. Faecalis): Was on
amp/gent from OSH for synergistic coverage for presumed
endocarditis. Recently on amp alone as all blood cx here (from
[**7-25**] onward) have been negative, possible sources (TV veg on
TTE, osteo, cervical fluid collection). tx for endocarditis and
osteo: abx x minimum 8wks. at [**Hospital1 18**] was on vanco/zosyn
[**Date range (1) 6231**], changed back to amp on [**8-5**]. blood cx negative at
[**Hospital1 18**] since [**7-25**]. 8 wk course = ampicillin until [**9-28**] for osteo
and endocarditis.
.
10. Diabetes Mellitus: Pt originally on ISS w/ good control.
The pts sugars elevated when steroids started so insulin drip
was used. The drip was d/ced [**8-25**] as steroid course finished
and pt put on ISS.
.
11. L foot ulcers: Likely secondary to poor wound healing and
Diabetes, no evidence of osteo on foot films. Also small ulcer
on right foot. Pt seen and evaluated by wound care.
.
12. Aortitis: There was a oncern for infrarenal aortitis on OSH
studies. On vascular read, also with possible ascending
aortitis. Final radiology CT read: chronic/dormant aortitis.
Per vascular surgery- no surgical intervention necessary.
.
13. Abdominal pain: Pt had intermittent episodes of abdominal
pain [**Date range (1) 6232**], appear to have resolved though pt
intubated/sedated: central/RUQ. Difficult to fully abscess given
intubation. Chest pain worked up as above. Possibly
constipation. [**8-11**] RUQ US -, LFTs nl except mild lipase
elevation at 64. Issue resolved on own.
.
14. Chest pain: Intermittent episodes of chest pain during MICU
admission. The last episode [**8-18**] early morning pt hypotensive w/
chest pain and diaphoresis. The levophed increased, pain
resolved. Cardiac enzymes were sent but ?relevance of results
given pt on CVVH. At micu admission pt w/ known CAD, cardiac
ischemia, elevated troponins (~6) w/ hypotension and tachycardia
thought to be likely demand ischemia versus ACS. Hx=NSTEMI [**5-22**],
pt refused cath. [**8-15**] TEE w/ EF of [**9-29**]% which is decreased
from prior estimate (8/14 20-30%). Pt medically managed (asa,
statin, plavix. We were unable to pursue cath at this time due
to + valve vegetations
.
15. A. [**Name (NI) 6233**] Pt started on amiodarone bolus/drip started [**8-9**] and
subsequently converted to PO. On [**8-10**]: pt converted to NSR at
~1030 On [**8-11**]: pt w/ irregular rhythm, ? aflutter w/ irreg
block. As of [**8-17**] pt has been stable on amiodarone.
.
16. [**Name (NI) 300**] pt found to be hypernatremia, continues to
receive free water bolus through NGT.
.
Medications on Admission:
Meds: on admission to OSH:
Nitro PRN
Flomax
pravastatin
ASA
NPH
folic acid
.
MEDS on transfer:
Ampicillin 2q4h
Gentamicin 100mg q8h
NPH 45 qAM, 31qPM
captopril 12.5 tid
metoprolol 12.5tid
vitamin C 500bid
znSo4 220qdaily
heparin SC 5000tid
diazepam 5mg qdaily
asa
finasteride 5mg qdaily
lasix 80 [**Hospital1 **]
folic acid 1mg qdaily
pravastatin 40qdaily
protonix 40IV
oxycodone 5 q6hPRN
ibuprofen 800 q6h PRN
tylenol 650 q4h PRN
had one dose of albumin
metronidazole 500tid
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
2. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
4. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
6. Atorvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
7. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff
Inhalation Q4-6H () as needed.
8. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4-6H () as needed.
9. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
10. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
11. Midodrine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
12. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
13. White Petrolatum-Mineral Oil Cream [**Hospital1 **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for to feet.
14. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q4H (every
4 hours) as needed.
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
17. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. Fludrocortisone 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
19. Ampicillin Sodium 1 g Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Injection Q6H (every 6 hours).
20. Haloperidol Lactate 5 mg/mL Solution [**Last Name (STitle) **]: One (1) Injection
TID (3 times a day) as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Enterococcus Sepsis
Endocarditis
Vertebral Osteomyelitis
Retropharyngeal Abscess
Tracheitis
Renal Failure
Respiratory Failure s/p tracheostomy
Hypoalbuminemia
Hypernatremia
Recurrent Pleural Effusion
CHF
AFib
CAD
Diabetes Mellitus
Anxiety
Discharge Condition:
Alert, able to communicate and speak via Passy Muir Valve. Able
to move all extremities. Occasionally anxious. Knows name and
hospital. Blood blister on L foot. Able to sit for short periods
in chair.
Discharge Instructions:
You are being discharged to [**Hospital1 **] for intensive
rehabilitation.
- you will continue to receive dialysis
- you will continue to be ventilated with a machine for a good
portion of the day.
- you continue to have infections which will require intravenous
antibiotics
Followup Instructions:
PCP
Completed by:[**2138-9-4**]
ICD9 Codes: 5849, 4280, 2760, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7302
} | Medical Text: Admission Date: [**2191-3-3**] Discharge Date: [**2191-3-11**]
Date of Birth: [**2128-11-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
syncope, abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
nasogastric tube placement
History of Present Illness:
62yF with hx of hypothyroidism, HTN, hyperlipidemia, and
diverticulosis presents following a syncopal episode this AM. Pt
reports reducing her PO intake over the weekend [**2-1**] work-related
stress and then feeling lightheaded and nauseated this morning
on her bus ride to work. She reached her office but fainted
while sitting at her desk. She reports vomiting once (no blood).
She denies chest pain, shortness of breath, palpitations,
diaphoresis, tongue-biting, or incontinence associated with this
syncopal episode. She denies hitting her head in the fall.
She had a similar syncopal episode two months ago, evaluted in
the [**Hospital1 18**] EW, thought to be non-cardiogenic in nature. No other
recent history of pre-syncope or syncope. She reports that her
general health is "good." On questioning, she admits to feeling
a constant diffuse abdominal pain for "a while," probably on the
order of weeks to months. The pain is crampy, worse with eating
(small meals are best), better with movement, not associated
with nausea/vomiting. Nothing else makes the pain better or
worse, and she has not sought medical attention for this issue.
She suffers from constipation (no BM in past week), punctuated
by occasional episodes of diarrhea (approx 1 episode per month).
No frankly dark or bloody stools. She denies fevers, sweats, and
weight loss, though she endorses occasional chills. She denies
sick contacts or recent antibiotic use.
She had a bleeding gastric ulcer 30 yrs ago. She had a
colonoscopy one month ago that revealed diverticulosis. She
admits to occasional non-adherence to medications (misses PM
dose of verapamil).
.
In the ED, initial VS were:
T 96.8 HR 119 BP 140/103 (91/36 15min later) RR 16 O2 99% RA
Labs @ 10am:
16.2 > 33.2 < 468 MCV 100
134 98 9
-----------< 142
3.5 16 1.0
Ca: 9.2 Phos:4.9 MG: 1.4
Anion Gap: 24
Lactate 6.1
AST 27 ALT 15 AP 85 Tbil 0.2 Lip 51 Alb 3.4
PTT 22.0 INR 0.8
Foley was placed.
UA: Positive for nitrates, with 21-50 WBC.
CXR was normal.
CT demonstrated pancolitis with marked bowel wall thickening but
no signs of obstruction, also intrahepatic and CBD dilation
terminating in the head of the pancreas, concerning for a
pancreatic mass.
CT Head revealed no acute intracranial process.
Pt received 5.5L NS, lactate dropped to 3.3, hypotension
resolved. Blood cx were sent. Pt was started on vanco, zosyn,
flagyl.
CVL (triple lumen cordis) placed in the RIJ. Placement confirmed
with CXR.
NGT placed --> 50cc bilious fluid.
General surgery was consulted, felt abdomen to be non-surgical.
.
On the floor, hemodynamically stable, but with continued
nausea/vomiting/watery diarrhea. Received 1L NS.
.
Review of sytems:
(+) Per HPI. Also: occasional joint pain in hands and knees;
neck pain; occasional incontinence of urine.
(-) Denies headache, vision changes, dysphagia, URI symptoms,
CP, SOB, cough, dysuria, hematuria, crampy leg pain, changes in
appetite or energy.
Past Medical History:
HTN
Hypercholesterolemia
Hypothyroidism
Diverticulosis
h/o breast CA - last mammogram [**2186**] (normal)
R, [**2173**]: invasive CA treated with lumpectomy and radiation
L, [**2182**]: DCIS treated with excision, radiation, tamoxifen x5 yrs
h/o gastric ulcer 30 yrs ago
Social History:
Drinks 1 shot gin per night. Denies EtOH-related withdrawal sx
or seizures. Remote tobacco use in teens. No illegal drugs.
Lives with sister in community living situation. One cat. Works
in billing at [**Hospital3 1810**]. Finds this work and her
commute stressful.
Family History:
Mother died of colon cancer at age 55.
Physical Exam:
Vitals: T:99.1 BP: 129/64 P:98 R: O2: on 97%
General: Pale, sweaty, fatigued, with coarse tremor in both
hands, but in no acute distress
HEENT: Fine hair; bilateral proptosis; MMM; oropharynx clear w/o
exudates; poor dentition
Neck: CVL in R IJ; no thyromegaly; JVP not elevated
Lungs: Clear to auscultation bilaterally w/o wheezes, crackles,
ronchi
CV: RRR, nl S1, S2, no murmurs
Abdomen: Soft, distended but not tympanitic, +BS, tender to deep
palpation without rebound or guarding
GU: Foley
Ext: Warm, well-perfused; DPs 2+ bilaterally
Pertinent Results:
[**2191-3-11**] 05:38AM BLOOD WBC-12.2* RBC-2.82* Hgb-8.7* Hct-27.7*
MCV-98 MCH-31.0 MCHC-31.5 RDW-11.8 Plt Ct-528*
[**2191-3-11**] 05:38AM BLOOD Plt Ct-528*
[**2191-3-11**] 05:38AM BLOOD Glucose-100 UreaN-4* Creat-0.6 Na-134
K-3.6 Cl-100 HCO3-25 AnGap-13
[**2191-3-11**] 05:38AM BLOOD ALT-9 AST-15 AlkPhos-98 TotBili-0.2
[**2191-3-11**] 05:38AM BLOOD Calcium-8.1* Phos-4.1 Mg-1.1*
[**2191-3-3**] 09:25AM WBC-16.2* RBC-3.33* HGB-10.8* HCT-33.2*
MCV-100* MCH-32.4* MCHC-32.6 RDW-11.8
[**2191-3-3**] 09:25AM NEUTS-80.1* LYMPHS-13.5* MONOS-2.0 EOS-4.2*
BASOS-0.2
[**2191-3-3**] 09:25AM PT-10.2* PTT-22.0 INR(PT)-0.8*
[**2191-3-3**] 09:25AM TSH-0.76
[**2191-3-3**] 09:25AM ALBUMIN-3.4* CALCIUM-9.2 PHOSPHATE-4.9*
MAGNESIUM-1.4*
[**2191-3-3**] 09:25AM ALT(SGPT)-15 AST(SGOT)-27 ALK PHOS-85 TOT
BILI-0.2
[**2191-3-3**] 09:25AM LIPASE-51
[**2191-3-3**] 09:25AM GLUCOSE-142* UREA N-9 CREAT-1.0 SODIUM-134
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-16* ANION GAP-24*
[**2191-3-3**] 10:32AM LACTATE-6.1*
[**2191-3-3**] 10:00PM FREE T4-1.2
[**2191-3-3**] 10:52PM LACTATE-1.1
[**2191-3-4**] 05:00AM BLOOD WBC-12.4* RBC-2.81* Hgb-9.6* Hct-28.5*
MCV-101* MCH-34.2* MCHC-33.8 RDW-11.1 Plt Ct-333
[**2191-3-4**] 11:32AM BLOOD WBC-12.2* RBC-2.82* Hgb-9.6* Hct-28.3*
MCV-101* MCH-34.2* MCHC-34.0 RDW-11.5 Plt Ct-328
[**2191-3-5**] 04:02AM BLOOD WBC-11.6* RBC-2.82* Hgb-9.4* Hct-29.1*
MCV-103* MCH-33.4* MCHC-32.3 RDW-11.8 Plt Ct-322
[**2191-3-6**] 05:36AM BLOOD WBC-11.8* RBC-2.87* Hgb-9.4* Hct-28.0*
MCV-98 MCH-32.6* MCHC-33.4 RDW-11.5 Plt Ct-281
[**2191-3-6**] 02:35PM BLOOD Hct-28.1*
[**2191-3-7**] 05:20AM BLOOD WBC-16.2* RBC-2.97* Hgb-9.9* Hct-29.8*
MCV-100* MCH-33.3* MCHC-33.1 RDW-11.8 Plt Ct-307
[**2191-3-8**] 06:02AM BLOOD WBC-13.9* RBC-2.81* Hgb-9.0* Hct-27.2*
MCV-97 MCH-32.0 MCHC-32.9 RDW-11.8 Plt Ct-297
[**2191-3-9**] 05:40AM BLOOD WBC-11.1* RBC-2.83* Hgb-9.2* Hct-27.9*
MCV-99* MCH-32.3* MCHC-32.8 RDW-11.8 Plt Ct-362
[**2191-3-10**] 05:45AM BLOOD WBC-13.4* RBC-2.86* Hgb-9.1* Hct-27.9*
MCV-98 MCH-31.8 MCHC-32.6 RDW-11.8 Plt Ct-476*
[**2191-3-5**] 04:02AM BLOOD Neuts-86.1* Lymphs-9.3* Monos-3.5 Eos-1.0
Baso-0.1
[**2191-3-9**] 05:40AM BLOOD PT-11.9 PTT-27.4 INR(PT)-1.0
[**2191-3-3**] 09:25AM BLOOD Glucose-142* UreaN-9 Creat-1.0 Na-134
K-3.5 Cl-98 HCO3-16* AnGap-24*
[**2191-3-3**] 10:00PM BLOOD Glucose-124* UreaN-13 Creat-0.6 Na-138
K-4.0 Cl-109* HCO3-20* AnGap-13
[**2191-3-4**] 05:00AM BLOOD Glucose-92 UreaN-12 Creat-0.7 Na-135
K-4.9 Cl-109* HCO3-21* AnGap-10
[**2191-3-5**] 04:02AM BLOOD Glucose-66* UreaN-5* Creat-0.5 Na-137
K-3.8 Cl-105 HCO3-21* AnGap-15
[**2191-3-6**] 05:36AM BLOOD Glucose-121* UreaN-3* Creat-0.5 Na-134
K-3.0* Cl-101 HCO3-22 AnGap-14
[**2191-3-7**] 05:20AM BLOOD Glucose-140* UreaN-3* Creat-0.5 Na-130*
K-4.2 Cl-98 HCO3-23 AnGap-13
[**2191-3-8**] 06:02AM BLOOD Glucose-99 UreaN-3* Creat-0.5 Na-132*
K-3.5 Cl-99 HCO3-26 AnGap-11
[**2191-3-9**] 05:40AM BLOOD Glucose-101* UreaN-3* Creat-0.6 Na-131*
K-3.4 Cl-99 HCO3-27 AnGap-8
[**2191-3-10**] 05:45AM BLOOD Glucose-102* UreaN-4* Creat-0.6 Na-134
K-3.7 Cl-99 HCO3-24 AnGap-15
[**2191-3-3**] 09:25AM BLOOD ALT-15 AST-27 AlkPhos-85 TotBili-0.2
[**2191-3-4**] 05:00AM BLOOD ALT-14 AST-37 AlkPhos-57 TotBili-0.2
[**2191-3-8**] 06:02AM BLOOD ALT-11 AST-15 AlkPhos-53 TotBili-0.2
[**2191-3-9**] 05:40AM BLOOD ALT-9 AST-15 AlkPhos-62 TotBili-0.2
[**2191-3-10**] 05:45AM BLOOD ALT-11 AST-16 LD(LDH)-166 AlkPhos-114*
TotBili-0.2
[**2191-3-3**] 09:25AM BLOOD Albumin-3.4* Calcium-9.2 Phos-4.9*
Mg-1.4*
[**2191-3-10**] 05:45AM BLOOD Albumin-2.5* Calcium-8.3* Phos-4.1
Mg-1.5*
[**2191-3-3**] 09:25AM BLOOD TSH-0.76
[**2191-3-3**] 10:00PM BLOOD TSH-0.46
[**2191-3-4**] 05:00AM BLOOD TSH-0.77
[**2191-3-3**] 10:00PM BLOOD Free T4-1.2
[**2191-3-4**] 05:00AM BLOOD Free T4-1.2
[**2191-3-3**] 09:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2191-3-3**] 10:32AM BLOOD Lactate-6.1*
[**2191-3-3**] 03:47PM BLOOD Lactate-3.3*
[**2191-3-3**] 10:52PM BLOOD Lactate-1.1
[**2191-3-4**] 05:15AM BLOOD Lactate-0.7
[**2191-3-4**] 05:15AM BLOOD freeCa-1.04*
CT Head ([**2191-3-3**])- FINDINGS: There is no acute hemorrhage, mass
effect, edema, or infarct. The ventricles and sulci are mildly
prominent, consistent with age-related volume loss. Note is made
of bilateral cavernous carotid calcifications.
Mucosal retention cysts are noted in the left maxillary and
right sphenoid
sinuses. There is opacification of a few ethmoid air cells. The
remaining
paranasal sinuses and mastoid air cells are clear.
IMPRESSION: No acute intracranial process.
CT Torso ([**2191-3-3**])- IMPRESSION:
1. Pancolitis, likely infectious or inflammatory in etiology.
2. Dilated intra and extrahepatic bile ducts, with abrupt cutoff
in the
visualization of the distal CBD at the level of the pancreatic
head, but no gross pancreatic head mass or intraluminal lesion
is visualized. Recommend MRCP for further assessment.
3. 2.8 cm right ovarian cyst, abnormal in postmenopausal female,
and not seen on prior CT from [**2179**]. Recommend pelvic ultrasound
to further characterize.
RUQ U/S- 1. 1.9 cm measuring echogenic lesion in the posterior
right lobe of the liver which was not visualized on the CT of
[**2191-3-3**]. This likely represents a hemangioma, however, MRI
of the liver is warranted for further workup.
2. Cholelithiasis without cholecystitis.
3. Small amount of free fluid in the anterior perihepatic space.
Knee X-ray ([**2191-3-5**])- Three views of the left knee demonstrate
mild medial and lateral compartmental osteoarthritis with
chondrocalcinosis. There is severe osteoarthritis of the
patellofemoral compartment with joint space narrowing and large
osteophyte formation with subchondral cystic change. In
addition, there is mild periosteal reaction of the medial aspect
of the distal femur. This is of unclear etiology. There is a
large joint effusion with apparent soft tissue mass within the
suprapatellar region. This may be better assessed with MRI. It
is unclear as to whether the periosteal reaction is reactive to
the suprapatellar process. There are multiple intra-articular
bodies.
MRCP ([**2191-3-7**])- 1. Incomplete study prematurely terminated at the
patient's request. No IV gadolinium administered.
2. Mild intra- and extra-hepatic bile duct dilatation with the
common bile
duct measuring up to 8-9 mm. Abrupt caliber change of the common
duct at the level of the ampulla of uncertain significance. No
periampullary or
pancreatic mass detected. However, sensitivity of this
examination is limited without contrast. Clinical correlation
with symptoms and LFT values recommended, and an ERCP can be
obtained for further evaluation.
3. Cholelithiasis.
4. Small bilateral pleural effusions and retroperitoneal edema
related to
pancolitis.
5. Left renal cysts.
6. Hiatal hernia.
7. No correlate identified to suspected echogenic lesion of the
right hepatic lobe on ultrasound [**2191-3-4**].
8. Duodenal diverticulum.
EUS ([**2191-3-10**])- No mass seen
Brief Hospital Course:
62yF with HTN, HLD, hypothyroidism, and diverticulosis, who
presented with an episode of non-cardiogenic syncope and
subsequently was found to have pancolitis on CT.
#) Pancolitis: CT demonstrated bowel wall thickening and mild
fat stranding throughout colon with no evidence of obstruction,
perforation, or abscess. Pt with low-grade fever, leukocytosis,
moderate NGT output and watery diarrhea, but benign abdominal
exam. Infectious etiology suspected, viral vs bacterial
pathogen. Pt initially received zosyn and flagyl for antibiotic
coverage. The zosyn was switched to cipro on ICU Day 1, given
low suspicion for biliary source of gut infection. C diff
negative x1. Trace guaiac positive, likely [**2-1**] gut irritation vs
NGT suction. Stool cultures were negative. Inflammatory etiology
less likely, given no evidence of inflammation on colonoscopy
one month ago. Surgery followed patient from ED, felt abdomen to
be non-surgical. GI was consulted for input on infectious vs
inflammatory pancolitis, specifically CT findings out of
proportion to those expected with a gastroenteritis. GI
initially recommended MRCP but study was limited by pain. It
showed CBD dilation of 8-9mm but no discrete pancreatic mass
(see below). Given this result, patient underwent EUS on [**3-10**]
which did not show any mass. The study was limited by prior
Bilroth I anastamosis. Patient's symptoms improved while here.
She was kept on cipro and flagyl and will complete a 14 day
course (last day is [**2191-3-16**]). Upon discharge, she denied
diarrhea, abdominal pain. She was afebrile and tolerating a
regular diet.
#) Syncope: Thought to be secondary to vasovagal event (given
prodromal symptoms) vs dehydration (given hypotension, poor PO
intake prior to admission). A cardiac etiology was thought
unlikely, given normal EKG, no tele events, no murmurs on exam,
no signs of LV dysfunction on stress MIBI from [**2181**]. Patient's
hypotension was corrected and she remained asymptomatic. Her BP
meds were resumed slowly- first lisinopril and then verapamil
daily to [**Hospital1 **]. We ask that her PCP recheck [**Name Initial (PRE) **] BP and HR on
[**2191-3-18**].
#) Hypotension: Fluid responsive after 4L NS, therefore most
likely [**2-1**] dehydration rather than sepsis. Pt remained
normotensive on the floor. Infectious work-up was unrevealing.
Patient continued on cipro and flagyl while here and will
complete a 10 day course of each (last day is [**2191-3-12**]).
Hypotension resolved and patient resumed on home BP meds.
#) Hypoalbuminemia: On admission, albumin low at 3.4, down to
2.6 on ICU Day 1. No baseline albumin in system. This is
concerning for underlying nutritional deficiency and decreased
hepatic production vs protein wasting gastroenteropathy.
Patient has no obvious edema on exam. Most likely due to poor
nutrition in recent weeks. We ask that patient sees a
nutritionist while at rehab.
#) UTI: UA positive for nitrates and WBCs, the latter of which
may have been [**2-1**] overwhelming inflammatory process in the gut.
Pt is without dysuria or frequency. The antibiotics for presumed
GI infection would also treat any UTI. Patient continued on
cipro while here. Last day will be [**2191-3-16**].
#) Anemia with macrocytosis: HCT down to 28 on ICU Day 1, down
from baseline 32 on admission. This may represent hemo-dilution
vs GI bleeding in setting of inflamed gut. Pt was typed and
screened. Pt's baseline MCV is 100. [**Month (only) 116**] be [**2-1**] folate and/or
vitamin B12 deficiency, given history of nightly, if moderate,
EtOH intake and possibly poor diet, though pt has had normal B12
and folate in past. Per chart, pt also has a remote history of
iron deficiency anemia. Hct remained near 28-29 while here. No
signs of blood in diarrhea. MCV of 98 on discharge. Patient is
being discharged on daily folate and thiamine.
#) Hypothyroidism: Pt carries dx of hypothyrodism but had
several signs/sx of hyperthyroidism on admission, including
tremor (gone the following morning), proptosis, fine hair, warm
skin. TSH came back normal at 0.77. Free T4 came back normal at
1.2. Pt was continued on home dose levothyroxine 75mcg PO daily
once tolerating POs.
#) Pancreatic mass: Bile duct dilatation seen on CT but LFTs
normal. Concern for mass in head of pancreas. This is a possible
explanation for patient's history of abd pain, though pt has no
other signs/sx of systemic illness, including wt loss, appetite
loss, etc, and pancreatic CA would not explain patient's
pancolitis. GI was consulted and patient underwent MRCP and EUS,
both of which did not show pancreatic mass. Patient will
follow-up with Dr. [**Last Name (STitle) **] in GI on [**2191-3-22**] at 3:00pm.
#) Ovarian cyst: Seen on CT. Non-urgent outpatient evaluation
recommended.
#) HTN: Lisinopril and verapamil initially held in setting of
hypotension. Antihypertensives were re-introduced gradually
following stabilization of pt's BP. Discharged on home doses of
both medications (lisinopril 20mg daily, verapamil 240mg PO
BID).
#) Hyperlipidemia: Pt was continue on her home dose simvastatin
20mg PO daily once tolerating POs.
#) Hypomagnesium- Patient had low magnesium while here of
unknown etiology. She received supplemental magnesium and
responded well. She is being discharged on PO magnesium. We ask
that her rehab facility checks daily magnesium and repletes as
needed.
#) Rash- Patient developed a rash in her groin while here that
was treated with topical miconazole to which she responded well.
She also had a rash on her left buttock that was noticed by
nursing on [**3-9**]. Denied any itching or pain. It was slightly
improved on discharge.
#) Knee pain- Patient developed knee pain while here. Joint
thought to be swollen. Aspirate taken- did not show signs of
infection or crystal arthritis. Cultures negative. X-rays
showed osteoarthritis. Pain improved with tylenol (avoided
NSAIDs given recent GI symptoms). Patient worked with PT while
here. By discharge, pain was drastically improved.
Medications on Admission:
Levothyroxine 75 mcg Tablet
Verapamil 240mg PO BID
Lisinopril 20mg PO daily
Simvastatin 20mg PO daily
ASA 81mg PO daily
Ergocalciferol 1000 unit pacsulte PO daily
Ferrous Gluconate 240mg PO daily
Aleve 220 mg POD [**Hospital1 **]-TID
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Ergocalciferol (Vitamin D2) 400 unit Capsule Sig: 2.5
Capsules PO once a day.
6. Ferrous Gluconate 240 mg (27 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days: last day- [**3-16**].
Disp:*18 Tablet(s)* Refills:*0*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days: last day- [**3-16**].
Disp:*12 Tablet(s)* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day: until [**3-16**].
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for irritation.
15. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location 4288**]
Discharge Diagnosis:
Primary: Colitis- resolved.
Secondary: Hypertension, hyperlipidemia, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Level of Consciousness: Alert and interactive
Discharge Instructions:
You were admitted to the hospital after passing out. While
here, it was found that you had an inflammation of your small
bowel. In addition, they found a dilation of your bile duct.
The gastroenterologist team evaluated you and performed an MRCP
followed by an endoscopic ultrasound, which did not show any
pancreatic mass. Your symptoms improved while here and your
remained hemodynamically stable. You tolerated a regular diet
without difficulty. You experienced some knee pain but it
improved on its own. Upon discharge, you were stable and
comfortable.
The following changes were made to your medications:
1. Please continue taking ciprofloxacin 500mg by mouth twice a
day (last day- [**2191-3-16**])
2. Please continue taking metronidazole 500mg by mouth three
times a day (last day- [**2191-3-16**])
3. Please START taking folic acid 1mg by mouth daily
4. Please START taking thiamine- 1 tablet by mouth daily
5. Please START taking magnesium oxide 400mg by mouth daily
while on cipro and flagyl (until [**2191-3-16**])
6. Please START taking calcium plus vitamin D daily
7. Please do not take Aleve anymore given your recent GI
symptoms.
Followup Instructions:
Please follow-up with your primary care physician (Dr. [**First Name (STitle) 6624**] on
Friday, [**2191-3-18**] at 11:00am
Please follow-up with Dr. [**Last Name (STitle) **] (Gastroenterology) on [**2191-3-22**]
at 3:00pm. This will be on the [**Hospital Ward Name 516**] in the [**Last Name (un) 6625**] building
([**Location (un) 448**]). You can contact him at [**Telephone/Fax (1) 463**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2191-3-11**]
ICD9 Codes: 5990, 2762, 4589, 4019, 2449, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7303
} | Medical Text: Admission Date: [**2167-9-27**] Discharge Date: [**2167-10-2**]
Date of Birth: [**2099-1-22**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
pericardiocentesis
pacer lead revision
History of Present Illness:
Ms. [**Known lastname **] is a 68 year old female with h/o TIAs, HTN, PAF s/p SSS
s/p pacer presented to OSH with 1 week nausea, SOB,
palpitations. Found to have small left pleural effusion and
small pericardial effusion without tamponade. Also her atrial
fibrilliation was controlled initially with amiodarone, and now
she is on a diltiazem drip. Transferred to [**Hospital1 18**] for possible
lead revision versus removal of pacemaker if perforation. She
had slight CHF by BNP but actually sounding pretty clear on CXR.
Also with transient facial numbness.
Past Medical History:
cardiac tamponade
pericardial effusion
pleural effusion
atrial fibrillation
tachy/ brady syndrome
s/p pacemaker
h/o TIA
diverticulosis
hypertension
peptic ulcer disease
Social History:
Lives alone. No alcohol or tobacco. Retired.
Physical Exam:
98.8, 87, 140/61, 16, 96%2L, 98.7kg
Cor: irregularly irregular, normal rate, 10mmHg pulsus
Chest: decreased breathsounds at L>R base with egophany.
Pertinent Results:
[**2167-9-28**] 02:40AM BLOOD WBC-9.9 RBC-3.10* Hgb-10.1* Hct-29.4*
MCV-95 MCH-32.8* MCHC-34.5 RDW-12.9 Plt Ct-330
[**2167-9-28**] 02:40AM BLOOD Glucose-112* UreaN-20 Creat-0.9 Na-142
K-3.5 Cl-104 HCO3-26 AnGap-16
[**2167-9-29**] 01:05PM BLOOD Type-ART O2 Flow-2 pO2-69* pCO2-49*
pH-7.42 calHCO3-33* Base XS-5 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2167-9-29**] 01:00PM OTHER BODY FLUID WBC-5300* Hct,Fl-2.5*
Polys-48* Lymphs-43* Monos-5* Eos-2* Basos-1* Mesothe-1*
[**2167-9-29**] 01:00PM OTHER BODY FLUID TotProt-4.7 Glucose-82
LD(LDH)-2093 Amylase-18 Albumin-2.7
ELECTROCARDIOGRAM PERFORMED ON: [**2167-9-28**]
Atrial fibrillation.
Nonspecific ST-T wave changes
Echo [**9-28**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal (LVEF
60-70%). Right ventricular chamber size and free wall motion are
normal. Right ventricular systolic function is normal. The
aortic valve leaflets (3) are mildly thickened but not stenotic.
Trace aortic regurgitation is seen. Trivial mitral regurgitation
is seen. There is a moderate to large sized pericardial
effusion. The effusion appears circumferential. There is brief
right atrial collapse. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling and early cardiac
tamponade.
A pacemaker wire is seen in the right heart [**Doctor Last Name 1754**]; the tip is
at the apex of the right ventricle. Perforation cannot be
excluded with certainty, but the tip of the wire was not
visualized outside the epicardial surface of the heart.
Impression: moderate-to-large circumferential pericardial
effusion with early cardiac tamponade.
Catheterization:
INDICATIONS FOR CATHETERIZATION:
Pericardial effusion
FINAL DIAGNOSIS:
1. Successful pericardiocentesis.
2. Mild pulmonary hypertension.
COMMENTS:
1. Limited resting hemodynamics prior to pericardiocentesis
showed a
mildly elevated pulmonary pressure (PA mean 28 mmHg). The left
and right
sided filling pressures were elevated and entrained in the
pericardial
pressure (RA mean 14 mmHg, PCW mean 19 mmHg, RVEDP 19 mmHg,
Pericardium
mean 15 mmHg). The cardiac output was normal (CO 4.5 l/min, CI
2.15
l/min/m2).
2. The mean right atrial and pericardial pressure after
pericardiocentesis of 600 ml of fluid was 7 mmHg and 4 mmHg,
respectively. Cardiac output and index were essentially
unchanged (CO
5.0 l/min, CI 2.4 l/min/m2).
3. An echocardiogram after pericardiocentesis showed minimal
residual
fluid in the pericardium.
4. The pacemaker lead positions were confirmed with fluroscopy
together with the electrophysiology team.
Echo: [**10-1**]
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There is a small to moderate
sized pericardial effusion subtending the right atrial and right
ventricular free walls. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. There are
no echocardiographic signs of tamponade. No right atrial
diastolic collapse is seen.
Compared with the findings of the prior study (tape reviewed) of
[**2167-9-30**], no major change is evident; a small-to-moderate
sized pericardial effusion without evidence of cardiac tamponade
persists.
CXR:
FINDINGS: Note is made of dual chamber cardiac pacemaker, with
two leads, one
terminating in the right atria appendage and the other one
terminating in the
right ventricle. No evidence of pneumothorax. Again note is made
of
cardiomegaly. The mediastinal and hilar contours are unchanged
compared with
previous study. Again note is made of bilateral pleural
effusions with left
lower lobe atelectasis, which is likely increased compared to
prior study.
Pulmonary vasculatures are within normal limits, and there is no
evidence of
cardiac failure.
There is no suspicious lesion in skeletal structures.
IMPRESSION: Cardiac pacemaker leads as described above. No
pneumothorax.
Cardiomegaly. Increased bilateral pleural effusion and
atelectasis.
Brief Hospital Course:
Ms. [**Known lastname **] is a 68 yo woman who underwent pacemaker placement two
weeks prior to admission, found to have subsequent pericardial
and pleural effusions with moderate tamponade. She then
underwent pericardiocentesis draining 600cc of fluid. Following
the procedure she was observed in the CCU, where she remained
stable until returning to the cardiology service a few days
later. After her pericardiocentesis, she underwent pacer lead
revision. A repeat Echo showed stable small to moderate
effusion without evidence for tamponade. She did have bilateral
pleural effusions, which were not clinically significant given
that her ambulatory saturations were >90% on room air.
Regarding her atrial fibrilliation, we titrated up her
beta-blocker because she was tachycardic upon exertion.
Cardioversion was not completed because anticoagulation is
contraindicated after pericardiocentisis.
Discharge Medications:
1. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QD (once a day).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
4. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Dorzolamide HCl 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 3 days.
Disp:*9 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
cardiac tamponade
pericardial effusion
pleural effusion
atrial fibrillation
tachy/ brady syndrome
s/p pacemaker
h/o TIA
diverticulosis
hypertension
peptic ulcer disease
Discharge Condition:
stable
Discharge Instructions:
please call your doctor or go to the emergency room if you
develop worsening shortness of breath
Followup Instructions:
with Primary care physician within one to two weeks of discharge
please call your cardiologist for a follow up appointment in [**12-19**]
weeks after discharge
Please keep scheduled appointment with Dr [**Last Name (STitle) 1911**] ([**Telephone/Fax (1) 55291**] in [**Location (un) **].
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 55292**] Call to schedule
appointment
ICD9 Codes: 4280, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7304
} | Medical Text: Admission Date: [**2156-12-8**] Discharge Date: [**2156-12-20**]
Date of Birth: [**2094-3-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
ETOH Cirrhosis and HCC now s/p orthotopic liver transplant
Major Surgical or Invasive Procedure:
[**2156-12-8**]: Orthotopic liver transplant
[**2156-12-17**]: ERCP
History of Present Illness:
62 y.o. male with ETOH cirrhosis/HCC with diuretic-resistant
ascites despite placement of a TIPS shunt and resultant
significant hydrocele and possible inguinal hernia. He is
requiring paracentesis approximately every 7 to 10 days. Last
tap 2 weeks ago and was scheduled for a tap today at [**Hospital1 3325**].
Past Medical History:
1. Alcohol-related cirrhosis status post TIPS placement
[**2154-10-8**]
requiring dilatation [**2154-10-15**]
2. Upper GI bleeding in [**2152**]. Patient was treated at an
outside
hospital and it is unclear whether his upper GI bleed was
secondary to esophageal varices or peptic ulcer disease.
3. Coronary artery disease status post angioplasty in the
[**2129**].
4. Diabetes mellitus type 2 diagnosed in [**2152**]. Hemoglobin A1c
[**2154-10-4**] was 6.3
5. Umbilical hernia status post repair [**2154-11-3**]
6. Right knee surgery
7. Depression
8. HCC, growth [**Last Name (un) 64259**] 2.5x2.5cm confirmed on [**2156-9-8**] at the dome
of the liver
9. Recurrent recent paracentesis due to refractory ascites
Social History:
Married with two adult sons. Formerly worked as a vice
president
of a trucking company. Drank from the age of 20 until [**2154-9-19**]. He never smoked. Denies IV drug use.
Family History:
Father and brother died of MI at the age of 52. His mother and
sister have diabetes.
Physical Exam:
98.3 59 123/72 20 99%RA 5'8", wt 104.8kg
A&O x3, nervous, wife present
anicteric sclerae, mmm, pharynx wnl, upper dentures
Neck: no LAD, no TM, 2+ bilat carotids without bruits
Luns: clear
Cor: RRR, no murmur
Abd: Large/ascites/tense, ventral hernia obvious with head to
chin tuck, NT
Back: R flank lipoma, no cvat tenderness
GU: large Right hydrocele
Vasc: 1+ femoral pulses, no bruits
Ext: trace ankle edema, 2+ DPs, no cyanosis
Neuro: A&O x3, no asterixis/flap, toes down Bilat. strength 5/5
bilaterally & equal,
skin: [**Location (un) **] erythema
Pertinent Results:
On Admission: [**2156-12-8**]
WBC-5.3 RBC-3.27* Hgb-10.5* Hct-29.8* MCV-91 MCH-32.1*
MCHC-35.3* RDW-14.4 Plt Ct-156
PT-13.6* PTT-31.7 INR(PT)-1.2* Fibrino-486*
Glucose-153* UreaN-21* Creat-1.7* Na-135 K-4.1 Cl-102 HCO3-24
AnGap-13
ALT-25 AST-43* AlkPhos-127* Amylase-50 TotBili-1.6* Lipase-44
On Discharge [**2156-12-20**]
WBC-7.7 RBC-2.74* Hgb-8.4* Hct-24.3* MCV-89 MCH-30.9 MCHC-34.7
RDW-17.3* Plt Ct-182 Fibrino-271
Glucose-111* UreaN-28* Creat-1.8* Na-134 K-4.5 Cl-104 HCO3-22
AnGap-13
ALT-55* AST-22 AlkPhos-171* Amylase-84 TotBili-0.8 Lipase-114*
Albumin-2.4* Calcium-7.6* Phos-2.9 Mg-1.9
Iron Studies: [**2156-12-19**]
Brief Hospital Course:
62 y/o male with Hepatitis C virus cirrhosis and hepatocellular
carcinoma is admitted for Orthotopic (piggyback) donor after
cardiac death (DCD) liver transplant, portal vein-portal vein
anastomosis, branch patch (recipient) to celiac patch (donor),
common bile duct to common bile duct anastomosis (no T tube)
with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please see the operative note for
surgical details. In addition it should be noted that this is a
DCD donor who also was HTLV1 and HTLV2 serologically
positive. Prior to surgery this was discussed in detail with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
in infectious disease and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] in hepatology. It
was determined that the risk of continued progression of his
hepatocellular carcinoma and risk of complications and death
from his end-stage liver disease was greater than the risk of
transmission and the development of disease related to the HTLV1
and HTLV2 positivity. This was discussed with Mr. and Mrs.
[**Known lastname 64260**] in great detail and informed consent was given.
At the time of exploration the patient had approximately 12
liters of ascites that was cloudy and appeared chylous. It did
not smell or appear grossly infected. There was no fibrin in the
peritoneal cavity and no inflammation suggestive of peritonitis.
The fluid was sent for Gram stain which returned 1+ polys.
Cultures were sent which were returned as no growth.He was given
vancomycin and Zosyn in
addition to his preoperative Unasyn and in addition received
routine induction immunosuppression. He had a small cirrhotic
liver with normal anatomy. There was a tumor in theright lobe of
the liver, but no evidence of any extrahepatic spread. The donor
liver had a replaced left hepatic artery.
Patient was transferred to the SICU following surgery. He was
extubated on POD 2, and subsequently transferred the same day.
Seen by [**Last Name (un) **] for blood glucose management. He was managing
glucose at home prior to surgery with diet but will be
discharged home on Lantus and a humalog sliding scale. Patient
and wife received teaching and meds/syringes/supplies were
ordered.
On POD 6 the patient suffered a hypotensive episode with
tachycardia that appeared to be AFib on telemetry. He denied
chest pain, SOB or palpitations. He received a NS bolus for BP
of 80/P. Cardiology was consulted. Enzymes were cycled (normal,
metoprolol was continued. An Echo was performed showing an EF of
35%. In addition findings included comparison with the prior
study (images reviewed) of [**2155-4-16**], showing the regional left
ventricular systolic dysfunction is new and c/w interim
ischemia/infarction (mid-LAD distribution). No anticoagulation
ws recommended, Metoprolol was increased to 25 [**Hospital1 **].
On POD 4 the medial drain started with more output and a drain
bili was sent with a result of 7.7. A CT was done showing no
drainable collections. After the patient fall he had an U/S of
the liver done to evaluate blood flow which was normal.
This output was followed for several days, and output was
replaced with albumin for each liter of output. When no relief
of drainage, patient was sent for an ERCP on [**12-17**] (POD 9)
Cholangiogram showed leak of contrast at the anastomotic site of
the [**Last Name (un) 28791**] and native bile duct and a 9cm by 10F Cotton [**Doctor Last Name **]
biliary stent was placed successfully across the anastomotic
leak site. Patient did have post ERCP pancreatitis, which was
treated with continued clears for an additional day. By POD 11
he was tolerating regular diet and the amylase and lipase
normalized.
On POD 12 (day of discharge) the final drain was removed and
suture placed.
He will go home with VNA for help with medications and blood
sugar management as this is a new therapy for him.
Medications on Admission:
Celexa 40', Furosemide 80', Spironolactone 25', Flomax 0.4',
Oxycodone 5'hs, Lactulose PRN,
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day for
3 days: Follow Prednisone Taper per transplant clinic
guidelines.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Continue as long as taking pain medication and as
needed.
Disp:*60 Capsule(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed
for constipation.
Disp:*60 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime: Then continue sliding scale Humalog.
14. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
15. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day: Total 2.5 mg [**Hospital1 **].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
ETOH cirrhosis and HCC now s/p liver transplant
Discharge Condition:
Good
Discharge Instructions:
Call the transplant office at [**Telephone/Fax (1) 673**] if you experience any
of the following symptoms: fever > 101, chills, nausea,
vomiting, diarrhea, inability to eat, or inability to take or
keep down medications.
Monitor for pain over the incision site or liver, yellowing of
the skin or eyes, an increase in abdominal girth. Monitor
incision for redness, drainage or bleeding.
Do not drive if you are taking narcotics.
Take your medications exactly as directed.
No heavy lifting
You may shower, pat incision dry
Have labs drawn every Monday and Thursday and have them faxed to
[**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, Alk Phos, Albumin, T Bili
and trough Prograf Level
Followup Instructions:
Please call [**Telephone/Fax (1) 673**] for appointment with Dr [**Last Name (STitle) **] on
Wednesday [**12-22**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2156-12-20**]
ICD9 Codes: 9971, 3572, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7305
} | Medical Text: Admission Date: [**2150-2-18**] Discharge Date: [**2150-3-10**]
Date of Birth: [**2124-5-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hurricaine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Thoracentesis [**2150-2-19**]
Bronchoscopy, Right VATS with lung decortication and chest tube
placement [**2150-2-20**]
Bronchoscopy, Right VATS, evacuation of hematoma [**2150-2-25**]
Transesophageal Echocardiogram [**2150-3-6**]
History of Present Illness:
This is a 25 year old gentleman with a history of IV drug abuse
who presented to [**Hospital1 **] [**Location (un) 620**] on [**2150-2-17**] with 2 weeks of pleuritic
chest pain and was found to have a large right-sided pleural
effusion and a left lower lobe infiltrate. The patient reports
pain with deep inspiration and coughin. He describes chills. He
has no prior history of pneumonia or pulmonary problems. At
[**Name2 (NI) **] he was febrile to a temp of 102 and cultures were drawn;
he was started empirically on ceftriaxone and zithromax. He
became progressively hypoxic to 88 on room air (up to 95% on 4
liters). A thoracentesis was performed but failed and his
effusion worsened.
Past Medical History:
Depression
Polysubstance Abuse
Suicidal Ideation
Motor Vehicle Accident
Social History:
The patient has a history of IV heroin and cocaine use. He
smokes 4 packs of tobacco/week. He completed some community
college. He lives with his mother in [**Name (NI) 932**], MA. He is working
in construction.
Family History:
Noncontributory
Physical Exam:
ON admission:
v/s 101.8, 148/66, pulse 120 sinus, 27, 93% on 4 L
Gen: answering questions appropriately, falling asleep
(sedatives on-board)
HEENT: PERRL, EOMI, MMM
Neck: no LAD
CV: sinus tachycardia, no murmur
Chest: poor inspiratory effort, bronchial breath sounds at right
base, crackles at left base
Abd: soft, + BS, nontender
Extr: warm, 2+ DP, no edema
Neur: CN 2-12 grossly intact, strength 5/5 throughout
Pertinent Results:
SEROLOGIES
[**2150-2-18**] 09:41PM BLOOD WBC-24.4* RBC-4.19* Hgb-12.3* Hct-34.5*
MCV-82 MCH-29.5 MCHC-35.8* RDW-13.0 Plt Ct-354
[**2150-2-19**] 06:45PM BLOOD WBC-18.3* RBC-3.21* Hgb-9.8* Hct-27.0*
MCV-84 MCH-30.4 MCHC-36.1* RDW-13.2 Plt Ct-276
[**2150-2-19**] 11:53PM BLOOD WBC-20.5* RBC-3.74* Hgb-11.0* Hct-31.3*
MCV-84 MCH-29.4 MCHC-35.1* RDW-13.1 Plt Ct-349
[**2150-2-23**] 10:40AM BLOOD WBC-12.9* RBC-2.97* Hgb-9.2* Hct-24.9*
MCV-84 MCH-30.9 MCHC-36.9* RDW-13.1 Plt Ct-500*
[**2150-2-26**] 03:29PM BLOOD WBC-16.6* RBC-2.90* Hgb-8.7* Hct-24.4*
MCV-84 MCH-30.1 MCHC-35.9* RDW-13.5 Plt Ct-571*
[**2150-3-6**] 06:00AM BLOOD WBC-12.7* RBC-3.50* Hgb-9.9* Hct-29.0*
MCV-83 MCH-28.3 MCHC-34.1 RDW-13.4 Plt Ct-592*
[**2150-3-7**] 10:00AM BLOOD WBC-10.5 RBC-3.36* Hgb-9.6* Hct-27.8*
MCV-83 MCH-28.6 MCHC-34.5 RDW-13.4 Plt Ct-541*
[**2150-3-8**] 04:35AM BLOOD WBC-9.6 RBC-3.56* Hgb-10.5* Hct-29.3*
MCV-82 MCH-29.4 MCHC-35.8* RDW-13.3 Plt Ct-474*
[**2150-2-18**] 09:41PM BLOOD PT-14.3* PTT-35.3* INR(PT)-1.4
[**2150-2-20**] 01:58AM BLOOD PT-13.6* PTT-33.2 INR(PT)-1.2
[**2150-3-5**] 11:46AM BLOOD Fibrino-738*
[**2150-3-6**] 06:00AM BLOOD Fibrino-767*
[**2150-3-6**] 09:00AM BLOOD Eos Ct-490*
[**2150-2-21**] 01:16PM BLOOD Ret Aut-1.0*
[**2150-2-18**] 09:41PM BLOOD Glucose-123* UreaN-8 Creat-0.7 Na-132*
K-4.0 Cl-96 HCO3-26 AnGap-14
[**2150-2-19**] 06:45PM BLOOD Glucose-97 UreaN-7 Creat-0.6 Na-134 K-4.0
Cl-97 HCO3-28 AnGap-13
[**2150-2-20**] 01:58AM BLOOD Glucose-119* UreaN-9 Creat-0.6 Na-135
K-3.8 Cl-97 HCO3-29 AnGap-13
[**2150-3-6**] 06:00AM BLOOD Glucose-89 UreaN-21* Creat-1.8* Na-142
K-4.8 Cl-103 HCO3-26 AnGap-18
[**2150-3-7**] 10:00AM BLOOD Glucose-91 UreaN-23* Creat-1.8* Na-140
K-4.5 Cl-104 HCO3-26 AnGap-15
[**2150-3-8**] 04:35AM BLOOD Glucose-104 UreaN-24* Creat-1.7* Na-141
K-4.2 Cl-104 HCO3-26 AnGap-15
[**2150-2-18**] 09:41PM BLOOD ALT-13 AST-17 LD(LDH)-197 AlkPhos-75
TotBili-0.6
[**2150-2-18**] 09:41PM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.9 Mg-1.7
[**2150-2-19**] 06:45PM BLOOD Albumin-3.3* Calcium-8.9 Phos-4.3 Mg-1.8
[**2150-2-21**] 01:16PM BLOOD Calcium-8.1* Phos-3.8 Mg-1.9 Iron-10*
[**2150-2-20**] 01:58AM BLOOD VitB12-714 Folate-7.2
[**2150-2-21**] 01:16PM BLOOD calTIBC-183* Ferritn-465* TRF-141*
[**2150-2-20**] 01:58AM BLOOD TSH-2.7
[**2150-3-6**] 09:00AM BLOOD C3-210* C4-50*
[**2150-2-26**] 05:13PM BLOOD HIV Ab-NEGATIVE
[**2150-2-22**] 06:00AM BLOOD Vanco-7.2*
[**2150-2-22**] 09:02PM BLOOD Vanco-4.4*
[**2150-2-28**] 08:34PM BLOOD Vanco-18.5*
[**2150-3-2**] 04:34PM BLOOD Vanco-24.2*
[**2150-3-4**] 09:45AM BLOOD Vanco-17.4*
RADIOLOGY:
[**2150-2-18**] CXR: There is a large right pleural effusion. Cannot
exclude loculation and decubitus chest radiograph could be
performed if indicated. The large pleural effusion obscures the
detail of the lung parenchyma. The left lung demonstrates only
mild atelectasis of the left base. No focal consolidations of
the left lung is seen. The pleural effusion is causing mass
effect and mild shift of the mediastinal structures to left
side. There is no evidence of pneumothorax.
[**2150-2-19**] CT Chest:
1) Massive right-sided pleural effusion, with associated
atelectasis of the entire right lung. No hematocrit level. No
particular loculations are seen, and the density attenuation
values are at the upper limits of normal for simple fluid.
Empyema should be considered in patient with history of IVDA.
Differential diagnosis includes TB, malignancy, and trauma (no
evidence of active or recent bleeding).
2) Left-sided peripheral ground glass opacities are likely
infectious. Septic emboli should be considered given history of
IVDA.
[**2150-2-23**] CT Chest: 1. Interval placement of two right-sided chest
tubes, as detailed above, with decrease in size of massive
right-sided effusion.
2. Residual loculated fluid collections within the right
hemithorax as
detailed above with higher attenuation collections near the
right lung apex, which could represent areas of hemothorax.
3. Small focal area of consolidation in the left lung base
medially, which could represent an area of rounded atelectasis
or small developing infiltrate.
[**2150-2-27**] Renal US: . No evidence of hydronephrosis.
2. Large kidneys bilaterally with relatively echogenic
cortices.
[**2150-3-4**] Ultrasound: No evidence of DVT in either lower
extremity.
[**2150-3-6**] TEE: A catheter is seen in the right atrium that extends
to the tricuspid annulus. There is no associated
thrombus/vegetation. No spontaneous echo contrast or thrombus is
seen in the body of the left atrium/left atrial appendage or the
body of the right atrium/right atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion. A TEE procedure related
complication occurred (see comments for details).
IMPRESSION: Low normal LV systolic function with mild mitral
regurgitation. Mild mitral regurgitation with normal valve
morphology. No definite evidence of endocarditis.
PATHOLOGY:
Pleural rind":
- Scant fibroadipose tissue and granulation tissue with
abundant fibrinopurulent exudates.
- No malignancy identified.
MICROBIOLOGY:
[**2150-2-19**] Pleural fluid culture: negative
[**2149-2-20**] Bronchial Fluid culture: negative
Brief Hospital Course:
This is a 25 year old gentleman with polysubstance abuse who
presented from [**Hospital1 18**] [**Location (un) 620**] with fevers and a large right
pleural effusion that was not drainable via thoracentesis. He
was admitted to the medical intensive care unit. He was started
on broad-spectrum antibiotics. Ultrasound-guided thoracentesis
was performed on admission but was unsuccessful in draining
adequate fluid. Thoracic surgery was consulted and the pateint
underwent a VATS with mechanical pleurodesis and placement of a
chest tube and [**Doctor Last Name 406**] drain on [**2150-2-19**] (please see the operative
note of Dr. [**Last Name (STitle) **] for full details). Infectious disease
consultation was obtained and the patient was started on Zosyn
and Vancomycin; AFB and sputum cultures were sent but were
negative. Given the patient's aggitation on admission and
substance abuse history, psychiatric consultation services were
obtained and recommended refraining from benzodiazepenes and
Haldol/Seroquel prn. On post-operative day 4 a CT scan revealed
worsening effusion and the patient again was taken for VATS with
evacuation of hemothorax. He did well post-operatively with no
pain-related or respiratory complications. A Trans-esophageal
echocardiogram was performed on [**2150-3-3**] but discontinued
secondary to hypoxia from meth-hemoglobinemia; a repeat TEE
performed on [**2150-3-7**] revealed no evidence of endocarditis. The
patient developed a rise in his creatinine around this time and
Renal consultation was obtained; it was thought that he
developed acute interstitial nephritis from his antibiotics and
the Vancomycin was discontinued. He remained afebrile with the
Zosyn and his leukocytosis resolved. His [**Doctor Last Name 406**] drain was changed
to a Heimlich valve on [**2150-3-5**]. His chest-tube was removed on
[**2150-3-6**] and his [**Doctor Last Name 406**] drain on [**2150-3-8**]. A PICC was placed for
outpatient continuation of his 4 weeks of antibiotics. Because
of the patient's substance abuse history, he was not deemed a
candidate for home antibiotic therapy and a rehabilitation
hospital was found for him. He was discharged with continuation
of his inpatient medications and planned follow-up with thoracic
surgery, infectious diseases, and psychiatry. All questions were
answered to his satisfaction upon discharge.
Medications on Admission:
Motrin
Discharge Medications:
1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
2. Senna Oral
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2-3 PRN () as
needed for pain.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day).
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for prn agitation.
9. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
10. Haloperidol 5 mg IV Q4H:PRN agitation
11. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 g Recon
Solns Intravenous Q8H (every 8 hours): Continue for total of 4
weeks, through [**2150-3-24**].
12. 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.
13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary: Right-sided hemothorax
Secondary: polysubstance abuse, depression, acute renal failure
from interstitial nephritis
Discharge Condition:
Tolerating POs. Good pain control. Afebrile.
Discharge Instructions:
Take all medications as prescribed. You should call the office
with any worsening shortness of breath or chest pain, or fevers
to 102. Only take narcotics as necessary for pain control, and
note that they can cause confusion and nausea. You may shower
and resume your regular diet and physical activity, but refrain
from strenuous activity for 3 weeks. Please call with any
questions.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2150-3-24**] 11:30 [Infectious [**Hospital 2228**] Clinic]
You should follow-up in the office with Dr. [**First Name (STitle) **] [**Name (STitle) **]
(thoracic surgery) within 2 weeks-- call for an appointment at a
time of your convenience at [**Telephone/Fax (1) 170**]
Follow-up with your outpatient psychiatrist (Dr. [**Last Name (STitle) 64786**]
[**Telephone/Fax (1) 64787**]) within 2 weeks.
Completed by:[**2150-3-9**]
ICD9 Codes: 486, 5845, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7306
} | Medical Text: Admission Date: [**2129-3-17**] Discharge Date: [**2129-3-23**]
Date of Birth: [**2101-10-19**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 824**]
Chief Complaint:
27 yoM otw healthy male who presents from OSH bladder
perforation
Major Surgical or Invasive Procedure:
Repair Bladder perforation
History of Present Illness:
27 yoM otw healthy male who presents from OSH with peritoneal
sxs, WBC 27, intraperitoneal fluid collection, and
extraperitoneal urine leak.
Mr. [**Known lastname 1356**] [**Last Name (Titles) 5058**] this AM with dark urine and severe abdominal
pain
radiating into L groin. OSH work-up revealed WBC 27 (18%
bands),
UA suspicious for UTI, and CT with air around SVs. Foley was
placed and patient was transferred to [**Hospital1 **] where follow-up CT
revealed increasing size in intraperitoneal fluid collection,
and
posterior bladder/urethra urine leak on cystogram. Patient has
been given morphine with some relief of pain. History notable
for fall one month ago(he was pushing [**Female First Name (un) 72809**] up ramp, ramp broke,
and he fell onto the handlebar of the [**Female First Name (un) 72809**] from a hight of 4
feet - handlebar hit his scrotum) He noted injury to right
anterior scrotum, requiring dermabond closure in ED. Per
patient
report, has healed well.
Patient reports increased frequency (q1hr) and nocturia (1-2x
per
night) that has started recently (unsure exactly when). He
denies hematuria/pneumaturia/fecaluria. No incontinence. No
history of kidney stones.
Past Medical History:
none, no prior surgeries or hospitalizations
Social History:
Works in construction
Family History:
noncontributory
Physical Exam:
alert, nad
rrr, cta
abd s/nt/nd
incision cdi, no evidence of infection
foley in place, fastened, draining clear urine
Pertinent Results:
....RADIOLOGY
[**3-17**] CT Urogram: IMPRESSION:
1. On delayed imaging (301B:24), there is evidence of a
superoposterior leak within the bladder, close to the site of
junction with prostatic urethra, with active but relatively
contained extravasation from this site. This finding suggests
that the significant free intrapelvic fluid represents urine
ascites. There is no foreign body identified within this site,
though this would be an unusual site of post-traumatic rupture.
2. No abnormality within the ischiorectal fossa fat and there is
no intrinsic abnormality within the rectosigmoid region to
specifically suggest rectal or other bowel injury or fistula to
bladder.
3. Two non-calcified pulmonary nodules noted in the right base.
In the absence of known malignancy recommend one-year follow up
to ensure stability.
COMMENT: These findings are most suggestive of a relatively
acute bladder rupture or perforation, with significant intra-
and and small extraperitoneal (retroperitoneal) components,
given the minute air bubbles in the seminal vesicles and ventral
to the psoas muscle. There is no evidence of involvement of the
extraperitoneal space of Retzius.
.
[**3-20**] CT Urogram: IMPRESSIONS:
1. Superior posterior bladder leak, in the same position as on
the prior examination. The extravasation appears, given
technique, less than before.
2. Bilateral atelectasis and/or airspace disease.
.
[**3-21**] CT Cystogram: IMPRESSION: Findings are consistent with
extravasation of contrast from the superoposterior aspect of the
bladder. Contrast remains between the bladder and the seminal
vesicles. There is no evidence of intraperitoneal extravasation
of contrast. Findings are similar to those described on the CT
scan performed approximately 12 hours earlier.
Brief Hospital Course:
Given the CT findings Mr. [**Known lastname 1356**] [**Last Name (Titles) 1834**] an uncomplicated
repair of bladder perforation. He was kept in ICU on first day
for close observation. His post-op course was uneventful.
After surgery, patients WBC continued to fall and his pain
resolved. He was extubated on POD1 and his pain was conrolled
with a dilaudid PCA. His diet was advanced on POD2 and he was
started on oral pain medications. On POD3 he was transferred
out of the SICU to 12 [**Hospital Ward Name 1827**]. However, he was noted on POD3 to
have increasing abdominal pain. A CT urogram was done on [**3-20**]
which showed on intraperitoneal leak and only a small
retroperitoneal leak. This was confirmed with a CT urogram on
[**3-21**]. He continued to be stable and his pain improved over the
next several days. On POD6 his JP drain was removed and he was
discharged home with a catheter in place, on a 10 day course of
ciprofloxacin. He will follow up with Dr. [**Last Name (STitle) 770**] as an
outpatient in 1 week.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day): apply to tip of penis while catheter is in.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q 24H (Every 24 Hours) as needed for constipation.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
continue while taking percocet.
6. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day: do not take at the same time as milk of mag.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bladder perforation
Discharge Condition:
Stable
Discharge Instructions:
Call if you develop fever greater than 101.5 or new nausea or
vomiting. Call if your incision becomes more red or has new
drainage. Call your doctor [**First Name (Titles) **] [**Last Name (Titles) 9140**] pain not controlled by
pain medications. You may shower, but no hot tubs/swimming for
2 weeks. Shower daily and clean any debris of the catheter. No
lifting greater than 15 pounds until follow up. The catheter
and staples will be removed at your follow-up appointment.
Continue the ciprofloxacin until your follow up appointment.
Followup Instructions:
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office to arrange follow-up in [**11-23**]
weeks. ([**Telephone/Fax (1) 7707**]
Completed by:[**2129-3-23**]
ICD9 Codes: 5990, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7307
} | Medical Text: Admission Date: [**2156-1-10**] Discharge Date: [**2156-1-19**]
Date of Birth: [**2071-4-23**] Sex: M
Service: MEDICINE
Allergies:
Robitussin Pediatric / Hytrin / Hydrochlorothiazide
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
HD line placement, intubation
History of Present Illness:
84 year old male with hx of HTN, CVA, cirrhosis, known ascites,
presents s/p fall. Patient says that he got up from his couch,
felt unsteady, and fell on his right shoulder and back. Says he
may have felt a little dizzy prior to falling, but is not sure.
The fall was unwitnessed. Patient doesn't think that he hit his
head or lost consciousness, but son reported that there was LOC.
He had had a beer and a sip of brandy prior to getting up off
the couch. He's had [**4-3**] other falls in the past. The most recent
of which was 1 week ago. Says that he had gotten his foot caught
on the carpetting and fell. Has felt slightly weaker in the past
week. Denies chest pain, SOB, palpitations, n/v.
.
Patient also complains of having diarrhea off and on. He had
diarrhea starting this morning, saying that he's had [**1-14**]
episodes of diarrhea already. Last incidence of diarrhea was
about 1-2 weeks prior to this one. Denies any fevers, abdominal
pain, nausea, vomiting.
.
In the ED, a bedside abdominal ultrasound was done to check for
abdominal bleeding, which returned positive. This prompted a CT
of the torso which showed no bleed. He received 2 L of fluids in
the ED for a lactate of 2.2. Lactate improved to 0.9.
Orthostatics reported to be normal. He was also noted to be
hyponatremic at 125.
.
On the floor patient is feeling comfortable. Not complaining of
anything other than a little soreness in his shoulder and back
from where he fell.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting,
constipation or abdominal pain. No dysuria. Denied arthralgias
or myalgias.
Past Medical History:
HTN
BPH
h/o ascites
CVA - [**2140**] visual field loss right eye. ?amaurosis. By report,
no etiol found. [**4-8**] ? h/o one week of right facial weakness.
Subtle
asymmetry on exam. Began ASA. Carotid U/S shows <40% stenosis
bilat. [**8-8**] branch retinal artery occlusion, Rx conservatively
(Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23333**]). Previous w/u for embolic source neg.
Resumed ASA.
Cirrhosis - [**8-7**] U/S suggestive of fibrosis
Allergic rhinitis
B12 deficiency anemia
EtOH abuse
Social History:
Drinks 5 beers and has a "couple of shots" of brandy a day, 12
pack year smoking hx quit [**2103**].
Retired, worked as a police officer
Recently widowed
Family History:
Sister had rectal cancer, brother with a history of brain
cancer.
Physical Exam:
On admission:
Vitals: 98.1, 174/87, 81, 20, 100%4L
General: AAOx3, NAD
HEENT: PERRLA, EOMI, OP clear, no JVD, no LAD, neck supple
Lungs: slight dullness to auscultation in right lower lobe,
otherwise clear breath sounds, no w/r/r
CV: S1S2, RRR, no m/r/g
Abd: soft, distended, +ascites, nontender, +BS
Ext: no e/c/c, 1+ peripheral pulses
Neuro: no nystagmus, CN II-XII grossly intact, 5/5 strength
throughout, good coordination
On discharge:
Pertinent Results:
[**2156-1-10**] 02:50PM GLUCOSE-94 UREA N-14 CREAT-1.5* SODIUM-125*
POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-19* ANION GAP-17
[**2156-1-10**] 02:50PM ALT(SGPT)-13 AST(SGOT)-38 ALK PHOS-204* TOT
BILI-0.4
[**2156-1-10**] 02:50PM ETHANOL-25*
[**2156-1-10**] 02:50PM WBC-6.7 RBC-3.82* HGB-10.5* HCT-31.3* MCV-82
MCH-27.5 MCHC-33.6 RDW-15.1
[**2156-1-10**] 02:50PM PT-13.2 PTT-29.4 INR(PT)-1.1
[**2156-1-10**] 02:55PM LACTATE-2.2*
[**2156-1-19**] 02:42AM BLOOD Hct-18.2*#
[**2156-1-19**] 09:42AM BLOOD Hct-26.7*
[**2156-1-19**] 05:44AM BLOOD PT-22.8* PTT-57.0* INR(PT)-2.2*
[**2156-1-19**] 03:24AM BLOOD Glucose-105* UreaN-75* Creat-5.7* Na-131*
K-4.7 Cl-97 HCO3-17* AnGap-22*
[**2156-1-19**] 03:24AM BLOOD ALT-11 AST-24 LD(LDH)-145 AlkPhos-134*
TotBili-5.9* DirBili-4.5* IndBili-1.4
[**2156-1-19**] 03:24AM BLOOD Albumin-3.3* Calcium-7.5* Phos-3.9 Mg-2.1
[**2156-1-19**] 05:47AM BLOOD Type-ART Temp-35.5 pO2-146* pCO2-33*
pH-7.30* calTCO2-17* Base XS--8 Intubat-INTUBATED
Micro:
[**2156-1-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY INPATIENT
[**2156-1-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-17**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2156-1-17**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL INPATIENT
[**2156-1-17**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-16**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2156-1-15**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Antigen Screen-FINAL; Respiratory Viral
Culture-FINAL INPATIENT
[**2156-1-15**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2156-1-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2156-1-13**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
[**2156-1-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2156-1-13**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
[**2156-1-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2156-1-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPH AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2156-1-12**] URINE URINE CULTURE-FINAL INPATIENT
[**2156-1-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPH AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL;
Anaerobic Bottle Gram Stain-FINAL INPATIENT
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2156-1-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2156-1-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Brief Hospital Course:
MEDICAL FLOORS COURSE:
Mr [**Known lastname 23334**] is an 84 M with HTN, h/o prior CVA, EtOH abuse who
presented s/p fall, subsquently found to have MSSA bacteremia,
SBP and transuduative pleural effusion; transferred to MICU on
[**1-17**] with altered mental status.
.
# Fall. Per report appears to have syncopized in setting of
hypovolemia (poor PO intake as well as diarrhea in days
preceding hospitalization). No indication of seizure activity
(no incontinence, no post-itcal state) No evidence of cardiac
cause as telemetrey monitored without evident, biomarkers
negative. CT head: negative.
.
# Cirrhosis/ascites/sbp. Regarding risk factors patient with
known h/o EtOH abuse as well as hep B infection which had been
cleared based on serologies. Hep C negative. Patient without
formal diagnosis of cirrhosis in past though hypothesized due to
[**2153**] US with nodular liver characterized. On admission physical
patient with signs of cirrhosis: tense peri-hepatic ascites,
bilateral peripheral edema, splenomegaly, spider angiomas,
Duputrons contractures. Diagnostic paracentitis performed with
peritoneal fluid consistent with SBP. Patient started on
ceftriaxone which was later switched to cipro/flagyl. Patient
received albumin per SBP protocal. Liver consulted for
assistance in management. Due to preserved synthetic function
there was question regarding etiology of ascites ? cirrhosis vs
cardiac however [**Year (4 digits) **] demonstrated preserved systolic function
with EF>55%. RUQ US obtained which demonstrated nodular hepatic
architecture, no focal liver lesion, no
biliary dilatation, mild splenomegaly, no e/o portal vein
thrombosis.
.
# Cough. Patient with 3-4months of productive cough which he
attributed to allergies.
Admission CT with moderate right pleural effusion with adjacent
compressive atelectasis. Patient found to be dyspneic on Day 2.
Diuresis with IV Lasix 20mg attempted without improvement of
symptoms. Decision made to proceed with diagnostic and
therapeutic thoracentitis. Fluid consistent with exudate
?parapneumonic. Urine legionella negative. Repeat CXR with
improved effusion with RLL opacity: atelectasis/fluid though
underlying consolidation could not be ruled out. Patient
initially treated for commmunity-acquired pneumonia with
ceftriaxone and azithromycin. ID consulted. In setting of
multiple infections drug regimen transitioned to naficillin,
azithromycin, cipro/flagyl. Due to nature of cough concern for
pertussis for which the patient was placed in isolation and
treated with a 5day course of azithromycin.
.
# MSSA bacteremia. Patient spiked a fever on [**1-12**]. Cultures
with gram positive cocci. Patient initially placed on
vancomycin. Switched to nafcillin when speciated out to MSSA on
[**1-14**]. ?Source: endocarditis vs skin source as patient with
several areas of excoriation on forearm and shins. TEE ordered
however patient unable to tolerate procedure to examine for
vegatations. Physical on the floor notable for stable, unchanged
murmur, negative for additonal exam findings consistent with
endocarditis. ID consulted. Recommended treating with IV
Nafcillin for likely 6weeks as endocarditis could not be ruled
out.
.
# Acute kidney injury. Patient with baseline chronic kidney
disease with creatinine at baseline 1.6. On admission,
creatinine 1.6. Bump in creatinine from 1.6 -> 2.2 noted on
[**1-14**]. Urine labs notable for negative eosinophilia, lytes
notable for Fena<.1 consistent with pre-renal vs hepatorenal
syndrome. Renal US negative for hydronephrosis ruling out
post-renal obstruction. Primary team concerned for hepatorenal
syndrome. Liver and renal consulted for question hepatorenal
syndrome especially in setting of SBP. At that time patient
without signs of decompensated liver failure via laboratory
data. Patient continued on albumin. Octreotide and midodrine
were not started. Renal suggested fluid challenge of 1-2L to
rule out pre-renal etiology also question contrast-induced
nephropathy as patient received CTA on [**1-10**]. Unable to spin
urine to assess for presence of casts. Patient did not respond
appropriately to fluids and became anuric on [**1-16**]. Decision
made to place a HD catheter on [**1-16**] in anticipation of renal
replacement.
.
# HTN - Patient continued on home amlodipine and atenolol on
admission. Atenolol switched to [**Hospital1 **] metoprolol in setting of
[**Last Name (un) **].
.
# Diarrhea. Per report patient with multiple episodes of
diarrhea on day prior to admission. C. diff negative and stool
studies negative in house. Diarrhea resolved in house.
# h/o CVA. Residual deficits: mild dysarthria. CT head negative
on admission for new stroke. Patient continued on ASA on the
floor.
.
MICU course:
1. Altered Mental Status: Patient was initially transferred to
MICU for concern of stroke, though upon discussion with neuro
and radiology, imaging did not suggest this. Seizure not
suspected. More likely toxic metabolic in the setting of liver
failure, multiple infections, renal failure, SBO, and GI bleed.
Patient intubated on early morning of [**1-19**] for airway
protection in setting of AMS.
2. Sepsis: Patient known to have MSSA bacteremia of unclear
source (negative [**Name (NI) **], refused TEE), for which he had been on
vancomycin-->nafcillin. Also with SBP, treated with
ceftriaxone-->cipro/flagyl. Patient hypothermic and hypotensive
to systolic pressures in 60's in MICU. Also ? evidence of
retrocardiac opacity on CXR. Would have broadened treatment to
cover for HCAP but family soon after decided not to pursue
aggressive measures. Transiently on peripheral dopamine before
family decided to make patient CMO.
3. Acute drop in hematocrit: Patient noted to have 10 point Hct
drop from evening of [**1-18**] to [**1-19**], also in setting of
coagulopathy (due to liver failure versus early DIC). He
received a total of 3 units PRBC and 1 bag of FFP. NG lavage
with blood tinged fluid, no gross blood. No plans to scope for
GI bleed in setting of critical illness and multiorgan failure
by AM of [**1-19**].
4. Acute renal failure: Thought initially to be due to contract
induced nephropathy, though urine sediment never obtained as pt
was oliguric during MICU stay. Urine lytes with Na<10, certainly
possible that he developed HRS in the setting of SBP and acute
liver decompensation. CVVH was not pursued based on goals of
care discussion.
5. Liver failure: Patient with e/o cirrhosis given nodularity of
liver and splenomegaly on ultrasound, in addition to presence of
ascites. On admission bilirubin 0.4 and INR 1.1, which
progressed to bilirubin peaking at 7 and INR peaking at 2.5,
suggesting acute liver decompensation. Possible precipitants may
have been sepsis causing cholestatic picture versus antibiotic
effect (ceftriaxone, nafcillin) in a poor substrate. Patient not
a candidate for transplant per liver team given critical illness
and multiorgan failure.
6. Goals of care discussion: Per discussion with HCP, son,
[**Name (NI) **], patient was full code for first 24 hours of course in
MICU. On [**1-19**], family meeting held with 3 children including
HCP, and given critical illness/multiorgan failure as well as
low likelihood of meaningful recovery, patient was made comfort
measures only at 10am on [**2156-1-19**] and expired later in the day.
Medications on Admission:
amlodipine 5 mg daily
atenolol 100 mg daily
finasteride 5 mg daily
Vitamin B12
ASA 81 mg daily
Iron supplement
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
ICD9 Codes: 486, 5845, 5180, 2761, 2762, 5715, 5859, 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7308
} | Medical Text: Admission Date: [**2170-2-7**] Discharge Date: [**2170-2-11**]
Date of Birth: [**2170-2-7**] Sex: M
Service: NEONATOLOG
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 46344**] [**Known lastname 4249**]
delivered at 35 and 5/7 weeks gestation weighing 2,845 grams
and was admitted to the Intensive Care Nursery around three
hours of age for management of respiratory distress.
estimated date of delivery of [**2170-3-9**]. Prenatal screens
included blood type A positive, antibody screen negative,
hepatitis B surface antigen negative, RPR nonreactive,
Rubella immune and group B strep unknown. The pregnancy was
uncomplicated until the mother presented with preterm labor
on the day of delivery. There was no maternal fever.
Membranes were ruptured about four hours prior to delivery
antibiotics for mitral valve prolapse and unknown group B
strep with prematurity. The mother received inter partum
antibiotics around five hours prior to delivery.
The infant emerged vigorous and was dry bulb suctioned.
Apgar scores were 9 and 9 at 1 and 5 minutes respectively.
The infant was transferred to Newborn Nursery. Around three
hours of age the baby was transferred to the Intensive Care
Nursery secondary to tachypnea grunting and nasal flaring.
PHYSICAL EXAM ON ADMISSION: Weight, 2,845 grams (75th
percentile); length, 48 cm (50 to 75th percentile); head
circumference, 35 cm (90th percentile); follow up head
circumference on day of life 4, 33 1/4 cm which is less (75
to 90th percentile). On admission, active, alert male
without rashes. Anterior fontanelle, open, flat, soft. No
cleft. Tachypnea, intermittent grunting and nasal flaring.
Breath sounds clear and equal. Heart rate, regular without
murmur. Pulses, 2+. Abdomen without hepatosplenomegaly. No
masses. Testes descended bilaterally with normal phallus.
Anus, patent. Spine, straight and intact without dimple.
Hips, stable. Tone and reflexes, appropriate for gestational
age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory - Mild respiratory distress on admission that
resolved by day of life 1. Never had an oxygen requirement.
Clinical course and chest x-ray consistent with
TTN
2. Cardiovascular - Cardiovascular has been hemodynamically
stable throughout admission. No murmur. Recent blood
pressure, 82/41 with a mean of 59
3. Fluids, electrolytes, nutrition - Fluids, electrolytes
and nutrition was initially maintained on D10W then started
feeds on day of life 1. Advanced to full feeds by breast or
bottle by day of life 3. Has been feeding well every two to
four hours. Discharge transfer weight, 2,500 grams.
4. Gastrointestinal - Started phototherapy on day of life 3
for a bilirubin total of 14.4, direct .4. Initially on a
single phototherapy light was placed with a bili blanket over
night and bilirubin is pending.
5. Hematology - Hematocrit on admission, 48.5 percent.
6. Infectious Disease - A CBC and blood culture was drawn on
admission. CBC showed a white count of 15,000; 59 polys; 1
band; 346,000 platelets. Did not receive antibiotics.
7. Neurological - On exam, age appropriate.
8. Sensory - A hearing screening is pending.
CONDITION AT TRANSFER: Four day old, former 35 and [**5-30**]
weeker, feeding well, with jaundice under phototherapy.
DISPOSITION: Transfer to Newborn Nursery.
NAME OF PRIMARY PEDIATRICIAN: [**Doctor First Name **] Bhimakivapu and telephone
number is ([**Telephone/Fax (1) 46345**].
CARE RECOMMENDATIONS:
1. Feeds ad lib demand, breast or bottle feeding.
2. Medications, none.
3. Car seat. Position screening has not been done and will
need prior to discharge as the infant was less than 37 weeks
gestation at birth.
4. State newborn screening was drawn on [**2170-2-10**] and is
pending.
5. Immunizations received - Received Hepatitis B
immunization on [**2170-2-11**].
6. Follow-up bilirubin to be checked with pediatrician on day
follwoing discharge.
DISCHARGE DIAGNOSIS:
1. AGA 35 5/7 weeks, preterm now.
2. Transient tachypnea of the newborn, resolved.
3. Rule out sepsis.
4. Indirect hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**First Name3 (LF) 37154**]
MEDQUIST36
D: [**2170-2-11**] 16:27
T: [**2170-2-11**] 16:29
JOB#: [**Job Number 46346**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7309
} | Medical Text: Admission Date: [**2136-8-14**] Discharge Date: [**2136-8-24**]
Date of Birth: [**2058-3-25**] Sex: F
Service: SURGERY
Allergies:
Demerol / Epinephrine / Fosamax / Latex / Dilaudid
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Right lower extremity rest pain/nonhealing ulcer
Major Surgical or Invasive Procedure:
[**2136-8-20**]: Right common femoral to anterior tibial artery
bypass with nonreversed saphenous vein graft.
History of Present Illness:
Mrs. [**Known lastname 33172**] has a history of severe degenerative spine disease
and also carotid artery disease. She recently has developed
increasing pain in her foot. She is very disabled by her back.
She does walk but uses a wheelchair a lot and is having severe
pain in her right foot. This is bad at all times but
particularly severe at night and she has now developed some
small ulcerations. She saw Dr. [**Last Name (STitle) **] at [**Hospital6 33**]
who did some noninvasives and told that her circulation was
really poor and suggested that she see Dr. [**Last Name (STitle) **]. It was
recommended that she be admitted to the hospital for an
arteriogram.
Past Medical History:
history of b/l hip and ankle ulcers
Chronic diarrhea / constipation of unclear etiology
Colonic polyps
PUD with hx of GIB
HTN
Fibromyalgia
Hypothyroidism
Glaucoma
Cataracts
"Irregular heartbeat"
h/o benign fallopian tumor, removed [**2085**]
SBO [**3-7**] adhesions [**2117**]
IBS
Gastritis
s/p multiple spinal fusions amd kyphoplasty
Osteoarthritis
h/o R hip fracture
frequent falls
h/o L CEA for "93% blockage" per pt
hx MRSA
35% burn s/p skin grafting
Social History:
She does smoke at least [**2-7**] pack per day, and has a 50 year
smoking history but does not drink alcohol. She has spent most
of the past several months in rehab. Needs assistance with ADLs.
Family History:
Mother with breast cancer and osteoarthritis. Father with
diabetes type 2. Her family history is negative for colorectal
cancer or inflammatory bowel disease.
Physical Exam:
On discharge:
Tm 98.0, Tc 96.0, HR 87, BP 98.58, RR 16, 93% on RA
AAO x3, in no acute distress
chest clear to auscultation bilaterally, heart rate regular.
abdomen soft, nontender, nondistended.
Right lower extremity warm, with palpable DP pulse, surgical
incision healing, with areas of serosanguinous drainage. Small
nonhealing ulcer at right lateral malleolus.
No clubbing, cyanosis, or edema.
Pertinent Results:
[**2136-8-24**] 04:53AM BLOOD WBC-5.0 RBC-3.06* Hgb-9.5* Hct-28.4*
MCV-93 MCH-31.1 MCHC-33.5 RDW-15.3 Plt Ct-216
[**2136-8-24**] 04:53AM BLOOD Glucose-92 UreaN-15 Creat-0.6 Na-142
K-3.9 Cl-112* HCO3-26 AnGap-8
[**2136-8-23**] 04:49AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1
[**8-21**] UCx: no growth (FINALIZED)
[**8-21**] U/A: >182 WBC, no epis, large leuks, no nitrites
[**8-21**] MRSA swab: positive
Brief Hospital Course:
Ms. [**Known lastname 33172**] [**Last Name (Titles) 1834**] a diagnostic angiography of her right lower
extremity on [**2136-8-14**], which revealed moderate to severe stenosis
in the SFA with complete occlusion distally, reconstituting into
the popliteal, but occluding again at the PT, with moderate to
severe stenosis of a diminutive DP. No intervention was
attempted. She went back to the operating room on [**2136-8-20**] for a
right femoral-AT bypass with nonreversed saphenous vein. Please
see operative report dictated [**2136-8-20**] for full details of the
operation.
Postoperatively, she was somewhat hypotensive and anemic, so a
fluid bolus was given and a blood transfusion attempted.
However, soon after starting the blood transfusion she became
rigorous, acutely hypotensive, and temporarily developed stridor
with decreased O2 sats that resolved spontaneously. She was
transferred to the ICU for closer monitoring. The blood bank
was notified of a possible transfusion reaction, and a complete
workup was performed which turned out negative for transfusion
reaction. She was transfused two more units of blood the next
day without issue.
She was transferred back to the VICU on [**2136-8-21**], and her
hematocrits stabilized. her foley catheter and arterial line
were discontinued, and she was started on a regular diet. Her
right foot was much warmer postsurgery, and she developed a
strong palpable pulse of her right foot, as well as a
dopplerable PT signal. She got out of bed to a chair on POD 2
and ambulated minimally with full assistance on POD3. By POD4
she was tolerating a regular diet, her pain was controlled, and
her incisions were healing nicely. She was discharged to an
extended care facility for intensive rehabilitation.
Medications on Admission:
amytriptyline 75''' PRN anxiety
Amlodipine 5'
Clonazepam 1-2 mg QHS PRN insomnia
Cosopt 0.5-2% 1gtt OU daily
Latanoprost 0.005% 1gtt OU QPM
Synthroid 100'
Lidocaine patch
Lovastatin 1 QPM
mesalamine 800'''
Oxycodone PRN
Oxycodone extended release 40''
protonix 40'
KCl
Promethazein 25''
Vitamin C
Colace
Vitamin D
Iron
Loperamide 2mg PRN diarrhea
MVI
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. amitriptyline 75 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for anxiety.
6. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
7. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic DAILY (Daily).
8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
13. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-5**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
15. insulin aspart 100 unit/mL Solution Sig: Zero (0) units
Subcutaneous QACHS: adjust sliding scale as needed.
16. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): LAST DAY [**2136-8-26**].
17. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
18. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
19. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
20. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab
Discharge Diagnosis:
right lower extremity nonhealing ulcer
right lower extremity bypass
Discharge Condition:
Alert and oriented x3
ambulating with [**Last Name (LF) **], [**First Name3 (LF) **] assist
Full weight bearing
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-8**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2136-9-6**] 1:45
Completed by:[**2136-8-24**]
ICD9 Codes: 4019, 2859, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7310
} | Medical Text: Admission Date: [**2125-4-8**] Discharge Date: 3/17/7
Date of Birth: [**2125-4-8**] Sex: F
Service: Neonatology
MATERNAL HISTORY: A 32-year-old gravida I, para II woman
with past medical history notable for infertility. Prenatal
screens were as follows: A positive, DAT negative, hepatitis
B negative, RPR nonreactive, rubella immune and GBS positive.
Antenatal history: [**Last Name (un) **] was [**2125-5-24**]. Pregnancy was
clomiphene induced, dichorionic, diamniotic 33 week twin
gestation, complicated by gestational insulin-dependent
diabetes and by cervical shortening and dilatation. The
mother was initially admitted at 23 weeks and was then placed
on bedrest. She received betamethasone at that time. She had
progressed at 33 weeks of dilatation and was progressed with
cesarean section under spinal epidural anesthesia for
transverse position of twin #2. There was no intrapartum
fever or other clinical evidence of chorioamnionitis and
intrapartum antibiotic therapy was not given. Membranes were
ruptured at delivery and yielded clear amniotic fluid.
NEONATAL COURSE: The infant was vigorous at delivery. She
was bulb suctioned, dried and subsequently was pink in no
distress in room air. Apgars were 8 at one minute and 9 at
five minutes. She was transferred to the NICU for
prematurity.
PHYSICAL EXAMINATION: A well appearing moderately preterm
infant with examination consistent with 33 weeks gestation.
Heart rate 160 to 170, respiratory rate 40s to 60s,
temperature was 98.3 with a blood pressure of 75/30 with a
mean of 47 and saturations were 96% in room air. Birth weight
was 1795 grams which was at the 25th to 50th percentile,
length was 41.7 cm at 10th to 25th percentile, head
circumference was 30 cm at 25th to 50th percentile. Head,
eyes, ears, nose and throat: Anterior fontanelle was soft and
flat. Nondysmorphic. Palate intact. Neck and mouth normal.
Normocephalic. No nasal flaring. Chest: Without retractions,
breath sounds equal and clear. No adventitious sounds.
Cardiovascular: Well perfused, heart rate regular rate and
rhythm, femoral pulses normal, no murmur. Abdomen: Soft,
nondistended, no organomegaly, no masses, bowel sounds
active, patent anus, 3 vessel umbilical cord. GU: Normal
female genitalia. CNS: Active, alert, responds to
stimulation, tone AGA and symmetric, moves all extremities.
Suck intact. Skin: Turgor normal. Normal spine, limbs, hips
and clavicles.
HOSPITAL COURSE: Respiratory: The infant has been stable in
room air since birth. Respiratory rate 30s to 40s. Breath
sounds equal and clear. The infant does have occasional self
resolving apnea and bradycardic episodes. Has not required
methylxanthine therapy.
Cardiovascular: No murmur. Heart rate 120s to 160s with
regular rate and rhythm. Blood pressure 73/43 with a mean of
57.
Fluid, electrolytes and nutrition: The infant initially NPO.
Initial IV fluids of D10 began during the newborn day.
Enteral feeds begun on day of life #1 of special care 20 or
breast milk at 30 per kilo per day, was advanced to 15 ml per
kilo b.i.d. Her most recent electrolytes were sodium 142, K 4.3,
Cl 108, and CO2 18. The infant feeds presently at 140 ml/kg/day
of BM or SSC 20 cal/oz and
most recent weight 1680grams.
GI: Phototherapy initiated on day of life #3 for a bilirubin
of 10.1/0.3. Her phototherapy was stopped on [**2125-4-14**] for a
bilirubin of 4.1/0.3.
Hematology: Initial hematocrit was 55.6 with a platelet count
of 308,000 on admission to NICU. The infant has not required
transfusion and no blood products have been done.
ID: CBC with diff, blood culture screen on admission to NICU.
Antibiotics discontinued after 48 hours negative blood
culture. Initial CBC, white count of 10.4, with 24 polys, 3
bands, 1 meta with a platelet count of 308,000.
Neurology: Infant does not meet criteria for head ultrasound.
Sensory: Audiology: Hearing screen will be performed prior to
discharge to home as recommended.
Ophthalmology: Does not meet criteria.
Psychosocial: [**Hospital1 18**] social worker involved with family. The
[**Hospital1 **] social worker can be contact[**Name (NI) **] at this number, [**Telephone/Fax (1) **].
CONDITION AT TRANSFER: Stable. Discharged to a level 2
nursery. Name of pediatrician has not been determined.
CARE AND RECOMMENDATIONS:
1. Feeds as SSC or BM 20 cal/oz at 140 cc/kg/day.
2. Infant is not on any current medications at this time.
3. Car seat position screening should be done prior to
discharge home.
4. State newborn screening sent on [**2125-4-11**], results are
pending.
5. Hepatitis B vaccine was given [**2125-4-13**].
6. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**]
for infants who meet any of the following 3 criteria:
1. Born at less than 32 weeks,
2. Born between 32 and 35 weeks with 2 of the
following:
Daycare during RSV season,
a smoker in the household,
neuromuscular disease,
airway abnormalities or
school age sibling
3. with chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once
they reach 6 months of age. Before this age and for the first
24 months of the
child's life, immunization against influenza is recommended
for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity at 33 and 3/7 weeks, twin gestation.
2. Infant of an insulin-dependent gestational diabetic
mother.
3. Sepsis evaluation, resolved
4. Apnea of prematurity.
5. Hyperbilirubinemia, resoloved
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Doctor Last Name 72140**]
MEDQUIST36
D: [**2125-4-12**] 19:15:50
T: [**2125-4-12**] 20:17:40
Job#: [**Job Number **]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7311
} | Medical Text: Admission Date: [**2138-8-15**] Discharge Date: [**2138-8-20**]
Date of Birth: [**2062-8-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
mild fatigue, mild DOE
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times 5;
left internal mammary artery graft to left anterior descending,
reverse saphenous vein grafts to the ramus intermedius, marginal
branch, right coronary artery and diagonal branch.
History of Present Illness:
75 yo M with PMH significant for hypertension, hyperlipidemia,
and diabetes with recent abnormal stress echo. He endorses only
mild fatigue and dyspnea on
exertion and denies chest discomfort or other anginal symptoms.
He presented for cardiac catheterization and was found to have
3VD and [**1-22**]+MR. We are asked to consult for surgical
revascularization and possible mitral valve repair or
replacement
Past Medical History:
Hypertension, Hyperlipidemia, Type I Diabetes on insulin pump,
Ulcerative Colitis, Prior remote GI Bleed, none in 10 yrs, GERD,
h/o broken right ankle, s/p total right hip arthroplasty
[**11/2137**], s/p tonsillectomy
Social History:
Family History:no CAD
Race:Caucasian
Last Dental Exam:[**2138-5-20**]
Lives with:wife at [**Name (NI) **] Retirement Community. Wife has
significant memory issues.
Occupation:
Tobacco:quit [**2091**]
ETOH:prior heavy drinking, quit last year
Family History:
Has 2 sons. Former marathon runner
Father had a stroke at around 70 years of age.
Physical Exam:
Pulse:76 Resp:18 O2 sat:98% RA
B/P Right:157/76 Left:156/71
Height:5'8" Weight:155 lbs
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 II/VI SEM
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: Dressing Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right/Left: Transmitted murmur
Pertinent Results:
Preop
[**2138-8-15**] 07:43AM HGB-12.4* calcHCT-37
[**2138-8-15**] 07:43AM GLUCOSE-206* LACTATE-1.0 NA+-134* K+-4.2
CL--99*
[**2138-8-15**] 11:25AM WBC-6.2 RBC-2.94*# HGB-9.8*# HCT-27.3*#
MCV-93 MCH-33.2* MCHC-35.8* RDW-14.0
[**2138-8-15**] 11:25AM PT-15.3* PTT-35.9* INR(PT)-1.3*
[**2138-8-15**] 11:25AM FIBRINOGE-193
[**2138-8-15**] 12:31PM UREA N-14 CREAT-0.6 SODIUM-139 POTASSIUM-3.7
CHLORIDE-108 TOTAL CO2-24 ANION GAP-11
Discharge
[**2138-8-15**] 11:25AM BLOOD WBC-6.2 RBC-2.94*# Hgb-9.8*# Hct-27.3*#
MCV-93 MCH-33.2* MCHC-35.8* RDW-14.0 Plt Ct-124*
[**2138-8-15**] 11:25AM BLOOD PT-15.3* PTT-35.9* INR(PT)-1.3*
[**2138-8-15**] 12:31PM BLOOD UreaN-14 Creat-0.6 Na-139 K-3.7 Cl-108
HCO3-24 AnGap-11
[**2138-8-17**] 02:36AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.8 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.2 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild 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.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
to moderate ([**12-21**]+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Mild 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.
Conclusions
PREBYPASS
The left atrium is mildly 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. Overall left ventricular
systolic function is normal (LVEF>55%).
Right ventricular chamber size is normal with normal free wall
contractility.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. The mitral
annulus is dilated (4.4 cm in the long axis and 3.3 cm in the
short axis) but the leaflets coapt well. Mild to moderate ([**12-21**]+)
mitral regurgitation is seen. Mitral regurgitation is not
worsened by fluid administration or afterload augmentation.
There is no pericardial effusion.
POSTBYPASS
The patient is AV paced and is not on any inotropes.
Left ventricular systolic function remains normal (LVEF>55%).
Mild aortic regurgitation persists.
Mitral regurgitation is slightly improved and is now mild. The
leaflets continue to coapt well.
The thoracic aorta is intact.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician
Radiology Report CHEST (PORTABLE AP) Study Date of [**2138-8-17**]
11:23 AM
Final Report
HISTORY: Chest tube removal, to assess for pneumothorax.
FINDINGS: In comparison with study of [**8-15**], all of the
monitoring and support devices have been removed. Specifically,
there is no evidence of
pneumothorax. Bibasilar atelectatic changes persist.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for coronary artery bypass graft surgery. See operative report
for further details. In summary he had:
Coronary artery bypass grafting times 5, with left internal
mammary artery graft to left anterior descending, reverse
saphenous vein grafts to the ramus intermedius, marginal branch,
right coronary artery and diagonal branch. His bypass time was
92 minutes with a crossclamp time of 79 minutes. He tolerated
the operation well and was transferred post-operatively to the
intensive care unit for recovery and further management.
Received cefazolin for perioperative antibiotics.
In first twenty four hours he was weaned from sedation, awoke
neurologically intact and was extubated without complications.
On post operative day one he remained in the intensive care unit
for blood glucose management and due to bradycardia requiring
pacing so he was not started on beta blockers. All tubes line
and drains were removed per cardiac surgery protocol. He
remained in the intensive care unit waiting for an available
floor bed. He was transferred to the stepdown floor on post
operative day three. The remainder of his hospital course was
uneveventful. Physical therapy worked with him on strength and
mobility. He continued to progress and was ready for discharge
home with services on post operative day 5. He is to follow up
with Dr [**Last Name (STitle) **] in clinic in 3 weeks.
Medications on Admission:
Atenolol 25mg po daily
Folic Acid 1mg po daily
Levothyroxine 100mcg po daily
Niacin 1000mg po qHS
Simvastatin 40mg po daily
Sulfasalazine 1000mg po BID
Valsartan 160mg po daily
ASA 81mg po BID
Calcium carbonate 500mg po PRN
Centrum Silver
Amoxicillin 2g po 1 hour before dental procedures
Discharge Medications:
1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Subcutaneous Insulin Pump Miscellaneous
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Niacin 500 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO HS (at bedtime).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
9. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for (R)forearm phlebitis for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
15. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]Hospice
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass grafting
times
5; left internal mammary artery graft to left anterior
descending, reverse saphenous vein grafts to the ramus
intermedius, marginal branch, right coronary artery and diagonal
branch.
PMHx: Hypertension, Hyperlipidemia, Type I Diabetes on insulin
pump,
Ulcerative Colitis, Prior remote GIB, none in 10 yrs, GERD, h/o
broken right ankle, s/p total right hip arthroplasty [**11/2137**],
s/p tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions: Sternal - healing well, no erythema or drainage
Leg bilateral EVH sites- healing well, no erythema or drainage.
Edema: 1+ pedal edema bilat
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2138-9-11**] 1:15
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9751**] is away on vacation. Dr [**Last Name (STitle) **]
office will schedule f/u appointment and call you next week to
let you know when it is.
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 56850**] in [**3-24**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2138-8-20**]
ICD9 Codes: 4111, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7312
} | Medical Text: Unit No: [**Numeric Identifier 71942**]
Admission Date: [**2159-3-22**]
Discharge Date: [**2159-3-28**]
Date of Birth: [**2159-3-22**]
Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 4597**] was born at 33-1/7-weeks
gestation and admitted to the NICU with prematurity and
respiratory distress. He is a 2610-gram product of a 33-1/7-
weeks gestation pregnancy born to a 20-year-old G3, P1, now 2
mother with an [**Name (NI) 37516**] of [**2159-5-9**]. Prenatal labs were blood
type B-positive, antibody negative, RPR nonreactive, rubella
immune, HBsAg negative, GBS unknown. This pregnancy was
notable for gestational diabetes treated with insulin
requiring several earlier hospitalizations. This pregnancy
was also complicated recently by development of pregnancy induced
hypertension and preterm labor prompting initial admission to
[**Hospital 1474**] Hospital and then transfer to [**Hospital1 18**] on [**2159-3-17**].
She was treated with betamethasone and complete on [**2159-3-19**], magnesium sulfate and ampicillin. Contractions
initially abated; but due to the persistent hypertension,
labor was subsequently augmented leading to a vaginal
delivery. There was no maternal fever during labor and
rupture of membranes occurred 4 hours prior to delivery. At
delivery, the infant emerged with a good cry and tone
requiring blow-by oxygen for duskiness with quick
improvement. Apgars were 8 and 9 at 1 and 5 minutes, and the
infant was brought to the NICU for prematurity. Infant was
placed on CPAP initially for intermittent apnea and moderate
work of breathing.
PHYSICAL EXAM ON ADMISSION: Birth weight 2610 grams which is
greater than 95th percentile, head circumference 32 cm which
is 75th percentile, length 45 cm which is 50th-75th
percentile. This is an LGA premature infant, mildly reduced
activity at rest, mild work of breathing on CPAP. Skin: Warm
and dry, no rash. HEENT: Fontanel soft and flat. Positive
molding. Palate intact. Ears and nares: Normal. Neck: Supple,
no lesions. Chest: Moderate aeration, mild retractions and
tachypnea on CPAP, symmetric breath sounds. Cardiac: Normal
rate and rhythm, no murmur, well perfused. Abdomen: Soft, no
hepatosplenomegaly, no mass, quiet bowel sounds. GU: Normal
male. Testes descended. Anus patent. Extremities, hips, back
normal. Neuro: Mildly reduced tone and activity. Intact Moro
and grasp.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: The infant remained on CPAP of 6 and low
FIO2 until day of life 2 at which time he weaned to low-
flow nasal cannula, weaned to room air by [**2155-3-26**],
day of life 3 and has been stable on room air since. He
has presented with mild apnea of prematurity having
approximately [**2-5**] quick self-resolved spells per day and
has not been treated with any methylxanthine therapy thus
far. He does remain comfortably tachypneic at times with
respiratory rates in the 60s-90s range, clear and equal
breath sounds, and very minor retractions.
2. Cardiovascular: He has maintained a stable cardiovascular
status with no murmurs, normal heart rate and blood
pressures throughout.
3. Fluid, electrolytes, and nutrition: He was made NPO on
admission to the NICU due to the respiratory distress and
a peripheral IV was placed. He was given IV fluids at
that time. His D-sticks have remained normal with no
hypoglycemia documented ever. Enteral feedings were
initiated on [**2159-3-24**], day of life 2. His enteral
feedings were slowly advanced over the next 4 days. He
achieved full enteral feedings by [**2159-3-28**] and is
presently taking Special Care 20 at 120 mL per kilogram
per day tolerating his feedings well. His most recent
weight is 2445 grams. He is voiding and stooling
normally. His most recent set of electrolytes was on
[**2159-3-24**]: Sodium 142, K of 5.3 which was slightly
hemolyzed, chloride 105, and CO2 29. A magnesium level
drawn on the newborn day and it was 2.8.
4. GI: He developed hyperbilirubinemia with a peak bilirubin
level of 13.5/0.3 which was on [**2159-3-25**], day of
life 3 at which time he started phototherapy and had
received 4 days of phototherapy which phototherapy lights
were discontinued on [**2159-3-28**], in the a.m. Most
recent bilirubin prior to that was 8.7/0.3 on [**2159-3-27**]. The plan was a repeat bilirubin level on [**2159-3-29**], as a rebound. He has had no other GI issues.
5. Hematology: Hematocrit at birth was 53 with a platelet
count of 308. No further hematocrits or platelets have
been measured. He has received no blood product
transfusions.
6. Infectious disease: The CBC and blood culture were
screened on admission to the NICU due to the premature
labor and premature delivery. The CBC was within normal
limits with no bands and no left shift. A blood culture
was drawn also on the newborn day. The infant received a
total of 48 hours of ampicillin and gentamicin which were
subsequently discontinued when the blood culture remained
negative at that time. There had been no further issues
with sepsis.
7. Neurology: The infant has maintained a normal neurologic
exam for gestational age after the initial hypotonia and
hypoactivity mentioned in the 1st 24 hours of life. No
neurologic testing has been done on this infant.
8. Sensory: A hearing screen has not yet been performed, but
will need to be performed prior to discharge to home.
CONDITION AT DISCHARGE: Fair.
DISCHARGE DISPOSITION: Transferred to [**Hospital3 417**]
Hospital's special care nursery. Name of primary pediatrician
is Dr. [**First Name (STitle) **] [**Name (STitle) 71943**] from [**Hospital1 1474**]; telephone number ([**Telephone/Fax (1) 71944**].
CARE AND RECOMMENDATIONS:
1. Feedings: Continue to advance feedings as needed and
continue to concentrate caloric density as needed. Infant
is currently on Special Care 20 at 1120 mL per kilogram
per day with a plan to advance by 15 mL per kilogram q.12
hours to a maximum intake of 150 mL per kilogram per day.
2. Medications: None.
3. Car seat position screening is recommended prior to
discharge from special care nursery.
4. State newborn screen was sent on [**2159-3-26**]. Results
are pending.
5. Immunizations - baby has not received any immunizations as
of yet.
6. Immunizations recommended. Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 4 criteria: 1) born at less
than 32-weeks gestation; 2) born between 32-35 weeks with
2 of the following: Daycare during RSV season, a smoker
in the household, neuromuscular disease, airway
abnormalities, or school-age siblings; 3) chronic lung
disease; or 4) hemodynamically significant congenital
heart defect.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable and at least 6 weeks, but fewer
than 12 weeks of age.
Follow-up appointments should be with a pediatrician after
discharge from the hospital.
DISCHARGE DIAGNOSES: Prematurity born at 33-1/7-weeks
gestation, respiratory distress resolving, sepsis ruled out,
infant of a diabetic mother, apnea of prematurity ongoing,
hyperbilirubinemia ongoing, large for gestational age infant.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2159-3-27**] 22:11:51
T: [**2159-3-28**] 07:27:21
Job#: [**Job Number 71945**]
ICD9 Codes: 7742, 769, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7313
} | Medical Text: Admission Date: [**2184-5-25**] Discharge Date: [**2184-6-20**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Afib / dehtyration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84M s/p SFA -> AT bypass ([**5-10**]) initially presenting to Dr. [**Name (NI) 22122**] office with dehydration/diarrhea, R foot infection. In
ED patient was found to be in rapid afib, with resultant
positive cardiac enzymes thought to be due to demand ischemia in
setting of hct to 24 and dehydration
Past Medical History:
CAD
HTN
Hypercholesterolemia
DM2
MI'[**74**]
Peripheral arterial disease
post-polio contractures
Social History:
no tobacco, occiasional EtOH
married, lives with wife
Family History:
non-contributory
Physical Exam:
afvss
frail
a/o
cts
ireg / ireg
benign
fem palp b/l, non palp distal pulses ecept left DP
Pertinent Results:
[**2184-6-18**] 05:15AM BLOOD
WBC-12.7* RBC-3.99* Hgb-12.0* Hct-36.0* MCV-90 MCH-30.1
MCHC-33.3 RDW-17.4* Plt Ct-453*
[**2184-6-18**] 05:15AM BLOOD
PT-28.3* PTT-37.3* INR(PT)-2.9*
[**2184-6-18**] 05:15AM BLOOD
Glucose-46* UreaN-5* Creat-0.5 Na-133 K-3.7 Cl-105 HCO3-20*
AnGap-12
[**2184-6-18**] 05:15AM BLOOD
Calcium-7.7* Phos-2.8 Mg-1.8
[**2184-6-5**] 03:04AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.043*
URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
URINE RBC-[**4-5**]* WBC-1 Bacteri-RARE Yeast-NONE Epi-0
[**2184-6-3**] 1:32 pm STOOL CONSISTENCY: WATERY Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2184-6-4**]):
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Brief Hospital Course:
84M with CAD, DM, hx Polio, s/p SFA -> AT bypass ([**5-10**]) initially
presenting to Dr.[**Name (NI) 10879**] office with dehydration/diarrhea, R
foot infection. In ED patient was found to be in rapid afib,
with resultant positive cardiac enzymes thought to be due to
demand ischemia in setting of hct to 24 and dehydration. TTE
revealed no WMA. Patient admitted to CCU for volume
resuscitation and anticoagulation.
Pt did r/i for MI - demand ishemia from rapid afib. Afib
resolved
Pt started on coumdin INR monitered throught out the hospital
course. In DC 2.9
Pt inability to eat speech and swallow, psych consulted. His
appetite has been poor but he manages to "force" himself to
finish his meals. At present, pt's presentation does not appear
to be c/w with the dx of a major depressive episode. Rather, his
hypothyroidism is likely to have contributed to some if not all
of the symptoms, such as psychomotor retardation and anorexia.
This prompted an endocrine consult
- Check anti-TPO
- Check thyroglobulin and anti-thyroglobulin
- Follow TFTs as an outpatient
Pt to schedule an appointment for follow-up.
Pt became febrile / pan cx'd / found to have C-Diff/ treated in
hospital for 14 days of flagyl. Problem has resolved. Family
requested GI consult. CT scan did confirm colitis.
Pt had prolong hospital stay, family difficult to understand
need for PT and nutrition for the patient. All doctors recommend
feeding [**Name5 (PTitle) **] for nutritional status. Then when patient regains
strength, can work on PT
A variety of social / ethic/ geriatric/ psych consults where
obtained during this hospital stay. Pt family refused to let the
pt leave the hospital. A family meeting was held on [**7-18**]. Family
finally agreed to put pt at reb. They still do not agree to
feeding [**Month/Year (2) **].
pt stable on DC
Medications on Admission:
[**Last Name (un) 1724**]: Plavix 37.5', Metoprolol 50", Lisinopril 20', Glyburide 5',
Prilosec, Zocor 5mg 3x/wk
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
AND PRN ().
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Clopidogrel 75 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
INR goal [**3-6**].
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itch/rash.
14. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Afib - demand ischemia resulting in pos cardiac enzymes
FTT
dehydration
R foot dry gangrene/ulcers/
PAD
c-diff
DM2
Discharge Condition:
Stable
Discharge Instructions:
When To See Your Doctor
You should contact your doctor if you have a fever and any of
these other symptoms.
When fever lasts for more than 48 hours.
When accompanied by vomiting or diarrhea that lasts more than 12
hours or is bloody.
When accompanied by a cough that produces yellow, green, tan or
bloody mucous.
When accompanied by a severe headache, neck stiffness,
drowsiness and vomiting. This is a medical emergency - go to the
Emergency Room immediately.
When fevers come and go, you have night sweats and swollen lymph
nodes.
When a mild fever comes and goes along with sore throat and
tiredness.
When accompanied by a sore throat and headache for more than 48
hours.
When accompanied by severe stomach pain, nausea and vomiting.
When accompanied by an earache.
When you have been exposed to high temperatures outside and you
cannot get your temperature down after attempting cool down
measures.
When you have recently started taking a new medicine and have no
other symptoms.
When you have pain or burning when urinating or back pain.
When temperature remains above 103 degrees despite medication
and other cool down measures (ie.taking a cool bath, cool
compresses on head and under arms, drinking cool drinks).
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2184-7-6**] 2:30
call Dr [**Last Name (STitle) **] office and schedule an appointmnet ([**Telephone/Fax (1) 10085**]
ICD9 Codes: 2761, 2720, 4019, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7314
} | Medical Text: Admission Date: [**2110-11-14**] Discharge Date: [**2110-11-26**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
female with a history of chronic obstructive pulmonary
disease, hypertension, no known coronary artery disease who
was in her usual state of health until the afternoon of
admission when she experienced the sudden onset of substernal
chest pain after arranging grocery bags. The pain was 10 out
of 10 with associated shortness of breath, but no nausea,
vomiting or diaphoresis. Her husband called emergency
medical services.
REVIEW OF SYSTEMS: Positive paroxysmal nocturnal
dyspnea/orthopnea times four to five years, dyspnea on
exertion with heavy lifting.
In the Emergency Department the patient received beta blocker
Nitroglycerin and heparin bolus.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease, etiology felt to
be from emphysema from a history of multiple pneumonias as a
teenager.
2. Hypertension.
3. Lupus.
4. Osteoporosis.
5. Total abdominal hysterectomy.
ALLERGIES: Morphine causes nausea.
MEDICATIONS: Fosamax, Advair, Singular, Prednisone,
Albuterol prn, Plaquenil.
FAMILY HISTORY: Mom died in 60s of heart disease,
grandmother died at 62 of heart disease.
SOCIAL HISTORY: No tobacco, occasional alcohol. Lives in
[**Location 745**] with husband. She worked as a former bookkeeper and
secretary.
PHYSICAL EXAMINATION: General: Patient in mild respiratory
distress, pursed lip breathing, using accessory muscles.
Vital signs, 95.6, 105, 88/56. Head, eyes, ears, nose and
throat: Pupils equal, round and reactive to light,
oropharynx clear. Neck, jugulovenous pressure approximately
9 cm, no thyromegaly. Cardiovascular, tachycardiac, regular
rhythm, S1 and S2, positive S3. Pulmonary, decreased
breathsounds with bibasilar rales, diffuse wheezes. Abdomen,
positive bowel sounds, soft, nontender, nondistended.
Extremities, no cyanosis, clubbing or edema. 2+ pedal pulses
bilaterally. Neurological, alert and oriented times three
moving all extremities, symmetric deep tendon reflexes.
LABORATORY DATA: White count 6.5/40.8/274. Potassium 4.9,
BUN 17, creatinine 0.7, creatinine kinase 125, troponin less
than 0.01. Electrocardiogram, sinus tachycardia, 128
beats/minute, 3 to [**Street Address(2) 5366**] elevations in V1 through V6, [**Street Address(2) 28585**] elevation in AVL.
HOSPITAL COURSE: 1. Coronary artery disease. Upon arrival
the patient was taken immediately to the Catheterization
Laboratory for anterior ST elevation myocardial infarction.
The catheterization revealed - 1. One vessel coronary artery
disease with a 95% left anterior descending thrombotic lesion
involving the first major diagonal intervened upon with a
hepacoat stent. Also found was a 60% distal right coronary
artery lesion that was not intervened upon. 2. Increased
right-sided and left-sided pressures, with RAV of 19, RV
51/21, PCWP 35. 3. The procedure was complicated by a
profound hypotensive episode, requiring Dopamine and
intra-aortic balloon pump. After the procedure the patient
was transferred to the CCU. The patient did well in the CCU.
A cardiac regimen of beta blocker and ACE was titrated and
intra-aortic balloon pump was discontinued without incident.
The patient was subsequently transferred to the floor. While
on the floor, the patient experienced a hypotensive episode
with systolic pressures in the 70s and responded to fluid
bolus. Etiology was felt to be secondary to medications. At
the time of discharge, the patient's antihypertensive regimen
consisted of Captopril 6.25 b.i.d. and Coreg 12.5 b.i.d.,
attempts at higher doses of Captopril were limited by her
blood pressure. At the time of discharge, systolic pressures
ranged 90 to 110 and heartrate was 90 to 100, the patient
remained chest pain free throughout her stay.
2. Congestive heart failure - Post procedure, the patient
had an echocardiogram which revealed - A. Ejection fraction
of 25 to 30% with apical akinesis and severe hypokinesis of
the anterior septum and anterior wall. She had normal right
ventricular function. B. Moderate to severe (3+) tricuspid
regurgitation, trivial mitral regurgitation, no aortic
stenosis or aortic regurgitation. Moderate pulmonary
hypertension was also noted. After her catheterization the
patient was continued on heparin and was eventually started
on Coumadin for prophylaxis of left ventricular thrombus.
The patient was maintained on prn diuretics with stable
respiratory status and oxygen saturations until the day prior
to admission where she experienced worsening shortness of
breath felt to be secondary to pulmonary edema. Therefore
the patient was initiated on a standing dose of Lasix prior
to discharge.
3. Rhythm - The patient experienced transient episode of
atrial fibrillation during stay with no further recurrence.
She was in normal sinus rhythm at the time of discharge.
4. Gastrointestinal - After hypotensive episode on the
floor, the patient experienced the onset of abdominal pain
and small amount of lower gastrointestinal bleeding. Her
abdominal pain persisted and a gastrointestinal consult was
obtained secondary to concerns for ischemic colitis.
Gastrointestinal consult agreed with concern for an ischemic
event and recommended computerized tomography scan of the
abdomen. Computerized axial tomography scan revealed a
thickened wall of the descending limb of the colon consistent
with colonic ischemic but did not reveal any pneumatosis or
free air. General Surgery was consulted and recommended
observation of hemodynamics, intravenous fluids, and triple
antibiotics. The patient's antihypertensives were
discontinued at this time. She was started on Ampicillin,
Levofloxacin and Flagyl and was transferred back to the CCU
for closer monitoring. Heparin and Coumadin were also
discontinued at this time secondary to the lower
gastrointestinal bleeding. The patient's clinical status
rapidly improved with resolution of her abdominal pain. She
remained abdominal pain-free throughout the rest of the stay.
At the time of discharge she was tolerating a p.o. diet, was
guaiac negative, and had her antihypertensive regimen
reinstituted without further onset of abdominal pain.
5. Pulmonary - The patient maintained stable oxygen
saturations throughout her stay. She experienced some
episodes of shortness of breath which were responsive to her
metered dose inhalers and nebulizers. Additionally she
experienced an episode of shortness of breath as previously
described and this was felt to be secondary to pulmonary
edema which responded to intravenous Lasix.
6. Renal - The patient's creatinine remained stable
throughout the stay with baseline of 0.5 to 0.6 at the time
of discharge.
7. The patient was found to have a left adnexa cystic lesion
on computerized tomography scan done when evaluated for
ischemic colitis. Radiology recommended this be followed up
with a pelvic ultrasound. Ultrasound was not done at the
time of discharge, and it is recommended follow up as an
outpatient. A Physical therapy consult was obtained who felt
the patient had decreased mobility, endurance and balance,
and therefore recommended acute rehabilitation. The patient
was screened and subsequently discontinued to [**Hospital1 **] for
cardiac rehabilitation.
CODE STATUS: The patient is full code.
CONDITION ON DISCHARGE: The patient discharged in stable
condition without supplemental oxygen requirement. The
patient was discharged to [**Hospital **] Rehabilitation Facility.
DISCHARGE DIAGNOSIS:
1. Anterior ST elevation myocardial infarction status post
PCI of left anterior descending.
2. Congestive heart failure.
3. Ischemic colitis.
4. Chronic obstructive pulmonary disease.
5. Cystic mass of left adnexa.
DISCHARGE MEDICATIONS:
1. Aspirin 325 p.o. q. day
2. Plavix 75 mg p.o. q. day
3. Captopril 6.25 mg p.o. b.i.d.
4. Carvedilol 12.5 mg p.o. b.i.d.
5. Digoxin 0.125 mg p.o. q. day
6. Lasix 20 mg p.o. q. day
7. Lipitor 10 mg p.o. q. day
8. Prednisone 5 mg p.o. q. day
9. Plaquenil 200 mg p.o. q. day
10. Atrovent inhaler
11. Albuterol prn
12. Flovent
13. Serevent
14. Protonix 40 mg p.o. q. day
15. Colace prn
16. Senna prn
FOLLOW UP PLAN: The patient is to call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
office for follow up upon discharge from rehabilitation.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Name6 (MD) 54516**]
MEDQUIST36
D: [**2110-11-26**] 07:46
T: [**2110-11-26**] 07:59
JOB#: [**Job Number 54517**]
ICD9 Codes: 4280, 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7315
} | Medical Text: Admission Date: [**2166-12-10**] Discharge Date: [**2166-12-17**]
Date of Birth: [**2101-6-19**] Sex: M
Service: MEDICINE
Allergies:
Benadryl / Morphine / Ativan / Compazine / Dilaudid
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Neck Pain
Major Surgical or Invasive Procedure:
Anterior Cervical diskectomy
History of Present Illness:
65Y M ESRD, CHF EF<20% with recuurent Listeria bacteremia X 2,
had complained of neck pain for several weeks. Pt was seen in
the ED treated with IV dilaudid. PT became sensitive and
developed respiratory distress and failure to normal doses of IV
narcotics in the ED. Pt eventually admitted to MICU, scheduled
for C-spine MRI in the setting of unstable respiratory status.
Pt coded in MRI holding underwen limited MRI studies which were
inconclusive. Pt was subsequently intubated for final MRI w/
gado. MRI eventually was suspicious for osteomyelitis of C4
with inflammation of C3C4, C4C5. Pt wwas scheduled for bone
biosy with tissue cx sent for micro and cyptococcal ag. Pt was
stablized, extubated, received HD after MRI and transferred to
the floor for pain control. Upon transfer, pt desated to 88% on
RA with complaint of SOB but no CP. Pt's HR was 100, increased
to RR 28, BP was 120/74. Pt immediately received O2. O2 was
titrated SpO2 >96%. Pt also received lopressor 25mg po to
control his rate. Pt was eventually stable on 2L. PT c/o
shoulder pain o/n.
Past Medical History:
1. Coronary artery disease: Myocardial infarction in [**2155**],
MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous
RCA stent patent at that time.
2. Nonischemic dilated cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**]
to 25%
3. Diabetes greater than 20 years; with triopathy.
4. Hypertension.
5. End stage renal disease on hemodialysis, q. Monday,
Wednesday and Friday via right arteriovenous fistula.
6. Hypothyroidism.
7. Chronic obstructive pulmonary disease.
8. Hepatitis C.
9. Chronic pancreatitis.
10. Peptic ulcer disease.
11. Right perinephric hematoma; status post embolization.
12. Obstructive sleep apnea on CPAP.
13. Ruptured right groin abscess; recurrent right groin
abscess in [**2162-12-4**].
14. Peripheral [**Year (4 digits) 1106**] disease.
15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein
16. Status post 2nd and 3rd toe amps
17. Status post left CFA to AK [**Doctor Last Name **] with PTFE
18. Status post L inguinal hernia repair
19. Status post umbilical hernia repair
20. Ischemic left foot
21. A - Fib- not well documented. Followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
cardiology who notes he was previously on coumadin.
Social History:
Lives in [**Location 686**] with wife, has older children
tobacco: 1 ppd x 60 yrs. quit 3 months ago, no EtOH. +Hx of
narcotic abuse. Should avoid IV pain medications, especially
dilaudid, morphine
Family History:
Non contributory
Physical Exam:
T 98.7 BP 140/74 HR 97 RR 16 SpO2 100 on 2L, FSBS: 113mg/dl
Gen: AOX3
HEENT: perrlA, EOMI. mmm
Neck: neck collar in place
Lung: CTA b/l
Heart: RRR nl S1S2 no M/R/G
Abdomen: Soft, ND/NT. No rebound or guarding
[**Location **]: Multiple toe amputations. Dopplerable DP pules b/l
Pertinent Results:
[**2166-12-10**] 11:56PM TYPE-ART TEMP-35.6 PO2-113* PCO2-48* PH-7.40
TOTAL CO2-31* BASE XS-4
[**2166-12-10**] 11:56PM LACTATE-0.8
[**2166-12-10**] 11:20PM GLUCOSE-70 UREA N-31* CREAT-4.8*# SODIUM-140
POTASSIUM-5.2* CHLORIDE-98 TOTAL CO2-28 ANION GAP-19
[**2166-12-10**] 11:20PM CK(CPK)-35*
[**2166-12-10**] 11:20PM CK-MB-NotDone cTropnT-0.18*
[**2166-12-10**] 11:20PM CALCIUM-9.7 PHOSPHATE-7.0* MAGNESIUM-2.2
[**2166-12-10**] 11:20PM WBC-6.4 RBC-3.91* HGB-12.2* HCT-38.3* MCV-98
MCH-31.3 MCHC-32.0 RDW-16.6*
[**2166-12-10**] 11:20PM NEUTS-54 BANDS-0 LYMPHS-19 MONOS-18* EOS-7*
BASOS-2 ATYPS-0 METAS-0 MYELOS-0
[**2166-12-10**] 11:20PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
TARGET-OCCASIONAL
[**2166-12-10**] 11:20PM PLT SMR-NORMAL PLT COUNT-232
[**2166-12-10**] 11:20PM PT-13.0 PTT-33.2 INR(PT)-1.1
[**2166-12-10**] 03:35AM GLUCOSE-116* UREA N-53* CREAT-6.0* SODIUM-139
POTASSIUM-5.5* CHLORIDE-92* TOTAL CO2-30 ANION GAP-23*
[**2166-12-10**] 03:35AM CALCIUM-10.3* PHOSPHATE-8.4*# MAGNESIUM-2.5
[**2166-12-10**] 03:35AM CRP-5.1*
[**2166-12-10**] 03:35AM WBC-5.8 RBC-4.19* HGB-13.0* HCT-40.2 MCV-96
MCH-30.9 MCHC-32.3 RDW-16.6*
[**2166-12-10**] 03:35AM NEUTS-35* BANDS-0 LYMPHS-40 MONOS-17* EOS-5*
BASOS-3* ATYPS-0 METAS-0 MYELOS-0
[**2166-12-10**] 03:35AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL
[**2166-12-10**] 03:35AM PLT SMR-NORMAL PLT COUNT-238
[**2166-12-10**] 03:35AM PT-13.4* PTT-34.6 INR(PT)-1.2*
[**2166-12-10**] 03:35AM SED RATE-5
[**2166-12-10**] 03:06AM TYPE-ART RATES-/24 O2 FLOW-5 PO2-99 PCO2-75*
PH-7.22* TOTAL CO2-32* BASE XS-0 INTUBATED-NOT INTUBA
[**2166-12-10**] 03:06AM O2 SAT-92
[**2166-12-9**] 06:13PM LACTATE-2.4*
[**2166-12-9**] 06:10PM GLUCOSE-169* UREA N-48* CREAT-5.8* SODIUM-140
POTASSIUM-5.1 CHLORIDE-92* TOTAL CO2-31 ANION GAP-22*
[**2166-12-9**] 06:10PM estGFR-Using this
[**2166-12-9**] 06:10PM WBC-6.8 RBC-4.29* HGB-13.2* HCT-41.3 MCV-96
MCH-30.9 MCHC-32.0 RDW-16.7*
[**2166-12-9**] 06:10PM NEUTS-55 BANDS-0 LYMPHS-27 MONOS-10 EOS-4
BASOS-1 ATYPS-3* METAS-0 MYELOS-0
[**2166-12-9**] 06:10PM PLT COUNT-242
[**2166-12-9**] 06:10PM NEUTS-55 BANDS-0 LYMPHS-27 MONOS-10 EOS-4
BASOS-1 ATYPS-3* METAS-0 MYELOS-0
CXR [**2166-12-10**]: no acute cardiopulmonary process. ET tube 2cm above
carina.
[**12-14**]: Right infrahilar consolidation has increased since
[**12-11**] consistent with worsening pneumonia. mid and lower
left lung atelectasis persists.
[**12-15**]: some progressive clearing of the right perihilar and
infrahilar consolidation, consistent with some improvement in
the pneumonia
.
MRI C-spine [**2166-12-10**]: Discitis, osteomyelitis C4 with
paraspinal phlegmon or abscess. Indicative of infectious
etiology. However, rarely florid inflammatory response to renal
spondyloarthopathy may demonstrate a similar picture.
.
US UE :Appropriate flow within the fistula with no surrounding
fluid
collections/abscess
Brief Hospital Course:
65 yo male with a past medical history of CAD, dilated CHF (EF <
20%), Type 2 Diabetes Mellitus, ESRD on HD, COPD, and recent
recurrent bacteremia (GBS bacteremia in [**7-10**] and Listeria
Bacteremia in [**9-9**]) is being transferred to the floor after MICU
admission for respiratory failure.
.
On [**2166-11-27**], patient complained of 3 weeks of neck pain. He
[**Date Range 1834**] an outpatient MRI on [**12-9**] which demonstrated C4-C5
discitis with destructive osteomyelitis, including pre-vertebral
involvement. No epidural abscess was seen at that time. He was
then sent to the ED for further evaluation by neurosurgery,
where he was found to have mild LUE weakness and unchanged
decreased sensation at fingertips and toes. This study was
limited by gado so they perform another MRI. Repeat MRI w/ gado
on [**12-10**] demonstrated known C4-5 spondylodiscitis, and no
evidence of an epidural component, but the study was limited by
patient motion.
.
Overnight, patient triggered for decreased responsiveness and
decreased SaO2 to 55% RA, increasing to 80% on 5L NC. He was
noted to be snoring at the time. He had received significant
amounts of dilaudid (4mg IV over the past few hours) and ativan
prior to this episode. RR was [**11-16**]. ABG was 7.22/75/99 on 5L NC
(PCO2 significantly above baseline). CXR showed clear lung
fields. 0.2mg Narcan was administered with immediate improvement
in mental status and oxygenation, improving to 98-100% on 5L,
which was quickly weaned. He immediately c/o [**11-12**] pain and
demanded additional pain medicine, and an additional 0.5mg IV
dilaudid was given. He was also noted to intermittently refuse
the hard c-collar.
.
Since the first two MRIs were limited (the first by lack of
gado, the second by motion), a third MRI was done with
anesthesia to definitively assess for epidural abscess. He was
intubated for the MRI and given midazolam and fentanyl. He was
initially extubated after the MRI but afterward has decreased
respirations and was reintubated for respiratory distress. After
he awoke, he complained of neck pain and was given fentanyl
boluses, a total of 100mcg. His BP was down to 80s/40s and he
was given a 500c bolus without improvement. A dopamine drip was
ordered but the patient improved to 90s/50s and the drip was
held. As he woke up, his BP improved to 120s/60s. He was
transferred to the MICU.
Pt was transferred from MICU after having HD. Patient's Spo2
reduced to 88% on RA after bed transfer, with complaint of SOB
but no CP. Pt's HR was 100, increased to RR 28, BP was 120/74.
Pt [**Name (NI) **]2 was titrated with NC to > 96%. Pt initially had
increased oxygen requirements. Pain control was initially
started with ketorolac and acetaminophen and subsequent to po
percoicet. Patient problems of respiratory failure and
hypotension resolved after all IV narcotics were stopped.
Osteomyelitis/Discitis: Tissue biopsy and surgery results failed
to confirm infectious etiology. Path results were consistent
with cartilaginous degenerative changes and bone fragments.The
neck pain was to be degenerative and inflammatory in etiology. A
rare disorder in chronic renal patient was known as destructive
renal spondyloarthopathy was suspected although there is no
clear diagnosis of this phenomenon. It was decided to continue a
3 week course of at hemodialysis to prophylax against
osteomyelitis given patient previous history of listeria
bacteremia.
Pneumonia: Chest xrays was concerning for worsening pneumonia
although pt did no show any clinical signs of the disease.
Endocarditis: Previous echo reports not consistent with
endocarditis while patient was in house. No additional measure
was taken to pursue.
Pain control: For his neck pain, patient has been
well-controlled on mild pain medications. He has previously been
VERY sensitive to IV narcotics.
Respiratory failure. Resolved Pt tolerated room air since all IV
narcotics were stopped. Ambulated without shortness of breadth.
Hypotension: Normalized since all IV narcotics were stopped.
ESRD on HD: Pt continued to receive dialysis on regular schedule
after additional HD to remove gadolinum contrast dye.
DM: Pt remained euglycemic during the course of his stay with a
sliding scale.
Congestive Heart Failure EF < 20: Pt was restricted to low Na
diet and 1500ml fluid restriction. Pt was continued on home
medications.
COPD: treatment was continued with Albuterol/Atrovent MDI prn
SOB, dyspnea
CAD: There was no evidence of active ischemia while in
hospital. Management continued with home regimen and
heart-healthy diet
Medications on Admission:
albuterol 1-2p q6h prn
amiodarone 100 qd
citalopram 20 qd
RISS
levoxyl 50 m-f/75 sat-sun
lipitor 10 qd
lisinopril 2.5 qd
percocet q4-6h prn
[**Name (NI) 4532**] 75 qd
reglan 5 qd
renagel 400 qd
toprol xl 25 qd on non-HD days
Meds on transfer
Acetaminophen 650 Q6H PRN
ALbuterol INH Q6H PRN
Amiodarone 100mg PO Daily
Atorvastatin 10mg daily
Bisacodyl 10mg PO/PR daily
Citalopram 20mg PO daily
[**Name (NI) **] 75mg daily
Colace 100mg po BID
Reglan 5mg PO daily
Toprol XL 25mg po daily
percocet 1-2 tabs po Q4H prn
Sevelamer 400mg PO TID meals
Levothyroxine 50mcg PO dailiy
Lisinopril 2.5 mg PO daily
Insulin SC
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
[**Name (NI) **]:*qs qs* Refills:*0*
3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
[**Name (NI) **]:*15 Tablet(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Name (NI) **]:*30 Tablet(s)* Refills:*2*
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name (NI) **]:*30 Tablet(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Name (NI) **]:*30 Tablet(s)* Refills:*2*
7. Humulin N 100 unit/mL Suspension Sig: One (1) Subcutaneous
twice a day: Please continue your insulin according to your
sliding scale. .
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Name (NI) **]:*40 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
[**Name (NI) **]:*15 Tablet(s)* Refills:*2*
10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO three times a
day.
[**Name (NI) **]:*45 Tablet(s)* Refills:*2*
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
[**Name (NI) **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
13. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
[**Name (NI) **]:*45 Tablet(s)* Refills:*2*
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol): You will receive 1 gram
of vancomycin at dialysis through [**2166-12-31**]. .
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
[**Month/Day/Year **]:*1 inh* Refills:*2*
16. Outpatient Lab Work
Please send weekly results of the following Labs to Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 4020**]. Fax: ([**Telephone/Fax (1) 4591**]
1. CBC
2. Chem 10
3. Vancomycin Trough.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Cervical spinal inflammatory process NOS.
2. Right lower lobe pneumonia.
3. Acute respiratory failure.
SECONDARY DIAGNOSIS:
1. Coronary artery disease: Myocardial infarction in [**2155**],
MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous
RCA stent patent at that time.
2. Chronic systolic heart failure-Ischemic dilated
cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**]
to 25%
3. Diabetes greater than 20 years; with triopathy.
4. Hypertension.
5. End stage renal disease on hemodialysis, q. Monday,
Wednesday and Friday via right arteriovenous fistula. `
6. Hypothyroidism.
7. Chronic obstructive pulmonary disease.
8. Hepatitis C.
9. Chronic pancreatitis.
10. Peptic ulcer disease.
11. Right perinephric hematoma; status post embolization.
12. Obstructive sleep apnea on CPAP.
13. Ruptured right groin abscess; recurrent right groin
abscess in [**2162-12-4**].
14. Peripheral [**Year (4 digits) 1106**] disease.
15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein
16. Status post 2nd and 3rd toe amps
17. Status post left CFA to AK [**Doctor Last Name **] with PTFE
18. Status post L inguinal hernia repair
19. Status post umbilical hernia repair
20. Ischemic left foot
21. A - Fib- not well documented. Followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
cardiology who notes he was previously on coumadin.
Discharge Condition:
Good. Patient is ambulating, tolerating oral intake, and has
returned to his baseline condition.
Discharge Instructions:
You were admitted to the hospital because of your neck pain. An
MRI was performed which was concerning for an infection of your
bone or the tissue around your bone. You were admitted to the
hospital for further evaluation of your neck pain and IV
antibiotics. A biopsy of your neck bone was taken for analysis
and did not demonstrate any infection. However given your
history of prior infections and blood infections, we decided to
treat you with a 3 week course of antibiotics. You will continue
to be treated with an antibiotic called vancomycin which you
will receive at dialysis. You should receive your last dose on
[**2167-1-7**].
While evaluating your neck pain, we needed to perform an MRI
with sedation. Unfortunately, you were very sensitive to the
sedating medicine and developed difficulty breathing, requiring
intubation and a short stay in the intensive care unit. You were
extubated without difficulty and have been breathing on room air
since then.
Please continue close management of your heart failure with the
following management:
- Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
- Adhere to 2 gm sodium diet
- Fluid Restriction:1500ml/ day
Please continue to take all of your medications as prescribed.
If you have any symptoms of fevers, chills, night sweats,
headaches, worsening or changing neck pain, back pain, change in
appetite,numbness, tingling sensation in your neck/ shoulders/
fingers, worsening cough or shortness of breath, leg swelling,
or chest pain, please seek immediate medical attention.
Followup Instructions:
Please follow-up with your neurosurgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**]. We
have scheduled an appointment for you on [**1-7**] at 1pm.
His office is lcoated at [**Last Name (NamePattern1) 439**]. You will also need
an MRI prior to this appointment. Dr.[**Name (NI) 2845**] office will call
you with an appointment time for your repeat neck MRI. Again,
you should wear your cervical collar AT ALL TIMES until your
appointment with Dr. [**Last Name (STitle) 548**].
Please also follow-up with your Infectious Disease Doctor, Dr.
[**First Name8 (NamePattern2) 108567**] [**Last Name (NamePattern1) 4020**]. We have scheduled an appointment for you on
Thursday [**1-8**] at 9:30am. Her office is located at [**Last Name (NamePattern1) 108568**]. If you need to reschedule,
please call her office at [**Telephone/Fax (1) 457**].
Please also follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. We have scheduled an appointment for you on [**2167-1-8**] at
12pm. If you need to reschedule, please call his office at
[**Telephone/Fax (1) 250**].
Please also continue with your previously scheduled appointments
with the [**Telephone/Fax (1) 1106**] lab on [**2166-12-18**] at 1:45pm. If you need to
rescehedule, please call them at [**Telephone/Fax (1) 1237**].
You will also have labwork drawn weekly at dialysis and faxed to
your infectious disease doctor Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4020**].
Completed by:[**2166-12-19**]
ICD9 Codes: 4254, 486, 5180, 5856, 3572, 2449, 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7316
} | Medical Text: Admission Date: [**2174-3-12**] Discharge Date: [**2174-4-7**]
Date of Birth: [**2129-9-27**] Sex: F
Service: MEDICINE
Allergies:
Narc.Analgesic, Non-Salicyl.Analg.&Barb.
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Jaundice, anemia
Major Surgical or Invasive Procedure:
PICC placement
Dobhoff placement
Paracentesis
History of Present Illness:
Ms. [**Known lastname 81279**] is a 44 year old female who was admitted on [**2174-3-9**]
with lethargy, weakness, confusion, and new onset jaundice. Per
her husband, she had had diarrhea (green colored but no melena)
for 2 weeks prior and she was taking immodium prn. Per patient
and husband, no new medication. She had had intermittent
productive cough as well. No report of chest pain, shortness of
breath, or lightheadedness at that time. Per husband, she was
disoriented and confused and had slowed speech. Her skin turned
pale and jaundiced over the next week. She had been taking "a
lot" tylenol for plantar fasciitis prior to admission.
.
Upon arrival to [**Hospital3 **], she was found to be anemic with an
initial Hct of 9.1 and jaundiced although predominantly and
indirect bilirubinemia. She was also hyponatremic to 116. Her
INR was 1.6, platelets of 62. Her tox screen was positive for
opiates, tylenol, and benzos. A non-contrast head CT was
negative. She was hemodynacmially stable but she was admitted
to the MICU.
.
In the MICU, She was trasfused 10 units of PRBCs in 3 days. She
had no obvious signs of GI bleeding, although she did have
ongoing diarrhea though she was not on lactulose and was c.diff
negative. Hematology was consulted due to the predominance of
indirect hyperbilirubinemia and they felt her anemia was
multifactorial. She was treated with Unasyn 1.5 g q6 hours
since [**2174-3-10**] for unclear reasons.
.
Upon arrival to the MICU, she denies fevers, chills, nausea,
vomiting, melena, BRBPR, chest pain, shortness of breath. She
does report ongoing diarrhea. She reports increased abdominal
distention over the past few weeks. She reports chronic lower
extremity edema. She denies suicidal ideation.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting,
constipation or abdominal pain. No dysuria. Denied arthralgias
or myalgias.
Past Medical History:
Presumed alcoholic cirrhosis
Alcohol abuse with daily alcohol use, last drink [**2174-2-12**]
Bipolar disorder
Plantar Fascitis
Endometriosis
Social History:
Patient is married, she previously drinks [**12-31**] a bottle of
alcohol/day, last drink [**2174-2-12**]. She denies current or former
IV drug use. She smokes [**5-4**] cigarrettes/day.
Family History:
Non-contributory
Physical Exam:
Vitals: T: BP: 121/63 P:99 R: 21 O2: 97% on RA
General: Alert, oriented, no acute distress, slowed speach
HEENT: Sclera icteric, 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, + systolic murmur,
no rubs, gallops
Abdomen: soft, non-tender, + distended with ascites, bowel
sounds present, no rebound tenderness or guarding, unable to
assess hepatosplenomegaly
Ext: Warm, well perfused,+ b/l LE pitting edema
Pertinent Results:
Admission Labs:
[**2174-3-12**] 04:05PM BLOOD WBC-9.1 RBC-3.02* Hgb-10.5* Hct-27.7*
MCV-92 MCH-34.6* MCHC-37.7* RDW-24.7* Plt Ct-37*
[**2174-3-12**] 04:05PM BLOOD Neuts-90.8* Lymphs-5.7* Monos-2.5 Eos-0.4
Baso-0.6
[**2174-3-12**] 04:05PM BLOOD Hypochr-NORMAL Anisocy-2+
Poiklo-OCCASIONAL Macrocy-2+ Microcy-OCCASIONAL Polychr-1+
Target-OCCASIONAL Schisto-OCCASIONAL
[**2174-3-12**] 04:05PM BLOOD PT-24.1* PTT-50.4* INR(PT)-2.3*
[**2174-3-12**] 04:05PM BLOOD Fibrino-112*
[**2174-3-12**] 04:05PM BLOOD FDP-40-80*
[**2174-3-12**] 04:05PM BLOOD Ret Aut-3.4*
[**2174-3-12**] 04:05PM BLOOD Glucose-105 UreaN-27* Creat-0.8 Na-128*
K-3.3 Cl-88* HCO3-32 AnGap-11
[**2174-3-12**] 04:05PM BLOOD ALT-18 AST-75* LD(LDH)-221 CK(CPK)-20*
AlkPhos-43 Amylase-11 TotBili-37.3* DirBili-23.1* IndBili-14.2
[**2174-3-12**] 04:05PM BLOOD Lipase-33
[**2174-3-12**] 04:05PM BLOOD Albumin-2.5* Calcium-8.9 Phos-2.8 Mg-2.1
Iron-150
[**2174-3-12**] 04:05PM BLOOD calTIBC-157* VitB12-GREATER TH Folate-5.7
Hapto-<20* Ferritn-1462* TRF-121*
[**2174-3-12**] 04:05PM BLOOD HBsAb-POSITIVE HBcAb-NEGATIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2174-3-12**] 04:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2174-3-12**] 04:05PM BLOOD HCV Ab-NEGATIVE
[**2174-3-12**] 04:42PM BLOOD Type-MIX Temp-36.5 pO2-110* pCO2-45
pH-7.49* calTCO2-35* Base XS-9 Intubat-NOT INTUBA
Comment-QUESTION S
[**2174-3-12**] 04:42PM BLOOD Lactate-2.3*
.
Micro:
HBV Viral Load - Not detectable
HCV Viral Load - Not detectable
[**3-13**] Stool Studies: No Salmonella, Shigella, Campylobacter. No
C. diff. E.Coli 0157:H7 negative.
[**3-13**] Peritoneal Fluid: Gram Stain 2+ PMNs, no organisms.
Cultures negative.
[**3-15**] Peritoneal Fluid: Gram Stain 2+ PMNs, no organisms.
Cultures negative.
[**3-20**] Peritoneal Fluid: Gram Stain 1+ PMNs, no organisms.
Cultures negative.
[**3-21**] Urine Cx: Yeast >100,000.
IMAGING:
[**2174-3-12**] CXR - The right subclavian line tip, the low
SVC/cavoatrial junction. Cardiomediastinal silhouette is
unremarkable. Lung volumes are very low with bibasilar opacities
most likely consistent with atelectasis. No pneumonia. No
pneumothorax or appreciable pleural effusion was demonstrated.
The high position of the diaphragms may be explained by ascitis.
[**3-12**] RUQ Ultrasound:
1. Nodular, shrunken heterogeneous appearance of the liver,
consistent with cirrhosis.
2. Ascites.
3. Splenomegaly.
4. Main portal vein thrombosis.
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [**2174-3-13**]:
IMPRESSION: Cirrhosis with ascites and splenomegaly. The
presence of portal venous thrombosis, seen on the earlier
ultrasound, cannot be assessed, particularly given the lack of
intravenous contrast administration.
CT HEAD W/O CONTRAST [**2174-3-13**]:
No acute intracranial process.
Portable TTE (Complete) [**2174-3-14**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
[**3-14**] CT Abd - 1. No apparent filling defects within the main
portal vein to suggest thrombosis.
2. Findings consistent with cirrhosis including ascites,
varices, and nodular and shrunken appearance of the liver with
caudate hypertrophy.
3. Sludge within the gallbladder, unchanged. No evidence of
intrahepatic or extrahepatic biliary dilatation.
4. Subcentimeter hypodensity within the right lobe of the liver
(2, 37),
incompletely characterized on this single phase study.
[**3-17**] KUB - Ascites. No evidence of obstruction or ileus.
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [**2174-3-20**]:
1. Severe ascites with interval development of intraperitoneal
hemorrhage.
2. Small hypodense abnormality compatible with clot demonstrated
projecting from the right flank parietal peritoneum. This may be
the sequelae of recent instrumentation.
3. New development of right lower lobe consolidation,
incompletely evaluated on this examination.
PORTABLE ABDOMEN [**2174-3-23**]:
IMPRESSION: Severe ascites. No evidence of obstruction.
CHEST (PORTABLE AP) [**2174-3-25**]:
IMPRESSION:
Since [**2174-3-23**], Dobhoff tube now ends in the upper-to-mid
esophagus.
Right PICC ends in the upper SVC. Cardiomegaly is unchanged.
Multifocal
opacities, more prominent on the right increased, worrisome for
progression of multifocal pneumonia.
Brief Hospital Course:
44 year old female with cirrhosis presumed secondary to alcohol
abuse and tylenol overuse, s/ p 2 week stay in the MICU
([**Date range (1) 81280**]), briefly transferred to floor, then transferred back
to MICU on [**3-25**] with worsening renal function, mental status
change, and respiratory distress thought likely secondary to
narcotics; after stabilization in mental status and improved UOP
and respiratory status, transferred back to floor on Liver
service. Given poor prognosis and worsening liver disease and
encephalopathy, pt was ultimately made CMO by family.
#. Anemia: Hematocrit on admission to outside hospital was 9.1.
The patient received 10U of PRBCs prior to transfer and
hematocrit on admission to our ICU was 27.7. Etiology of
profound anemia is likely multifactorial, including anemia of
chronic disease (according to iron studies), low-grade GI bleed
(with guaiac positive stool), and possible viral gastroenteritis
plus alcohol use resulting in marrow supresssion. Reticulocyte
count of 4 from OSH argues against hemolysis and more towards
marrow supression. There was concern for DIC or TTP given low
fibrinogen, elevated PTT, and thrombocytopenia, rare
schistocytes; however, our suspecion was that these
abnormalities are secondary to liver failure. MCV of 120
suggestive of alcohol abuse and liver failure. The liver service
did not feel that concern for GI bleed was high enough to
warrant endoscopy or colonoscopy during ICU course.
In addition, the patient had acute blood loss from
intraperitoneal bleed likely secondary to paracenteses in the
setting of coagulopathy. She had a diagnostic paracentesis on
[**3-13**] and on repeat diagnostic para on [**3-15**], ascitic fluid was
blood-tinged. Over the next several days the patient required 7U
PRBCs for multiple Hct drops. Therapeutic paracentesis on [**3-20**]
removed 2.5L of grossly bloody fluid with an ascitic Hct of 8.
CT Abd at that time showed evidence of hemoperitoneum with
possible bleeding vessel on the right parietal peritoneum. The
patient was transfused multiple units of FFP (8-12U per day x
4days) and platelets. She was evaluated by both general surgery
and transplant surgery, and neither team felt that operative
correction of her bleeding was appropriate due to her extremely
high mortality rate. By [**3-22**], the patient's hematocrit had
stabilized and she no longer required blood transfusions or
further FFP.
#. Cirrhosis: On admission, and throughout ICU course, patient
had mild transaminitis with thrombocytopenia, ascites, LE edema,
hepatosplenomegaly, and elevated INR to 2.5. This is likely
secondary to cirrhosis from alcoholism, with a potential
contribution of recent heavy tylenol use. Per patient and
husband, the patient had not been drinking for 1 month prior to
admission. The patient had no history of liver biopsy, no prior
EGD/[**Last Name (un) **], and had never seen a hepatologist. The patient also
had an ultrasound which showed portal vein thrombosis, which was
not observed on CT scan. However, per radiology, ultrasound is a
more sensitive test and thus the patient was presumed to have an
acute portal vein thrombosis contributing to her worsening
ascites and splenomegaly. The patient was not a candidate for
anticoagulation or thrombolysis due to her high risk for
bleeding complications. The liver team followed along while in
the MICU and the patient was treated with N-acetylcysteine for 3
days. She was also maintained on lactulose, octreotide,
rifaximin, and a PPI. In addition, the patient had 2 diagnostic
paracenteses, the second of which showed evidence of SBP.
Bladder pressures were monitored, and when bladder pressure was
elevated >20mmHg on [**3-20**], the patient had a therapeutic
paracentesis to remove 2.5L bloody ascitic fluid.
#. SBP: On second paracentesis, the patient had evidence of SBP.
She was treated with Unasyn x3days, Ceftriaxone x2days, and
finally vancomycin/zosyn for 9 days. She was then transitioned
to ciprofloxacin to complete a 2 week course on [**3-28**]. Ascitic
fluid cultures were negative. The patient also had 2 KUBs to
rule out obstruction as cause of abdominal distension and
abdominal pain, both of which were negative for obstruction.
#. Acute Renal Failure: The patient had elevation in Creatinine
with peak of 3.0. FeNa was <1%. Differential included prerenal
and hepatorenal syndrome. Creatinine normalized after albumin
infusion x3, which argues against hepatorenal. On HD 12,
Creatinine again elevated from 0.5 to 1.5, in the setting of
having d/c'd octreotide and midodrine for one day. Albumin
infusion was given again, but discontinued on the floor. Cr
stabilized at 1.5.
#. Diarrhea: Patient had diarrhea prior to admission and was not
on lactulose/rifaximin. All stool studies were negative, though
concern remained for viral gastroenteritis vs. med effect (was
on magnesium oxide at OSH). The patient was started on
lactulose/rifaximin during this admission and she continued to
have mild diarrhea on this regimen. Pt also experienced rectal
prolapse during this time.
#. Hyperbilirubinemia. Patient has first onset jaundice in
setting of heavy alcohol abuse and recent heavy tylenol use due
to plantar fascitis. Concerning for jaudice due to liver
failure, though per OSH report on presentation,
hyperbilirubinemia was predominantly indirect (T. bili 17.1, D.
bili 5.4). In the setting of getting 10 units of blood, T. bili
rose to 37 with D. bili of 23. Suspect that hyperbilirubinemia
is related to liver failure, but may have element of hemolysis
(though labs do not substantiate this - retic count 4, LDH
normal, hapto undectable but liver patient). Pt did not have any
new signs of active bleeding or hematoma and no localizing
symptoms.
.
#. Altered mental status. Patient had AMS that waxed and waned
but improved slowly in the ICU. This was likely secondary to
hepatic encephalopathy, SBP, and initially hyponatremia, which
became hypernatremia during the second half of ICU stay. Head CT
showed no evidence of acute intracranial process. Mental status
improved on day of transfer to floor from MICU. Patient was
oriented x [**12-31**] on the floor, with speech continuing to remain
slow. Mental status and level of alertness continued to wax and
wane throughout stay prior to her expiration.
#. Thrombocytopenia: Likely secondary to liver failure and
sequestration due to splenomegaly. Patient had evaluation for
TTP and DIC, which was difficult to interpret due to liver
failure, but was not highly suspicious. Rare schistocytes on
smear with elevated PTT, low fibrinogen, and hyperbilirubinemia.
However, LDH normal. As above, suspicion for DIC and HUS was
very low. The patient received 2 U platelets while she had
intraperitoneal bleed. Platelets stabilized in the 50s.
#. Hyponatremia: Patient was hyponatremic on admission, likely
secondary to ascites and LE edema. Once tube feeds were started,
the patient became hypernatremic. Free water boluses and D5W was
continued to correct serum sodium.
.
# Urinary Tract Infection: The patient's urine grew yeast on
[**3-22**] and foley was changed. Patient was receiving Cipro for SBP
already and thus no further antibiotics were added.
.
#. LE edema: The patient had bilateral LE pitting edema on
admission, which was thought to be related to liver failure.
However, cardiac function was evaluated with an echocardiogram,
which showed normal LV systolic function and mild pulmonary
hypertension. Her edema persisted throughout the admission.
.
# H/O Alcohol Abuse: The patient completed 5 days of high dose
thiamine. She was continued on multivitamins and folate.
.
# CMO: At family meeting, was ultimately decided by family,
including husband [**Name (NI) 382**] that pt would not want to continue with
aggressive medical management under these circumstances. Pt was
made CMO, with Morphine IV/PO SL made available. Hospice
arrangements were initiated. Pt eventually expired prior to
discharge to hospice, with family present at bedside.
Medications on Admission:
Tylenol prn
Xanax 0.5 QID PRN
lexapro 30 mg daily (takes intermittently)
zolpiden prn
hydrocodone prn (not prescribed to her)
Discharge Medications:
N/A, Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest
ETOH cirrhosis
Discharge Condition:
N/a, Expired
Discharge Instructions:
N/a, Expired
Followup Instructions:
N/a, Expired
Completed by:[**2174-6-1**]
ICD9 Codes: 5849, 2761, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7317
} | Medical Text: Admission Date: [**2132-7-27**] Discharge Date: [**2132-8-25**]
Date of Birth: [**2050-9-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lasix / Bumex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2132-8-8**] Coronary Artery Bypass Graft x 5 (Left internal mammary
artery > Left anterior descending, saphenous vein graft >
diagonal, saphenous vein graft > obtuse marginal 1, saphenous
vein graft > obtuse marginal 2, saphenous vein graft > posterior
descending artery)
[**2132-7-30**] Cardiac Catherization
History of Present Illness:
81M complains of "constant tiredness" over 10-12 days, worse
than previous chronic intermittent breathing problems; sudden
onset [**8-12**] "heavy feeling" in abdomen; 2-3 days coryza, cough,
sore throat, chills. [**7-26**] T 99.6F PO. No dizziness, no changes
in chronic BLE edema, no N/V, and reports no other symptoms.
.
81 y/o with h/o HTN, valvular diseas 1+MR, 1+ [**Last Name (LF) **], [**First Name3 (LF) **] 60%
([**2131-9-10**])who presents with few days of increasing SOB. He notes
that he has been feeling poorly over the last few days and has
had a heavy feeling in his stomach. While he has been having
increased DOE x last few days, he feels that this is part of a
more chronic process that has been going on for the past few
months. Denied any chest pain/discomfort, but noted DOE. He is
still able to climb 1 flight of stairs. Notes Orthopnea, denied
PND. + Dry cough, + Chills, + rhinnorhea last two days. Denied
fever, palpitations, irregular heart beats, worsening of chronic
[**Location (un) **] (had for years. Complaiant with all his meds. Denied any
dietary indiscretions.
Past Medical History:
HTN
CAD
Mitral regurg
Aortic regurg
Dyslipidemia
Hypothyroidism
Gout
Bladder CA (12 years ago)
pericarditis (remote)
Social History:
Pt. is a semi-retired CPA.
Pt. lives with his family.
Pt. has never smoked, does not drink alcohol, and has never used
recreational drugs.
Family History:
Pt. does not have any family history of premature coronary
artery disease.
Physical Exam:
T: 97.5 BP:148/70 P:70 RR:20 O2 sats: 95% on 2L
Gen: Obese male sleeping comfortably
HEENT: PEERL EOMI OP dry
Neck: JVD could not be appreciated [**3-7**] girth. Supple
CV: +s1+s2. No murmurs appreciated. RRR
Resp: CTA B/L No RRW
Abd: Obese. NTND
Back: Seborrheic keratoses and skin tags
Ext: 2+ peripheral edema up to knees
Pertinent Results:
[**2132-7-27**] 04:40PM CK-MB-17* MB INDX-12.1* cTropnT-0.33*
proBNP-7201*
[**2132-7-27**] 04:40PM CK(CPK)-141
[**2132-7-28**] 01:15AM CK-MB-15* MB Indx-10.7* cTropnT-0.41*
[**2132-7-28**] 07:20AM CK-MB-11* MB Indx-10.4* cTropnT-0.38*
.
[**2132-8-1**] 06:55AM WBC-5.0 RBC-2.70* Hgb-8.9* Hct-25.7* MCV-95
MCH-33.1* MCHC-34.7 RDW-14.9 Plt Ct-201
.
[**2132-8-2**] 07:15AM Glucose-106* UreaN-70* Creat-2.5* Na-141 K-4.2
Cl-103 HCO3-31 AnGap-11
[**2132-8-7**] 07:10AM Glucose-104 UreaN-58* Creat-1.9* Na-145 K-4.4
Cl-105 HCO3-35* AnGap-9
.
[**2132-8-6**] 06:30AM proBNP-4448*
.
EKG: 5pm in ED: Sinus bradycardia with 1 degree AVB. Normal
axis. Qt not prolonged. No EKGs in last 10 years to compare to.
.
CXR: [**2132-7-27**]
FINDINGS: Lateral blunting of the right costophrenic sulcus is
stable and unchanged compared to the most recent examination.
This is likely scondary to pleural thickening. The cardiac
silhouette is moderately enlarged. The pulmonary vasculature is
mildly prominent. Prominence of the central pulmonary arteries
is unchanged compared to the most recent examination. Right
apical pleural thickening is unchanged. A small calcified focus
projected over the right clavicle consistent with calcified
granuloma is also unchanged compared to previous examinations.
The lungs are grossly clear. There are no pleural effusions. The
soft tissues and osseous structures are unremarkable.
IMPRESSION: No direct evidence of CHF. Evidence of probably
interstial lungn disease in the mid-lower lungs with associated
prominent hila/bilateral lymphadenopathy. Pulmonary arterial
prominence likely reflects underlying pulmonary hypertension.
Relatively unchanged examination compared to most recent
radiographs of [**2131-9-4**].
.
CXR: [**2132-8-7**]
Brief Hospital Course:
He awaited stable creatinine and hematacrit prior to undergoing
CABG on [**2132-8-8**]. After surgery he was transferred to the SICU
in critical but stable condition on epi and neo. Post op
oliguria improved with volume and natrecor. He was followed
closely by Renal. He was extubated on POD #2. His creatinine
continued to worsen, he continued on diuril and torsemide and a
dialysis catheter was placed. CVVH was started on [**8-13**] to aid
in fluid removal. He was started on amiodartone and coumadin for
atrial fibrillation. His kidney function and urine output
improved and CVVH was stopped. He was transferred to the floor
on POD #12. He was started on vancomycin and levofloxacin for
erythema of his sternal incision, which improved and the vanco
was discontinued. He was ready for discharge to rehab on [**8-25**]
with a wound check in one week.
Medications on Admission:
Torsemide 60 mg [**Hospital1 **]
Terazosin 10 mg [**Hospital1 **]
Norvasc 10 mg [**Hospital1 **]
Clonodine 0.3 mg [**Hospital1 **]
Allopurinol 200 mg daily
Synthroid 0.025 mg daily
Lipitor 10 mg daily
Diovan 320 mg daily
Toprol XL 50 mg daily
Lexapro 20 mg daily
Ranitidine 150 mg daily
MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO twice a day.
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
12. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
13. Lexapro 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
16. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
17. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for
2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Acute tubular necrosis
Heart Failure - diastolic dysfunction
Hypercholesteremia
Hypertension
Hypothyroidism
Gout
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1000
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr [**Last Name (STitle) 58**] after discharge from rehab [**Telephone/Fax (1) 3329**]
Dr [**Last Name (STitle) **] 2 weeks
Completed by:[**2132-8-25**]
ICD9 Codes: 5859, 5845, 2762, 4019, 2720, 2749, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7318
} | Medical Text: Admission Date: [**2104-3-26**] Discharge Date: [**2104-4-1**]
Date of Birth: [**2104-3-26**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: The patient is the 2.35 kg
product of a 33-week gestation born to a 38-year-old, G1, P0
mom. OB history is significant for diet controlledgestational
diabetes, maternal obesity, rupture of membranes on [**3-23**],
adequate antibiotic coverage and betamethasone complete.
The infant delivered by cesarean section due to fetal heart
decelerations with Pitocin. Apgar scores were 9 and 9.
PHYSICAL EXAMINATION: General: On admission birth weight was
2.35 g, length 47.5 cm, head with significant molding,
anterior fontanel soft and flat. Eyes, ears, nose and mouth:
Appear within normal limits. Oropharynx: Within normal
limits. Eyes: With red reflex. Neck: Clavicles within normal
limits. Chest: Symmetric breath sounds. Shallow intermittent
grunting. Cardiovascular: Heart sounds appear within normal
limits. No murmur. Well perfused. Normal peripheral pulses.
Abdomen: No hepatosplenomegaly or masses. Nontender. Soft,
full, 3-umbilical vessels. Genitalia: Normal premature male.
Anus patent. Back: Within normal limits. Skin: Within normal
limits. Extremities: Appear normal. Neurologic: Normal for
premature infant of tone, posture movement, cry and normal
state changes.
HOSPITAL COURSE: Respiratory: The infant was admitted to the
newborn intensive care unit and placed on nasal prong CPAP
for management of increased work of breathing. Chest x-ray
revealed mild to moderate respiratory distress syndrome. The
infant was intubated. He received 1 dose of surfactant and
was extubated by 24 hours of age.
He was on nasal cannula oxygen for 48 hours and transitioned
to room air. He remained stable in room air. He had
occasional apnea of bradycardia episodes since starting
caffeine citrate on [**3-28**]. He is currently receiving 7
mg/kg/day.
Cardiovascular: No issues.
Fluids and electrolytes: Birth weight was 2.35 kg. Discharge
is . The infant initially started on 80 cc/kg/day of D10W.
Enteral feedings were initiated on day of life #1 and
advanced to full enteral feedings by day of life #4 and is
currently on 140 cc/kg/day of premature Enfamil or breast
mild 20 calories. On admission, he had a dextrose stick of
24, required a D10 bolus. The infant euglycemic since that
time. Most recent set of electrolytes were on [**3-29**];
sodium 145, potassium 5.0, chloride 108, total CO2 24.
GI: Peak bilirubin on day of life #2 was 9.7/0.3. He received
phototherapy which was discontinued on the 26th. Rebound
bilirubin was 9/0.2. His most recent bilirubin was on [**2104-4-1**], and the result is epmding at the time of discharge.
Will contact [**Name (NI) **] with this result when available. .
Hematology: Hematocrit on admission was 50.6. He has not
required any blood transfusions.
Infectious disease: CBC and blood culture were obtained on
admission. CBC was benign, and blood culture remained
negative at 48 hours at which ampicillin and gentamicin were
discontinued. Initial showed a white count of 11.2, platelets
257, 16 polys, 1 band, 66 lymphs.
Sensory: Hearing screen has not yet been performed but should
be done prior to discharge home.
Psychosocial: A social worker has been involved with the
family and can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To a level [**Hospital **] hospital.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66076**], [**Telephone/Fax (1) 58419**].
FEEDS AT DISCHARGE: Continue 140 cc/kg/day of breast milk or
Premature Enfamil 20 calorie. Advance caloric intake as
appropriate.
MEDICATIONS: Continue caffeine citrate of 7 mg/kg/day.
CAR SEAT POSITION SCREENING: Has not been performed.
STATE NEW BORN SCREENING: Has been sent; most recently on
[**3-29**], has been within normal limits.
IMMUNIZATIONS RECEIVED: The infant received hepatitis B
vaccine on [**2104-3-28**].
DISCHARGE DIAGNOSIS: Premature infant born at 32 and 2/7
weeks' gestation, respiratory distress syndrome, rule out
sepsis with antibiotics, infant of a diabetic mother,
hyperbilirubinemia, apnea and bradycardia of prematurity.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2104-3-31**] 19:48:58
T: [**2104-3-31**] 20:20:05
Job#: [**Job Number 66077**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7319
} | Medical Text: Admission Date: [**2194-7-16**] Discharge Date: [**2194-7-24**]
Date of Birth: [**2121-10-22**] Sex: M
Service: TSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
right-sided chest pain and shortness of breath
Major Surgical or Invasive Procedure:
s/p apical wedge/talc pleuredhesis on [**2194-7-7**] and axillary
thoracotomy with drainage on [**2194-7-16**].
History of Present Illness:
72M admitted to an outside hospital with a diagnosis of
right-sided spontaneous pneumothorax. A chest tube was placed
but the patient continued to have a persistent air leak. On
[**2194-7-7**] he underwent broncoscopy and VAWR of the right upper
lobe with talc pleuredhesis for a bronchopleural fistula. He
was found to have a bulla on the apical segment of the RUL.
During this admission he was diagnosed with MRSA and started on
vancomycin and tobramycin. He also developed new onset afib.
V/Q scan was indeterminate and head CT (obtained for a change in
mental status) was negative for acute changes. He was
transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
probably COPD
high cholesterol
s/p appy
umbilical hernia
s/p hemmoroidectomy
afib
Social History:
quit smoking 21 years ago
drinks EtOH daily
Family History:
n/c
Physical Exam:
T 96.9 HR 95-129 and afib BP 110/64 oxygen 93%
HEENT: PERRLA, no JVD
Lungs: left CTA, right decreased at base, chest tube draining
Heart: irregularly irregular
Abdomen: + BS, NT/ND
Neuro: A + O x 3
Pertinent Results:
[**2194-7-16**] 02:17AM WBC-14.3* RBC-3.88* HGB-11.9* HCT-34.1*
MCV-88 MCH-30.7 MCHC-34.9 RDW-13.7
[**2194-7-16**] 02:17AM PLT COUNT-187
[**2194-7-16**] 02:17AM PT-13.8* PTT-28.3 INR(PT)-1.3
Brief Hospital Course:
The patient was s/p for a R VAWR/talc pleuredhesis/bleb
resection. He was taken to the operating room on [**2194-7-16**] for a
right axillary thoracotomy and drainage of empyema. He
tolerated the procedure wellHe was admitted to the ICU and
remained intubated. CT revealed a dominant apical fluid
collection. He continued to be weaned from his sedation, his
pressors, and was extubated.
He was trasferred to the floor on [**2194-7-19**]. He continued to
drain fluid from both chest tubes. His heparin was discontinued
and he was placed first on 3mg of coumadin, and later down to
2.5mg. He continued to void and ambulate appropriately. On
[**2194-7-23**] one of his chest tubes was removed and his central line
was removed. A PICC line was placed as well.
On [**2194-7-24**] the patient pulled out his PICC line by accident and
it had to be replaced. His second chest tube was converted to a
drain and he was discharged to [**Hospital 5503**] rehab facility.
Medications on Admission:
vancomycin 1g q12
tequin
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO three
times a day.
Disp:*180 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q12H
(every 12 hours).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Vancomycin HCl 10 g Recon Soln Sig: 1 vial Recon Soln
Intravenous Q12H (every 12 hours) for 4 weeks: 1g q12h.
Disp:*qs Recon Soln(s)* Refills:*2*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
8. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day.
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
status/post apical wedge/talc pleuredhesis on [**2194-7-7**] and
axillary thoracotomy with drainage on [**2194-7-16**].
hypercholesterolemia
umbilical hernia
status/post hemmorhoidectomy
appendectomy
new atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to
the ER if your wound becomes red, swollen, warm, or produces
pus.
You may remove your dressings 2 days after your surgery if they
were not removed in the hospital.
Leave the steri strips on until they begin to peel, then you may
remove
them.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
Be sure to take your complete course of antibiotics.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed
from your wounds.
Followup Instructions:
Call to set up an appointment with Dr. [**Last Name (STitle) **] in 1 week. Call to
schedule a follow up appointment in [**12-27**] weeks with Dr. [**Last Name (STitle) 952**]
([**Telephone/Fax (1) 1504**]).
The patient's primary care physician will follow him for his
coumadin therapy as well as the drain care. The drain should be
withdrawn [**12-27**] inches per week until it is out. PCP is [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 15170**] MD, ([**Telephone/Fax (1) 50234**].
ICD9 Codes: 496, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7320
} | Medical Text: Admission Date: [**2172-1-4**] Discharge Date: [**2172-1-8**]
Date of Birth: [**2096-8-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
right hip pain and cellulitis of left lower extremity
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 M with history of cardiomyopathy with EF35% 2/2 rheumatic
fever, atrial flutter, HTN, HL, mantle cell lymphoma in
remission, right hip pain secondary to degenerative hip disease
presents with fevers, chills, increasing generalized weakness
for 3 days as well as productive cough with yellowish phlegm x2
weeks. Patient reports that for the past few [**Last Name (un) 32460**] he has felt
increasingly lethargic. He has been taking frequent naps which
is unusual for him. He also noted progressively worsening
mobility due to pain/stiffness in his joints. He has chronic
right hip and knee pain. This morning, he was unable to change
positions from sitting to standing. He remained in bed due to
weakness. He denies worsening swelling or erythema in his lower
extremities. He did have some mild pain in his left leg and
knee. He developed chills around 7:15 am and came to the ER for
evaluation. In addition, he reports 2.5 weeks of cough
productive of grey/yellow sputum. He denies any chest pain or
shortness of breath associated with cough. He notes that it has
improved in the last several days.
.
Of note, patient went to the podiatrist Tuesday and had his toe
nails clipped. Left second toe was accidentally cut. He did
not really notice that his left leg was erythematous until he
got to the ED. Says that his left leg is usually more swollen
anyway since his ankle injury.
.
In the ED, initial VS were as follows: 99.6 86 137/71 18 95% RA.
Was noted to be in Afib with heart rates to 120s, but holding
blood pressure. Was given IV fluids with return to normal sinus
rhythm. Tmax in ED was [**Age over 90 **]F. He was noted to have erythema of
right leg. He was also noted to be soaked in urine and with
stage 1 ulcer overlying swelling of right posterior hip. He was
also noted to have a dressing on his left 2th toe that had
adhered to nailbed from his podiatry appointment on Wednesday;
dressing was removed with gauze in ED. He was given a dose of
vancomycin to treat cellulitis. His hip was considered for
septic joint, however exam showed that his hip joint was
rangeable. His CXR was not very concerning for pneumonia, but
given that he was producing sputum and having fever, was given
levofloxacin.
.
Vitals in ED at time of bed request were as follows: 99.6 86
137/71 18 95%RA. About half hour after getting a dose of
oxycodone, his blood pressures were 87/50s while asleep, blood
pressure responded to IV fluids. Patient intermittently would
continue to dip down into the 80s, each time responsive to IV
fluids. Received a total of 3 L NS. Lactate improved from 2.7
to 1.1. VS in ED prior to transfer were as follows: 82, 96/41,
17, 96% RA
.
On arrival to the ICU, vital signs were T103.0 BP 119/51 HR 90
saturating on RA. He was talkative and had no complaints of
pain.
.
Past Medical History:
# Rheumatic heart disease with mitral regurgitation
- Status post acute rheumatic fever and pericarditis in [**2103**]
# Cardiomyopathy, non-ischemic
- initially thought to be secondary to chemotherapy, then
attributed to potential tachycardia-induced cardiomyopathy
- echocardiogram on [**2171-5-17**] showed moderate LV global
hypokinesis (EF 35%)
# Atrial flutter - on warfarin
- plan by cardiologist to set up Holter in 6 months ([**6-/2172**]) and
consider stopping anticoagulation if no recurrence of arrhythmia
# Hypertension
# Hyperlipidemia
# Prediabetes
# Mantle Cell Lymphoma
- s/p chemotherapy, 6 cycles Bendamustine/Rituxan - last
session [**2171-4-5**]
- currently in remission, followed by Dr. [**Last Name (STitle) **]
- on rituximab for maintenance, started [**12/2171**]
# Adenocarcinoma of prostate with [**Doctor Last Name **] score of 6
- status post radiation in [**2158**]
# Right knee degenerative joint disease
# Status post left scapular fracture
# Status post right big toe fracture
# Status post right leg osteomyelitis at age 30 years old
# Gout associated with hyperuricemia
# Status post volar plate injury of right fifth digit
# Abdominal sepsis in [**2149**]
# Allergic rhinitis
# Chronic pedal edema
# Cervical disc disease
# Lumbar disc disease associated with right sciatica
# Vitamin D deficiency
# s/p Open reduction and internal fixation left ankle
post-fracture.
Social History:
Patient lives with his wife and his two children lvie with their
families in the same building. He has three grandchildren. He
is retired, but used to work as a maintenance, as machinist and
in shipyard (he was exposed to asbestos from [**2136**] and [**2142**]). He
quit smoking 25 years ago. He used to smoke for 10 years
approximately one pack per week. He is consuming alcohol
occasionally
Family History:
Negative for any type of cancer, leukemia, or lymphoma; however,
his sister has anemia and significant weight loss.
Physical Exam:
Vitals: T: 103.0 BP: 119/51 P: 90 R: 18 O2: 94% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL, oropharynx dry but without
exudate or erythema.
Neck: supple, JVP not elevated, no lymphadenopathy palpated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext:
RIGHT LOWER EXTREMITY- right hip with limited active range of
motion, full passive range of motion without pain. No swelling
or erythema of hip, swelling without erythema of right knee.
Full active/passive ROM of ankle. 2+ pitting edema to knee.
LEFT LOWER EXTREMITY- full active/passive ROM of hip/knee/ankle.
Strength 5/5.
Skin:
Right lower extremity with superficial excoriation on right shin
without surrounding erythema and no exudate.
Left 2nd toe with dried blood above nailbed, no swelling of toe.
Erythema from base of left MTPs tracking up to knee and then
continuing in lymphatic pattern into medial aspect of thigh.
Mild induration, mostly 2+ pitting edema. + warmth. no
tenderness.
.
ON DISCHARGE:
PE: AF Tmax 99.6 BP 102-120/70 70s 20 97% RA
Appearance: alert, NAD
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2 -m/r/g, 1+ peripheral lower extr edema
Pulm: clear bilaterally
Abd: soft, obese, nt, nd, +bs
Msk: 5/5 strength throughout, + left ankle deformity, no
cyanosis or clubbing
Neuro: cn 2-12 grossly intact, no focal deficits. pt can not
lift his left leg off the bed
Skin: LLE erythema - improved, mildly tender, some wrinkling of
skin, erythema significantly reduced, 2+ pitting edema
Walking with walker with limp, but able to apply weight to both
legs
FROM of left hip
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
Pertinent Results:
ADMISSION LABS:
[**2172-1-4**] 09:20AM BLOOD WBC-12.8*# RBC-3.19* Hgb-10.2* Hct-32.7*
MCV-102* MCH-31.9 MCHC-31.2 RDW-18.8* Plt Ct-207
[**2172-1-4**] 09:20AM BLOOD Neuts-82* Bands-8* Lymphs-6* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2172-1-4**] 09:20AM BLOOD PT-33.7* PTT-46.9* INR(PT)-3.3*
[**2172-1-4**] 09:20AM BLOOD ESR-60*
[**2172-1-4**] 09:20AM BLOOD Glucose-117* UreaN-22* Creat-0.9 Na-137
K-6.6* Cl-98 HCO3-25 AnGap-21*
[**2172-1-4**] 09:20AM BLOOD proBNP-1199*
[**2172-1-4**] 09:20AM BLOOD cTropnT-0.03*
[**2172-1-5**] 04:08AM BLOOD cTropnT-0.02*
[**2172-1-4**] 09:20AM BLOOD CRP-47.7*
[**2172-1-4**] 09:40AM BLOOD Lactate-2.7* K-5.5*
[**2172-1-4**] 03:46PM BLOOD Lactate-1.1
Micro:
UA ([**2172-1-4**]) - negative
blood cultures x2 ([**2172-1-4**]) - pending
.
Images:
LLE LENI ([**2172-1-4**]) - No evidence of DVT, although the left
peroneal veins not visualized
.
CXR ([**2172-1-4**]) - my read - mild cardiomegaly, no pleural
effusion, no infiltrate
.
DISCHARGE LABS:
[**2172-1-8**] 05:45AM BLOOD WBC-4.6 RBC-2.26* Hgb-7.6* Hct-23.3*
MCV-103* MCH-33.8* MCHC-32.8 RDW-17.8* Plt Ct-106*
[**2172-1-8**] 05:45AM BLOOD PT-26.2* INR(PT)-2.5*
[**2172-1-8**] 05:45AM BLOOD Glucose-101* UreaN-21* Creat-0.7 Na-136
K-3.7 Cl-100 HCO3-28 AnGap-12
[**2172-1-8**] 05:45AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.6
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
This is a 75 M with history of degenerative hip disease, mantle
cell lymphoma, presenting with fevers, chills, fatigue, right
hip pain, and cough, noted to be intermittently hypotensive in
the ED, concern for sepsis who was admitted to the ICU briefly
for stabilization then transferred to the floor for management
of cellulitis.
.
ACTIVE ISSUES:
#. Hypotension/Cellulitis - Met SIRS criteria with fever and
white count. Hypotensive to SBP to 80s in the ED, which was
fluid responsive. CBC with differential showing 8% bands. Most
likely source seems to be from left lower extremity cellulitis,
point of entry probably from the cut on his toe. He also has
skin breakdown on his right leg however with no localized
erythema. Patient complains of a nagging cough, but CXR without
any signs of pneumonia. Ortho examined the patient and felt hip
unlikely to be source or septic joint. His blood pressure and
anti-hypertensive medications were held. He was started on
vancomycin for treatment of his cellulitis with significant
improvement in his leg exam. He was called out to the floor on
HD 2. Pt remained normotensive, vancomycin was discontinued and
bactrim and keflex were started. Pt has penicillin allergy but
he stated it made him turn red and he never had any difficulty
breathing. He also felt that he recalled being treated with
keflex in the past. His home bp meds were also restarted on HD
2. Tolerated PO abx well with continued improvement in leg
exam.
.
#. Afib w/ RVR - Patient was tachycardic in the ED which
persisted on arrival to [**Hospital Unit Name 153**] with HR stably in 130-140s - afib
with rapid ventricular response on EKG. He has a history of
paroxysmal afib that failed cardioversion this summmer. Thought
[**3-6**] fluid depletion and infection. He was given IVF, started on
PO metoprolol and given IV metoprolol 2.5 with initial
conversion into sinus. His cardiologist was emailed regarding
his admission and recommended that no significant changes be
made to his medication list. Accordingly he was sent out on his
home dose of carvedilol and warfarin. He had no episodes of A
fib on telemetry on the Oncology floor. Was continued on
coumadin, last INR 2.5 on [**1-8**]. Pt needs INR closely monitored
as this is a rapid overnight change. Additionally he was started
on bactrim which can alter warfarin levels.
.
INACTIVE ISSUES:
#. Right Hip pain- limited ROM, concerning for seeded joint from
initial cellulitis leading to bacteremia. Orthopaedics evaluated
joint and felt joint not septic.
.
#. Hypertension - intermittently hypotensive, held home
antihypertensives while in [**Hospital Unit Name 153**] but restarted on the floor prior
to discharge without issue.
.
#. h/o rheumatic heart disease - TTE in [**5-/2171**] shows moderate LV
global hypokinesis with EF 35%. CXR shows a heart silouette
that is larger than it had been in the past. Pt to follow up
with cardiologist.
.
#. Hyperlipidemia - not on statin at home, did not start here.
.
#. Pre-diabetes - had been on metformin in the past, but
currently not on anything at home. Pt was maintained on insulin
sliding scale and sent home without medications for blood sugar
management as he had been admitted without those as well.
.
#. Mantle Cell Lymphoma - s/p 6 cycles of Bendamustine/Rituxan
(last session [**2171-4-5**]). Currently in remission, maintained on
rituximab, last dose on [**2171-12-23**]. Followed by Dr. [**Last Name (STitle) **]
with tentative plan for dose at next appointment.
.
#. Gout- continued allopurinol
.
TRANSITIONAL ISSUES:
- Follow-up: Pt needs INR checked tomorrow [**2172-1-9**]. INR [**1-7**] of
1.9 and [**1-8**] of 2.5. Coumadin restarted [**1-6**]. Pt was sent out on
his home dose of warfarin, 5mg daily.
- Appointment with Dr. [**Last Name (STitle) **] on [**1-20**] for Oncology follow up
.
Pt was maintained as full code throughout the course of this
hospitalization.
Contact: wife [**Name (NI) **] [**Telephone/Fax (1) 110899**]
- son [**Name (NI) **] [**Telephone/Fax (1) 110900**]
- [**Name2 (NI) **]ter [**Name (NI) 2411**] [**Telephone/Fax (1) 110901**]
Medications on Admission:
allopurinol 300 mg daily
carvedilol 3.125 mg [**Hospital1 **]
furosemide 40 mg [**Hospital1 **]
hydrocodone-acetaminophen 5 mg-500 mg Tablet - 1-2 tabs q6h prn
pain
lisinopril 5mg daily
lorazepam 0.5 mg q6h prn anxiety
omeprazole 20 mg daily
ondansetron 8 mg q8h prn nausea
polyethylene glycol daily prn constipation
warfarin 5 mg daily
acetaminophen 325-650 mg q6h prn fever, pain
docusate sodium 100 mg [**Hospital1 **] prn constipation
senna 2 tabs qhs
Discharge Medications:
1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO q8prn as needed for nausea.
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) dose PO daily:prn.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
14. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 9 days.
15. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 9 days.
16. neomycin-bacitracnZn-polymyxin 3.5-400-5,000 mg-unit-unit/g
Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed
for abrasion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
Primary: Left lower leg cellulitis
Secondary:
Follicular lymphoma
Chronic systolic heart failure
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 **],
It was a pleasure taking care of you during your
hospitalization. You were admitted because of a severe
cellulitis of your left lower leg. Your blood pressure was low
initially so you were admitted to the ICU. They stabilized you
and you were transferred to the Oncology floor. You were
initially getting IV antibiotics, but we switched these to oral
antibiotics and watched for 24 hours on them; you did fine. You
were seen by our physical therapists who recommended rehab
placement to give you some extra support while you increase your
strength.
.
We are keeping you on your same regimen for your heart disease.
.
We made the following changes to your medications:
Bactrim DS 2 tabs by mouth twice daily for 9 more days
Keflex 500mg by mouth every 6 hours for 9 more days
Bacitracin ointment to be applied to the scab on your right
foreleg
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2172-1-20**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BMT CHAIRS & ROOMS
When: MONDAY [**2172-1-20**] at 9:30 AM
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2172-1-20**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13863**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
ICD9 Codes: 0389, 4254, 4280, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7321
} | Medical Text: Admission Date: [**2176-10-6**] Discharge Date: [**2176-10-14**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 79 year old female
with past medical history including chronic obstructive
pulmonary disease, aortic insufficiency, mitral stenosis, and
hypertension who presented from an outside hospital with
pneumonia and congestive heart failure exacerbation. In
outside hospital notes, notes record that the patient's
daughter reports that the patient had some shortness of
breath on the evening prior to admission. It was worse on
the morning of admission and so EMS was called to transport
the patient to the hospital. On their arrival, they found
the patient to be severe respiratory distress with oxygen
saturation of 80% in room air and unable to speak. The
patient was given 80 mg of Lasix and easily intubated. She
was extubated in the Emergency Department at the outside
hospital and initially did well on BiPAP. However, while on
100% nonrebreather, the patient's oxygen saturation decreased
to 93% and she was tachypneic at 34 to 38. Arterial blood
gases at that time revealed pH of 7.22, pCO2 of 55 and pO2 of
90. The patient was intubated and transferred to the outside
hospital Coronary Care Unit.
In the Coronary Care Unit at the outside hospital, chest
x-ray was consistent with congestive heart failure with
extensive infiltrate in the right lung. White blood cell
count was 24.0. The patient was started on Levofloxacin for
presumed community acquired pneumonia. During this time, the
patient was ruled out for a myocardial infarction with
negative enzymes times three. However, her electrocardiogram
showed symmetric deep T wave inversion. When an attempt was
made to wean the patient off the ventilator, she developed
rapid atrial fibrillation with a rate of 150. She received
Diltiazem and Lopressor with a decrease in her rate to the
80s. She was subsequently started on Heparin drip and
cardioverted. The patient was then transferred to [**Hospital1 1444**] for further care.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Type 2 diabetes mellitus.
3. Aortic insufficiency/aortic stenosis/mitral stenosis.
4. History of rheumatic fever.
5. Paroxysmal atrial fibrillation.
6. Hypertension.
7. Congestive heart failure.
8. Coronary artery disease.
ALLERGIES: Sulfa.
MEDICATIONS ON ADMISSION:
1. Glucophage 1000 mg twice a day.
2. Glyburide 5 mg p.o. once daily.
3. Prilosec 20 mg p.o. once daily.
4. Coumadin.
5. Tiazac 120 mg three times a day.
6. Lasix 20 mg p.o. once daily.
7. Lanoxin 0.125 mg p.o. once daily.
8. Diovan 80 mg p.o. once daily.
9. Folic Acid 1 mg p.o. once daily.
10. Evista 60 mg p.o. once daily.
11. Vitamin B6 25 mg p.o. once daily.
12. Vitamin B12 250 mg p.o. once daily.
13. Advair two puffs once daily.
14. Rhinocort 32 mg two puffs once daily.
PHYSICAL EXAMINATION: On admission, physical examination
revealed a temperature of 99.0, blood pressure 114/74, heart
rate 68. The patient was intubated. Vent settings were
assist control with a tidal volume 600, respiratory rate 10,
PEEP 5 and FIO2 of 0.4. In general, the patient was sedated
on ventilator, nonresponsive. Cardiovascular - regular rate
and rhythm, S1 and S2, III/VI systolic ejection murmur at the
base. No carotid bruits, no appreciable jugular venous
distention. Pulmonary - coarse breath sounds bilaterally.
The abdomen is soft, nontender, nondistended, positive bowel
sounds, no hepatosplenomegaly. Extremities revealed no
cyanosis, clubbing or edema, 2+ dorsalis pedis pulses.
LABORATORY DATA: Sodium 139, potassium 3.8, chloride 108,
bicarbonate 25, blood urea nitrogen 28, creatinine 0.8,
glucose 121, calcium 8.5, magnesium 2.1, phosphorus 3.6.
White blood cell count 14.1, hematocrit 31.2, platelet count
368,000. Prothrombin time 22.2, partial thromboplastin time
45.3, INR 3.3.
Chest x-ray on admission revealed a heart size the upper
limits of normal. Upper zone redistribution with mild
diffuse vascular blurry consistent with congestive heart
failure, probable right effusion. Increased retrocardiac
density consistent with left lower lobe collapse and/or
consolidation. Minimal atelectasis at the right base.
HOSPITAL COURSE:
1. Cardiac - Coronaries - The patient ruled out for
myocardial infarction at outside hospital. On admission,
electrocardiogram revealed sinus rhythm at 60 beats per
minute with deep T wave inversion throughout the precordium.
Very well, T waves were considered as possible explanation
given the patient's negative cardiac enzymes. A CT of the
head was obtained on the evening of admission which was
normal. Cardiac catheterization was subsequently performed
on [**2176-10-10**], to evaluate the size of the patient's coronary
arteries. It revealed a right dominant system with mild
single vessel disease. The left main coronary artery had no
angiographically appearing flow limiting stenosis. The left
anterior descending had no angiographically appearance of
flow limiting stenosis. The left circumflex had no
angiographically flow limiting stenosis. The right coronary
artery had no significant disease, and the posterior
descending artery had a focal 70% tubular lesion in the
distal vessel. Resting hemodynamics revealed normal right
sided filling pressures with a mean right atrial pressure of
5 mmHg. There were elevated left sided filling pressures
with a left ventricular end diastolic pressure of 12. The
cardiac index was normal at three liters per minute per meter
square. There was moderate pulmonary hypertension with a
pulmonary artery pressure of 36 mmHg. Left ventriculography
revealed 1+ mitral regurgitation, no wall abnormalities, and
calculated ejection fraction of 55%. Further evaluation of
the aortic valve revealed a peak gradient across the aortic
valve of 21 and a mean gradient of 16. Calculated valve area
was 1.3 centimeter squared. Evaluation of the mitral valve
revealed a mean gradient of 12. Although the patient had no
critical coronary artery disease on cardiac catheterization,
given her history of diabetes mellitus, she was started on a
statin during the admission. A lipid panel from [**2176-10-11**],
revealed a triglyceride level of 114, HDL of 50 and LDL of
74.
Rhythm - The patient had a history of paroxysmal atrial
fibrillation in the past and an episode of rapid atrial
fibrillation during extubation attempt at the outside
hospital. She was electrically cardioverted at the outside
hospital and arrived to [**Hospital1 69**]
on an Amiodarone drip. On her arrival, the patient was in
sinus rhythm. She was continued on the Amiodarone 400 mg
p.o. twice a day. This dose was continued for one week at
which time the patient's Amiodarone dose was decreased to 400
mg p.o. once daily for a total of one week. At the end of
this period, the patient will be on a standing Amiodarone
dose of 200 mg p.o. once daily. In addition, the patient was
anticoagulated for her atrial fibrillation while in the
hospital. This was initially accomplished with a Heparin
drip as it was the plan for the patient to go for
catheterization. Following catheterization, the patient was
restarted on Coumadin with a Heparin bridge until
therapeutic. The patient remained in sinus rhythm throughout
the hospitalization.
Pump - The patient with a history of congestive heart
failure. On admission, the patient did not appear volume
overloaded. An echocardiogram was obtained on [**2176-10-8**], to
evaluate her pump status. It revealed moderate dilation of
the left and right atrium. There was mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function with a left ventricular ejection fraction of greater
than 55%. Regional left ventricular wall motion was normal.
The aortic valve leaflets were moderately thickened with mild
1+ aortic regurgitation. The mitral valve leaflets were
moderately thickened. They show characteristic rheumatic
deformity with diffuse commissures and tethering of the
leaflet motion. There was mild mitral annular calcification.
There was moderate mitral stenosis. Mild to moderate 1 to 2+
mitral regurgitation was also seen. Mild to moderate 1 to 2+
tricuspid regurgitation was seen. There was mild pulmonary
artery systolic hypertension. There was a small pericardial
effusion. With the information obtained from the
echocardiogram and subsequent cardiac catheterization, it was
determined that the patient did not require immediate valve
repair. However, this is the likely possibility in the
future. Early during the admission, the patient was gently
diuresed for her congestive heart failure.
2. Pulmonary - The patient arrived from outside hospital
with diagnosis of community acquired pneumonia. However, the
infiltrate which had been visualized at the outside hospital
was no longer present on chest x-ray the morning following
admission. Therefore, it is most likely that the patient's
acute respiratory decompensation and pulmonary symptoms were
due to congestive heart failure exacerbation. However, a
seven day course of Azithromycin and Ceftriaxone were
completed for the presumed community acquired pneumonia. The
patient tolerated the ventilator well during the first few
days of admission. She was extubated on [**2176-10-9**], without
events. She continued to do well throughout the remainder of
the admission with oxygen saturation in the high 90s in room
air. The patient's inhalers for chronic obstructive
pulmonary disease were continued throughout the admission.
3. Hypertension - The patient's hypertensive medications
were titrated up over the course of the admission. Her
probable final doses on discharge will be Metoprolol 50 mg
p.o. twice a day and Lisinopril 40 mg p.o. once daily.
4. Hematology - The patient anticoagulated for atrial
fibrillation with Heparin drip early in the admission in
preparation for subsequent cardiac catheterization. Elevated
INR was reversed with Vitamin K times two doses. Following
cardiac catheterization, the patient was restarted on
Coumadin with a Heparin bridge until she had a therapeutic
INR. The patient's hematocrit remained stable throughout the
hospitalization. She did not require any transfusion.
5. Diabetes mellitus, type 2 - The patient continued on
sliding scale insulin and scheduled insulin throughout the
admission. American Diabetic Association diet.
6. Prophylaxis - The patient anticoagulated with Heparin for
her atrial fibrillation essentially covering her for deep
vein thrombosis prophylaxis. Proton pump inhibitor for
gastrointestinal.
7. Rehabilitation - The patient worked with physical therapy
as an inpatient. It was felt that she would benefit from a
short stay in acute rehabilitation facility.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged to acute
rehabilitation facility for a short stay.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Mitral stenosis.
3. Aortic valve insufficiency.
4. Hypertension.
5. Chronic obstructive pulmonary disease.
6. Respiratory distress.
7. Diabetes mellitus type 2.
8. Paroxysmal atrial fibrillation.
9. History of rheumatic fever.
MEDICATIONS ON DISCHARGE:
1. Fluticasone 110 mcg two puffs inhaled twice a day.
2. Ipratropium 18 mcg two puffs inhaled four times a day.
3. Pantoprazole 40 mg p.o. once daily.
4. Aspirin 325 mg p.o. once daily.
5. Amiodarone 400 mg p.o. once daily until [**2176-10-21**], and
from that time on, the patient will be taking 200 mg p.o.
once daily.
6. Atorvastatin 10 mg p.o. once daily.
7. Eucerin cream topical four times a day p.r.n.
8. Metoprolol 50 mg p.o. once daily.
9. Docusate Sodium 100 mg p.o. twice a day.
10. Lisinopril 40 mg p.o. once daily.
11. Glucophage 1000 mg p.o. twice a day.
12. Glyburide 5 mg p.o. once daily.
13. Folic Acid 1 mg p.o. once daily.
14. Evista 60 mg p.o. once daily.
FOLLOW-UP PLANS: The patient will follow-up with her
cardiologist, Dr. [**Last Name (STitle) 82074**], at the [**Hospital6 15291**]. She will schedule this appointment to suit her
convenience.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**]
Dictated By:[**Name8 (MD) 315**]
MEDQUIST36
D: [**2176-10-13**] 13:00
T: [**2176-10-13**] 13:46
JOB#: [**Job Number 100914**]
ICD9 Codes: 496, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7322
} | Medical Text: Admission Date: [**2201-7-22**] Discharge Date: [**2201-7-24**]
Date of Birth: [**2117-11-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Phenergan Plain / Aldactone / Digoxin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 female with history of CAD s/p CABG and DES to LMCA, dCHF,
DMII, ESRD on HD (started last month), COPD, HL, PVD, HTN,
recent admission for colitis ([**2201-5-23**] to [**2201-5-28**]) who reports
never feeling quite same since last discharge. She was doing
well until three days ago when she fell on her back without head
trauma, LOC, chest pain or palpatations while getting up because
her legs gave up. She presented to the ED and was noted to have
hypoglycemia to 42 which improved with D50. She was discharged
home but represented yesterday as she still felt weak and did
not think she could tolerated dialysis yesterday.
.
In the ED initial vital signs were 98.6 HR 68 BP 188/48 RR 16
97%RA
Exam was notable for poor joint sense in L>R LEs, stance and
gait unsteady, unable to ambulate without assistance. Slow but
intact heel-shin. CN II-XII intact, strength 5/5 throughout,
sensation intact. No spine tenderness. Patient was given
kayexelate for K=5.8. CXR was done revealing mild fluid overload
and could not exclude pneumonia. Initially she was medically
cleared for discharge from ED, but patient failed PT eval. She
was seen by case management and admitted to [**Hospital1 **] observation for
dialysis tomorrow morning since she missed HD yesterday.
However, upon getting ready to transfer to the floor, BP was
noted to be 208/59. She was given metoprolol and hydralazine IV
with no improvement in BP. Denied HA, blurry vision or CP at any
time throughout episode. Given the persistently elevated BP, the
decision was made to admit her to the MICU yesterday.
.
In the MICU, she received dialysis this morning with removal of
2L to her dry weight of 63 kg. She was restarted on her home
antihypertensive regimen with nifedipine, metoprolol and
lisinopril. She was tranferred to medicine floor for further
evaluation and management of her weakness.
.
On the floor, she does not report headache, fever, chills, chest
pain, shortness of breath, myalgias, abdominal pain, back pain,
nausea, vomiting or dysuria. She reports bilateral ankle pain L
> R.
Past Medical History:
- CAD: s/p 5V CABG [**2180**]; echo [**3-24**] 45-50%; cath [**4-20**] showed 3V
disease. Cath [**4-1**] w successful stenting of the LMCA into LAD
with Endeavor DES.
- Chronic diastolic CHF
- CVA: subacute stroke R MCA in [**12/2197**]
- COPD: [**4-20**] PFT showed reduced FVC with low-normal TLC
- Hyperlipidemia
- PVD - s/p angioplasty in LLE and s/p bypass in RLE
- Sensorineural hearing loss - partial loss in Left ear, with
hearing aid; complete loss in R ear
- HTN
- Chronic low back pain
- ESRD on HD
- DM-II
- Diabetic neuropathy
- s/p cataract surgery
- Depression
Social History:
- Former school secretary
- Involved in senior citizens club with active social life
- Tobacco: 120 pack-year smoking history
- etOH: Rare
- Illicits: Denies
Family History:
- 2 parents and 6 siblings all died of DM and heart disease
Physical Exam:
PHYSICAL EXAM:
VS: 96.4 56 116/60 100%2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Chest: Tunneled HD catheter in R subclavian
Lungs: Bibasilar crackles
CV: Regular rate and rhythm, normal S1, split S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: No foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 intact. [**5-21**] LE strength (able to stand up from
sitted position). Sensation intact. Normal gait. 2+ DTR.
Discharge PE
PHYSICAL EXAM:
VS: 96.0 P 66 BP 135/77 O2 100%RA
General: NAD
HEENT: MMM, oropharynx clear
Neck: supple, no JVD
Chest: Tunneled HD catheter in R subclavian
Lungs: CTAB
CV: Regular rate and rhythm, normal S1, split S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: No foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 intact. [**5-21**] LE strength. Sensation intact. Normal
gait. 2+ DTR.
Pertinent Results:
[**2201-7-22**] 12:10PM GLUCOSE-208* UREA N-57* CREAT-6.2*#
SODIUM-141 POTASSIUM-5.8* CHLORIDE-100 TOTAL CO2-27 ANION GAP-20
[**2201-7-22**] 12:10PM CALCIUM-9.3 PHOSPHATE-3.6 MAGNESIUM-2.0
[**2201-7-22**] 12:10PM WBC-6.2 RBC-3.93* HGB-12.3 HCT-40.2 MCV-102*
MCH-31.2 MCHC-30.5* RDW-14.9
[**2201-7-22**] 12:10PM NEUTS-61.7 LYMPHS-29.7 MONOS-5.9 EOS-2.5
BASOS-0.2
[**2201-7-22**] 12:10PM PLT COUNT-224
[**2201-7-23**]
WBC 7.4, Hgb 12.4 Hct 39.6 Plt 225
B12: 705, folate: WNL
[**2201-7-24**]
glucose 52, BUN 36, Cr 4.7, Na 141, K 4.3 Cl 96 HCO3 34
TSH 1.6
ECG [**2201-7-23**]
Sinus bradycardia. Left ventricular hypertrophy with secondary
repolarization
abnormalities. Compared to the previous tracing of [**2201-7-22**]
repolarization
abnormalities are somewhat more pronounced, a non-specific
finding.
[**2201-7-23**] CXR
Findings compatible with fluid overload with possible pneumonia
in the right lower lung.
Brief Hospital Course:
83 year old female with ESRD on HD, CAD s/p CABG, chronic
diastolic CHF, diabetic neuropathy who presented with subacute
progressive weakness and subsequently missed HD admitted to ICU
with hypertensive urgency.
.
# Hypertensive Urgency: Was likely due to volume overload from
missing HD. BP was unresponsive to medications, but after HD the
following day, her pressures normalized. 2L of fluid was
removed with HD and she returned to dry weight. She was
discharged with all of her home antihypertensives and on
discharge she was normotensive.
# Weakness/Gait instability: Progressive weakness seems to have
been present over several months. Neuro exam nonfocal. Pt does
have h/o spinal stenosis, PVD and diabetic neuropathy which
could certainly contribute to feelings of weakness and gait
instability. She also reported that this has happened after HD,
which is a common HD side effect. Lastly, on presentation to
ED, she was hypoglycemic which might have explained weakness. A
B12, folate and ESR level were all normal indicating that
weakness is not secondary to B12/folate deficiency or
inflammatory condition like PMR. Pt is followed by neurology at
[**Hospital1 18**] for previous CVA and will be followed up by neurology post
discharge. PT evaluated pt and determined that she was able to
be discharged with home PT.
.
# ESRD: Was dialysed twice during hospital stay. Will continue
to HD on MWF at [**Hospital1 18**]. She was discharged home on sevelamer,
nephrocaps and Iron.
#Type II Diabetes Mellitus: throughout hospital course, pt was
on ISS. She was discharged on home regimen and continued with
gabapentin for peripheral neuropathy.
.
#Hyperlipidemia: Pt was discharged home on normal statin dose.
.
#Chronic back pain: Likely secondary to spinal stenosis, which
as per patient will not be managed surgically.
.
#CVA prophylaxis/CAD: Discharged on home regimen of aspirin,
clopidogrel, BB and statin.
No pending results or reports at time of discharge.
.
Medications on Admission:
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day chol
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg Capsule - 1
Capsule(s) by mouth once a day Selimi
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once
a
day hx stent
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth at bedtime
leg cramps, restless leg syndrome
LISINOPRIL - 30 mg Tablet - 1 Tablet(s) by mouth once a day bp
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth three
times a day bp, cad
NIFEDIPINE - 30 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth once a day for bp
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually as directed as needed for chest pain can repeat
every 5minutes three times, call 911 if chest pain not resolved
ONDANSETRON HCL - 4 mg Tablet - 1 Tablet(s) by mouth twice a day
as needed for nausea
POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - 2 tsp by mouth
4
oz water daily hs
SEVELAMER HCL [RENAGEL] - (Prescribed by Other Provider) -
Dosage uncertain
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet,
Delayed Release (E.C.)(s) by mouth DAILY (Daily) prevention
INSULIN REGULAR HUMAN [HUMULIN R] - 100 unit/mL Solution -
inject
sq qpm 5 units or ut dict
NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
inject 30 units qam, 16units q pm
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
8. polyethylene glycol 3350 17 gram/dose Powder Sig: Two (2) tsp
PO DAILY (Daily) as needed for constipation.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. insulin regular human 100 unit/mL Solution Sig: Five (5)
units Injection at bedtime.
11. Humulin N 100 unit/mL Suspension Sig: Thirty (30) units
Subcutaneous qAM.
12. Humulin N 100 unit/mL Suspension Sig: Sixteen (16) units
Subcutaneous at bedtime.
13. sevelamer HCl Oral
14. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for nausea.
15. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual PRN as needed for Chest Pain: take for chest pain can
repeat every five minutes for a max dose of three times, call
911 if chest pain not resolved.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
- Intermittent gait instability NOS
- Hypertensive Urgency
- Hyperkalemia
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 Mrs. [**Known lastname **],
It was a pleasure taking care of you. You were admitted to the
hospital because of your gait instability and hypertensive
urgency. You were hemodialysed and all of your home medications
were restarted. Your blood pressure improved. In addition,
physical therapy re-evaluated you and believe that you can go
home with services to assist with ambulation.
Please continue all of your home medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with the following physicians:
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: TUESDAY [**2201-8-4**] at 1:50 PM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: NEUROLOGY
When: TUESDAY [**2201-8-18**] at 4:30 PM
With: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD [**Telephone/Fax (1) 657**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5856, 2767, 4280, 3572, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7323
} | Medical Text: Admission Date: [**2190-9-1**] Discharge Date: [**2190-9-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Cough and sob
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 year old female with from nursing facility, non-productive
cough for 2 weeks. Nursing home found her more short of breath
today using accessory muscles to breathe with RR 22-24 and
82%RA, Temp 98.9F, HR 106, BP 170/82. She was placed on 2L
nasal canula and sent to ED for further evaluation. Patient
denies shortness of breath, chest pain, leg swelling, PND,
orthopnea. Main complaint is cough. Was started on keflex at
NH on [**8-18**], unclear reasons although per pt for cough.
Past Medical History:
Hyperthyroidism (toxic multinodular goiter)
Hypertension
h/o fainting/falls with transient syncope
- Admission [**4-28**] initially sinus bradyarrhytmia, resolved when
HR>60; Admit [**6-26**] r/o MI; no evidence of arrhytmia on tele
- Last echo [**10-26**]: EF > 55%, Normal wall motion, mildly dilated
left atrium, trivial MR, E/A 0.50
GERD
Recurrent UTIs (last [**4-28**])
CRI: baseline Creatinine 1.2-2.0
ORIF femoral fracture
h/o B12 deficiency
dementia
Social History:
Lives in nursing home. Some distant tobacco use, denies etoh.
Previously worked as a receptionist. Son, [**Name (NI) 3924**] [**Name (NI) 97379**]
(HCP/POA: [**Telephone/Fax (1) 97380**]) lives in [**Location 7349**].
Family History:
No history of CAD, sudden death
Physical Exam:
V: 97.0F HR 80 BP 155/64 RR 26 94/6L n.c.
Gen: awake, alert and oriented x 2+ (not oriented to month/day
but oriented to year), tachypneic, frequent rattling cough but
able to speak in short sentences
HEENT: PERRL, EOMI, OP clear, MM sl dry
Neck: supple, JVP 7cm
CV: RRR, S1, S2, no murmurs appreciated
Pulm: bilateral coarse breath sounds, crackles left base, right
with scattered rhonchi and prolonged exp wheeze
Abd: Normoactive BS, soft, ND/NT
Ext: WWP, no edema, dry skin
skin: seborrheic keratosis and multiple bruises but no rash
Pertinent Results:
WBC 11.0 Hct 34.4 Plt 214
N:83 Band:10 L:4 M:3 E:0 Bas:0
.
136.|.100.|.31 258
---------------
4.2.|.21.|.1.4
.
8:00 p.m. CK: 108 MB: 3 Trop-T: <0.01
.
proBNP: 1461
.
UA: large leuks, neg nitrites, small blood, [**5-2**] WBC, 0-2 RBC,
few bacteria
.
lactate:2.7
.
CXR: New right middle and right lower lung zone opacities and
bilateral peribronchial cuffing representing either multifocal
pneumonia, asymmetric pulmonary edema, or bronchitis.
.
EKG: Sinus tachy 108, normal axisand intervals. TWIS III old.
Only change from prior is tachycardia.
Brief Hospital Course:
In the ED upon first arrival Temp 102.4F and given tylenol.
Given Vancomycin 1g x 1 and Levofloxacin 750mg x 1. Given
Albuterol and Ipratropium Nebs and solumedrol 125mg x 1. UA was
negative. Blood and urine cultures done. EKG done without
evidence of acute ischemia. Oxygen increased from 2L to 6L
(Oxygen sat 94%/6L). And she was admitted to ICU for further
monitoring. After 1 day in the ICU she was deemed stable, and
though direct discharge from ICU was considered, decision was
made to monitor one more day on the general medical floor.
Course as outlined below:
# Pneumonia - Given fever, elevated white count with bands,
hypoxia and RML, RLL opacities consistent with pneumonia. Most
c/w with CAP, no history of aspiration. No h/o COPD. Urine
legionella negative. Did well the night of admit with minimal
O2 requirements, cough remained unproductive so no sputum
culture was obtained. Throughout stay continued to deny SOB or
increased WOB, was afebrile throughout hospital stay.
Originally started on Levo/vanc for HAP and flagyl for possible
aspiration PNA. Antiobiotics narrowed the morning of admission
at recommendation of pulmonary ICU attending to Levofloxacin,
renally dosed, with projected duration of 10 days for CAP, last
dose to be [**2190-9-10**]. On day of discharge o2 sat 93% RA.
# Elevated BNP - Did have some crackles in bases on lung exam
consistent with atelectasis, does not appear volume overloaded,
no peripheral edema. Was monitored for signs of volume overload
but did not develop overt heart failure during hospitalization.
# CRI - Creatinine on admit at baseline. CRI felt to be due to
HTN. Throughout stay was monitored for worsening renal function
but none was observed. All medications renally dosed during
stay. At discharge creatinine was 1.3 down from 1.4 on
admission.
# HTN - Well controlled at baseline. Not an issue since admit.
Was continued on home norvasc dosing.
All other chronic medical issues did not necessitate medical
intervention or medication adjustments during her
hospitalization.
Any necessary communication was with her son: [**Name (NI) 3924**] [**Name (NI) 97379**],
HCP/POA: [**Telephone/Fax (1) 97380**]
FULL CODE reconfirmed by son and pt.
Medications on Admission:
amlodipine 5mg daily
donepezil 10mg po qhs
raloxifene 60mg daily
methimazole 5mg daily
ASA 325mg daily
cholecalciferol 400unit daily
Calcium Carbonate 500 mg po q12hours
colace/senna/dulcolax/MOM prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for Pain or Fever.
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO Daily ().
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for Constipation.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for Constipation.
11. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 7 days: last dose [**2190-9-10**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please call your primary care doctor or return to the ER with
any increased shortness of breath or other concerning symptoms.
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2190-9-3**]
ICD9 Codes: 486, 5990, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7324
} | Medical Text: Admission Date: [**2170-8-13**] Discharge Date: [**2170-10-18**]
Date of Birth: [**2102-6-15**] Sex: F
Service: SURGERY BLUE
HISTORY OF PRESENT ILLNESS: Briefly, this is a 67 year old
female who presented to an outside hospital with abdominal
pain, distention, nausea, for approximately three days. Her
last bowel movement was approximately the day prior to her
admission which was in [**2170-2-10**]. She had had a history
of small bowel obstructions and had felt these symptoms in
previous episodes. Of note, the patient had a history of a
gastric bypass performed several years ago as well as an
incarcerated hernia repair. The patient was admitted to an
outside hospital and ultimately underwent an exploratory
laparotomy and repair of hernia and was being taken care of
at the outside hospital. However, during her hospital course
there, she was found to have serous drainage from her wound
and was found to have developed a significant enterocutaneous
fistula. Therefore, it was decided at the outside hospital
that she would be transferred to [**Hospital1 190**] for further management by Dr. [**Last Name (STitle) 957**].
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. Pancreatitis.
3. Asthma.
4. History of pneumonia.
5. History of varicose veins.
6. History of small bowel obstructions in the past.
PAST SURGICAL HISTORY:
1. Gastric bypass approximately fifteen years ago.
2. Cholecystectomy.
3. Exploratory laparotomy and lysis of adhesions times two
for small bowel obstruction.
4. Breast reduction surgery.
5. Several ventral hernia repairs.
ALLERGIES: Penicillin and Iodine.
MEDICATIONS ON TRANSFER:
1. Octreotide.
2. Fentanyl patch.
3. Levaquin.
4. Flagyl.
5. Dilaudid PCA.
6. Lopressor.
7. Vancomycin.
8. Atrovent nebulizers.
9. TPN.
She also had a PICC line which was placed at the outside
hospital and was having wet to dry dressing changes to her
abdominal wound. A G-J tube had been placed during her
operation at the outside hospital and those were kept on
intermittent suction. She also had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain
which was also to bulb suction.
PHYSICAL EXAMINATION: On admission to [**Hospital1 190**], the patient was afebrile and her vital signs
were stable. She was an obese female in no apparent
distress. She was saturating 98% on two liters nasal
cannula. Her lungs had some mild crackles but were clear.
Her heart was regular. Her abdomen was obese, nontender, and
she had an open enterocutaneous fistula times three and open
surgical wound on her belly with retention sutures in place
and Foley catheter was also in place. Her extremities were
severely edematous which stated by her was her baseline.
LABORATORY DATA: The patient's laboratories are all within
normal limits.
HOSPITAL COURSE: The patient was admitted to the Blue
Surgery service and was continued on TPN for preoperative
nutritional enhancement and it was planned the patient would
ultimately undergo exploratory laparotomy and repair of the
enterocutaneous fistula. On [**2170-8-31**], the patient was taken t
the operating room for an attempted revision of her multiple
enterocutaneous fistulas. The patient did well from the
operation, however, postoperatively she developed single
enterocutaneous fistula which caused wound breakdown and
again she was started on tube feeding as well as TPN for
nutritional enhancement. The enterocutaneous fistula was not
able to be closed with just nutritional enhancement.
Therefore, it was decided that the patient would have to
return to the operating room on [**2170-9-13**], for a reexploration
and component separation and flap closure, split thickness
skin graft closure for this enterocutaneous fistula. Dr.
[**Last Name (STitle) **], the plastic surgery service, was consulted for this
workup and followed this patient along throughout her entire
hospital course. The patient was taken to the operating room
on [**2170-9-13**], where closure of her enterocutaneous fistula was
done and split thickness skin graft was also performed as
well as a revision of her G-J tube. Postoperatively, the
patient was transferred to the Intensive Care Unit for blood
pressure support and prolonged ventilatory support. The
patient was slowly weaned from the ventilator
postoperatively, however, after extubation, she had
significant respiratory distress and required significant
fluid management. Therefore, she was reintubated and
continued in the Intensive Care Unit. Again, she required
prolonged pressor support for her blood pressure and fluid
management. She slowly improved from a pulmonary standpoint
after the second intubation and she was able to be diuresed
gently from her fluid. She was started on TPN and she was
successfully able to be weaned from the ventilator
postoperatively. The patient also had episodes of
temperature spikes and was found to have gram positive cocci
in blood cultures as well as on line cultures. Therefore,
she was started on broad spectrum antibiotics. She was
continued on multiple antibiotics and ultimately completed a
twenty-two day course of Zosyn for the positive blood
cultures and for her line sepsis. She continued to improve
slowly in her Intensive Care Unit stay and her bowel function
slowly returned. Her tube feeds were slowly advanced through
this time frame which she was able to tolerate. She was
extubated on [**2170-9-19**], and was able to tolerate for a day,
however, she had an episode of bradycardia and asystole on
[**2170-9-20**], requiring emergent intubation. She responded to
Epinephrine and returned to sinus rhythm with her blood
pressure returning to greater than 200. It was noted that
the patient had increased distention of her abdomen after
this event of respiratory failure with difficulty to intubate
and she was noted to have some increased erythema around the
graft site. Her gastrostomy tube was placed to gravity due
to the distention and nasogastric tube which had been placed
was removed. The patient was successfully extubated again
after response of her respiratory failure. She continued to
slowly improve after these events. She slowly improved from
her ventilatory standpoint and she was continued on TPN for
support for this. A vac was placed over her wound site for
her erythema and she was diuresed for her pulmonary status as
well as for her fluid overload. The vac was managed by the
plastic surgery service and was changed multiple times with
assessment of her skin graft on every change. Her donor site
was doing well and continued on blow drying of the wound site
and dressing changes. Just prior to discharge to
rehabilitation, her vac dressing was removed and two small
areas of questionable success and viability of the graft were
noted. It was decided that Xeroform gauze dressing changes
would be used over the skin graft site for continued wound
care. She was restarted no her tube feeds on [**2170-9-26**], after
being held and which she tolerated. Her tube feeds were
slowly increased over the next couple days. The patient
continued on broad spectrum antibiotics including Vancomycin,
Levofloxacin, Flagyl, Zaroxolyn, Fluconazole and as stated
before Zosyn. She was also given a course of Linezolid. She
was able to be weaned over a very long period down to a
pressure support of 5 and PEEP of 5 and it is planned that
the patient would be extubated after being successfully
diuresed. Her [**Location (un) 1661**]-[**Location (un) 1662**] drains which had been placed
intraoperatively were removed by the plastic surgery service
after decreased output was noted. After significant
diuresis, the patient was able to tolerate extubation as well
as able to tolerate low pressure support and minimal vent
settings. Therefore, it was decided the patient would be
extubated. The patient was extubated on [**2170-10-4**], which she
was able to successfully maintain her oxygenation and breathe
comfortably. The patient was started on a clear liquid diet
on [**2170-10-5**], which she tolerated. She had return of bowel
function during her Intensive Care Unit stay and her wounds
remained clean, dry and intact. Physical therapy as well as
occupational therapy were consulted for ambulation as well as
strength training as well as to manage all her
deconditioning. Speech and swallow was also consulted for a
bedside evaluation which she did well with. Orthopedics was
consulted early due to knee pain and was found to have
osteoarthritic changes of her knee. Her white blood cell
count rose after being off antibiotics and it was felt the
patient had a line infection and therefore, she was started
on Zosyn. Her TPN was stopped. She responded well to the
Zosyn and her white blood cell count had normalized prior to
discharge. Neurosurgery was also consulted for low back pain
which was a chronic issue which she had had for multiple
years. Ultimately, it was felt that this pain was chronic
degenerative changes and there was no plan for change in
management. The patient also had some mild diarrhea which
was controlled with Imodium. Her stool cultures were
negative. The patient also underwent calorie counts which
she did well with. On [**2170-10-10**], plastic surgery took her
back to the operating room for a repeat split thickness skin
graft which she successfully underwent. This graft as
mentioned before had two areas that ultimately looked
questionable for viability and therefore, Xeroform dressing
changes were done. However, the remainder of the wound site
was viable and nice. Therefore, it was felt that the graft
had taken quite nicely. Her tube feeds were began to be
cycled at that time and the patient was transferred out to
the floor. She continued to do well and continued to do well
from a dietary standpoint on regular diet and her tube feeds
which were cycled were able to be stopped completely prior to
discharge. She also completed as stated before a twenty-two
day course of Zosyn for infected line as well as for
bacteremia. The vac was removed on [**2170-10-17**], which again
showed viable graft site. Physical therapy had seen the
patient and it was decided the patient should return to
[**Hospital3 **] which is where she had been
previously prior to long hospital course for further
rehabilitation. The patient was tolerating a regular diet.
It was planned also that the patient would keep her Foley
catheter for the time being and when the patient was more
ambulatory and more functional, it could be removed in the
rehabilitation facility. The patient was also planned to
follow-up with Dr. [**Last Name (STitle) 957**] in three weeks time for evaluation
as well as wound care check. She is also to be followed by
Dr. [**Last Name (STitle) **] in the plastic surgery service for her skin graft
and also for her abdominal closure. The patient was planned
for discharge on [**2170-10-18**], and was tolerating a regular diet
without needing tube feeds. It was planned that the patient
would be discharged to rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Enterocutaneous fistula, status post repair times two
including a component separation and split thickness skin
grafting by plastic surgery service.
2. Small bowel obstruction, status post exploratory
laparotomy and lysis of adhesions times two.
3. Gastric bypass in the past.
4. Cholecystectomy.
5. Breast reduction.
6. Multiple ventral hernia repairs.
7. Enterocutaneous fistula formation previously from that.
8. Hypothyroidism.
9. Pancreatitis.
10. Asthma.
11. History of pneumonia.
12. History of varicose veins.
13. Status post respiratory failure requiring emergent
reintubation.
14. Multiple line infections and bacteremia requiring
multiple antibiotic treatments with prolonged treatment
times.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. once daily.
2. Ativan 0.5 to 1 mg p.o. q4hours p.r.n.
3. Ambien 5 mg p.o. q.h.s.
4. Dilaudid 2 to 4 mg p.o. q4hours p.r.n.
5. Loperamide 2 mg p.o. twice a day.
6. Zinc Sulfate 220 mg p.o. twice a day.
7. Lopressor 75 mg p.o. twice a day.
8. Paroxetine 20 mg p.o. once daily.
9. Tylenol 325 to 650 mg p.o. q4hours p.r.n.
10. Levoxyl 300 mcg p.o. once daily.
11. Insulin sliding scale.
13. Ipratropium inhaler four puffs four times a day.
14. Albuterol four puffs q4hours p.r.n.
15. Phenazopyridine 200 mg p.o. three times a day.
16. Cycled tube feeds, one half strength Impact, at 20cc per
hour from 7:00 p.m. to 6:00 a.m.
DISCHARGE STATUS: The patient was discharged to
rehabilitation facility in stable condition.
FOLLOW-UP: The patient is instructed to follow-up with Dr.
[**Last Name (STitle) 957**] in three weeks time, with Dr. [**Last Name (STitle) **] in two to three
weeks time, as well as follow-up with her primary care
physician.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2170-10-17**] 18:29
T: [**2170-10-17**] 19:11
JOB#: [**Job Number 22339**]
ICD9 Codes: 5185, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7325
} | Medical Text: Admission Date: [**2126-6-29**] Discharge Date: [**2126-7-23**]
Date of Birth: [**2077-7-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Multiple stab wounds to chest, abdomen, neck, and head
Major Surgical or Invasive Procedure:
1. Trauma laparotomy with repair of stab wound enterotomies x36
and total mobilization left colon.
2. Bilateral neck exploration
3. Laparotomy and lysis of adhesions, reduction of internal
hernias and volvulized small bowel segment.
History of Present Illness:
48 yo male patient with MS, [**First Name3 (LF) **], and substance abuse
presents with multiple stab wounds to chest/abdomen/neck/head
with an ice pick. He presented with tension PTX. 2 chest tubes
were placed and he was taken to OR for multiple stab wounds.
Past Medical History:
MS
[**First Name (Titles) **]
[**Last Name (Titles) 7344**] abuse
Social History:
-[**Name (NI) **], wife of 23 years, left him in [**3-14**]
-sister [**Name (NI) 5627**] [**Name (NI) 83433**] ([**Telephone/Fax (1) 83434**]) is his health care proxy
-patient living in his mother's house in [**Location (un) 5503**]
Family History:
Not applicable to current care
Physical Exam:
Upon admission:
T:100.6 BP:165/78 HR:97 RR:30
O2Sats:95% on shovel mask at 95%
Gen: Patient is agitated and leans to the right side in the bed.
HEENT: Right orbit is swollen shut, ecchymotic, and erythematous
Pupils:were dilated by opthamology today - 8mm bilaterally
EOMs-impaired in the right eye, intact in the left eye
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, +tenderness, there are multiple stab wounds, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, somewhat uncooperative with
exam,
flat affect.
Orientation: Oriented to person and hospital.
Language: Slight dysarthria, perseverative. Does not appear able
to comprehend complex commands.
Cranial Nerves:
I: Not tested
II: Pupils have both been dilated by opthamology and are 8mm
bilaterally.
III, IV, VI: Extraocular movements intact on the left and
impaired on the right.
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 [**4-9**] on the right side. The LUE
5-/5 and the LLE is [**4-9**] in IP and [**3-10**] distally. Unable to
participate with pronator drift testing.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Pertinent Results:
[**2126-6-29**] 11:15PM TYPE-ART TEMP-36.9 RATES-18/ TIDAL VOL-450
PEEP-0 O2-60 PO2-138* PCO2-48* PH-7.25* TOTAL CO2-22 BASE XS--6
INTUBATED-INTUBATED VENT-CONTROLLED
[**2126-6-29**] 11:03PM GLUCOSE-142* UREA N-14 CREAT-0.9 SODIUM-149*
POTASSIUM-4.0 CHLORIDE-120* TOTAL CO2-22 ANION GAP-11
[**2126-6-29**] 11:03PM WBC-13.6* RBC-3.19* HGB-10.6* HCT-33.4*
MCV-105* MCH-33.4* MCHC-31.8 RDW-14.4
[**2126-6-29**] 11:03PM PLT COUNT-343
[**2126-6-29**] 11:03PM PT-13.0 PTT-26.5 INR(PT)-1.1
[**2126-6-29**] 01:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2126-6-29**] 01:39PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
Brief Hospital Course:
Mr [**Known lastname 45957**] is a 48 year old male w/ PMH of multiple sclerosis who
was admitted to the Trauma service; in the ED he was noted with
tension pneumothorax upon arrival and received a chest tube. He
was taken to the operating room for trauma laparotomy secondary
to multiple stab wounds; 35 enterotomies were found in his small
intestine and were oversewn. He was rewarmed in the unit and
taken back to the OR for exploration of 3 stab wounds to his
neck.
Head CT showed intraventricular hemorrhage and a neurosurgical
consult was obtained. It was felt that this bleed did not
require surgical management. Serial head CT scans were followed
and the initial follow up scan did reveal an increase in the
intraventricular hemorrhage. His neurologic status was watched
closely, a repeat head CT on the next day remained stable with
no interval increase. Presently his mental status is that he is
alert, oriented x2-3, with some short term memory loss; and he
is cooperative with his care. He will follow up as an outpatient
with Dr. [**Last Name (STitle) 548**] for repeat head imaging.
During his hospitalization, Mr. [**Known lastname 45957**] was seen by Psychiatry and
his meds were adjusted to decrease agitation and avoid sedation.
He was seen by Ophthalmology, Plastics, and Neurology for
damage to his right eye which prevents him from opening the lid,
although he has preserved vision. An MR of his head and orbits
were done which did show a right inferior rectus muscle into the
fracture defect. Plastics felt that this was caused by superior
orbital fissure syndrome and recommended that he see Dr. [**First Name8 (NamePattern2) 2398**]
[**Last Name (NamePattern1) **] at [**Hospital3 2576**] for evaluation and treatment in the next
several weeks. No procedures were done in the hospital for his
eye; he was prescribed eye drops.
While in the hospital, he was treated with
vancomycin/Cipro/Zosyn for fever and altered mental status. He
had a fever work-up which revealed pan-sensitive E. coli in his
urine. He completed a course of Cipro and antibiotics were
discontinued.
On HD # 18 he acutely developed nausea and vomiting requiring an
NGT placement. A CT scan of his abdomen confirmed a
post-operative mechanical obstruction. He was taken back to the
operating [**2126-7-16**] for laparotomy and lysis of adhesions.
He was admitted back to the floor and made NPO with NGT and
maintained on IVF. On POD 1 the NGT was removed and his diet was
slowly advanced as tolerated. He is currently tolerating a
regular diet.
He was followed by Social work due to the nature of his trauma.
He was also evaluated by Physical and Occupational therapy and
is being recommended for short term rehab following his acute
hospital stay.
Medications on Admission:
Confirmed from pharmacy: Paroxetine 40mg qhs (from Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]); trazadone 100mg qhs, topiramate 100mg [**Hospital1 **] (filled [**6-12**]),
seroquel 50mg TID prn agitation (filled [**6-26**])-these 3from Dr.
[**Last Name (STitle) 83435**]; excelon 6mg [**Hospital1 **],baclofen, naproxen
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for heartburn.
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. Tetracaine HCl 0.5 % Drops Sig: Three (3) drops Ophthalmic
once a day: OU.
5. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for PRN agitation.
6. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Rebif 44 mcg/0.5 mL Syringe Sig: One (1) Subcutaneous 3
times per week .
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stools.
9. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
s/p Multiple stab wounds to abdomen, chest, face, and neck
Left maxilla fracture
Bilateral orbital roof fractures w/ right inferior rectus
entrapment
Samll intraventricular hemorrhage
Pneumomediastinum
Small bowel obstruction
Discharge Condition:
Hemodynamically stable; pain adequately controlled and
tolerating a regular diet
Discharge Instructions:
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 3 weeks with
head CT. Please call [**Telephone/Fax (1) 2992**] for this appt.
Please call Dr. [**First Name8 (NamePattern2) 2398**] [**Last Name (NamePattern1) **] at [**Hospital3 **] to schedule
an appointment for ongoing evaluation and treatment of your eye.
The number is:([**Telephone/Fax (1) 83436**]
Please follow-up with Dr. [**Last Name (STitle) **] in trauma clinic in 2 weeks
for evalaution following your small bowel surgery. The number
to call and schedule an appointment is [**Telephone/Fax (1) 2359**].
Please follow up with your primary care Neurologist Dr. [**Last Name (STitle) 77121**]
after discharge from rehab for continued management of your
multiple sclerosis.
Completed by:[**2126-7-23**]
ICD9 Codes: 5990, 2762, 5070, 2760, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7326
} | Medical Text: Admission Date: [**2127-11-11**] Discharge Date: [**2127-11-24**]
Date of Birth: [**2055-5-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This was a 71-year-old male who
was struck by a car and found to have a GCS of 5 on the scene
and was intubated by EMS. He was initially hypertensive and
tachycardiac and was then flighted to [**Hospital6 649**].
PAST MEDICAL HISTORY: Right hip repair.
ALLERGIES: PENICILLIN, PERCOCET.
MEDICATIONS ON ADMISSION: None.
PHYSICAL EXAMINATION: Vital signs: He was intubated and
tachycardiac at 110, and hypertensive at 174/100. His GCS
was 6T. HEENT: Pupils equal, round and reactive to light;
however, he did have blood in his left tympanic membrane.
The rest of his exam showed deformities of the right tibia,
as well as scalp laceration, as well as an elbow laceration.
LABORATORY DATA: Within normal limits.
HOSPITAL COURSE: The patient was admitted to the Trauma
Service and ultimately required a craniotomy for a subdural
hematoma. He also ended requiring a washout of his left open
tibia-fibular fracture and was transferred to the Intensive
Care Unit.
He had a prolonged Intensive Care Unit stay including
multiple antibiotics for infection, prolonged ventilation,
and ventriculostomy drain for control of his subdural
hematoma.
An IVC filter was also placed postoperative for prophylaxis
against deep venous thrombosis. Due to his bleed, he was
unable to receive Heparin.
The patient continued to have significant hemodynamic
instability and was unable to wean off of his ventilator
during his hospital course.
He was taken to the Operating Room for his tibia-fibular
repair and again was continued on multiple antibiotics for
CSF infection, as well as pneumonia. He was given tube feeds
for nutritional support through his hospital stay, and he was
given Dilantin for seizure prophylaxis. He had elevated
fevers throughout his hospital stay.
Ultimately a family meeting was held on [**2127-11-22**], and
it was decided by the family that the patient would be DNR.
It was decided on [**2127-11-22**], after further discussion
with the family that the patient be made CMO. On [**2127-11-23**], he was made DNR. The vent drain was removed. The
patient was extubated, and he was put on a Morphine and
Fentanyl drip for comfort. The patient expired on [**2127-11-24**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2128-3-23**] 09:53
T: [**2128-3-23**] 09:53
JOB#: [**Job Number 53461**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7327
} | Medical Text: Admission Date: [**2114-7-12**] Discharge Date: [**2114-7-29**]
Date of Birth: [**2040-9-4**] Sex: F
Service: CME
HISTORY OF PRESENT ILLNESS: The patient was originally
admitted to the Vascular Surgery Service and was then
transferred three to four days later to the C-MED Service.
This is a 73-year old female with coronary artery disease
(status post coronary artery bypass grafting and multiple
cardiac catheterizations and percutaneous interventions at
outside hospitals), peripheral vascular disease, chronic
renal insufficiency, and insulin-dependent diabetes mellitus
who was transferred to [**Hospital1 69**]
from an outside hospital to the Vascular Surgery Service with
a right lower extremity gangrenous ulceration. The reason
for transfer was for possible vascular intervention.
On arrival to the Vascular Surgery Service the patient's INR
was elevated as she had been on Coumadin for atrial
fibrillation. She was given two units of fresh frozen plasma
to reverse her coagulopathy and developed jaw pain (her
anginal equivalent) and went into acute cardiogenic pulmonary
edema. The patient was nearly intubated but improved with a
nitroglycerin drip and Natrecor.
She was then transferred to the C-MED Service for further
diuresis and because her exercise tolerance test sestamibi
obtained following her acute cardiogenic pulmonary edema
showed reversible anterior defects as well as partially
reversible lateral wall defects. Her creatine kinase and
troponin were flat at the time of the acute cardiogenic
pulmonary edema. The patient did report some baseline
shortness of breath, but felt that it was worse at the time
of transfer to C-MED Service. However, at baseline the
patient can only walk 15 feet with a walker and is limited by
anginal pain or shortness of breath. The patient did report
paroxysmal nocturnal dyspnea, orthopnea, and lower extremity
edema in the past - but not currently. The patient uses 2
liters of oxygen at home.
PAST MEDICAL HISTORY: Diabetes mellitus.
Coronary artery disease; status post coronary artery bypass
grafting and multiple percutaneous coronary interventions.
Chronic renal insufficiency.
Peripheral vascular disease; status post lower extremity
interventions.
History of deep venous thrombosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter
placement.
Congestive heart failure with an ejection fraction of 35
percent.
Parkinson disease.
Anemia of chronic disease.
Atrial fibrillation (on amiodarone and Coumadin).
Gout.
Gastroesophageal reflux disease.
Depression.
Polymyalgia rheumatica.
Status post cholecystectomy.
MEDICATIONS ON TRANSFER TO THE C-MED SERVICE:
1. Mucomyst 600 mg twice per day.
2. Allopurinol 100 mg once per day
3. Albuterol as needed.
4. Aspirin 81 mg once per day.
5. Amiodarone 20 mg once per day.
6. Wellbutrin 25 mg once per day
7. Famotidine 20 mg twice per day.
8. Subcutaneous heparin.
9. Heparin drip.
10. Insulin sliding scale and NPH insulin.
11. Lactulose.
12. Vancomycin.
13. Simvastatin.
14. Ropinerole 0.25 four times per day.
15. Prednisone 5 mg once per day.
16. Nitroglycerin drip.
17. Nitroglycerin patch.
18. Toprol 25 mg once per day.
19. Levaquin 250 once per day.
20. Synthroid 50 mcg once per day.
SOCIAL HISTORY: The patient is widowed and has two
daughters. She does not smoke or drink.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 99.2, heart rate was 69 (range 60 to 69),
blood pressure was 147/35 (range 120 to 141/29 to 63), and 98
percent on 4 liters. In general, the patient was a
chronically ill-appearing elderly female sitting upright in
mild respiratory distress. Head, eyes, ears, nose, and
throat examination the pupils were equal, round, and reactive
to light. The extraocular movements were intact. The moist
mucous membranes. Neck revealed jugular venous pressure
approximately 14 but difficult to assess given the patient's
neck pannus. Cardiovascular examination revealed a regular
rate and rhythm. A 2/6 systolic murmur at the left upper
sternal border. Lungs with bibasilar rales halfway up. The
abdomen was obese, slightly distended, left-sided scar, and
nontender. Extremities revealed trace edema of right and
left foot.
PERTINENT LABORATORY VALUES ON PRESENTATION: Significant for
a hematocrit of 31.8, INR of 1.5, a partial thromboplastin
time of 58.8, and creatinine of 1.4.
PERTINENT RADIOLOGY-IMAGING: The patient's previous
catheterization in [**2105**] at the [**Hospital6 1708**]
showed saphenous vein graft to left anterior descending
patent, and saphenous vein graft to posterior descending
artery patent, skip graft to the obtuse marginal from the
posterior descending artery which was occluded. The left
circumflex was totally occluded with collaterals. The right
coronary artery with 95 percent tubular stenosis. No
intervention was done at this last previous catheterization
in [**2105**].
SUMMARY OF HOSPITAL COURSE:
1. CONGESTIVE HEART FAILURE ISSUES: The patient was
transferred to the C-MED Service and initiated on Natrecor
as well as intravenous Lasix. The patient's volume status
throughout her hospital course was difficult to evaluate
given her lack of neck veins; however, her lungs had shown
evidence of volume overload as did her chest x-ray.
The patient did respond with much diuresis with the Natrecor.
An ACE inhibitor was initiated as the patient had not been on
it previously and a low ejection fraction. The following day
- after two doses of captopril and continuing the Natrecor -
the patient developed acute-on-chronic renal failure with a
creatinine that bumped to 2 and hypotension which responded
to a 250-cc normal saline bolus. Her captopril was held, and
the patient's blood pressure stabilized.
The following day the patient was transferred to the Coronary
Intensive Care Unit for possible Swan-Ganz catheter
placement. As the patient's respiratory status had appeared
to become depressed, and secondary to increased creatinine,
the diuresis was not going well. In the Coronary Care Unit
the Natrecor was restarted. A nitroglycerin drip was also
initiated. The patient did not further diurese but did
improve respiratory wise and was called back out to the C-MED
Service floor.
The patient was continued on Natrecor and was also tried on
Lasix as well as Bumex and Zaroxolyn. The patient did
respond somewhat to the Zaroxolyn and Lasix combination, but
her sodium subsequently dropped from 130 to 125 two days
status post Zaroxolyn, and this was again held. The patient
did again have a further episode of what appeared to be acute
cardiogenic pulmonary edema on [**7-24**] which responded to
nitroglycerin, morphine, and hydralazine, as well as the
Natrecor which was already present. During all of these
episodes the patient was very hypertensive, and it was
thought that impaired filling was causing the acute
decompensation.
The patient's creatinine did improve enough that she was able
to go for a cardiac catheterization. The cardiac
catheterization also had a right heart catheterization which
was performed to the neck secondary to the [**Initials (NamePattern4) 228**]
[**Last Name (NamePattern4) 260**] filter. The pulmonary capillary wedge pressure
was 24, and her right atrial pressure was 12 during that
catheterization.
Following this cardiac catheterization, the patient was back
to the floor and the plan was to further diurese her because
her lungs still sounded wet. However, the patient was not
responding to the Natrecor and Lasix - and the problems
mentioned above of electrolytes occurring with the Zaroxolyn
also began to complicate matters. The patient seemed very
hyponatremic on [**7-29**]; probably either from over diuresis
or from worsening heart failure and hypovolemic hyponatremia.
On [**7-29**], the patient had an episode of extreme hypotension
and severe respiratory distress which was again thought to be
acute cardiogenic pulmonary edema. Again, the patient had
not been significantly diuresed even since admission. During
this acute decompensation required intubation and was
transferred to the Coronary Care Unit on [**7-29**].
1. ISCHEMIA ISSUES: The patient did have several episodes of
anginal pain with occasional small troponin leaks of up to
0.19. The cardiac catheterization demonstrated distal 20
percent left main coronary artery, patent high diagonal in
the left anterior descending, but left anterior descending
occluded after the diagonal origin, the left circumflex
with ostial stem with 30 percent in-stent restenosis, him
obtuse marginal occluded, LPL 50 percent, and right
coronary artery with ostial 50 percent, mid 80 percent,
and then total occlusion. The saphenous vein graft to
left anterior descending showed mild plaquing, and the mid
left anterior descending filling retrograde with moderate-
to-severe diffuse disease. The saphenous vein graft to
posterior descending artery was patent, but the segment to
the obtuse marginal was occluded.
Given the patent stents and vein grafts, no intervention was
done at the time. The patient was continued on her aspirin,
statin, and beta blocker.
1. RHYTHM ISSUES: The patient has a history of paroxysmal
atrial fibrillation. She remained on a heparin drip but
was intermittently transitioned to Lovenox in an attempt
to cut down on her fluid intake. She was then switched to
a heparin drip on transfer back to the Coronary Care Unit
the second time. The patient was also continued on her
amiodarone dose. She was thought to go into atrial
fibrillation during her final episode of acute cardiogenic
pulmonary edema, but then converted back to a sinus rhythm
after transfer to the Coronary Care Unit.
1. PERIPHERAL VASCULAR DISEASE ISSUES: The patient had
bilateral foot ulcerations; right greater than left. They
was thought to be dry gangrene. The Vascular Surgery team
followed and did debride the wound once during this
hospitalization. The patient's wound had grown
methicillin-resistant Staphylococcus aureus at an outside
hospital. Thus, the patient was continued on vancomycin
(renally dosed). She was initially of Levaquin on
transfer from the hospital, and this was continued but
then discontinued when the culture data was followed up
on. The overall plan was for the patient to go for an
angiogram of her bilateral lower extremity so that the
possibility for intervention could be assessed. At the
time of this dictation, the patient had still had not
become stable enough or have an appropriate creatinine to
tolerate the angiogram, and this was postponed for this
reason.
1. CHRONIC RENAL INSUFFICIENCY ISSUES: The patient's
creatinine went from approximately 1.3 to 2.5 during her
hospital course. It remained mostly in the 1.3 to 1.6
range. Medications were renally dosed, and the chronic
renal insufficiency made diuresis very limited. On
transfer to the Coronary Care Unit a workup was begun for
renal artery stenosis, and this was in progress at the
time of this dictation.
1. DIABETES ISSUES: The patient was continued on her NPH
dose and regular insulin. She was significantly
hyperglycemic during her admission.
1. PARKINSON DISEASE ISSUES: The patient was continued on
her ropinirole.
1. HEMATOLOGIC ISSUES: The patient did have an anemia of
chronic disease, and her hematocrit drifted down during
her hospital admission. She did require one unit of blood
which she tolerated well, with Lasix following the
transfusion. The patient's hematocrit then remained
stable at around 30.
This Discharge Summary covers the admission up until [**2114-7-29**]. The rest of the dictation will be dictated by the
Coronary Care Unit intern.
[**Name6 (MD) **] [**Last Name (NamePattern4) 2862**], [**MD Number(1) 2863**]
Dictated By:[**Last Name (NamePattern1) 2864**]
MEDQUIST36
D: [**2114-7-30**] 14:23:17
T: [**2114-7-30**] 16:56:23
Job#: [**Job Number 2865**]
ICD9 Codes: 4280, 5849, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7328
} | Medical Text: Admission Date: [**2198-6-27**] Discharge Date: [**2198-7-13**]
Date of Birth: [**2123-8-22**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
[**2198-6-28**] Exploratory laparotomy, duodenotomy, ligation of
duodenal bleeder
[**2198-7-7**]: PICC line placement
History of Present Illness:
The patient is a 74-year-old female
with a history of pyloric channel ulcer on nonsteroidal anti-
inflammatory drugs chronically without proton pump inhibitor or
H2 blocker presented due to GI bleed to an outside hospital.
Reports diarrhea and melena for approximately 3 weeks. She
passed out 3 times leading to admission at [**Hospital3 **] where
she was transferred to the [**Hospital1 69**]
for further management. She was
admitted to the ICU and underwent brief resuscitation and EGD
which revealed a very large 3 cm ulcer with visible clot,
which was not amenable to any endoscopic treatment per the
gastroenterologist. Additionally interventional radiology
was not available to assist with her case immediately, and she
did continue to bleed requiring several units of blood and
hemodynamic instability. We elected to take her emergently to
the operating room. She was mentating appropriately and as such
we discussed risks, benefits, and alternatives to exploratory
laparotomy with the patient, including but not limited to
bleeding, infection, injury to surrounding structures,
duodenal leak, fistula, death, gastric outlet obstruction,
recurrence of ulcer disease, injury to the bile duct,
pancreatic duct, and other issues. The patient did wish to
go ahead and proceed with surgery.
Past Medical History:
Pyloric ulcer and pre-pyloric ulcer obstructing 80% of the
pylorus and antrum, HTN, T12 compression fracture, Osteoporosis,
Severe COPD, Malnutrition, Depression, Glaucoma, AAA (4.4cm)
PSH: Denies (lower midline incision present)
ALL: NKDA
[**Last Name (un) 1724**]: Celecoxib 100 [**Hospital1 **], Flagyl 250''', KCL, Tramadol 50''',
Neurontin (unk dose), Vicodin 5/500''':PRN
Social History:
Tobacco: 2ppd, current, EtOH: Rare, IVDU/Illicits: Denies
Family History:
nc
Physical Exam:
On admission:
VS: T 98.6, HR 108st, BP 89/57, RR 25, SaO2 100%2Lnc
GEN: NAD, A/Ox3, pale appearing
HEENT: EOMI, dry mucus membranes
CV: sinus tachycardia, no M/R/G
PULM: CTAB
ABD: soft, well-healed lower midline incisional scar, no masses,
mild tenderness in midepigastrium, no rebound or guarding, no
fluid wave
PELVIS: rectal tube in place, 300-400cc frank blood and clots in
drainage bag
EXT: WWP, thready radial pulses
PSYCH: Nl judgment
On discharge:
VS: T 98.0 90/56 90 16 94% RA
GEN: A&O, NAD
PULM: CTAB
ABD: midline surgical incision with steristrips intact, dry. No
errythema. Abd soft, appropriately minimally tender at incision
site, nondistended.
EXTR: Warm, pink, well-perfused. No edema
Pertinent Results:
[**2198-7-3**] 05:35AM BLOOD WBC-15.4* RBC-3.32* Hgb-9.8* Hct-30.4*
MCV-92 MCH-29.5 MCHC-32.1 RDW-14.8 Plt Ct-176#
[**2198-7-2**] 12:12PM BLOOD Hct-31.3*
[**2198-7-2**] 04:50AM BLOOD WBC-14.8* RBC-3.15* Hgb-9.6* Hct-28.4*
MCV-90 MCH-30.6 MCHC-34.0 RDW-15.0 Plt Ct-117*
[**2198-6-28**] 04:32AM BLOOD WBC-12.7* RBC-2.03*# Hgb-6.1*# Hct-19.1*
MCV-94 MCH-30.0 MCHC-31.8 RDW-13.7 Plt Ct-132*
[**2198-6-27**] 10:21PM BLOOD WBC-16.4* RBC-3.74* Hgb-11.5* Hct-34.4*
MCV-92 MCH-30.7 MCHC-33.4 RDW-15.7* Plt Ct-133*#
[**2198-6-27**] 07:50PM BLOOD WBC-14.9* RBC-4.63 Hgb-14.2 Hct-42.0
MCV-91 MCH-30.8 MCHC-33.9 RDW-15.4 Plt Ct-297
[**2198-6-28**] 07:26AM BLOOD Neuts-73* Bands-5 Lymphs-17* Monos-2
Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2198-7-3**] 05:35AM BLOOD Plt Ct-176#
[**2198-6-29**] 02:08AM BLOOD PT-11.3 PTT-25.5 INR(PT)-1.0
[**2198-6-28**] 05:40AM BLOOD Fibrino-175*#
[**2198-6-28**] 04:32AM BLOOD Fibrino-94*
[**2198-7-3**] 05:35AM BLOOD Glucose-123* UreaN-8 Creat-0.5 Na-141
K-3.0* Cl-103 HCO3-31 AnGap-10
[**2198-7-2**] 04:50AM BLOOD Glucose-147* UreaN-9 Creat-0.4 Na-138
K-3.0* Cl-101 HCO3-31 AnGap-9
[**2198-6-27**] 07:50PM BLOOD Glucose-154* UreaN-26* Creat-1.0 Na-139
K-4.4 Cl-106 HCO3-18* AnGap-19
[**2198-6-29**] 02:08AM BLOOD ALT-22 AST-55* LD(LDH)-366* AlkPhos-40
TotBili-0.6
[**2198-6-27**] 07:50PM BLOOD ALT-14 AST-32 AlkPhos-75 TotBili-2.0*
[**2198-6-27**] 07:50PM BLOOD Albumin-3.0* Calcium-8.2* Phos-6.4*
Mg-1.6
[**2198-6-29**] 02:24AM BLOOD Type-ART pO2-139* pCO2-39 pH-7.45
calTCO2-28 Base XS-3
[**2198-6-29**] 02:24AM BLOOD Glucose-93 Lactate-1.7 K-3.4
[**2198-6-28**] 06:25AM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-98
[**2198-6-29**] 02:24AM BLOOD freeCa-1.22
[**2198-6-27**]: EKG:
Baseline artifact. Sinus tachycardia. Left axis deviation.
Possible inferior wall myocardial infarction of indeterminate
age. Low QRS voltages in the limb leads. No previous tracing
available for comparison.
[**2198-6-28**]: chest x-ray:
FINDINGS: As compared to the previous radiograph, the patient
has received a new left subclavian catheter. The course of the
catheter is unremarkable, the tip of the catheter projects over
the middle parts of the SVC, no evidence of complications,
notably no pneumothorax.
[**2198-6-29**]: chest x-ray:
IMPRESSION: Interval development of bilateral pleural effusions
with adjacent atelectasis, on a background of severe bullous
emphysema.
[**2198-7-1**]: EKG:
Severe baseline artifact. Likely atrial fibrillation with
controlled
ventricular response. Markedly diminished precordial limb lead
voltages.
Compared to the previous tracing of [**2198-6-27**], the rhythm now
appears to be atrial fibrillation. Otherwise, no diagnostic
interim change.
[**2198-7-1**]: upper GI/contrast:
IMPRESSION:
Delayed gastric emptying with only minimal passage of contrast
from the
stomach into the small bowel.
No duodenal leak is demonstrated but minimal contrast
opacification limits sensitivity in this setting. An NG tube
is recommended to suction out the contents in the stomach given
the delayed gastric emptying.
[**2198-7-3**]: chest x-ray:
FINDINGS: AP single view of the chest has been obtained with
patient in
semi-upright position. Analysis is performed in direct
comparison with the next preceding similar study of [**2198-6-29**]. Previously described left subclavian approach central
venous line remains in unchanged position. Previously present
endotracheal tube has been removed. No pneumothorax has
developed. The previously identified NG tube is again seen and
reaches now further down below the diaphragm indicating its
position in a distended stomach. There is status post recent
abdominal surgery with cutaneous sutures in the midline and one
drainage tube terminating in the fundus area of the stomach.
The heart size has not changed, and no pulmonary congestion has
developed. There exist, however, hazy densities bilaterally in
the lung bases with moderate blunting of the pleural sinuses.
Comparison with examination of [**6-29**] indicates stable findings.
No new parenchymal infiltrates have developed, but the crowded
appearance of the pulmonary vasculature on the bases related to
the pleural effusions remains.
[**2198-7-4**]: EKG:
Atrial fibrillation with rapid ventricular response. Low QRS
voltage,
particularly in the limb leads. Diffuse T wave flattening.
Compared to the previous tracing of [**2198-7-1**], the rate is little
faster. Otherwise, no
diagnostic change.
[**2198-7-4**]: CTA abdomen:
IMPRESSION:
1. No evidence of active GI bleed.
2. Filling defect in proximal portion of the GDA. This
appearance is
concerning for thrombosis or possibly related to recent surgery.
3. 4.6 cm infrarenal abdominal aortic aneurysm.
4. L1 vertebral body compression fracture, age indeterminate.
5. Bilateral large pleural effusions with associated
atelectasis.
6. Left adrenal adenoma.
[**2198-7-5**]: x-ray of the abdomen:
IMPRESSION: No evidence of obstruction or free air. No oral
contrast seen on these radiographs.
[**2198-7-7**]: chest line placment:
There has been placement of right-sided PICC line whose distal
tip is in the distal SVC. There is a left-sided central venous
catheter with the distal tip at the mid SVC. Heart size is
normal. There is a nasogastric tube whose tip and side port are
below the GE junction. Small bilateral pleural effusions are
seen. The heart size is normal.
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2198-7-2**]):
POSITIVE BY EIA.
(Reference Range-Negative).
[**2198-7-5**] 2:51 pm URINE Source: Catheter.
**FINAL REPORT [**2198-7-7**]**
URINE CULTURE (Final [**2198-7-7**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
MORGANELLA MORGANII. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
MORGANELLA MORGANII
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
The patient was admitted to the acute care service with upper GI
bleed. Prior to admission, she required blood products and
pressors for blood pressure support. A GI consult was obtained
and PPI, octreitide infusion was recommended. An EGD was done
which showed a 3cm ulcer with overlying clot which was not
clipped or injected. She was admitted to the intensive care
unit for monitoring.
On HD #2, the patient continued to bleed and was taken to the
operating room where she underwent an exploratory laparotomy,
duodenotomy with oversewing of bleeding duodenal ulcer with a
visible vessel, and an omental patch. During the operative
procedure, she required several blood products including
crystalloid, fresh frozen plasma, packed red blood cells,
platelets, and cryoprecipitate. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed in the
right upper quadrant. She remained intubated after the procedure
and transported to the intensive care unit for further
monitoring. She was weaned and extubated in 24 hours. The
[**Last Name (un) **]-gastric tube remained to suction, but later removed by the
patient. Her vital signs remained stable and she was
transferred to the surgical floor.
On POD #3, she passed a large melanotic stool, followed by
coffee-ground emesis. She remained hemodynamically stable.
Because of a recurrence of bleeding, she was transferred to the
intensive care unit for serial hematocrits. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube
was placed with the removal of coffee ground fluid. Her
hematocrit remained stable. Her [**Last Name (un) **]-gastric tube was removed on
POD # 4 and she was started on clear liquids and transferred to
the surgical floor.
The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **]-gastric tube was again removed and she had
recurrence of nausea and vomiting. She required replacement of
the tube and was made NPO. An upper GI study was done which
showed delayed gastric emptying with only minimal passage of
contrast from the stomach into the small bowel. She was placed
on reglan to help promote motility. She was reported to have an
irregular heart rate on POD #7. An EKG was done which showed
atrial fibrillation. Her electrolytes were repleted and she has
remained in intermittent atrial fibrillation at a controlled
rate. On HD #9, because of her lack of oral intake, a PICC
line was placed and she was started on intravenous nutrition.
She began to move her bowels on POD # 11 and she was started on
clear liquids and slowly advanced to a regular diet. She has
needed encouragement to eat. Marinol was added to help
stimulate her appetite and ensure nutritional supplements were
added. He TPN was weaned off. Her staples were removed from the
surgical wound and the [**Doctor Last Name 406**] drain was discontinued. She was
reported to have urinary frequency and a urine culture was sent
which grew Morganella. Her foley catheter was removed and she
was started on a 3 day course of ciprofloxacin. During her
hospitalization, she was reported to have a positive serology
for H. Pylori and on POD # 12 she was started on a 2 week course
of amoxicilllin, biaxin, and prilosec for treatment.
Her vital signs have been stable and she has been afebrile. Her
white blood cell count has decreased to 10 and her hematocrit
has stabilized at 27. She has been evaluated by Physical therapy
and was reported to be functioning below her baseline status.
Recommendations were made for discharge to a rehabilitation
facillity where she can further regain her strength and
mobility.
She is preparing for discharge with follow-up appointments with
the acute care service and with the GI service.
Medications on Admission:
Celecoxib 100 [**Hospital1 **], Flagyl 250''', KCL, Tramadol 50''',
Neurontin (unk dose), Vicodin 5/500''':PRN
Discharge Medications:
1. Amoxicillin 500 mg PO Q8H Duration: 2 Weeks
last dose [**2198-7-23**]
2. Clarithromycin 500 mg PO Q12H Duration: 2 Weeks
last dose [**2198-7-23**]
3. Heparin 5000 UNIT SC TID
4. Pantoprazole 40 mg PO Q24H
5. Ciprofloxacin HCl 500 mg PO Q12H
3 day course, last day [**7-14**]
6. Metoclopramide 10 mg PO QIDACHS
please discontinue on [**2198-7-16**]
7. Citalopram 20 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
9. Klor-Con M10 *NF* (potassium chloride) 10 mEq Oral daily
10. Gabapentin 100 mg PO BID
11. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q4H:PRN pain
12. Dronabinol 2.5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
bleeding duodenal ulcer
hypovolemia
shock
gastroparesis
h.pylori
urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a bleeding from your
stomach. You required blood products and medication to support
your blood pressure. You were taken to the operating room where
you were found to have an ulcer which was oversewn. You were
monitored in the intensive care unit after the procedure. Once
your vital signs stabilized, you were transferred to the
surgical floor. You required placement of the [**Last Name (un) **]-gastric tube
in your stomach to help relieve the nausea and vomiting and you
were started on intravenous nutrition. Your nausea and vomiting
subsided and the tube in your stomach was removed. You were
started on a regular diet and are slowly regaining your
strength. You are preparing for discharge to a rehabilitation
facility where you can further regain your strength.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2198-7-24**] at 3:15 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV. OF GASTROENTEROLOGY
When: FRIDAY [**2198-8-3**] at 9:30 AM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2198-7-13**]
ICD9 Codes: 5990, 5180, 496, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7329
} | Medical Text: Admission Date: [**2191-3-29**] Discharge Date: [**2191-3-31**]
Date of Birth: [**2116-9-12**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Complete heart block
Major Surgical or Invasive Procedure:
Placement of dual chamber pacemaker
History of Present Illness:
Mr. [**Known lastname 3903**] is a 74 year old obese male with PMH of HTN, [**Hospital **]
transferred from OSH with symptomatic heart block.
Patient complains of worsening dyspnea on exertion with
nonradiating chest pressure x 1 -2 weeks. + dizziness, no
syncope, nausea/ vomiting, diaphoresis or other associated
symptoms. Symptoms of dyspnea have progressed so that patient
can not walk > 1 block without needing to rest. No preceding
fevers, sore throat or recent tick bites. Of note, the patient
has complained of intermittent DOE for approx 10 yrs with
comprehensive evaluation by both cardiology and pulmonary,
including PFT, stable persantine stress test (last in [**6-/2190**]),
coronary CT scan and PFTs.
Today, presented to his PCP office where HR was in the 40s so
sent for further evaluation to ED. At [**Hospital1 **] [**Location (un) 620**], VS: T98.4
P44 RR18 BP181/74 and SaO2 97%. Initial labs were remarkable
for negative cardiac enzymes; EKG showed 2:1 heart block with PR
prolongation and intraventicular conduction delay and then
complete heart block. Given ASA 325mg and fentanyl x 1. After
consultation with cardiology, the patient was transferred to
[**Hospital1 18**] for evaluation and management by EP.
On arrival to the CCU, patient had HR in the 30s, but was
asymptomatic- denying any chest pain, shortness of breath,
confusionor other complaint. 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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. OTHER PAST MEDICAL HISTORY:
- s/p R hip replacement [**8-/2190**]
- s/p L hip replacement
- hydrocele
- s/p R knee arthroscopy
Social History:
Lives with wife, used to work as a courrier of a local newspaper
but now works as a house inspector for the bank
- Tobacco history: quit 40yrs ago, previously smoked 3ppd
- ETOH: quit 6 yrs ago, moderate previous use
- Illicit drugs: none
Family History:
- Mother: CAD requiring CABG in 60s
- Father: active tuberculosis in 40s
Physical Exam:
On Admission:
VS: T= 97.2 BP= 146/84 HR= 40 RR= 12 O2 sat= 95% RA
GENERAL: NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM
NECK: Supple with JVP of 7 cm, no hepatojugular reflex
CARDIAC: bradycardia, regular rhythm. S1 S2. no m/r/g
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge Exam:
Tc: 96.8, P: 62, BP: 152/99, RR: 13, 99% on RA
GENERAL: NAD. Oriented x3.
HEENT: NCAT. MMM
NECK: Supple with JVP of 7 cm
CARDIAC: distant heart sounds, regular rate rhythm. Normal S1,
S2. no m/r/g
LUNGS: mild crackles at bilateral bases, otherwise CTAB
ABDOMEN: Soft, obese, NTND. No HSM or tenderness.
EXTREMITIES: no edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: + DP 2+ PT 2+
Pertinent Results:
Admission Labs ([**3-29**]):
WBC-6.4 RBC-4.53* Hgb-13.3* Hct-39.0* MCV-86 MCH-29.4 MCHC-34.1
RDW-15.0 Plt Ct-249 Neuts-55.2 Lymphs-33.5 Monos-6.3 Eos-3.5
Baso-1.5
PT-13.6* PTT-23.4 INR(PT)-1.2*
ESR-5 TSH-2.0 CRP-2.9
Glucose-100 UreaN-21* Creat-1.3* Na-142 K-4.8 Cl-108 HCO3-25
ALT-38 AST-31 CK(CPK)-63 AlkPhos-64
Calcium-9.5 Phos-4.2 Mg-2.0.
CK-MB-4 cTropnT-<0.01
.
Imaging:
CXR Pa/Lat ([**2191-3-31**]): pacer lead in place over right atrium and
right ventricle. final read pending.
.
Discharge Labs:
[**2191-3-31**] 05:05AM BLOOD WBC-5.9 RBC-4.39* Hgb-13.3* Hct-37.5*
MCV-86 MCH-30.4 MCHC-35.6* RDW-14.9 Plt Ct-199
[**2191-3-31**] 05:05AM BLOOD Glucose-89 UreaN-17 Creat-1.1 Na-138
K-4.1 Cl-105 HCO3-25 AnGap-12
[**2191-3-31**] 05:05AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.0
Other:
[**2191-3-29**] 08:29PM BLOOD TSH-2.0
[**2191-3-29**] 08:29PM BLOOD CRP-2.9
[**2191-3-29**] 08:29PM BLOOD ESR-5
Brief Hospital Course:
74 y/o obese male with PMH of HTN, [**Hospital **] transferred from OSH with
symptomatic complete heart block.
# Heart block:
EKGs showed significant conduction disease with underlying
rhythm complete heart block. QT interval was prolonged placing
patient at risk of torsades. Patient was asymptomatic at rest
with no indications for emergent transcutaneous/transvenous
pacing. Etiology remained unclear although given risk factors,
most likely cause would be ischemic heart disease vs idiopathic
fibrotic reaction. Sarcoidosis, lymes disease, tuberculosis are
much less likely, although still on differential. Endocarditis
affecting conduction system extremely unlikely with lack of
systemic symptoms. Pt was monitored on tele overnight with no
changes. ESR/CRP and TSH were normal. Made NPO after midnight
for pacemaker placement and pacer successfully placed on
afternoon of [**2191-3-30**]. Rate had been mid 30s before pacing and
was paced around 60 after placement. Pt did well post-proceedure
and was discharged home the next day. ACEI level still pending
at time of discharge and pt will be considered for outpt MRI to
further eval possible etiology of complete heart block.
# HTN:
Hypertensive with SBP in the 140- 180s in the setting of
bradycardia. Although patient has known HTN, may be high
catecholamine response to maintain organ perfusion. As patient
asymptomatic, so initial treatment deferred until pacer placed.
Despite hx of HTN, pt not on any home medications. After pacer
was placed, systolic BPs up to 200s. There was thought that in
setting of high catecholamines and new increased cardiac output
with pacer placed that BP had been further elevated. Pt was
started on captopril 12.5mg TID to titrate to dose with BP
falling into 150s systolic over next 12 hrs. Will plan to
discharge on lisinopril 20 mg po daily and follow-up BP for
further titration as outpatient.
# HLD:
Per prior records, LDL elevated to 153 with [**Location (un) 47**] 10 yr
cardiovascular risk of 44% indicating that patient would likely
benefit from statin therapy. Pt not on any home medications,
though previously on red rice yeast until 4-5 months ago. He was
started on simvastatin 10 mg po daily.
# Coronaries:
No know history of CAD but multiple risk factors including age,
HTN, HL, prior smoking. C/o symptoms consistent with stable
angina for years although evaluation with stress test has shown
stable reversible defect alone. As above, heart block is mostly
likely related to ischemia. He was started on aspirin 81 mg po
daily.
#Code: Full Code (confirmed with patient)
#Transition of Care:
-ACE level pending
-Consider cardiac MRI as outpatient to further evaluate etiology
of heart block
-Follow electrolytes as patient has been started on an ACE
inhibitor.
Medications on Admission:
None
Discharge Medications:
1. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 doses.
Disp:*4 Capsule(s)* Refills:*0*
2. aspirin 81 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*
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain for 3 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
Please check electrolytes on [**2191-4-7**]: Na, K, Cl, HCO3, BUN,
Creatinine. Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22882**] at Fax #
[**Telephone/Fax (1) 82575**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Complete Heart Block
Secondary:
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 3903**],
You were admitted to the hospital due to a slow heart rate and
EKG findings showing complete heart block. You were monitored in
the cardiac intensive care unit overnight and had a pacemaker
successfully placed the next day. After pacemaker placement,
your blood pressure was running high so you were started on a
medication for blood pressure control.
You may need to have a cardiac MRI to further evaluate the cause
of your low heart rate. You should discuss the need for further
testing with Dr. [**Last Name (STitle) **].
New medications started this admission:
- Cephalexin 500 mg by mouth every 6 hours for 4 more doses.
This is an antibiotic to prevent an infection at the pacemaker
site.
- Lisinopril 20 mg by mouth once a day for high blood pressure
- Aspirin 81 mg by mouth once a day for heart protection
- Simvastatin 10 mg by mouth once a day to lower cholesterol
- Percocet 1 tab every 4 hours as need for pain control
You should follow-up with your cardiologist, Dr. [**Last Name (STitle) **] on
[**2191-4-14**] at 1:30 pm.
Followup Instructions:
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**2191-4-14**] at 1:30 pm
[**Name (NI) **] Brothers [**Name (NI) **], [**Name (NI) **], [**Location (un) **], MA
Ph: [**Telephone/Fax (1) 8725**]
If you need to change this appointment please call [**Doctor Last Name 1022**] at [**Hospital1 18**]
at [**Telephone/Fax (1) 1536**].
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7330
} | Medical Text: Admission Date: [**2138-12-2**] Discharge Date: [**2138-12-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 F with PMH HTN, vertigo, tx from [**Hospital3 2558**] for
evaluation of BRBPR. Pt woke up this AM with red blood and
clots on bedsheet and diaper. In ED, passed 2 clots and 20 cc
red blood in diaper. She denies LH/abd
pain/n/v/melena/diarrhea/. Per her report, she had normal BM
without blood the day prior. ROS is otherwise negative.
In ED, 500cc via NG lavage was clear but complicated by brief
vasovagal episode. Pt admitted to MICU for observation and
planned for o/n prep and colonoscopy following AM.
Past Medical History:
HTN
Depression
chol
MR
LVH
Osteoporosis
h/o Fall
cataracts
Vertigo ([**12-17**] Cervicogenic vertigo- previously had MRI with mild
intracranial atherosclerotic changes; carotid U/S with
<40%stenosis b/l and [**Doctor Last Name **] of hearts monitor)
Social History:
lives alone; denies tobacco use, reports occassional alcohol
use; former French teacher; She has a brother who was a former
cardiologist (Dr. [**Name (NI) **] [**Name (NI) 13534**] - son of Dr. [**Known lastname 13534**] of
[**Known lastname 13534**]-Parkinson-White syndrome) at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] and is involves
with her care.
Family History:
Non-contributory
Physical Exam:
97.8 165/58 68 18 98%(2L)
Gen: AOx3, lying comfortably, NAD
HEENT: PERRL, EOMI,
Neck: supple, no LAD, no thyromegaly
CV: RRR, [**1-18**] harsh systolic murmur throught precordium
Pulm: CTA b/l
Abd: soft/nt/nd, +bs, no hepatosplenomegly
Ext: no edema, +2 dorsalis pedis pulses b/l
Rectal (per ED notes): large clot in diaper, blood in vault, no
hemorrhoids; pt refused digital rectal exam
Pertinent Results:
[**2138-12-1**] 07:10PM WBC-7.6# RBC-3.56* HGB-12.2 HCT-35.1* MCV-99*
MCH-34.3* MCHC-34.8 RDW-15.2
[**2138-12-1**] 07:10PM NEUTS-76.6* LYMPHS-16.9* MONOS-4.5 EOS-1.7
BASOS-0.3
*
[**2138-12-1**] 07:10PM GLUCOSE-129* UREA N-24* CREAT-0.7 SODIUM-137
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-32* ANION GAP-11
[**2138-12-1**] 07:10PM ALT(SGPT)-23 AST(SGOT)-26 TOT BILI-0.3
[**2138-12-1**] 07:10PM ALBUMIN-2.8*
Brief Hospital Course:
Pt admitted to ICU and transfused 2U pRBC. Pt refused prep in
MICU and pt transferred to floor on following day [**12-2**]. On
that day, she had large BRBPR and SBP dropped from 130's-->
100's. Pt subsequently transferred back to MICU. Tagged RBC
scann was scheduled by in scanner pt refused testing. She was
monitored in the ICU with stable hct. Again she refused
go-lytely prep. Colonoscopy was performed but aborted due to
large amount of stool.
Pt transferred to floor on [**12-4**]. Pt hct remained stable
during rest of hospital course and no further episodes of BRBPR.
After further discussions with her brother [**Name (NI) 382**] and her PCP
(Dr. [**Last Name (STitle) 1728**] pt agreed to attempt bowel prep. 3 attempts at NGT
placement were made but pt was not able to tolerate and refused
further attempts. She was given fleet phospho-soda prep PO x2
with dulcolax laxatives. Pt had large BM but still had stool in
rectal vault. Multiple enemas were attempted but patient did
not tolerate procedure [**12-17**] discomfort. Pt was asked to take
go-lytely prep again as tolerated over course of 2 days ([**12-6**]
and [**12-7**]) but again pt refused.
Medications on Admission:
lipiotor 40 PO Qday
aspirin 81 mg PO Qday
Buproprion 150 mg PO BID
calcium carbonate PO TID
tylenol prn
Lacutlose
colace
senna
atenolol 25 mg PO Qday
Lisinopril 20 mg PO Qday
Vit D 800 mg PO Qday
maalox prn
celexa 20 mg PO Qday
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. Lower GI bleeding
Discharge Condition:
good
Discharge Instructions:
1. if have large bright red stools or black stools call 911 or
go to the nearest ER for evaluation.
2. please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1728**], in the next 1
week.
3. please see your gastroenterologist, Dr. [**Last Name (STitle) 7307**] on [**12-17**]
@ 3:20 pm in [**Hospital Ward Name 23**] [**Location (un) 436**].
Followup Instructions:
1. See Dr. [**Last Name (STitle) 1728**] in 1 week to check your hematocrit; call
617-731-
*
2. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Where: [**Hospital6 29**] MEDICAL SPECIALTIES
Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2138-12-17**] 3:20
ICD9 Codes: 5789, 2765, 2851, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7331
} | Medical Text: Admission Date: [**2101-9-27**] Discharge Date: [**2101-10-6**]
Date of Birth: [**2032-10-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2101-9-28**] Aortic Valve Replacement (21mm [**Company 1543**] Mosaic Porcine
Valve), Augmentation Aortoplasty with Pericardial patch
History of Present Illness:
68 y/o female with known aortic stenosis with dyspnea on
exertion and decreased exercise tolerance who was experiencing
increased heart failure symptoms. She has known critical aortic
stenosis with normal coronaries and LV function. Also was on
Coumadin for paroxysmal atrial fibrillation. Being admitted
prior to surgery for Heparin.
Past Medical History:
Aortic Stenosis, Congestive Heart Failure - Diastolic,
Paroxysmal Atrial Fibrillation, Thoracic Lymphadenopathy,
Hypertension, Obesity, Mild COPD, Goiter, s/p C-section x 2, s/p
Hysterectomy, s/p Excision of Liver cyst
Social History:
Quit smoking 20yrs ago after 20pk/yrhx
Social ETOH use 2 drinks/month
Family History:
Father died from CAD at 60
Physical Exam:
At discharge:
VS:T98 BP87/44 P86 SB RR20
Gen:NAD
Chest:CTA Bilaterally
Heart:RRR, Sternum stable
Abd:S, NT, ND
Ext:1+ LE
Incision:distal pole MSI beefy, no drainage
Pertinent Results:
[**9-28**] Echo: Pre Bypass: No thrombus is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the aortic root. There are
complex (>4mm) atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is moderate to severe aortic valve
stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Post Bypass: Preserved biventricular
function. A bioprosthetic aortic valve is seen. (#21 [**Company **]
mosaic ultra per surgeons). No perivalvular leaks. Trace central
AI. Peak gradient 62-65 mm Hg, mean gradient 22-25 mm Hg. Mitral
regurgitation remains 1+. Aortic contours intact. Remaining exam
is unchanged. All findings discussed with surgeons at the time
of the exam.
[**2101-10-6**] 05:20AM BLOOD WBC-13.2* RBC-3.43* Hgb-10.2* Hct-30.7*
MCV-90 MCH-29.8 MCHC-33.3 RDW-14.8 Plt Ct-429#
[**2101-10-6**] 05:20AM BLOOD Plt Ct-429#
[**2101-10-6**] 05:20AM BLOOD Glucose-107* UreaN-27* Creat-1.1 Na-134
K-4.6 Cl-100 HCO3-24 AnGap-15
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname 80397**] was admitted one day prior
to surgery. She was started on Heparin and underwent usual
pre-operative work-up. On [**9-28**] he was brought to the operating
room where he underwent a aortic valve replacement. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. She was found to be in atrial fibrillation and
amiodarone was started. EP was consulted and suggested medical
treatment with amiodarone instead of electrical cardioversion.
Her chest tubes were removed and she was transferred to the
floor. Her wires were removed and she was started on coumadin.
She was agressively diuresed. By post-operative day 8 she was
ready for discharge to home.
Medications on Admission:
Cardizem 120mg qd, Lisinopril 10mg qd, MVI, Coumadin 4mg qd
(stopped [**9-23**])
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day): take 2.5 tablets for a total of 125mg three times
per day.
Disp:*225 Tablet(s)* Refills:*0*
5. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours) for 5 days: sternal erythema.
Disp:*15 Capsule(s)* Refills:*0*
6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses: please take 1 mg daily or as directed by the office of
Dr. [**Last Name (STitle) 47403**].
Disp:*40 Tablet(s)* Refills:*0*
7. Furosemide 40 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 Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Outpatient Lab Work
INR to be drawn on Monday [**2101-10-10**] with results sent to the
office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47403**], fax ([**Telephone/Fax (1) 80398**]
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Congestive Heart Failure - Diastolic
PMH: Paroxysmal Atrial Fibrillation, Thoracic Lymphadenopathy,
Hypertension, Obesity, Mild COPD, Goiter, s/p C-section x 2, s/p
Hysterectomy, s/p Excision of Liver cyst
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 11763**]
Dr. [**Last Name (STitle) 3321**] in [**12-26**] weeks
Dr. [**Last Name (STitle) 47403**] in [**11-24**] weeks ([**Telephone/Fax (1) 80399**]. INR to be drawn on
Monday with results sent to the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47403**],
fax ([**Telephone/Fax (1) 80398**]. Plan confirmed with [**Doctor First Name 4134**].
Completed by:[**2101-10-6**]
ICD9 Codes: 4241, 5990, 4280, 4019, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7332
} | Medical Text: Admission Date: [**2162-7-30**] Discharge Date: [**2162-8-14**]
Date of Birth: [**2162-7-30**] Sex: F
Service: NEONATOLOGY
INTERIM SUMMARY - HISTORY: Baby Girl [**Known lastname **] is a now 15-day-old
ex 1,185 gm infant born at 30-3/7's week gestation to a
40-year-old G4, P2 mom ,whose pregnancy was complicated by
chronic hypertension requiring labetalol and hydralazine.
Mom was admitted in the beginning of [**Month (only) 216**] for these
symptoms and treated with increasing doses of meds to control
her hypertension. She did receive a course of betamethasone
on [**7-12**]. Her prenatal screens were complete and
unremarkable including O+ status.
Mom was taken to C-section when concerns for abnormal fetal
heart tracings. Infant emerged with decreased tone and
respiratory activity, requiring bag mask ventilation for
approximately 1 minute at resus. The heart rate was over 100
throughout. Apgar scores ultimately were 4 and 9. The
patient was brought to the NICU for further care.
PHYSICAL EXAM:
Birth Weight 1,185 gm(25%) Discharge wgt 1245
Birth length 37.5 cm (>10 %)
Birth HC 27.5 (25 %)
Active, nondysmorphic infant, well-perfused with saturations in
the high-90s on blow-by O2. Skin without lesions but bruising
noted on legs.
HEENT within normal limits. Cardiovascular - normal S1, S2,
no murmur. Lungs - coarse breath sounds bilaterally, mild
grunting, flaring and retracting. Abdomen benign. Nonfocal
neuro exam and age-appropriate. Hips normal. Genitalia
normal. Spine intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEM - 1) RESPIRATORY: The
patient required intubation within the first few hours of
life with subsequent surfactant x 2. She was able to be
extubated prior to 24 hours and remained on CPAP through day
of life #4. Since that time, she has gradually weaned on
nasal cannula, and is currently on 100 % 25 cc with persistent
mild tachypnea. The patient was started on caffeine citrate on
day of life #5 with apnea bradycardia spells. These have
responded well to medication. Her current dose of caffine
citrate is 9 mg po/pg=7.2 mg/kg/day
2) CARDIOVASCULAR: A murmur was noted on day of life #3
concerning for PDA. An echo was obtained at that time and
confirmed the presence of a large duct. Indocin was
subsequently initiated with good response. A follow-up echo was
obtained [**8-5**] (day of life #6) for acidosis and concerns of a
silent PDA recurrence. This study demonstrated that Indocin had
resulted in duct closure and was wnl
She currently is stable with no murmur.
3) FEN: The patient was supported with PN starting on day of
life #1. Enteral feedings were started on feeds at day of life
#3 prior to Indocin course, then held during treatment. Once it
was apparent the PDA was closed, enteral feedings were restarted
and advanced to full feedings without incident. SHe is currently
feeding BM24cals per ounce with 4 cals per ounce of hmf. She has
some small spits and gavage feedings have been extended to run
over 1 hr 10 minutes to help with nonbilious aspirates. Total
fluids are 150 cc/kg/d. Plan is to continue to advance caloric
density and add promod. th. Current weight is 1,245.
Most recent electrolytes on [**8-7**] are 143,
5.4 112, 20, and a glucose of 68.
4) GI: The patient has had mild hyperbilirubinemia peaking
of day of life #4 at 7.1 with gradual decline. Rebound was
3.5/.4 3.1
5) HEMATOLOGY: CBC obtained at admission had a hematocrit of
55.5, white count 7.1 with out shift, platelet count 211.
Follow-up CBC on day of life #6 (with concerns of acidosis)
was hematocrit 43.6 and stable platelets and white blood cell
count. Mom is known to be O+. Baby is also O+, Coomb's
negative.
No blood products were required during this admission.
6) INFECTIOUS DISEASES: The patient received a rule out
sepsis at delivery with ampicillin and gentamicin for 48
hours. Antibiotics were discontinued with negative blood
culture. Additional blood culture obtained on day of life #6
with concerns for acidosis. The culture remained negative with
improvement of labs.
7) NEUROLOGY: Cranial ultrasound obtained on [**8-6**] within
normal limits. Plan to repeat at 1 month.
8) SOCIAL: Parents are appropriately concerned, but coping well
with patient's prematurity. They look forward to transition
closer to home
CONDITION AT TIME OF Transfer: Stable.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**]
CARE/RECOMMENDATIONS:
1. Feeds: BM24=150 cc/kg/d Intention to advance caloric density
if tolerated.
2. Medications: Caffeine IV at 9 mg/kg/D, nasal cannula O2
3. Car seat positioning: Pending.
4. State newborn screen: Sent.
5. Immunizations received: None.
INTERIM DIAGNOSES LIST:
1. Prematurity at 30-3/7 week's gestation.
2. Patent ductus arteriosus, status post Indocin.
3. Hyperbilirubinemia, resolved.
4. Hyaline membrane disease, status post surfactant,
resolving
5. Metabolic acidosis, resolved.
6. Apnea of prematurity
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 52192**]
: [**2162-8-6**] 14:00
T: [**2162-8-6**] 14:34
JOB#: [**Job Number 52193**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7333
} | Medical Text: Admission Date: [**2109-2-11**] Discharge Date: [**2109-2-14**]
Date of Birth: [**2067-2-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Stab wound to left arm
Major Surgical or Invasive Procedure:
[**2109-2-11**] Repair of left brachial artery and vein ligation
History of Present Illness:
41 yo male s/p self inflicted stab wound to left arm sustaining
injury to his left brachial artery. He was taken to an area
hospital where he was transfused with 2 units PRBC's and was
intubated. He was then transferred to [**Hospital1 18**] for further care.
Past Medical History:
Substance abuse
Depression
Social History:
Substance and EtOH abuse, drinks beer daily [**3-31**]/day with
occasional cocaine use
Family History:
Noncontributory
Pertinent Results:
[**2109-2-11**] 04:06PM GLUCOSE-81 UREA N-12 CREAT-0.7 SODIUM-140
POTASSIUM-4.3 CHLORIDE-117* TOTAL CO2-20* ANION GAP-7*
[**2109-2-11**] 04:06PM CALCIUM-7.7* PHOSPHATE-3.5 MAGNESIUM-2.5
[**2109-2-11**] 12:05PM PT-13.3* PTT-30.8 INR(PT)-1.2*
[**2109-2-11**] 08:37AM WBC-16.6* RBC-3.77* HGB-11.4* HCT-34.0*
MCV-90 MCH-30.3 MCHC-33.6 RDW-15.4
[**2109-2-11**] 08:37AM PLT COUNT-143*
[**2109-2-11**] 08:37AM PT-15.1* PTT-150* INR(PT)-1.4*
CT HEAD W/O CONTRAST
Reason: FOUND UNRESP.
[**Hospital 93**] MEDICAL CONDITION:
41 year old man with selfinflicted wound to L arm, found
unresponsive
REASON FOR THIS EXAMINATION:
eval: bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 41-year-old man with self-inflicted wound to left
arm. Found unresponsive. Evaluate for bleed.
CT HEAD WITHOUT CONTRAST: There is no evidence of hemorrhage,
mass effect, shift of normally midline structures, or
infarction. There are two subcentimeter foci of hypodensity
adjacent to each other in the deep white matter of the right
frontal lobe, which may represent small vessel ischemic
infarcts. The ventricular size is normal. Fixation screws,
likely from prior trauma are seen near the right frontozygomatic
suture. Visualized paranasal sinuses and mastoid air cells are
clear.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or acute
fractures.
2. Two subcentimeter foci of decreased CT attenuation in the
deep white matter of the right frontal lobe are consistent with
chronic small vessel ischemic infarcts.
CHEST (PORTABLE AP)
Reason: tube position
[**Hospital 93**] MEDICAL CONDITION:
41 year old man with ett s/p stab wound to arm, ETT, CVL
REASON FOR THIS EXAMINATION:
tube position
EXAMINATION: AP supine chest.
INDICATION: Intubation.
A single AP view of the chest is obtained [**2109-2-11**] at 0912 hours
and is compared with the radiograph performed approximately five
hours previously. Patchy linear opacity at both bases may be
secondary to subsegmental atelectasis or may reflect the
relative degree of hypoinflation of the lungs on this image. The
ET tube is approximately 4.5 cm above the carina. There is no
evidence of acute consolidation or large pleural effusion
visible on the current study.
Brief Hospital Course:
He was admitted to the Trauma Service under the care of Dr.
[**Last Name (STitle) **]. He underwent CT imaging; no intracranial hemorrhage or
solid organ injuries were identified.
Vascular surgery was consulted because of the left brachial
artery injury; he was taken to the operating room for repair of
this along with ligation of the vein. There were no
intraoperative complications and postoperatively he has done
well. Daily dry sterile dressing changes are being performed;
currently his wounds are clean, and without any visible signs of
infection. Pain is being controlled with Percocet prn. His
chemistry and CBC panels have been followed closely. Because of
the blood loss associated with his injury his hematocrit did
drop from low 30's to mid 20's. Hemodynamically he has been
stabile. It is expected that his hematocrit will improve given
his age and lack of co-morbidities.
Psychiatry was also consulted given that this was a suicide
attempt; he also has a history of substance abuse and
depression. He was placed on 1:1 sitters; Ativan was started prn
per CIWA protocol and agitation. Haldol was recommended if
Ativan not effective. He has been cooperative with his care and
at this point there have been no behavioral issues.
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
3. Haldol Sig: 1-2 MG PO every 6-8 hours as needed for
agitation.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
5. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
6. Lopressor 50 mg Tablet Sig: [**1-31**] Tablet PO twice a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Stab wound to left arm
Left brachial artery injury
Discharge Condition:
Stable
Discharge Instructions:
DO NOT bear any weight on your left upper extremity.
You should return to the Emergency room if you develop any
fevers, chills, increased redness, drainage, swelling from your
surgical site and/or any other symptoms that are concerning to
you.
Followup Instructions:
Follow up with Vascular Surgery in [**8-6**] days for re-evaluation
of your left arm and removal of sutures. Call [**Telephone/Fax (1) 1237**] for
an appointment.
Follow up as needed in Trauma Clinic by calling [**Telephone/Fax (1) 6429**] to
schedule an appointment if needed.
Completed by:[**2109-2-18**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7334
} | Medical Text: Admission Date: [**2115-5-17**] Discharge Date: [**2115-5-30**]
Date of Birth: [**2051-7-24**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Penicillins / Iodine; Iodine Containing / Shellfish
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
Acute renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 63 year old female with a history of CAD s/p
angioplasty 10 years ago who presented to [**Hospital3 **]Hospital on [**2115-5-16**] for the chief complaint of fevers, chills,
diarrhea and abdominal pain. The patient first noted symptoms on
Saturday when she developed fevers to 102. As a result, she
began to take approximately 12 advils for her fevers Monday to
Tuesday and then subsequently developed "dark" diarrhea with
diffuse abdominal pain and lower back pain (chronic). She also
experienced nausea with minimal, non-bilious vomiting. She
denies any sick contacts. She admits to having increased urinary
frequency, urgency, but denies any dysuria. She had not been
taking any antibiotics before the onset of her diarrhea.
The patient has a history of pyelonephritis approximately 10
years ago. She has had a recent colonoscopy with no
abnormalities. She currently admits to having nonbloody
diarrhea.
At [**Location (un) **], the patient was found to have an anion gap of 22
with a Cr of 5.0 which rose to 5.4 with a K of 5.6. She has no
known baseline renal insufficiency (Cr 0.9-1.0 in [**2111**]). A CT
scan of the abdomen reportedly showed pyelonephritis with
bilateral kidney enlargement and soft tissue, perinephritic
stranding. The patient was started on Ceftriaxone 1 gm. She was
given kayexelate and given IVF with 1 amp of HCO3. Her stool was
described as yellow with her urine cultures pending.
ROS: No chest pain, shortness of breath. The patient has never
had substernal chest pain - her anginal equivalent is right arm
pain.
Past Medical History:
1)CAD s/p cath [**2111**] (right dominant, single vessel disease, 50%
eccentric LAD, RCA diffusely diseased with 100% mid with
left-right collaterals)
2) h/o hematuria- posterior wall thickening noted on CT
abd/pelvis in [**6-/2114**], with normal appeearing kidneys, cr normal
at 0.9, cystoscopy showed no abnormalities, urethral scrituring
from inflammation (treated w/ macrodantoin).
Social History:
The patient lives with her husband in [**Name (NI) **]. She is married
with 3 children. She is a former smoker (quit 10 years ago) and
formerly smoked 1 pdd x 30 years. She denies any EtOH/drug use.
Family History:
Mother - multiple medical problems, deceased from unknown cause
Father - CABG in 70s
Brother - DM
h/o SLE in family
Physical Exam:
Tc=98.7 P=102 BP=133/55 98% O2 on RA
Gen - NAD, AOX3
HEENT - Dry [**Last Name (LF) 5674**], [**First Name3 (LF) 13775**]
Heart - RRR, no M/R/G
Lungs - Bibasilar crackles bilaterally
Abdomen - Soft, mildly diffusely tender, active bowel sounds, no
rebound/guarding
Ext - No C/C/E, + 2 d. pedis
Pertinent Results:
Admission Labs ([**5-17**]):
CBC: WBC-16.2* RBC-4.13* HGB-13.0 HCT-37.0 MCV-90 MCH-31.4
MCHC-35.1* RDW-14.9
*
DIFF: NEUTS-83* BANDS-9* LYMPHS-6* MONOS-2 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0
*
CHEM: GLUCOSE-125* UREA N-73* CREAT-5.3* SODIUM-140
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-19* ANION GAP-23*
ALBUMIN-3.2* CALCIUM-8.0* PHOSPHATE-4.9* MAGNESIUM-1.8 URIC
ACID-9.5* CHOLEST-88
*
ABG: Lactate- 1.9, ABG-PO2-71* PCO2-39 PH-7.23* TOTAL CO2-17*
BASE XS--10
*
LFTs: ALT(SGPT)-96* AST(SGOT)-146* LD(LDH)-409* ALK PHOS-156*
AMYLASE-49 TOT BILI-1.0 LIPASE-15 GGT-27
*
Lipids: TRIGLYCER-154* HDL CHOL-12 CHOL/HDL-7.3 LDL(CALC)-45
*
Urine Studies ([**5-17**]):
--------------------
*BLOOD-LGE NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG *UROBILNGN-NEG PH-6.5 LEUK-MOD RBC>50 WBC>50
BACTERIA-FEW YEAST-NONE
*EOS-POSITIVE Moderate EOS
*OSMOLAL-347
*COLOR-LtAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
*RANDOM CREAT-42 SODIUM-90
*RANDOM CREAT-49 TOT PROT-334 PROT/CREA-6.8
*
Micro Data:
------------
[**5-17**] Urine Culutre- 10-100,000 pan sensitive
[**5-17**] Stool Culture- No salmonella, shigella,campylobacter. Cdiff
neg.
[**5-17**] Blood Culture- No growth
[**5-21**] Stool Culutre- No O&P. Few PMN's. Charcot-[**Location (un) 5244**] Crystals.
[**5-21**] Stool- E.Coli 0157:H7 pending
*
Other Labs:
-----------
[**2115-5-21**] Ret Aut-0.5
[**2115-5-18**] Fibrino-904 D-Dimer-5737
[**2115-5-18**] Fibrino-909 D-Dimer-5772
[**2115-5-21**] Fibrino-594 D-Dimer-7665
[**2115-5-21**] calTIBC-150 VitB12->[**2110**] Folate-15.1 Ferritn-556
TRF-115
[**2115-5-20**] Hapto-291
[**2115-5-19**] HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2115-5-22**] [**Doctor First Name **]-PND
[**2115-5-19**] HCV Ab-NEGATIVE
[**2115-5-21**] freeCa-0.94
[**2115-5-22**] freeCa-0.90
*
Lipase Trend:
------------
[**2115-5-17**] Lipase-15
[**2115-5-18**] Lipase-29
[**2115-5-21**] Lipase-981
[**2115-5-22**] Lipase-534
[**2115-5-22**] Lipase-300
[**2115-5-23**] Lipase-294
*
Chemistry Trend:
---------------
[**2115-5-17**] Glucose-125* UreaN-73* Creat-5.3* Na-140 K-4.2 Cl-102
HCO3-19
[**2115-5-17**] Glucose-101 UreaN-92* Creat-5.7* Na-138 K-4.4 Cl-102
HCO3-16
[**2115-5-18**] Glucose-67* UreaN-104* Creat-6.4* Na-137 K-3.9 Cl-101
HCO3-13
[**2115-5-19**] Glucose-101 UreaN-125* Creat-7.4* Na-131* K-4.0 Cl-96
HCO3-16
[**2115-5-19**] Glucose-79 UreaN-132* Creat-8.4* Na-132* K-4.3 Cl-94*
HCO3-15
[**2115-5-20**] Glucose-75 UreaN-114* Creat-7.3* Na-131* K-4.4 Cl-94*
HCO3-15
[**2115-5-20**] Glucose-82 UreaN-79* Creat-5.5* Na-138 K-4.3 Cl-100
HCO3-20
[**2115-5-21**] Glucose-95 UreaN-86* Creat-6.0* Na-137 K-4.5 Cl-100
HCO3-19
[**2115-5-22**] Glucose-66* UreaN-94* Creat-6.5* Na-134 K-4.6 Cl-97
HCO3-18
[**2115-5-22**] Glucose-137* UreaN-95* Creat-6.5* Na-134 K-4.7 Cl-99
HCO3-15
[**2115-5-22**] Glucose-124* UreaN-96* Creat-6.4* Na-131* K-4.7 Cl-98
HCO3-16
[**2115-5-23**] Glucose-101 UreaN-94* Creat-6.3* Na-133 K-4.7 Cl-100
HCO3-16
*
Reports:
--------
Abd U/S [**5-17**]: The liver demonstrates no focal or textural
abnormality. The gallbladder is mildly distended with no
evidence of stones or acute cholecystitis. The right kidney
measures 12.2 cm in length and appears mildly full. The cortex
appears echogenic diffusely. There are no stones, masses, or
evidence of hydronephrosis. The left kidney measures 11.4 cm;
Conclusion- Echogenic renal cortices raising the possibility of
chronic renal parenchymal disease. The kidneys appear mildly
full with no evidence of obstruction or perinephric collection.
*
CXR [**5-17**]: No radiographic evidence of acute cardiopulmonary
process
*
CT Abd [**5-21**]:
1. Bilateral enlarged, edematous kidneys without perinephric
stranding. This appearance may be consistent with medical renal
disease. Other considerations are bilateral renal vein
thrombosis, although the renal veins are do not appear expanded
on this noncontrast study and toxic metabolic injury.
2. Peripancreatic stranding consistent with pancreatitis without
focal fluid collection in the peripancreatic bed.
3. Small right-sided effusion.
4. Atherosclerotic disease of the aorta.
*
ECHO: Conclusions-
1.The left atrium is normal in size.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4. The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6.There is mild pulmonary artery systolic hypertension.
7.There is no pericardial effusion. There is an anterior space
which most
likely represents a fat pad, though a loculated anterior
pericardial effusion cannot be excluded.
8. While the study is technically limited, there does not appear
to be an
overt evidence of an infilatrative cardiomyopathy.
Brief Hospital Course:
The patient is a 63 year old female with a history of CAD s/p
angioplasty who presented to [**Hospital3 7571**]Hospital on [**2115-5-16**]
with acute renal failure with a history of excessive NSAID use
in the setting of E. coli pyelonephritis and bacteremia now
thrombocytopenia, anemia, resolving transaminitis and acute
pancreatitis s/p ERCP with sphincterotomy on [**5-22**].
.
Bilateral Pyelonephritis
- with 1 week of fever, 9% bandemia and gram negative rods in
urine culture from [**Location (un) **] with white cell casts
- original CT scan from Nashobam showed "perineprhic fat
stranding" although no perinephric stranding seen on ultrasound
and enlarged kindeys on ultrasound which renal believes is
consistent with acute bilateral pyelonephritis.
- [**Location (un) **] showed Gram (-) rods in 2 blood culture bottles and
the patient has E.coli in her urine that is pansensitive.
- Pt was treated with a total 14day course of renally dosed
Levaquin 250 mg.
.
Acute renal failure with oliguria and proteinuria
- baseline Cr in [**7-8**] is 0.9; Her Cr continued to rise with
worsening gap acidosis this was deemed to be from combination
of volume depletion [**2-6**] diarrhea, NSAIDs and pyelonephritis.
Renal ultrasound showed no obstruction and in fact, ? signs of
chronic renal changes which after discussing with renal, may be
consistent with bilateral pyelonephritis. The patient's Cr
continued to climb on [**5-19**] and she became more lethargic
indicating uremia and thus renal felt the patient needed HD
which she received on [**5-19**] with good effect. She had another
round of HD on [**5-20**]. The patient had a RSCL tunneled catheter
placed on [**5-22**] and received her last HD tx on [**2115-5-23**] for a
total of three treatments. Her mental status change (lethargy)
was felt to be due to uremia and after HD, improved
significantly. Upon transfer to the floor her creatinine began
to normalize and she was making good urine. At the time of d/c
her creatinine was 2.0. She was instrucred to follow up with
nephrology in one month's time.
.
Pancreatitis
- A CT scan of her abdomen on [**5-21**] showed pancreatitis most
likely caused by an obstructing stone/sludge not seen on CT. GI
was consulted on [**5-21**] and an ERCP was performed on [**5-22**] which
showed large craters in the stomach and duodenum, sludge in the
CBD that does not explain her symptoms with no stones/ductal
dilatation. A sphincterotomy was performed. Her pain was
controlled with MSO4. She was restarted on a PPI which was
initially discontinued secondary to her thrombocytopenia. She
was made NPO and given TPN. Eventually she started to tolerate
po's and her pancreatic enzymes began to normalize. She was
eating a normal diet at the time of d/c.
.
Thrombocytopenia
- The patient is HIT negative. A prior DIC panel showed an
elevated DDimer which is nonspecific in setting of infection
with normal fibrinogen and FDP. A repeat D-dimer showed an
increased value which again is nonspecific and hematology feels
this is most likely [**2-6**] infection. Hematology was consulted on
[**5-21**] for ?TTP/ITP/DIC. They feel her anemia and thrombocytopenia
were consistent with infection, not necessarily TTP/ITP/DIC.
Her platelets eventually stabilized.
.
Anemia
- Iron studies showed chronic disease with a low reticulocyte
count that likely represents bone marrow suppression with active
infection.
- The patient's baseline Hct is 39 and dropped to 26.9 with no
clear guaiac but evidence of large craters in her stomach and
duodenum. She was transfused 1 unit on [**5-22**] with a goal Hct of >
28.
- on [**5-24**], her Hct has dropped from 30-27 with no clear source.
She was transfused another unit of PRBCs. It was thought that
she had bone marrow suppression from her infection. She remained
guiac negative.
.
Transaminitis:
- After speaking to her PCP [**Last Name (NamePattern4) **] [**5-20**], it is clear that the
patient has no underlying liver abnormality with normal LFTs in
6'[**14**].
- She did receive vitamin K and FFP for INR>1.5.
- She is HepB surface Ab negative, hep C negative. Viral
hepatitis seems unlikely although a core antibody was not
obtained. Abdominal ultrasound showed no abnormalities.
- A CT scan showed pancreatitis and her transaminitis was
attributed to possible microlithiasis/sludge and
post-sphincterotomy, have returned to [**Location 213**].
-Her tbili rose and she appeared mildly jaundiced after her LFTs
have normalized. Her lipase significantly decreased post-ERCP.
Her jaudice also began to resolve prior to d/c.
.
CAD:
- Bblocker D/C'd initially in setting for potential sepsis,
statin, d/c ASA in face of interstitial nephritis and potential
for renal biopsy. She was started on lopressor 50 [**Hospital1 **] on [**2115-5-24**]
(she was taking atenolol but this is renally cleared)given her
extensive ectopy on [**5-23**] with frequent runs of NSVT (thought
believed to be secondary to electrolyte abnormalities). She was
eventually d/c with metoprolol, norvasc, and artovastatin
.
Disp - the patient was d/c to home and told to f/u with her pcp
in one week.
Medications on Admission:
Norvasc 1.25 mg PO QD
Atenolol 50 mg [**Hospital1 **]
ASA
Vitamin E 400 units daily
Calcium Carbonate 600 mg PO BID
Discharge Medications:
1. Norvasc 2.5 mg Tablet Sig: [**1-6**] Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
2. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
4. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Discharge Disposition:
Home
Discharge Diagnosis:
pyelonephritis
pancreatitis
Discharge Condition:
stable
Discharge Instructions:
Please call your primary care physician if you experience back
pain, painful urination, decreased urination, blood in urine,
abdominal pain, continuous nausea and vomiting, fevers, chills,
bloody stool.
.
Please do not take your aspirin until after you have seen your
primary care physician.
Followup Instructions:
Please make an appointment to see your primary care physician
within the next two weeks.
.
Please call the nephrology clinic at [**Hospital1 18**] to be seen in the
next month ([**Telephone/Fax (1) 773**].
ICD9 Codes: 5845, 2875, 4280, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7335
} | Medical Text: Admission Date: [**2151-2-15**] Discharge Date: [**2151-2-25**]
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Neomycin
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
[**2151-2-15**] Placement of left suclavian line, right radial arterial
line.
History of Present Illness:
[**Age over 90 **] y/o F w/COPD, CHF, recent admit for COPD/pna and hip pain,
sent from NH where she was noted to be "unresponsive, inaudible
bp, pulse 47, 67% on RA." Transferred to [**Hospital1 18**] ER for urgent
care.
.
She was admitted from [**Date range (1) 66385**] and discharged to a nursing home
with a prednisone taper and levofloxacin and pain service f/u
for likely radicular pain.
.
In the ED she was hypotensive to 70s, sat 88%RA. BP raised to
90s with 3L IVF, UOP 35 cc while in ED, lactate 2.0. New ARF -
Cr 3.6(baseline 1.4), K 8.3 (not hemolyzed, given calcium,
glucose/insulin, bicarb), WBC 20.
.
Given vanc/zosyn in ER, started on peripheral dopamine given
hypotension. Also found to have guaiac positive brown stool on
exam (per NH has had recent blood in stool accompanied by
constipation).
.
Transferred to ICU for further management. Arterial line and L
SC catheters placed. On arrival, patient intubated, sedated,
but able to respond yes/no to posed questions appropriately:
notes hip pain, denies any other pain. She denies any
antecedent trauma.
Past Medical History:
1. COPD
2. CHF - EF 50%
3. CKD
4. Spinal Stenosis
5. HTN
Social History:
Used to work at a factory, no smoking, no EtOH. Remainder of SH
unable to be obtained secondary to mental status.
Family History:
Non-contributory
Physical Exam:
T 97.2 BP 109/54 P 88-104 RR 21 O2 sat 90% on A/C, FiO2 0.5, Vt
480, PEEP 5
General: Intubated, lying in bed, responsive, following
commands.
HEENT: Pupils reactive bilaterally. No neck stiffness, negative
Brudzinski's sign.
Heart: S1 S2 with no MRG, no S3/S4.
Lung: CTA anteriorly.
Abd: Soft, nondistended.
Ext: No edema, 1+ distal pulses.
Neuro: Somewhat sedated but following commands, moving all four
extremities.
Skin: Scattered ecchymoses on stomach consistent with heparin /
SC injection irritation.
Pertinent Results:
[**2151-2-24**] 05:16AM BLOOD WBC-12.0* RBC-2.70* Hgb-8.4* Hct-25.2*
MCV-94 MCH-31.1 MCHC-33.2 RDW-15.0 Plt Ct-332
[**2151-2-15**] 07:50PM BLOOD WBC-20.0*# RBC-3.31* Hgb-10.5* Hct-30.3*
MCV-92 MCH-31.6 MCHC-34.5 RDW-14.7
[**2151-2-20**] 03:41AM BLOOD PT-11.8 PTT-23.4 INR(PT)-1.0
[**2151-2-24**] 05:16AM BLOOD Glucose-80 UreaN-20 Creat-0.8 Na-141
K-4.1 Cl-102 HCO3-33* AnGap-10
[**2151-2-15**] 07:50PM BLOOD Glucose-146* UreaN-106* Creat-3.6*#
Na-129* K-8.3* Cl-87* HCO3-31 AnGap-19
[**2151-2-16**] 11:54AM BLOOD ALT-18 AST-21 LD(LDH)-225 AlkPhos-50
TotBili-0.4
[**2151-2-15**] 09:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2151-2-15**] 09:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
.
MICROBIOLOGY:
[**2151-2-16**] 3:35 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2151-2-19**]**
GRAM STAIN (Final [**2151-2-16**]):
[**10-6**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): YEAST(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final [**2151-2-19**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
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------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
Imaging:
CXR [**2-15**]
1. Interval improvement in right base opacity.
2. Subtle left mid zone opacity that may represent an early
pneumonic process.
3. Vascular redistribution without overt CHF.
.
Renal U/S [**2-16**]
IMPRESSION: Normal renal ultrasound.
.
Head CT [**2-16**]
IMPRESSION: No evidence of acute intracranial hemorrhage.
.
Brief Hospital Course:
[**Age over 90 **] yo with h/o COPD, CHF (EF 50%) presents with hypotension,
hyperkalemia, and sepsis from unknown source, likely pulmonary /
pneumonia.
.
1. Hypotension/Sepsis:
On presentation, pt was found down. Pt was admitted to the [**Hospital Unit Name 153**]
and treated with initial pressors, and intubated for pulmonary
support. Pt was placed on IV Vanco/Zosyn for presumptive
empiric coverage and was pancultured. Sputum cultures later
returned back MRSA and patient was treated as presumptive MRSA
pneumonia complicated by sepsis. Pt responded well to
aggressive fluid hydration and was able to be extubated, with
pressors weaned 1 day after initiation. Her Zosyn was
discontinued and pt was transferred to the floor and continued
on IV Vanco to complete a 14 day course. Pt continued to
improve clinically, remained afebrile, and blood cultures
remained negative on day of discharge. Pt was eventually
discharged to a rehab hospital once stable for continued rehab
after discharge.
.
2. COPD Exacerbation
Pt with symptoms consistant with a COPD exacerbation and had
previously still been on an prednisone taper from her previous
discharge. Pt was placed on IV solumedrol while in the ICU but
gradually transitioned to Prednisone 40mg daily when she was
transferred to the floor. Nebulizers, and inhaled steroids were
continued throughout her admission. Pt's symptoms improved and
patient was discharged on Pred 20mg daily to complete a slow 2
week taper off of steroids.
.
3. Acute renal failure:
Has baseline CRI but creatinine acutely elevated on elevated
which was largely attributed to prerenal azotemia from
hypotension and volume depletion. Pt was aggressively hydrated
while in the ICU and her Creatinine rapidly returned to [**Location 213**].
A renal u/s was obtained that was negative for any postrenal
obstruction.
.
4. CHF -
Pt with a h/o CHF with a baseline EF of 50%, with some chronic
vascular markings c/w chronic changes attributable to CHF.
Despite aggressive hydration, clinically pt did not exhibit any
signs of CHF. Pt was continued on her home dose of ASA and ACE.
Pt is not on a bblocker due to her COPD. Pt to continue to f/u
as an outpt.
.
5. Proph: Per Dr. [**Last Name (STitle) **], MRSA precautions not indicated unless
patient has cough.
.
6. Dispo/Code: Full Code. Pt was to be discharged to rehab to
complete a 14 day course of IV Vanco for her MRSA pneumonia. Pt
is to f/u with her outpt PCP once able.
Medications on Admission:
Meds per nursing home.
1. Aspirin 325 mg po qd
2. Pantoprazole 40 mg po qd
3. Acetaminophen 500 mg po q 6 hrs
4. Levofloxacin 250 mg q 48 for 7 days (finish [**2-17**])
5. Tizanidine 2 mg po qHS
6. Lisinopril 2.5 mg po qd
7. Prednisone (has received 40 mg qd since [**2-10**])
Disp:*30 tabs* Refills:*1*
8. Gabapentin 300 mg po HS
9. Oxycodone 10 mg po q4-6 hr prn
10. MOM 30 cc prn, dulcolax, fleet enema prn.
11. Duonebs q 4 hr prn.
12. Spiriva inhaler qd.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Disp:*qs units* 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. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
10 days: Please take as taper after the 10 days of prednisone
20mg daily.
Disp:*10 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) nebulizer
treatment Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*qs nebulizer treatments* Refills:*0*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
Disp:*qs nebulizer* Refills:*2*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 3 days: Begin with
dose on [**2-25**].
Disp:*3 gram* Refills:*0*
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
14. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
15. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Sepsis secondary to MRSA Pneumonia
COPD Exacerbation
.
Secondary Diagnosis:
CHF EF 50%
COPD
Discharge Condition:
Stable to be discharged to rehab
Discharge Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 5351**] after discharge. Please
call [**Telephone/Fax (1) **] to schedule that appointment.
.
2. Please take medications as below.
.
3. Per Dr. [**Last Name (STitle) **], MRSA precautions
.
4. If develop chest pain, fever or chills, shortness of breath,
or any other symptoms, please call Dr. [**Last Name (STitle) 5351**] or report to the
nearest ER.
Followup Instructions:
(Your pain management appointment needs to be rescheduled)
Please follow-up with Dr. [**Last Name (STitle) 5351**] within 1 week.
Completed by:[**2151-2-25**]
ICD9 Codes: 0389, 5849, 4280, 2767, 5859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7336
} | Medical Text: Admission Date: [**2180-9-4**] Discharge Date: [**2180-10-20**]
Date of Birth: [**2109-8-6**] Sex: M
Service: CARDIAC CARE UNIT
HISTORY OF THE PRESENT ILLNESS: The patient is a 71-year-old
male with a history of biventricular pacer and AICD with CHF
who had a mechanical fall and bruised his left side.
Approximately one week ago, he began to develop fevers,
chills, as well as warmth and erythema around the area of his
pacer pocket. He had a flu shot one day prior and thought
that the fevers and chills were related to that. He went to
an outside hospital and was diagnosed with cellulitis, given
one dose of IV antibiotics and sent home. He was told to
return to the hospital and was given IV Unasyn. An
ultrasound of the area was done. No blood cultures were
recorded. The patient was transferred for medical management
and possible surgical drainage removal of pacer.
PAST MEDICAL HISTORY:
1. CAD: Two vessel disease of RCA and mid LAD which were
findings noted on catheterization in [**2171**]. He has 2+ MR.
The patient is status post MI in [**2171**].
2. CHF: Ejection fraction of 20% in [**2180-4-23**]. Status
post upgrade ICD to biventricular ICD because of increasing
symptoms and left bundle branch block.
3. Bronchiolar alveolar carcinoma of the lung.
4. Chronic renal insufficiency.
5. Spinal stenosis.
6. Melanoma removed in [**2169**].
7. Hypercholesterolemia.
8. Hypertension.
9. Left cerebellar CVA.
SOCIAL HISTORY: Tobacco history, quit 15 years ago at 60
pack years. History of alcohol use. Lives with wife and two
children.
FAMILY HISTORY: Noncontributory.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Aldactone 12.5 b.i.d.
2. Aspirin 325 q.d.
3. Lipitor 20 q.d.
4. Coreg 6.25 b.i.d.
5. Fluoxetine 40 q.d.
6. Lasix 20-40 b.i.d.
7. Sectral 400 q.d.
8. Zestril 10 q.d.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98, blood pressure 108/52, heart rate 80, respirations 18, 02
saturations 100% on room air. General: The patient was
calm, in no acute distress. HEENT: Anicteric, mucosa moist,
JVD at 9 cm, no lymphadenopathy. Chest: Clear to
auscultation bilaterally. Cardiovascular: Distant heart
sounds, no murmurs, rubs, or gallops. Abdomen: Soft,
nontender, nondistended. Extremities: No clubbing, cyanosis
or edema. Chest wall: Area of left pacer pocket mildly
erythematous, fluctuant, nontender, with one area of
induration on lateral aspect.
LABORATORY/RADIOLOGIC DATA: From the outside hospital:
White blood cell count 15.5, crit 40, platelets 165,000,
neutrophils 82, lymphs 6, monophils 10, eosinophils 2. PT
13.7, PTT 24.6, INR 1.1. Sodium 130, potassium 4.2, chloride
97, bicarbonate 20, BUN 57, creatinine 1.9, glucose 102.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 2548**]
MEDQUIST36
D: [**2180-10-20**] 12:06
T: [**2180-10-20**] 12:19
JOB#: [**Job Number 2549**]
ICD9 Codes: 4280, 7907, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7337
} | Medical Text: Admission Date: [**2176-7-20**] Discharge Date: [**2176-7-23**]
Date of Birth: [**2109-7-29**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 66 year old
gentleman with a history of obesity, peripheral vascular
disease, hypertension and heavy tobacco use was admitted
initially to [**Hospital3 1280**] on [**7-19**] complaining of chest pressure,
dizziness, weakness, diaphoresis and hypotension. He was in
his usual state of health until 11:00 p.m. that night when he
took a double dose of Zestril and suffered an episode of
nausea, vomiting, diaphoresis and chest pressure [**5-25**] without
relief which lasted about three hours until he came to the
emergency department. In the E.D. patient's blood pressure
was 90/58, heart rate 82. Within an hour patient's systolic
blood pressure dropped to 45, heart rate dropped to 32 and
patient was found in 2:1 heart block. Patient received 0.5
mg of atropine and 1 mg of epi after which patient went into
SVT at a rate of 180. Patient was cardioverted out of this
rhythm with 50 joules after which patient's systolic blood
pressure dropped to the mid-60s and patient was started on
dopamine 10 mcg per kg per hour. Patient was transferred to
the CCU at [**Hospital3 1280**]. His EKG showed sinus tachycardia with
frequent ectopy. Per notes from the outside hospital, his
EKG was suspicious for right sided MI especially in the
context of receiving aggressive fluid replacement, close to 4
liters, and remaining persistently hypotensive. Patient was
started on acute coronary syndrome protocol, aspirin, heparin
drip, Integrilin drip. Beta blocker was held secondary to
bradycardia. Dopamine drip was weaned off and Neo drip was
started. The next morning patient had an echocardiogram
which showed ejection fraction of 40% and inferior/right
ventricular hypokinesis. Patient's CK peaked at 1293.
Patient was transferred to [**Hospital1 188**] for cardiac catheterization. On arrival to [**Hospital1 1444**], patient was chest pain free.
He was on Neo-Synephrine drip with blood pressure of 140/100,
pulse 75.
PAST MEDICAL HISTORY: Hypertension. Peripheral vascular
disease, status post right carotid endarterectomy in [**2172**].
History of TIA. History of anxiety disorder. History of
obesity. History of heavy tobacco use.
MEDICATIONS: Zestril, Paxil 5 mg p.o. q.d., Xanax 0.25 mg
p.o. q.i.d., aspirin.
MEDICATIONS ON TRANSFER: Aspirin, heparin, Integrilin,
Neo-Synephrine 20 mcg per minute, Protonix 40 p.o. q.d.,
Paxil 10 p.o. q.d., Xanax, Levaquin 500 p.o. q.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Coronary artery disease. Father died of
myocardial infarction at the age of 79. Diabetes in
patient's mother. Hepatocellular carcinoma in patient's
father.
SOCIAL HISTORY: More than 50 pack year smoking history.
Alcohol use one to two drinks per day. Patient is retired.
He has four children.
PHYSICAL EXAMINATION: On transfer to the cardiac intensive
care unit, the patient's temperature was 98.2, pulse 82,
blood pressure 112/66, respirations 22, 95% on 3 liters,
pulsus paradoxus 3 to 5 mm. Patient was on Neo-Synephrine 0.2
mcg per minute. In general, patient demonstrated labored
breathing, was speaking in short sentences, was lying in bed
in mild respiratory distress. HEENT patient had very mild
right eyelid droop. Pupils were equal, round, and reactive
to light and accommodation. There was poor dentition, but
normal oropharyngeal mucosa. Neck no carotid bruits. There
was 3 to 4 cm jugular venous distention above the clavicle.
Pulmonary there was poor air movement, extensive audible
wheezing in all fields, difficult to appreciate crackles.
Cardiovascular distant heart sounds with no murmurs, gallops
or rubs noted. Abdomen positive bowel sounds, distended and
tight, but no fluid wave, no hepatosplenomegaly. Extremities
no cyanosis, clubbing or edema. Normal peripheral pulses.
Neurologic was intact.
LABORATORY DATA: Peak CK 1500. White count 16.5, hematocrit
39.3, platelets 183. Sodium 138, potassium 4.4, chloride
104, bicarb 28, BUN 17, creatinine 1.0, glucose 122. Normal
LFTs. UA showed small blood, positive nitrite, positive
leukocyte esterase, more than 100 WBC, 20 to 30 RBC. EKG
showed normal sinus rhythm, T wave inversions in leads 2, 3
and aVF and development of progressive Q waves in leads 2, 3
and aVF.
HOSPITAL COURSE: The patient underwent cardiac
catheterization which showed right atrial pressure of 19,
pulmonary artery pressure of 51/30, pulmonary capillary wedge
pressure (PCWP) of 27, cardiac output of 4.6, cardiac index
of 2.0. Patient showed left dominant system and one vessel
disease with totally occluded mid-circumflex just after large
obtuse marginal. Patient's left sided PDA filled via left to
left collaterals. PTCA and stenting were done with no
residual stenosis and TIMI 3 flow. LV-gram was not performed
due to reported creatinine of 1.6 at the outside hospital.
Patient had a chest x-ray which showed bilateral opacities
consistent with pulmonary edema, no hyperinflation.
1. Cardiovascular. The patient is status post PTCA and
stenting of mid-circumflex, status post inferior posterior MI
[**97**] hours prior to presentation complicated by hypotension and
bradycardia, still requiring pressors during cardiac
catheterization. Upon transfer from the cardiac
catheterization lab, aspirin, Plavix and Integrilin were
continued. Patient was started on Lipitor. Cardiac enzymes
were cycled q.eight hours and were followed to the peak. It
was postulated that patient's persistent hypotension was due
to heightened vagal tone since there was no evidence of right
sided MI by cardiac catheterization. Patient was
subsequently weaned off Neo-Synephrine and was started on ACE
inhibitor which he tolerated well. Initially beta blockers
were held due to presumed COPD exacerbation, although patient
does not have an official diagnosis of COPD. Patient was
given Lasix 20 mg p.o. once and showed good urinary output
response to that, since patient did appear in mild pulmonary
edema. However, most of patient's wheezing and shortness of
breath were secondary to pulmonary etiology. Patient has
done very well in the intensive care unit and was
subsequently transferred to the general medical floor.
Patient was started on a low dose beta blocker and tolerated
that well. Patient is to have cardiology followup. It was
suggested that patient could follow up with a physician at
[**Hospital1 69**], however, patient
preferred to have followup set up by his primary care
physician in his community.
2. Pulmonary. The patient does not have a documented
history of COPD, however, given his extensive history of
smoking and extensive wheezing and good response to
bronchodilators, patient most likely does have COPD. Patient
was given continuous neb treatments which we were able to
change to metered dose inhalers. Patient did receive
appropriate education about their use. Patient would greatly
benefit from outpatient pulmonary function tests for proper
diagnosis of COPD. Patient received excessive education on
the necessity of quitting smoking. That was done repeatedly
during daily conversations with the patient.
3. GI. The patient was treated with Protonix for
prophylaxis.
4. Renal. The patient received Mucomyst pre-cath and
post-cath. Patient's creatinine and electrolytes remained
stable throughout the hospitalization.
5. ID. The patient had E.coli UTI per records from the
outside hospital. Patient was started on Levaquin at the
outside hospital. Here the antibiotic was changed to Bactrim
which patient is to take for the few consecutive days during
his hospitalization.
6. Anxiety. The patient was continued on Xanax and Paxil.
7. Nutrition. The patient is to follow a cardiac, low
sodium diet. The patient received extensive education about
the importance of adhering to this diet regimen.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Status post myocardial infarction.
DISCHARGE MEDICATIONS:
1. Aspirin.
2. Plavix.
3. Toprol XL 12.5 mg p.o. b.i.d.
4. Lipitor 20 mg p.o. b.i.d.
5. Lisinopril 10 mg p.o. b.i.d.
6. Serevent MDI two puffs p.o. b.i.d.
7. Albuterol MDI two puffs q.four to six hours p.r.n.
FOLLOWUP: The patient is to follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10269**], on [**2176-7-26**] at 3:45 p.m., phone number
[**Telephone/Fax (1) 52278**]. Patient's primary care physician is to
schedule outpatient cardiology followup for patient about two
weeks after discharge. Patient will also need an
echocardiogram four weeks after discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Doctor Last Name 51186**]
MEDQUIST36
D: [**2176-7-28**] 23:07
T: [**2176-8-2**] 09:50
JOB#: [**Job Number 52279**]
cc:[**Last Name (NamePattern4) 52280**]
ICD9 Codes: 496, 5990, 4111, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7338
} | Medical Text: Admission Date: [**2107-1-10**] Discharge Date: [**2107-1-27**]
Date of Birth: Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 49 year old male with
a past medical history of Hepatitis C and alcoholic hepatitis
and cirrhosis which is complicated by three to four months of
ascites and spontaneous bacterial peritonitis. He had
extensive ascites and a history of a gastrointestinal bleed.
No history of encephalopathy; no history of hypertension;
diabetes mellitus; asthma or epilepsy.
He was admitted for an elective TIPSS procedure for the
indication of his refractory ascites which was requiring
paracentesis every five days. Prior to the procedure a
routine EKG showed normal sinus rhythm with decreased
voltage. A chest x-ray showed question of interstitial lung
disease with reticular shadowing. An echocardiogram showed
mild pulmonary artery hypertension but normal systolic
function with an ejection fraction greater than 55%.
PAST MEDICAL HISTORY:
1. Cirrhosis secondary to hepatitis C and alcohol.
2. Spontaneous bacterial peritonitis.
3. History of upper gastrointestinal bleed.
4. Hypertension.
5. Chronic obstructive pulmonary disease.
ALLERGIES: Codeine.
MEDICATIONS:
1. Aldactone 50 mg p.o. q. day.
2. Lasix 120 mg twice a day.
3. Inderal 10 mg twice a day.
4. Imdur 30 mg q. day.
5. Lactulose.
6. Protonix.
SOCIAL HISTORY: The patient lives with his mother. [**Name (NI) **] has
a history of tobacco and extensive alcohol use.
PHYSICAL EXAMINATION: Temperature 98.5 F.; blood pressure
94/66; respiratory rate 20; pulse 86; oxygen saturation 91%
on room air. The patient in general is in no acute distress.
He is alert and oriented times three. His Head, Eyes, Ears,
Nose and Throat are remarkable for the absence of icterus.
His neck is supple without bruits. His chest is clear
bilaterally without crackles or wheezes. His heart has a
regular rate and rhythm with no murmurs, rubs or gallops.
His abdomen is soft and nontender, with extensive ascites to
percussion. His extremities have no edema. Neurologically,
he has no flap.
LABORATORY: White blood cell count 10.9; hematocrit 47.3,
platelets 116. Sodium 129, potassium 4.2, chloride 97;
bicarbonate 28, BUN 19, creatinine 1.1, glucose 96. ALT 37,
AST 66, alkaline phosphatase 120, total bilirubin 1.0, direct
bilirubin 0.4, albumin 2.3. Alpha fetoprotein 1.7. HIV
serology is negative.
EKG as noted above. Echocardiogram as noted above. Chest
x-ray as noted above.
HOSPITAL COURSE: The patient was admitted for elective
TIPSS procedure for his refractory ascites. Prior to
admission he was noted to have a question of interstitial
lung disease on routine chest x-ray. An echocardiogram
showed mild pulmonary hypertension and normal systolic
function. He underwent the procedure on [**2107-1-11**].
The procedure was complicated by desaturation of his oxygen
levels to 89% and drop in his blood pressure to the 80s. His
heart rate was also in the 150s. He became agitated and his
oxygen saturation dropped further. He was given Adenosine
without effect. His endotracheal tube was suctioned with
copious white clear secretions and improved compliance. He
was then given Esmolol which, as his heart rate was elevated,
with a decrease in his heart rate to 116 and the blood
pressure in the 120s.
Extubation was then attempted, however, the patient did not
tolerate extubation and he was quickly re-intubated. His
blood pressure again dropped to 80 systolic and a STAT chest
x-ray showed that he was in congestive heart failure. He was
given Lasix, Midazolam, and transferred to the Post
Anesthesia Care Unit where he became unstable. He was
started on Levophed which initially had good effect with
elevation in his blood pressure to 130s and heart rate to
100.
His oxygen saturation remained in the 90s. At that point,
the Medical Intensive Care Unit Service was consulted. An
emergent echocardiogram revealed extensive left ventricular
dysfunction and an ejection fraction of less than 20% with
global hypokinesis, right ventricular dilatation and
dysfunction. The patient was continued on Levophed. A
Swan-Ganz catheter was passed which revealed a pulmonary
wedge pressure of 30 and a systemic vascular resistance of
1,016 and a cardiac output of 4.8 with an index of 2.58.
The patient was started empirically on broad-spectrum
antibiotics. His ascitic fluid which had been removed prior
to the TIPSS procedure was not indicative of SBP. Cardiac
enzymes indicated that the patient did not have a myocardial
infarction.
The patient was started on Dobutamine in addition to Levophed
for inotropic support. During his hospital course, the
patient remained hypoxic and hypotensive. The source for his
heart failure remained unclear. It was felt that most likely
he had an underlying cardiomyopathy that was exacerbated
and/or revealed by the hemodynamic changes from the TIPSS
procedure. Repeated blood cultures and ascites cultures were
negative. The patient was continued on pressors and
broad-spectrum antibiotics and remained intubated.
He did develop low-grade DIC as indicated by his hematology
labs. Repeated attempts to wean off his pressor support were
unsuccessful. Ultimately, given the patient's extensive
underlying disease and poor overall prognosis, after
extensive discussion between the Medical Team and the
patient's family, the family elected to withdraw care.
Care was withdrawn on [**2107-1-26**], after meeting with
the family and answering all their questions. The patient
expired on [**2107-1-26**], of cardiac failure and hepatic
failure following TIPSS for refractory ascites from alcoholic
and viral hepatitis.
DIAGNOSES AT DEATH:
1. Congestive heart failure.
2. Hepatic failure.
3. Status post TIPSS.
4. DIC.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2107-5-23**] 12:15
T: [**2107-5-23**] 19:56
JOB#: [**Job Number 36898**]
ICD9 Codes: 4280, 486, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7339
} | Medical Text: Admission Date: [**2132-5-16**] Discharge Date: [**2132-5-20**]
Date of Birth: [**2102-4-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Alcohol withdrawal w/seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
30 y/o male with h/o ETOH abuse, seen 1 week ago at [**Hospital1 **] ER for
alcohol intoxication, discharged home, and resumed drinking.
This admission the patient presents s/p ?seizure (witnessed by
wife, pt unable to describe event further) after "self-tapering"
EtOH intake over the past week. Pt states he has been drinking
about 1 L of whiskey per day, then quit alcohol and his
prescription meds simultaneously on [**2132-5-16**]. He was told by his
wife he had a seizure that evening while watching television.
.
In the ED VS = 97.9 163 163/93 20 99%RA. He received 4L NS, 45
mg IV valium, levofloxacin (for unclear indication), and
remained tremulous. He reported n/v x 1, which improved with
zofran. His labs were notable for lactate 4.1 (venous), INR 1.0,
HCO3 15, GAP 31, TBIL 2.0, and ALT 203, AST 404, PLT 69. Serum
ETOH 82. CXR without focal infiltrate. ECG revealed sinus
tachycardia. He received 3L IVF and 200mg IV thiamine. His HR
improved to the 90s. At the time of transfer, VS=100.4 101->97
bpm 143/112 26 100%RA
Past Medical History:
- s/p fall/abrasion [**5-/2130**]
- hx of EtOH abuse, began drinking at age 14, consuming [**11-23**] -
[**12-25**] handle of whiskey, s/p detox 2 years ago but resumed
drinking one month ago after losing job. Alcohol intoxication
(BAL 373) on [**9-/2131**]
- ? hx of suicidal ideation
- HTN
Social History:
He reports having had a problem with alcohol from a young age. 2
years ago went to a detox program. Was successful until he was
laid off from his management consulting job. He has never had
any seizures or DTs from withdrawal. Patient denied IVDU. Remote
hx of marijuana and cocaine during his college years (none
recently). Denies heroin. + 1 ppd smoking since age 15. College
graduate, was working as a manager in a company. Married
Family History:
Significant for alcohol addiction in the patient's mother and
maternal grandmother
Physical Exam:
General: Alert, oriented, still somewhat tremulous
HEENT: Sclera anicteric, oropharynx clear, no nystagmus
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorally, no wheezes, rales,
ronchi
CV: tachy, reg rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender (including RUQ), non-distended, bowel
sounds present, no rebound tenderness or guarding, neg [**Doctor Last Name **]
sign, no organomegaly appreciated
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: pupils 5 mm --> 4 mm bilaterally, moving all extremities,
oriented x 3
Pertinent Results:
[**2132-5-16**] 11:08PM URINE HOURS-RANDOM
[**2132-5-16**] 11:08PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2132-5-16**] 11:08PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2132-5-16**] 11:08PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2132-5-16**] 11:08PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-<1
[**2132-5-16**] 11:08PM URINE MUCOUS-MOD
[**2132-5-16**] 10:39PM GLUCOSE-88 UREA N-10 CREAT-0.6 SODIUM-140
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-24 ANION GAP-16
[**2132-5-16**] 10:39PM CK(CPK)-142 DIR BILI-0.8*
[**2132-5-16**] 10:39PM ALBUMIN-3.8 MAGNESIUM-1.8
[**2132-5-16**] 09:46PM TYPE-[**Last Name (un) **] PO2-142* PCO2-35 PH-7.42 TOTAL
CO2-23 BASE XS-0
[**2132-5-16**] 09:46PM LACTATE-4.1*
[**2132-5-16**] 08:31PM PT-12.1 PTT-28.0 INR(PT)-1.0
[**2132-5-16**] 07:50PM GLUCOSE-135* UREA N-13 CREAT-1.0 SODIUM-140
POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-15* ANION GAP-35*
[**2132-5-16**] 07:50PM estGFR-Using this
[**2132-5-16**] 07:50PM ALT(SGPT)-203* AST(SGOT)-484* TOT BILI-2.0*
[**2132-5-16**] 07:50PM LIPASE-50
[**2132-5-16**] 07:50PM OSMOLAL-320*
[**2132-5-16**] 07:50PM ASA-NEG ETHANOL-82* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2132-5-16**] 07:50PM WBC-4.7 RBC-4.61 HGB-15.1 HCT-45.3 MCV-98#
MCH-32.7* MCHC-33.3 RDW-16.0*
[**2132-5-16**] 07:50PM NEUTS-55.9 LYMPHS-36.2 MONOS-6.4 EOS-0.9
BASOS-0.7
[**2132-5-16**] 07:50PM PLT SMR-VERY LOW PLT COUNT-69*
CT HEAD W/O CONTRAST Study Date of [**2132-5-17**] 7:56 AM
Final Report
HISTORY: 30-year-old male with seizure.
COMPARISON: None available.
TECHNIQUE: Axial imaging is performed from the cranial vertex to
the foramen magnum without IV contrast.
HEAD CT WITHOUT IV CONTRAST: There is no fracture, hemorrhage,
edema, mass
effect, shift of midline structures, or other evidence of acute
process. The ventricles and sulci are normal in size and
configuration for the patient's age. Soft tissues and osseous
structures appear unremarkable.
IMPRESSION: No evidence of acute process.
ECG Study Date of [**2132-5-18**] 6:35:38 AM
Sinus rhythm. Compared to the previous tracing of [**2132-5-17**] mild
QTc interval prolongation is again present with prominent
precordial voltage which could be due to a physiologic variant
or left ventricular hypertrophy. Non-diagnostic RSR' pattern in
leads V1-V2 which may be seen as a physiologic variant.
Brief Hospital Course:
30 y/o male with h/o ETOH abuse, seen 1 week ago at [**Hospital1 **] ER for
alcohol intoxication, discharged home, and resumed drinking.
This admission the patient presents s/p ?seizure (witnessed by
wife, pt unable to describe event further) after "self-tapering"
EtOH intake over the past week. Pt states he has been drinking
about 1 L of whiskey per day, then quit alcohol and his
prescription meds simultaneously on [**2132-5-16**]. He was told by his
wife he had a seizure that evening while watching television.
.
In the ED VS = 97.9 163 163/93 20 99%RA. He received 4L NS, 45
mg IV valium, levofloxacin (for unclear indication), and
remained tremulous. He reported n/v x 1, which improved with
zofran. His labs were notable for lactate 4.1 (venous), INR 1.0,
HCO3 15, GAP 31, TBIL 2.0, and ALT 203, AST 404, PLT 69. Serum
ETOH 82. CXR without focal infiltrate. ECG revealed sinus
tachycardia. He received 3L IVF and 200 mg IV thiamine. His HR
improved to the 90s. His vitals upon transfer to the ICU were
VS=100.4 101->97 bpm 143/112 26 100%RA.
In the ICU, the patient was at times combative, on at least two
occasions tore out his IV and tried to leave. He was for a time
in 4-point restraints and receiving Haldol for agitation and
combativeness. His agitation resolved and his vitals and labs
normalized. But he remained somewhat tremulous and had low
platelet counts. He was discharged to the medicine floor where
his platelet counts rose up to above 100.
# Alcohol withdrawal: He had consults with social work and with
our addiction management experts. Received thiamine, folate.
Patient was informed he could not drive for 6 months because of
his seizure history.
.
# Thrombocytopenia - rose from 30s-> 52-> 102 at d/c. Never
symptomatic (e.g. no bleeding, petechiae, etc.) Likely secondary
to EtOH toxicity. Resolved.
Medications on Admission:
- Atenolol 75mg PO daily
- Seroquel 75mg PO daily
- Klonopin 1mg PO AM, 2mg PO PM
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Alcohol withdrawal
Secondary:
Alcohol dependence
Withdrawal-induced seizure
Hypertension
Discharge Condition:
Able to ambulate, tolerating food well, HR 80s-90s, calm,
cheerful, no acute issues.
Discharge Instructions:
You've been admitted to the hospital with a short stay in the
Intensive Care Unit for alcohol withdrawal and seizure. While
you were here we monitored your withdrawal, and you progressed
safely. Our alcohol specialists spoke with you and you have
developed a plan with them to remain sober.
Please note that because of your seizure you are not allowed to
drive a car for 6 months.
There have been no changes to your medications.
Please call your doctor or 911 if you experience any seizures,
withdrawal symptoms such as sever shaking, hallucinations, chest
pain, trouble breathing or any other concerning medical
symptoms.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 62488**] tomorrow morning at [**Telephone/Fax (1) 2261**] and
make an appointment to see him in the next 1-2 weeks.
We have provided you with other resources including Alcoholics
Anonymous information which we strongly encourage you to use.
Completed by:[**2132-5-30**]
ICD9 Codes: 2762, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7340
} | Medical Text: Admission Date: [**2110-8-11**] Discharge Date: [**2110-8-14**]
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / Sulfa (Sulfonamide Antibiotics) /
Tetracycline / Erythromycin
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
SOB- found to have gallstone pancreatitis/cholangitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Ms. [**Name13 (STitle) **] is a [**Age over 90 **]yo woman with hx of dementia, endometrial ca,
and prior CVA who initially presented to [**Hospital3 3583**] from
her nursing facility with SOB on [**2110-8-10**]. In the ambulance she
was given lasix 20mg IV x 1 and at [**Hospital3 **] she was given
levofloxacin 750mg IV x 1 and solumedrol 125mg IV x 1 for
possible asthma / COPD flare (no known history of this.) Labs
revealed lipase >5000, TBili 1.8 at [**Hospital1 46**] so the patient was
transferred to [**Hospital1 18**] for ERCP. She underwent ERCP and there was
difficulty navigating the duodenem due to tortuosity so the ERCP
was aborted with a plan for percutaneous biliary drain. The
patient was improving symptomatically improving and lipase/LFTs
were improving. Given her improvement and discussions with her
health care proxy ([**Name (NI) **] [**Name (NI) 87604**] [**Telephone/Fax (1) 87605**]) plan was made to
conservatively manage with IV abx levo/flagyl x 2 weeks and
readdress perc biliary drain should she worsen.
In addition the patient's blood cultures from [**Hospital3 3583**]
from [**8-10**] grew gram negative rods, prelim pan sensitive without
speciation yet. Blood cultures from [**Hospital1 18**] [**8-11**] no growth to
date.
Prior to transfer from the [**Hospital Ward Name 332**] ICU the patient feels well,
denies N/V, no abd pain, no SOB, no chest pain. She is
pleasantly demented and AOx1-2 but states in general she feels
well. During her ICU stay the patient rec'd IV abx, underwent
unsuccessful ERCP as above, and was 2.6 L + legnth of stay. She
was not intubated nor on pressors.
Past Medical History:
Alzeimer's dementia
osteoporosis
Gout
PMR on prednisone 5mg po daily
depression
anxiety
anemia
h/o fall
frequent UTIs
Past Surgical History:
R THR
tendon repair L hamstring
TAH
sebaceous cyst
Social History:
Nursing home resident, otherwise unknown
Family History:
unknown
Physical Exam:
VS T 98.7 HR 80 BP 114/79 RR 16 O2 99% on 3L, 97% on RA
GEN: NAD, AOx1-2 (name, [**Month (only) 216**], unsure of year, thinks she is in
[**Location (un) **], MA)
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, 3/6 SEM > RUSB
PULM: Crackles R side [**12-29**] way up with bilateral mild wheezes
diffusely
ABD: Soft, nondistended, tender on deep palpation of LLQ, no
guarding or rebound tenderness, +BS
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
Imaging:
RUQ US [**8-11**] IMPRESSION: Limited study demonstrating no evidence
of gallbladder disease or biliary dilation.
CXR PA/L [**8-11**]: IMPRESSION: Bibasilar atelectasis and small
effusions. Limited exam.
CXR [**2110-8-12**]: In comparison with the study of [**8-11**], the outer
portion of the right hemithorax has been excluded from the
image. Low lung volumes with technically limited study make it
difficult to assess the size of the heart. Tortuosity of the
aorta is seen in a patient with prominent kyphosis that limits
evaluation on the frontal projection. Some prominence of
interstitial markings could reflect elevated pulmonary venous
pressure. The left hemidiaphragm is not sharply seen, raising
the possibility of some atelectasis or effusion at the left
base.
ERCP [**2110-8-11**]:
The stomach was entered and seemed to be very friable. The was
severe external duodenal compression and deformity and the scope
not be safely passed into the second portion.
[**2110-8-12**] 04:15AM BLOOD WBC-13.4* RBC-3.25* Hgb-9.9* Hct-29.6*
MCV-91 MCH-30.4 MCHC-33.4 RDW-13.6 Plt Ct-117*
[**2110-8-12**] 04:15AM BLOOD Neuts-82* Bands-5 Lymphs-9* Monos-3 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2110-8-12**] 04:15AM BLOOD Glucose-81 UreaN-41* Creat-1.4* Na-144
K-4.4 Cl-111* HCO3-25 AnGap-12
[**2110-8-12**] 04:15AM BLOOD ALT-259* AST-240* LD(LDH)-224 AlkPhos-89
TotBili-0.6
[**2110-8-12**] 04:15AM BLOOD Lipase-462*
[**2110-8-12**] 04:15AM BLOOD Calcium-8.0* Phos-4.0 Mg-2.3
[**2110-8-12**] 04:50AM BLOOD Lactate-1.6
Discharge Labs: [**2110-8-14**] 06:30AM
WBC-10.0 RBC-3.29* Hgb-9.7* Hct-30.9* MCV-94 Plt Ct-117*
Glucose-80 UreaN-29* Creat-1.0 Na-142 K-4.1 Cl-107 HCO3-29
AnGap-10
ALT-115* AST-51* AlkPhos-74 TotBili-0.6
Brief Hospital Course:
Cholangitis: Likely secondary to common bile duct obstruction
with stone. ERCP was unsuccessful, but patient clinically
improved and LFT's and lipase decreased. She remained afebrile
and pain free on Levofloxacin and Flagyl, and had her diet
advanced without difficulty. She should complete a total of ten
days of antibiotics. Blood cultures are pending from the 16th
and 18th, but are currently no growth to date. Given friability
of gastric mucosa seen on endoscopy patient was started on a
PPI.
Pancreatitis: Likely secondary to gallstones as above; patient
never experienced abdominal pain and tolerated a PO diet.
Acute Renal Failure: Resolved with IV fluids.
Duodenal Extrinsic Compression: When clinically improved from
current illness, discuss with patient and family further workup
including further imaging with CT abd/pelvis. No current
evidence of bowel obstruction
Dementia: No difficulties with agitation or sundowning. Mood
stable.
PMR: Patient was continued on Prednisone 5mg po daily
Code Status: DNR/DNI
Medications on Admission:
- Prednisone 5mg po daily
- Folate 1mg po daily
- Miralax daily
- Tylenol 1g qam
- Alphagan 0.1% dropps - one drop both eyes [**Hospital1 **]
- Pepcid OTC 20mg po daily
- Tums 500mg po daily
- Vitamin D 400 units [**Hospital1 **]
- Calcium 600mg po bid
- Milk of mag prn
Discharge Medications:
1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6
hours) as needed for SOB.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Inhalation Q6H (every 6 hours).
6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for shortness of breath or wheezing for 7 days.
7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other
day for 3 doses.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
once a day.
Discharge Disposition:
Extended Care
Facility:
Lifecare of [**Location (un) 3320**]
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were transferred to the [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 19806**]
ERCP to remove a gallstone. The procedure was unsuccessful, but
you continued to improve with antibiotics. You were also started
on nebullizers for wheezing, and were weaned off of oxygen.
Aside from being started on antibiotics, no changes were made to
your home medications.
Followup Instructions:
Please follow-up with your primary care provider within one week
of discharge.
ICD9 Codes: 5849, 2749, 2859, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7341
} | Medical Text: Admission Date: [**2104-2-19**] Discharge Date: [**2104-2-22**]
Date of Birth: [**2032-12-8**] Sex: M
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest Pain. Transfer for STEMI.
Major Surgical or Invasive Procedure:
Cardiac Catheterization - LAD total occlusion, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2.
History of Present Illness:
Patient is a 71 year old gentleman who was experiencing 3 weeks
of intermittent chest and back pain and presented to [**Hospital1 2519**] with 4 days of constant chest pain, worse [**10-5**], in
addition to tingling down both arms (ulnar distribution in
hands), back pain, nausea and diaphoresis. He was noted to have
an ST eleveation MI, elevations in V2-V5. CK peaked at [**2093**],
and Trop peaked at 74. He was given a heparin bolus and started
on a heparin drip, then transferred to [**Hospital1 18**] for Cardiac
Catheterization.
Review of Systems: Patient complains of dyspnea on exertion for
the last 2-3 weeks. He has 2pillow orthopnea at home. He has had
anginal symptoms in the past for years, just worsened in the
last few weeks. He admits to pain in legs when walking,
particularly in right groin, improves after resting for a long
period of time. He denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, black stools or red
stools. He denies recent fevers, chills or rigors. He does admit
to chronic diffuse abdominal pain.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: None
3. OTHER PAST MEDICAL HISTORY:
Acid Reflux
Lower extremity edema
Neuropathy
BPH
COPD (?- used Advair in past without memorable benefit)
Chronic back pain, sciatica per patient, and foot pain
Hemorrhoids
4. PAST SURGICAL HISTORY:
Bunionectomy left foot
Tonsillectomy sinus surgery
Bilateral lens transplants
5. PREVENTION:
Colonoscopy, [**2100-2-24**]
PSA 17.4, [**2101-2-24**]
Social History:
Married, 4 children, used to work for [**Company 2318**]
-Tobacco history: 50 years x 1ppd, quit 8 years ago.
-ETOH: occasional glass of wine.
Family History:
Mother [**Name (NI) 2481**] disease. Mother had MI in 50s or 60s, older
brother with MI age 70s (several months ago) and peripheral
vascular disease. Father's cardiac history unknown. Patient
endorsed positive stroke history for mother and father.
Physical Exam:
At admission to CCU s/p PCI:
VS: T=100.4 BP=117/69 HR=74 RR=19 O2 sat= 97% 4L NC
GENERAL: Well nourished male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. CN II-XII intact.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVD of 10+ cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. soft systolic murmur.
LUNGS: No chest wall deformities. Resp unlabored, no accessory
muscle use. Diffuse crackles, increased at bases bilaterally.
ABDOMEN: Soft, obese, mildly distended, diffusely mildly tender.
EXTREMITIES: Trace bilateral lower extremity edema. Right groin
site tender in one spot, no hematomas, bruits, or bleeding,
clean/dry/intact.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
Pertinent Results:
Outside Hospital Labs:
TROP-I 74.8
WBC 14.0
HCT 48.0
NA 139
BUN/CR 11/1.2
Admission Labs:
[**2104-2-19**] 07:31PM BLOOD WBC-14.5* RBC-4.54* Hgb-13.0* Hct-39.5*
MCV-87 MCH-28.7 MCHC-33.0 RDW-13.5 Plt Ct-145*
[**2104-2-19**] 07:31PM BLOOD Neuts-83.1* Lymphs-8.5* Monos-7.5 Eos-0.7
Baso-0.2
[**2104-2-19**] 04:30PM BLOOD Glucose-107* UreaN-11 Creat-1.0 Na-137
K-3.5 Cl-103 HCO3-24 AnGap-14
[**2104-2-19**] 07:31PM BLOOD PT-12.9 PTT-24.7 [**Month/Day/Year 263**](PT)-1.1
[**2104-2-19**] 07:31PM BLOOD Calcium-8.6 Phos-2.7 Mg-1.5*
Cardiac Biomarkers:
[**2104-2-19**] 04:30PM BLOOD CK-MB-147* MB Indx-48.5* cTropnT-8.62*
[**2104-2-19**] 07:31PM BLOOD CK-MB-122* MB Indx-6.7* cTropnT-16.72*
[**2104-2-20**] 05:08AM BLOOD CK-MB-75* MB Indx-5.6
Cardiac Risk Factors:
[**2104-2-20**] 05:08AM BLOOD %HbA1c-5.5 eAG-111
[**2104-2-20**] 05:08AM BLOOD Triglyc-85 HDL-42 CHOL/HD-4.0 LDLcalc-111
Discharge Labs:
[**2104-2-22**] 05:55AM BLOOD WBC-8.5 RBC-4.19* Hgb-12.2* Hct-35.7*
MCV-85 MCH-29.1 MCHC-34.1 RDW-13.3 Plt Ct-157
[**2104-2-22**] 05:55AM BLOOD Glucose-110* UreaN-19 Creat-1.3* Na-138
K-4.2 Cl-102 HCO3-22 AnGap-18
[**2104-2-22**] 05:55AM BLOOD PT-13.6* PTT-64.2* [**Month/Day/Year 263**](PT)-1.2*
Urine Analysis:
[**2104-2-20**] 12:50PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Microbiology:
[**2104-2-21**] 3PM BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2104-2-21**] 4PM BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2104-2-19**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
EKG: Persistent elevations in V2-V5
.
[**2104-2-20**] Transthoracic Echocardiogram demonstrates EF30%.
Moderate to severe regional left ventricular systolic
dysfunction with mid to distal septal, anterior, antero-lateral
and apical hypokinesis to akinesis. No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size is normal with borderline
normal free wall function. Trivial pericardial effusion. Trivial
MR.
[**2104-2-21**] Chest X-ray: Cardiac silhouette is upper limits of
normal in size, and pulmonary vascularity is within normal
limits for portable semi-upright technique. Patchy opacities in
both infrahilar areas, most prominent in the left retrocardiac
region, could be due to atelectasis, aspiration and less likely
developing infection.
.
Cardiac catheterization: [**2104-2-19**]
COMMENTS:
1. Selective coronary angiography in this left dominant system
demonstrated single vessel disease. The LMCA, LCx and RCA had
minimal
disease. The LAD had a total occlusion mid-vessel.
2. Successful PCI of the mid-LAD with non-overlapping Promus
DES:
2.5x18mm distally and 3.0x23mm proximally (post-dilated to
3.5mm).
3. Successful closure of the right femoral arteriotomy site with
a 6F
Perclose device.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful PCI of the LAD with DES.
Brief Hospital Course:
71 year-old male presenting with 4 days of severe chest pain
with elevated cardiac biomarkers transferred to [**Hospital1 18**] for
cardiac catheterization and stent placement.
#STEMI:
Patient presented s/p [**Hospital **] transferred from outside hospital
with peak CK [**2093**] and Trop-I of 74, reportedly after 4 days of
constant chest pain. Two drug-eluting stents were placed in the
mid-LAD and the mid-distal LAD for total occlusion. He was
transferred to the CCU where he recieved frequent morphine
boluses and a nitroglycerin drip for chest pain. Patient
continued to endorse chest pain overnight post procedure. It
was similar in quality and site to presentation pain, but less
intense. Chest pain persisted intermittently on the day
following procedure, but only with exertion, which was also
accompanied by SOB. Patient completed integrilin drip for 18hrs
post procedure. EKG shows persistent ST elevations in leads
V2-V5 after intervention. Post-procedure TTE demonstrated EF30%
as well as moderate to severe regional left ventricular systolic
dysfunction with mid to distal septal, anterior, antero-lateral
and apical hypokinesis to akinesis. No VSD, masses, or thrombi
are seen in the left ventricle. Trivial pericardial effusion.
Trivial MR. In addition to aspirin patient was treated with
prasugrel as an anti-platelet [**Doctor Last Name 360**] indicated for this patient
with post-PCI angina and to reduce stent thrombosis and ischemic
events. Metoprolol 25mg [**Hospital1 **] was initiated, well tolerated by
blood pressure during hospitalization. Low dose ACE inhibitor
was started upon discharge, held initially in the setting of
acute kidney injury.
#Apical hypokinesis.
Patient noted to have Left ventricular akinesis on Echo, so he
was started on anticoagulation for prevention of LV thrombus
formation. He was started on a heparin IV drip then lovenox
injections for bridge to longterm warfarin anticoagulation. He
was discharged with lovenox, to be injected daily by visiting
nurse [**First Name (Titles) 4**] [**Last Name (Titles) 263**] becomes therapeutic on warfarin. Patient will
require anticoagulation for at least 3 months to 1 year. He
should be reevaluated with echocardiogram at 3 months for
reassessment of longterm anticoagulation needs.
#Acute Systolic Congestive Heart Failure.
Patient noted to have decreased EF of 30% on Echo. Acute
systolic congestive heart failure secondary to decreased EF post
infarction and likely stunned myocardium post MI. There was
likely a chronic element based on endorsed PND, orthopnea, and
LE swelling. Patient was intermittently diuresed with IV
furosemide, responding well to 20mg boluses. Patient's pulse
oximetry demonstrated 95% on room air on day of discharge.
Patient will be discharged on 20mg furosemide PO daily.
Potassium levels should be re-assessed at follow-up.
#Acute Kidney Injury
Acute Kidney Injury demonstrated by elevated Cr to 1.6 from 1.0
on admission following PCI. Contrast nephropathy likely given
Cr peak roughly 48 hours post PCI with 130mL of contrast, less
likely atheroemboli. Decreased heart function post MI may have
contributed to poor forward flow. ACEi started on discharge.
#Hyperlipidemia.
Patient was treated and discharged on high dose statin. LDL was
elevated at 111 post-MI justifying continued high dose statin
thearpy at discharge.
#Hypertension:
Patient remained normotensive during hospitalization except for
episodes of agitation with metoprolol and lasix PRN dyspnea.
#Benign Prostate Hyperplasia:
Patient was treated with Doxazosin and Tamsulosin during
admission. Per outside hospital records, patient had recent
elevated PSA of 17. Note that patient also has history of lower
back pain.
#COPD: Patient has significant smoking history and was
intermittently wheezy on exam. Albuterol/Ipratropium nebulizer
treatments were used intermittently.
Medications on Admission:
Ambien
Cardura (doxazosin) 1mg qhs
celebrex 200mg daily
cyclobenzaprine 10mg qhs
diazide (triamterene/hctz) 37.5/25mg qday
flexeril 10mg qhs
flomax (tamsulosin) 0.4mg qday
levitra 20 mg prn
oxycodone prn pain
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for chronic back pain.
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Flexeril 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Lovenox 150 mg/mL Syringe Sig: One (1) Subcutaneous once a
day.
Disp:*4 syringes* Refills:*2*
13. Outpatient Lab Work
Please get your [**Last Name (Titles) 263**] checked by the VNA on Monday [**2-25**] and
call results to Dr. [**Last Name (STitle) 18323**] at [**Telephone/Fax (1) 18325**]. The office will send
a standing order to [**Hospital3 4107**] lab.
14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes as needed for chest pain: Take 5
minutes apart. If you still have chest pain after 2 doses, call
911.
Disp:*25 tablets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Acute systolic Dysfunction
Hypertension
Benign Prostatic Hypertrophy
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You had a large heart attack and required 2 drug eluting stents
to open your left anterior descending coronary artery. You had
some chest pain after the catheterization that has now resolved.
You will need to take Prasugrel and aspirin every day for the
next year in order to keep the stents open and prevent another
heart attack. Do not stop taking Prasugrel for any reason unless
Dr. [**Last Name (STitle) 10543**] tells you to. Your heart is weak after your heart
attack and you developed some fluid in your lungs because of
this. You are at risk for having more fluid in your lungs and
have been started on Furosemide (Lasix) daily to prevent this.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 18323**] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Medication changes:
1. Stop taking all of your medicines at home except Cardura,
oxycodone, Flexaril and Flomax. Please talk to Dr. [**Last Name (STitle) 18323**] about
continuing to take Levitra.
2. Start taking Aspirin and Prasugrel every day to keep the
stent open. Missing doses or stopping this medicine will result
in another heart attack.
3. Start taking Furosemide to prevent fluid buildup in your
lungs
4. Start taking Lisinopril to keep your blood pressure low and
prevent fluid buildup
5. Start taking Metoprolol long acting to keep your heart rate
low and prevent another heart attack.
6. Start taking Simvastatin (Zocor) to lower your cholesterol.
7. Start taking Lovenox once daily to prevent blood clots. You
will use this until your coumadin level is > 2.0. The VNA can
give you these injections.
8. Start taking coumadin to prevent blood clots. You will need
to take this for at least a few months.
Followup Instructions:
Primary care:
Dr [**Last Name (STitle) 18323**] Phone: [**Telephone/Fax (1) 18325**], [**Street Address(2) **] [**Hospital1 **] (next
to hospital) Date/Time: Thursday [**2-28**] at 2:00pm with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6164**] PA. Dr.[**Name (NI) 72943**] office will tell you how much coumadin
to take every day.
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] ([**Telephone/Fax (1) 24747**] [**Apartment Address(1) **], [**Street Address(2) 86092**],
[**Hospital1 **]. Date/time: Thursday [**3-13**] at 10am.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 5849, 4019, 2724, 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7342
} | Medical Text: Admission Date: [**2151-8-20**] Discharge Date: [**2151-9-12**]
Date of Birth: [**2070-5-18**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Metoclopramide / Cephalosporins / Penicillins
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
IR guided replacement of blocked J-tube
History of Present Illness:
87 yo NH resident with h/o cervical ca and XRT,
vescicovaginal/rectovesicle/rectovaginal fistulas, s/p bilateral
percutaneous nephrostomy, and recurrent UTIs presents with
fevers, rigors, fatigue, and decreased UOP. She presented to the
hospital when her family noticed that she was not feeling well,
acting lethargic, and producing less urine from her bilateral
nephrostomy. The patient did not complain of chest pain, SOB,
cough, or GI symptoms. These symptoms have been relatively new,
as she had felt well in the week prior to admission. Her
activity level is limited by her functional status, and has not
traveled as a result. Her daughter also denies obvious sick
contacts.
.
Of note, the patient has been admitted multiple to times for
dislodged nephrostomy tubes, as well as recurrent UTIs. Her most
recent UTI consisted of ESBL Klebsiella resulting in sepsis,
central line placement, and treated with Meropenem and Flagyl x
2wks for question of C. diff infection. Previous UTIs have
included VRE/MRSA bacteria, treated with linezolid and
vancomycin.
.
In the ED, 97.0, 82, 102/50, 16, 97 % RA. She was noted to have
rigors, and her BP decreased to 70's/40's. She was also
tachycardic to the 110's. She was given IVF and sent to the MICU
for close observation. While in the ED, the patient and her
family refused central line placement. Pt recieved 5 L NS.
.
Admitted to [**Hospital Unit Name 153**] for sepsis.
Past Medical History:
1. Cervical Cancer 30 yrs ago, treated with XRT. Known
vesicovaginal fistula, with recently discovered rectovaginal
fistula, and rectovesical fistula. Per d/c summary, she is a
poor surgical candidate for repair of this, but could consider a
diverting colostomy done endoscopically, however patient did
not want any further invasive procedures. Status post bilateral
nephrostomy tubes which per notes were last placed [**2151-4-8**].
2. Type 2 DM
3. Hypothyroidism
4. History of VRE, MRSA UTIs
5. Bipolar d/o
6. Anemia of chronic disease, baseline around 28.
7. delirium.
8. UTI's with Klebsiella, VRE/MRSA, s/p meropenem, vancomycin,
and linezolid therapy.
9. Pressure sores- stage IV decubitus ulcer
Social History:
Living at [**Hospital3 2558**] currently. Daughter [**Name (NI) **] is HCP.
Family History:
Non-contributory
Physical Exam:
VITALS: 76/33, 79, 16, 100% 5L NC (upon admission to [**Hospital Unit Name 153**])
GEN: Lying in bed, pale appearing, sleeping.
HEENT: PERRL, anicteric sclera, dry MM, conjunctival pallor
Neck: supple, no JVD appreciated
Lung: Poor inspiratory effort, decreased BS on left
Heart: Distant sounds, RRR, no m/r/g
Abd: Soft, NT/ND
Ext: warm, perfused, 1+ DP pulses, R PICC, bilat heels dressed
Back: buttock dressing dry, intact
Skin: pale apprearing, no ecchymosis or rashes noted
Neuro: no focal deficits appreciated
Pertinent Results:
[**2151-8-20**] 12:27AM BLOOD Lactate-6.5*
[**2151-8-30**] 04:00AM BLOOD calTIBC-88* VitB12-854 Folate-12.4
Ferritn-867* TRF-68*
[**2151-8-19**] 08:38PM BLOOD Glucose-245* UreaN-19 Creat-0.6 Na-133
K-4.3 Cl-100 HCO3-25 AnGap-12
[**2151-8-20**] 05:40AM BLOOD WBC-17.2* RBC-2.47* Hgb-6.1* Hct-21.1*
MCV-85 MCH-24.7* MCHC-29.0* RDW-18.2* Plt Ct-704*
[**2151-9-4**] 05:45AM BLOOD WBC-5.6 RBC-3.00* Hgb-8.0* Hct-25.5*
MCV-85 MCH-26.7* MCHC-31.5 RDW-19.6* Plt Ct-429
.
[**2151-8-30**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT: No
growth
[**2151-8-23**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {[**Female First Name (un) **]
PARAPSILOSIS}; ANAEROBIC BOTTLE-FINAL INPATIENT
[**2151-8-20**] URINE URINE CULTURE-FINAL {MORGANELLA MORGANII, 2ND
ISOLATE}; ANAEROBIC CULTURE-FINAL INPATIENT
[**2151-8-20**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {KLEBSIELLA
PNEUMONIAE, PROTEUS MIRABILIS}; ANAEROBIC BOTTLE-FINAL
{KLEBSIELLA PNEUMONIAE, KLEBSIELLA PNEUMONIAE} EMERGENCY [**Hospital1 **]
[**2151-8-20**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE};
ANAEROBIC BOTTLE-FINAL {KLEBSIELLA PNEUMONIAE} EMERGENCY [**Hospital1 **]
.
CTA Chest/Abdomen
INDICATION: 81-year-old female with cervical cancer status post
CRT with rectovesicovaginal fistulas, bilateral nephrostomy
tubes and sacral decubitus ulcer.
.
TECHNIQUE: MDCT acquired axial images of the pelvis were
obtained without IV contrast. IV contrast enhanced images of the
chest were obtained per PE protocol with preliminary
non-contrast enhanced images of the chest. Multiplanar
reformations were obtained.
.
CT PELVIS WITHOUT IV CONTRAST: Stool and oral contrast are seen
within what appears to be the vagina. The rectum contains
moderate wall thickening with small amount of perirectal
stranding. The inferior small and large bowel are otherwise
unremarkable. There is a small amount of free fluid within the
pelvis, with multiple surgical sutures along the pelvic
sidewalls. Surrounding subcutaneous tissues contain diffuse soft
tissue stranding consistent with third spacing.
.
The patient is status post right hip replacement. There is a
soft tissue defect extending to the lower sacrum/coccyx with
surrounding soft tissue density with no evidence of lytic
changes or sclerotic changes to suggest osteomyelitis.
.
CTA CHEST: There is no evidence of filling defects within the
pulmonary arterial vasculature. No evidence of pulmonary
embolism. The aorta is of normal caliber throughout its
visualized thoracic course with no evidence of dissection. There
are coronary artery and aortic calcifications present. There are
no pathologically enlarged nodes within the mediastinum, hila,
or axilla. There is bilateral atelectasis with no focal areas of
consolidation.
.
BONE WINDOWS: No suspicious lytic or sclerotic bony lesions.
Unchanged bilateral sacroiliac sclerotic changes.
.
IMPRESSION:
.
1. Stool and oral contrast seen anterior to the rectum
consistent with rectovaginal fistula. The urinary bladder is not
clearly visualized.
2. Rectal wall thickening. Etiologies for this appearance
include infection, inflammatory change and malignancy.
3. Sacral decubitus ulcer with no evidence of osteomyelitis.
4. No evidence of pulmonary embolism or aortic dissection
.
[**8-30**] Echo:
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated. The aortic
valve leaflets are moderately thickened. No masses or
vegetations are seen on the aortic valve. There is mild to
moderate aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. Trivial mitral regurgitation is seen. Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) left ventricular diastolic dysfunction. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is a small pericardial
effusion. There are no echocardiographic signs of
tamponade.
.
CXR [**9-1**]:
There is a new left PICC terminating in the expected location of
the left brachiocephalic vein. There is interval removal of the
right PICC. There is a persistent left-sided pleural effusion,
with probable left lower lobe atelectasis. No evidence of
pneumothorax. The right lung is clear. No pleural effusion is
appreciated on this frontal view of the chest on the right.
There are aortic calcifications. There are bilateral nephrostomy
tubes in place, seen within the abdomen.
SUPINE PORTABLE RADIOGRAPH OF THE CHEST: A left-sided PICC line
is seen with the tip in the left brachiocephalic vein.
Differences in opacity of the lungs are most likely due to
layering of the previously seen pleural effusions on this supine
radiograph. Hazy opacity in the right upper lung is likely
atelectasis. The heart size is stable. Again noted are bilateral
nephrostomy pigtail catheters.
Note is made of air-filled stomach and several air-filled bowel
loops in mid abdomen.
IMPRESSION:
1. Tip of left-sided PICC line in left brachiocephalic vein.
2. Bilateral layering pleural effusions with mild right upper
lobe atelectasis.
PORTABLE ABDOMEN
Reason: r/o obstruction
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with MMP, including multiple intrapelvic
fistulas, now with increasing abdominal distension and lower GI
bleeding. Hypoactive BS on exam. Please eval for obstruction.
REASON FOR THIS EXAMINATION:
r/o obstruction
INDICATION: Recent abdominal distention, lower GI bleeding,
please rule out obstruction.
COMPARISON: CT scan [**2151-9-8**].
FINDINGS: Multiple distended small bowel loops are present,
measuring up to 4.5 cm. The stomach is distended with air. The
large bowel is collapsed. There is a foreign body in the right
lower quadrant, confirmed by later CT available at the time of
dictation. Bilateral nephrostomy tubes are present as well as
right proximal femoral hardware.
IMPRESSION: Small-bowel obstruction.
Dr. [**Last Name (STitle) **] was aware of these findings at the time of dictation.
CT ABDOMEN W/O CONTRAST [**2151-9-8**] 5:15 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: r/o SBO
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with MMP including multiple intrapelvic
fistulas and recurrent UTIs, tx to [**Hospital Unit Name 153**] for hypotension.
Developing abd distension, [**Month (only) **] BS, abd XR worrisome for SBO.
REASON FOR THIS EXAMINATION:
r/o SBO
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 81-year-old female with multiple medical problems
and intrapelvic fistulas now with hypotension and abdominal
distention.
COMPARISON: [**2151-8-20**].
TECHNIQUE: MDCT axial images of the abdomen and pelvis were
obtained without IV contrast. Multiplanar reformatted images
were also performed.
CT ABDOMEN WITHOUT IV CONTRAST: There are small bilateral
pleural effusions, left greater than right with associated
atelectasis. There is a small pericardial effusion. Given the
limitations of evaluation without IV contrast, the liver,
gallbladder, spleen, and adrenal glands are unremarkable. There
is a small amount of perihepatic fluid. A hyperdensity within
the pancreatic duct, likely represents refluxed contrast.
Bilateral percutaneous nephrostomy tubes are again seen.
A catheter is seen within the stomach. There is massive gastric
dilatation as well as massive dilation of the loops of small
bowel. There are scattered air fluid levels. Contrast reaches
the level of the proximal small bowel. Marked wall thickening is
seen at this level and vascular compromise cannot be excluded. A
G-tube plug is seen in the terminal ileum. The loops of small
bowel distal to this plug are collapsed. This likely represents
the site of obstruction. A small amount of fluid is seen
surrounding the small bowel loops at this location.
Contrast within the ascending colon likely represents retained
contrast from the previous examination.
CT PELVIS WITHOUT IV CONTRAST: There is a moderate amount of
fluid within the pelvis. Stool is likely seen within the bladder
consistent with the patient's known rectovaginal fistula.
A fixation pin is seen within the proximal femur. A soft tissue
defect in the lower outer sacrum/coccyx is seen with no evidence
of cortical destruction to suggest osteomyelitis.
BONE WINDOWS: Again demonstrate bilateral sacroiliac sclerotic
changes.
Multiplanar reformatted images confirmed the above findings.
IMPRESSION:
1. Mechanical small-bowel obstruction with transition point in
the terminal ileum likely secondary to G-tube plug. A small
amount of fluid surrounds the small bowel loops at the point of
obstruction. Wall thickening of the proximal small bowel is
concerning for vascular compromise.
2. Bilateral small pleural effusions.
3. Small pericardial effusion.
4. Sacral decubitus ulcer.
5. Findings consistent with known rectovaginal fistula.
The findings were discussed with Dr. [**Last Name (STitle) **] at 9:20 p.m. on
[**2151-9-8**].
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-9-11**] 04:34AM 10.8# 3.43* 9.1* 32.5* 95# 26.6* 28.1*
19.1* 608*
[**2151-9-10**] 06:05AM 6.5 3.22* 8.8* 28.3* 88 27.2 31.0 18.9*
410
[**2151-9-9**] 06:22AM 7.6 2.94* 8.0* 25.3* 86 27.2 31.7 19.0*
348
[**2151-9-8**] 04:34AM 5.5 3.32* 8.8* 29.1* 88 26.4* 30.1* 18.9*
402
[**2151-9-7**] 09:06PM 29.0*
Fibrino FDP D-Dimer
[**2151-9-7**] 06:00AM 0-10
[**2151-9-7**] 06:00AM [**Telephone/Fax (1) 32812**]*
[**2151-9-7**] 01:47AM 234 951*
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2151-9-11**] 04:34AM 172* 12 0.7 134 4.3 104 27 7*
[**2151-9-10**] 06:05AM 103 10 0.5 139 3.9 110* 25 8
[**2151-9-9**] 09:55PM 113* 11 0.6 138 3.9 108 27 7*
[**2151-9-9**] 06:22AM 92 12 0.6 141 3.2* 109* 29 6*
[**2151-9-8**] 04:34AM 188* 13 0.5 140 3.4 107 30 6*
Brief Hospital Course:
Hospital Course:
1. Polymicrobial Bacteremia/Sepsis due to Coagulase Negative
Staphlococcus, ESBL-Klebsiella, Proteus Mirabilis, Candidia
Parapsilosis: the patient was initially hospitalized and
stablized in the ICU, and started on broad spectrum antibiotics.
Blood cultures grew the organisms as listed above. She had two
Echos which did not reveal any evidence of vegetations. Given
her fungemia, the patient had an eye exam by Opthamology which
did not reveal any evidence of endopthalmitis. Her original
PICC line (R sided) was changed over a wire to a double-lumen
PICC, but after new fungemia, this was removed and a new L sided
PICC line was placed. Following antibiotics were continued- IV
Vancomycin, Meropenem, Fluconazole, and Metronidazole (as C diff
ppx) -initial planned for stopping on [**2151-9-14**].
Also per ID, she was not a candidate for long term suppressive
therapy; the etiology of her polymicrobial sepsis was most
likely the numerous intra-abdominal fistulas that provide a
conduit for blood stream infections.
.
2. Urinary Tract Infection secondary to Morganella Morganii: as
above, this organism was sensitive to Meropenem.
3. Aspiration s/p failed speech and swallow evaluation: the
patient was noted to cough frequently while fed. Several speech
and swallow evaluations confirmed that the patient was
aspirating, and the speech/swallow specialists recommended
keeping the patient strict NPO with J tube feeds. The patient
was started on tube feeding during her hospitalization as she
was noted to be extremely malnourished (albumin < 2). This issue
of feeding for comfort was brought up with the daughters, given
her limitied life expectancy, but during the family meeting one
daughter was so interested in her decubitus ulcer that this
issue could not be resolved. However, eventually the J-tube was
clogged and [**Company 19015**] and bicarb did not unclog the tube. She
subsequently underwent IR guided replacment of her J-tube.
.
4. Multifocal Atrial Tachycardia, resolved after repletion of
her K/Mg and treatment with IV Beta Blocker.
.
5. Bilateral Pleural Effusions/LE edema: likely secondary to
volume overload
and third spacing. Once on abx, she did not have any fevers or
leucocytosis to suggest complicated parapneumonic effusions or
empyema. Etiology of effusions and LE edema likely secondary to
IVF given during sepsis-resuscitation and very low albumin
(1.7). As mentioned, no evidence of CHF on Echos.
6. Anemia of Chronic Disease: as noted by high Ferritin/low
TIBC. HCT remained stable.
.
7. Stage IV decubitus Ulcer: this was treated aggressively
during her hospitalization with frequent dressing
changes/debridement. She was turned frequently and aggresive
wound care was maintained.
.
8. Blocked J-tube s/p IR guidied replacement: As above, the
patient's J-tube was clogged, and therefore she underwent IR
guided replacement of her J-tube. Eventually in view of the
bowel obstruction (see below) - [**Company 32813**] was started in the ICU
(second transfer) at the request of daughter - [**Name (NI) 1060**].
.
9. Vesicovaginal, Rectovaginal, Rectovesicular Fistulas: pt
deemed
not to be surgical candidate per discussion with patients PCP,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**].
10. Hypotension: The patient was retransferred to the ICU for
hypotension resulting from a vaginal bleed. Pressors were not
started as per family preferance (see below). The BP responded
transiently to boluses of IV fluids.
11. Bowel obstruction: 3-4 days prior to the patient's death -
when she was in the ICU for hypotension - It was noted that the
patient's abdomen was distended, sluggish bowel sounds and also
constipation was noted. Flat plate and CT abdomen showed small
bowel obstruction with possible ichemia of bowel . Surgery was
consulted and their recommendation was that the patient was a
very poor surgical candidate. The family also did not want
operative intervention at this time. The results of conservative
management for ischemic bowel and obstruction was made clear to
the patient's family as well as the fact that she will likely
progress in terms of the bowel ostruction and ischemia and will
have a very poor prognosis. Their questions were answered.
.
12. End of Life issues: Several family meetings were held
between the hospitalists, Dr. [**Last Name (STitle) 5351**], and her two daughters.
One daughter seemed almost fixed on her decubitis ulcer and
steered the conversation away from any and all end-of-life
issues such as feeding for comfort; what to do when the patient
develops sepsis again, etc.
On [**2151-9-10**], in the ICU, the patient had a bowel movement.
However, the patient continued to remain hypotensive (SBP 70's).
BP responded to small boluses of IV fluids. Family did not want
central lines or pressors. On [**2151-9-10**] - After a long family
conference with the ICU physicians - the family came to a
consensus that there would be no escalation of care, including
central lines and pressors. Morphine drip was started to make
the patient comfortable and pt transferred to the medical floor.
Overnight, on the floor the morphine drip was stopped because of
decrease in resp rate to [**6-24**]/min. The patient was noted to be in
no pain or discomfort, was not moaning.
On [**2151-9-11**] - the patient was not responding to verbal or pain
commands and agonal respirations were noted.
Both daughters - [**Name (NI) **] (- HCP) and [**Doctor Last Name **] were at the bedside.
The hospitalist had a long discussion with them - In view of
very poor prognosis, there was a discussion regarding pursuing
'comfort care only'. However, the family wanted to discuss
further about this among themselves but did say that they wanted
to stop the antibiotics, give morphine only if patient was noted
to be in discomfort and asked that no further fluid boluses be
given for the low BP and no throat suction for secretions. They
also did not want scopolamine patch or levsin sublingual to dry
out the oral and throat secretions. They still wanted their
mother to get the [**Name (NI) 32813**]. There was a conflict of opinion noted
between the two sisters [**Name2 (NI) **] who was the HCP and [**Name (NI) 1060**])
during this decision making process. All their questions and
concerns were appropriately answered. Assistance of palliative
care team was obtained over the telephone and social worker was
consulted to offer help to the family.
At about 5-15am on [**2151-9-12**] - the patient was pronounced dead by
the oncall doctor, Dr [**Last Name (STitle) 9570**]. Family requested an autopsy.
Clinical details were provided to the pathologist performing the
autopsy.
Medications on Admission:
Zyprexa, synthroid, gabapentin, oxycodone, iron, prilosec, MVI,
megace
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 U U
Injection TID (3 times a day).
Disp:*qs U* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluconazole in Normal Saline 200 mg/100 mL Piggyback Sig: Two
Hundred (200) mg Intravenous once a day: Note: course to end
on [**9-14**].
Disp:*qs qs* Refills:*2*
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*qs Tablet(s)* Refills:*0*
7. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q6H (every 6 hours): Note: course to end on [**9-14**].
Disp:*[**Numeric Identifier **] mg* Refills:*2*
8. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q6H (every 6
hours) as needed.
Disp:*qs mg* Refills:*0*
9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
Disp:*qs mg* Refills:*2*
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
Disp:*qs Capsule(s)* Refills:*0*
11. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours): Note:
course to end on [**9-14**].
Disp:*qs mg* Refills:*2*
12. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
Disp:*qs qs* Refills:*2*
13. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN
(as needed).
Disp:*qs qs* Refills:*2*
14. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
Disp:*qs qs* Refills:*0*
15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous Q 24H (Every 24 Hours): Note: course to end on
[**9-14**].
Disp:*30 gm* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
Death:
1. Polymicrobial Bacteremia/Sepsis: Coagulase Negative
Staphlococcus, ESBL-Klebsiella, Proteus Mirabilis, Candidia
Parapsilosis
2. Urinary Tract Infection secondary to Morganella Morganii
3. Aspiration s/p failed speech and swallow evaluation
4. Multifocal Atrial Tachycardia, resolved
5. Bilateral Pleural Effusions, likely secondary to volume
overload
and third spacing
6. Anemia of Chronic Disease
7. Stage IV decubitus Ulcer
8. Blocked J-tube s/p IR guidied replacement
9. Vesicovaginal, Rectovaginal, Rectovesicular Fistulas: pt
deemed
not to be surgical candidate
10. Small bowel obstruction/ischemia
Secondary Diagnoses:
1. h/o Cervical Cancer s/p XRT
2. Hypothyroidism
3. Bipolar Disorder
Discharge Condition:
Patient died in hospital
Discharge Instructions:
Patient died in hospital
Followup Instructions:
Patient died in hospital
ICD9 Codes: 5990, 5070, 4271, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7343
} | Medical Text: Admission Date: [**2109-9-30**] Discharge Date: [**2109-10-2**]
Date of Birth: [**2065-9-15**] Sex: M
Service: MEDICINE
Allergies:
Vioxx
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
44 yo M with h/o HIV/AIDS, last CD4 123, most recent VL <50
(one month prior), and hx of CNS [**Hospital 38229**] transferred from [**Hospital3 56608**]Med Center after an episode of witnessed tonic
clonic seizures that lasted 10 minutes while riding in a car.
Pt arrived in ED with seizure. Seizure was broken with 8mg
ativan in the ED. Pt was reported to have a significant post
ictal period and was intubated to protect his airway. Pt was
loaded with dilantin at [**Location (un) **]. Prior to this episode pt had
experienced 2 days of fever, and uri sx.
The pt's wife reports the first episode of seizure was
approximately 1.5 years ago. This led to a workup that revealed
CNS toxoplasmosis and his diagnosis of HIV. The seizure left
the pt with a residual left hemiparesis. His second episode of
seizure occured two month ago when he was witnessed to have had
letward head deviation, altered awareness and picking movements
o his right hand towards his left hand.
HIV was diagnosed in the setting of his first seizure as
above. He has been treated with HAART in the past with a
?compliance and poor response. The patient is currently being
tx'd with epivir, ritonovir and atazanavir (2PPI+NRTI). He has
not had any other opportunistic infections in the past (aside
from toxo). He was recently taken off azithromycin due to CD 4
count of 123.
.
Past Medical History:
1. SZ - two prior episodes (1st one 1.5years ago, 2nd one two
months previous)
2. HIV
3. DM - off all insulins due to repeated episodes of
hypoglycemia
4. CRI - baseline Cr of 2.5-5 as per outpatient renal. refused
bx.
5. COPD/Asthma
6. HTN
Social History:
Pt is married and lives with wife and kids.
Family History:
NC
Physical Exam:
PE:
-VS: BP: 170/80 Hr: 65 RR: 24 SaO2: 100% on 80%
-Drips: Propofol
-Vent settings: AC with TV 600 and RR 24, FiO2 0.8, PEEP 5
-Gen: middle age male lying in bed at 30 degrees on vent with
propafol gtt.
-Neck: supple (full ROM not tested as pt has ET tube in place)
-CV: RRR, S1, S2, no murmurs, rubs, gallops
-Chest: bibasilar crackles on back
-Abd: soft, NT, ND, BS+ bilaterally
-Ext: warm to touch, no clubbing, cyanosis, edema
-Neuro: Pupils 4mm bilaterally and sluggishly reacts to light.
Pt moves all extremities spontaneously, DTP is +1 on knee jerk
and ankle jerk and +2 on biceps. Positive bilateral babinksi
sign.
Pertinent Results:
[**2109-9-30**] 10:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2109-9-30**] 10:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2109-9-30**] 10:50AM URINE RBC-[**2-8**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2109-9-30**] 10:50AM WBC-6.3 LYMPH-18 ABS LYMPH-1134 CD3-85 ABS
CD3-966 CD4-7 ABS CD4-76* CD8-76 ABS CD8-864* CD4/CD8-0.1*
[**2109-9-30**] 10:50AM PT-12.5 PTT-23.7 INR(PT)-1.0
[**2109-9-30**] 10:50AM PLT COUNT-222
[**2109-9-30**] 10:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2109-10-1**] 01:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2109-9-30**] 10:50AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2109-9-30**] 10:50AM URINE Blood-MOD Nitrite-NEG Protein-500
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2109-9-30**] 10:50AM URINE RBC-[**2-8**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2109-9-30**] 10:50AM PHENYTOIN-10.7
[**2109-9-30**] 10:50AM ALBUMIN-3.9 CALCIUM-8.3*
[**2109-9-30**] 10:50AM PHOSPHATE-5.7* MAGNESIUM-2.1
[**2109-9-30**] 10:50AM LIPASE-55
[**2109-9-30**] 10:50AM ALT(SGPT)-16 AST(SGOT)-21 LD(LDH)-251*
CK(CPK)-434* ALK PHOS-114 AMYLASE-66 TOT BILI-1.0
[**2109-9-30**] 10:50AM GLUCOSE-196* UREA N-52* CREAT-4.2* SODIUM-136
POTASSIUM-6.2* CHLORIDE-110* TOTAL CO2-16* ANION GAP-16
[**2109-9-30**] 10:56AM LACTATE-1.0
[**2109-9-30**] 01:30PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-0
LYMPHS-0 MONOS-0
[**2109-9-30**] 01:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-47*
GLUCOSE-117
[**2109-9-30**] 02:00PM URINE HOURS-RANDOM CREAT-55 SODIUM-55
POTASSIUM-47 CHLORIDE-49 TOT PROT-269 PROT/CREA-4.9*
[**2109-9-30**] 10:50AM BLOOD WBC-6.3 Lymph-18 Abs [**Last Name (un) **]-1134 CD3%-85
Abs CD3-966 CD4%-7 Abs CD4-76* CD8%-76 Abs CD8-864* CD4/CD8-0.1*
[**2109-10-2**] 07:35AM BLOOD Glucose-170* UreaN-39* Creat-4.0* Na-139
K-4.4 Cl-108 HCO3-20* AnGap-15
[**2109-10-2**] 07:35AM BLOOD WBC-5.5 RBC-2.69* Hgb-8.3* Hct-24.8*
MCV-92 MCH-31.0 MCHC-33.5 RDW-14.5 Plt Ct-179
.
.
"[**2109-9-30**] 1:30 pm CSF;SPINAL FLUID:TUBE 3.
GRAM STAIN (Final [**2109-9-30**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
CRYPTOCOCCAL ANTIGEN (Final [**2109-10-1**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
Performed by latex agglutination.
Reference Range: Negative.
Results should be evaluated in light of culture results
and clinical
presentation.
FUNGAL CULTURE (Pending)"
.
.
"[**2109-9-30**] 5:58 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2109-10-1**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH
OROPHARYNGEAL FLORA"
.
.
Blood cultures, fungal culturs, AFB cultures: pending"
.
.
Renal US [**2109-9-30**]:
"The right kidney measures 13.5 cm, and the left kidney measures
11.3 cm. Images of the left kidney are somewhat limited. Both
kidneys demonstrate normal cortical thickness and echogenicity.
There is no evidence of hydronephrosis, stone, or mass in either
kidney. No perinephric fluid collections are seen. A Foley
catheter is seen within a collapsed bladder.
IMPRESSION:
No evidence of hydronephrosis. "
.
.
CXR [**2109-9-30**]:
"CLINICAL INDICATION: Status post seizure. Intubated.
An endotracheal tube is in satisfactory position. A nasogastric
tube terminates within the proximal stomach, but the side port
is likely above the GE junction level. Cardiac and mediastinal
contours are normal. There are patchy opacities present in the
infrahilar regions bilaterally. The lungs otherwise appear
grossly clear.
IMPRESSION:
1. Satisfactory position of ET tube.
2. Nasogastric tube side port is likely above the GE junction.
3. Patchy opacities in the infrahilar regions bilaterally, which
may be due to aspiration or atelectasis. "
.
.
CXR [**2109-10-1**]:
"IMPRESSION:
1) Satisfactory position of ET tube.
2) Unchanged position of the nasogastric tube, whose side port
may lie above the gastroesophageal junction.
3) New areas of linear segmental patchy atelectasis bilaterally.
4) Possible mild left ventricular failure."
.
.
EEG [**2109-9-30**]:
"FINDINGS:
ABNORMALITY #1: There are scattered theta frequency intrusions
most
prominent over the right centro-parietal region at the T4, P4
contacts.
These are of mild amplitude.
ABNORMALITY #2: Occasional mild theta frequency slowing was also
seen
over the left temporal region.
ABNORMALITY #3: There is occasional low amplitude generalized
delta
frequency slowing.
BACKGROUND: Is obscured by beta frequency activity in the 15 Hz
frequency range.
HYPERVENTILATION: Was not performed due to the patient's
clinical
condition.
INTERMITTENT PHOTIC STIMULATION: Was not performed because the
study
was a portable study.
SLEEP: Normal transitions of the sleep architecture were not
seen;
however, variations within the amplitude of the background
rhythm over
the course of the record was observed with increased amplitude
in the
setting of movement.
CARDIAC MONITOR: Normal sinus rhythm with a rate of 66 bpm.
IMPRESSION: This is an abnormal portable EEG due to the presence
of
scattered theta frequency intrusions most prominent in the right
centro-parietal region and less often seen in the left temporal
region.
These findings suggest subcortical dysfunction in the right
centro-parietal and left temporal regions. Occasional
generalized delta
frequency slowing that was of low amplitude was also observed
which
suggests deep midline subcortical dysfunction and may reflect
the
effects of Propofol. In addition, beta frequency activity was
superimposed on the background rhythm and this is likely a
medication
effect. No epileptiform abnormalities were seen during the
recording. "
.
.
ECG [**2109-9-30**]: Normal Sinus Rhythm at 62. nml axis, nml
intervals, LVH, QS in V2 - ? due to lead placement. No previous
tracing
.
.
MRI of head [**2109-10-1**]:
"FINDINGS: There are multiple areas of T2 signal abnormality in
the brain one of which is in the right cerebellar white matter
and the rest are in the cortical-subcortical junction region in
the cerebral hemispheres. There is no definite evidence of
abnormal contrast enhancement associated with these. There is no
definite mass effect. There is no definite evidence of
hemorrhage except for the lesion in the right cerebellar
hemisphere. There is no evidence of a focal extra-axial lesion
or fluid collection. There is increased signal in the mastoid
and paranasal sinuses.
IMPRESSION: Multiple lesions of the brain of unknown etiology.
These could represent treated CSF infections such as
toxoplasmosis. The appearance does not strongly suggest
neoplasm."
.
.
Brief Hospital Course:
A/P:
A/P: 44yo male with HIV (CD4 of 123 and VL <50) and seizure
hx transferred from OSH with episode of seizure that lasted
>10min and broke with 8mg ativan in ED and prolonged post ictal
period. Pt intubated for airway protection resulting in ICU
transfer. Pt initially presented with 1st episode of seizure
1.5 years ago resulting in diagonsis of CNS toxo and HIV. Since
then, the patient has only had one other episode of seizure two
month previous. This episode of seizure preceded by some fever
and URI sx in recent weeks.
.
1. Sz: Pt arrived to the [**Hospital1 18**] [**Hospital Ward Name 332**] ICU sedated with
endotracheal tube in place. The etiology of the seizure remains
unclear, however it is most likely secondary to known focal
toxoplasmosis. Other infectious etiologies of seizures were
fuled out with an LP which found only 1 WBC, 1RBC, 47 protein
and 117 glucose, which is not consistent with bacterial, HSV,
fungal, or TB infection. The CSF was also analyzed for [**Country **]
ink which was negative for cryptococcus. A CT scan at the OSH
showed multiple ring enhancing lesions which could be consistent
with lymphoma. No cells were found in the CSF however and an
MRI done the following day was inconsistent with lymphoma. The
patient was also ruled out for toxic injection or withdrawal
with a serum and urine tox screen both of which were negative.
Other metabolic syndromes were also ruled out with normal
electrolytes, glucose, and SaO2. In addition, the patient also
received an EEG which revealed no obvious epileptiform foci.
The work up left us with our most likely diagnosis of resistant
or previously treated toxo as a possible seizure focus and the
MRI was consistent with lesions that may represent previously
treated toxo. A neurology consult was called who recommendation
we stop the dilantin (as it can interfer with his HAART
medication) and start Keppra 250mg [**Hospital1 **] (renal dosing). The
patient was monitored overnight while sedated on the ventilator
as well as another over night off sedation and the ventilator
without a witnessed episode of seizure while being treated with
Keppra. The patient was discharged home from the ICU on Keppra
250mg [**Hospital1 **], with instruction to have his blood levels of Keppra
measured at [**University/College **] the following day and with follow up
appointments made with his PCP-[**Last Name (NamePattern4) **]. [**Last Name (STitle) 56609**], as well as ID-Dr.
[**Last Name (STitle) 56610**], and Renal-Dr. [**Last Name (STitle) 56611**] (all or whom are at [**University/College **]:
[**Telephone/Fax (1) 56612**]). His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 56609**] has agreed to follow up on
the results of the blood and urine cultures still pending. The
patient was instructed to arrange follow up for a neurologist at
[**University/College **] upon discussion with his PCP.
.
2. Respiratory: Pt was intubated for airway protection and
aspiration risk at the outside hospital. Upon admission to the
[**Hospital Unit Name 153**], we placed the patient on a propofol gtt and a ventilator
with the following settings: AC mode with RR 18 and Tv 600
(ovserved Tv of 640), FiO2 of 0.5, PEEP of 5 and Plateau
pressure of 14 and Peak inspiratory pressure of 18 and i/e:
1.28. A CXR demonstrated proper ET tube placement. The patient
was weaned off the ventilator the following day with a
successful spontaneous breathing trial. The patient denied any
swelling or pain in the neck/throat after extubation and several
hours later was found to be eating without any discomfot,
talking in full complete sentences and in NAD. The patient was
observed overnight for signs of laryngeal swelling or trauma but
none were found. The patient was discharged in good condition,
completely independent of the ventilator and with no
complications. The patient was saturating well (>97%) at room
air and was breathing at a rate of [**9-17**] in no acute distress.
The rest of his vital signs were also stable.
The CXR at the time did however reveal some questionable
increased vascularity in LLL suggestive of atelectasis. However
the patient was found to have some mild crackles and decreased
breath sounds in association with a slight bandemia on WBC
count. This was thought to be a possible aspiration pneumonia
(most likely at the time of the seizure) and the patient was
treated with clindamycin 600mg IV q8hours. On discharge the
patient was not complaining of any SOB, cough or fever. The
patient was discharged with a prescription for clindamycin 600mg
PO TID for seven days and referred for outpatient follow up.
.
3. CRI: Pt with baseline Cr of 2.5 to 5 as per outpatient
nephrologist. On admission to [**Hospital1 18**] was found to have a Cr of
4.2 which is within the baseline for this patient. The pt
appeared slightly dry on exam and an ABG showed the following:
7.28/39/353 with gap of 14 (non-gap metabolic acidosis most
likely due to chronic renal failure). The patient was therefore
given 1L of D5W with 3 amps of bicarb (to create isotonic
solution without giving Cl as part of NaCl as Cl is already at
110). The electrolytes and fluid status were monitored very
carefully during the admission and on HD#2, the AM bicarb was
found to be 20 thereby obviating the need for D5W with bicarb as
pt does not have a significant bicarb defecit. At this point
the IVF were held and as patient was extubated, he was
encouraged to take PO. At discharge the patient had a
Creatinine of 4, which is within his baseline range and slightly
improved from admission. The patient was also followed by the
renal consult service while in house.
.
4. HIV: The patient continued to receive his full HIV meds
during the admission. His CD4 count was found to be 74 during
this hospitalization which is basically unchanged to slightly
lower than his previous finding of 123 1 month previously. The
patient also continued to receive his HIV prophylaxis in the
form of sulfadiazne, pyrimethamine and leukovorin. The MRI
performed on HD#2 wa suggestive of old toxo lesions that were
previously treated. The patient was discharged with follow up
arranged at his outpatient ID physician at [**Name9 (PRE) **].
.
5. DM: As per wife, the patient is not currently on any
insulin due to repeated episodes of hypoglycemia although his
records show he was previously on lantus with a RISS. Due to
high infection risk as well as risk of repeated seizures, while
in the ICU, the patient was started on a RISS with QID FS. At
time of discharge, the patient was back on a sliding scale,
however he was not re-started on his lantus. It is recommended
that he discuss his diabetes management in more detail with his
PCP.
.
6. HTN: Pt on outpatient norvasc 5mg once daily with 200mg
once daily of metoprolol XL. However at time of admission,
there was no need for anti-hypertensives as the propofol had
dropped his SBP to 130s. Once the propofol was discontinued
prior to extubation, the patient was re-started on his
antihypertensive medication with good success. The patient was
discharged on the same outpatient regimen as he came in on.
.
7. HCV: As per wife, this is not an active issue. As he had
no abdominal findings on exam, or lab tests this issue was
deferred for managemtent by his PCP.
.
8. Asthma/COPD: Although the patient carries a diagnosis of
asthma and COPD, the exact nature of this medical condition is
unclear. There were no baseline PFTs done and this does not
seem like an active issue as pt is only on MDIs at home. Even
after successful extubation, the patient never complained of
tighness, SOB, or cough and was never found to be wheezing. An
outpatient PFT is recommended once his trial of antibiotics are
completed.
.
9. Anemia: Pt with baseline anemia. During this particular
hospital course, the patient was found to be guaiac negative and
a type and screen was sent in case of emergencies. At time of
discharge, the patient did have a low Hct of 24.8, down from 28
at admission. However the patient received several liters of
IVF and the other blood lines were also decreased suggesting
this was most likely due to hemodilution. Due to the patient's
chronic anemia, the nephrologists at [**Hospital1 18**] recommended the pt
receive procrit 4000 units sub cutaneous injections three times
a week. Unfortunately the patient could not be started on
procrit due to his short length of stay. This will be followed
up with his outpatient nephrologist. In addition, the patient
will have his Hct checked tomorrow Thurs [**2109-10-3**] while at the
lab to follow up on his levels of Keppra (see above).
.
10 Oxybutynin: Althought the patient's wife provided us with a
complete list of his medications, she was unclear as to the
reason why he was taking oxybutynin. Therefore this particular
medication was not started during his current hospital
admission. It is recommended that the patient follow up with
his PCP regarding the necessity of this medication.
.
11. Prophylaxis: Pt received heparin sub Q TID for DVT
prophylaxis. No PPI were given as patient was anticipated to
have only a intubation course.
.
12. Code: Full code
.
Medications on Admission:
1. Epivir 150mg once daily
2. Ritonivir 100mg once daily
3. Atazanavir 150mg [**Hospital1 **]
4. Leucovorin 5mg [**Hospital1 **]
5. Oxybutynin 5mg once daily
6. Daraspin 25mg once daily
7. Sulfadiazne 500mg TID
8. Norvasc 5mg once daily
9. Insulin Lantis and regular as needed
10. Toprol XL 200mg once daily
11. Tylenol 325mg as needed
Discharge Medications:
1. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Leucovorin Calcium 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Pyrimethamine 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Sulfadiazine 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
10. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO
DAILY (Daily).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
14. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
15. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO three
times a day for 7 days.
Disp:*42 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Seizure
Secondary: DM, HIV, CRI, HTN
Discharge Condition:
Good.
Discharge Instructions:
Please take all of your medication.
Please follow up with all of your doctors.
Followup Instructions:
Primary Care: Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 56609**]. There
is already an appointment scheduled for you for [**10-11**] (Fri) at
2:30PM.
Infectious Disease: Please follow up with your infectious
disease doctor Dr. [**Last Name (STitle) 56610**]. [**Name2 (NI) **] has already been informed
regarding your hospital course here at [**Hospital1 18**] and will call you
with an appointment date at home upon discharge.
Neurology: Please have Dr. [**Last Name (STitle) 56609**] arrange for a follow up with a
neurologist at [**University/College **] at your next earliest convenince.
Renal: Please follow up with Dr. [**Last Name (STitle) 56613**] regarding your kidney
function. He can also arrange for injections of epoiten
(procrit) 4000units three times a week for your anemia. The
nephrologists at [**Hospital1 18**] has already contact[**Name (NI) **] him regarding your
current medical issues.
Laboratory: Please have your blood levels of Keppra, as well as
your Hct checked on Thurs ([**2109-10-3**]) at [**University/College **]. Dr.
[**Last Name (STitle) 56609**]/[**Last Name (STitle) 56610**] will contact you regarding changing the dose
of keppra (your seizure medication). [**Doctor First Name **], Dr.[**Name8 (MD) 56614**] NP has
already arranged for a lab slip to be left at the laboratory in
[**University/College **], please anticipate her call.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2109-10-2**]
ICD9 Codes: 5849, 2762, 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7344
} | Medical Text: Admission Date: [**2192-10-20**] Discharge Date: [**2192-10-23**]
Date of Birth: [**2114-7-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Lower back pain, fevers
Major Surgical or Invasive Procedure:
placement of right internal jugular central line
History of Present Illness:
78 y/o with Dementia, urinary incontinence presents with 4 days
of lower back pain, and rigors/fevers. [**Name (NI) **] husband reports
abrupt change in his wife's behavior on Tuesday morning.
Wednesday night she had chills and sweats as well as back ache.
He also notes that she is not walking properly, but is not
focally weak. She has had decreased PO intake during this time
as well. Mild diarrhea during this time. No abd pain. Denies
dysuria or hematuria. Husband reports patient is normally
oriented x 3.
Review of systems: No SOB, cough. No NS. No chest pain, no
palpatations. No abd pain. No N/V. No rash.
In the emergency department VS 99.6, 108/76, 78, 18, 100% RA. In
ED spiked to 103. BP to 69/42. Received 4 L NS. Peripheral
dopamine was started and titrated up to 15 mcg/kg/min. Given
Cipro 400mg IV, Ceftriaxone IV and tylenol 1gm PO x 1. VS prior
to transfer 98.2, 92, [**11/2152**], 14, 100% 4-6L NC. Right IJ placed
in ED. After withdrawing RIJ 2 cm developed transient SOB.
On tranfer to the floor, she had no complaints. She was having
difficulty remembering why she had come into the hospital, but
after reorientation, understood this. She had no chest pain,
shortness of breath, abdominal pain, fevers, chills, night
sweats, nausea, vomting, dysuria, hematuria.
Past Medical History:
Dementia
Chronic constipation
Osteopenia
Spinal stenosis
posterior vitreous attachment right eye
urinary incontinence
s/p hysterectomy [**2153**]
h/o Lyme disease
h/o hepatitis
Social History:
Lives with husband [**Name (NI) 95086**], has son who is involved w/ care
Family History:
Mother died with lymphoma, age 80, [**2173**]
Father died age 67 colon cancer
One brother, 18 months younger, in [**Location (un) **], healthy with some
heavy alcohol use
5 pregnancies, first ended at 7 months with stillbirth of
siamese twins; 3 spontaneous vaginal deliveries of healthy
children all alive and well; one miscarriange
Diabetes: aunt
Physical Exam:
GENERAL: Pleasant, well appearing, in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP not elevated
LUNGS: crackles L base > R, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Appropriate. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. Gait assessed on the day
after transfer to floor and gait was wnl.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2192-10-20**] 11:03AM GLUCOSE-145* UREA N-13 CREAT-1.1 SODIUM-138
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
[**2192-10-20**] 05:28PM HCT-31.4*
[**2192-10-20**] 04:51AM cTropnT-<0.01
[**2192-10-19**] 06:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2192-10-19**] 06:00PM URINE RBC-[**5-30**]* WBC-[**11-9**]* BACTERIA-MOD
YEAST-NONE EPI-0
[**2192-10-19**] 06:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2192-10-19**] 08:23PM ALT(SGPT)-34 AST(SGOT)-45* ALK PHOS-57 TOT
BILI-0.3
CT Abd:
1. Abnormal striated hypoenhancement in the right kidney,
compatible with
infectious process such as pyelonephritis and focal nephronia.
No renal
abscess or perinephric fluid collection.
2. No psoas abscess.
3. 3-cm right adnexal cyst, comparable in size compared to the
prior
ultrasound.
Also:
A 2-mm calcified nodule noted in the
right lower lobe is compatible with a calcified granuloma.
[**10-23**] CXR
Cardiac size is top normal. Small bilateral pleural effusions
are unchanged.
Right lower lobe atelectasis has improved. Left lower lobe
retrocardiac
opacity has also improved, consistent with improved atelectasis.
Mild
degenerative changes in the thoracic spine.
Brief Hospital Course:
Ms. [**Known lastname 27644**] is a 78 year-old lady with Dementia and urinary
incontinence who presented with fevers and back pain, consistent
with urosepsis from pyelonephritis. She was admitted to the ICU
for hypotension requiring pressors in the Emergency Department
and then transferred to the floor on [**2192-10-22**].
1. UROSEPSIS- secondary to pyelonephritis given findings on CT
abdomen, urinalysis and physical exam. She received IV
Ciprofloxacin and Ceftriaxone in the Emergency Department. Due
to persistent hypotension in the ED, she required pressors and
was transferred to the unit. In the ICU, Admission Chest X-rays
were negative for infection and non-focal neuro exam suggested
against meningitis. Dopamine (initial pressor) was changed to
levophed, and mean arterial pressure was titrated to > 65 mmHg.
IV Ceftriaxone was contuned in-house. Patient's urine output
continued to improve during her ICU course and her blood
pressures improved. On [**10-21**], pressors were discontinued and
patient was observed- her blood pressures remained stable over
24 hours off pressors. She was converted to levofloxacin for
HAP (see below) and should continue this for a total of 2 weeks.
On discharge, she was afebrile.
2. Pneumonia - due to presence of increased left lower lobe
opacity and probable evidence for superimposed infection in the
bilateral basis, decision was made to treat with levofloxacin
750mg q48hrs, but repeat CXR showed improvement in bilateral
atelectasis. Given these findings, she did not have pneumonia,
but atelectasis from prolonged bedrest in the ICU.
3. Altered Mental Status: Pt with baseline dementia. Per
husband, she is usually oriented. On admission, she was
disoriented to time and place which could be due to a
combination of her baseline, infection, and delrium. Sedatives
were avoided, and patient was frequently reoriented to her
surroundings. Mental status improved to her baseline during her
ICU stay and per her husband and son, she was at her baseline
prior to transfer to floor and on discharge
4. Acute renal failure - Admission Creatinine was 1.4 which was
likely prerenal given her hypotension. Creatinine trend
continued to improve during her course and was at her baseline
on discharge.
5. Chest pain - Overnight on [**10-20**], the pt had an episode chest
pain overnight with ST depressions laterally in the setting of
urosepsis and infection. She had troponins cycled which were
negative. Repeat EKG on [**10-21**] showed resolution of her EKG
changes. She had no recurrent chest pain and no events on
telemetry. She had lipids checked and revealed LDL of 100 and
triglycerides of 188. She had not recurrence of chest pain
during her hospital stay. She would benefit from an outpatient
stress test given the above history. She was not started on ASA
as this is on her list of allergies. She is already scheduled
for follow up with her primary care on [**11-7**].
Medications on Admission:
Medications (from OMR):
ascorbic acid 500 mg daily
B-complex vitamins
calcium citrate-vitamin d
cyanocobalamin
glucosamine/chondroitin
omega-3
Discharge Medications:
1. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Colace 100 mg Capsule Sig: Two (2) Capsule PO once a day as
needed for constipation.
3. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 11 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Dementia
Urinary urgency
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with fevers, chills and rigors. In the
emergency room, your blood pressure was low and you were given
fluids, antibiotics and were sent to the ICU. Your CT scan
images showed that you had an infection in your kidney. You
also had a chest X ray that was concerning for a pneumonia, but
the repeat imaging does not look like you have this. You were
started on a new medication called levofloxacin for your kidney
infection. You will have to continue this for 2 weeks.
Antacids containing magnesium or aluminum, as well as
sucralfate, metal cations such as iron, and multivitamin
preparations with zinc, should not be taken within 2 hours
before or after LEVAQUIN?????? administration
Please return to the emergency room if you develop persistent
fevers, chills, night sweats, nausea, vomiting, back pain.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7869**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2192-11-22**]
1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6310**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2192-11-7**]
3:20
ICD9 Codes: 0389, 5849, 5180, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7345
} | Medical Text: Admission Date: [**2167-2-26**] Discharge Date: [**2167-3-11**]
Date of Birth: [**2093-4-25**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
woman with known aortic stenosis and mitral stenosis,
admitted in [**2164-3-23**], with acute congestive heart failure
and a myocardial infarction. Catheterization at that time
showed no significant coronary artery disease. The patient
was again admitted in [**2166-11-24**], with congestive heart
failure and referred for stress testing. Stress test done in
[**Month (only) 404**] showed an ejection fraction of 70 percent with no
inducible ischemia. Catheterization done on [**2167-2-20**],
showed three vessel disease as well as aortic and mitral
stenosis. The patient was then referred to Cardiothoracic
Surgery for aortic valve replacement, mitral valve
replacement, coronary artery bypass graft. Transesophageal
echocardiogram done [**2167-2-10**], showed an aortic valve area
of 0.5 to 0.6 centimeter squared with one plus aortic
insufficiency and moderate to severe mitral stenosis with a
mitral valve area of 1.4 and two plus mitral regurgitation.
It also showed severe mitral annular calcification and left
ventricular hypertrophy with an ejection fraction of 65
percent.
PAST MEDICAL HISTORY: Hypertension.
Hyperlipidemia.
Diabetes mellitus.
Congestive heart failure.
Aortic stenosis.
Mitral stenosis.
Peripheral vascular disease.
Gastroesophageal reflux disease.
Osteoporosis.
PAST SURGICAL HISTORY: Right carotid endarterectomy done in
[**2163**].
ALLERGIES: The patient states no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg daily.
2. Lipitor 40 mg daily.
3. Toprol 12.5 mg daily.
4. Lotrel 5 to 20 mg daily.
5. Aspirin 81 mg daily.
6. Protonix 40 mg daily.
7. K-Lor 20 daily.
8. Fosamax 70 mg weekly, typically taken on Sunday.
SOCIAL HISTORY: Widowed, livers with son in [**Name (NI) 3494**].
Remote tobacco history, quit over twenty years ago, and rare
alcohol use.
FAMILY HISTORY: Significant for mother who died of
myocardial infarction at age 57 and father who died of
myocardial infarction at age 80.
PHYSICAL EXAMINATION: Height five feet, weight 151 pounds.
Vital signs revealed temperature 98, heart rate 66, sinus
rhythm, blood pressure 105/38, respiratory rate 18, oxygen
saturation 97 percent in room air. In general, she is lying
in bed in no acute distress. Neurologically, she is alert
and oriented times three, moves all extremities, follows
commands, nonfocal examination. Respiratory is clear to
auscultation bilaterally. Cardiovascular regular rate and
rhythm, S1 and S2, with a IV/VI systolic ejection murmur
radiating bilaterally to the carotids. Abdomen is soft,
nontender, nondistended, with normoactive bowel sounds.
Extremities are warm and well perfused with no edema or
varicosities. Pulses - Radial two plus bilaterally, dorsalis
pedis and posterior tibial one plus bilaterally.
LABORATORY DATA: White blood cell count 5.4, hematocrit
30.0, platelet count 165,000. Prothrombin time 14.0, partial
thromboplastin time 28.0, INR 1.2. Sodium 135, potassium
4.5, chloride 104, CO2 23, blood urea nitrogen 30, creatinine
1.2, glucose 88. Liver function tests within normal limits.
Urinalysis is negative. Carotids with mild plaque
bilaterally with no hemodynamic significance.
HOSPITAL COURSE: The patient was a direct admission to the
operating room where she underwent an aortic valve
replacement, mitral valve replacement, coronary artery bypass
graft times three. Please see the operative report for full
details. In summary, the patient had an aortic valve
replacement with a number 19 St. [**Male First Name (un) 923**] mechanical valve,
mitral valve replacement with a number 25 St. [**Male First Name (un) 923**] mechanical
valve and a coronary artery bypass graft times three with
left internal mammary artery to the left anterior descending
coronary artery, saphenous vein graft to obtuse marginal and
saphenous vein graft to right coronary artery. Her bypass
time was 223 minutes with a cross clamp time of 198 minutes.
The patient tolerated the operation and was transferred from
the operating room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient had Milrinone at 0.25
mcg/kg/minute and Neo-Synephrine at 1.5 mcg/kg/minute. The
patient did well in the immediate postoperative period. Her
anesthesia was reversed. She was weaned from all sedation,
moved all extremities to commands and then was resedated
during the course of the operative night. On postoperative
day number one, her sedation was again lightened. She was
weaned from the ventilator and successfully extubated. She
remained hemodynamically stable throughout this period. On
postoperative day number two, the patient continued to
progress. She was begun on beta blockade. Her Swan-Ganz
catheter was removed and her activity level was advanced with
the assistance of the nursing staff. Later in the day of
postoperative day number two, the patient went into a rapid
atrial fibrillation which she did not tolerate well
hemodynamically and therefore she remained in the
Cardiothoracic Intensive Care Unit. Additionally, an
Amiodarone infusion was begun. On postoperative day number
three, the patient was hemodynamically stable on beta
blockade as well as Amiodarone drip. Diuretics were also
begun at that time. She was transfused with two units of
packed red blood cells and her chest tubes were removed.
Because of intermittent atrial fibrillation, the patient
remained in the Cardiothoracic Intensive Care Unit.
Postoperative day number four, the patient continued to have
episodes of rapid atrial fibrillation which she did not
tolerate hemodynamically. Amiodarone infusion continued.
The patient was also begun on Heparin at that time.
Additionally, she was loaded with Digoxin which seemed to
slow her ventricular response rate. Ultimately, the patient
returned to a sinus rhythm, however, during this period, the
patient had poor urine output and during that time she was
begun on a Natrecor infusion as well. Postoperative day
number five, the patient had improved hemodynamically. She
remained in sinus rhythm with adequate cardiac output and
index. She was aggressively diuresed. he Swan-Ganz catheter
was removed on postoperative day number six. The patient
continued to make progress hemodynamically. Her Amiodarone
infusion was stopped and she was begun on oral Amiodarone.
Her Natrecor infusion was weaned. She was placed on oral
diuretics postoperative day number seven. The patient
continued to do well. Her beta blockade was increased. Her
temporary pacing wires were removed. Her right IJ was
removed. On postoperative day number eight, she was
transferred to the floor for continued postoperative care and
cardiac rehabilitation. Additionally, the patient was begun
on oral Coumadin. Once on the floor, the patient had an
uneventful postoperative course. Her activity level was
increased with the assistance of the nursing staff as well as
the physical therapy staff. On postoperative day thirteen,
it was decided that the patient was stable and ready to be
discharged to home with visiting nurses. At the time of this
dictation, the patient's physical examination is as follows:
Temperature 100, heart rate 80 and sinus rhythm, blood
pressure 123/62, respiratory rate 18, oxygen saturation 95
percent in room air. Weight preoperatively 69 kilograms and
at discharge 67.3 kilograms. Laboratories showed sodium 140,
potassium 4.1, chloride 101, CO2 32, blood urea nitrogen 25,
creatinine 1.3, glucose 107. Prothrombin time 14.0, partial
thromboplastin time 75, INR 2.3. White blood cell count is
4.5, hematocrit 38.0, platelet count 467,000. Physical
examination, neurologically, the patient is alert and
oriented times three, moves all extremities, follows
commands, nonfocal examination. Pulmonary is clear to
auscultation bilaterally. Cardiac regular rate and rhythm,
sternum stable and incision with Steri-Strips without
drainage or erythema. Abdomen is soft, nontender,
nondistended with normoactive bowel sounds. Extremities are
warm and well perfused with trace edema. Right endoscopic
saphenous vein graft harvest site with Steri-Strips, open to
air, clean and dry. Left open saphenous vein graft harvest
site with staples, open to air, clean and dry.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass grafting times three, left internal
mammary artery to the left anterior descending coronary
artery, saphenous vein graft to obtuse marginal and saphenous
vein graft to right coronary artery.
Aortic stenosis, status post aortic valve replacement with
number 19 St. [**Male First Name (un) 923**] mechanical valve.
Mitral stenosis, status post mitral valve replacement with
number 25 St. [**Male First Name (un) 923**] mechanical valve.
Diabetes mellitus.
Hypertension.
Hypercholesterolemia.
Congestive heart failure.
Peripheral vascular disease.
Gastroesophageal reflux disease.
Osteoporosis.
Status post right carotid endarterectomy.
DISCHARGE STATUS: The patient is to be discharged home with
visiting nurses.
FOLLOW UP: She is to have follow-up with Dr. [**Last Name (STitle) **] in one
to two weeks, with Dr. [**Last Name (STitle) **] in two to four weeks, and
with Dr. [**Last Name (STitle) **] in four weeks.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Aspirin 81 mg daily.
3. Percocet 5/325 one to two tablets q4-6hours as needed.
4. Captopril 12.5 mg three times a day.
5. Prilosec 40 mg daily.
6. Lipitor 40 mg daily.
7. Amiodarone 400 mg daily times seven days, then 200 mg
daily.
8. Metoprolol 75 mg three times a day.
9. Lasix 40 mg daily.
10. Potassium Chloride 20 mEq daily.
11. Warfarin as directed with a target INR of 3.0 to
3.5. Initial INR check is on Friday, [**2167-3-13**], with
results to be called to Dr.[**Name (NI) 58873**] office.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2167-3-11**] 16:56:31
T: [**2167-3-11**] 19:06:18
Job#: [**Job Number 58874**]
ICD9 Codes: 9971, 4019, 2720, 4439, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7346
} | Medical Text: Admission Date: [**2127-12-4**] Discharge Date: [**2127-12-13**]
Date of Birth: [**2056-4-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Positive stress test
Major Surgical or Invasive Procedure:
[**2127-12-5**] - Urgent off-pump coronary artery bypass graft x3: Left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to diagonal and posterior descending
arteries.
[**2127-12-4**] - Cardiac catheterization
History of Present Illness:
This is a 71 year old male with polycystic kidney disease,
dialysis dependent who was in the process of kidney transplant
evaluation. The patient had CT chest on [**2127-10-1**] revealing a 2.2
x 2.1 x 2.4 cm right upper lobe lung nodule, which was treated
with antibiotics. He then had a repeat CT chest [**2127-11-6**]
revealing increased size to 2.9 x 2.5 x 2.6 cm. Patient was
being worked up for a right upper lobe nodule removal and was
found to have a positive stress test. Upon telephone interview
with patient he states he gets fatigue very easily, he denies
chest discomfort. Patient complains of shortness of breath on
exertion for the past six months.
Past Medical History:
Hypertension
COPD
Polycystic Kidney Disease on HD since [**1-5**] 3x week M-W-F
Left leg claudication
Ventral Hernia
Hypercholesterolemia
Cardiac Arrest [**2124**]
GERD
Arthritis
Past Surgical History
Cerebral artery aneurysm clipping [**2114**]
Abdominal Aortic aneurysm repair [**2124**] at [**Hospital1 112**]
Social History:
Lives with:Married with a son and daughter [**Name (NI) 2270**] who is his
health care proxy, his wife has [**Name (NI) 2481**].
Occupation:retired
Tobacco:denies (quit 3 years ago), smoked 1ppd for 50 yrs
ETOH:denies (quit 3 yrs ago)
Family History:
Family History:adopted, family history unknown
Physical Exam:
Pulse: 67 Resp: 14 O2 sat: 99% RA
B/P Right: 184/78 on nitro
Height:6'1" Weight:214lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x](distant)
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]large abdominal incision, midline
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 1+ Left:1+
Carotid Bruit Right: - Left:-
LEFT ARM FISTULA
Pertinent Results:
[**2127-12-4**] Cardiac Catheterization
1. Coronary angiography in this right dominant system
demonstrated a
distal lesion in the LMCA extening in the proximal LAD of 60-70%
stenosis. The LAd had a 60-70% mid ulcerated lesion with a 90%
distal
lesion into the diag bifurcation. The Lcx was normal. The RCA
had a 60%
mid and 70% distal lesion.
2. Limited hemodynamics revealed severe centralized
hypertenison to
193mm Hg that was treated with a nitroglycerine drip during the
procere.
3. In the post procedure holding are the patient developed a
mild-moderate size hematoma in the right groin that was easily
controlled and regressed with manual pressure
[**2127-12-5**] ECHO
Intraoeprative findings:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %).
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 ascending aorta. The aortic arch is
mildly dilated. There are complex (>4mm) atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen.
Mild to moderate ([**12-28**]+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) 7772**] was notified in person of the results.
[**2127-12-5**] Carotid ultrasound
Mild heterogeneous plaque bilaterally with bilateral 1-39% ICA
stenosis. Vertebral abnormalities as described above without any
significant evidence of inflow disease on the left.
[**2127-12-5**] Femoral ultrasound
Normal study, without pseudoaneurysm, AV fistula, or hematoma.
[**2127-12-10**] 07:01AM BLOOD WBC-7.4 RBC-2.67* Hgb-8.8* Hct-26.3*
MCV-99* MCH-32.9* MCHC-33.3 RDW-15.1 Plt Ct-174#
[**2127-12-5**] 05:07PM BLOOD PT-14.9* PTT-28.4 INR(PT)-1.3*
[**2127-12-10**] 07:01AM BLOOD Glucose-125* UreaN-65* Creat-8.1*# Na-137
K-4.7 Cl-95* HCO3-26 AnGap-21*
[**Known lastname 21376**],[**Known firstname 21377**] [**Medical Record Number 21378**] M 71 [**2056-4-26**]
Radiology Report CHEST (PA & LAT) Study Date of [**2127-12-9**] 9:04 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2127-12-9**] 9:04 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 21379**]
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
71 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
r/o inf, eff
Final Report
CLINICAL HISTORY: Status post CABG, evaluate for pleural
effusion.
COMPARISON: Multiple radiographs dating back to [**2127-12-5**], most
recently
[**2127-12-6**]; outside CT [**2127-11-6**] and PET [**2127-11-15**].
FINDINGS: Compared to [**2127-12-6**], lung volumes are improved.
There is mild
bibasilar atelectasis with improvement in retrocardiac
atelectasis. A tiny
left pleural effusion is seen. There is no pneumothorax or
pulmonary vascular
congestion. A calcified granuloma is at the right lung base. A
right medial
apical mass corresonds to mass seen on outside CT and PET. The
heart is stably
enlarged. The mediastinal width is decreased since [**2127-12-6**] in
this patient
status post CABG. A right internal jugular catheter terminates
in the mid
SVC.
IMPRESSION:
1. Tiny left pleural effusion.
2. Improved retrocardiac atelectasis with mild persistent
bibasilar
atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: TUE [**2127-12-9**] 1:41 PM
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2127-12-4**] for a cardiac
catheterization following a positive stress test. He underwent
stress testing due to an enlarging right upper lobe lung nodule
which is being followed by thoracic surgery with planned future
surgical intervention. His catheterization revealed severe left
main and three vessel disease. Given the severity of his
disease, the cardiac surgical service was consulted. Mr. [**Known lastname **]
was worked-up in the usual preoperative manner including a
carotid duplex ultrasound which showed mild bilateral internal
carotid artery disease. On [**2127-12-5**], Mr. [**Known lastname **] was taken to the
operating room where he underwent off-pump coronary artery
bypass grafting to three vessels. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Over the next 24 hours, he awoke neurologically
intact and was extubated. Beta blockade, aspirin and a statin
were resumed. Plavix was started and is to be continued for 3
months given his off-pump surgery. He resumed his hemodialysis
as per preoperatively. The renal service followed him closely
while recovering from his cardiac surgery. On postoperative day
one, he was transferred to the step down unit for further
recovery. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. Lasix
was resumed at 40mg daily per the renal service and per
preoperatively. He continued to not make a significant amount of
urine. He had a short episode of atrial fibrillation which
quickly converted back to normal sinus rhythm with amiodarone.
He continued to make steady progress and was discharged home on
postoperative day 6. He will follow-up with Dr. [**First Name (STitle) **], Dr.
[**Last Name (STitle) 7047**] and Dr. [**Last Name (STitle) 17918**] as an outpatient. He will also resume
his normal hemodialysis schedule as an outpatient. He will
follow-up with Dr. [**First Name (STitle) **] of thoracic surgery on [**1-6**] @ 9AM
regarding management of his lung nodule. He will get home PT
with VNA services.
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - [**12-28**] every four (4) hours as needed for
shortness of breath or wheezing
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by
Other Provider) - 1 mg Capsule - one Capsule(s) by mouth daily
CALCIUM ACETATE - (Prescribed by Other Provider) - 667 mg
Capsule - two Capsule(s) by mouth three times daily
EPOETIN ALFA [EPOGEN] - (Prescribed by Other Provider) - 2,000
unit/mL Solution - 2400 units 3x/week
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth daily
LABETALOL - (Prescribed by Other Provider) - 300 mg Tablet - 1
Tablet(s) by mouth twice a day
PARICALCITOL [ZEMPLAR] - (Prescribed by Other Provider) - 2
mcg/mL Solution - 3mcg three times a week with dialysis
REMVELA - (Prescribed by Other Provider) - - two tablets
three
times daily
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth daily
VERAPAMIL - (Prescribed by Other Provider) - 180 mg Cap,24 hr
Sust Release Pellets - 0.5 (One half) Cap(s) by mouth four times
a week, S,T,T, S
Medications - OTC
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
iron) Tablet - one Tablet(s) by mouth daily
FIBER - (Prescribed by Other Provider) - 0.52 gram Capsule - 2
(Two) Capsule(s) by mouth twice daily
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
2. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day for 3
months.
Disp:*90 Tablet(s)* Refills:*0*
3. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*0*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO Daily in the
evening.
Disp:*30 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. paricalcitol 5 mcg/mL Solution Sig: 3mcg Intravenous 3X/WEEK
(TU,TH) as needed for w/ HD.
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks: Then switch to 1 tablet, 200mg daily thereafter.
Disp:*37 Tablet(s)* Refills:*0*
10. labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day:
hold until after HD on dialysis days .
Disp:*60 Tablet(s)* Refills:*0*
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Epogen 2,000 unit/mL Solution Sig: 2400 (2400) Units
Injection Three times per week with hemodialysis.
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] home care
Discharge Diagnosis:
Coronary artery disease s/p off pump CABG
Atrial Fibrillation
Hypertension
Chronic obstructive pulmonary disease
Polycystic Kidney Disease on HD
Left leg claudication
Ventral Hernia
Hypercholesterolemia
Cardiac Arrest [**2124**]
Gastroesophageal reflux disease
Arthritis
Calcified aorta
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocer
Incisions:
Sternal - healing well, no erythema or drainage
Leg: Left - healing well, no erythema or drainage.
Edema +1 bilateral
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then again in the
evening. Please also take your temperature, these should be
written down on the chart provided.
4) No driving for approximately one month and while taking
narcotics. This will be discussed at follow up appointment with
surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Continue hemodialysis per your schedule and as instructed by
your nephrologist [**Doctor First Name **] [**Doctor Last Name **].
7) Take amiodarone 400mg (Two tablets) daily for 1 week and then
decrease to 200mg (1 tablet) daily until otherwise instructed by
your cardiologist and/or PCP.
8) Take plavix 75mg daily for 3 months then stop. This is for
your off-pump surgery.
9) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2128-1-5**] 1:00
Thoracic Surgery: Dr [**First Name (STitle) **] [**0-0-**] Date/Time:[**2128-1-6**] 9:00
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17918**] in [**3-31**] weeks [**Telephone/Fax (1) 17919**]
Cardiologist: Dr. [**Last Name (STitle) 7047**] in 4 weeks.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2127-12-11**]
ICD9 Codes: 5856, 496, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7347
} | Medical Text: Admission Date: [**2177-4-29**] Discharge Date: [**2177-5-13**]
Date of Birth: [**2110-4-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Hemoptysis
DVT
Major Surgical or Invasive Procedure:
PICC placement
Transfusion of packed red blood cells
Ventilator use (hooked up to tracheostomy)
IVC filter placement
IR coiling of laryngeal artery
Tooth extraction
History of Present Illness:
This is a 67 yo man w/ HTN, CVA, COPD, hyponatremia, EtOH abuse,
and SCC of the larynx s/p coil embolization of right inferior
thyroid artery for hypopharyngeal bleed [**3-/2177**], s/p tracheostomy
and PEG [**3-/2177**], recently discharged to rehab from MICU [**Location (un) **],
who was admitted to the floor on [**4-29**] for right LE DVT. His right
leg has become more warm and edematous, with mild pain, compared
to the left x3 days, and LENIs showed a right partially occluded
distal femoral and popliteal DVT. Given his recent bleed,
anticoagulation was not started, and he was transferred to [**Hospital1 18**]
for consideration of an IVC filter. Also completing course of
antibiotics for suspected aspiration pneumonia from prior
admission.
While on the floor early morning of [**4-30**] he started coughing and
was noted to have bleeding from his trache. He did not have any
respiratory difficulties, and ~150cc of blood was suctioned out
through the trach, the cuff was inflated for airway protection
and he was transfered to MICU green for monitoring. ENT saw the
patient, who was known to them, suspected bleeding from mass
on direct visualization. Pt was being taken down to IR for IVC
filter when he began to bleed again from his trach site. At
that time he was placed on the ventilator, paralyzed and
sedated. ENT packed his oral cavity. Pt then transported to IR
for IVC filter placement. Given that his bleeding has been
attributed to his mass, he is being transfered to the [**Hospital Ward Name **] ICU for ongoing care while he initiates XRT to his mass.
Hematocrit was stable and he was HD stable, so he is being
transferred to the ICU for closer airway monitoring.
Denies CP, SOB, palpitations, change in chronic productive
cough. No other bleeding. Denies fever, chills, dysuria.
Currently pain free.
Past Medical History:
Cerebrovascular accident, treated at [**Hospital1 2025**] [**2157**] with residual gait
weakness
Chronic obstructive pulmonary disease
Hypertension
Gout
Hyponatremia
SCC of the larynx diagnosed [**2177-3-31**], s/p coil embolization of
right inferior thryroid artery for hypopharangeal bleed
S/p tracheostomy and peg [**2177-4-1**] at [**Hospital1 34**]
EtOH abuse
Social History:
Former smoker quit at day of dx, EtOH 14 beers daily up until 1
month ago.
Family History:
Per report-lymphoma and lung ca.
Physical Exam:
GEN:Chronically ill appearing, pleasant, NAD, frequently
suctioning with yankauer
HEENT: nc/at MM dry OP clear with thick clear secretions
CV: Distant. RRR No m/r/g
Resp: Coarse rhonchorous BS throuhgout. No w/r
Abd: Soft. NTND +BS. No HSM
Ext: 2+RLE edema to upper calf with erythema. Trace edema LLE
Neuro: AAOx3. CM [**2-6**] intact. MAE.
Pertinent Results:
Labs at Admission:
[**2177-4-29**] 09:00PM BLOOD WBC-14.4* RBC-3.15* Hgb-9.6* Hct-28.5*
MCV-90 MCH-30.6 MCHC-33.8 RDW-13.9 Plt Ct-584*#
[**2177-5-1**] 04:06AM BLOOD Neuts-85.6* Lymphs-7.2* Monos-6.2 Eos-0.6
Baso-0.3
[**2177-4-29**] 09:00PM BLOOD PT-12.4 PTT-26.3 INR(PT)-1.0
[**2177-4-29**] 09:00PM BLOOD Glucose-93 UreaN-15 Creat-0.4* Na-128*
K-4.2 Cl-91* HCO3-30 AnGap-11
[**2177-4-29**] 09:00PM BLOOD Calcium-8.8 Phos-4.5 Mg-2.1 Iron-30*
[**2177-4-29**] 09:00PM BLOOD calTIBC-230* VitB12-GREATER TH
Folate-18.1 Ferritn-217 TRF-177*
[**2177-4-30**] 02:05AM BLOOD Osmolal-270*
[**2177-4-30**] 09:59PM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-50
pO2-170* pCO2-45 pH-7.43 calTCO2-31* Base XS-5
[**2177-5-1**] 10:17AM BLOOD Hgb-9.5* calcHCT-29
.
Imaging Studies:
[**4-30**] Procedure:
IMPRESSION: Prominent bilateral superior thyroidal arteries and
left inferior thyroidal artery supplying hypervascular
oropharyngeal mucosa.
Successful embolization of blood supply to hypervascular tumor
via the
bilateral superior thyroidal arteries and left inferior
thyroidal artery.
.
[**5-5**] Panorex:
read pending
.
[**5-5**] CT head:
IMPRESSION:
1. No acute intracranial process; specifically no evidence for
enhancing
masses. MR is more sensitive for the detection of small masses.
2. Bilateral maxillary sinus mucosal disease.
.
[**5-5**] CT neck:
IMPRESSION:
1. Extensive hypopharyngeal mass appearing similar to prior with
evaluation of supraglottic extension difficult.
2. No obvious lymphadenopathy.
3. Persistent left vertebral artery nonvisualization and plaque
in the left carotid bifurcation.
.
[**5-5**] CT Chest:
IMPRESSION:
1. New multifocal ground-glass opacity and consolidation in left
lung, mostly in the peribronchial and peripheral distribution,
with one wedge shaped peripheral opacity. Findings are
nonspecific but could be due to infection such as angioinvasive
fungus (for example, mucormycosis);
hemorrhage; or, alternatively, with history of DVT, this could
reflect infarct from non- visualized pulmonary embolism.
2. Thickening and calcification of the anterolateral wall of the
trachea and both mainstem bronchi, could be idiopathic or
related to relapsing
polychondritis. Diffuse bronchial wall thickening, slightly more
prominent on the left associated with left lower lobe mucoid
impaction could be related to infection or inflammation.
3. Minimal emphysema.
4. Moderate left and small right pleural effusion. Small
pericardial
effusion. Bibasilar atelectasis.
5. Enlargement of main pulmonary artery, suggesting possible
pulmonary
hypertension.
6. Severe calcifications of the left main coronary artery.
7. Secretions in the carina and both mainstem bronchi, which
could be blood in setting of tracheal bleed.
8. Please see separately dictated neck CT.
Brief Hospital Course:
Patient is a 67 year old man with history of HTN, CVA, COPD,
status post recent diagnosis of SCC of larynx status post coil
embolization of right inferior thyroid artery for hypopharyngeal
bleed [**3-/2177**], status post trach and PEG [**3-/2177**], recently
discharged to rehab approximately 1 month ago, who initially
presented and was admitted to the floor on [**4-29**] for right LE DVT,
with subsequent complicated hospital course for bleeding at
tracheostomy site.
# Bleeding from tracheostomy site: 24 hours after admission to
floor, patient was noted to have coughing and bleeding from his
tracheostomy site. This was initially managed by inflating the
cuff for airway protection, as well as transfer to the MICU
(initially to [**Hospital Ward Name **] MICU) for closer monitering. He also
received 2 units of packed RBC.
ICU course: Despite the cuff inflation, the patient had
intermittent bleeding from his tracheostomy site, requiring
placement on the ventilator. ENT was involved, and site was
packed (where patient was transiently on prophylactic
clindamycin). He went to IR for IVC filter placement to address
his DVT, at which time he also underwent coiling of a thyroid
artery.
Oncology was also involved during his hospital course, and he
was ultimately transferred from the [**Hospital Ward Name **] MICU to the [**Hospital Ward Name **] [**Hospital Unit Name 153**] for initiation of emergent radiation to be able to
stop the bleeding. He therefore underwent salvage radiation with
control of the bleeding, and was successfully weaned off the
ventilator, and currently remains stable on trach mask.
FLOOR COURSE: After stabilization in the ICU, patient was
transferred back to regular medical floor where bleeding
remained stable. Cancer was addressed as below.
# Right lower extremity deep venous thrombosis: Patient was
admitted to the floor on [**4-29**] for right lower extremity DVT. His
initial complaints were right leg pain, warmth, edema x 3 days,
with lower extremity ultrasound (performed at rehab)
demonstrating a right partially occluded distal femoral and
popliteal DVT. He was sent to [**Hospital1 18**] with above for
consideration of IVC filter (as no plans for anti-coagulation
given recent hypopharyngeal bleed). He successfully underwent
placement of IVC filter in IR on [**4-30**] without complication.
# Laryngeal Cancer: As above, complicated by recurrent bleeds,
now status post 2 coil artery embolizations, status post trach
and PEG. Oncology, radiation oncology, ENT involved early
during hospital course. Patient required dental work prior to
initiation of regular radiation therapy, and chemotherapy
waiting on regular radiation therapy.
Given this delay of therapy, panorex was obtained, dental
consult and maxillofacial surgery consults were obtained.
Patient underwent tooth extraction in OR on [**2177-5-8**], where
evaluation by ENT under anaesthesia was also performed.
Patient also underwent CT head/neck/chest for further evaluation
of the cancer.
Following the tooth extraction, radiation oncology and medical
oncology were consulted and recommended initiation of cetuximab
on [**5-15**] as well as radiation therapy, tentatively scheduled for
[**5-21**]. XRT treatments will be daily Monday through Friday for
seven weeks; he underwent radiation treatment planning in-house
before discharge. Cetuximab will be administered weekly by his
oncologists.
The patient should follow up with ENT (Dr. [**Last Name (STitle) 1837**] in [**2-26**]
weeks.
# Aspiration pneumonia: He has a history of aspiration PNA on
admission and completed a 10-day course of ceftaz and Vanco on
the day after admission.
# Hypertension: We continued his home lisinopril 40 mg daily.
# Anemia: Stable from recent baseline 25-28. Likely secondary
to bleed and inflammation. Iron studies suggest anemia of
chronic disease. Patient received 2 units pRBC on [**4-30**].
# Hyponatremia: Chronic, improved over the course of his
hospitalization.
# Chronic obstructive pulmonary disease: Continued home
nebulizers PRN.
# Status post cerebrovascular accident: There were no active
issues. He is not on aspirin due to bleeding risk.
# FEN: Tube feeds
# Code status: Full
Medications on Admission:
B12 1000 mcg IM qmonth
Folic acid 1
Lisinopril 40
Ranitidine 150 [**Hospital1 **]
Thiamine 100
Allopurinol 300
Mulitivitamin
Ceftazidime 1 q8 x 10 days for HAP, last day [**2177-4-30**]
Colace 100 [**Hospital1 **]
Vancomycin 1000 IV bid last day [**2177-4-30**]
? sq heparin
Dulcolax
Senna
Tylenol
Lorazepam 1mg IV q4PRN
Nebs prn
Oxycodone 5 q4 PRN
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
per PEG tube.
2. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily): per PEG tube.
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth care for 1 weeks.
5. Senna 8.8 mg/5 mL Syrup Sig: 8.8 MLs PO BID ().
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): per PEG tube.
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): per PEG tube.
10. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150)
mg PO BID (2 times a day): per PEG tube.
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): per PEG tube.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Right lower extremity DVT
Bleeding from tracheostomy site, acute blood loss anemia
Secondary:
SCC of larynx
Tracheostomy/PEG tube
COPD
Hypertension
Discharge Condition:
good, stable, managing secretions with suctioning, alert,
interactive
Discharge Instructions:
You were admitted to the hospital from rehab with DVT, but also
had complications with bleeding from your tracheostomy site.
You were stable at time of discharge.
Please take medications as directed.
Please follow up with appointments as directed.
Please contact physician if bleeding at tracheostomy site recurs
(bring to emergency room immediately), any respiratory distress,
fevers/chills, any other questions or concerns.
Followup Instructions:
Follow up with oncology (Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 1852**]). You have an
appointment on Thursday [**5-15**] at 11:30am at which point you
will be started on chemotherapy (cetuximab). Call Dr.[**Name (NI) 21829**]
office at [**0-0-**] or Dr.[**Name (NI) 22252**] office at [**Telephone/Fax (1) 22**]
with any questions.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2177-5-15**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2177-5-15**] 11:30
Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2177-5-15**] 1:00
Follow up with the ENT surgeons. Dr.[**Name (NI) 20390**] office was
contact[**Name (NI) **] for an appointment in [**2-26**] weeks, and they will call
your facility with the time and date. If they do not hear from
them, they can call his office at [**Telephone/Fax (1) 41**].
Follow up with your primary care physician 1-2 weeks asfter
discharge from rehab.
ICD9 Codes: 2761, 2851, 4019, 496, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7348
} | Medical Text: Admission Date: [**2146-10-9**] Discharge Date: [**2146-10-11**]
Date of Birth: [**2090-12-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55 y/o man with PMH significant for depression, type 2 diabetes
mellitus, and HTN admitted through the ED with mental status
changes and fever. Per report, pt was in his normal state of
health this morning when he went out to buy groceries. He had a
normal conversation with his wife on his cell phone at
approximately 1:00 PM. Then, at around 3:00 PM, his wife noted
him to be confused and diaphoretic. He was apparently talking
giberish. EMS was called and his VS were 162/90 130 16 98%.
Pt was given narcan with no improvement in his mental status and
he was brought to the [**Hospital1 18**] ED for further care. In the ED, the
pt's VS were 102.3 ---> 103.8 134 153/96 25 97% 2L NC. He
had a head CT which did not show any acute process. Pt had a LP.
His urine tox screen was positive for opiates. In the ED, the pt
received ceftriaxone 2 gm IV x1, flagyl 500 mg IV x1, acyclovir
800 mg IV x1, ampicillin 2 gm IV x1, and vancomycin 1 gm IV x1.
He also received multiple doses of ativan and valium.
.
In further discussion, pt reports that he has been SOB recently
but is unable to tell me how long. Per report he has had
increased wheezing and SOB over the past few weeks and received
a Z pack without any improvement in his symptoms. Pt reports
that he had a headache this morning. He is unable to give any
further ROS.
Past Medical History:
1. Depression- Per report, pt has been more depressed than
baseline over the last two months.
2. COPD
3. Type 2 diabetes mellitus
4. Hypercholesterolemia
5. Hypertension
6. Substance abuse- Cocaine and percocet.
Physical Exam:
101.1 152/90 101 22 92% 2L NC Weight- 103 kg
Gen- Alert to person and year. Talking very quickly and
antimatedly. NAD.
HEENT- NC AT. PERRL. EOMI. Anicteric sclera. Mildly dry mucous
membranes. No lesions in the oropharynx.
Cardiac- RRR. S1 S2. No m,r,g.
Pulm- Diffuse end expiratory wheezing bilaterally. No rales or
rhonchi.
Abdomen- Obese. Soft. NT. ND. Positive bowel sounds.
Extremities- Warm. No c/c/e. 2+ DP pulses bilaterally.
Neuro- Alert to person and year. No oriented to place. Talking
very quickly with waxing and [**Doctor Last Name 688**] attention. Able to spell
"world" forward but not backward. Able to remember three words
immediately but not in five minutes. CN II-XII intact. [**3-31**]
strength in upper and lower extremities bilaterally. Symmetric
DTRs bilaterally. [**Name2 (NI) **] within normal limits.
Pertinent Results:
ECG- Sinus tach at 130 beats per minute. No ST-T wave changes.
.
CXR- Left costophrenic angle is partially excluded from the
radiograph. Heart size and mediastinal contours appear within
normal limits. Prominence of the upper zone pulmonary
vasculature may relate to supine positioning. Within the left
lung base, there is a focal area of patchy opacity that could
represent atelectasis versus early consolidation. A rounded
opacity seen at the right lung base laterally could represent a
nipple shadow. No pleural effusion or pneumothorax are
identified. Osseous structures appear within normal limits.
.
CT head- Study is limited by patient motion. No gross
intracranial hemorrhage or mass effect. There is no shift of
midline structures. Differentiation of [**Doctor Last Name 352**] and white matter
appears preserved. no hydrocephalus is demonstrated and sulci
are within normal limits. Sulci and basal cisterns appear
unremarkable. Minimal mucosal thickening is demonstrated within
both ethmoid sinuses. Small amount of mucosal thickening is also
seen within the right maxillary sinus. Pt is s/p left anterior
maxillary wall surgery. Remaining visualized paranasal sinuses
and mastoid air cells are clear.
Brief Hospital Course:
55 y/o man with PMH significant for depression, type 2 diabetes
mellitus, and HTN admitted through the ED with mental status
changes and fever.
.
1. Delirium: It is unclear why he would be having this. Included
in the differential diagnosis are infection, overdose, serotonin
syndrome, neuroleptic malignant syndrome, and hyperthyroidism.
MRI did not show any reason for acute change in MS: no sign of
HSV encephalitis; did show Tiny nonspecific elevated FLAIR
signal intensity foci in the cerebral white matter and mid-
pons. TSH was within normal limits. It is unlikely the pt's PNA
alone would have caused his delirium as he is relatively young
and healthy and the PNA does not seem abnormally severe. Most
likely ethanol or withdrawal were the cause of his delirium. He
denied drinking but was taking benzodiazepines and opioids that
he has obtained on the street. He was given 110 mg of diazepam
before significant decrease in his agitation making
benzodiazepine or alcohol withdrawal the likely etiology. Urine
tox screen was negative for amphetamines. Speaking with his
wife, she had found two bottles of meds in his room at home but
was not sure what they were as they had been placed in spare
bottles. Pills were found to be ibuprofen 600mg, tramadol, and
xanax 1mg.
The patient's med list was obtained from his PCP's office on
[**10-10**]. no psychotropic medications are prescribed. the [**Doctor First Name **]
pharmacy also had no record of psychotropic medications being
filled. His PCP confirmed [**Name Initial (PRE) **]/o substance abuse but the patient
reported being clean at last visit on [**10-5**]. Patient was treated
with diazepam for CIWA>10. His agitation, hypertension and fever
resolved by the morning after admission. He was alert and
oriented but was still with pressured speech. Despite our
recommendations he left the hospital against medical advice.
2. [**Name (NI) **] Pt found to have an infiltrate on CXR in addition to
being febrile and having an elevated WBC count. Also concern for
concurrent COPD exacerbation. He was treated with steroids,
azithromycin and oxygen to maintain sats around 93 %. Ct scan
was planned to further characterize this process. However, the
patient left before this study could be completed. He was
strongly advised to follow up with his PCP to follow up his
chest x-ray abnormality.
.
3. HTN- [**Doctor First Name **] pharmacy was contact[**Name (NI) **] and it was found that he
was taking lisinopril, carvedilol, Lipitor and niacin. These
medications were continued during his hospital stay.
.
4. Type 2 [**Name (NI) 1568**] Pt takes insulin at home but his wife is unaware
of the dose. Metformin and Humulin were held during admission.
Fingersticks were well controlled with RISS.
.
Discharge Disposition:
Home
Discharge Diagnosis:
Altered metal status
Discharge Condition:
Left AMA
Discharge Instructions:
Left AMA but was strongly advised to get follow up of his chest
x-ray.
Followup Instructions:
as above
ICD9 Codes: 486, 496, 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7349
} | Medical Text: Admission Date: [**2201-1-31**] Discharge Date: [**2201-2-4**]
Date of Birth: [**2154-5-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Altered mental status s/p fall, drowsiness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 46 yo male with a history of bilateral AVN s/p
hip replacement x2, DM2, depression, and OSA on CPAP who
presented s/p 2 falls at home. 2 days prior to admission, he was
walking at home at 2 am, and reports a mechanical fall in which
he hit the side of a cabinet while walking, and fell back and
hit the back of his head. The fall was unwitnessed, and the
patient is unsure if he had LOC. He denied palpitations,
prodrome, or loss of bowel or bladder function. He believes the
fall may be secondary to cold symptoms vs. his diabetes. He
reports that he had not been checking FSBGs, but he had felt a
little diaphoretic. During the 2 days s/p the fall, his family
reported that he was more confused and lethargic than usual.
Then on the day of admission, he was walking and again fell. He
landed on his knees but did not hit his head. He called out to
his mother for help, but she did not respond so he pushed his
life line button for EMS. Of note, he has had several falls in
the past year secondary to his obesity and chronic pain.
.
Mother reports that patient put on Wellbutrin in past 2 weeks
for smoking cessation. Last year, was at [**Location (un) 38**] at which time
started celexa, buspar, and haldol.
.
His SaO2 was 83% on RA in ambulance. Vital signs in the ED were
temp 96.9, HR 96, bp 154/83, RR 13, SaO2 up to 91% on 4L NC,
FSBG 143. He was found to be Pickwickian, and was alert and
oriented x2. EKG showed NSR at a rate of 83. Head CT showed no
acute intracranial process, and CT C-Spine showed no cervical
spine fracture or malalignment. Blood cultures were sent, CXR
was a l imited study given low lung volume but no definite acute
cardiopulmonary process detected, and he was given Levaquin 750
mg IV x1. ABG showed 7.28/74/63, and he was put on BiPAP and
given Narcan 0.4 mg IV x1. He was admitted for hypercarbic
respiratory acidosis.
.
The patient was initially admitted to the floor, and on the
evening of admission felt agitated as if he was withdrawing from
his medications. He was A&Ox3. He was given Ativan 1 mg PO x2,
Oxycodone 5 mg PO x1, and Dilaudid 0.5-1 mg IV x1. Psych was
consulted and recommmended continuing short-acting opioids and
withholding long-acting opioids. He was started on Oxycodone
5-10 mg PO q4 hr prn, Ativan 1 mg PO q6hr prn, and Morphine 2 mg
IV q2 hr prn. He then developed altered mental status and
somnolence, and ABG showed 7.41/60/40. He received Narcan 0.4 mg
IV x1 then 2 mg IV x2. He was transferred to the MICU, and his
mental status improved with CPAP and brief Narcan gtt. He
remained hemodynamically stable, and ABG improved to 7.47/53/79.
.
The patient currently reports [**3-28**] pain, and localizes his pain
to his back, hips, and knees. He denies nausea.
Past Medical History:
-DM2 has been followed at [**Last Name (un) **]
-OSA on CPAP at home
-Hepatits C - s/p aborted course of interferon
-Major depressive disorder, ? of schizophrenia and bipolar
disorder
-Hypertension
-Bilateral avascular necrosis of femoral heads s/p hip
replacements in '[**79**] and '[**85**]
-s/p L1/L2 kyphoplasty after fall [**6-25**]
-s/p left distal radius fracture after fall [**6-25**]
-Bilateral lower extremity edema, thought to be secondary to
venous stasis
-DJD of his back
-Osteoporosis
-Morbid Obesity
Social History:
- On disability, lives with his mother, attends a day program.
- Smokes 1.5 ppd for > 10yrs, no EtoH for 15 years or illicits
for the past 13 years
- Stopped IVDA in [**2186**] aver 3 years of use, cocaine with heroin
use.
- Has been in psychiatric partial hospitalization program in
[**Location 1268**] for the past six years.
Family History:
Non contributory
Physical Exam:
vitals- T 99.4F, BP 142/96, HR 90, RR 22, O2 96% 3L, Weight: 350
lbs
gen- morbidly obese, sitting in chair, in mild discomfort
secondary to leg pains.
heent- EOMI. OP clear.
pulm- CTA b/l. no r/r/w
cv- RRR. normal S1/S2. no m/r/g
abd- soft, NT/ND. well healed surgical scars. Normal active
bowel sounds
ext- 2+ pitting edema b/l LEs. + Erythema anterior shins b/l
LEs, warm to touch, w/o associated ulceration; symmetric. no
evidence of lymphangitic spread or palpable cords; distal pulses
palpable 1+ b/l.
neuro- alert and oriented x 3. motor strength 5/5 b/l. unable to
flex or extend hips due to previous surgeries.
Pertinent Results:
LABS:
[**2201-2-1**] 08:00AM BLOOD WBC-7.1 RBC-4.43* Hgb-13.4* Hct-40.9
MCV-92# MCH-30.3 MCHC-32.9 RDW-15.8* Plt Ct-133*
[**2201-2-4**] 07:15AM BLOOD WBC-5.1 RBC-4.43* Hgb-13.3* Hct-40.9
MCV-92 MCH-30.0 MCHC-32.5 RDW-16.6* Plt Ct-117*
[**2201-2-1**] 08:00AM BLOOD Neuts-84.8* Lymphs-12.7* Monos-2.2
Eos-0.1 Baso-0.2
[**2201-2-1**] 01:23PM BLOOD Neuts-86.2* Lymphs-11.8* Monos-1.7*
Eos-0.1 Baso-0.1
[**2201-2-1**] 08:00AM BLOOD PT-13.5* PTT-25.9 INR(PT)-1.2*
[**2201-2-1**] 01:23PM BLOOD Fibrino-305
[**2201-1-31**] 10:15AM BLOOD ESR-8
[**2201-1-31**] 10:15AM BLOOD Glucose-113* UreaN-11 Creat-0.7 Na-140
K-4.6 Cl-96 HCO3-38* AnGap-11
[**2201-2-4**] 07:15AM BLOOD Glucose-231* UreaN-9 Creat-0.6 Na-136
K-3.3 Cl-94* HCO3-35* AnGap-10
[**2201-1-31**] 10:15AM BLOOD ALT-143* AST-134* LD(LDH)-193 CK(CPK)-63
AlkPhos-83 Amylase-26 TotBili-0.3
[**2201-2-1**] 01:23PM BLOOD ALT-119* AST-90* LD(LDH)-210 CK(CPK)-176*
AlkPhos-75 Amylase-34 TotBili-0.6
[**2201-1-31**] 10:15AM BLOOD Lipase-20
[**2201-2-1**] 01:23PM BLOOD Lipase-21
[**2201-1-31**] 10:15AM BLOOD cTropnT-<0.01
[**2201-2-1**] 01:23PM BLOOD CK-MB-6 cTropnT-<0.01
[**2201-2-1**] 08:00AM BLOOD Calcium-9.5 Phos-2.2* Mg-1.0*
[**2201-2-1**] 01:23PM BLOOD Albumin-3.7 Calcium-9.9 Phos-2.7 Mg-1.0*
UricAcd-5.0 Iron-72 Cholest-132
[**2201-2-4**] 07:15AM BLOOD Calcium-9.1 Phos-2.5* Mg-1.5*
[**2201-2-1**] 01:23PM BLOOD calTIBC-471* Ferritn-94 TRF-362*
[**2201-2-3**] 08:10AM BLOOD %HbA1c-6.5*
[**2201-2-1**] 01:23PM BLOOD Triglyc-86 HDL-56 CHOL/HD-2.4 LDLcalc-59
[**2201-2-1**] 01:23PM BLOOD TSH-0.16*
[**2201-2-1**] 01:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2201-1-31**] 10:26AM BLOOD Type-ART pO2-63* pCO2-74* pH-7.28*
calTCO2-36* Base XS-4
[**2201-2-1**] 01:07PM BLOOD Type-ART Temp-37 pO2-45* pCO2-54* pH-7.43
calTCO2-37* Base XS-9 Intubat-NOT INTUBA Comment-NON-REBREA
[**2201-2-1**] 01:12PM BLOOD Type-ART Temp-37 pO2-40* pCO2-60* pH-7.41
calTCO2-39* Base XS-10 Intubat-NOT INTUBA Comment-NON-REBREA
[**2201-2-1**] 05:12PM BLOOD Type-ART PEEP-11 pO2-79* pCO2-53*
pH-7.47* calTCO2-40* Base XS-12 Intubat-NOT INTUBA
[**2201-1-31**] 10:42AM BLOOD Lactate-2.5*
[**2201-1-31**] 01:12PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2201-2-1**] 10:33PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2201-1-31**] 01:12PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2201-2-1**] 10:33PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2201-2-1**] 10:33PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
MICRO:
Blood Cx ([**1-31**]): No growth x2
Blood Cx ([**2-1**]): No growth
Urine Cx ([**2-1**]): <10,000 organisms/ml
.
IMAGING:
ECG ([**1-31**]): Sinus rhythm at a rate of 83. Compared to the
previous tracing of [**2200-9-8**] no change.
.
CXR Portable ([**1-31**]): Study is limited secondary to lordotic
positioning and low lung volumes. The cardiomediastinal
silhouette is grossly within normal limits given AP and lordotic
positioning. Perihilar vascular crowding is believed secondary
to low lung volumes. No focal consolidation is appreciated.
Degenerative changes are noted at the left acromioclavicular
joint and a well-corticated ossific density is present superior
to this joint.
IMPRESSION: Limited study given low lung volume, AP technique
and lordotic positioning. No definite acute cardiopulmonary
process detected.
.
Head CT ([**1-31**]): There is no evidence of hemorrhage, edema,
mass, mass effect or infarction. The ventricles and sulci are
normal in size and configuration. There is no fracture.
IMPRESSION: No acute intracranial process.
.
CT C-Spine ([**1-31**]): There is no cervical spine fracture or
malalignment. There is minimal straightening of normal cervical
spine lordosis. Prevertebral and paraspinal soft tissues are
not enlarged. Visualized outline of the thecal sac appears
unremarkable, please note however, that CT is unable to provide
intrathecal detail comparable to MRI. Incidental note is made of
increased ground-glass attenuation, and interlobular septal
thickening at the lung apices, which could be suggestive of
increased volume status.
IMPRESSION: No cervical spine fracture or malalignment.
.
CXR Portable ([**2-1**]): There are low lung volumes. There is
prominence of the central pulmonary vasculature, but the lungs
are probably clear, with the exception of mild atelectasis at
the left costophrenic angle.
IMPRESSION:
Atelectasis left costophrenic angle, otherwise probably clear.
Brief Hospital Course:
# Altered Mental Status: The patient presented with increased
lethargy and confusion s/p 2 falls at home. The falls sounded
mechanical as he reported hitting the side of a cabinet, but he
did hit the back of his head during the first fall. Head CT
showed no acute intracranial process, and CT C-Spine showed no
cervical spine fracture or malalignment. Blood cultures showed
no growth, and Urine culture showed <10,000 organisms/mL. The
patient became agitated on the night of admission possibly
secondary to withdrawal from his medications, and received
Ativan 1 mg PO x2, Oxycodone 5 mg PO x1, and Dilaudid 0.5-1 mg
IV x1. He then developed altered mental status and somnolence,
and ABG showed 7.41/60/40. He received Narcan 0.4 mg IV x1 then
2 mg IV x2. He was transferred to the MICU for oversedation, and
his mental status improved with CPAP and a brief Narcan gtt. He
remained hemodynamically stable, and ABG improved to 7.47/53/79.
His altered mental status was thought to be due to a combination
of fall (post-concussion) with polypharmacy from his home
narcotic medications. His mental status was clear at the time of
discharge. He was discharged on his home doses of Oxycontin 100
mg PO q8hr, Percocet 5-325 mg, 1-2 Tablets PO q6 hr prn,
Alprazolam 2 mg PO qid, Buspirone 10 mg tid, Citalopram 40 mg
daily, Haldol 5 mg PO bid, and Quetiapine 200 mg PO qhs. His
Temazapam and Wellbutrin were held during this admission, and
can be added back as an outpatient.
.
# Pain management: The patient is on multiple pain medications
at home given his chronic back, hip, and knee pain. The pain
service was consulted during this admission. He was placed on a
Clonidine patch TTS 1 qweekly during this admission, but this
was not continued at the time of discharge. His other pain
medications include Oxycontin 100 mg PO q8 hr and Percocet [**11-19**]
tabs q6 hr prn breakthrough pain.
.
# OSA: The patient has a history of OSA and is intermittently on
CPAP at home. He may have a component of obesity hypoventilation
leading to hypoxia and wheezing. TTE [**8-25**] showed borderline
pulmonary artery systolic hypertension. The patient was given
Nasal BiPap at night, and satted well on room air. He was given
Albuterol and Atrovent nebs prn. He was scheduled for an
outpatient follow up appointment with Pulmonary in the Sleep
Clinic.
.
# Hypertension: The patient was continued on Toprol XL 100 mg
daily. He was started on Lisinopril 5 mg daily, and this can be
titrated up as an outpatient for further blood pressure control.
.
# Diabetes Mellitus Type 2: His last HgA1c was 6.2% in [**6-25**], and
a repeat HgA1c during this admission was 6.5%. He was continued
on Metformin 1000 mg [**Hospital1 **].
.
# Depression/Anxiety: The patient has a history of depression
and has had auditory hallucinations for the past 3 years. During
this admission he continued to have auditory hallucinations of
voices telling him he is a fraud and that he should be able to
walk. He denied visual hallucinations. He denied suicidal
ideation, but does wonder "what will my life become" given his
frequent pain. Psychiatry was consulted during this admission.
He was continued on Haldol 5 mg [**Hospital1 **], Seroquel 200 mg qhs, Celexa
40 mg daily, Xanax 2 mg qid, Buspar 10 mg tid. His Temazapam and
Wellbutrin were held per psychiatry recommendations, and these
can be added back as an outpatient as needed. His TSH was
slightly low at 0.16 during this admission, and will need to be
rechecked as an outpatient.
.
# Tobacco Abuse: He was started on a Nicotine patch 14 mg daily.
Medications on Admission:
Medications on Admission (Psych confirmed with Strand Pharmacy)
-Alprazolam 2 mg QID
-Buspirone 10 mg tid
-Celexa 40 mg daily vs. 30 mg [**Hospital1 **]
-Docusate Sodium 100 mg Capsule [**Hospital1 **]
-Haloperidol 5 mg Tablet [**Hospital1 **]
-Magnesium Oxide 400 mg [**Hospital1 **]
-Metoprolol Succinate (Toprol XL) 100 mg daily
-Metformin 1000 mg [**Hospital1 **]
-Hexavitamin daily
-Oxycodone 100 mg Tablet Sustained Release q8hr
-Quetiapine 200 mg qhs
-Tylenol 1000 mg qid prn pain
-Wellbutrin SR 100 mg [**Hospital1 **]
-Temazapam 30 mg qhs
-Zocor 80 mg daily
.
Allergies: Codeine
Discharge Medications:
1. Alprazolam 1 mg Tablet Sig: Two (2) Tablet PO four times a
day.
2. Buspirone 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
6. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Oxycodone 60 mg Tablet Sustained Release 12 hr Sig: 1.5
Tablet Sustained Release 12 hrs PO Q8H (every 8 hours).
**** Please note: This should actually read Oxycodone 100 mg PO
q8 hr (not 90 mg PO q8hr). The patient was aware of this at the
time of discharge.
12. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for breakthrough pain.
14. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY:
Altered Mental Status
Respiratory Depression
Hypertension
.
SECONDARY:
Diabetes Mellitus
Obstructive Sleep Apnea
Depression
Anxiety
Tobacco Abuse
Discharge Condition:
Afebrile, awake and alert, ambulating with PT
Discharge Instructions:
1. If you develop chest pain, shortness of breath, fever >101.5,
confusion or mental status changes, falls, loss of
consciousness, lightheadedness or dizziness, weakness or
numbness, or any other symptoms that concern you, call your
primary care physician or return to the ED.
2. Take all medications as prescribed.
3. Attend all follow up appointments.
4. Your Temazapam and Wellbutrin were held during this
admission. You should ask your primary care physician or
psychiatrist if and when these medications should be restarted.
5. You were started on Lisinopril 5 mg daily to help with your
blood pressure.
6. You were started on a Nicotine Patch to help you stop
smoking.
Followup Instructions:
You will need to follow up with Dr. [**Last Name (STitle) 2204**], you primary care
physician ([**Telephone/Fax (1) 2205**]) in the next 1-2 weeks. His office will
call you in the next few days with an appointment date and time.
.
You have a follow up appointment with [**Doctor First Name **] in Vascular
([**Telephone/Fax (1) 1237**]) on [**2201-2-16**] at 1:00 in VASCULAR [**Apartment Address(1) 871**] of the
[**Hospital Unit Name **], [**Location (un) **]. You then have an appointment with Dr.
[**Last Name (STitle) **] in Vascular ([**Telephone/Fax (1) 1237**]) on [**2201-2-16**] at 2:00.
.
You have a follow up appointment with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **] in the Pulmonary Sleep Clinic ([**Telephone/Fax (1) 612**]) on [**2-17**] at
9:30 in the [**Hospital Ward Name 23**] Center [**Location (un) 858**].
ICD9 Codes: 2762, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7350
} | Medical Text: Admission Date: [**2201-5-15**] Discharge Date: [**2201-5-17**]
Date of Birth: [**2123-7-21**] Sex: M
Service: MEDICINE
Allergies:
Cefazolin
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
right internal jugular central venous catheter insertion
History of Present Illness:
77 year old male with a history of known 5 cm AAA and
penetrating thoracic aortic ulcerations, CHF with EF 30-35%, DM,
ESRD on HD(MWF) via LUE AV fistula, carotid disease, chronic
dyspnea on 3LNC, previous MSSA bacteremia presents from dialysis
with hypotension. Pt here from dialysis after full run with c/o
bright red blood from rectum on toilet paper. Denies abd pain,
CP, SOB, lightheadedness, or dizziness in dialysis. Of note,
patient admitted from [**Date range (1) 29411**] for similar presenation after
dialysis. He had a CT scan at that point which ruled out AAA
rupture. He was initially on dopamine but once it was determined
that thigh BPs were higher than arms, he was quickly weaned off.
It was ultimately thought that BPs low from intravascular
depletion after dialysis. He had an episode of somnolent and
delirium after receiving ativan. During this admission he was
also intubated on admission after reaction while getting blood
and Vancomycin while hypertensive so thought to have flash pulm
edema. This resolved quickly. He was guaic positive previously.
.
In the ED initial vitals were: 96.8 72 97/68 20 93% 3L.
Triggered for BPs to 70s -> bolus. Prior to transfer, 98.6, HR
74 paced, 103/67, 16 100% 3l n/c. V-Paced, [**Doctor Last Name **] to prior. Brwn
stool, guaiac positive. CBC- hct stable. Pt SBPs 90s, int then
dropped to 70s, trigger x3 but asymptomatic. Cautious IVF->500cc
fluids x2. Asictes thought [**1-14**] CHF in past. RIJ placed in ED for
levofed on 0.01 BPs now 96/65 77. Mentating ok. Doesn't urinate
a lot.
.
Upon arrival to the ICU, patient was asking for food but was
otherwise without complaints. His SBPs in thighs showed SBPs in
200s and levofed was immediately shut off. There was noticeable
difference in upper ext BPs by 100mmHG lower which had been
reported previously. He reported not feeling well in the months
prior but no recent changes in symptoms since recent hospital
discharge. Reports having occasional episodes of spots bright
red blood in toilet but no profuse bleeding. Denied CP, SOB,
cough, fever, dizziness, N/V/D but did endorse abdomen more
distended.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
or constipation. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
-HTN
-DM
-ESRD on HD MWF
-PVD
-Carotid stenosis
-infrarenal AAA
-DVT [**2195**]
-Dementia
-UC - quiet x 25 years
-R adrenal adenoma
-Gout
-Prostate Ca
-Kidney stones
-Fe deficiency anemia
-Aphasic episode - ? CVA
PSH:
-PM ([**Company 1543**] pacemaker, Sensia SEDR01) [**2-19**]
-s/p L BK [**Doctor Last Name **]-DP w RGSVG [**6-20**]
-s/p LUE AVF [**12-19**], s/p mult angioplasties
-s/p prostatectomy 00
- L ureteral stent [**92**]
Social History:
Quit smoking at age 73. Retired as a chemical mixer from a
leather tannery. No alcohol or illicit drug use.
Family History:
Brother had liver cancer. Father and mother had CVAs. Paternal
grandfather had rectal cancer.
Physical Exam:
VS: Temp: 98.6 BP: 118/92 HR:78 RR: 24 O2sat 100%3L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, jvd difficult to
appreciate with line, no carotid bruits, no thyromegaly or
thyroid nodules
RESP: crackles at left bases, no wheezes or rhonchi
CV: RR, S1 and S2 wnl, 2/6 SEM best heard at LUSB, no r/g
ABD: distended with ascites, +b/s, soft, TTP in LLQ, no masses
or hepatosplenomegaly appreciated, no rebound or guarding
EXT: no c/c, 1+ edema to b/l knees, left 2nd toe s/p amputation,
DP dopplerable b/l
SKIN: no jaundice/no splinters, erythema in b/l legs c/w venous
stasis changes
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
Admission labs:
[**2201-5-15**] 12:30PM BLOOD WBC-12.2*# RBC-2.74* Hgb-8.8* Hct-27.5*
MCV-101* MCH-32.2* MCHC-32.0 RDW-21.6* Plt Ct-140*
[**2201-5-15**] 12:30PM BLOOD PT-13.9* PTT-27.1 INR(PT)-1.2*
[**2201-5-15**] 12:30PM BLOOD Glucose-77 UreaN-13 Creat-3.6* Na-145
K-3.4 Cl-97 HCO3-38* AnGap-13
[**2201-5-15**] 12:30PM BLOOD cTropnT-0.72*
[**2201-5-15**] 12:30PM BLOOD CK-MB-4
[**2201-5-15**] 12:43PM BLOOD Glucose-78 Na-145 K-3.4* Cl-92*
calHCO3-38*
.
Discharge labs:
[**2201-5-16**] 08:32PM BLOOD Hct-25.6*
.
Microbiology:
Blood culture [**2201-5-15**]: no growth to date at time of discharge
MRSA screen [**2201-5-16**]: pending at time of discharge
.
EKG: Vpaced at 77bpm, unchanged from prior [**2201-4-4**]
.
Imaging:
.
CXR (portable AP) [**2201-5-15**]: Again seen is a pacemaker with dual
leads seen projecting in the right atrium and right ventricle.
The degree of enlargement of the cardiac silhouette is
unchanged. There is haziness of the pulmonary vasculature
suggesting mild failure. There are no pleural effusions. There
is trace atelectasis seen in the left lower lobe. IMPRESSION:
Mild pulmonary edema.
Brief Hospital Course:
77 year old male with a 5 cm AAA and penetrating thoracic aortic
ulcerations, CHF with EF 30-35%, DM, ESRD on HD(MWF) via LUE AV
fistula, carotid disease, chronic dyspnea on 3LNC, previous MSSA
bacteremia presents from dialysis with hypotension.
.
#. Hypotension/hypertension: The patient was initially thought
to be hypotensive, with blood pressures in his right arm as low
as the 70s. He was never symptomatic. In the emergency
department, he was treated with IV fluids. Additoinally, a
central venous catheter was placed in the ED, norepinephrine,
and the patient was transferred to the MICU.
.
In the MICU, prior records were reviewed, including the
partially-completed discharge summary from the patient's
[**Date range (1) 29412**] admission for asymptomatic hypotension after
dialysis. During this prior admission, it was determined that
the blood pressures in his right upper extremity were
significantly different (by 100 points) from his right thigh
pressures, and it was recommended that blood pressures be
checked in the patient's thigh. Based on this information, the
patient's right thigh pressure was checked and was found to be
in the 200s. Norepinephrine was shut off, with improvement in
the patient's right thigh pressure to the 160s. As before, the
patient had a significant difference between his his right arm
and thigh blood pressures. Antihypertensives were initially
held, but the right thigh blood pressure rose to the 230s during
ultrafiltration on [**2201-5-17**]. Lisinopril and metoprolol were
restarted, with improvement in the patient's right blood
pressure to the 160s. The patient was never symptomatic.
.
Consideration was given to whether the patient's arm-thigh blood
pressure difference might be a sign of acute aortic pathology.
The same concern was raised during the patient's [**Date range (1) 29411**]
admission, during which CT angiography of the chest from showed
extensive but stable aortic atherosclerotic disease, and CTA of
the abdomen and pelvis showing the patient's known abdominal
aortic aneurysm without evidence of leak or rupture.
.
The patient's arm-thigh blood pressure difference was discussed
with the vascular team who cared for the patient during his
prior admission. They concluded that it was very difficult to
determine the patient's true aortic blood pressure, which was
probably somewhere in between the blood pressures that were
being measured in the patient's arm and thigh. They thought the
patient's arm pressure was probably more accurate, but that it
might not be completely accurate given the patient's extensive
peripheral vascular disease and the fact that he was hypotensive
in the right arm but asymptomatic.
.
At the time of discharge, the patient's right thigh blood
pressure was in the 160s, and his right arm blood pressure was
in the 110s with a pediatric cuff. The patient was discharged
without any medication changes, with instructions to follow up
with his vascular surgeon and his primary care physician for
further management of his hypertension.
.
#. Leukocytosis: WBC count was elevated to 12.2 on admission,
but the patient had no fever or focal signs of infection. CXR
showed some atelectasis but no infiltrate. The patient's oxygen
requirement remained at his baseline of 3L. The patient refused
to be catheterized for urinalysis and culture. A blood culture
showed no growth to date at the time of discharge.
.
#. Right red blood per rectum: The patient's hematocrit remained
stable during his admission. However, the nurses noted a very
small amount of blood in the commode after the patient used it.
The patient's stool was brown but guaiac positive. The reported
that he occasionally saw blood on his toilet paper at home. The
nurses were not certain if the bleeding was coming from the
patient's GI or GU tract, but the patient refused urinalysis for
further evaluation of this. The patient was instructed to follow
up with his primary care doctor for further evaluation of the
bleeding.
.
#. Anemia: Chronic. Hct stable. Likely related to chronic kidney
disease +/ chronic blood loss. No concern for acute bleeding.
The patient was instructed to follow up with his primary care
doctor regarding the bleeding.
.
# Thrombocytopenia: Platelet count at baseline.
.
# ESRD: The patient is dialyzed on a MWF schedule and also
receives ultrafiltration on Saturdays. He received
ultrafiltration on [**4-16**]. He continued phoslo and B complex
vitamins.
.
# Ascites: Tapped on previous admission with SAAG 1.3 c/w portal
hypertension. Likely related to CHF.
.
# Peripheral vascular disease: Followed by vascular surgery as
outpatient for toe amputation. The wounds appeared clean dry and
intact. Aspirin, plavix, and simvastatin were continued. The
patient was instructed to follow up with vascular surgery.
.
# DM2: On glipizide at home. The patient was monitored on an
insulin sliding scale while in house and was discharged on his
home dose of glipizide.
.
TRANSITIONAL ISSUES:
-PCP [**Name9 (PRE) 702**] for bright red blood on toilet paper. The patient
may also require further evaluation with colonoscopy.
-Vascular surgery follow-up for recent toe amputation.
-Vascular surgery and PCP [**Name9 (PRE) 702**] for [**Name9 (PRE) 29413**] BP difference
and further management of hypertension. The patient should
undergo arterial ultrasound of his right upper extremity to
evaluate for peripheral vascular disease, although he is
unlikely a candidate for intervention unless he develops
symptoms.
-Important info for all providers: Mr. [**Known lastname **] has very significant
peripheral vascular disease and BP varies very widely in each
limb.
-Labs pending at time of discharge: blood culture, MRSA screen
Medications on Admission:
Medications at home: (discharge summary [**2201-5-7**])
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
1.5 (one and a half) Tablet Extended Release 24 hrs PO once a
day.
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day:
PLEASE HOLD on days of dialysis ([**Month/Day/Year 766**], Wednesday, Friday).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*2*
6. PhosLo 667 mg Capsule Sig: Two (2) Capsule PO three times a
day: with meals.
7. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO twice a day.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule,
Delayed Release(E.C.)(s)* Refills:*2*
10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Peripheral vascular disease
Hypertension
Hypotension
.
Secondary:
End stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with low blood pressure. It was
determined that there is a difference between the blood pressure
in your arm and the blood pressure in your thigh. Please discuss
this with your vascular surgeon Dr. [**Last Name (STitle) 1391**] when you see him
this week. Please also discuss this discrepancy with your
primary care physician.
You got some IV fluids in the emergency department and were
treated with ultrafiltration on [**2201-5-16**].
You had a small amount of blood in your urine or stool, but your
blood counts were stable.
There are no changes to your medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to arrange to be seen
within the next week for further management of your blood
pressure.
Talk to your primary care doctor about the blood that you have
had in your stool and possibly your urine.
Department: HEMODIALYSIS
When: [**Last Name (Titles) **] [**2201-5-18**] at 7:30 AM
Department: CARDIAC SERVICES
When: FRIDAY [**2201-6-12**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
ICD9 Codes: 5856, 4280, 2749, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7351
} | Medical Text: Admission Date: [**2147-9-21**] Discharge Date: [**2147-9-25**]
Date of Birth: [**2075-3-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**Known firstname 1406**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2147-9-21**] Coronary artery bypass graft x 3 with left
internal mammary artery to left anterior descending artery,
and reverse saphenous vein graft to the first diagonal artery
and the first obtuse marginal artery.
History of Present Illness:
This 72 year old man has a history of hypertension,
hyperlipidemia and CAD s/p OM and LAD stenting in [**2141-8-22**],
s/p Taxus stenting of ISR of the OM1 in [**2142-7-22**]. The patient
has been feeling well and recently underwent surveillance stress
testing. This was notable for abnormal ST and BP response to
exercise. Anterior, lateral and apical reversible defects were
noted. LVEF was reported as 20% in the immediate post exercise
images, 45% on resting images. He was referred for coronary
angiography which showed left main disease and now is referred
for surgery.
Past Medical History:
Coronary artery disease s/p OM and LAD stenting [**8-28**], Taxus
stenting of OM1 restenosis in [**2142**]
Hypertension
Hyperlipidemia
[**2137**] prostate cancer, s/p brachytherapy/hormone therapy
? Reiter's syndrome (patient reports no arthritis symptoms in 20
years)
Squamous cell skin cancer s/p resection on [**9-5**]
Social History:
Race:caucasian
Last Dental Exam:two weeks ago, Dentist [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] in [**Location (un) **]
Lives with:Married two his second wife. [**Name (NI) **] has three children
from his first marriage.
Contact: [**Name (NI) 2411**] [**Name (NI) 36055**] (wife) Cell Phone #[**Telephone/Fax (1) 36056**]
Occupation: Patient is a retired airline pilot.
Cigarettes: Never smoked
Other Tobacco use:denies
ETOH: < 1 drink/week [] [**2-28**] drinks/week [x] >8 drinks/week []
Illicit drug use: Denies
Family History:
Family History:Sister with CABG at age 70.
Physical Exam:
Pulse: 41 Resp:15 O2 sat:99%
B/P 145/63mmHg
Height:5 feet 10 inches Weight:193 pounds
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x]
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right:- Left:-
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 36057**] (Complete)
Done [**2147-9-21**] at 9:25:57 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**Known firstname **] C.
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: [**2075-3-2**]
Age (years): 72 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intracardiac echo guidance provided for CABG.
ICD-9 Codes: 410.91, 786.51
Test Information
Date/Time: [**2147-9-21**] at 09:25 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2012AW3-: Machine: u/s 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.0 cm <= 3.0 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 17 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 7 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *1.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection
velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum.
LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV
cavity. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. 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: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Prebypass:
The left atrium is normal in size. No thrombus is seen in the
left atrial appendage. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. Overall
estimated left ventricular systolic function is mildly depressed
(LVEF= 40-45 %). There is mild hypokinesis of the anterior and
anterioseptal walls of the left ventricle. Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results on [**2147-9-21**] at 0900.
Postbypass:
There is no evidence of aortic dissection. There is improved
left ventricular function with estimated Ejection Fraction of
50-55%. The anteroseptal wall has improved function.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
?????? [**2138**] CareGroup IS. All rights reserved.
[**2147-9-25**] 05:45AM BLOOD WBC-8.0 RBC-3.05* Hgb-9.5* Hct-27.3*
MCV-90 MCH-31.0 MCHC-34.6 RDW-13.4 Plt Ct-230
[**2147-9-21**] 11:10AM BLOOD WBC-8.5# RBC-3.38*# Hgb-10.5*# Hct-30.5*#
MCV-90 MCH-30.9 MCHC-34.3 RDW-13.3 Plt Ct-168
[**2147-9-22**] 02:02AM BLOOD PT-11.5 PTT-28.1 INR(PT)-1.1
[**2147-9-21**] 11:10AM BLOOD PT-13.6* PTT-27.5 INR(PT)-1.3*
[**2147-9-25**] 05:45AM BLOOD UreaN-15 Creat-0.9 Na-136 K-4.4 Cl-100
[**2147-9-21**] 12:20PM BLOOD UreaN-15 Creat-0.9 Na-142 K-4.2 Cl-110*
HCO3-26 AnGap-10
[**2147-9-25**] 05:45AM BLOOD Mg-2.4
Brief Hospital Course:
Mr. [**Name13 (STitle) **] was a same day admit and brought directly to the
operating room where he underwent a coronary artery bypass graft
x 3(with left internal mammary artery to left anterior
descending artery,and reverse saphenous vein graft to the first
diagonal artery and the first obtuse marginal artery) with
Dr.[**Last Name (STitle) **]. Please see operative note for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Later this day he was weaned
from sedation, awoke neurologically intact and extubated. He
weaned off pressor support. All lines and drains were
discontinued per protocol. Beta-blocker/Statin/ASA and diuresis
were initiated.POD#1 he transferred to the step down unit for
further monitoring. Physical Therapy was consulted to evaluate
his strength and mobility. The remainder of his hospital course
was essentially uneventful. He continued to progress. By the
time of discharge on POD#4 he was ambulating well and his
incisions were clean/dry/ and intact. He was discharged to home
with VNA services. All follow up appointments were advised.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - atenolol 25 mg
tablet 0.5 (One half) tablet(s) by mouth qam
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) -
Lipitor 80 mg tablet 1 Tablet(s) by mouth qpm
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - Plavix
75 mg tablet 1 Tablet(s) by mouth qam
EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - Zetia 10 mg
tablet 1 tablet(s) by mouth daily
LISINOPRIL - (Prescribed by Other Provider) - lisinopril 20 mg
tablet 1 tablet(s) by mouth qam
NITROGLYCERIN - (Prescribed by Other Provider) - nitroglycerin
0.4 mg sublingual tablet 1 Tablet(s) sublingually every five
minutes for chest discomfort. Call 911 if pain persists longer
than 15 minutes
Medications - OTC
ASPIRIN - Prescribed by Other Provider) - aspirin 325 mg tablet
1 Tablet by mouth qam
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
3. Ezetimibe 5 mg PO DAILY
RX *ezetimibe [Zetia] 10 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
4. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
6. Metoprolol Tartrate 25 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
7. Oxycodone-Acetaminophen (5mg-325mg) [**1-23**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg [**1-23**] tablet(s)
by mouth q4-6 hours Disp #*50 Tablet Refills:*0
8. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
Hold for K+ > 4.5
RX *potassium chloride 20 mEq 1 tab by mouth daily Disp #*7
Tablet Refills:*0
9. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl [Zantac] 150 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*1
10. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x
Past medical history:
Hypertension
Hyperlipidemia
s/p OM and LAD stenting [**8-28**], Taxus stenting of OM1 restenosis
in [**2142**]
[**2137**] prostate cancer, s/p brachytherapy/hormone therapy
? Reiter's syndrome (patient reports no arthritis symptoms in 20
years)
Squamous cell skin cancer s/p resection on [**9-5**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **], office #[**Telephone/Fax (1) 170**], will contact you to
arrange follow up appointment and wound check
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], please call to arrange follow up
visit in [**1-23**] weeks
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] in [**4-27**] 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:[**2147-9-25**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7352
} | Medical Text: Admission Date: [**2198-3-2**] Discharge Date: [**2198-3-3**]
Date of Birth: [**2144-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
53F with history of HCV Cirrhosis, ? ETOH, and Varices s/p
banding in [**2190**] as well as known PUD, past admissions for GIB
with portal hypertensive gastropathy most recently on [**11/2197**]
who presents with one episode of coffee ground emesis today.
Patient states that her abd has been more distended over the
last 2 weeks. She was planning to have a therapeutic para, but
her sister passed way this week and she missed her appointment.
She has never had a paracentesis before and this is the most abd
distension she has noticed. She had ~ 2.5 glasses of wine last
night and today she had nausea and vomitted ~ 0.5 cup of coffee
ground emesis. She denies having any bright red blood. No abd
pain, no fever, no chills. She had a small amount of loose stool
today. No sick contacts. [**Name (NI) **] unusual foods. She has not been able
to drink or eat. She has been taking her protonix and nadolol,
but may have missed one dose yesterday. This is similar to her
prior upper GI episodes and she came into the ED.
On arrival to the ED, 98.6 120 124/81 18 100% on arrival. She
had another episode of coffee ground emesis ~ 400 mls. She was
given zofran 8mg, Lorazepam 2mg, octreotide gtt, one dose of
Protonix, and erythromycin. She had no NG lavage and has refused
to have NG tube placed. She had a transient drop on her O2, then
quickly return to 100% on 2L N/C. Her vitals have remained
stable. Her labs were notable for Hct of 23.9 (her last Hct at
Atrius was 21.9 in [**2199-1-5**]), INR of 2.5.
Of note during her last admission in [**Month (only) **], she had EGD,
colonoscopy and capsule study which did not show esophageal
varices, but portal hypertensive gastropathy, angioectasias in
the cecum and terminal ileum. No active source of bleeding was
identified. Pt has been followed by hepatology, her last viral
load was 173,000 IU/mL on 09/[**2197**].
On arrival to the ICU, pt was retching and only had scant amount
of brownish fluid/bile emesis. She was given one dose of Zofran
and Ativan. She refused to have NG tube placed. She denies
having any pain
.
Review of systems: Neg for fever, chills. Feeling fatigue.
Increase in abd girth. Occ SOB, no cough. No abd pain, + n/v
today (as noted above), no blood or black tarrry stools noted.
Voiding without difficulty, yellow urine. No yellowing of the
skin. Occ muscle aches and pain for which she takes Ultram with
good result.
Past Medical History:
- Hepatitis C c/b by varices s/p banding in [**5-15**]
- h/o PUD and antral erosions in past s/p H. pylori treatment in
[**9-/2194**]
- Iron deficiency anemia
- GERD
- Hypertension
Social History:
She lives alone, works in marketing for the Mayor's office. Her
family is in NJ. Her sister just passed away this week and she
is planning to leave to NJ on Sun morning. She states that she
will leave AMA if not ready for d/c on Mon morning. She states
to have supportive friends.
- [**Name2 (NI) 1139**]: denies
- Alcohol: occasionally has a few glasses of wine when out with
her friends. [**Name (NI) **] ETOH intake yesterday, ~ 2.5 glasses
- Illicits: denies
Family History:
NC
Physical Exam:
General Appearance: In distress due to vomiting, pleasant and
conversing
HEENT: scleara non-icteric, conjuctiva non-injected, PERLA, MM
dry
CV: RRR, tachy, Normal S1 and S2, no m/r/g
LUNGs: CTAB, no c/w/r
Abd: very distended, + ascitis with fluid wave, soft, non-tender
to palpation
Extremities: Trace of edema on bil ankles, no cyanosis, or
clubbing, no asterixus, warm, dry
Neurologic: A+O x3, following commands. conversing
Pertinent Results:
Admission Labs:
[**2198-3-2**] 06:00PM BLOOD WBC-6.3# RBC-2.68*# Hgb-6.6*# Hct-23.9*#
MCV-89 MCH-24.7*# MCHC-27.7*# RDW-22.1* Plt Ct-210#
[**2198-3-3**] 05:03AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Burr-1+
Tear Dr[**Last Name (STitle) 833**]
[**2198-3-2**] 05:20PM BLOOD PT-25.7* PTT-31.9 INR(PT)-2.5*
[**2198-3-2**] 06:00PM BLOOD Glucose-103* UreaN-14 Creat-0.5 Na-144
K-3.5 Cl-107 HCO3-22 AnGap-19
[**2198-3-2**] 06:00PM BLOOD ALT-29 AST-99* AlkPhos-79 TotBili-1.5
[**2198-3-2**] 06:00PM BLOOD Albumin-2.6*
[**2198-3-3**] 12:03AM BLOOD Calcium-7.5* Phos-3.4 Mg-1.4*
[**2198-3-2**] 06:00PM BLOOD ASA-NEG Ethanol-89* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2198-3-2**] 06:04PM BLOOD Hgb-7.1* calcHCT-21
Discharge Labs:
[**2198-3-3**] 03:10PM BLOOD Hct-26.7*
[**2198-3-3**] 05:03AM BLOOD WBC-5.1 RBC-2.61* Hgb-6.8* Hct-22.9*
MCV-88 MCH-26.0* MCHC-29.6* RDW-21.2* Plt Ct-123*
[**2198-3-3**] 05:03AM BLOOD Neuts-74.9* Bands-0 Lymphs-17.7*
Monos-6.5 Eos-0.5 Baso-0.4
[**2198-3-3**] 05:03AM BLOOD Plt Smr-LOW Plt Ct-123*
[**2198-3-3**] 05:03AM BLOOD PT-28.0* PTT-36.0 INR(PT)-2.7*
[**2198-3-3**] 05:03AM BLOOD Glucose-129* UreaN-13 Creat-0.6 Na-145
K-3.6 Cl-113* HCO3-24 AnGap-12
[**2198-3-3**] 05:03AM BLOOD ALT-25 AST-85* AlkPhos-67 TotBili-1.6*
[**2198-3-3**] 05:03AM BLOOD Calcium-7.2* Phos-2.9 Mg-1.4*
Imaging:
CXR:
FINDINGS: Allowing for differences in technique, the cardiac,
mediastinal and hilar contours appear unchanged. The lung
volumes are low. No focal
opacities are demonstrated. There is no pleural effusion or
pneumothorax.
IMPRESSION: Low lung volumes. No evidence of acute disease.
Abdominal Ultrasound: prelim:
IMPRESSION:
Preliminary ReportLimited study demonstrates a cirrhotic liver
with patent portal veins with Preliminary Reporthepatopetal flow
along with moderate ascites.
Endoscopy:
Impression: 2 cords of grade I varices -- no evidence of recent
bleeding
5-7mm clean based ulcer in the body of the stomach
Edematous gastric folds with mosaic pattern consistent with
hypertensive portal gastropathy
Friable duodenum with multiple polyps
Antral polyps
Otherwise normal EGD to third part of the duodenum
Recommendations: Stop protonix and octreotide gtts
Monitor h/h -- transfuse to keep h/h [**8-12**]
Protonix 40 mg po bid
Continue nadolol - titrate as BP and HR tolerate
Repeat endoscopy in 4 weeks to re-evaluate gastric ulcer
Brief Hospital Course:
****Patient left Against Medical Advice****
53F with history of HCV Cirrhosis, recent ETOH use (although
patient denies despite positive serum levels) and Varices s/p
banding in [**2190**] as well as known PUD, past admissions for GIB
with portal hypertensive gastropathy most recently on [**11/2197**]
who presents with coffee ground emesis after drinking ETOH and
worsening abdominal distention. Despite multiple attempts to
have patient stay for close monitoring and paracentesis after
EGD, the patient decided to leave AMA.
# Upper GI bleed: Received 2 units prbcs with appropriate rise
in Hematocrit. Started on octreotide and pantoprazole gtts as
well as ceftriaxone. EGD performed in the MICU and patient did
not have any active bleeding. She continued to have varices,
portal gastropathy, and a known gastric ulcer. It was felt her
bleeding was likely from the portal gastropathy in setting of
recent ETOH use. The patient continued to have melana and was
strongly encouraged to stay for close monitoring, but the
patient left AMA from the MICU despite knowing the risk of
re-bleeding and death. It was also advised that she undergo a
diagnostic paracentesis, but the patient did not want to wait
for this procedure. She was advised to continue her pantoprazole
[**Hospital1 **], nadalol and was given cipro to be taking antibiotics for 5
days. She will need a re-scope in 4 weeks. She was strongly
advised to call her PCP and gastroenterologist on Monday.
.
# ETOH Abuse: No signs of withdrawal. Gave a banana bag as well
as thiamine, folic acid, MVI and placed on CIWA protocol, but
did not score.
TRANSITIONAL ISSUES:
- Will need repeat EGD in 4 weeks
Medications on Admission:
-Nadolol 60 [**Hospital1 **] (on last d/c)
-Tramadol 50mg [**Hospital1 **] PRN (only taking occ)
-Folic acid 1mg daily- not currently taking this
-Thiamine 1mg daily - not currently taking this med
-Flonase
-Protonix 40mg [**Hospital1 **]
- Monthly iron infusions
- Iron daily
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
2. nadolol 20 mg Tablet Sig: One (1) Tablet PO twice a day.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. multivitamin Capsule Sig: One (1) Capsule PO once a day.
6. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4
days.
Disp:*8 Tablet(s)* Refills:*0*
7. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO three times a day.
8. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray
Nasal twice a day as needed for allergy symptoms.
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you were vomiting blood. You were
given two units of blood and the gastroenterologists performed
and endoscopy and this showed an ulcer in the stomach, enlarged
blood vessels in the esophagus called varices, and changes in
the stomach secondary to elevated blood pressures in your gut.
These findings are all secondary to your cirrhosis.
You were advised to stay in the hospital for further monitoring
and a paracentisis, but you left against medical advice.
It is important that you stop drinking and take your
medications.
You should continue all of your medications with the following
important addition.
Cipro 500 mg twice a day for 4 more days starting [**2198-3-4**]
Followup Instructions:
You should follow up with your GI doctor and primary care doctor
this week.
PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2261**]
Gastroenterologist: Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 26390**] Phone: [**Telephone/Fax (1) 2296**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7353
} | Medical Text: Admission Date: [**2148-8-1**] Discharge Date: [**2148-8-6**]
Date of Birth: [**2096-5-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vicodin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion, Fatigue & Palpitations
Major Surgical or Invasive Procedure:
Closure of ASD and baffling of anaomolous pulmonary vein [**2148-8-1**]
History of Present Illness:
52 year old female with history of hypertension, non-ST segment
elevation MI in [**2147-11-6**] treated with a drug-eluting stent
in the mid RCA and PTCA of the
posterolateral branch at [**Hospital3 **] Hospital. Was also found
to have a dilated right ventricle on a TEE, but without
clear-cut left to right shunting at a degree that would cause
such a dilation of the right ventricle. For further exploration
she underwent a cardiac MRI at [**Hospital1 18**] on [**2-16**] that showed
a significant left to right shunting with Qp/Qs flow at 2.6.
However, the level of the shunting was not able to be identified
clearly. As a result, she then underwent a chest CTA on [**4-11**],
which conclusively showed the presence of anomalous pulmonary
vein return with the right superior pulmonary vein draining into
the right atrium and also the right inferior pulmonary vein
being confluent with the left atrium and right atrium. The
patient
reports having an episode week prior to cath where her heart
"was racing"
and she was feeling lightheaded/dizzy for about an hour and a
half. She did not have any chest pain but she took 2 SL
nitroglycerin and then took her night dose metoprolol finally
with improvement. This is the only episode of palpitations she
has had since having the MI. She continues to complain of
feeling extremely fatigued. She denies any chest pain. She did
report dyspnea in the hot weather and a one week history of LE
edema, worsening at night. Her activity level has been low. She
presented for cardiac catherization prior to
correction of her anomalous pulmonary veins which showed no
significant coronary artery disease. She had an E coli urinary
tract infection which was treated prior to her same day
admission for surgery.
Past Medical History:
Coronary artery disease s/p Non-ST segment elevation MI in
[**2147-11-6**] treated with a drug-eluting stent in the mid RCA
and PTCA of the posterolateral branch at [**Hospital1 **]
Episode of Atrial Fibrillation following PCI/stenting, s/p DCCV
Hypertension
Obesity
Past Surgical History:
s/p Left ankle surgery
s/p C-sections x 2
s/p Tonsillectomy
Social History:
Race: Caucasian
Lives with: Husband
Occupation: Currently unemployed
Tobacco: Never smoked
ETOH: Rare
Family History:
Remarkable for early coronary artery disease. Her brother had
quintuple CABG at age 50. Her father had an MI in his 60's and
her mother had an MI in her 70's
Physical Exam:
Pulse: 67 Resp: 13 O2 sat: 100% RA
B/P Right: 139/83 Left:
Ht: 5'8" Weight 115.2 kg
General: No acute distress, pleasant
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 - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x] Obese
Extremities: Warm [x], well-perfused [x] trace LE edema
Varicosities: Both GSV were suitable without varicosities,
varicose veins bilaterally behind knees
Neuro: Grossly intact
Pulses:
Femoral Right: cath site Left: 1
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 1 Left: 1
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2148-8-5**] 04:42AM BLOOD WBC-12.8* RBC-3.19* Hgb-10.0* Hct-29.3*
MCV-92 MCH-31.2 MCHC-34.0 RDW-13.9 Plt Ct-176
[**2148-8-5**] 04:42AM BLOOD Glucose-106* UreaN-16 Creat-0.6 Na-138
K-4.3 Cl-102 HCO3-29 AnGap-11
[**2148-8-4**] 05:31AM BLOOD WBC-15.9* RBC-3.14* Hgb-9.8* Hct-28.8*
MCV-92 MCH-31.1 MCHC-33.9 RDW-14.0 Plt Ct-151
[**2148-8-4**] 05:31AM BLOOD UreaN-18 Creat-0.6 Na-135 K-4.2 Cl-102
[**2148-8-6**] 06:32AM BLOOD WBC-12.8* RBC-3.39* Hgb-10.5* Hct-30.4*
MCV-90 MCH-31.0 MCHC-34.5 RDW-13.5 Plt Ct-241
[**2148-8-6**] 06:32AM BLOOD Glucose-97 UreaN-17 Creat-0.7 Na-136
K-3.9 Cl-97 HCO3-28 AnGap-15
[**2148-8-3**] 06:41AM BLOOD PT-12.3 INR(PT)-1.0
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 88206**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 88207**] (Complete)
Done [**2148-8-1**] at 9:56:57 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2096-5-16**]
Age (years): 52 F Hgt (in): 68
BP (mm Hg): 149/92 Wgt (lb): 253
HR (bpm): 69 BSA (m2): 2.26 m2
Indication: Intraoperative TEE for repair of ASD, repair of
anomalous pulmnonary veins
ICD-9 Codes: 746.9, 424.1, 424.2
Test Information
Date/Time: [**2148-8-1**] at 09:56 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: Saline Tech Quality: Adequate
Tape #: 2011AW2-: Machine: U/S 6
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 65% >= 55%
Aorta - Ascending: 2.3 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.6 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 2.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 16 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 8 mm Hg
Aortic Valve - LVOT diam: 1.6 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. At
least one pulmonary vein entering the right atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Sinus venosus
ASD. Prominent Eustachian valve (normal variant).
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AS. Mild to moderate ([**1-7**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Trivial MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild to
moderate [[**1-7**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. There is a congenital defect.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. At least one pulmonary
vein may be entering the right atrium. A patent foramen ovale is
present. A sinus venosus atrial septal defect is present.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is dilated with normal free wall
contractility. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild to moderate ([**1-7**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
POST BYPASS The patient is atrially paced. There is normal
biventricular systolic function. The mitral regurgitation is now
mild. The sinus venosus defect has been closed though small
residual flow can not be completely ruled out. The foramen ovale
has also been closed. Very small pin-hole flow can be seen in
the area of the foramen ovale. The thoracic aorta is intact
after decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2148-8-1**] 11:36
?????? [**2140**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Ms.[**Known lastname **] presented for cardiac catherization prior to
correction of her anomalous pulmonary veins which showed no
significant coronary artery disease. Her preoperative workup
revealed an E coli urinary tract infection which was treated
prior to her same day admission for surgery.
On [**2148-8-1**] she was taken to the operating room and underwent
repair of partial anomalous pulmonary venous return and sinus
venosus atrial septal defect, and closure of patient foramen
ovale. Please see operative report for further details. She
tolerated the procedure well and was transferred to the CVICU
intubated and sedated. She awoke neurologically intact and was
extubated without difficulty. Beta-blocker/Statin/Aspirin was
initiated. Diuresis was initiated. Plavix was resumed for her
history of stents. All lines and drains were discontinued when
criteria was met. POD#1 she was transferred to the step down
unit for further monitoring. Physical Therapy was consulted for
evaluation of strength and mobility. She continued to progress
and was cleared for discharge to home on POD# 5. All follow up
appointments were advised.
Medications on Admission:
Lisinopril 20 mg daily
Aspirin 81 mg daily - has not been taking consistently recently
secondary to GI irritation - instructed to take daily with PPI
Plavix 75 mg daily
Metoprolol 25 mg [**Hospital1 **]
Simvastatin 80 mg daily
Fish oil 1000 mg TID
Allergies: Sulfa - rash
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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. 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*
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
Disp:*120 Tablet Extended Release(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO three times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Closure of ASD and baffling of anaomolous pulmonary vein [**2148-8-1**]
Coronary artery disease s/p Non-ST segment elevation MI in
[**2147-11-6**] treated with a drug-eluting stent in the mid RCA
and PTCA of the posterolateral branch at [**Hospital1 **], Episode of
Atrial Fibrillation following PCI/stenting, s/p DCCV,
Hypertension, Obesity, s/p Left ankle surgery, s/p C-sections x
2, s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check in the cardaic surgery office [**Hospital Unit Name **]
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on *********** in the [**Hospital **]
medical office building [**Hospital Unit Name **].
Cardiologist: [**Doctor First Name **] [**Doctor Last Name 1911**]
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 88208**] in [**4-9**] 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:[**2148-8-6**]
ICD9 Codes: 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7354
} | Medical Text: Admission Date: [**2180-7-21**] Discharge Date: [**2180-8-5**]
Date of Birth: [**2100-2-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Myocardial infarction
Major Surgical or Invasive Procedure:
[**2180-7-31**] coronary artery bypass surgey x2 (LIMA to LAD, SVG to
OM 1 )
Biopsy of abdominal mass
History of Present Illness:
80 y/o M PTOH w/CP and dyspnea. ECG showed 1 mm STE in V2-V3
w/bifasic T waves in V3-4, and laterally T wave inversion. EF
20% and Trop T: 0.11. Tx: ASA, lasix, NTG and taken to the
cath.lab: 70%LM and 90% LAD stenosis. IABP
placed at 1:1. Transfered to [**Hospital1 18**] for surgical
revascularization. Pt on coumadin for AFIB, INR 3,4.
Past Medical History:
chronic Afib on coumadin, HTN, NIDDM, HL, CRI, MI, ccy in [**2153**],
appy [**2117**]
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
The blood pressure was 1442/47 mmHg supine. The pulse was 83
bpm. The respiratory rate was 18. The patient was afebrile.
Generally the patient appeared to be well developed, well
nourished and well groomed. The patient was oriented to person,
place and time.
There was no xanthalesma and conjunctiva were pink with no
pallor
or cyanosis of the oral mucosa. The neck was supple with JVP of
8 cm water. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs had rales at bases
bilaterally
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line.
There were no thrills, lifts or palpable S3 or S4.
The heart sounds were irregular with a normal S1 and
physiologically split S2. There were no rubs, murmurs, clicks or
gallops.
The abdominal aorta was not enlarged by palpation. There was no
organomegaly or tenderness.
The extremities had no pallor, cyanosis, clubbing or edema.
There
were no abdominal, femoral or carotid bruits.
Inspection and/or palpation of skin and subcutaneous tissue
showed no stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Conclusions
PRE BYPASS The left atrium is markedly dilated. Mild spontaneous
echo contrast is seen in the body of the left atrium. The left
atrial appendage emptying velocity is depressed (<0.2m/s). A
left atrial appendage thrombus is not seen but cannot be
completely excluded. The right atrium is dilated. A patent
foramen ovale is present. A left-to-right shunt across the
interatrial septum is seen at rest. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
mild to moderate hypokinesis of the anterior, anterolateral,
anteroseptal, and apical walls. Overall left ventricular
systolic function is moderately depressed (LVEF= 35 %). The
right ventricle displays mild global free wall hypokinesis.
There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-14**]+) mitral regurgitation
is seen. There is a small pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the study.
POST BYPASS The patient is in a junctional rhythm and is
receiving epinephrine by infusion. There is normal biventricular
systolic function with an LVEF of 55%. The mitral regurgitation
is improved - now trace to mild. The tricuspid regurgitation is
slightly worsened but still in the mild to moderate range. The
PFO remains with left to right flow evident. The thoracic aorta
appears intact. No other significant changes.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2180-7-31**] 18:03
?????? [**2174**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Mr. [**Known lastname 82846**] was admitted to the [**Hospital1 18**] on [**2180-7-21**] for further
management of his myocardial infarction. As his INR was elevated
due to coumadin, he was placed on heparin while awaiting his INR
to to trend down. He was worked-up in the usual preoperative
manner. He was noted to have a dropping hematocrit and a CT scan
was performed to rule out a retroperitoneal bleed. IABP was
removed. Scan showed no evidence of a retroperitoneal bleed
however showed a spiculated mesenteric soft tissue mass with a
punctate foci of calcification, and numerous omental/peritoneal
soft tissue implants. Markedly enlarged diaphragmatic lymph
nodes were also seen in the chest making the mass highly
suggestive of a malignancy. The gastroenterology service was
consulted for assistance in his care who suggested a biopsy.
The cardiology service was also consulted in the event that a
malignancy was diagnosed and stenting was a possible option.
Oncology consulted and CT guided biopsy suggested carcinoid
tumor.
When his INR was normal, he was taken to OR on [**7-31**] for surgery
with Dr. [**Last Name (STitle) **]. Transferred to the CVICU in stable condition
on epinephrine, propofol, and insulin drips. Extubated the next
morning and awoke neurologically intact. Transferred to the
floor on POD #1 . His temporary pacing wires and chest tubes
were removed per protocol. He was in atrial fibrillation and
developed brdaycardia. Electrophysiology and a pacer was
considered by deemed not necessary as his heart rate stabilized.
His couamdin for atrial fibrillation was resumed. Dr. [**Last Name (STitle) **] will
resume coumadin follow up. Mr [**Known lastname 82846**] was evaluated by physical
therapy and cleared for discharge to home on POD #5.
Medications on Admission:
Glyburide, Atenolol, Zestril, Coumadin
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Warfarin 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily):
dosed by Dr. [**Last Name (STitle) **].
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
12. Outpatient Lab Work
INR check on monday [**2180-8-7**] and call results to Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 64750**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass surgey x2
MI
Abdominal mass
PMH: Atrial fibrillation, hypertension, diabetes,
hyperlipidemia, chronic renal insufficiency
PSH: open Cholecystectomy [**2153**], open appendectomy [**2117**], right
shoulder surgery remote
Discharge Condition:
good
Discharge Instructions:
no lotions, creams , or powders on any incision
shower daily and pat incisions dry
no driving for one moneth AND off all narcotics
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week.
follow the instructions provided for your [**Doctor Last Name **] of hearts
monitor.
call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 3 weeks at [**Hospital1 **] for wound check and post-op
follow-up : [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) 14334**] in 3 weeks
Next INR check on monday [**2180-8-7**]
Dr. [**Last Name (STitle) **] will follow your INR and dose your coumadin also make a
follow up appointment to be seen by Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 64750**] in 2
weeks
[**Doctor Last Name **] of Hearts - Dr. [**Last Name (STitle) 73**] (cardiologist)to follow
[**Telephone/Fax (1) 62**]
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (surgery) [**Telephone/Fax (1) 673**] and Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (oncologist)[**Telephone/Fax (1) 9645**] reagrding your abdominal
biopsy.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2180-8-5**]
ICD9 Codes: 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7355
} | Medical Text: Admission Date: [**2184-4-7**] Discharge Date: [**2184-4-21**]
Date of Birth: [**2112-6-18**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD
PICC line placement
History of Present Illness:
71 year old female with history of AF on coumadin, CHF with EF
35%, t2DM on insulin, CAD/PVD s/p multiple stenting and
interventions presents with 4 days of dark stools. She has been
stooling about 3x/day for these past 4 days, accompanied by a
decrease in appetite and headaches. 1 day prior to admission,
she began to feel increasingly dizzy and weak, with the onset of
chills but no documented fevers. She was unable to walk today
on her own and was instructed to be taken to the Emergency Room.
She denies any recent weight loss, hematemesis, hematochezia,
bruising/mucosal bleeding, chest pain, or palpitations. No
recent NSAID use. She does endorse shortness of breath with
minimal activity, no different than her baseline. She also
states that while someone comes to her house every week to check
her INR, no one had come this week and she missed her check
(confusion with not hearing the doorbell when VNA arrived). She
was supposed to have it checked this Friday.
In the ED, initial vitals were 98.0, 88/60, 57, 20 and 97% on
RA. Labs notable for BUN 132, Cr 2.1, WBC 20.1 (N 86, 0 bands),
Hb 5.9 / Hct 19.0 (re-check 17), INR 4.1. U/A large blood, mod
bact, trace leuks. Patient was given 1 unit FFP, 2 units pRBCs,
vit K 10mg IM, and acetaminophen x1 for headache. She was seen
by GI who recommended reversing the INR, PPI drip, and NG lavage
(which patient refused), and blood cx's. She was sent to the
ICU with an 18g in R foot and 22g in R hand. No other available
peripheral access. Vitals on transfer: 97.1, 105/64, 72, 16 and
100% on 2L.
In the ICU, she is hemodynamically stable and is pleasant and
conversive, visiting with family. She still has a headache, but
has not had a melenotic stool yet.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations. Denies nausea, vomiting, diarrhea.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
1. Diabetes
2. Hypertension
3. Coronary artery disease
- MI [**2168**]
- PCI [**2173-6-29**]
- Cath [**7-21**]
4. Atrial fibrillation
5. CHF, EF 35% ([**Hospital1 112**] TTE on [**11/2182**]), LVH, mod TR/pulm HTN
6. PVD s/p multiple lower ext bypasses
7. CKD (baseline Cr 1.2)
8. Colonic adenoma (on [**2180-4-13**])
9. Anxiety
10. Gout
Social History:
Lives with daughter, spends most of the day alone, but has a
"lifeline" for emergencies. Able to get up and down her stairs
with some difficulty.
Occupation: homekeeper
Tobacco: quit in [**2178**], 10pack years,
EtOH: denies
Family History:
Lung cancer - son
CAD/PVD - mother, maternal grandmother
Physical Exam:
Vitals: T: 98.5, BP: 111/42, P: 57, R: 20, O2: 100% on 2L
General: Alert, oriented, no acute distress, pleasant
HEENT: NC/AT, PERRL, EOMI, sclera anicteric, conjunctivae pale,
dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregularly irregular, normal S1 + S2, II/VI holosystolic
murmur best heard over LLSB; no rubs or gallops
Abdomen: obese, soft, mildly tender in RUQ (no [**Doctor Last Name 515**]),
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly appreciated
GU: foley in place
Ext: trace edema B/L, right leg slightly cooler than the left,
1+ pulses; no clubbing, cyanosis; scarring from previous bypass
surgeries over left lower leg
Pertinent Results:
EGD ([**2184-4-8**]): Erythema and erosion in the stomach body
compatible with gastritis. Diverticulum in the unlcear -
somewhere between the second and fourth part of the duodenum.
Just proximal to the diverticulum a large necrotic area was seen
on the side wall of the duodenum. The full extent could not be
visualized. There was fresh and old blood pooling throughout the
duodenum with no obvious source. With extensive washing this was
confined to the regiion between the second and fourth portions
of the duodenum. There were several large clots in this area
preventing full visualzation of the underlying mucosa. Otherwise
normal EGD to third part of the duodenum.
.
CT ABD & PELVIS W/O CONTRAST Study Date of [**2184-4-10**] Final Report
INDICATION: Recent GDA embolization. Assess for duodenal wall
ischemia.
TECHNIQUE: Axial imaging post-oral contrast medium was performed
from the
lung bases to pubic symphysis. Intravenous contrast was not
administered due to renal impairment.
FINDINGS: The majority of the oral contrast had passed through
the duodenum at the time of imaging. A 2.3 x 3.1 cm duodenal
diverticulum is present at the junction of D3 and D4 (series 2,
image 35). Oral contrast is retained within the diverticulum
with evidence of layering. No proximal obstruction is
identified. No intramural air is present and there is no
significant stranding around the duodenum. Embolization clips
are present in the gastroduodenal artery. .
Non-contrast imaging of the liver, spleen, pancreas are normal.
The
gallbladder appears distended and hyperdense. The increased
density is likely related to vicarious excretion of the contrast
from the embolization procedure. The renal cortex also appears
dense again likely related to delayed excretion of the contrast
from the embolization procedure. A 17-mm nodule is present in
the left adrenal gland with mean Hounsfield units of -100.
Features consistent with a myelolipoma. The right adrenal gland
is normal. Extensive colonic diverticulosis is present.
PELVIS: No small or large bowel obstruction. Diverticulosis as
noted above.
Review of the lung bases demonstrates right-sided linear
atelectasis with
pleural thickening. Minor pleural thickening is also present in
the left
base. Cardiomegaly is noted.
Bone review is unremarkable.
IMPRESSION: There is a duodenal diverticulum at the junction of
D3 and D4. The duodenal wall appears normal.
.
[**2184-4-21**] ABDOMEN (SUPINE & ERECT) Preliminary Report !! PFI !!
No evidence of obstruction or perforated viscus.
.
URINE CULTURE (Final [**2184-4-16**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 8 S <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
.
.
[**2184-4-7**] 11:14AM BLOOD WBC-20.1*# RBC-2.28*# Hgb-5.9*#
Hct-19.0*# MCV-83 MCH-25.9* MCHC-31.2 RDW-18.6* Plt Ct-307
[**2184-4-20**] 03:04AM BLOOD WBC-8.2 RBC-3.34* Hgb-9.8* Hct-28.4*
MCV-85 MCH-29.4 MCHC-34.5 RDW-16.8* Plt Ct-474*
[**2184-4-7**] 11:14AM BLOOD Glucose-156* UreaN-132* Creat-2.1* Na-137
K-4.8 Cl-103 HCO3-20* AnGap-19
[**2184-4-21**] 04:17AM BLOOD Glucose-162* UreaN-42* Creat-1.1 Na-138
K-4.5 Cl-106 HCO3-27 AnGap-10
[**2184-4-21**] 04:17AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.8
[**2184-4-21**] 04:17AM BLOOD Triglyc-186*
.
INR (On Warfarin 5 mg po q day since [**4-14**]); dose increased at
discharge.
[**4-17**] 1.3
[**4-19**] 1.5
3.9 1.3
Brief Hospital Course:
1. Gastrointestinal bleed. Presented with upper GI bleed
requiring massive transfusion (9 units within first 24 hours).
EGD showed large necrotic duodenal lesion of unclear nature.
After patient declined surgerical intervention, interventional
radiology performed angiography with prophylactic embolization
of the gastroduodenal artery.
Given desire to promote as much healing as possible, patient was
kept NPO and TPN was initiated. After bowel rest for ~week, oral
feeding was restarted and attempted to wean TPN off, however pt
continued to have poor po intake and some nausea with po intake.
GI is to see the patient in follow-up on [**2184-4-22**] with possible
repeat EGD for biopsy to be scheduled. Per discussion with
Gastroenterology consult, planning for EGD/biopsy approx [**7-20**]
weeks to allow stabilization of embolized territory.
Regarding anti-coagulation, given history of CAD with prior MI
and stenting, aspirin was felt ideal with low-dose (81 mg) used.
Similarly, given stroke risk in atrial fibrillation, warfarin
was restarted. She was started on Warfarin 5 mg po q day, but
her INR did not increase, so her dose was increased at discharge
to 7 mg po q day.
2. Congestive heart failure. No evidence of fluid overload on
admission, but did devlop some SOB and crackles after massive
transfusion in the ICU. At the time of discharge, remained off
furosemide with excellent saturations.
Her other chronic CHF medication, metoprolol, was also held
during much of the hospitalization. Initially this was in
setting of her GI bleed. Over the last days of admission, her HR
would range in the 40s-50s (asymptomatic) so it remained on
hold.
3. Acute on chronic renal failure. Elevated to 2.1 in the
setting of hypovolemia; improved with blood. Pt later developed
worsened Bun/Cr in the setting of treatment of UTI with Bactrim;
her Cr gradually improved after discontinuation.
4. Diabetes mellitus. Patient presented on high-dose of lantus
insulin. While NPO she did not require lantus and while on TPN
she recieved 15 units with each infusion.
5. Coronary artery disease. Aspirin as above. Metoprolol was
discontinued due to GI bleed and persistent bradycardia.
6. Right buttock pain. Chronic in nature. Used dilaudid/lyrica;
lidocaine patch was not helpful.
7. Urinary tract infection. Noted to have dysuria and positive
UA with bactrim sensitive e.coli. Pt received Bactrim for 3 days
with resolution of symptoms.
Communication: [**Name (NI) 46144**] [**Known lastname 174**] - son and HCP ([**Telephone/Fax (1) 46145**])
Code: Full (discussed with patient)
Medications on Admission:
Medications (confirmed with HCP and prior records):
*Calcium 600mg daily
*ASA 325mg daily
*Colace 100mg daily
*Coumadin 8mg daily
*Simvastatin 40mg daily
*Metoprolol 25mg [**Hospital1 **]
*Lasix 40mg QAM
*Lasix 40mg QAM (M,W,F)
*Lasix 20mg QPM (T,Th,[**Last Name (LF) **],[**First Name3 (LF) **])
*Omeprazole 20mg [**Hospital1 **]
*Allopurinol 100mg daily
*Lyrica 300mg daily
*Trazodone 50mg-100mg QHS
*Lantus 52 units qhs
*Novolog sliding scale
Discharge Medications:
1. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. pregabalin 75 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
9. trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
10. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: Please see attached sliding scale.
11. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
13. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-15**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
1. Acute blood loss anemia
2. Duenodenal necrosis
3. GI bleeding
4. CAD, native vessel
5. Diabetes, type II, controlled with complications
6. CKD, stage II
7. Malnutrition, moderate
8. Atrial fibrillation
9. Urinary tract infection
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted with bleeding from your gastrointestinal tract
(possibly from a large necrotic lesion in the duodenum). After
many blood transfusions your blood counts have stabilized. Given
that you need to be on aspirin and coumadin long-term, it will
be important that you remain attentive to the possibility of
future bleeding.
Followup Instructions:
Rehabilitation will schedule a follow-up appointment with your
PCP.
Name: [**Last Name (LF) 26390**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: Gastroenterology
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Thursday, [**4-22**] at 2:40PM
ICD9 Codes: 2851, 5849, 5990, 2761, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7356
} | Medical Text: Admission Date: [**2184-9-12**] Discharge Date: [**2184-9-21**]
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Tetracyclines
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
generalized weakness, anorexia
Major Surgical or Invasive Procedure:
Left internal jugular tunneled hemodialysis catheter [**2184-9-16**]
History of Present Illness:
[**Age over 90 **] y/o [**Age over 90 **] y/o F w/ AFib on coumadin, tachy-brady syndrome s/p
PPM, CKD, and diastolic CHF a/w malaise, weakness, and decreased
PO intake for two days and an episode of urinary incontinence
the night prior to admission. Per the patient's family, she felt
well until 2 days ago when she noted multiple episodes of
diarrhea in the setting of an increase in her laxative regimen
intended to treat constipation and associated abdominal
discomfort. She has not had any recent antibiotic use or health
care exposures. She denies fevers, chills, dysuria, hematuria,
flank pain, or changes in mental status. Family does state that
renal function has steadily declined over the past 6 months for
which she has been followed closely by a nephrologist.
.
In the ED VS 96.2, 60, 110/64 19 99% 2L. EKG unchanged from
prior. Had transient fluid-responsive systolic hypotension to
SBP 85. Received levofloxacin 750 mg x1. She was transferred to
the MICU for close observation given hypotension in the setting
of delicate volume status.
Past Medical History:
AFib
Tachy-brady s/p PPM [**3-9**]
CKD stage IV b/l ~Cr 2.2
SCC leg and neck s/p radiation [**1-9**]
4+ TR
2+ MR
[**First Name (Titles) **] [**Last Name (Titles) **] HTN
Hypothyroidism
HTN
IBS
Anemia b/l Hct ~34%
Diverticulosis
Social History:
Retired. No current alcohol or tobacco use. Dtrs very active in
her care. Lives in house in [**Location (un) 10059**] with live-in aide.
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 96.2 108/60 72 18 96% RA
Gen: NAD, Alert, Oriented to Location, Person, but not to date
HEENT: PERRLA, EOMI, Dry MM
Neck: Supple, No LAD, No appreciable JVD
CV: reg rate (paced) nl S1S2 no m/r/g
[**Location (un) **]: Decreased BS on R
Abd: Soft, mildly-distended, NT BS+
Extrem: warm, dry 2+ pitting edema to knees bilaterally
Pertinent Results:
[**2184-9-19**] HEPARIN DEPENDENT ANTIBODIES
TEST RESULT
---- ------
HEPARIN DEPENDENT ANTIBODIES NEGATIVE
COMMENT: NEGATIVE FOR HEPARIN PF4 ANTIBODY BY [**Doctor First Name **]
.
[**2184-9-12**] 11:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2184-9-12**] 11:30AM URINE RBC-[**5-11**]* WBC-[**5-11**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
.
[**2184-9-12**] 9:24 pm URINE Site: CLEAN CATCH Source:
Catheter.
**FINAL REPORT [**2184-9-17**]**
URINE CULTURE (Final [**2184-9-17**]):
IDENTIFICATION AND SENSITIVITIES REQUESTED BY DR.[**Last Name (STitle) 99804**].
STAPH AUREUS COAG +. ~1000/ML.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
[**2184-9-12**] CHEST RADIOGRAPH, PA AND LATERAL
Dual-lead right pectoral pacemaker with
right atrial and right ventricular leads is unchanged from prior
studies.
Cardiomegaly is again noted, although the right heart border is
now obscured by right basilar opacity which also obscures the
right hemidiaphragm, consistent with moderate-sized pleural
effusion and related atelectasis, although underlying pneumonic
consolidation cannot be excluded. There is also a small left
pleural effusion with milder left retrocardiac atelectasis. The
remainder of the lungs are grossly clear, without evidence of
overt pulmonary edema or lung consolidation . There is no
evidence of pneumothorax. Calcifications are again noted along
the aorta. Old right lateral rib fracture is unchanged.
IMPRESSIONS: Increased right basilar opacity, with increased and
now
moderate-sized right pleural effusion, and related atelectasis,
although
underlying pneumonic consolidation cannot be excluded. Small
left pleural
effusion with left basilar atelectasis.
.
[**2184-9-14**] TTE
The left atrium is mildly dilated. The right atrium is markedly
dilated. The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 55-60%). The right
ventricular cavity is moderately dilated with mild 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. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. The tricuspid valve leaflets fail to fully
coapt. Severe [4+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. The main pulmonary artery is
dilated. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Dilated right ventricle with mild global systolic
dysfunction and evidence of volume overload. Normal global and
regional left ventricular systolic function. Mild aortic
regurgitation. Mild mitral regurgitation. Severe functional
tricuspid regurgitation.
Compared with the prior study (images reviewed) of [**2184-7-2**],
findings are similar. Left ventricular systolic function may
have been slightly underestimated on the prior study.
.
[**2184-9-16**] VASCULAR U/S-GUIDED CATHETER PLACEMENT
FINDINGS:
1. Patent left internal jugular vein, accessed under son[**Name (NI) 493**]
guidance.
2. Placement of tunneled 15.5 French x 27 cm cuff-to-tip
angiodynamics
hemodialysis catheter via the left internal jugular vein.
3. Post-procedure chest radiograph showed the catheter tip in
the right
atrium with no kinks along the course of the catheter and no
pneumothorax.
Incidental note is made of atrioventricular pacing wires in
expected position placed through the right subclavian vein.
IMPRESSION: Successful placement of left internal jugular
tunneled
hemodialysis catheter. The catheter is ready for immediate use.
Brief Hospital Course:
#CKD stage IV - The patient presented with symptoms consistent
with uremia. Volume overload was refractory to diuretic therapy
due to worsening renal function. Left IJ tunneled HD catheter
was placed on [**9-16**] with subsequent initiation of hemodialysis
that day, followed by [**9-17**], [**9-18**], [**9-20**], and [**9-21**]. Nephrocaps
were added. Lasix and [**Last Name (un) **] were discontinued. Phosphate binder
therapy was not added as the calcium-phosphate product was
approximately 18. PPD was read as 0 mm induration on [**9-19**]. The
patient will continue to receive HD as an outpatient.
.
#Acute on chronic diastolic CHF - Admission CXR showed a
moderately-sized right pleural effusion with associated
atelectasis and a small left pleural effusion with left basilar
atelectasis. TTE [**9-14**] showed a dilated RV with mild global
systolic dysfunction and evidence of volume overload, normal
global and regional LV systolic function (LVEF 55-60%), and
severe functional TR and mild AR/MR. Respiratory status remained
stable with adequate room air oxygenation. Volume status was
managed with HD, as above.
.
#Thrombocytopenia - The patient did not have clinical signs or
symptoms of bleeding or thrombosis. Attributed to an effect of
cephalosporin therapy but other possible offending medications
including heparin, protonix, and atorvastatin were discontinued.
Indwelling catheter was flushed with citrate solution rather
than heparin during HD sessions. PF4 antibody was negative. The
patient will have a repeat CBC two days after discharge to
continue to monitor platelet count.
.
#Anemia of chronic kidney disease - Hematocrit remained stable,
obviating the need for transfusion. She may continue to receieve
erythropoeitin therapy as an adjunct to hemodialysis.
.
#UTI - Admission urinalysis showed [**5-11**] WBC, moderate bacteria,
and trace leukocyte esterase. She was treated with 3 days of
ceftriaxone until urine culture revealed ~1000 colonies MRSA,
likely a skin contaminant. She was placed on contact precautions
accordingly.
.
#Atrial fibrillation - Anticoagulation was reversed with vitamin
K and FFP prior to HD catheter placement. Coumadin was resumed
after the procedure with a goal INR 2.0-3.0. The patient will be
discharged with VNA services to monitor INR and adjust coumadin
dosing accordingly.
.
#Hypertension - Blood pressure was low-normal during the
hospitalization and metoprolol was decreased to 25 mg qHS due to
concerns for hypotension, particularly in the setting of
hemodialysis.
.
#Hypothyroidism - Continued levothyroxine.
.
#Nutrition - Heart-healthy diet. Calcium and vitamin D were
continued.
Medications on Admission:
ATORVASTATIN 10 mg PO daily
EPOETIN ALFA 40,000 units SC Q2wks
FUROSEMIDE 20 mg PO QOD
HYDROCORTISONE-PRAMOXINE CREAM (1 %-1%) TP to hemorrhoids TID
LEVOTHYROXINE 50 mcg PO daily
LOSARTAN 25 mg PO daily
METOPROLOL SUCCINATE - 50 mg PO QAM, 25 mg PO QPM
PANTOPRAZOLE - 40 mg PO Daily
POLYETHYLENE GLYCOL 1 tablespoon powder PO Daily
WARFARIN 2.5 mg Tablet PO Daily
Restasis *NF* 0.05 % OU [**Hospital1 **] to each eye
Citalopram Hydrobromide 10 mg PO QHS
CALCIUM CARBONATE 600 mg (1,500 mg) Tablet - 2 Tabs PO BID
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 400 unit Tablet 1 tab
PO daily
Discharge Medications:
1. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] to each eye ().
2. Citalopram 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Lactaid 3,000 unit Tablet Sig: One (1) Tablet PO QAC ().
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablespoon
powder PO once daily as directed.
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Adjust dose as directed to maintain INR 2.0-3.0.
8. Nystatin 100,000 unit/g Cream Sig: One (1) application
Topical twice a day as needed for itching.
9. Outpatient Lab Work
Please check complete blood count on Thursday, [**9-23**] and
fax the results to the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 716**].
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: hold for sbp<100.
11. Home Equipment
Please provide a hospital bed for home.
12. Citracal + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO
twice a day.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
14. Medication
You may continue taking your hydrocortisone-lidocaine compound
topically as needed for discomfort due to hemorrhoids.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary
1) Chronic kidney disease stage V on hemodialysis
2) Acute on chronic diastolic heart failure
3) Thrombocytopenia
4) Urinary tract infection
Secondary
1) Atrial fibrillation
2) Anemia of chronic kidney disease
3) Hypothyroidism
Discharge Condition:
clinically improved with stable vital signs.
Discharge Instructions:
You were admitted to the hospital with generalized weakness and
poor appetite most attributable to worsening kidney function, or
uremia. A catheter was placed and hemodialysis was initiated on
[**2184-9-16**].
Your next hemodialysis session is at [**Location (un) **] [**Location (un) **] on
Thursday, [**9-23**] at 3:00 PM. You will continue to have
dialysis on Tuesdays, Thursdays, and Saturdays.
You were also found to have a low platelet count likely due to
an effect of medication. Antibiotics, protonix, and lipitor, all
of which can cause this problem, were discontinued. Please have
a complete blood count checked on Thursday, [**9-23**] and
ensure that the results are faxed to the office of Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 716**].
The follow medications were changed:
1) Vitamins called nephrocaps were started.
2) Lasix and losartan were discontinued as you will continue to
receive hemodialysis.
3) Metoprolol was decreased to 12.5 mg twice daily due to low
blood pressure.
4) Calcium and vitamin D were changed to a combination pill
called Citracal+D, 2 tablets twice daily.
5) Citalopram (celexa) was increased to 10 mg (1 full tablet)
daily.
Please weigh yourself daily and call your physician if your
weight increases by more than 3 pounds.
Please adhere to diet containing than 2 grams of sodium daily.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Wednesday [**9-29**] at 4:00 PM. If you need to reschedule this appointment,
please call [**Telephone/Fax (1) 719**].
Please call your physician or return to the Emergency Department
immediately if you experience fever, chills, sweats, dizziness,
lightheadedness, passing out, falling, chest pain, palpitations,
shortness of breath, cough, abdominal pain, vomiting, diarrhea,
bloody or dark stools, discomfort with urination, or leg
swelling or pain.
Followup Instructions:
Your next hemodialysis session is at [**Location (un) **] [**Location (un) **] on
Thursday, [**9-23**] at 3:00 PM. You will continue to have
dialysis on Tuesdays, Thursdays, and Saturdays.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Wednesday [**9-29**] at 4:00 PM. If you need to reschedule this appointment,
please call [**Telephone/Fax (1) 719**].
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2184-10-22**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2184-10-22**] 10:40
Completed by:[**2184-9-21**]
ICD9 Codes: 5849, 5990, 4280, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7357
} | Medical Text: Unit No: [**Numeric Identifier 64480**]
Admission Date: [**2180-11-4**]
Discharge Date: [**2181-4-20**]
Date of Birth: [**2180-11-4**]
Sex: F
Service: NB
This is a discharge addendum. A prior discharge dictation has
already been dictated. Please see prior discharge summary for
detailed history of present illness, physical exam and
hospital course up until [**2181-4-12**]. This is a discharge
addendum discussing her hospital course from [**4-12**] to [**2181-4-20**].
Respiratory: [**Known lastname 64481**] returned from her G-tube placement on
[**2181-4-12**], and required a mild amount of nasal cannula
oxygen postoperatively. She continued to require this oxygen
for 2-3 days following the G-tube placement and developed a
cough and some mild rhinorrhea. At this time a viral
respiratory panel was sent. It was found that she had
parainfluenza virus. She continued on nasal cannula oxygen
until [**2181-4-18**], and since that time has remained in room
air. She has occasional desaturations for which she responds
spontaneously. Her cough is much improved at this time. She
has been off oxygen for 3 days prior to discharge and is
doing well. She should be followed closely. The parents have
been instructed as to what symptoms to watch for for signs
and symptoms of croup.
Gastrointestinal: [**Known lastname 64481**] had her G-tube placed on [**2181-4-12**]. We were able to start using it on [**2181-4-13**]. She had
no problems with this. She had some mild erythema around it
to which bacitracin was placed, but now it is looking well.
It is just to be cleaned with tap water daily. There are no
concerns about the use of the G-tube, and she is tolerating
it well. She is currently receiving 165 cc/kg per day of
Enfamil. The grandmother has been taught how to use the G-
tube. She is to receive 4 bolus G-tube feeds during the day
and continuous feeds from 11 p.m. to 5 a.m. Her growth has
been good on this regimen. She is to be discharged with this.
Her discharge weight is 4775 grams.
ID: Parainfluenza virus was obtained from nasal secretions on
[**2181-4-17**]. She did have symptoms including a
conjunctivitis, rhinorrhea and a cough that were all
consistent with this infection. She was treated for a 7-day
course of erythromycin ointment for conjunctivitis. This has
cleared nicely. She has been off any ointment for 2 days
prior to discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home with her grandparents. She is
in DSS custody, but her grandparents will have physical
custody.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] in [**Location (un) 5165**], [**State 350**];
phone number [**Telephone/Fax (1) 64482**].
CARE RECOMMENDATIONS: She is being discharged to home on
Enfamil 20 calories per ounce at 165 cc/kg per day with a
regimen of 4 bolus feeds during the daytime and continuous
feeds at nights.
MEDICATIONS:
1. Zantac.
2. Reglan.
3. Iron as described in the prior dictation.
She has passed a carseat examination. She has received
newborn state screening as above. She received her
immunizations as dictated in the prior discharge summary.
DISCHARGE DIAGNOSES: As above in the prior discharge summary
and additional.
1. Parainfluenza virus.
2. Gastrostomy tube placement.
3. Aspiration.
[**First Name11 (Name Pattern1) 3692**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 27992**], MD
Dictated By:[**Last Name (NamePattern4) 64483**]
MEDQUIST36
D: [**2181-4-20**] 12:16:12
T: [**2181-4-20**] 12:56:19
Job#: [**Job Number 64484**]
ICD9 Codes: 769, 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7358
} | Medical Text: Admission Date: [**2197-12-13**] Discharge Date: [**2197-12-18**]
Date of Birth: [**2142-10-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Antihistamines - 1st Generation Classif. / Nsaids
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x 3 (LIMA-LAD, SVG-OM, SVG-DG)
[**12-15**]
left heart catheterization, coronary angiography
History of Present Illness:
This 55 year old white male had the onset of angina with minimal
exertion two months ago. he had a positive exercise stress test
and was referred for catheterization. This was done to reveal
50% left main and double vessel disease of the left system. He
was kept in house for revascularization.
Past Medical History:
hypertnsive
hypercholesterolemia
s/p lens implant O.D.
Social History:
remote smoker
social ETOH use
works in an office
lives with his wife
Family History:
grandfather had an MI at age 59
Physical Exam:
Admission:
VSS, Afebrile
Neuro- intact
lungs- clear
Cor-RSR w/o murmur
Exts- benign. Pulses symmetric and normal
Pertinent Results:
[**2197-12-17**] 06:40AM BLOOD WBC-12.0* RBC-2.99* Hgb-9.2* Hct-25.1*
MCV-84 MCH-30.7 MCHC-36.6* RDW-13.3 Plt Ct-210
[**2197-12-16**] 01:41AM BLOOD WBC-15.4* RBC-3.49* Hgb-10.7* Hct-29.1*
MCV-83 MCH-30.6 MCHC-36.8* RDW-13.1 Plt Ct-292
[**2197-12-17**] 06:40AM BLOOD Glucose-123* UreaN-14 Creat-1.0 Na-137
K-4.1 Cl-104 HCO3-25 AnGap-12
[**2197-12-16**] 01:41AM BLOOD Glucose-78 UreaN-8 Creat-0.7 Na-139 K-3.9
Cl-109* HCO3-26 AnGap-8
[**2197-12-13**] 09:50AM BLOOD ALT-50* AST-20 CK(CPK)-41 AlkPhos-69
Amylase-23 TotBili-0.8
[**2197-12-15**] 06:34PM BLOOD Type-ART pO2-128* pCO2-45 pH-7.37
calTCO2-27 Base XS-0
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 80696**] (Complete)
Done [**2197-12-15**] at 3:52:21 PM FINAL
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: [**2142-10-5**]
Age (years): 55 M Hgt (in): 66
BP (mm Hg): 120/60 Wgt (lb): 176
HR (bpm): 60 BSA (m2): 1.90 m2
Indication: coronary artery disease
ICD-9 Codes: 786.05
Test Information
Date/Time: [**2197-12-15**] at 15:52 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 #: 2009AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
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: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: 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: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened 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: 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. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 45 cm
from the incisors.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**Known lastname **] at
8AM before surgery start.
.
POST-BYPASS:
Preserved biventricular systolic function. LVEF 55%
Intact thoracic aorta.
Minimal MR [**First Name (Titles) **] [**Last Name (Titles) **].
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2197-12-15**] 15:56
[**Known lastname **],[**Known firstname **] G [**Medical Record Number 80697**] M 55 [**2142-10-5**]
Cardiology Report C.CATH Study Date of [**2197-12-13**]
*** Not Signed Out ***
BRIEF HISTORY: Mr. [**Known firstname **] [**Known lastname **] is 55 years old with a history
of
hypertension and dyslipidemia referred for cardiac
catheterization in
the setting of exertional chest pain. He underwent exercise
stress
testing with nuclear imaging on [**2197-12-5**] during which he
completed 8
minutes of [**Doctor First Name **] protocol, stopped due to chest pain, with
distal
anteroseptal and apical reversible perfusion defect.
INDICATIONS FOR CATHETERIZATION:
CAD, Exertional chest pain, Abnormal stress test
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French angled pigtail catheter,
advanced
to the left ventricle through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Left Ventriculography: was performed in the 30 degrees [**Doctor Last Name **]
projection,
using 39 ml of contrast injected at 13 ml/sec, through the
angled
pigtail catheter.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.87 m2
HEMOGLOBIN: gms %
ENTRY
**PRESSURES
LEFT VENTRICLE {s/ed} 134/22
AORTA {s/d/m} 134/78/80
LEFT VENTRICULOGRAPHY:
Volumetric data:
LV end diastolic volume index (nl 50-90 ml/m2). 44.5
LV end systolic volume index (nl 15-30 ml/m2). 16
LV stroke volume index (nl 35-75 ml/m2). 28.5
LV ejection fraction (nl 50%-80%). 64
Regurgitant fraction. 0
Qualitative wall motion:
[**Doctor Last Name **]:
1. Antero basal - normal
2. Antero lateral - normal
3. Apical - normal
4. Inferior - normal
5. Postero basal - normal
Other findings:
Mitral valve was normal.
Aortic valve was normal.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DISCRETE 50
6) PROXIMAL LAD DISCRETE 50
7) MID-LAD DISCRETE 80
9) DIAGONAL-1 DISCRETE 70
12) PROXIMAL CX DISCRETE 80
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour30 minutes.
Arterial time = 0 hour11 minutes.
Fluoro time = 6.7 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 119
ml, Indications - Renal
Premedications:
ASA 325 mg P.O.
Fentanyl 25 mcg iv
Versed 0.5 mg iv
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 0 units IV
Cardiac Cath Supplies Used:
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
5FR [**Company **], MULTIPACK
COMMENTS:
1. Coronary angiography of this right dominant system revealed
left
main and 2 vessel CAD. The LMCA had a 50% distal stenosis
extending
into the ostium of the LAD and circumflex vessels. The LAD had
a 50%
ostial stenosis and an 80% proximal stenosis across the origin
of the
first diagonal branch, which itself had a 70% ostial stenosis.
The LCx
had an 80% ostial stenosis. The RCA had mild luminal
irregularities.
2. Entry hemodynamics revealed elevated left sided filling
pressures
with LVEDP of 22 mm Hg. Systemic arterial pressures were mildy
elevated
with aortic systolic pressure of 134 mm Hg.
3. Left ventriculography revealed no mitral regurgitation.
LVEF was
calculated at 64%.
FINAL DIAGNOSIS:
1. Left main and 2 vessel CAD.
2. Normal left ventricular systolic function.
3. Left ventricular diastolic dysfunction.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) 80698**],[**Name11 (NameIs) 80699**] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) 80700**],[**First Name3 (LF) **] J.
ATTENDING STAFF: [**Last Name (un) 80698**],[**Last Name (un) 80699**] J.
Brief Hospital Course:
He was admitted after catheterizationa nd remained pain free.
Workup was completed and on [**12-15**] he went to the Operating Room
where triple bypass grafting was accomplished. He weaned from
bypass on Propofol. He was easily weaned from the ventilator,
extubated and begun on beta blockers.
CTs were removed on the day after surgery and diuresis was
begun. He was transferred to the floor where he made an
uneventful recovery.
He was cleared by physical therapy for d/c to home on POD#3.
Medications on Admission:
Metoprolol 25mg [**Hospital1 **]
ASA 325mg/D
Propecia 1 tab/D
Crestor 20mg/D
Valerian Root Extract
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
10. Propecia 1 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Coronary artery disease
s/p coronary artery bypass grafts x3
hypertension
hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
wound clinic on [**Hospital Ward Name 121**] 6 in 2 weeks
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in [**11-17**] weeks ([**Telephone/Fax (1) 27360**])
Dr. [**Last Name (STitle) **] [**Name (STitle) **] in 2 weeks ([**Telephone/Fax (1) 52395**])
Please call for appointments
Completed by:[**2197-12-18**]
ICD9 Codes: 4111, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7359
} | Medical Text: Admission Date: [**2133-2-2**] Discharge Date:
Date of Birth: [**2133-2-2**] Sex: M
Service: NEONATOLOG
HISTORY OF THE PRESENT ILLNESS: The infant is a full-term
boy born to a 42-year-old gravida 5, para 4 to 5 mom,
hepatitis B surface antigen negative, RPR nonreactive,
antibody negative, rubella immune, GBS negative, A positive
mom. [**Name (NI) 37516**] [**2133-1-23**]. Infant was born at 41 and [**2-5**]
week estimated gestational age and induced due to post dates.
Otherwise, pregnancy was uncomplicated.
LABOR AND DELIVERY HISTORY: Infant was a brow presentation
with evidence of late decelerations on fetal monitoriong
necessitating a stat cesarean section. Rupture of membranes
occurred ten hour prior to delivery. In the operating
room the infant was depressed. The infant was flaccid
with poor color and heart rate of less than 100. 1 minute
Apgar of 1. The infant received positive pressure
ventilation and eventual intubation; 5 and 10 minute Apgars
were 5 and 7 respectively.
Prior to transfer to NICU the infant self extubated and had a
strong cry. The infant appeared pale with poor perfusion,
but with spontaneous respirations and adequate aeration. The
infant was transferred to the NICU for further management.
PHYSICAL EXAMINATION: Examination on admission revealed the
weight of 3815 grams, 98th percentile. Height: 21.5 cm,
95th percentile. OFC: 35.5 cm, 75th percentile.
Vigorous, pale infant with strong cry. Weak distal pulses
noted. There was a large frontal hematoma with bruising.
The eyelids were swollen. The anterior fontanelle was open,
flat, and soft. The neck was slightly bruised. The
clavicles were intact. Chest was clear with adequate
aeration. Heart was regular with normal S1 and S2. There
were no murmurs. Abdomen was slightly distended, but soft.
Liver was 1 cm below the costal margin. There was normal
male genitalia. Testes were down and the anus was patent.
Neurological examination was nonfocal.
#1. RESPIRATORY: Initial impression was respiratory
distress in the delivery room necessitating intubation as
part of the resuscitative effort. After self extubation in
the delivery room, however, the infant did not have
persistent respiratory problems and was on room air
throughout the remainder of the course in the NICU. The
infant has not demonstrated any apnea or impaired respiratory
drive. Chest was clear at the time of discharge to the
Newborn Nursery.
#2. CARDIOVASCULAR: Perfusion was poor in the early NICU
course. The infant was given boluses of normal saline and
bicarbonate to correct metabolic acidosis. ABG showed pH of
7.3, pCO2 28, with bicarbonate of 14, and base deficit of -10.
This corrected with aggressive fluid resuscitation. Repeat
blood gas after resuscitation showed a pH of 7.39 with
resolved metabolic acidosis and a base excess of only -2.
#3. FLUIDS, ELECTROLYTES, AND NUTRITION: Infant was kept
NPO in the immediate postnatal period, but then slowly
allowed to feed. Currently, the baby is taking ad lib p.o.
feeds by breast and bottle. Electrolytes have not been
obtained.
#4. GASTROINTESTINAL: The infant is stooling without
difficulty and has no active GI issues.
#5. HEMATOLOGY: The infant had hematocrit on admission of
43 with platelet count of 295,000. There have been no
concerns.
#6. INFECTIOUS DISEASE: The infant had a white count on
admission of 21.8 with 27% polys, 2% bands, and 58% lymphs.
The infant received 48 hours of antibiotics and cultures have
been negative. There was no prolonged rupture of membranes.
Mom was GBS negative. There was no maternal fever or any
other sepsis risk factors. Antibiotics were started
empirically simply for poor perfusion after delivery.
Likely, this was due to head compression immediately prior to
delivery of the infant. There have been no other concerns
for infection.
#7. NEUROLOGICAL: Upon transfer to the Newborn Nursery
the infant had a nonfocal neurological examination.
CONDITION ON TRANSFER: Stable and appropriate for transfer
to the Newborn Nursery.
DISCHARGE DISPOSITION: Newborn Nursery, [**Hospital1 346**].
Primary pediatrician: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Street Address(1) 38837**]
Pediatrics in [**Location (un) 5176**].
CARE RECOMMENDATIONS:
Feeding: Ad lib p.o. feeding, either mother's milk nursing
or bottle feeding as desired.
Medications: None.
State Newborn Screens: Sent and need to be followed up.
Immunizations received: The infant has not yet received
hepatitis B immunizations.
DISCHARGE DIAGNOSES:
1. Perinatal depression.
2. Sepsis evaluation.
3. Full-term baby boy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2133-2-4**] 15:26
T: [**2133-2-4**] 15:33
JOB#: [**Job Number 38838**]
ICD9 Codes: 769, 2762, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7360
} | Medical Text: Admission Date: [**2195-1-12**] Discharge Date: [**2195-1-29**]
Date of Birth: [**2116-10-23**] Sex: F
Service: SURGERY
Allergies:
Morphine Sulfate / Iodine-Iodine Containing / Oxycodone /
Minocycline / Erythromycin Base / Dust & Pollen Filter Mask /
water, dove soap, seasonal allergies / water
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
nausea and vomitting
Major Surgical or Invasive Procedure:
Central line placment [**2195-1-17**]
Diagnostic paracentesis
PICC line
Nasogastric tube
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 78 year old female who complains of
vomiting.
This patient is one-week status post right hemicolectomy for
a cecal volvulus. She's been having vomiting and retching
for the last several days. She went to the [**Hospital 620**] campus
where she had a KUB which showed: a 12 cm colon.
She has no real abdominal pain but is complaining of some
"heartburn".
She was given Cipro and Flagyl and sent. They also put a
Foley catheter in and found 500 cc of urine. No fevers or
chills. She actually denies abdominal pain. She has been
having difficulty urinating but denies any dysuria or any
hematuria.
Timing: Sudden Onset, Intermittent
Quality: Mostly retching,
Severity: 5 times in the last 24 hours
Duration: Several days,
Context/Circumstances: See above
Associated Signs/Symptoms: Decreased p.o. intake
Past Medical History:
PMH:
- rectocele and rectal prolapse s/p multiple surgeries (see
below)
- colonic adenomas s/p sigmoid colectomy [**2182**] (last colonoscopy
[**2192**], sigmoidoscopy [**2193**])
- diverticulosis
- hemorrhoids
- severe anxiety / depression
- osteopenia
- degenerative joint disease, planned for L hip surgery with
Dr.
[**Last Name (STitle) **] [**2195-1-13**]
- lumbar spondylosis
- chronic pain
- chronic constipation
- asthma
- syncope / vasovagal episodes
PSH:
- cholecystectomy [**2180**]
- sigmoid colectomy for tubobillous adenoma [**2182**]
- rectopexy and rectocele repair ([**Doctor Last Name 1120**] [**2191**])
- posterior colporraphy ([**Doctor Last Name **] [**2192**])
- removal of retained sigmoid suture ([**Doctor Last Name **] [**2193**])
Social History:
Former smoker, quit 25 years ago; no EtOH, no IVDU; lives with
husband. PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 67282**] ([**Hospital1 18**]).
Family History:
- father: deceased of colon cancer (age unknown), mother: CVA
and endometrial cancer, brother: lung cancer, DM and MI, son:
lung cancer
Physical Exam:
PHYSICAL EXAMINATION: upon admission: [**2195-1-17**]
Temp:99.2 HR:90 BP:132/83 Resp:16 O(2)Sat:95 Normal
Constitutional: Comfortable
HEENT: Extraocular muscles intact
Mucous membranes moist
Chest: Clear to auscultation
Cardiovascular: Normal first and second heart sounds
without murmur
Abdominal: Soft, Nontender without distention and with
clean-looking staple line
GU/Flank: No costovertebral angle tenderness
a Foley catheter is in a draining clear yellow urine.
Extr/Back: Mild edema on both sides
Neuro: Speech fluent
Psych: Normal mood
Physical examination upon discharge:
[**2195-1-29**]
General: Sitting in chair, alert and oriented, skin warm, dry,
pink
vital signs: t=98.6, hr=88, bp=130/90, resp. rate=20, oxygen
saturation room air=96%
CV: Ns1, s2, -s3, -s4
LUNGS: Diminished bases ( left >right)
ABDOMEN: Suture line clean and dry, no exudate, non-tender,
soft
EXT: Mild edema lower ext., + dp bil.
Pertinent Results:
[**2195-1-27**] 05:18AM BLOOD WBC-11.2* RBC-3.00* Hgb-8.8* Hct-25.4*
MCV-85 MCH-29.2 MCHC-34.4 RDW-14.0 Plt Ct-519*
[**2195-1-26**] 05:10AM BLOOD WBC-12.6* RBC-3.22* Hgb-8.9* Hct-27.3*
MCV-85 MCH-27.6 MCHC-32.6 RDW-14.0 Plt Ct-567*
[**2195-1-25**] 05:22AM BLOOD WBC-10.7 RBC-3.19* Hgb-9.0* Hct-27.1*
MCV-85 MCH-28.3 MCHC-33.4 RDW-13.9 Plt Ct-582*
[**2195-1-12**] 05:55PM BLOOD WBC-17.9*# RBC-4.53# Hgb-12.9# Hct-38.0#
MCV-84 MCH-28.5 MCHC-34.0 RDW-13.6 Plt Ct-590*#
[**2195-1-15**] 05:58AM BLOOD Neuts-80.3* Lymphs-13.0* Monos-4.3
Eos-2.0 Baso-0.5
[**2195-1-27**] 05:18AM BLOOD Plt Ct-519*
[**2195-1-23**] 05:33AM BLOOD PT-11.7 PTT-26.3 INR(PT)-1.0
[**2195-1-18**] 02:10AM BLOOD Fibrino-313
[**2195-1-17**] 05:32PM BLOOD Fibrino-385
[**2195-1-27**] 05:18AM BLOOD Glucose-149* UreaN-21* Creat-0.5 Na-138
K-3.5 Cl-107 HCO3-25 AnGap-10
[**2195-1-26**] 05:10AM BLOOD Glucose-128* UreaN-16 Creat-0.5 Na-136
K-3.4 Cl-103 HCO3-25 AnGap-11
[**2195-1-25**] 05:22AM BLOOD Glucose-186* UreaN-15 Creat-0.5 Na-137
K-4.2 Cl-106 HCO3-26 AnGap-9
[**2195-1-17**] 05:32PM BLOOD Glucose-240* UreaN-26* Creat-0.9 Na-137
K-3.8 Cl-100 HCO3-24 AnGap-17
[**2195-1-17**] 04:58AM BLOOD Glucose-163* UreaN-22* Creat-0.8 Na-130*
K-3.8 Cl-93* HCO3-30 AnGap-11
[**2195-1-17**] 01:30AM BLOOD Glucose-227* UreaN-19 Creat-0.8 Na-131*
K-3.5 Cl-94* HCO3-29 AnGap-12
[**2195-1-22**] 05:49AM BLOOD ALT-30 AST-19 AlkPhos-65 Amylase-9
TotBili-0.2
[**2195-1-18**] 02:10AM BLOOD ALT-183* AST-137* CK(CPK)-203* AlkPhos-69
TotBili-0.2
[**2195-1-17**] 05:32PM BLOOD ALT-211* AST-248* CK(CPK)-60 AlkPhos-76
TotBili-0.3
[**2195-1-18**] 09:04AM BLOOD CK-MB-6 cTropnT-0.02*
[**2195-1-18**] 02:10AM BLOOD CK-MB-8 cTropnT-0.03*
[**2195-1-17**] 05:32PM BLOOD CK-MB-3 cTropnT-0.01
[**2195-1-12**] 07:25AM BLOOD cTropnT-<0.01
[**2195-1-27**] 05:18AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.1
[**2195-1-22**] 05:49AM BLOOD calTIBC-159* TRF-122*
[**2195-1-18**] 10:23AM BLOOD D-Dimer-[**Numeric Identifier **]*
[**2195-1-18**] 05:11PM BLOOD Type-ART pO2-92 pCO2-34* pH-7.48*
calTCO2-26 Base XS-2
[**2195-1-18**] 09:21AM BLOOD Type-ART pO2-142* pCO2-34* pH-7.48*
calTCO2-26 Base XS-3
[**2195-1-18**] 09:21AM BLOOD Glucose-91 Lactate-0.6
[**2195-1-18**] 03:33AM BLOOD Lactate-0.8
[**2195-1-17**] 06:14PM BLOOD Hgb-10.2* calcHCT-31
[**2195-1-12**]: EKG:
Sinus rhythm. Low voltage. Mild Q-T interval prolongation. ST-T
wave
abnormalities. Since the previous tracing of [**2194-12-30**] precordial
ST-T wave
abnormalities are more prominent. Clinical correlation is
suggested.
TRACING #1
[**2195-1-14**]: Abdominal cat scan:
IMPRESSION:
1. Mild dilation of the proximal and mid small bowel loops
measuring up to a maximum of 3.5 cm in diameter. There is no
definite discrete transition point in small bowel although
proximal bowel is somewhat more dilated than distal residual
small bowel. However, noting marked colonic dilatation on the
recent prior radiographs, which has improved, this evolution is
suggestive of an ileus. Small bowel obstruction is not entirely
excluded, however, and if it were confirmed, then ascites could
suggest considerable congestion or even potentially ischemia in
the appropriate clinical setting, although there is no bowel
wall thickening.
2. Moderate amount of ascites, new since the prior study, and
could be
secondary to fluid resuscitation/ cardiac / hepatic dysfunction.
Peritoneal inflammation with secondary ileus and ascites could
also be considered in the differential, noting substantial
ascites and ileus, which together could be seen with peritonitis
although the findings are non-specific. Although ascites does
not appear loculated, if clinical concern persists, then an
examination with intravenous contrast would be more sensitive
for the possibility of any potential early abscess formation.
3. Malpositioned nasogastric tube with a retrograde turn and
terminating in the distal esophagus.
4. Small exophytic left renal lesion; suggest follow-up
ultrasound evaluation
[**2195-1-15**]: Diagnostic paracentesis:
IMPRESSION: Successful, ultrasound-guided diagnostic and
therapeutic
paracentesis yielding 2.2 liters of reddish fluid
[**2195-1-16**]: Liver/gallbladder ultrasound:
IMPRESSION:
1. Patent hepatic vasculature, note is made that the midline
vessels are
obscured from view by overlying bowel.
2. Minimal ascites and a small right pleural effusion.
3. No liver lesion and no biliary dilatation.
[**2195-1-18**]: Chest x-ray:
IMPRESSION: Evidence for pulmonary vascular congestion. Left
pleural fluid.
Bilateral subsegmental atelectasis and possibly focal
consolidation. The
right internal jugular catheter terminates at the level of the
right atrium.
There is distended colon below the level of the diaphragm (see
accompanying
report)
[**2195-1-23**]: EKG:
Artifact is present. Sinus rhythm. Low voltage in the precordial
leads.
Compared to the previous tracing of [**2195-1-23**] limb lead voltage
has improved
marginally
[**2195-1-24**]: KUB:
FINDINGS: Moderate-to-severe intestinal distention with multiple
air-fluid
levels but no evidence of wall thickening. Given the multiple
overlays of
gas-filled bowel loops no change in caliber can be clearly
determined.
Therefore, CT is recommended. No evidence of free air. No safe
evidence of
pathological calcifications. Contrast material in the rectum
[**2195-1-24**]: Chest x-ray:
FINDINGS: The nasogastric tube that has newly been placed is in
the stomach.
A right internal jugular vein catheter projects into the basal
parts of the right atrium, the device should be pulled back by
approximately 7 cm.
Unchanged moderately distended segments of the colon. Subtle
bilateral areas of atelectasis at the lung base. Borderline size
of the cardiac silhouette without pulmonary edema.
[**2195-1-25**]: Chest x-ray:
FINDINGS: The patient has received a new PICC line. The line can
be followed over its entire course, the tip projects over the
right atrium, the line should be pulled back by approximately 4
cm to ensure position within the mid-to-low SVC. No evidence of
pneumothorax, the other monitoring and support devices are
unchanged. Mildly increasing colonic distention.
Brief Hospital Course:
78 year old female s/p right hemi-colectomy re-admitted to the
Acute Care Service with vomitting. Upon admission, she was made
NPO, given intravenous fluids, and had imaging studies of her
abdomen which showed an ileus and ascites. Because of her
abdominal distention and nausea, she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube
placed. A diagnostic paracentesis was done for the fluid
collection in her abdomen. It did not grow any bacteria. Her
fluid status was tenuous during this time and she did require
additional fluid to maintain an adequate urine output. In order
to maintain her nutritional staus, she was started on TPN on
[**1-16**] after a nutrition consult. On [**1-17**], she was transported to
the Intensive Care Unit after she sustained a PEA arrest vs.
vaso-vagal event. She was intubated and her cardiac enzymes
were cycled. Her EKG did not show any evidence of a myocardial
infarction. An echocardiogram showed possible antero-septal
hypokinesis with an EF> 50%. She was bronched with no evidence
of aspiration. Ultrasound was negative for DVT. She was
extubated within 24 hours and discharged from the Intensive Care
Unit.
Upon return to the floor, she had a follow-up GI consult who
recommended a bowel regimen to alleviate her constipation and
reduce her abdominal distention. Her [**Last Name (un) **]-gastric tube was
discontinued on [**1-22**] after she tolerated it being clamped.
She was started on clear liquids with the gradual advancement to
a regular diet. She did continue to have an elevated white blood
cell count and was found to have a urinary tract infection for
which she is currently on ampicillin until [**1-30**]. Because of her
colonic inertia, her narcotics were discontinued and she was
given mineral oil, reglan, and azithromycin with successful
passage of stool. Her abdominal distention has diminished and
she is tolerating a regular diet. Her TPN has been discontinued
on [**1-26**]. She has been evaluated by physical therapy and has been
seen by the social worker for additional emotional support.
She is preparing for discharge to a extended care facility
where she will be able to increase her strength and stamina
through physical therapy and ADL's. Her vital signs are stable
and she is tolerating a regular diet without complaint of
nausea, but her appetite is still diminished. Her foley catheter
is to gravity drainage. She has been followed by the
Nurtritionist who has made recommendations about her diet. She
has been ambulating with assistance.
Follow-up visit is recommended with her primary care provider
where she will need further investigation about the left renal
lesion. In addition to this, she will need to follow up with her
Dr. [**Last Name (STitle) 79**], who will make recommendations about the length of time
for azithromycin usage for colonic motility. She will need to
schedule an appointment with the Acute care service in 2 weeks.
Of note: MRSA +
Medications on Admission:
[**Last Name (un) 1724**]: albuterol 1-2 puffs inh QID prn, clonazepam 1mg PO BID,
compazine 5mg PO prn, flovent 110 mcg 3 puffs inh TID, Anusol
ointment prn, lidocaine 2% prn, Metrogel 1% prn, simvastatin
10mg
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
2. Cepacol Sore Throat + Coating 15-5 mg Lozenge Sig: One (1)
lozenger Mucous membrane every 4-6 hours as needed for throat
pain.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheezing.
4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back and chest pain .
5. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. mineral oil Oil Sig: Thirty (30) ML PO EVERY OTHER DAY
(Every Other Day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 1 days: 1 dose this pm, and 2 doses 1/28...then
d/c.
Disp:*6 Capsule(s)* Refills:*0*
14. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
15. calcium carbonate 250 mg Tablet, Chewable Sig: [**1-4**] Tablet,
Chewables PO three times a day: as needed for heartburn.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Ileus
Post-operative ascites
Enterococcus urinary tract infection
PEA arrest
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 recently discharged from the hospital after you had a
portion of your bowel removed for a cecal vovulus. You were
discharged to a rehabilitation center but returned 3 days later
with inability to tolerate food and nausea. Since your
re-admission, you have had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastic tube placed to
allerviate your nausea. You also were noted to have a
collection of fluid in your abdomen which was cultured, did not
show any bacteria. Your bowels were slow to move, but since you
have been off narcotics, and with laxatives, you have
successfully moved your bowels. You have been able to tolerate a
diet. You are now preparing for discharge to a rehabiltation
facility with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered, especially the bowel regimen which has been
prescribed
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2195-2-17**] 1:20
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2195-5-12**] 12:20 (please
reschedule this appointment so that your visit will be withing
the next 2-3 weeks. You will also need follow-up ultrasound for
the kidney lesion.
Please follow up with the Acute Care Service in 2 weeks, you can
schedule this appointment by calling #[**Telephone/Fax (1) 600**]. You will
also need ultra-sound follow-up for the kidney lesion was was
noted.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2195-1-29**]
ICD9 Codes: 4275, 5990, 5119, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7361
} | Medical Text: Admission Date: [**2165-12-19**] Discharge Date: [**2165-12-25**]
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 86 year-old male multiple medical problems who
presents with hypoglycemia since last night. The patient was
admitted to the hospital from [**Date range (1) 68760**] wtih hypoglycemia. He
was evaluated by endocrinology at that time and the most likely
etiology of his hypoglycemia was felt to be pre-diabetes causing
hyperinsulinemia. Work-up revealed an elevated C-peptide (18.1),
elevated insulin level of 41, negative sulfonylurea screen, and
low beta-hydroxybutyrate. These labs had all been pending at the
time of discharge. He was discharged home with instructions to
eat frequent small meals (to prevent hyperinsulinemia), follow
fasting and post-prandial fingersticks, and follow-up with his
[**Date range (1) 3390**] and endocrinology. Family has been checking FS multiple
times daily, mostly ranging 80-150's. Reportedly had a similar
episode at some point in the '90s.
.
Pt had been feeling in his usual state of health until several
days ago when he developed cough, low-grade fevers (to 38
degrees celsius over the weekend, more recently normal) and
dyspnea with ambulation. He was seen by his [**Date range (1) 3390**] yesterday and
was found to have rales at the R mid and lower lung fields,
afebrile, breathing comfortably. He was started on levoquin for
empiric CAP coverage. PA and lateral CXR was negative for
pneumonia.
.
Last night around 10pm he became tremulous and diaphoretic. FS
was noted to be in the 40s. His family gave him juice and honey.
At 2am, he had a similar episode with tremors, FS in the 40s,
and again received juice and honey. He slept well until 8am when
he had a third episode. At this point, they called EMS. On
arrival, FS was 48. He was given an amp of D50 and his FS
improved to 180. Family declined having him brought to the ED.
Less than one hour later, his FS again dropped to the 40s. At
this point, EMS was called again and he was brought to the ED.
.
In the ED, initial vitals were T 96.7, BP 145/115, HR 70, RR12,
100% on RA. Mental status was at baseline. Exam notable for
left-sided rhonchi. CXR was clear. UA negative. No leukocytosis.
Given levofloxacin. FS on arrival was 49 and he received 1 amp
D50. FS dropped again to 40s within an hour, symptomatic with
tremors, and he was given another amp of D50. Started D5 drip
and admitted to the [**Hospital Unit Name 153**] for close FS monitoring.
Past Medical History:
#. Tension headache
#. Benign Essential Tremor
#. ? Alzheimer's Dementia
#. CAD s/p CABG
#. Chronic Diastolic CHF, EF 60%
#. Sick sinus s/p PPM
- comlpicated by pacer infection [**2159-2-23**] with note of
significant cognitive problems since that prolonged
hospitalization0
#. Paroxysmal atrial fibrillation
- on coumadin
#. Peripheral vascular disease
#. s/p aorto-iliac bypass
#. Chronic kidney disease
#. Dyslipidemia
#. Hypertension
#. Colonic adenoma
#. s/p cholecystectomy
#. Anemia
#. Benign prostatic hypertrophy
Social History:
The patient is Russian-speaking only and lives with his wife in
[**Name (NI) **]. The patient was previously employed as an
electrician. They have a home aide that comes twice a week to
help with cooking, cleaning and bathing the patient. He walks
with a cane at baseline, is able to dress himself, transfer to
commode, feed himself.
Tobacco: None
ETOH: Rare social use previously
Illicits: None
Family History:
noncontributory
Physical Exam:
Vitals: T: 97 BP: 177/57 HR: 64 RR: 19 O2Sat: 99% on RA
GEN: Well-appearing, well-nourished, elderly male no acute
distress
HEENT: EOMI, PERRL, sclera anicteric, mildly dry MM, OP Clear
NECK: No JVD, no bruits, no cervical lymphadenopathy, trachea
midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: rales at R mid-lower lung fields, otherwise clear, no
wheezes
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and year. 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: scattered ecchymoses on his bilateral upper extremities
Pertinent Results:
[**2165-12-19**] 11:03AM COMMENTS-GREEN TOP
[**2165-12-19**] 11:03AM LACTATE-2.1*
[**2165-12-19**] 10:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2165-12-19**] 10:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2165-12-19**] 10:25AM GLUCOSE-36* UREA N-63* CREAT-2.7* SODIUM-140
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18
[**2165-12-19**] 10:25AM WBC-5.2 RBC-4.54* HGB-12.2* HCT-36.7* MCV-81*
MCH-26.9* MCHC-33.3 RDW-16.7*
[**2165-12-19**] 10:25AM WBC-5.2 RBC-4.54* HGB-12.2* HCT-36.7* MCV-81*
MCH-26.9* MCHC-33.3 RDW-16.7*
[**2165-12-19**] 10:25AM PLT COUNT-165
[**2165-12-19**] 10:25AM PT-30.2* PTT-71.8* INR(PT)-3.1*
.
CXR:[**Hospital 93**] MEDICAL CONDITION:
86 year old man with h/o chf but now with recent fevers,
cough, rales right
lung fields
REASON FOR THIS EXAMINATION:
r/o pneumonia
Final Report
INDICATION: 86-year-old man with history of CHF, now with recent
fevers,
cough, rales in the right lung field. Rule out pneumonia.
COMPARISON: Multiple chest radiographs, most recent on [**12-2**], [**2164**].
TECHNIQUE: PA and lateral views of the chest.
FINDINGS: Left-sided pacer leads are intact and terminate in the
expected
location in the right atrium and ventricle, unchanged. Midline
sternotomy
wires are again noted with a small fracture in the third wire,
which is
unchanged since [**2159**].
Vascular engorgement has improved since the prior study. The
lungs appear
clear with no evidence of pneumonia. Cardiomegaly is stable. The
aorta is
calcified and slightly tortuous.
IMPRESSION: No evidence of pneumonia. Improved vascular
engorgement since
prior study.
.
Renal Ultrasound:
NDINGS: This study is limited by patient body habitus and
limited ability
to cooperate with the exam. The left kidney measures 9.9 cm and
the right
kidney measures 9.1 cm. There is no nephrolithiasis or
hydronephrosis in
either kidney. There is a simple cyst arising from the mid pole
of the left
kidney.
The bladder is obscured by shadowing from the air within the
urinary bladder,
likely due to air of Foley catheter placement.
IMPRESSION:
1. Limited study. No hydronephrosis.
2. Non-visualization of the bladder due to air within the
bladder. If
further evaluation is required, consider alternative imaging
methods (MR) or
cystoscopy.
.
CT abdomen/pelvis [**2165-12-23**]:
NDICATION: Dementia, hematuria and anticoagulation with drop in
hematocrit.
Please evaluate for retroperitoneal bleed.
COMPARISON: CT abdomen [**2161-9-17**].
TECHNIQUE: MDCT axially acquired images were obtained from the
lung bases to
the symphysis without contrast. Multiplanar reformatted images
were obtained
and reviewed.
CT ABDOMEN WITHOUT CONTRAST: There are small bilateral pleural
effusions with
associated passive atelectasis. Evaluation of the lung
parenchyma is limited
given respiratory motion. No large mass is detected. Pacer wires
are
detected within the right ventricle and right atrium. There is
CT evidence of
anemia. No pericardial effusion is present.
Evaluation of intra-abdominal and intrapelvic parenchymal organs
is limited
given lack of IV contrast administration. However, no focal mass
lesion is
identified within the liver. Tiny hypoattenuating lesions within
the liver
are too small to adequately characterize. The spleen, stomach
and pancreas
appear grossly unremarkable. There is calcification of the
abdominal aorta
and iliac branches with a small ectasia of the infrarenal aorta
measuring
maximum diameter of 2.3 cm. There is atrophy of the right kidney
with respect
to the left. A probable AML is again noted within the interpolar
region of
the left kidney. There is a splenule within the splenic hilum.
Dense
calcified atherosclerotic plaque is noted within the tortuous
splenic artery.
Dense calcified atherosclerotic plaque is present within the SMA
with
approximately 50% luminal narrowing (series 3: image 28). There
is no
evidence of bowel obstruction or retroperitoneal bleed.
CT PELVIS WITHOUT CONTRAST: The prostate is enlarged measuring
5.5 cm in
greatest transverse dimension. The bladder wall is subjectively
thickened
with foci of intraluminal air within the bladder lumen. No
pelvic or inguinal
adenopathy is detected.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
identified.
Multilevel degenerative changes are present within the lumbar
spine with
intervertebral body disc space narrowing and vacuum phenomenon
most prominent
at L4-5 and L5-S1.
IMPRESSION:
1. No retroperitoneal bleed.
2. Prostatic enlargement with subjective bladder wall
thickening. Foci of
gas within the bladder lumen is presumed secondary to Foley
catheter
placement. Please correlate clinically.
3. Small bilateral pleural effusions.
4. Anemia.
5. Dense calcified atherosclerotic plaque within the abdominal
aorta and
major branches without aneurysmal dilitation.
,
CXR [**2165-12-23**]: FINDINGS: Cardiomediastinal contours are
unchanged. Increased opacity
overlying the lower thoracic spine on the lateral view likely
localizes to the
posterior basilar segment of the right lower lobe on the PA
projection, and
could be due to atelectasis, aspiration, or a developing
pneumonia. Followup
radiographs may be helpful in this regard. Probable small right
pleural
effusion.
Brief Hospital Course:
This is an 86 year-old male with a history of CAD, CHF, afib,
HTN, CKD who presented with recurrent hypoglycemia, acute renal
failure and delerium. He was initially admitted to the ICU.
.
# Hypoglycemia: Differential diagnosis on admission included
reactive hypoglycemia/pre-diabetes, medication effect from
levofloxacin, and insulinoma. Pt had been admitted earlier this
month for hypoglycemic episodes, thought to be due to
hyperinsulinemia in the setting of pre-diabetes and decreased
renal clearance. On the last admission, his insulin levels and C
peptide levels were elevated with low hydroxybutyrate which
could be consistent with insulinoma. However, these test results
are difficult to interpret in the setting of having just
received glucagon prior. Per the family, the pt had been
checking his fingersticks with his wife up to 4 times a day
after his last discharge, with most values in the 100s. The pt
was diagnosed with bronchitis or CAP the day prior to admission
this time, and was started on levofloxacin. In the ICU the
patient required IV d5 overnight to keep FSG>60 (with q1hour FS
checks). Endocrine was consulted who originally recommended
supervised fast to discern between reactive hypoglycemia and
insulinoma. However, the patient had ST depressions overnight
with slight bump in his troponins so it was decided not to
stress the heart by fasting. On the day after admission the
patient started taking PO (diabetic/consistent carb diet). His
FSG was maintained >100 overnight and he was called out to the
floor. After the pt had been off of levofloxacin for 72 hours,
endocrine wanted to pursue a fasting trial for 48 hours, as
90-95% of pts can be diagnosed with insulinoma with only a 48 hr
fast (as opposed to 72) hr fast. The lowest his fingerstick
dropped to was 79, at which point insulin, beta-hydroxybutyrate,
and proinsulin levels were drawn (pending at discharge). He
fingerstick quickly came back up to 90 on its own. Endocrine
felt based on this fasting test, the pt likely has reactive
hypoglycemia and not an insulinoma. The patient should not ever
take a fluoroquinolone again given risk of hypoglycemia. He
should continue to follow a diabetic diet, eat small and
frequent meals (to prevent post-prandial hyperinsulinemia), and
check fingersticks fasting in the morning and at various times
during the day at home. (in the morning and before meals at
rehab). He was provided with a glucagon emergency kit on his
last admission. He has outpatient endocrine follow up.
.
#Acute Renal Faiure: Patient's creatinine increased to 3.1 in
the ICU. We stopped lasix and spironolactone. Urine output
remained stable, urine lytes were c/w FeUrea of 25%. He was
continued on IVF and creatinine fell to 2.3 (back to baseline)
at time of discharge. His lasix and aldactone can be restarted
if he gains more than 3 lbs or has any evidence of volume
overload.
.
#Demand Ischemia/ Tachycardia; Patient became tachycardic
overnight on admission->CK: 55 MB: 11 MBI: 20.0 Trop-T: 0.23,
started heparin gtt and called cardiology consult. Cardiology
did not feel his presentation was consistent with ACS, so we
stopped heparin, and started aspirin 81. CE trended down->
48/9/0.20 then 37/7/0.21.
.
# Community-acquired pneumonia: Patient reported cough for the
past few days with dyspnea on exertion and R-sided crackles. We
had started the patient on levofloxacin but per endocrine there
are case reports of levoflox causing hypoglycemia so we changed
to cefpodoxime and azithromycin to complete a 5 day course. The
pt did have noted RLL ronchi, and later in the hospital stay CXR
did show a small RLL infiltrate. He continues to have a cough
and some ronchi, which is likely residual from his PNA, +/-
bronchitis. Was satting 97% RA at discharge.
.
# Anemia CKD/Hematocrit drop: Pt had hct drop from 29 to 24 over
[**Date range (1) 94100**], down from baseline of 30. At baseline pt is anemic
likey due to CKD, and has been receiving epogen as an
outpatient. Hct on admission was 36, which is higher than his
baseline. Suspect in part this drop was due to dilution. It is
possible his hematuria caused a small amount of hct drop as
well, but his hematuria resolved over 2 days with some blood
clots, but not significant enough to explain [**4-30**] pt hct drop. CT
of the abdomen/pelvis was performed to r/o RP bleed, but this
was negative. Repeat hct was 26, and the following day was 25.
He was given 1 unit PRBC with hct rising to 27 prior to
discharge.
.
# Atrial Fibrillation: Goal INR is 1.5-2.5 per [**Month/Day (3) 3390**] [**Name Initial (PRE) 626**]. INR
supratherapeutic at 3.1 on admission, (likely [**1-26**] levoquin and
decreased PO intake). No signs of active bleeding. Coumadin was
held. On discussion through email with pts [**Month/Day (2) 3390**], [**Name10 (NameIs) **] was decided
to hold pts coumadin in the setting of these recent hypoglycemic
episodes and risk of fall. He was started on ASA 81 mg a day for
his demand ischemia. Given his hematuria and hct drop while
here, increasing it to 325 mg daily was deferred.
.
# Delirium: Pt has underlying dementia, but from caring for pt
on last admission pt was less oriented and agitated. Pt had
pulled his foley in the ICU, causing hematuria, and a 3 way
foley was placed. Upon transfer to the floor the 3 way foley was
removed as were soft wrist restraints. He received zyprexa 2.5
mg once with good effect. Delirium was cleared by 48 hours of
discharge, but at baseline pt does have some sundowning.
.
# Hypertension: Patient arrived hypertensive with SBP 170s. We
held lopressor as it can mask symptoms of hyperglycemia. His BP
was well controlled on hydralazine and Imdur. In the setting of
demand and tachycardia, however, his beta blocker was restarted.
.
# Hematuria: Pt had pulled his foley in the ICU, causing
hematuria, and a 3 way foley was placed. Upon transfer to the
floor the 3 way foley was removed and the pt continued to pass
blood clots without any PVR. No hematuria for 72 hours prior to
discharge.
.
# Coronary Artery Disease s/p CABG: Patient was continued on
simvastatin. Lopressor was restarted and ASA was started after
it was noted pt had demand ischemia.
.
# Chronic diastolic CHF: Appears euvolemic/dry. He was
continued on imdur, but we held lasix and spironolactone in the
setting of acute renal failure.
.
# Dementia: Continued donepezil and aricept
.
# Hyperlipidemia: cont statin
.
# BPH: cont finasteride
Medications on Admission:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): If you are on lipitor then resume taking lipitor.
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. Glucagon Emergency 1 mg Kit Sig: One (1) injection Injection
once as needed for low blood glucose : Give for fingerstick less
than 60 and symptoms unresponsive to food/candy.
Disp:*2 kits* Refills:*1*
13. Outpatient Lab Work
CBC, PT, PTT, INR, sodium, potassium, chloride, bicarbonate,
BUN, creatinine, and glucose to be drawn on [**2165-12-6**]
14. Accu-Chek Aviva Strip Sig: One (1) strip In [**Last Name (un) 5153**] as
directed.
15. Accu-Chek Multiclix Lancet Misc Sig: One (1) lancet
Miscellaneous as directed.
Disp:*100 lancets* Refills:*2*
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF
(Monday-Wednesday-Friday).
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Hypoglycemia
Acute on chronic renal failure
Demand cardia ischemic
Community acquired pneumonia
.
Secondary:
Dementia
Coronary artery disease
Atrial fibrillation
Discharge Condition:
stable
Discharge Instructions:
You were admitted with hypoglycemia (low blood sugar), felt to
be the cause of your symptoms. Your hypoglycemia is thought to
be due to pre-diabetes and having taken the antibiotic
levofloxacin. You should not take this antibiotic in the future,
nor any other antibiotic in its class.
.
You were treated for pneumonia with antbiotics. You have
completed this course of antibiotics.
.
Your coumadin was stopped upon discussion with Dr. [**Last Name (STitle) **]. We
feel that with these recent episodes of low blood sugar, you are
at risk of falling and hitting your head. If you are on
coumadin, this can increase your risk of bleeding. We would like
you to start taking aspirin instead..
.
You were noted to have acute kidney failure. Your lasix was held
while you were here. Your kidney failure improved with IV
fluids.
.
You received 1 unit of blood for your anemia while you were
here.
.
You should check your fingerstick fasting (before breakfast) and
2 hours after breakfast several mornings a week, and bring
these readings with you to Dr. [**Last Name (STitle) **]/Abrahmson of endocrine at
[**Last Name (un) **].
.
You were provided with a glucagon pen on your last admission.
This is an injection that someone can give you if you are found
to have low blood sugars again (fingerstick less than 60) and
unable to eat. The glucagon pen is for emergencies only when you
cannot eat with a low fingerstick. If your fingerstick is less
than 70, you should drink juice or eat candy to try to bring
your fingerstick up to at least 70s-80s. If your fingerstick is
very low (less than 60) or you have symptoms of low blood sugar,
you should eat candy and sugar, then use the glucagon emergency
kit if your fingersticks are still low and don't respond to
food. (ie remains less than 60)
.
You should eat small and frequent meals (5 small meals a day as
opposed to 3 large meals a day. This is to prevent your sugar
levels from dropping.
.
Call your doctor or return to the ER for recurrent shaking,
fingerstick less than 60 or symptoms from low blood sugar, odd
facial/bodily movements, confusion, lightheadedness/fainting,
nausea/vomiting, fevers, palpitations, or any other concerning
symptoms.
Followup Instructions:
1. Primary Care: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2166-1-3**] 3:40 PM
.
2. Endocrine: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10145**] and Dr. [**Last Name (STitle) **] at the [**Hospital **]
Clinic [**1-5**], 3:00 PM, [**Hospital Ward Name 517**] [**Hospital1 **];
Address: One [**Last Name (un) **] Place [**Location (un) 86**], [**Numeric Identifier 718**]
General Info and Appointments: ([**Telephone/Fax (1) 4847**]
.
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2166-3-31**] 1:00
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2166-4-23**] 11:30
ICD9 Codes: 5849, 486, 2930, 5859, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7362
} | Medical Text: Admission Date: [**2137-2-25**] Discharge Date: [**2137-3-2**]
Date of Birth: [**2077-7-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Zestril / Heparin Agents / Heparin,Beef
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
59M with hx COPD, HTN, UGIB (duodenitis) [**2135**] and [**Year (4 digits) 1291**] [**2137-1-16**]
with complicated post op course highlighted by shock liver, ARF,
afib and respiratory failure necessitating trach and PEG, with 3
days of ?dark stools at [**Hospital1 **].
[**2-13**] Hct 28.7
[**2-18**] Hct 21 -> 2 u pRBC -> Hct 26
[**2-23**] profuse epistaxis, Hct 23 -> 2 u pRBC
[**2-25**] at [**Hospital1 18**] ED: Hct 20, G+ black stool, NG lavage negative
Past Medical History:
Hypertension
severe COPD
s/p vasectomy
s/p rhinoplasty as a child because of fx
h/o adrenal mass
s/p removal of skin cancers
[**2132**]- hx L hip osteomyelitis, s/p hip replacement
[**2133**]- L wrist septic arthritis
[**2135**]- duodenitis, UGIB
[**2136**]- Aortic stenosis -> [**Year (4 digits) 1291**] [**1-5**] [**Company **] porcine valve, p/op
course c/b delerium, ARF, afib, shock liver, repiratory failure
(re-intubated X 2 after surgery) trach and PEG, PNA (Staph, tx
with Vanc until [**2-18**])
EF 40%
h/o HIT
Social History:
Married, retired fire fighter.Cigs: smoked [**2-3**] ppd x 30-40 years
and quit in 7/04ETOH: weekend beer drinker
Family History:
+ CAD
Physical Exam:
At admission:
T 98.9 HR 75 BP 107/99 R 22 sat 98% RA
gen NAD A+OX3
HEENT mmm no JVD
CV [**4-7**] sys m at RUSB, RRR
pulm bilat exp wheezes
abd s/nt/nd +BS
extr no edema, 2+ pulses
rectal: guiac positive black stool
Pertinent Results:
Studies: CXR [**2-26**] poor film, ?perihilar fullness (CHF vs new
infiltrate) but poor study, re-shoot film
EKG: [**2-26**] NSR 90 bpm inverted T II, III, F, V1-V6, 0.5-1.[**Street Address(2) **]
dep II, F, V3-V5, ST dep slightly more prominent c/t [**2137-2-5**] EKG
[**2137-2-25**] 05:15PM PT-14.1* PTT-27.6 INR(PT)-1.3
[**2137-2-25**] 05:15PM PLT COUNT-175#
[**2137-2-25**] 05:15PM NEUTS-80* BANDS-1 LYMPHS-11* MONOS-7 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2*
[**2137-2-25**] 05:15PM WBC-8.5 RBC-2.38*# HGB-6.6*# HCT-20.8*#
MCV-88 MCH-27.6# MCHC-31.5 RDW-20.2*
[**2137-2-25**] 05:15PM DIGOXIN-0.8*
[**2137-2-25**] 05:15PM GLUCOSE-82 UREA N-35* CREAT-1.0 SODIUM-140
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-34* ANION GAP-9
Brief Hospital Course:
1. GIB: NG lavage negative in ED, hx of duodenitis, EGD showed
gastric ulcer (non bleeding)
[**2-13**] Hct 28.7
[**2-18**] Hct 21 -> 2 u pRBC -> Hct 26
[**2-23**] profuse epistaxis, Hct 23 -> 2 u pRBC
[**2-25**] at [**Hospital1 18**] ED: Hct 20, G+ black stool, NG lavage negative
Pt admitted to floor team, but transferred to [**Hospital Unit Name 153**] [**3-6**] concern
for respiratory distress and possible need for ventilation
during c-scope-
[**2-27**] transferred back to medical floor s/p procedure Hct 28
[**2-28**] a.m. hct 28, no evidence of epistaxis but 1 black stool
bleeding in oropharynx and posterior pharynx upon removal of
endoscope(resolved).
received vanc and gent X 1 dose for ppx prior to scope
-PPI
-Pt should follow up in [**Hospital **] clinic in [**2-3**] months
-no biopsy taken during this EGD, h. pylori neg in '[**34**]
-Hx of HIT + which most likely caused the patient to have
decreased platelets. Platelets at admission were ~140. However,
on smear patient has some plasma cells, (no schistocytes), may
need repeat smear to differentiate the cause of his
thrombocytopenia.
-Needs repeat hct in 2 days, would add differential to check for
plasma cells.
-given Vitamin K since INR was 1.6 (most likely from abx)
2. COPD flare:
--COPD flare: prednisone taper (st [**2-27**] at 40mg daily)
--Given nebs q3hr prn
--goal O2 sat 90-94%
--frequent suctioning
--sputum GS grew GPC, started levo given COPD flare (cont for 10
days)
--speaking valve was placed
[**Hospital 8890**] transfer to ICU, ABG 7.4/51/67 HCO3 34 (resp acid + met
alk), hypoxic
3. CV: Pump, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1291**], [**First Name3 (LF) **] 40%
--lasix 40 mg PO qD (held at admission, resumed after egd)
CV: Rhythm, hx of afib, now in sinus (throughout
hospitalization), there were no events on tele
--amio was continued, held digoxin (d/c'd at discharge),
continued on diltiazem
--needs to follow up in cardiology clinic regarding length of
amioderone, digoxin was d/c'd during this hospitalization
CV: Cor, lat ST dep on EKG
--held digoxin
[**First Name3 (LF) 1291**]: [**First Name3 (LF) 1291**] on [**2137-1-29**], surgical clips removed [**2137-2-27**]
4. Psych:
--continue olanzapine but hold valproate given change in MS
[**Name13 (STitle) 8891**] level 23
5. HTN: continued valsartan and diltiazem
6. Code: full
7. FEN: was npo for EGD and then tube feeds were restarted with
no complications.
8. PPx: pneumoboots, PPI, Insulin while on steroids
Medications on Admission:
Meds on transfer:
protonix 40 IV BID
Atrovent neb q6
Amio 200 qD
pulmicort 0.25 [**Hospital1 **]
Digoxin 0.125 qD
Dilt 120 QID
Valsartan 80 qD
Folic Acid 1 qD
Thiamine 100 Qd
Olanzapine 10 [**Hospital1 **]
Valproate 125 [**Hospital1 **]
Vanc 1g X 1
Gent X 1
Azith 500 IV qD
Methylpred 60 IV TID
Insulin SQ
NS 100cc/hr X 2L
allergy:
All: PCN, zestril, h/o HIT
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
Gastrointestinal Bleed- s/p egd
Gastric ulcer
COPD Flare
Secondary Diagnoses:
Thrombocytopenia
Hypertension
s/p vasectomy
s/p rhinoplasty as a child because of fx
h/o adrenal mass
s/p removal of skin cancers
[**2132**]- hx L hip osteomyelitis, s/p hip replacement
[**2133**]- L wrist septic arthritis
[**2135**]- duodenitis, UGIB
[**2136**]- Aortic stenosis -> [**Year (4 digits) 1291**] [**1-5**] [**Company **] porcine valve, p/op
course c/b delerium, ARF, afib, shock liver, repiratory failure
(re-intubated X 2 after surgery) trach and PEG, PNA (Staph, tx
with Vanc until [**2-18**])
EF 40%
h/o HIT
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters
Please return to the ED if you feel short of breath or if you
have chest pain or if you have continued black stools or if you
have increased cough. Call your doctor if you have any
concerning symptoms.
Followup Instructions:
Please follow up with your pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4127**] within 1 week
CAll [**Telephone/Fax (1) 2660**] for an appointment
Please follow up with gastroenterology in [**3-7**] months
Call ([**Telephone/Fax (1) 8892**] for an appointment
Please follow up with cardiology in 1 month
Call ([**Telephone/Fax (1) 2037**] for an appointment
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Where: [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[**2137-5-15**] 11:00
ICD9 Codes: 2851, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7363
} | Medical Text: Admission Date: [**2130-11-29**] Discharge Date: [**2130-12-5**]
Date of Birth: [**2073-10-14**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Carbamazepine
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Pedestrian struck
Major Surgical or Invasive Procedure:
[**2130-11-30**]: ORIF left tibial plateau fracture
History of Present Illness:
Ms. [**Known lastname **] is a 57 year old female who was a pedestrian struck by
a car traveling approximately 30-40mph. She was taken to the
[**Hospital1 18**] for further evaluation and care.
Past Medical History:
PMH: seizures, DM-2, HLD
PSH: R femur rod placed
Social History:
no EtOH, tobacco, or drug use
Family History:
noncontributory
Physical Exam:
On discharge:
Afebrile, All vital signs stable
General: Alert and oriented, No acute distress
Extremities: left lower extremity in hinged knee brace; incision
C/D/I with staples; 2+ pulses, sensation intact in foot, full
toe flexion and extension
Weight bearing: LLE touchdown weightbearing, RLE weightbearing
as tolerated
Pertinent Results:
[**2130-11-29**] 09:50AM PT-13.5* PTT-27.4 INR(PT)-1.2*
[**2130-11-29**] 09:50AM PLT COUNT-226
[**2130-11-29**] 09:50AM WBC-3.8* RBC-4.07* HGB-12.9 HCT-38.2 MCV-94
MCH-31.6 MCHC-33.7 RDW-13.4
[**2130-11-29**] 09:50AM UREA N-14 CREAT-0.6
[**2130-11-29**] 09:55AM GLUCOSE-109* LACTATE-1.8 NA+-141 K+-4.0
CL--93* TCO2-32*
[**2130-11-29**] 12:08PM HGB-12.3 calcHCT-37
[**2130-11-29**] L leg xray: There is an extensively comminuted depressed
lateral tibial plateau fracture. A component of the fracture
does extend medial to the medial tibial eminence as well.
Baseline chondrocalcinosis is suspected as well. There is
underlying lipohemarthrosis. No further fracture is identified.
[**2130-11-29**] CT pelvis: . Bilateral superior and inferior pubic rami
fractures as well as a left horizontal sacral ala fracture.
There is no widening of the sacroiliac joints and these injuries
are most consistent with a type 1 lateral compression fracture.
[**2130-11-29**] CT LLE: Left lateral tibial plateau fracture with 12 cm
of central displacement and extension to the medial tibial
eminence. There is also a nondisplaced fibular head fracture as
well as a fracture through the medial aspect of the inferior
pole of the patella. There is resultant lipohemarthrosis.
Brief Hospital Course:
Ms. [**Known lastname **] presented to the [**Hospital1 18**] on [**2130-11-29**] after being a
pedestrian struck by a car. She was evaluated by the trauma
surgery and orthopaedic surgery service. She was admitted to
the T/ICU for monitoring. On [**2130-11-30**] she was taken to the
operating room and underwent an ORIF of her left proximal tibia
fracture. She tolerated the procedure well. On [**2130-12-1**] she
was transferred from the T/SICU to the floor for further care.
She was seen by physical therapy to improve her strength and
mobility.
The rest of her hospital stay was uneventful with her lab data
and vital signs within normal limits and her pain controlled.
She is being discharged today in stable condition.
Medications on Admission:
Keppra 1500 [**Hospital1 **], Phenobarbital 60 QHS, Lamictal 100'',
Simvastatin 40 QHS, Metformin 1000'', Calcium, Ferrous
sulfate''', Zonisamide 100 [**Last Name (LF) 24018**], [**First Name3 (LF) **], Phosamax.
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
3. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous at bedtime for 4 weeks.
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
9. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
10. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. zonisamide 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. insulin regular human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Pedestrian struck
LC1 pelvic fracture
Left tibial plateau fracture
Left fibula head fracture
Left medial platella fracture
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 touchdown weight bearing on your left leg
Continue your lovenox injections as instructed for a total of 4
weeks after surgery
Please take all your medication as prescribed
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department.
You have been prescribed a narcotic pain medication. Please
take only as directed and do not drive or operate any machinery
while taking this medication. There is a 72 hour (Monday
through Friday, 9am to 4pm) response time for prescription refil
requests. There will be no prescription refils on Saturdays,
Sundays, or holidays. Please plan accordingly.
Physical Therapy:
Activity: As tolerated
Left lower extremity: Touchdown weight bearing
[**Doctor Last Name **] brace unlocked/ROM knee as tolerated
Brace may come off for daily care/hygeine
Treatments Frequency:
Staples out 14 days after surgery
Dry dressing as needed for comfort over knee with brace
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7364
} | Medical Text: Admission Date: [**2109-10-16**] Discharge Date: [**2109-10-24**]
Date of Birth: [**2041-12-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2109-10-18**] - Coronary artery bypass grafting x3 with the left
internal mammary artery to the left anterior descending
artery and reversed saphenous vein grafts to the obtuse
marginal artery and the second diagonal artery.
History of Present Illness:
Mr. [**Known lastname 33059**] is a 67 year old male with a history of
hypertension, hypercholesterolemia, palpitations, and coronary
artery disease who was transferred from [**Hospital3 19345**] after a cardiac catheterization revealed lesions in his
left anterior descending and left circumflex coronary arteries.
Ruled in for myocardial infarction based on CK and troponin
Past Medical History:
Hypertension, Dyslipidemia, h/o palpitations with APC and VPCs
on Holter monitor, hiatal hernia, GERD, colonic polyps s/p
polypectomy, mild carotid disease, s/p melanoma L shoulder
resection, s/p cholecystectomy, s/p L knee surgery, s/p
tonsillectomy as child
Social History:
Mr. [**Known lastname 33059**] lives alone, as his wife passed away 3 days ago.
He has three children (one daughter is [**Name8 (MD) **] RN). He is the
assistant director of athletics at [**University/College 33060**]. He quit
smoking 37 years ago. He occasionally drinks alcohol and denies
recreational drug use.
Family History:
non-contributory
Physical Exam:
General: Middle aged male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema - none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
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 33061**]
(Complete) Done [**2109-10-18**] at 9:17:17 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2041-12-28**]
Age (years): 67 M Hgt (in): 71
BP (mm Hg): 113/57 Wgt (lb): 90
HR (bpm): 50 BSA (m2): 1.50 m2
Indication: Intra-op TEE for CABG
ICD-9 Codes: 410.91, 786.51, 424.1
Test Information
Date/Time: [**2109-10-18**] at 09:17 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic
function. 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. Normal
descending aorta diameter.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). No AS. Mild to moderate ([**12-28**]+) AR.
Eccentric AR jet.
MITRAL VALVE: No MS. Trivial MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS: No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. Mild to
moderate ([**12-28**]+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric and directed towards the
interventricular septum. Trivial mitral regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is in
sinus rhythm.
1. Biventricular function is normal
2. Aortic contours appear intact post decannulation
3. Other findings are unchanged
Dr. [**Last Name (STitle) **] was notified in person of the results.
Brief Hospital Course:
Transfer from outside hospital for surgical evaluation, he
[**Last Name (STitle) 1834**] preoperative workup. On [**10-18**] Mr. [**Known lastname 33059**] [**Last Name (Titles) 1834**]
a coronary artery bypass grafting times three (LIMA to LAD, SVG
to DIAG, and SVG to OM) with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He tolerated this
procedure well and was transferred to the intensive care unit.
He was extubated and weaned from his pressors. His chest tubes
were removed and he was transferred to the surgical step down
floor. His epicardial wires were removed and he was diuresed
toward his pre-operative weight. His lopressor was increased as
tolerated. He was seen in consultation by the physical therapy
service. On post operative day four he had episode of nausea
with diaphoresis that progressed to dizzness, he was found to be
hypotensive and was transferred to the intensive care unit for
evaluation. Echocardiogram ruled out tamponade and chest CT
ruled out aortic dissection. He had no further episodes and was
transferred back to the floor on postoperative day five. He
continued to progress, physical therapy saw he evaluation. He
was ready for discharge home with services on post operative day
six with plan for daughter to stay with him for assistance.
Medications on Admission:
Atenolol 50mg po daily
Lisinopril 5mg po daily
Omeprazole 20mg po daily
ASA 81mg po daily
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. 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*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. xanax
you make take Xanax as previously prescribed by PCP as needed
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
coronary artery disease s/p CABG
Non ST elevation myocardial infarction
Vasovagal episode
Hypertension
Dyslipidemia
hiatal hernia
GERD
colonic polyps s/p polypectomy
carotid disease
s/p melanoma L shoulder resection
s/p cholecystectomy
s/p L knee surgery
s/p tonsillectomy as child
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 100.5
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) **] ([**Telephone/Fax (1) 170**]) - [**2109-11-13**] at 1pm [**Hospital **] medical buiding
[**Hospital Unit Name **] - [**Doctor First Name **]
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12816**] (PCP) - Tuesday [**11-12**] at 10 am
([**Telephone/Fax (1) 33062**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2109-11-13**] 11:40
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2109-10-24**]
ICD9 Codes: 4241, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7365
} | Medical Text: Admission Date: [**2128-5-9**] Discharge Date: [**2128-6-1**]
Date of Birth: [**2050-6-10**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Change in mental status
Major Surgical or Invasive Procedure:
Tracheostomy placemnet
PEG tube placement
IVC filter placement
History of Present Illness:
The patient is a 77 year old man with a h/o atrial fibrillation
transferred from an outside hospital for unresponsiveness
(intubated/sedated at OSH). Patient reportedly has not been his
"normal self" lately. He has been more agitated (getting
ativan), confused, and lethargic at times. He had had several
hospital visits for a pneumonia and had been on vancomycin and
levoquin. Patient reportedly found unresponsive with "eyes
rolled back". He was not shaking or tremoring. An ambulance
was called and he was taken to [**Hospital **] Hospital. There he was
found to be minimally responsive, blood pressures 170s to 180s
over 80's, with a fever to 102.2, his blood sugar was 61, and
NIH stroke scale was calculated at 24 primarily for minimal
movement on the right, no verbal output, and decreased level of
attention. He was treated with unasyn, levaquin, IVF and loaded
with dilantin.
Two hours later the patient received a head ct which showed a
left frontal hypodensity. Three hours later, he remained
lethargic and was intubated for airway protection (etomidate,
succin., vecuron.). He was transferred and arrived at [**Hospital1 18**]
approximately 90 minutes later.
Past Medical History:
-h/o recent LLL pna
-deafness since 20yrs ago
- blindness since childhood - optic nerve atrophy?
-adult onset diabetes
-h/o decreased vision
-h/o dvt's
-h/o atrial fibrillation
-esophagitis
-h/o seizures
-h/o closed head injury
Social History:
Sister is HCP Resident of [**Location (un) 511**] Home for Deaf. The
patient lives at the home for the deaf, and does not smoke or
drink alcohol.
Family History:
No family history of strokes.
Physical Exam:
Vitals: 102.2 126 164/102 20
General: older man in no distress, intubated
Neck: supple
Lungs: decreased breath sounds at bases
CV: tachcardic, no murmur appreciated
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema
Neurologic Examination:
intubated and sedation; no eye opening to loud voice or [**Last Name (un) **];
agitated to sternal rub; pupils reactive to light 3 to 1 mm
b/l;
no blink to threat b/l, intact corneal; facial asymmetry
difficult to appreciate with intubation tube; slightly increased
tone throughout (L>R), spontaneous mvt in left arm and leg,
withdraws to noxious stimuli on right arm and leg (left side
too), reflexes 2+ at knees, 1 at ankles, 2 in Bic, Tric, [**Last Name (un) 1035**],
toe up on right, equiv. on left
EXAM AT DISCHARGE:
Pertinent Results:
MRA BRAIN W/O CONTRAST [**2128-5-9**] 9:04 PM
MRI OF THE BRAIN WITH MRA OF THE CIRCLE OF [**Location (un) **]
CLINICAL INDICATION: Infarction and neurologic deficit.
Multiplanar T1- and T2-weighted images of the brain was
obtained. MRA of the circle of [**Location (un) 431**] was performed according to
standard departmental protocol.
No prior brain MRIs are available for comparison. There is a
moderate-sized area of diffusion abnormality involving the left
frontal lobe and a smaller region involving the left internal
capsule consistent with areas of subacute infarction. These
might contain byproduct of blood due to susceptibility. The
ventricular system is symmetrical without hydrocephalus.
Scattered areas of magnetic susceptibility are noted within the
left basal ganglia and the right parietal [**Doctor Last Name 352**]-white junction.
These could represent areas of hemosiderin deposition or foci of
amyloid angiopathy. Correlation with CT of the brain would be
helpful to exclude the possibility of hemorrhagic lesions. T2
hyperintensity is noted within the brainstem and periventricular
white matter suggestive of chronic microvascular ischemic or
gliotic changes. No subdural hemorrhage is seen. The study is
degraded by motion artifact. There is opacification of the
paranasal sinuses.
Signal flow voids are present along the intracranial portions of
the carotid and basilar arteries. There is absence of signal
flow void within the right vertebral artery suggestive of total
occlusion.
IMPRESSION: Diffusion abnormality involving the left internal
capsule and the left frontal lobe most likely consistent with
areas of subacute infarction. Overall study was degraded by a
motion artifact. Scattered foci of magnetic susceptibility
suggestive of possible amyloid angiopathy. There is suggestion
of a small left-sided developmental venous anomaly involving the
left parietal lobe. Correlation with gadolinium-enhanced images
might be helpful along with followup. Areas of chronic ischemia
are seen within the brainstem and thalami.
MRA of the circle of [**Location (un) 431**] was performed according to standard
departmental protocol. There is significant ectasia and
dilatation of the distal vertebrobasilar circulation with slight
aneurysmal fusiform dilatation of the proximal basilar artery.
There is significant tortuosity of the cavernous ICA. The right
distal vertebral artery is not visualized and is probably
totally excluded. No intracranial aneurysms are seen involving
the anterior or middle cerebral arteries.
IMPRESSION: Significant ectasia of the distal vertebrobasilar
circulation with mild fusiform aneurysmal dilatation of the
proximal basilar artery. Total occlusion of the right distal
vertebral artery. The intracranial circulation was otherwise
patent.
CT HEAD W/O CONTRAST [**2128-5-11**] 9:20 AM
FINDINGS: There is redemonstration of the large left posterior
frontal acute infarction with a small amount of hemorrhagic
contents. Infarction also appears to extend to the posterior
limb of the left internal capsule where the largest hemorrhagic
component, approximately 3 mm in size is visualized. These
findings were demonstrated on the prior MR study. There is a
minor amount of mass effect caused by the infarct, as shown by
continued demonstration of a few millimeters rightward bowing of
the septum pellucidum. There has been no change in ventricular
size. The prominently ectatic and partially calcified visualized
distal left vertebral artery as well as basilar artery are
imaged. There are likely ectatic as well as calcified components
involving the cavernous portion of the left internal carotid
artery with atherosclerotic calcification of the cavernous
portion of the right internal carotid artery. There is a
moderate amount of mucosal thickening in the right ethmoid
sinus, with a meniscus-shaped soft tissue density, probably
fluid and mucosal thickening, within the posterior aspect of the
right and left sphenoid air cells.
CAROTID SERIES COMPLETE PORT [**2128-5-10**] 1:03 PM
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Minimal plaque was identified.
On the right, peak systolic velocities are 107, 84, 104 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.3.
This is consistent with less than 40% stenosis.
On the left, peak systolic velocities are 115, 92, 140 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.3.
This is consistent with less than 40% stenosis. The right
vertebral artery was not visualized due to an IV line and the
jugular vein. There is antegrade flow in left vertebral artery.
IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis.
Cardiology Report ECHO Study Date of [**2128-5-12**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.2 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 0.75
Mitral Valve - E Wave Deceleration Time: 215 msec
TR Gradient (+ RA = PASP): *19 to 27 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
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 root diameter. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
No cardiac source of embolus identified (cannot definitively
exclude).
Agitated saline contrast study at rest (2 injections) revealed
evidence of intracardiac shunt consistent with the presence of
an atrial septal defect (or stretched patent foramen ovale).
Neurophysiology Report EEG Study Date of [**2128-5-12**]
OBJECT: 77-YEAR-OLD MAN WITH LEFT FRONTAL STROKE, R/O SEIZURE
ACTIVITY. THE HEART WAS MONITORED BECAUSE DISORDERS OF HEART
RHYTHMS
[**Month (only) **] PRODUCE NEUROLOGICAL COMPLAINTS AS DESCRIBED ABOVE DISORDERS
SUCH AS
SEIZURES, WHEN SYMPTOMATIC, [**Month (only) **] PRODUCE CARDIAC ARRHYTHMIAS.
TIME SAMPLES: In wakefulness, the background over the entire
left
hemisphere is low voltage and slow in the 7 Hz theta frequency
range.
In addition, there is diffuse delta frequency slowing seen over
the
entire left hemisphere. In addition, there are bursts of
generalized
slowing in the [**2-9**] Hz delta frequency range.
BACKGROUND: Over the right hemisphere is also slow with the [**7-14**]
Hz
theta frequency range but well-defined. There are sharp features
over
the right parietal region with phase reversing around P4.
PUSHBUTTONS: There is one pushbutton event recorded. There is no
seizure activity recorded in this file.
AUTOMATIC SEIZURE DETECTIONS: Captured three events. Two events
represent movement artifact due to manipulation of the
respiratory
tubes. The third event is due to a technical artifact over the
O2 lead.
AUTOMATIC SPIKE DETECTIONS: This algorithm captured 186 events.
The
majority of the events were due to movement artifact. Some
events
show moderate to high voltage sharp slowing with phase reversing
around
P4.
SLEEP: Review of the time sample showed some prolonged episodes
of slow
wave sleep. In this episode, the background asymmetry was not as
emphasized as in wakefulness.
CARDIAC MONITOR: Normal sinus rhythm wtih a rate of 84 bpm.
IMPRESSION: This is an abnormal 24-hour discontinuous EEG
telemetry
obtained in wakefulness progressing to stage IV sleep due to the
presence of slow background activity and low voltage activity
over the
entire left hemisphere with intermixed delta frequency slowing.
In
addition, there is sharp slowing with phase reversing in the
right
parietal region. This finding suggests cortical and subcortical
dysfunction over the entire left hemisphere with cortical
dysfunction
over the right parietal region. The background activity suggests
deep,
midline subcortical dysfunction and is consistent with a mild
diffuse
encephalopathy. There were no clear epileptiform discharges
seen.
PERC G/G-J TUBE PLMT [**2128-5-14**] 7:55 AM
PHYSICIANS: [**First Name8 (NamePattern2) **] [**Doctor Last Name 26181**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3175**] with Dr. [**First Name (STitle) 3175**], the
attending radiologist, present and supervising during the
procedure.
PROCEDURE: Following written informed consent, the patient was
positioned supine on the angiography table. A preprocedure
timeout was performed to confirm patient, procedure, and site.
Standard sterile prep and drape of the ventral abdomen.
Initial fluoroscopy confirmed appropriate positioning of the
nasogastric tube within the proximal stomach. Air outlined the
transverse colon which is situated inferior to the gastric air
bubble. Air was insufflated through the nasogastric tube to
distend the stomach. Local anesthesia with 10 cc of 1% lidocaine
subcutaneously. Using fluoroscopic guidance and a 19-gauge
needle, two percutaneous T-fasteners were placed in the stomach
near the junction of the proximal two-thirds and distal
one-third. In each instance confirmation of positioning of the
needle in the stomach lumen was confirmed by efflux of air from
the needle and by the instillation of contrast outlining rugal
folds of the stomach. After placing the second T- fastener, a
0.035-inch guidewire was advanced through the needle into the
stomach and the needle was exchanged for a 5-French Kumpe
catheter. Using a guidewire and Kumpe catheter, the guidewire
was advanced beyond the ligament of Treitz into the jejunum. The
catheter was exchanged for 10-French and then 12-French fascial
dilators and then a 14-French peel-away sheath. A 14-French
[**Doctor Last Name 9835**] gastrojejunostomy catheter was placed over the guidewire
through the sheath and positioned with its tip in the proximal
jejunum. The peel-away sheath and guidewire were removed. The
catheter's locking loop was formed within the second portion of
the duodenum. Contrast injection through the catheter confirmed
appropriate positioning of the catheter tip within the jejunum.
Peristalsis was present within the opacified jejunal loops.
The catheter was flushed with saline and then capped. The
catheter was fixed in place with a StatLock device and a sterile
dressing was applied. The catheter can be used in four hours
post- procedure if there are no signs of peritonitis. The cotton
roll anchors for the T-fasteners should be removed in seven- ten
days.
IMPRESSION: Successful placement of a 14-French [**Doctor Last Name 9835**]
gastrojejunostomy catheter with tip in the jejunum. The catheter
can be used four hours post- procedure if there are no signs of
peritonitis.
[**2128-5-9**] 05:45PM %HbA1c-10.0* [Hgb]-DONE [A1c]-DONE
[**2128-5-9**] 04:21PM LACTATE-3.5* NA+-140 K+-5.1
[**2128-5-9**] 08:24PM CEREBROSPINAL FLUID (CSF) PROTEIN-65*
GLUCOSE-134
[**2128-5-9**] 08:24PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-16*
POLYS-81 LYMPHS-19 MONOS-0
[**2128-5-9**] 08:24PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-67*
POLYS-90 LYMPHS-10 MONOS-0
[**2128-5-9**] 04:21PM HGB-15.0 calcHCT-45
[**2128-5-9**] 04:20PM GLUCOSE-281* UREA N-9 CREAT-0.9 SODIUM-134
POTASSIUM-7.9* CHLORIDE-98 TOTAL CO2-20* ANION GAP-24*
[**2128-5-9**] 04:20PM ALT(SGPT)-45* AST(SGOT)-71* LD(LDH)-995* ALK
PHOS-120* AMYLASE-105* TOT BILI-0.8
[**2128-5-9**] 04:20PM LIPASE-29
[**2128-5-9**] 04:20PM ALBUMIN-3.7 CALCIUM-9.0 PHOSPHATE-3.2
MAGNESIUM-1.8
[**2128-5-9**] 04:20PM TRIGLYCER-170*
[**2128-5-9**] 04:20PM TSH-0.69
[**2128-5-9**] 04:20PM PHENYTOIN-20.1*
[**2128-5-9**] 04:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.0
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2128-5-9**] 04:20PM WBC-9.4 RBC-4.73 HGB-15.1 HCT-43.8 MCV-93
MCH-31.9 MCHC-34.5 RDW-15.0
[**2128-5-9**] 04:20PM NEUTS-79.5* LYMPHS-15.1* MONOS-4.2 EOS-0.4
BASOS-0.7
[**2128-5-9**] 04:20PM PLT COUNT-429
[**2128-5-9**] 04:20PM PT-13.8* PTT-21.9* INR(PT)-1.2*
Title: WOUND CARE
Asked to evaluate Mr. [**Known lastname 66946**] for impairment in skin integrity.
He is a 77 year old male admitted from NH for the deaf in
[**Location (un) 4047**]. Medical history: Afib, PNA, DM, DVT's, Seizures,
Closed Head Injury, deafness.
He has had frequent stooling. He has an erythematous rash with
fungal involvement B/L groin, medial thighs, perianal tissue,
gluteals, and coccyx. There are two partial thickness ulcers
B/L
gluteals related to excoriation. Each site is approx. 1.5 x 1
cm., 100% pink and superficial, irregular wound edges, no
drainage, periwound tissue is erythemic with fungal infection.
There is no edema, induration, crepitus, or fluctuance.
Alb 2.7 on [**5-16**], Hgb 10.4, Hct 32.2, Glucose 149, BUN 3
Recommendations: Pressure relief measures per pressure ulcer
guidelines.
On Atmos Air Air Mattress for pressure relief
Turn and repostion every 1-2 hours off back
If OOB, limit sit time to one hour at a time
and sit on a pressure relief cushion
Gentle cleansing perianal and gluteal tissue
with foam cleanser
Pat dry
Apply antifungal ointment to affected skin,
follow with Double Guard Zinc Oxide Paste -
esp over partial thickness ulcers on
gluteals
follow with Aloe Vesta Moisture Barrier
Ointment TID and prn
Support nutrition
CXR [**5-24**]:
CHEST AP: There is interval development of left retrocardiac
opacity and an evolving opacity in the left perihilar region. A
right IJ line is seen with its tip in the right atrium.
Tracheostomy tube is in place. Linear atelectasis is present in
the right lung base.
An IVC filter is in place. Splenic artery calcification is
noted.
IMPRESSION: New retrocardiac consolidation with an evolving left
hilar pneumonia.
CTA [**5-19**]:
INDICATION: Tachypnea, fever, and increased sputum in a patient
with known deep venous thrombosis.
COMPARISON: No previous chest CT. Abdominal CT of one day prior
is available for correlation.
TECHNIQUE: Axial multidetector CT images of the chest were
obtained without contrast utilizing low-dose technique and then
with intravenous Optiray administered at 2 cc per second via a
central venous catheter. Multiplanar reformatted images were
obtained.
CHEST CT ANGIOGRAM: Good opacification of the pulmonary arteries
was achieved despite the slow rate of injection. Filling defects
are present in the lobar arteries to the right upper and right
lower lobes, as well as in many of their segmental and
subsegmental branches, consistent with acute pulmonary embolism.
No left-sided pulmonary emboli are identified. Extensive
atherosclerotic calcifications are present in the aorta and
coronary arteries. There is no pericardial effusion.
Small bilateral pleural effusions are present, previously noted
on the abdominal CT of one day earlier. There is no enhancement
of pleural surfaces and no evidence of loculation to suggest
empyema, although empyema cannot be excluded by CT scan. There
is moderate atelectasis in both lower lobes. The
tracheobronchial tree is patent to the subsegmental levels.
The imaged portions of the liver and spleen appear unremarkable.
Extensive splenic artery calcifications are noted. There are no
suspicious lytic or sclerotic bone lesions.
CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the
findings demonstrated on the axial images. Value grade is 2.
Findings were discussed with Dr. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **] at 5 p.m. on
[**2128-5-18**].
IMPRESSION:
1. Pulmonary emboli in the right upper and right lower lobar
arteries and their segmental and subsegmental branches.
2. Small bilateral pleural effusions. Empyema cannot be excluded
by CT scan.
3. Moderate bibasilar atelectasis.
4. Atherosclerosis in the aorta and coronary arteries.
LE U/S:
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of both common
femoral, superficial femoral and popliteal veins were performed.
Thrombus is identified in both lower extremities extending from
the common femoral veins to the popliteal veins. The thrombus
appears occlusive on the left side. On the right, there is a
large rounded but nonocclusive thrombus within the right common
femoral vein. It appears somewhat unstable in appearance. More
echogenic contours in the right superficial femoral vein may
represent chronic thrombus. These findings were discussed with
Dr. [**Last Name (STitle) 724**] at 4:45 p.m., [**2128-5-14**].
IMPRESSION: Extensive bilateral lower extremity DVTs as
described above.
Brief Hospital Course:
The patient is a 77 year old man with a history of afib p/w
fever and decreased responsiveness. Neuroimaging consistent with
subacute left frontal infarction with hemorrhagic conversion and
chronic hypertensive microangiopathy.
1. Neurologic:
The patient is deaf and legally blind at baseline. His initial
exam on presentation: No eye opening to noxious stimuli
(although has opened eyes briefly to sternal rub). Pupils:
briskly reactive, left irregular post-surgical. Right faical
weakness, OCRs and corneals intact. Withdraws left arm, and
both legs to noxious stimuli, minimal proximal withdrawal of
right arm to noxious. Both toes up bilaterally. MRI/MRA was
performed and showed left frontal DWI bright, T2 FLAIR
hyperintensity, likely aubacute infarction; susceptibility
artefact into left frontal stroke bed and ipsilateral posteior
internal capsule with extension into posterior [**Doctor Last Name 534**] of left
lateral ventricle. Carotid U/S showed < 40% stenosis.
EEG was abnormal 24-hour discontinuous EEG telemetry obtained
in wakefulness progressing to stage IV sleep due to the presence
of slow background activity and low voltage activity over the
entire left hemisphere with intermixed delta frequency slowing.
In addition, there is sharp slowing with phase reversing in the
right
parietal region. Corrected dilantin levels were initially
slightly supratherapeutic. The patient was in the ICU for
several weeks with no neurological improvement. Trach and peg
were placed as he could not be weaned from the vent or fed.
When transferred to the floor, dilantin was discontinued for no
real suggestion of seizure activity (medication had been started
for EEG rather than clinical finding). After several weeks of
no neurological progress on the floor, and several days after
dilantin was discontinued, he began to wake up and move both
extremities spontaneously. He was treated with coumadin due to
the likely embolic nature of the stroke, as well as various
comorbidities (including afib, dvt's and PEs). On the day of
discharge, he was awake and alert; he could not follow verbal
commands (deaf and legally blind) but appeared to be scanning
sentences when written in large, dark, block letters. He had no
speech production. He did, however, pick up on nonverbal cues
at times, lifting his arm appropriately when presented with a
blood pressure cuff. He continued to move his arms and legs
very well, thought could not follow commands to test specific
muscle strength; he could get out of bed to chair with a lot of
assistance. He showed normal sensation to light tactile
stimulation on four extremites and face (tickling) with
localization. He worked well with PT and had made some
neurological progress; rehab facility was suggested, and he was
transferred there when medically stable.
2. Respiratory:
He initially had a pneumonia treated with Zosyn + Flagyl x 7 day
course early in the hospitalization. For failure to wean from
the vent, a trach was placed. He tolerated trachmask, and was
transferred to the stepdown unit on the floor. Later, on the
floor, after DVT's had been detected on LE u/s, and after a
filter had been placed and the patient started on coumadin, he
developed persistent tachycardia, tachypnea and low sats; CTPA
was performed and revealed several PE's in the right lung. He
was continued on coumadin and heparin (discontinued when
coumadin therapeutic) and respiratory rate and tachycardia
improved greatly within 3-4 days. He also developed increased
secretions and the need for suctioning the trach site; chest
xray showed a new pneumonia and he was initially treated with
flagyl and levaquin; this was switched to flagyl + zosyn when he
dropped his bp to 80s as well as sats once again. He improved
the following day, and as his clinical status improved, he made
neurological headway as well. He should remain on flagyl +
zosyn for completion of 14 day course(to be completed at rehab
facility on [**2128-6-7**]).
3. CVS -
He was found to be in atrial fibrillation initially requiring
rate control; Echo showed EF>55%, ASD (likely) vs PFO. He was
treated with heparin and coumadin, and transitioned to coumadin
alone when INR was therapeutic. His rate normalized later in
the hospitalization once infections and pulmonary embolus were
better treated. Lower extremity ultrasounds were checked
revealing bilateral LE DVTs: thrombus occlusive on the left
side. Nonocclusive thrombus right common femoral vein,
unstable in appearance. More echogenic contours in the right
superficial femoral vein may represent chronic thrombus. He had
a R IVC placed; arteriogram was performed to evaluate IVC filter
via R IJ; duplicate left renal system noted and left iliac vein
not seen. Subsequent to filter placement, abdominal CT-venogram
was performed which revealed a tortuous renal artery (see
results section). Subsequent to filter placement, he developed
pulmonary embolism and
4. Endocrine: he was placed on an insulin sliding scale, close
fingersticks were checked. Blood sugars were elevated and Hba1c
>10. Sliding scale was tightened around the time of discharge.
5. Renal: monitor ins/outs; occasionally he had low urine
output and required fluid boluses. Ins and outs were even and
renal function was adequate at discharge.
6. ID: Bcx, UCx, CSF Cx were negative. LP had been performed and
CSF was not suspicious for meningitic/encephalitic picture. He
was treated twice for pneumonia (see above). He does have a
history of cdiff, but is on flagyl currently. He had no cdiff
during this admission.
7. GI: he underwent PEG (G-J tube) placement by IR, and tube
feeds were started and eventually achieved goal. Hospital course
was complicated by GI bleeding and dropping hematocrits,
requiring blood transfusions. As his INR was not therapeutic at
the time, this was thought potentially related to bowel
ischemia. Coumadin was continued despite GI bleeding, as he had
overwhelming coagulopathic disorders (PEs, DVTs, ASD in heart,
stroke). GI was consulted and recommended PPI; they did not
feel scope would be beneficial as it would not change
management, and that he would need to be continued on coumadin.
GI bleeding stopped when INR was therapeutic, and he tolerated
coumadin well. Tube feeds had been held for GI workup, and were
restarted once the patient's GI bleeds had stablized. He has
brown OB+ stool at this time. He should have egd and
colonoscopy as an outpatient.
8. CODE STATUS:
This was addressed with his HCP, his sister [**Name (NI) 66947**] [**Name (NI) 66946**]
[**Telephone/Fax (1) 66948**]. He was made DNR/DNI.
Medications on Admission:
-insulin
-plavix
-protonix
-scopalamine patch
-glyburide
-trazodone
-milk of magnesia
-colace
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Cartridge [**Telephone/Fax (1) **]: use as
directed below Injection ASDIR (AS DIRECTED): Check BG 4x/d
-If bg<70 give [**2-9**] amp d50
-If bg 71-150 do nothing
-If bg 151-200 give 3 units insulin
-If bg 201-250 give 6 units insulin
-If bg 251-300 give 9 units insulin
-If bg 301-350 give 12 units insulin
-If bg >350 give 12 units insulin and notify MD.
2. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
3. Docusate Sodium 150 mg/15 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day) as needed.
4. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
5. Warfarin 2 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO HS (at bedtime).
6. Piperacillin-Tazobactam 4.5 g Recon Soln [**Month/Day (2) **]: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 7 days: please
continue until [**2128-6-7**]; d/c central line when abx complete.
7. Metronidazole 500 mg IV Q8H
8. Flagyl 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO three times a day
for 7 days: please continue until [**2128-6-7**].
9. 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
10. Prevacid 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Left frontal stroke
Bilateral lower extremity DVT
Pulmonary Embolism
Duplicate left renal system
Atrial fibrillation
GI Bleed - likely related to bowel ischemia
Atrial septal defect (vs PFO)
Pneumonia x 2
Discharge Condition:
Stable - please see d/c summary for d/c exam.
Discharge Instructions:
Please [**Name8 (MD) 138**] MD or return to ED if new symptoms of focal weakness
or new neurological impairment.
Followup Instructions:
Please call Dr.[**Name (NI) 35878**] office for f/u appointment (neurology)
after discharge from rehab (in [**7-15**] weeks) ([**Telephone/Fax (1) 7394**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2128-6-1**]
ICD9 Codes: 5180, 486, 5789, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7366
} | Medical Text: Admission Date: [**2194-1-1**] Discharge Date: [**2194-1-21**]
Date of Birth: [**2116-5-12**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bactrim / Cozaar / Captopril
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
1. right-sided thoracentesis [**2194-1-3**]
2. left-sided thoracentesis [**2194-1-4**]
3. right chest tube placement [**2194-1-6**]
4. right subclavian CVL [**2194-1-6**], replaced [**2194-1-12**]
5. trach/PEG [**2194-1-10**]
History of Present Illness:
77F s/p fall from standing; initially seen at OSH; she
reportedly became agitated when a c-collar was placed, and
required sedation, and was subsequently intubated for
respiratory distress. She was transferred to [**Hospital1 18**] for further
care. Her injuries noted were a C7 fracture, and
chronic-appearing bilateral pleural effusions.
Past Medical History:
1. CHF
2. AF
3. HTN
4. NHL
5. ?radiation treatment to thyroid
Pertinent Results:
[**2194-1-1**] CT cspine: 1. Acute fracture involving the superior
endplate of C7 vertebral body with approximately 2 mm of
retropulsion of the posterior cortex without significant canal
stenosis. 2. Degenerative disease with facet changes as
described above. Widening at C3-4 on the right is likely
chronic. 3. Bilateral pleural effusions and atelectatic changes
are better assessed on corresponding CT torso performed
concurrently."
[**2194-1-2**] ECHO: "Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild calcific aortic stenosis. Mild aortic regurgitation.
Moderate mitral regurgitation. Moderate pulmonary hypertension."
[**2194-1-2**]: "1. C7 compression fracture and T2 horizontal vertebral
body fracture without evidence of ligamentous injury or cord
injury."
[**2194-1-4**] BAL: MSSA 10,000-100,000 ORGANISMS/ML..
Brief Hospital Course:
Neuro: Identified C7 fracture on imaging; she was placed in a
[**Location (un) 2848**]-J collar. A spine consult was obtained and recommended
that she remain in the collar until they would be able to
examine her clinically (off sedation). An MR was also obtained.
She was switched to a softer collar that allowed for slightly
more flexion. She is to remain in the collar until follow up
with Dr. [**Last Name (STitle) 363**] on roughly [**2194-1-20**] for reevaluation.
She was sedated with propofol, but alert and oriented. A
geriatrics consult was obtained -- her nighttime agitation was
subsequently managed with Seroquel 25mg QHS.
CV: An ECHO on [**1-2**] did not demonstrate significant cardiac
abnormalities. Mild aortic stenosis was noted. She was
maintained on her home beta blocker dose. She did require
neosynephrine while on propofol, which was given while intubated
and post-intubation for agitation. Geriatrics was consulted and
suggested giving seroquel 12 mg qhs for agitation instead.
Resp: In contact with her PCP who noted that her pleural
effusions were chronic. We attempted extubation on Hd #2, but
she developed tachypnea and respiratory distress and was
reintubated. It was thought that her pleural effusions may have
contributed to her respiratory compromise, and she had a right
and left-sided thoracentesis on Hd #3 and 4 (respectively).
Extubation was attempted a 2nd time, but again, she quickly
failed after an hour, and was once again reintubated. A CVL was
also placed at this time -- on imaging, she was noted to have
persistent right pleural effusion and a small apical
pneumothorax. Given concern that she had respiratory distress
upon extubation, and was now currently on positive pressure
ventilation, a 20Fr chest tube was placed in her right side.
Pleural fluid analyses demonstrated a transudative fluid, which
was not infected. Follwoing the chest tube placement, a 3rd
extubation was attempted, but she again required reintubation.
At this point, there was concern that there may be an anatomic
component to her respiratory failure -- Interventional Pulmonary
was asked to evaluate the patient's airways. Her son had given
a vague history of a possible prior tracheostomy, and radiation
to her neck -- perhaps causing some tracheal stenosis. On
bronchoscopy, close evaluation demonstrated upper airway edema,
with no leak when the cuff was down. She was placed on
steroids, but given these findings, the decision was made to
proceed with a trach/peg, expecting a longer than expected
vent-dependence. She had her trach/PEG on [**2194-1-10**]. On [**1-11**] she
had a episode of desaturation to the 80s for which she underwent
another bronchoscopy that revealed thick brown sputum. She was
placed on Vancomycin and Zosyn empirically until sputum cultures
and BAL returned negative.
At the time of discharge, she was tolerating increase intervals
on trach mask and off the vent.
GI: She received tube feeds through a dobhoff tube, then through
her PEG tube. On [**1-11**] she had several loose stools and the tube
feedings were held. Stool cultures x 2 were sent and found to be
negative. Tube feedings were restarted on [**1-13**].
Heme: She is on Coumadin at home for her history of atrial
fibrillation; she was maintained on a heparin drip while in the
unit until she became therapeutic.
GU: She maintained a stable creatinine and adequate urine
output.
ID: A [**1-4**] BAL demonstrated only 10^4 organisms of MSSA -- she
was, however, on steroids, and the ICU team placed her on
Levofloxacin. On [**1-11**] she had an episode of desaturation and a
bronch revealed thick brown mucous. She was placed on empiric
Vancomycin, Zosyn for three days until cultures returned
negative. On [**1-11**] she also had an episode of hypotension
concerning for septic physiology. Labs drawn at the time showed
WBC = 29. Blood cultures were still negative at 4 days out.
Endocr: She received a 48 hour course of dexamethasone for her
supraglottic swelling, in hopes that this would improve her
chances of extubation. These were discontinued following her
tracheostomy.
[**1-3**]: s/p R thoracentesis
[**1-4**]: s/p L thoracentesis, bronch with bal
[**1-5**]: cxr shows increased R apical PTX; failed extubation, will
likely need trach so not starting coumadin for now, on hep gtt
[**1-6**]: LMA bronch, R 20F CT, failed extubation (x3)
[**1-7**]: Repositioned CT
[**1-8**]: CT to WS, added levofloxacin for MSSA on BAL in setting of
steroids
[**1-9**]: bronch ([**Last Name (un) **], ETT) - narrowed, edematous nasopharynx, no
air leak even with cuff down; pulm -> resp alkylosis (likely
overbreathing [**12-30**] agitation, baseline CO2 likely 48, consider
decrease MV by decreasing PS (no change in peep) to allow
increased CO2 prior to extubation (maximizing respiratory drive)
[**1-10**]: Trach and Peg. #8 Portex.
[**1-11**]: TM for 4 hrs, then mucus plug requiring return to vent,
hypotensive, pan-cx, CT pulled, vanc/zosyn started
[**1-12**] CVL L removed (tip cxr sent), R subclavian placed, flagyl
started for ?cdiff (diarrhea, mild abd pain, 1st set cdiff neg);
bronch -> unremarkable, BAL sent, small but stable R apical PTX
[**1-13**]: new small left apical ptx; hep gtt stopped
[**1-14**]: ? new small pneumomediastinum, abx stopped; ger c/s - low
dose Seroquel 12.5 po QHS for agitation
[**1-15**]: [**Female First Name (un) **] c/s -> switch to PPI (less agitation), seroquel 25
qhs and qam PRN agitation
[**1-16**]: PMV during day, agitated pm; [**Female First Name (un) **] recs - lopressor 12.5
[**Hospital1 **] (avoid atenolol), seroquel 25mg ghs and gam, NO olanzapine,
DC famotidine
[**1-18**]: doing well, required some pressors over night
[**1-19**]: off neo, doing well on CPAP/trach mask
Medications on Admission:
Coumadin
Atenolol
Lasix
ASA
Calcium
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Year (2) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed.
4. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
5. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1)
Injection ASDIR (AS DIRECTED).
6. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
TID (3 times a day) as needed.
7. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every
4 hours) as needed.
8. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times
a day).
11. Midodrine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a
day).
12. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QHS (once a
day (at bedtime)).
13. Levothyroxine 200 mcg Recon Soln [**Last Name (STitle) **]: 200mcg Recon Solns
Injection DAILY (Daily).
14. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
2.5-3.0 mg qday. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
- C7 fx
- bilateral pleural effusions s/p thoracentesis
- right pneumothorax s/p right chest tube placement
- mild AS/AR
- atrial fibrillation
- hypertension
- ?CHF
Discharge Condition:
Stable
Discharge Instructions:
If you have fevers/chills, persistent nausea/vomiting, severe
abdominal pain, difficulty breathing, please [**Name8 (MD) 138**] MD.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**11-29**] weeks. Call for an
appointment.
Please follow up with Dr. [**Last Name (STitle) **] in trauma clinic in [**1-1**] weeks,
call for an appointment at [**Telephone/Fax (1) 6429**]
Please follow up with Dr. [**Last Name (STitle) 363**] (Orthopedics/Spine) in [**11-29**]
weeks. Call [**Telephone/Fax (1) 3573**]
Completed by:[**2194-1-21**]
ICD9 Codes: 2930, 4280, 4019, 496, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7367
} | Medical Text: Admission Date: [**2167-10-13**] Discharge Date: [**2167-11-21**]
Date of Birth: [**2097-2-20**] Sex: F
Service: SURGERY/BLUE
REASON FOR ADMISSION: The patient is a 70-year-old female,
with COPD, 100-pack year tobacco use and currently still
smoking 1-pack per day, coronary artery disease status post
MI, and PTCA with stent in [**2162**], hypercholesterolemia,
hypothyroidism, who fell down two steps on the [**10-8**]
suffering multiple ribs fractures on the left. The patient
presented to an outside hospital, [**Hospital 1562**] Hospital,
Emergency Department and became hypotensive, and a needle
thoracostomy was performed for decompression followed by a
tube thoracostomy. The patient was intubated and taken to
the ICU there. She remained intubated over the weekend and
continued to have worsening subcu emphysema, and persistent
air leaks from the chest tube. She was extubated the day
prior to transfer and then sent to the thoracic surgery
service at [**Hospital1 18**] for further work-up and treatment.
PAST MEDICAL HISTORY: As above.
MEDS AT HOME:
1. Atenolol 50 qd.
2. Losartan 50 [**Hospital1 **].
3. Lasix 20 qd.
4. Aspirin 325 qd.
5. Zantac 150 [**Hospital1 **].
6. Prilosec 20 qd.
7. Norvasc 10 qd.
8. Zocor 10 qd.
9. Synthroid 0.1 qd.
10.Atarax prn.
11.Motrin prn.
12.Colace 100 [**Hospital1 **].
13.Atrovent MDI prn.
14.Albuterol MDI prn.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Smoking as above and occasional alcohol.
PHYSICAL EXAM ON ADMISSION: Vitals - 97.4, 85, 162/94, 18,
94% on 2 liters. General - The patient was an elderly,
pleasant female in no acute distress. Pupils equally round
and reactive to light. There was extensive subcu emphysema
of the left eye and face, as well as the neck and chest. The
trachea was midline. Chest exam was limited by crepitus.
There was no hyperresonance to percussion. There was
ecchymosis of the left chest wall, and a 24 French chest
tube. The site was without erythema. Heart was regular rate
and rhythm. Abdomen was soft, nontender. There was slight
increased firmness to the left midabdominal and subcostal
area. No discrete masses. No organomegaly. Back showed
ecchymosis to the left flank. Extremities - a right femoral
central line was in place. There was no clubbing, cyanosis
or edema, and there were palpable femoral, popliteal,
dorsalis pedis and posterior tibial pulses bilaterally.
Rectal showed no mass and was guaiac negative.
PERTINENT LABS: The patient's white count was 14.5, crit
39.1, platelets 305, sodium 131, potassium 3.9, chloride 94,
CO2 29, BUN 11, creatinine 0.5, glucose 114. [**Name (NI) 2591**] - PT
12.9, PTT 22.9, INR 1.1. ABG was 7.47, 41, 68, 31 and 5, 93%
on 2 liters. Chest x-ray showed extensive subcu emphysema,
chest tube in place, and no residual pneumothorax, rib
fractures.
IMPRESSION: The patient is a 70-year-old female with severe,
underlying lung disease, status post left chest blunt trauma
with rib fractures and pulmonary parenchymal injury leading
to pneumothorax and persistent air leak.
HOSPITAL COURSE: The patient was admitted and had a chest
x-ray which showed a small pneumomediastinum, chest tube, and
posterior rib fractures 6 through 9 which were displaced, and
extensive subcu air.
SUMMARY OF PATIENT'S PROCEDURES THIS ADMISSION: On [**10-14**], the patient went to the OR for a left video-assisted
thoracoscopic surgery with debridement of the broken rib
spicules, as well as wedge resection of the damaged lung
parenchyma. On [**10-16**], the patient was taken to the OR
for an acute abdomen and was found to have a gangrenous right
colon. She underwent a right colectomy, end-ileostomy, and
transverse colon mucous fistula. The small bowel was found
to have patchy areas of ischemia. On [**10-19**], the patient was
taken back to the OR for a second-look laparotomy, and
underwent small bowel resection and end-ileostomy. On [**10-23**],
the patient was taken back for a third-look laparotomy and
was found to have a bowel perforation x 2. She had further
bowel resection with end-jejunostomy, resulting in a total
bowel length of approximately 3'. On [**11-9**], the patient
underwent percutaneous tracheostomy, and on [**11-17**], the
patient underwent left ultrasound-guided thoracentesis.
Additionally, the patient had multiple monitoring lines
placed this admission.
HOSPITAL COURSE BY SYSTEM - 1) CENTRAL NERVOUS SYSTEM: The
patient had no mental status changes during this admission.
Earlier in her acute hospital course, she required a morphine
drip for pain control and intermittent ativan for sedation,
as well as a propofol drip early-on. Most recently, her pain
has been managed with dilaudid prn, as well as a dilaudid
PCA.
2) CARDIOVASCULAR: The patient had a septic physiology
through her initial three laparotomies requiring Swan-Ganz
catheter placement and monitoring with pressor management
including Levophed and vasopressin. The patient underwent an
echo after the initial laparotomy to look for an embolic
source; however, no clot was identified on the limited study,
and her ejection fraction was 55%. On serial cardiac
enzymes, the patient was found not to have any evidence of
myocardial ischemia. At this time, the patient is
hemodynamically stable and is receiving metoprolol for beta
blockade at a dose of 25 mg [**Hospital1 **]. She is in sinus rhythm, and
her blood pressure is 143/59.
3) RESPIRATORY: Due to the patient's persistent air leak,
she was taken by the thoracic service on the 10 for a VATS
procedure. The broken ends of the ribs were debrided which
had punctured and damaged the lung parenchyma, resulting in a
persistent air leak. This section was lung was resected. On
postop day #1 from that, the patient was stable and was
transferred to the floor, and her chest tube was DC'd.
However, the patient developed respiratory distress and was
reintubated on the [**10-15**], with an ABG showing a
PCO2 of greater than 100, and a pH of 7.0. A new left chest
tube was placed with a moderate egress of air. Additionally,
a left subclavian Cordis was placed, a Swan-Ganz catheter,
and a right femoral A-line was placed. Resulting chest x-ray
showed no pneumothorax.
The patient then had an acute abdomen and was transferred to
the general surgery service. Her chest tube was kept in
place to suction and was finally put to water-seal and then
DC'd on the [**10-29**].
The patient had multiple attempts at vent weaning, however
failed spontaneous breathing trials, and this was felt to be
multifactorial due to her underlying lung disease, as well as
malnutrition, volume loss in her left thorax, and a residual
pleural effusion on the left, as well as a pneumonia. The
patient underwent percutaneous tracheostomy on the [**11-9**] to facilitate pulmonary toilet, as well as weaning,
and an ultrasound-guided left thoracentesis for 250 cc on the
[**11-17**]. This showed no organisms on Gram stains, and
no neutrophils, and grew nothing on culture. On [**11-5**], the
patient had a sputum positive for Klebsiella pneumoniae for
which she was treated with a course of aztreonam and
gentamycin double-antibiotic coverage. Despite this, the
patient has been persistently unable to tolerate weaning
trials and is currently vent dependent on pressure support of
10 and PEEP of 5, with a RSBI of 55, and a PCO2 of 55.
4) ABDOMEN: After the patient's reintubation on the 11, the
patient was found to be persistently hypotensive and acidotic
requiring pressors, and a new abdominal finding of distention
and tenderness was noted. A general surgery consult was
obtained on the [**10-16**]. At this point, the patient
had a white count of 19.7 and a lactate of 1.6, and she was
on a Neo drip for blood pressure support. The patient was
placed on broad-spectrum antibiotic coverage of vancomycin,
Levofloxacin and Flagyl.
A rigid sigmoidoscopy was done at the bedside which showed
viable sigmoid mucosa. A KUB showed a dilated colon. The
patient was taken later that day on the [**10-16**] to
the OR for an exploratory laparotomy where a gangrenous right
colon was resected. There were several patchy areas of small
bowel ischemia which were left alone initially, and the
patient was given an end-ileostomy, a transverse colon mucous
fistula, and was sent back to the ICU for further
resuscitation with a planned second-look laparotomy. At this
time, the patient was on Levophed for blood pressure support
and was continued on broad-spectrum antibiotics.
On the [**10-19**], the patient was taken to the OR for a
second-look where frankly necrotic small bowel was resected,
and the end-ileostomy was refashioned. The transverse mucous
fistula was left in place. At this time, the patient was
also evaluated for sources of possible embolic phenomenon
with an echo which did not show any mural thrombus. A
vascular consult was also obtained, and the patient's
ischemic bowel was felt likely due to a low-flow state.
On the [**10-20**], the patient was started on TPN, and
then on the 18 the patient had a desaturation episode. A CTA
was negative for a PE and did show a left upper lobe
infiltrate. She was requiring more fluid, had a persistent
acidosis, and was on increasing Levophed and pressor
requirements. Fluconazole was added to the vanc, levo and
Flagyl. The levo was then DC'd and imipenem was started.
The patient's white count was now 31.7, and on the [**10-23**] the patient was taken to the OR again and found to
have two small bowel perforations which were resected, and
the patient was given an end-jejunostomy with a resultant
approximate 3' of small bowel remaining. The patient was
persistently hypotensive and vasopressin was added to her
pressor management.
On the [**10-29**], due to refractory leukocytosis, an ID
consult was obtained, and recommendation was made to increase
her fluconazole dose. Tube feeds were also instituted at a
trophic rate of 10 cc/h of half strength alimental tube
feeds.
Following the third laparotomy, the patient gradually
stabilized over the remainder of her hospital course, and her
tube feeds were gradually advanced. Her ostomies remained
viable, and her abdominal exam improved. The lower portion
of her lower wound separated and has been managed by [**Hospital1 **]
wet-to-dry packings. Most recently, it has required some
debridement if some fibrinous exudate at the base of the
wound.
Today, the patient's abdomen is soft. Her ostomies, that is
her jejunostomy and mucous fistula, are pink and viable. Her
lower wound separation is granulating laterally with a
fibrinous exudate at the base with visible fascial sutures at
the base of the wound. This will be managed with [**Hospital1 **]
wet-to-dry dressing changes.
5) GU AND RENAL: The patient's renal function remained
stable throughout all of her septic complications. She had a
Foley in place throughout this hospitalization and maintained
good urine output. Following her final laparotomy, the
patient did require diuresis to facilitate weaning of her
ventilator. However, this has not helped with the vent
weaning. The patient is currently on lasix 40 per NG tube
[**Hospital1 **].
6) INFECTIOUS DISEASE: The patient has had multiple
infectious complications during this complicated admission.
Her swab from the laparotomy on the 15 grew out yeast and
Klebsiella. Additionally, she had Klebsiella grown out of
her sputum on the 13, and yeast of the sputum on the 16, as
well as MRSA. On the 18, an additional sputum culture grew
out Klebsiella, and her urine from the 18 grew out yeast.
Wound culture from the 19 and 23 grew out yeast. These were
all sensitive to fluconazole. Currently, the patient is on
aztreonam day 11 and gentamicin day 12 of a 14-day course for
a Pseudomonas and Klebsiella culture that was grown out from
her sputum on the [**11-5**]. Additionally, she is on a
fluconazole course also to be completed for a 14-day course.
The patient has remained afebrile over the last week, and
currently her refractory leukocytosis is at 17.1.
7) HEMATOLOGY: The patient has had rare transfusion
requirements after her laparotomies. Additionally, after her
initial laparotomy she required a platelet transfusion for a
thrombocytopenia, and her heparin was also held at that
point, and a HIT antibody was sent which ultimately came back
negative, and she was restarted on heparin for DVT
prophylaxis. Currently, her crit is 31.2 and her platelets
249. Her INR is 1.1, and PTT is 27.2.
8) FEN: The patient has become TPN dependent essentially.
She is also receiving tube feeds at a rate of 60 an hour
using Impact with fiber 3/4 strength, and this is felt not to
be adequately absorbed with her short-gut syndrome. So, she
is also on essentially goal TPN calories. She also has
hyponatremia of 129. Her K is 4.6, chloride 94, mag 1.8,
phos 2.7, calcium 8.4. The hyponatremia is being treated
with decreasing her free-water intake.
9) ENDOCRINE: The patient has been managed with a regular
Insulin sliding scale.
10) PROPHYLAXIS: The patient has received GI prophylaxis
using a proton pump inhibitor. Currently, she is on
lansoprazole 30 per NG tube qd. Additionally, she is
receiving heparin in her TPN, and has Pneumoboots in place
for DVT prophylaxis.
TUBES, LINES AND DRAINS: Currently, the patient has a Foley,
a transpyloric feeding tube, a tracheostomy tube, a PICC
line, and A-line.
DISCHARGE DIAGNOSES:
1. Multiple left rib fractures.
2. Left pneumothorax.
3. Status post left video-assisted thoracic surgery (VATS)
with debridement of rib fragments and wide-resection of
injured lung segment.
4. Infarcted small bowel and right colon.
5. Status post laparotomy with right colectomy,
end-ileostomy, and transverse colon mucous fistula.
6. Second-look laparotomy with small bowel resection and redo
end-ileostomy.
7. Third-look laparotomy for small bowel perforation x 2,
status post further small bowel resection, end-jejunostomy.
8. Short-gut syndrome with total parenteral nutrition
dependence.
9. Klebsiella and Pseudomonas pneumoniae.
10.Peritoneal fluid yeast positive culture.
11.Ventilator dependence, status post tracheostomy.
12.Coronary artery disease, status post myocardial infarction
with percutaneous transluminal coronary angioplasty and stent
in [**2162**].
13.Chronic obstructive pulmonary disease.
14.Hypercholesterolemia.
15.Hypothyroidism.
16.Hyponatremia.
17.Leukocytosis.
18.Midline laparotomy wound infection, status post wet-to-dry
dressing changes [**Hospital1 **].
DISCHARGE MEDICATIONS:
1. Tincture of opium per NG tube qid.
2. Sodium chloride 1 tablet tid.
3. Lansoprazole 30 per NG tube qd.
4. Dilaudid prn.
5. Lasix 40 per NG tube [**Hospital1 **].
6. Levothyroxine 100 per NG tube qd.
7. Metoprolol 25 per NG tube [**Hospital1 **].
8. Fluconazole 400 per NG tube qd.
9. Albuterol and Atrovent nebs per tracheostomy prn.
10.Gentamicin 400 mg IV qd, day 12 of 14.
11.Aztreonam 1 gm IV q 8, day 11 of 14.
12.Regular Insulin sliding scale.
DISCHARGE PLAN: Discharge to [**Hospital3 **] pending bed
availability, and further addendums will be dictated in a
separate report.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Last Name (STitle) 50865**]
MEDQUIST36
D: [**2167-11-20**] 12:14
T: [**2167-11-20**] 12:27
JOB#: [**Job Number 50866**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7368
} | Medical Text: Admission Date: [**2148-8-11**] Discharge Date: [**2148-8-22**]
Date of Birth: [**2089-11-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 6169**]
Chief Complaint:
Induction chemotherapy for MDS transformed to AML
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 66632**] is a 58 year old male with a history of MDS
/myeloproliferative disease overlap syndrome that has
transformed to AML. He was admitted to the Heme Malignancies
service on [**2148-8-11**] for initiation of induction chemotherapy.
Past Medical History:
1. MDS/Myeproliferative disease overlap syndrome--> AML
2. Glaucoma
3. h/o HTN
4. GERD
Social History:
Custodian at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Occasional ETOH. No drug use. 30
year smoking history, at least 3 packs/week.
Family History:
Older sister with some type of cancer, not very close
Physical Exam:
Physical Exam:
VS: T: 99.4 HR: 105 BP: 140s/70s RR: 20s O2: 93-98% cool neb
Gen: Patient lying in bed. Appears older than stated age.
HEENT: MMM, no thrush. Sclerae anicteric.
Neck: Bilateral swelling in submandibular area.
CV: S1, S2. Tachy. No m/r/g.
Lungs: CTA anteriorly.
Abdomen: Distended. Spleen is palpable 4-6 cm below the left
costal margin. Liver edge is palpable 4-6 cm below the right
costal margin. No ascites or tender to deep palpation. No
rebound, no inguinal or femoral adenopathy.
Skin: His right leg, he has a skin graft that is
healing well, cutaneous ulcer approximately 2 x 3 cm that is
granulating well.
Extremities: Bilateral +1 pitting edema.
Pertinent Results:
[**2148-8-11**] 08:36PM POTASSIUM-3.5
[**2148-8-11**] 08:36PM LD(LDH)-467*
[**2148-8-11**] 08:36PM PHOSPHATE-4.4# URIC ACID-9.1*
[**2148-8-11**] 08:36PM WBC-55.7* RBC-3.20* HGB-9.3* HCT-26.2* MCV-82
MCH-29.1 MCHC-35.5* RDW-18.7*
[**2148-8-11**] 08:36PM NEUTS-23* BANDS-2 LYMPHS-8* MONOS-41* EOS-1
BASOS-2 ATYPS-0 METAS-1* MYELOS-2* BLASTS-20*
[**2148-8-11**] 08:36PM PLT COUNT-17*#
[**2148-8-11**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2148-8-11**] 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2148-8-11**] 11:45AM GLUCOSE-102 UREA N-24* CREAT-1.2 SODIUM-137
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2148-8-11**] 11:45AM ALT(SGPT)-23 AST(SGOT)-31 ALK PHOS-178*
[**2148-8-11**] 11:45AM ALBUMIN-3.1* CALCIUM-7.9* PHOSPHATE-2.5*
MAGNESIUM-1.5* URIC ACID-8.4*
[**2148-8-11**] 11:45AM WBC-97.2* RBC-2.82* HGB-8.2* HCT-24.2* MCV-86
MCH-29.2 MCHC-34.0 RDW-19.0*
[**2148-8-11**] 11:45AM PLT COUNT-40*
.
[**8-17**] CT Neck with contrast
IMPRESSION:
1. Soft tissue stranding within the subcutaneous and underlying
soft tissue of the entire neck most notable within the right
infra-auricular region where there is a marked amount of skin
thickening. Thickening of soft-tissues in larynx. These findings
could represent cellulitis in the appropriate clinical setting
or could be due to radiation therapy.
2. Likely diffuse reactive lymphadenopathy.
3. No evidence of focal drainable fluid collections.
.
A note should be made that this patient coded in the CT scanner
(CT scanner #2). Findings were discussed with the code team at
approximately 12:45 p.m. The patient is currently intubated.
.
[**8-18**] CT Head w/o contrast
1. No hemorrhage or mass effect.
.
[**8-19**] Soft tissue U/S of neck
IMPRESSION:
1. No evidence of internal jugular or subclavian vein
thrombosis.
2. No evidence of fluid collections concerning for abscess.
2. 2.1 cm right thyroid nodule.
.
[**8-20**] EEG
IMPRESSION: Mildly slowed posterior background suggestive of a
mild
diffuse encephalopathy. No discharging features were noted.
Brief Hospital Course:
He was found to have C diff colitis on admission, so his
induction therapy was delayed a few days. The patient was
administered his first treatment with MEC (mitoxantrone,
etoposide, and Ara-C) on [**2148-8-13**].
.
In the morning on [**2148-8-14**], the patient was noted to have tumor
lysis, with a potassium level elevated at 7.0. The patient was
also noted to have poor urine output, abdominal distention, and
respiratory distress. The patient was transferred to the [**Hospital Unit Name 153**]
for further management. He initially required blood pressure
support with Levophed. The Renal team was consulted, and the
patient underwent hemodialysis given his persistently elevated
potassium and episodes of widened QRS and transient complete
heart block on EKG/telemetry. The patient also had a
coagulopathy, and he requried transfusion of FFP prior to
placement of his hemodialysis catheter. The patient's potassium
level then normalized. During his admission, he required more
than seven packed red blood cell transfusions, and eight
platelet transfusions. He required more than six units of FFP.
.
Developed neck swelling on Friday ([**8-16**]) morning which was
dramatically worse on Saturday am ([**8-18**]). CT scan of neck was
ordered on Friday am but not completed by Sat am. Sat am, ENT
was consulted with concern for airway given that pt was having
trouble swallowing. ENT scoped him and said that he was okay to
go to CT scan. Had a respiratory arrest in the CT scanner and
was in PEA when we arrived. Anesthesia got an LMA in as we were
not able to bag him. Pulse back after about 10 minutes. In afib
when arrived to the floor with hypotension on levophed.
Syncronized cardio brought him back to sinus rhythm at 1:00 pm
[**2148-8-17**] and was hemodynamically stable after that on the vent.
.
With consult from Neuro, Mr. [**Known lastname **] was assessed to have
suffered hypoxic brain injury secondary to his code on [**8-18**] and
he had not improved his mental status beyond corneal blink and
moving eyes for more than 48 hours after he suffered PEA. His
wife decided to withdrawl ventilatory support due to his poor
prognosis and the fact that he was very unlikely to regain any
functional status.
.
He died on [**8-22**], just a few hours after he was extubated.
Medications on Admission:
His medicines have included allopurinol 300 daily,
hydroxyurea, recently increased to 3 g daily, prednisone 20 mg
PO
qd, Voriconazole 200 mg PO BID, Timolol 0.25% eye drops [**Hospital1 **],
Bactrim three times a week, ACV 600 mg PO TID, and PCN 500 mg PO
TID.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
AML
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 5849, 2767, 2762, 4275, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7369
} | Medical Text: Admission Date: [**2190-8-19**] Discharge Date: [**2190-8-19**]
Date of Birth: [**2113-12-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 76M with metastatic cholangiocarcinoma who
presented to [**Hospital 47255**] with coffee ground emesis. The
patient was given IV fluids, blood transfusion, protonix IV.
There was concern for obstruction of small intestine. He was
transferred to [**Hospital1 18**] for duodenal stent on [**2190-8-19**]. There he
was noted to be hypotensive to the 50s systolic, refractory to
IVF. He was transferred to the ICU.
Past Medical History:
Mr. [**Known lastname 20083**] was in his usual state of good health until the
summer of [**2187**] when he began to feel unwell. He eventually
underwent imaging, which showed a left kidney mass. In [**Month (only) 359**]
[**2187**], this was resected via a left nephrectomy and pathology on
this was reportedly benign. He then developed flu-like symptoms
in [**2188-12-5**] and was admitted for three days with increasing
LFTs as well as a fever. He then developed increased jaundice
and was taken for an ERCP at an outside institution on
[**2189-1-26**], which revealed a common bile duct stricture. He then
was seen here at [**Hospital1 **] by Dr. [**First Name (STitle) **] [**Name (STitle) **] who
repeated his ERCP on [**2189-2-2**], which revealed a malignant
appearing irregularity of the common bile duct just distal to
the confluence of the right and left hepatic ducts with
intrahepatic biliary dilation. Two stents were placed at the end
of the examination. The biopsies from the ERCP revealed a
biliary tissue with high-grade dysplasia and features highly
suggestive of invasive adenocarcinoma. On [**2189-2-16**], he
underwent a CT scan, which showed that he was status post
biliary stent placement with residual minimal dilation of the
left biliary system. There was a vague perihilar enhancement
concerning for intrahepatic involvement cholangiocarcinoma.
There was also an enlarged portacaval lymph node. On [**2189-2-27**],
Dr. [**First Name (STitle) **] took him to the operating room and performed an
exploratory laparotomy and extrahepatic bile duct resection and
Roux-en-Y hepaticojejunostomy. Pathology from this procedure
showed adenocarcinoma of the bile duct consistent with
cholangiocarcinoma. In addition, both the distal and proximal
margins were involved with adenocarcinoma. Also, the tumor was
arising in a background of high-grade dysplasia with focal
papillary architecture, which involved essentially all of the
evaluable biliary system. There were no lymph nodes removed for
evaluation. He completed concomitant chemotherapy with external
beam radiation and capecitabine (1000 mg [**Hospital1 **]) on [**6-5**]. He
commenced adjuvant, weekly cisplatin (25 mg/m2) and gemcitabine
(800 mg/m2) two of every three weeks on [**7-3**] and completed his
seventh cycle [**2190-5-16**].
.
He was admitted first to [**Hospital3 **] and then to [**Hospital1 18**] from [**12-26**]
to [**1-3**]. He grew streptococcus anginosus from his blood and
completed a four week course of ceftriaxone. He has since
commenced prophylactic levofloxacin under the direction of Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
.
Other Past Medical History:
-GIB [**5-/2190**], d/t gastritis
-Hypertension.
-Status post resection of benign nodules of the left kidney in
[**2187**]
-GERD
-H/o PUD [**2163**]
-h/o of streptococcus anginosus [**12-15**] - chronically on
levofloxacin by Dr. [**Last Name (STitle) 724**]
Family History:
Older brother died of pancreatic cancer at age of 67, another
brother died of prostate cancer at the age of 81. No other
history of cancer in his family.
Physical Exam:
GEN: pleasant, awake, communicates w/ son in [**Name (NI) 73060**]
HEENT: [**Name (NI) 22116**] not elevated
LUNG: CTA bilaterally
CV: S1, S2 increased rate, normal rhythm
ABD: soft, distended, catheter in place capped in LUQ
EXT: warm, palpable femoral pulse
Pertinent Results:
[**2190-8-19**] 06:15PM BLOOD WBC-22.6*# RBC-3.23* Hgb-10.3* Hct-29.2*
MCV-90 MCH-31.8 MCHC-35.3* RDW-17.4* Plt Ct-104*
[**2190-8-19**] 06:15PM BLOOD Neuts-90* Bands-2 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0
[**2190-8-19**] 06:15PM BLOOD Plt Ct-104*
[**2190-8-19**] 06:15PM BLOOD Albumin-2.0* Calcium-7.3* Phos-3.8 Mg-1.9
Iron-57
Brief Hospital Course:
HYPOTENSION:
He was started on vasopressors. A CVL was placed on arrival to
the MICU. Labs were notable for leukocytosis concerning for
sepsis likely from abdominal source. He experienced an episode
of billious vomitting. Soon after he became bradycardic and
unresponsive. He expired on 7:44PM with his son at his side.
Medications on Admission:
Unknown
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 0389, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7370
} | Medical Text: Admission Date: [**2157-8-4**] Discharge Date: [**2157-8-12**]
Date of Birth: [**2104-5-13**] Sex: M
Service: SURGERY
Allergies:
Peanut
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
S/P assault with mul
Major Surgical or Invasive Procedure:
[**2157-8-4**]
1. Bilateral neck exploration and packing and
closure.
2. Direct laryngoscopy and esophagoscopy.
[**2157-8-4**]
1. Repair of complex 2 cm laceration of the right neck.
2. Repair of simple 1 cm laceration of right neck.
3. Repair of complex 5 cm laceration of the right neck.
4. Repair of 1 cm simple laceration of the left neck.
5. Bronchoscopy.
History of Present Illness:
53 M brought by EMS with multiple stab wounds. He is noted to be
somewhat lethargic in the field. No vital signs were available
prior to arrival. Upon arrival the patient had blood pressure in
the 70 systolic and was
tachycardic. He has multiple stab wounds throughout his neck
anteriorly or posteriorly with in zone 2 and 3. He also has
multiple stab wounds in the posterior aspect of his thorax
to the right side of his chest in the midline. The patient
gives no history regarding the attack.
Past Medical History:
PMH: asthma
PSH: none
Social History:
Divorced, lives alone, 2 children
ETOH
Tobacco
Family History:
NC
Physical Exam:
Per ED Trauma eval:
On admission
Constitutional: Patient with GCS of 14
Multiple stab wounds
Chest: Breath sounds bilaterally but multiple stab wounds
on the posterior aspect on the right
Cardiovascular: Tachycardic
Abdominal: Soft, Nontender, Nondistended
Pertinent Results:
[**2157-8-4**] 03:21AM GLUCOSE-270* LACTATE-4.9* NA+-134* K+-3.8
CL--110
[**2157-8-4**] 03:21AM HGB-9.9* calcHCT-30
[**2157-8-4**] 03:15AM PLT COUNT-128*#
[**2157-8-4**] 02:01AM GLUCOSE-301* LACTATE-10.2* NA+-137 K+-3.3*
CL--98* TCO2-16*
[**2157-8-4**] 05:57AM ALT(SGPT)-9 AST(SGOT)-19 ALK PHOS-27* TOT
BILI-0.7
[**2157-8-4**] CTA Neck: 1. Nonopacification of V2 segment of right
vertebral artery closely abutting site of right submandibular
laceration is highly concerning for dissection or intimal
injury.
2. Apparent contrast extravasation within superficial right
submandibular
laceration and post surgical exploration site (3, 167), possibly
contiguous with adjacent venous structures.
3. Short segment left internal jugular vein non-opacification
below the
jugular foramen may indicate vascular injury with thrombosis.
4. Multiple stab wounds and extensive superficial and deep soft
tissue
emphysema including air extending within the danger space into
the
mediastinum.
5. Bilateral pneumothorax with chest tubes in place. Small right
hemothorax.
[**2157-8-3**] CT Chest :
1. No vascular or solid organ injury identified. Predominantly
simple fluid noted within the abdominal cavity with slightly
denser fluid noted within the pelvic cavity. While this may
simply reflect third spacing from vigorous fluid resuscitation,
occult mesenteric or bowel injury cannot be entirely excluded
although.
2. Small right and minimal left remaining pneumothoraces with
bilateral chest tubes in place of which the right is partially
intrafissural and the left has portions completely surrounded by
lung likely related to lung collapsed around the tube within the
pleural space (less likely the tube may be partially
intraparenchymal in location).
3. Bilateral lower lobe patchy opacities which may reflect
pulmonary
contusion or underlying aspiration pneumonitis/pneumonia.
4. Subcutaneous emphysema within the superior mediastinum, neck,
and chest
with no large intramuscular hematoma noted.
5. Slight hyperenhancement of the bowel mucosa suggestive of
underlying
hypertension/shock. Multiple scattered mesenteric lymph nodes of
uncertain
significance but presumably reactive.
Brief Hospital Course:
Mr. [**Known lastname **] was evaluated in the Emergency Room by the Trauma
team and bilateral chest tubes were placed. He was then
emergently taken to the Operating Room for neck exploration &
packing, esophagoscopy and laryngoscopy. His admission
hematocrit was 31 and fell to a low of 22. He was resuscitated
with multiple units of packed cells and fresh frozen plasma as
he had greater than a liter of blood drain from each chest tube.
Following this initial resuscitation he was taken back to the
Operating Room for reexploration and closure of his wounds. He
maintained stable hemodynamics and remained intubated overnight.
He was extubated on [**2157-8-5**] but had an episode of desaturation
while turning and was immediately reintubated. Subsequent
bronchoscopy revealed multiple bilateral airway mucous plugging
and some airway edema. A BAL showed only minimal GNR's. He
underwent vigorous pulmonary toilet and was diuresed. He was
successfully extubated on [**2157-8-8**].
Following transfer to the Surgical floor he continued to make
good progress. His hematocrit was stable, his bilateral chest
tubes were removed without difficulty and then his ability to
cough and deep breath improved. He was gradually able to
tolerate a regular diet and he was seen by both Physical Therapy
and Occupational Therapy to help increase his mobility. The
Social Worker was involved with both he and his family to help
with coping during this difficult period. There was also a
question of the patient being sexually assaulted by the intruder
and for that reason was seen by the Center for Violence
Prevention. He underwent testing for hepatitis and HIV and was
prophylactically placed on anti virils. He wiil need to follow
up with the Infectious Disease service following discharge for
management of these drugs. Treatment is anticipated to go over
4 weeks.
Mr. [**Known lastname **] multiple surgical sites were healing well although
his right shoulder wound may need a skin graft in time. He was
discharged to his former wife's home with VNA follow up for
wound care and general assessment. He has multiple follow up
appointments in the next few weeks to both keep a close check on
his physical and emotional progress.
Medications on Admission:
none
Discharge Medications:
1. Outpatient Occupational Therapy
Dx: Mulitple stab wounds to neck, shoulder, arms and right hand.
s/p EXPLORATION & CLOSURE W/PACKING MULTIPLE NECK & BACK WOUNDS,
LARYNGOSCOPY, ESOPHAGOSCOPY, REPAIR OF MULTIPLE RIGHT HAND
LACERATIONS, REPAIR LEFT EAR LACERATIONS
2. Outpatient Physical Therapy
Dx: Mulitple stab wounds to neck, shoulder, arms and right hand.
s/p EXPLORATION & CLOSURE W/PACKING MULTIPLE NECK & BACK WOUNDS,
LARYNGOSCOPY, ESOPHAGOSCOPY, REPAIR OF MULTIPLE RIGHT HAND
LACERATIONS, REPAIR LEFT EAR LACERATIONS
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain, fever.
7. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*1*
9. Santyl 250 unit/g Ointment Sig: One (1) appl Topical once a
day: to right shoulder.
Disp:*1 tube* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Eastern Mass
Discharge Diagnosis:
S/P assault
1. Bilateral zone 2 neck wounds
2. Posterior deep neck wound over spine
3. Three right back stab wounds
4. One posterior left back stab wound
5. Superficial neck wound
6. Bilateral pneumothoraces
7. Acute blood loss anemia
8. Right basilic vein thrombosis
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 multiple stab wounds
and a collapsed lung which happened during your assault.
* You were taken to the Operating Room ffor hemostasis and wash
out of the wounds. Currently they are healingwell.
* Should you develop any shortness of breath or chest pain you
should return to the Emergency Room.
* Continue to increase your activity, stay hydrated and eat well
to heal all of your wounds.
* Should you have any fevers or redness or drainage from your
neck and back wounds please call the [**Hospital 2536**] Clinic.
Followup Instructions:
Urgent Care Infectious Disease Clinic [**2157-8-18**] at 9:30
AM in the [**Hospital **] medical Building, basement floor [**Telephone/Fax (1) 457**]
[**Hospital 2536**] Clinic on Tuesday, [**2157-8-16**] at 3 PM ([**Telephone/Fax (1) 600**])
in the [**Hospital Unit Name **] [**Last Name (NamePattern1) **]. [**Location (un) 470**] 3A
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 2349**] for a follow up appointment
with Dr. [**First Name (STitle) **] in [**12-11**] weeks.
Call Dr. [**Last Name (STitle) 60967**] for an appointment in [**12-11**] weeks.
Completed by:[**2157-8-12**]
ICD9 Codes: 5185, 2851, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7371
} | Medical Text: Admission Date: [**2106-11-24**] Discharge Date: [**2106-12-3**]
Date of Birth: [**2082-11-1**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
jaundice after blunt trauma
Major Surgical or Invasive Procedure:
aspiration and drainage of hepatic fluid collection
endoscopic retrograde cholangiopancreatography
R tube thoracostomy
History of Present Illness:
24M s/p blunt liver and spleen injury, managed non-operatively
with IR guided embolization. Doing well at home, and felt
better, tolerating food, until the patient noticed that he
became frankly jaundiced. Patient presented to his pcp and told
to report to the ED for definitive care. Today he is noticably
jaundiced with a tbili of 6.7. otherwise, the patient notes
fevers to 101 within the last twenty-four hours, but he has
otherwise felt great and done well.
Interventional Procedure from previous admission: IR placed 4
coils to 2 branches of replaced R hepatic artery, L hepatic gel
foam, 1 upper splenic branch coil + gel foam.
Past Medical History:
Non contributory
Social History:
Lives with wife. + etoh use, denies illicts
Family History:
Non contributory
Physical Exam:
Afebrile, hemodynamically stable
A+Ox3, NAD clearly icteric
CTAB
RRR
distended and firm but mildly tender diffusely, no peritoneal
signs, no guarding, no rebound
Pertinent Results:
[**2106-11-24**] 06:40PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2106-11-24**] 06:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-8* PH-7.0
LEUK-NEG
[**2106-11-24**] 06:40PM URINE RBC-[**2-26**]* WBC-[**2-26**] BACTERIA-OCC YEAST-NONE
EPI-<1
[**2106-11-24**] 04:03PM LACTATE-1.5
[**2106-11-24**] 03:55PM GLUCOSE-99 UREA N-16 CREAT-0.7 SODIUM-124*
POTASSIUM-3.6 CHLORIDE-85* TOTAL CO2-28 ANION GAP-15
[**2106-11-24**] 03:55PM ALT(SGPT)-499* AST(SGOT)-119* ALK PHOS-148*
TOT BILI-6.7* DIR BILI-4.1* INDIR BIL-2.6
[**2106-11-24**] 03:55PM LIPASE-31
[**2106-11-24**] 03:55PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-2.3
[**2106-11-24**] 03:55PM WBC-15.5* RBC-3.69* HGB-11.5* HCT-31.8*
MCV-86 MCH-31.0 MCHC-36.1* RDW-13.0
[**2106-11-24**] 03:55PM NEUTS-72* BANDS-1 LYMPHS-11* MONOS-12* EOS-1
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2106-11-24**] 03:55PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL
[**2106-11-24**] 03:55PM PLT SMR-NORMAL PLT COUNT-352#
[**2106-11-24**] 03:55PM PT-12.9 PTT-22.6 INR(PT)-1.1
BCx [**2106-11-24**]: Coag neg staph [**12-26**] sets only
RUQ U/S [**2106-11-24**]: 1. Large hematoma involving the right lobe of
the liver, in the region of the known lacerations. Echogenic
foci within the region of hematoma compatible with gas likely
related to recent gelfoam embolization. Biloma cannot be
excluded on this imaging study. 2. Large amount of complex fluid
within the abdomen, compatible with hemoperitoneum. 3. Probable
sludge within the gallbladder. 4. No intra- or extra-hepatic
biliary ductal dilatation.
CTAP [**2106-11-25**]: 1. Status post embolization of several hepatic
arterial branches as well as splenic artery branches.
Post-procedural changes are noted in the liver including air
within the embolized hepatic parenchyma. 2. No evidence for
biliary obstruction from the known hematoma. 3. Hemoperitoneum
is slightly increased in size from prior study; however, this
likely represents continuous bleeding before the embolization
procedure. 4. Hematoma of the right adrenal gland is stable. 5.
New bilateral pleural effusion, moderate on the right and small
on the left with complete atelectasis of the right lower lobe
and mild atelectasis of the left lower lobe
CT guided aspiration [**2106-11-25**]: Technically successful
percutaneous transhepatic aspiration of right liver
laceration/hematoma yielding 1-2 cc of bloody aspirate, specimen
sent to microbiology as above.
[**Month/Day/Year **] [**2106-11-26**]: Successful biliary cannulation. Extravasation was
noted from at least three smaller biliary radicles off the right
intrahepatic duct. This is consistent with bile leak status post
blunt trauma to the liver and known liver laceration. Successful
sphincterotomy to faciliatate stent placement. Two 7cm by 10FR
Cotton [**Doctor Last Name **] biliary stent were placed successfully in the main
duct. Otherwise normal [**Doctor Last Name **] to third part of the duodenum
CTAP [**2106-12-1**]: 1. Stable right liver lobe hematoma extending into
the subphrenic space. 2. Unchanged hemoperitoneum. 3. Stable
left upper pole splenic laceration.
Brief Hospital Course:
Mr. [**Known lastname 88473**] was admitted to the Acute Care Surgery Service
with hyperbilirubinemia and general feeling of unwellness. A RUQ
ultrasound showed a large fluid collection around his lacerated
liver. Blood cultures from [**2106-11-24**] grew out coag neg staph and
he was placed empirically on vanc/zosyn for fevers. He underwent
IR drainage of the perihepatic fluid collection on [**2106-11-25**]. On
[**2106-11-26**], he underwent [**Date Range **] which demonstrated extravasation from
at least three smaller biliary radicles off the right
intrahepatic duct, consistent with bile leak status post blunt
trauma to the liver and known liver laceration. He had a
sphincterotomy and placement of two 7cm by 10FR Cotton [**Doctor Last Name **]
biliary stents in the main duct to decompress the biliary tree.
After the procedure, he developed respiratory distress but was
able to be extubated in the PACU. A CXR showed a large R pleural
effusion for which a R chest tube was placed. He ultimately
improved in the ICU and was advanced to regular diet and
transferred to the floor. He was offered surgery to deal with
his large perihepatic hematoma, but as he appeared to remain
stable, he opted to hold off on surgical exploration at that
point. As his chest tube output decreased, it was placed on
water seal and then removed, with a small, stable residual
post-pull pneumothorax. As he was feeling better and did not
desire surgical options at that time, he was discharged home on
[**2106-12-3**] with close follow up in the Acute Care Surgery Clinic.
He agreed to return should any further problems arise and so was
sent out.
Medications on Admission:
percocet
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 doses.
Disp:*4 Tablet(s)* Refills:*0*
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA & Hospice
Discharge Diagnosis:
s/p tractor rollover accident
liver laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for abdominal pain and
underwent drainage of a collection around your liver as well as
an [**Location (un) **] which showed some small bile leaks due to your recent
tractor accitdent.
Followup Instructions:
You have a follow up appointment in Acute Care Surgery Clinic
next Tuesday at 2:15 PM on the [**Location (un) **] of the [**Hospital **] Medical
Office Building at [**Last Name (NamePattern1) 439**], [**Location (un) 86**], MA
You also have an appointment for [**Location (un) **] to determine status of
your bile leak as outlined below:
Provider: [**Name Initial (NameIs) **] 2 ([**Hospital Ward Name **] 4) GI ROOMS Date/Time:[**2106-12-28**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2106-12-28**] 1:00
ICD9 Codes: 5185, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7372
} | Medical Text: Admission Date: [**2155-8-16**] Discharge Date: [**2155-8-20**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Hyperkalemia, AFIB RVR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57yo M with a h/o systolic (EF 20-25) and grade 4 diastolic
heart failure, ESRD [**2-15**] DM on HD, atrial fibrillation with RVR,
severe depression, crack cocaine use presents with hyperkalemia
to 7.4 and atrial fibrillation with RVR to 150s in setting of
missing dialysis for the past week, of note patient with long
history of missing dialysis sessions. Patient recently
discharged on [**8-10**] with c.diff colitis, claims did crack cocaine
2 days ago and has had persistent diarrhea. He has missed
dialysis for the past week, he states he was told not to go to
HD since he was having active diarrhea.
In the ED, was treated for hyperkalemia with 2 grams calcium
gluconate, dextrose, IV regular insulin, 30g kayexalate, bicarb.
Renal was consulted and will plan on HD tomorrow a.m. Cards was
consulted for afib RVR and rec IV labetalol which converted him
back into SR in the 110s.
.
ROS: patient with depressed mental status
Past Medical History:
ESRD on hemodialysis (Tues/Thurs/Sat, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] Dialysis,
[**Location 1268**], [**Telephone/Fax (1) 69669**])
Type II diabetes mellitus
CAD s/p MI (pt does not recall), MIBI in [**11-19**] showed reversible
defects inferior/lateral
CHF with EF 20-25% (from echo in [**6-/2155**]) and severe global
hypokinesis
Hypertension
Dyslipidemia
Atrial fibrillation
History of gastrointestinal bleed: Duodenal, jejunal, and
gastric AVMs, s/p thermal therapy; sigmoid diverticuli.
Chronic pancreatitis
Hepatitis C
GERD
Gout s/p arthroscopy with medial meniscectomy [**5-/2149**]
Depression s/p multiple hospitalizations due to SI
Polysubstance abuse: crack cocaine, EtOH, tobacco
Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**]
Social History:
Smokes 3 cigarettes/day. 42 pack year history. Hx of alcohol
abuse, with DTs and detoxification. Last crack cocaine use was
day prior to admission. Lives with a female partner.
Family History:
Father with alcoholism. Cousin with [**Name2 (NI) 14165**] cell. Mother with
renal failure, d. 58. Son with diabetes.
Physical Exam:
VS- 95.7 115 (Afib) 135/88 24 95%4L NC
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
ADMISSION LABS
.
[**2155-8-16**] 09:00PM PT-17.8* PTT-33.6 INR(PT)-1.6*
[**2155-8-16**] 09:00PM PLT COUNT-335
[**2155-8-16**] 09:00PM WBC-5.1 RBC-5.38 HGB-16.1# HCT-49.7 MCV-92
MCH-29.8 MCHC-32.3 RDW-16.6*
[**2155-8-16**] 09:00PM NEUTS-74.0* LYMPHS-17.5* MONOS-6.0 EOS-0.4
BASOS-2.1*
[**2155-8-16**] 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2155-8-16**] 09:00PM CALCIUM-11.1* PHOSPHATE-6.9*# MAGNESIUM-2.9*
[**2155-8-16**] 09:00PM CK-MB-12* MB INDX-11.8*
[**2155-8-16**] 09:00PM cTropnT-0.34*
[**2155-8-16**] 09:00PM LIPASE-39
[**2155-8-16**] 09:00PM ALT(SGPT)-45* AST(SGOT)-69* CK(CPK)-102 ALK
PHOS-153* TOT BILI-1.8*
[**2155-8-16**] 09:00PM GLUCOSE-117* UREA N-85* CREAT-10.4*#
SODIUM-137 POTASSIUM-7.4* CHLORIDE-99 TOTAL CO2-19* ANION
GAP-26*
[**2155-8-16**] 09:02PM freeCa-1.13
[**2155-8-16**] 09:02PM HGB-17.5 calcHCT-53 O2 SAT-85 CARBOXYHB-3.8
MET HGB-0.0
.
CXR [**2155-8-16**]
IMPRESSION: Increased moderate-to-large right pleural effusion
and slightly decreased small left effusion. Slightly worsened
pulmonary edema.
.
At time of transfer frm ICU to medical floor on [**2155-8-19**] the
patient's K+ was 4, Na 139, Cl 98, Bicarb 26, BUN 37 and Cr 7
and Glu 172 and CBC showed wbc 4.7, Hgb 14.2, Hct 44.3, Plts 246
and 2 sets Blood Cultures drawn [**8-16**] are still pending.
.
Discharge Labs:
[**2155-8-20**] 06:15AM BLOOD WBC-4.1 RBC-4.24* Hgb-13.1* Hct-39.6*
MCV-94 MCH-30.9 MCHC-33.0 RDW-15.9* Plt Ct-217
[**2155-8-20**] 06:15AM BLOOD Glucose-127* UreaN-42* Creat-8.0* Na-138
K-4.3 Cl-102 HCO3-25 AnGap-15
[**2155-8-18**] 07:20AM BLOOD ALT-64* AST-76* CK(CPK)-69 AlkPhos-111
TotBili-1.0
Brief Hospital Course:
58yo M with a hx of systolic (EF 20-25%) and grade 4 diastolic
heart failure, ESRD [**2-15**] DM on HD, atrial fibrillation with RVR,
severe depression, and recent crack cocaine use presents with
hyperkalemia to 7.4 and atrial fibrillation with RVR to 150s in
the setting of missing dialysis for the past week. Of note,
patient has had a long history of missing dialysis sessions.
.
Upon presentation to ED, patient was treated for hyperkalemia
with 2 grams calcium gluconate, dextrose, IV regular insulin,
30g kayexalate, and bicarb. Renal was consulted and urgent HD
was [**Month/Day (2) 1988**] for [**8-18**] in the early a.m. hours and approximately
1 Liter of fluid was removed. Cardiology was also consulted for
afib with RVR and recommended IV labetalol, which converted him
back into SR in the 110s. During his stay in the unit, pt
remained rate controlled in the 90s-110s and was NSr at time of
transfer to the general medical floor. Patient was resumed on
his home dose of Labetalol.
.
Lisinopril was initially held due to hyperkalemia setting but
plan was to resume his oupatient dose once discharged. Potassium
this morning, [**8-19**], was K 4.0 and team felt comfortable
switching patient back to his Ace-inhibitor. Additional ESRD
medications, cinacalcet and sevelamer were also continued for
electrolyte/Phos level control.
.
During admission, the patient also complained of intermittent
non-radiating chest pressure. SL Nitro was given with no effect.
Pain episodes would eventually resolve without intervention.
Repeat EKGs showed no change from admission, and no new
ischemia/infarction. The pain was reproducible on physical exam
at the lower edge of xiphoid and epigastric region and responded
to Maalox and it was felt that these complaints were large GI
related vs. cardiac. He continued to have chest pain while on
the floor, and again it was relieved with tylenol and maalox,
thought to be more GI related at that time.
.
Patient was discharged from recent hospital stay on [**8-10**] with C.
Diff colitis and still has about a week left of his Flagyl
therapy. Patient continues to c/o daily diarrhea at this time
but the frequency has decreased. Flagyl was continued during
this admission. He had three days left of treatment at the time
of discharge.
.
The patient has a history of DM-2 and was initially placed on
Humalog sliding scale after acute presentation. Now that patient
has stabilized he can return to his usual NPH daily schedule of
15 Units a.m. and 10 Units p.m.
.
For his history of depression he was continued on daily Zoloft
home dose.
.
On the floor, he was seen by a social work to address his
absence from dialysis the week before admission. He obviously
has insight into the medical problems it causes, but continues
to do crack cocaine and miss his sessions. He has an
appointment at the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to follow up his substance
abuse and was discharged with goals of staying sober and
attending all his dialysis sessions. He will continue his Tues,
Thurs, Sat schedule as an outpatient.
Medications on Admission:
Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
Pantoprazole 40 mg Tablet, Delayed Release (E.C.)
Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
Senna 8.6 mg Tablet
Diphenhydramine HCl 25 mg Capsule q6h prn
Camphor-Menthol 0.5-0.5 % Lotion
B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**1-15**] Sublingual
Acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO
Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID
Insulin Lispro 100 unit/mL Solution sliding scale
Metronidazole 500 mg Tablet Sig: TID x 14 days started [**8-10**]
Insulin NPH Human Recomb 15 qam and 10 qpm
Discharge Medications:
1. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 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 Q24H (every 24 hours).
[**Month/Year (2) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
[**Month/Year (2) **]:*9 Tablet(s)* Refills:*0*
10. Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous QAM.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous every morning.
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for chest/abdominal
discomfort.
16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
17. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
18. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: Ten
(10) units Subcutaneous every night.
[**Month/Year (2) **]:*1 pen* Refills:*2*
19. Insulin Lispro 100 unit/mL Insulin Pen Sig: One (1) unit
Subcutaneous as directed by sliding scale.
[**Month/Year (2) **]:*1 pen* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. End Stage Renal Disease on hemodialysis
2. Type II diabetes mellitus
3. Congestive Heart Failure
.
Secondary:
3. CAD s/p MI
4. CHF with EF of 20-25%
5. Hypertension
6. Atrial fibrillation
7. Polysubstance abuse: crack cocaine
Discharge Condition:
vital signs stable, afebrile, breathing room air comfortably,
ambulating without difficulties, normal mentation.
Discharge Instructions:
You were admitted for high potassium levels in the setting of
missed dialysis visits. You were dialyzed here in the hospital
and we continued treatment for your c difficile colitis.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
.
Please return to the hospital for worsening chest pain,
shortness of breath, abdominal pain, fainting, nausea, vomitting
or any other concerns. Call 911 if it is an emergency.
Followup Instructions:
Please follow up in hemodialysis, it is very important that you
continue to make these appointments. Your schedule is Tues,
Thursday, Saturday at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] Dialysis. Their phone number
is [**Telephone/Fax (1) 69669**].
.
Please see your PCP:
[**Name Initial (NameIs) 2169**]: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2155-8-27**]
10:10
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
Completed by:[**2155-8-22**]
ICD9 Codes: 5849, 4280, 2767, 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7373
} | Medical Text: Admission Date: [**2160-9-19**] Discharge Date: [**2160-9-28**]
Date of Birth: [**2097-12-31**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Tracheal stent placed twice
Inominate vein stent placed
Radiation therapy
Intubation
Midline placement
History of Present Illness:
This 62 year old male with a history of COPD presented to [**Hospital **] with acute shortness of breath. He was unwell one
week prior to admission, with shortness of breath making it
difficult to sleep. He also had experienced some chest tightness
and notes non-painful mass in the side of his neck. At admission
he denied fever, vomiting or diarrhea. He had wheezes on exam
and was given bronchodilators with some improvement. He was
hypertensive at the time of arrival 180/100. His WBC was
elevated to 15.5, ABG 7.28/73/63.
At [**Hospital6 **] a CXR showed right upper lobe mass. A CT
was performed which showed a spiculated mass in the right upper
lobe with contiguous and marked mediastinal adenopathy,
compression and distortion of the superior vena cava, extending
up into the superior mediastinum in the supraclavicular area and
compression of the right brachiocephalic vein, narrowing of the
trachea. The patient had elevated CE at the OSH, he was started
on Heparin despite the most likely diagnosis being demand
ischemia in the setting of hypoxia.
He was on BiPap at the OSH for his decreased saturation. He was
transfered to [**Hospital1 18**] for bronchoscopy to obtain tissue for
diagnosis. He currently feels well except for some shortness of
breath. He also notes that his face feels warm and eyes are
iritated.
Past Medical History:
1. COPD - no intubations, no home O2
2. Alcoholic cirrhosis
3. Hematuria
4. Hypertension
5. Chronic back pain s/p laminectomy
6. Splenectomy s/p motor vehicle accident
7. Obstructive sleep apnea
8. Prior PEs
Social History:
occasional alcohol, prior history of heavy drinking
quit smoking one year ago, 80 pack year history
Was in the military then worked for airlines, no known asbestos
exposure, reports some exposure to epoxy without mask.
Currently lives in [**Location **] with two roomates, sister is his HCP
Family History:
Mother with DM, Father with heart trouble
Physical Exam:
Vitals Temp 98.7 BP 134/60, HR 85, RR 26, 90% on 5L NC
Gen: alert, oriented, cooperative male resting comfortably
HEENT: MMM, OP clear, face red, PERRL
Lungs: clear to auscultation bilaterally, distant BS
CV: distant HS, RRR, nl S1S2, no murmers
Abd: obese, soft, non-tender, normal BS
Ext: trace edema
Neuro: grossly intact
Pertinent Results:
[**2160-9-19**] 03:17PM BLOOD WBC-18.7* RBC-4.97 Hgb-16.2 Hct-49.2
MCV-99* MCH-32.6* MCHC-33.0 RDW-13.6 Plt Ct-241
[**2160-9-24**] 04:26AM BLOOD WBC-15.6* RBC-4.98 Hgb-15.7 Hct-49.2
MCV-99* MCH-31.4 MCHC-31.8 RDW-13.0 Plt Ct-215
[**2160-9-28**] 09:34PM BLOOD Hct-27.8*
[**2160-9-19**] 03:17PM BLOOD Glucose-130* UreaN-22* Creat-1.0 Na-136
K-4.7 Cl-95* HCO3-31 AnGap-15
[**2160-9-28**] 03:46AM BLOOD Glucose-149* UreaN-54* Creat-2.6* Na-137
K-3.9 Cl-93* HCO3-35* AnGap-13
[**2160-9-24**] 02:58AM BLOOD Type-ART pO2-77* pCO2-76* pH-7.32*
calHCO3-41* Base XS-8
Brief Hospital Course:
He was diagnosed with likely NSCLC (definitive pathology had not
returned). A CT showed tracheal compression and compression of
[**Last Name (LF) 17911**], [**First Name3 (LF) **] he underwent a tracheal stent and inominate stenting.
He was trasiently intubated for hypoxia but improved.
On [**9-23**], Mr. [**Known lastname **] was transferred to the [**Hospital Unit Name 153**] for radiation
therapy. However, following his first treatments of chemo and
radiotherpay the patient requested to have his code status
changed to DNR/DNI on [**2160-9-28**]. He refused telemetry. He was
found later that night after having expired. The [**Hospital 228**]
health care proxy, his sister [**Name (NI) **], refused a postmortem. The
[**Hospital 228**] health care proxy, his sister [**Name (NI) **], was notified of
the patient's demise.
1. Respiratory status:
He has respiratory distress due to both the lung cancer and
COPD. He has been retaining CO2 and on transfer his PCO2 was
76. He also was desatting into the mid 80s at night and
positive pressure ventiulation was attempted using both face
mask and nasal positive pressure, however the patient was
extremely uncomfortable and didn't tolerate the positive
pressure. Therefore, at night he had been on face mask with
FiO2 titrated to keep his oxygen saturation at 90 or above.
During the day he had been satting in the mid 90s on nasal
cannula oxygen. On [**2160-9-28**], he became acutely hypoxic from a
presumed PE and expired.
2. Lung CA:
The pathology suggests stage IIIb non small cell lung cancer.
Tissue was obtained from both bronchoscopy and mediastinoscopy.
A head CT was negative for metastases, as was a bone scan for
osseous metastases. He will be treated with a 5 week course of
radiotherapy four times per week along with weekly
radiosensitizing chemotherapy of carbaplatin and paclitaxel. He
received his first dose of radiation therpay on [**9-24**] and his
first dose of chemotherpay on [**9-25**]. He was quite nauseous
after the first dose of chemo requiring antiemetics. He was
also put on atovaquone for PCP [**Name Initial (PRE) 1102**]. There were no
immediate side effects of the radiation therapy.
3. Vena Cava Syndrome: Shortly after arrival to the [**Hospital Ward Name 332**] ICU,
the patient had a stent placed in his right inominate artery.
His facial swelling decreased after the stent, thoguh he
continued to have facial flushing. A follow up CT venogram
showed persistent narrowing the the [**Hospital Ward Name 17911**]. The patient was also
anticoagulated with heparin with a goal PTT of 60-80 for the
vascular stent, however this was discontinued on [**2160-9-26**] after
the patient developed a retroperitoneal bleed.
4. Fever: During his hospital course, the patient began spiking
fevers to 101 and developed a new infiltrate in his right upper
lung field concerning for pneumonia.
penumonia. He was started on a 10 day course of zosyn. It is
possiblke that the poneumonia was postobstructive from the lung
cancer or alternatively from aspiration following the tracheal
stent placement.
5. Retroperitoneal bleed: Shortly after beginning
anticoagulation therapy, a retroperitoneal bleed was noted on
the patient's follow up CT scan. His hct dropped 10 points, and
his heparin was discontinued.
6. The patient's code was changed to DNR/DNI on [**9-28**]. He was
very clear that he wanted this change in code status.
Medications on Admission:
Albuterol
Atrovent
Levothyroxine
Atenolol
Meloxicam
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Distress
Presumed Non-small cell lung cancer
Superior vena cava syndrome
Tracheal compression with stent placement
Retroperitoneal bleed
Secondary:
1. COPD - no intubations, no home O2
2. Alcoholic cirrhosis
3. Hematuria
4. Hypertension
5. Chronic back pain s/p laminectomy
6. Splenectomy s/p motor vehicle accident
7. Obstructive sleep apnea
8. Prior PEs
Discharge Condition:
Expired
ICD9 Codes: 496, 486, 5849, 4275, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7374
} | Medical Text: Admission Date: [**2139-10-6**] Discharge Date: [**2139-10-12**]
Date of Birth: [**2099-6-16**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8480**]
Chief Complaint:
right neck swelling
Major Surgical or Invasive Procedure:
[**2139-10-6**]: Incision and drainage of right neck abscess
History of Present Illness:
40 y/o M with h/o IVDA (last used 4 months ago) who presented to
OSH with R neck swelling and odynophagia. Sore throat began on
Saturday, neck swelling began on Sunday. He went to [**Hospital 4199**] hosp
on Monday who told him he had a blocked salivar gland, and
started augmentin. His swelling worsened today and he went back
to [**Hospital 4199**] hospital where they obtained a neck CT which was read
as a having a cystic neck mass with some compression of airway.
He was given decadron 10 x1, and unasyn and transferred to
[**Hospital1 18**]. He states he has some difficulty breathing through his
mouth, but breathing easily through his nose. He is tolerating
po's. He has some deepening of his voice. Denies fevers,
chills, dysphagia, fevers, chills, diplopia, blurry vision, cp,
sob, n, v, abd pain, otalgia, ear complaints, headache,
numbness, weakness. Per report negative HIV 6 months ago. Of
note the patient self-aspirated 1cc of pus from right neck mass.
Last po intake 1pm. No previous neck infections.
Past Medical History:
PMH: IVDA 4 months ago last use, Hep C, Chronic LBP, rcotic
dependence
PSURG Hx: bilateral hip surgeries, adenoidectomy, tonsillectomy
as a child
Social History:
On disability, 2ppd x 27 years, non drinker, former cocaine
and heroin user.
Family History:
non-contributory
Physical Exam:
98.0 80 115/80 16 99 RA
NAD
RRR
CTA B
moderate right neck swelling, much improved from before.
CN [**Last Name (LF) **], [**First Name3 (LF) 81**], and XII intact
Pertinent Results:
[**2139-10-5**] 10:03PM PT-13.5* PTT-27.6 INR(PT)-1.2*
[**2139-10-5**] 10:03PM WBC-10.4 RBC-4.23* HGB-11.8* HCT-35.7* MCV-84
MCH-27.8 MCHC-33.0 RDW-14.1
[**2139-10-5**] 10:03PM PLT COUNT-176
[**2139-10-5**] 10:03PM GLUCOSE-120* UREA N-8 CREAT-0.8 SODIUM-137
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-12
[**2139-10-5**] 10:06PM LACTATE-0.7
[**2139-10-6**] 05:07AM PT-14.2* PTT-27.3 INR(PT)-1.2*
[**2139-10-6**] 05:07AM WBC-8.1 RBC-3.94* HGB-11.3* HCT-32.9* MCV-84
MCH-28.8 MCHC-34.4 RDW-14.7
[**2139-10-6**] 05:07AM PLT COUNT-184
[**2139-10-6**] 05:07AM GLUCOSE-164* UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
[**2139-10-6**] 05:07AM CALCIUM-9.0 PHOSPHATE-2.3* MAGNESIUM-2.3
CT OSH, Second Opinion Read from [**2139-10-5**]: 1. Large rim-enhancing
fluid collection below the right angle of mandible, centered in
the right parapharyngeal space and extending to the submucosa as
described above, displacing adjacent structures. Diagnostic
possibilities include an abscess and a superinfected branchial
cleft cyst. 2. Extension of hypodense material from the
collection to the retropharyngeal and prevertebral spaces at
C3-C6, concerning for phlegmon or early abscess formation. C5-6
endplate irregularities are most likely degenerative, but
infection cannot be excluded. Cervical spine MRI is suggested
for further evaluation.
MRI Spine [**2139-10-8**]: Extensive soft tissue edema and residual right
parapharyngeal fluid collection as described above. Extremely
limited study due to motion and lack of IV contrast. Please
refer to concurrent CT neck for details.
CT Neck [**2139-10-8**]: 1. Interval drainage of a large rim-enhancing
right neck fluid collection with multiple small residual
collections in the operative bed, colectively measuring upto 3.6
cm.
Brief Hospital Course:
Mr. [**Known lastname 67102**] was transferred from an OSH for a large right neck
abscess and odynophagia. The patient was taken to the OR for
operative drainage. Please see dedicated operative report for
full details. The patient was kept intubated and taken to the
ICU for overnight observation. On POD 1, the patient was
extubated and his diet was advanced. He stayed one more day in
the ICU while awaiting a bed and was then transferred to the
floor. He had been started on vanc/unasyn in the ED here at
[**Hospital1 18**] and cultures were obtained, which grew out beta lactamase
negative Haemophilus influenzae. Due to continuing concern about
his neck, an MRI was attempted on [**2139-10-8**], but the patient could
not tolerate the procedure. A follow up CT was then obtained and
further drainage was deemed unnecessary based on those results.
An ID consult was obtained and the antibiotics were changed to
cefepime and flagyl. They also suggested an HIV test, which was
negative. The patient responded well on this regimen. During his
hospital stay, he had good pain control on oral meds, had normal
hemodynamics and oxygen saturations, was ambulatory, and
tolerated an oral diet. On Monday, [**2139-10-12**], the patient expressed
a desire to go home. ID recommendations included a week of IV
antibiotics. Thus, the patient decided to sign himself out of
the hospital against medical advice. He will be completing a
course of oral antibiotics, will have VNA services for dressing
changes, and will follow up with Dr. [**First Name (STitle) **] soon. The patient was
counseled as to the risks of his going home, and he decided to
leave against medical advice to go home.
Medications on Admission:
Methadone 100mg QD, oxycodone 15mg q6 prn pain
Discharge Medications:
1. Methadone 40 mg Tablet, Soluble Sig: 2.5 Tablet, Solubles PO
DAILY (Daily) as needed for home maintenence dose.
2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
3. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q6H (every 6
hours) as needed for pain.
Disp:*300 mL* Refills:*0*
4. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 21 days.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
right neck abscess
Discharge Condition:
Stable
Discharge Instructions:
VNA will come to change your packing and dressing once a day.
Call your doctor's office or go to the ED if you start to have
fevers/chills, increasing difficulty breathing, new redness or
swelling at the surgical site, or if you have any other
concerns.
Followup Instructions:
Call Dr.[**Name (NI) 18353**] office at [**Telephone/Fax (1) 2349**] to schedule a follow-up
appointment to be seen in [**8-14**] days.
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7375
} | Medical Text: Admission Date: [**2105-12-26**] Discharge Date: [**2106-1-7**]
Date of Birth: [**2082-3-9**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Paralysis of bilateral legs
Major Surgical or Invasive Procedure:
T4-T8 laminectomy with excision of dorsal epidural abscess.
History of Present Illness:
Patient is a 23 y/o F IVDA, who noted four days worth of back
pain prior to presentation. She presented to the emergency room
on [**2105-12-26**] with paralysis of her bilateral lower extremities,
MRI showed an epidural abscess in her T spine and was taken
urgently to the OR.
Past Medical History:
IVDA
Physical Exam:
Afebrile
BUE: [**4-14**] deltoid, biceps, triceps, WF, WE, FF, FAb
BUE: SILT C4-T1
BLE: no motor below T9
BLE: no sensation BLE T9-S1.
incontinent of bowel and bladder, foley catheter dependent
poor rectal tone
Pertinent Results:
[**2105-12-26**] 03:55PM WBC-18.7* RBC-3.28* HGB-10.0* HCT-29.0*
MCV-88 MCH-30.6 MCHC-34.6 RDW-12.6
[**2105-12-25**] 10:57PM CRP-GREATER TH
[**2105-12-25**] 10:57PM WBC-19.8* RBC-4.22 HGB-12.8 HCT-36.6 MCV-87
MCH-30.3 MCHC-34.9 RDW-12.5
[**2105-12-25**] 10:57PM SED RATE-75*
[**2105-12-25**] 10:57PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2105-12-25**] 10:57PM URINE BLOOD-TR NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2105-12-25**] 10:57PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
Brief Hospital Course:
The patient was taken emergently to the operating room on the
day of presentation. She underwent a decompression from T5-T8
(Laminctomies). Frank pus was removed from the epidural space
which was shown to be + for MRSA. She was taken to the SICU
immediately after surgery. Her SICU course was uneventful and
she was discharged to the floor. She was given a PICC line for a
total of a 10 week course of vancomycin to be followed by
infectious disease. See discharge instructions for follow-up
information. She was discharged to a spinal cord rehabilitation
facility once her insurance company provided approval.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/fever > 100.4, pain.
5. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q8H (every 8 hours).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for if no BM in > 24 hours.
9. Hydromorphone 4 mg Tablet Sig: 1 [**12-12**] to 2 [**12-12**] Tablet PO Q3H
(every 3 hours) as needed for pain.
10. Methadone 10 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8
Hours): Methadone is being for pain management as per the
recommendation of chronic pain management services.
11. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
12. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
13. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO
Q6H (every 6 hours) as needed for rash/itching.
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
16. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
17. Vancomycin 500 mg Recon Soln Sig: 2 [**12-12**] Recon Solns
Intravenous Q 8H (Every 8 Hours).
18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Thoracic epidural abscess from T4-T8
Discharge Condition:
Stable.
Tolerating oral diet.
Alert and oriented.
Discharge Instructions:
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without moving around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You may have been given a brace. This brace is to be
worn when you are walking. You may take it off when sitting in a
chair or lying in bed.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing and call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
o We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
-For your vancomycin, please have a weekly CBC with
differential, ESR, CRP, and vancomycin trough faxed to the
Infectious Disease clinic at [**Telephone/Fax (1) 1419**] attention Dr. [**Last Name (STitle) **]
[**Name (STitle) 84167**]
Physical Therapy:
OOB to chair,
Passive ROM in ankle, knee and hip joints.
Wheelchair mobilization.
Treatments Frequency:
IV antibiotics through the PICC line.
Physical therapy in the form of OOB to chair.
Removal of staples in 3 weeks.
Followup Instructions:
Follow up in 6 weeks with Dr [**Last Name (STitle) 1007**]. Please call [**Telephone/Fax (1) 9769**] to
make an appointment.
Follow up in Six weeks at the infectious disease clinic at [**Hospital1 1535**] [**Hospital Ward Name 516**]. Please follow-up in
six weeks. Please call office to schedule an appoinement.
Follow-up with the Chronic Pain service, Dr. [**Last Name (STitle) 13284**], [**Hospital1 1535**], in four to six weeks. Please
call his office to schedule an appointment.
Completed by:[**2106-1-7**]
ICD9 Codes: 7907, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7376
} | Medical Text: Admission Date: [**2156-4-17**] Discharge Date: [**2156-4-30**]
Date of Birth: [**2093-7-2**] Sex: M
Service: MEDICINE
Allergies:
Ativan / Diovan
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Back pain and leg weakness
Major Surgical or Invasive Procedure:
Thoracentesis
Hemodyalisis
History of Present Illness:
Mr. [**Known lastname 68820**] is a 62yo M with history of Hepatitis C with
cryoglobulinemia s/p renal transplant in [**2152**] who presented to
an outside hospital with midthoracic back pain and left leg
weakness. He was transferred to [**Hospital1 18**] when he was found to be
in worsening renal failure.
.
Of note, he had a right pleural effusion drained a week ago. On
this presentation, he complains of some increased shortness of
breath and CXR at OSH showed reaccumulation of his pleural
effusion. Patient has had pleuritic chest pain almost constantly
for an unclear period of time but at least since Thursday which
is worse with inspiration. His pain briefly improved after
thoracentesis for R pleural effusion but worsened soon after.
He decided to see his doctor yesterday after he awoke with left
leg weakness and difficulty picking up his leg.
.
Over the past couple of weeks, he was found to be hypertensive
and started on amlodipine in addition to his other
antihypertensives. After patient's thoracentesis, he continued
these antibiotics and was hypotensive at the OSH to 94.
.
In the ED, initial vs were: T 98.3 P 81 BP 103/41 R 20 O2 sat
100% 2L NC. Patient's labs were significant for a K of 6.7 and
Cr of 7.1. The patient was given calcium gluconate, Insulin and
D50, and Kayexelate. He was given 750mg IV Levofloxacin x1,
Zofran, Valium 5mg. He was started on levophed briefly for
hypotension and weaned prior to arrival to the MICU. MRI of the
spine was performed which was negative for cord compression.
.
In the ICU, he complains of diffuse pain, mostly in his back and
left flank. He had back pain at baseline and it worsened a week
ago after seeing his chiropracter. His review of systems is
positive for intermittent headaches, pleuritic chest pain, back
pain and leg numbness and weakness. He has had decreased urine
output over the past day.
Past Medical History:
-ESRD dx [**2146**] [**2-4**] HTN now s/p LRRT [**2152-3-28**]
-HTN
-CAD, s/p MI with stent
-Hyperlipidemia
-HCV genotype 1,PEG interferon
monotherapy for 28 weeks and then was stopped due to low blood
counts. Bx 06 showed chr hep c
-paraproteinemia/paraproteinuria of uncertain significance.
-H/o coagulation disorder due to reaction to HCV medication
resulting in DVT and ensuing vascular compromise/gangrene
resulting in a lower extremity amputation.
-Anemia of chronic disease
Social History:
On disability. was working as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3456**]. social etoh, 42 pack year
h/o smoking and still smokes
Family History:
No family h/o cad, brother has renal cell ca-fully treated and
dtr with chronic kidney disorder of uncertain etiology. His
mother had DM
Physical Exam:
ADMISSION PHYSICAL:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, strabismus and blindness in R eye, MM
slightly dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Some decreased air movement at right base, otherwise
clear to auscultation bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender graft in RLQ, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley
Back: Tenderness over left upper flank, no spinal process
tenderness, tenderness over left SI joint
Ext: warm, well perfused, R AKA and LLE without edema or
cyanosis, 2+ DP on LLE, strength 3+/5 in LLE, [**5-6**] in bilateral
upper extremities
Pertinent Results:
STUDIES:
CXR [**2156-4-17**]:
FINDINGS: Frontal and lateral views of the chest are obtained.
Again seen is
a moderate right pleural effusion with overlying atelectasis. A
trace left
pleural effusion is likely also present, as noted on the lateral
view.
Increased markings along the right lung may relate to layering
effusion
although slightly asymmetric interstitial edema may be present.
Underlying
infection cannot be excluded. The cardiac silhouette, while
cannot be
accurately assessed due to the right effusion, may be mildly
enlarged. The
aorta is calcified and tortuous.
.
SKULL X-RAY [**2156-4-18**]:
FINDINGS:
Two views of the skull demonstrate no radiopaque metallic
foreign body in and about the orbits. Sinuses are clear.
.
MRI L-SPINE [**2156-4-18**]:
CONCLUSION: No evidence of cord or cauda equina compromise.
Mild degenerative changes.
Vertebral body hypointensity as discussed above.
.
RENAL TX U/S [**2156-4-18**]:
Preliminary Report !! PFI !!
PFI:
1. Transplant kidney with no definite perinephric collections.
2. Main renal artery and main renal vein are patent. Resistive
indices in
interlobular arteries are 0.78, 0.87, and 0.83 in the upper,
mid, and lower poles, respectively.
.
LENI LLE [**2156-4-18**]:
IMPRESSION: No evidence of DVT in the left lower extremity.
.
CXR [**2156-4-19**]:
FINDINGS:
Frontal view of the chest is compared to multiple prior
examinations. Since the prior study, there is interval worsening
in the appearance of the chest, with accumulation of
moderate-to-large right-sided pleural effusion, right lower lobe
consolidation, left lower lobe consolidation increased. Mild
congestive failure has developed. Heart is top normal in size.
Mediastinum is stable.
.
MICRO:
UCX [**2156-4-18**]: NO GROWTH
BCX [**4-18**], [**4-19**]: PENDING
Labs:
[**2156-4-17**] 07:50PM BLOOD WBC-6.9 RBC-2.99* Hgb-8.4* Hct-27.1*
MCV-91 MCH-28.1 MCHC-31.0 RDW-20.6* Plt Ct-228
[**2156-4-27**] 05:10AM BLOOD WBC-12.2* RBC-2.95* Hgb-7.8* Hct-26.3*
MCV-89 MCH-26.3* MCHC-29.6* RDW-20.4* Plt Ct-374
[**2156-4-17**] 07:50PM BLOOD PT-15.0* PTT-27.7 INR(PT)-1.3*
[**2156-4-27**] 05:10AM BLOOD PT-14.9* PTT-29.5 INR(PT)-1.3*
[**2156-4-17**] 07:50PM BLOOD Glucose-104* UreaN-64* Creat-7.1*# Na-136
K-6.7* Cl-108 HCO3-17* AnGap-18
[**2156-4-27**] 05:10AM BLOOD Glucose-66* UreaN-33* Creat-4.0* Na-136
K-4.2 Cl-103 HCO3-23 AnGap-14
[**2156-4-17**] 07:50PM BLOOD ALT-30 AST-65* AlkPhos-172* TotBili-0.3
[**2156-4-26**] 05:45AM BLOOD ALT-16 AST-25 LD(LDH)-280* AlkPhos-176*
TotBili-0.3
[**2156-4-17**] 07:50PM BLOOD cTropnT-0.04*
[**2156-4-18**] 02:00AM BLOOD cTropnT-0.03*
[**2156-4-18**] 08:46AM BLOOD CK-MB-6 cTropnT-0.04*
[**2156-4-18**] 02:32PM BLOOD CK-MB-6 cTropnT-0.03*
[**2156-4-26**] 05:45AM BLOOD calTIBC-121* Ferritn-724* TRF-93*
[**2156-4-21**] 12:00PM BLOOD PTH-113*
[**2156-4-21**] 05:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-POSITIVE
[**2156-4-17**] 07:50PM BLOOD RheuFac-561*
[**2156-4-26**] 11:20AM BLOOD C3-112 C4-4*
[**2156-4-27**] 05:10AM BLOOD HIV Ab-NEGATIVE
[**2156-4-27**] 05:10AM BLOOD Cyclspr-88*
[**2156-4-26**] 05:45AM BLOOD Cyclspr-92*
[**2156-4-25**] 06:55AM BLOOD Cyclspr-79*
[**2156-4-21**] 05:25AM BLOOD HCV Ab-POSITIVE*
[**2156-4-17**] 10:21PM BLOOD K-5.2
Brief Hospital Course:
Mr. [**Known lastname 68820**] was a 62 year-old man with a history of hepatitis C
with cryoglobulinemia status post renal transplant in [**2152**]
presenting with pleural effusion and worsening renal failure.
.
ACTIVE ISSUES:
# Acute on chronic renal transplant failure: Patient had
progressively worsening renal transplant failure, most recently
CKD stage 4. He had been followed by nephrology as an
outpatient and was in discussions to start peritoneal dialysis
in the near future. He was evaluated by the renal serivce and
his urine sediment was found to be relatively [**Name2 (NI) 29734**] without any
casts to suggest GN or muddy brown casts. His worsened renal
function was consistent with graft failure and he was started on
hemodialysis. He was continued on cyclosporine, cellcept and
bactrim. He will continue hemodialysis as an outpatient and
follow up with his transplant nephrologist.
.
# Pleural effusion: He reported having thoracentesis at OSH on
Thursday and had reaccumulation of pleural effusion on here
that drained by the interventional pulmonology service with
analysis consistent a transudative effusion. Following his
thoracentesis, he was saturating well on room air. It was
suspected that his pleural effusion resulted from poor nutrition
with a low albumin and worsening of renal failure. Rapid
reaccumulation of his pleural effusion was not appreciated. His
pleural effusion will be followed by his primary care physcian
in one week.
.
# Pleuritic chest pain: His pleuritic chest pain was likely due
to his pleural effusion or MSK pain. MI was unlikely and he had
two sets of cardiac enzymes in the ER that were reassuring. PE
is also a possibility but low likelihood given his lack of
tachycardia and stable oxygen saturations. Left LENI was
negative for DVT. His pleuritic chest pain improved
significantly following draining of pleural effusion. On the day
of discharge, his pain was well controlled on with tylenol and
lidocain patches.
.
# Back pain: He had diffuse back pain and left flank that was
difficult to localize. It was suspected that his back pain
resulted from his pleural effusion. Muscle strain in setting of
chiropracter manipulation was also a consideration. Cord
compression and neoplastic disease was considered unlikely in
the setting of reassuring C/T/L spine MRI. His pain was
controlled with low dose oxycodone, tylenol and lidocaine
patches. He was discharged on tylenol and lidocaine patches.
.
# Hep C: He was previously being treated with interferon but had
been discontinued for unclear reasons. He will follow up with
liver clinic as an outpatient.
Medications on Admission:
1. Doxazosin 4mg po daily
2. Furosemide 40mg po daily
3. Lisinopril 20mg po daily
4. Metoprolol tartrate 50mg po bid
5. CellCept 250mg po bid
6. Omeprazole 20 mg po bid
7. Interferon -unknown dose
8. Simvastatin 40 mg po daily
9. Procrit sc weekly
10. Bactrim one daily
11. Cyclosporine 75 mg in am and 50 mg in pm twice
12. Aspirin 81mg po daily
13. Oxycodone prn
Discharge Medications:
1. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
2. multivitamin Capsule Sig: One (1) Capsule PO once a day.
3. B Complex Capsule Sig: One (1) Capsule PO once a day.
4. doxazosin 4 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO HS (at bedtime).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
9. cyclosporine modified 25 mg Capsule Sig: One (1) Capsule PO
twice a day.
Disp:*60 Capsule(s)* Refills:*2*
10. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day: Please
take on days that you do not go to dialysis.
Disp:*30 Tablet(s)* Refills:*2*
11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back pain.
Disp:*qs Adhesive Patch, Medicated(s)* Refills:*0*
13. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 12 days: On dialysis days please take
morning dose after dialysis.
Disp:*48 Capsule(s)* Refills:*0*
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. Renvela 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
17. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 635**] vna
Discharge Diagnosis:
Transudative Pleural Effusion
Renal Transplant Graft Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 68820**],
You were admitted to the hospital for fluid accumulating around
your lungs. You were evaluated and treated by the medicine
service. The fluid around your lungs was drained and studied.
There was no evidence of infection or cancer found in this
fluid. You were also found to have worsening of your renal
failure. You were started on hemodialysis. You will continue
hemodialysis as an outpatient. Please take your medications as
prescribed and keep your outpatient appointments. If you
continue to not urinate on your own, please straight catheterize
yourself twice daily to ensure your bladder remains empty.
The following changes have been made to your home medications.
1. You have been STARTED on Lidoderm patch for your back pain.
2. You have been STARTED on Ampicillin 500mg twice daily for
eleven more days, Please take morning dose after dialysis
3. You have been STARTED on Nephrocaps daily
4. You have been STARTED on Lisinopril 20mg daily
5. You have been STARTED on Zofran every 8 hours for nausea for
7 days
6. Your Cyclosporin dose has been CHANGED to 25mg twice daily
7. Your Furosemide has been CHANGED to 80mg daily on
non-dialysis days
8. Your Metoprolol has been STOPPED please discuss this change
with your kidney doctor
9. Your Norvasc has been STOPPED please discuss this chage with
your kidney doctor.
.
No other changes have been made to your home medication.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - It is recommeneded that a repeat chest
X-ray to follow the fulid in your lungs and urine analysis and
urine culture for your urinary tract infection be collected
after you finish your ampicillin.
Location: [**Location (un) **] FAMILY MEDICINE
Address: [**Street Address(2) 68821**], [**Location (un) **],[**Numeric Identifier 18235**]
Phone: [**Telephone/Fax (1) 62646**]
Appointment: Wednesday [**5-5**] at 10AM
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2156-5-5**] at 2:00 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2156-5-18**] at 1:40 PM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: LIVER CENTER
When: WEDNESDAY [**2156-6-16**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
ICD9 Codes: 5856, 5849, 5990, 2767, 412, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7377
} | Medical Text: Admission Date: [**2183-3-20**] Discharge Date: [**2183-3-23**]
Date of Birth: [**2135-12-12**] Sex: M
Service: MEDICAL INTENSIVE CARE UNIT
CHIEF COMPLAINT: Hematemesis and melena.
HISTORY OF THE PRESENT ILLNESS: The patient is a 47-year-old
Russian male with no significant past medical history who
presents with three to four episodes of hematemesis and three
days of melena following a one week history of epigastric
"heaviness". One week prior to admission, the patient
reports new onset epigastric heaviness which was described as
intermittent and worse following eating. The patient also
noted several days of black tarry stools, three to four
stools per day.
The day of admission, the patient reports progressive onset
of fatigue and anorexia with nausea. While laying down, the
patient became acutely nauseous with vomiting "maroon-colored
material". On rising, the patient turned pale and fainted
(falling into the cough without head trauma). The patient
reportedly vomited coffee ground material three to four times
before presenting to the Emergency Department. The patient
denied bright red blood per rectum, history of NSAID
(nonsteroidal anti-inflammatory drugs), heavy alcohol use,
anticoagulant medications, and prior similar episodes.
In the Emergency Department, the patient was found afebrile
with a blood pressure of 118/84, heart rate 112, and oxygen
saturation 96% on room air. Two large boar peripheral
intravenous catheters were placed and the patient was started
on normal saline intravenous fluid wide open. The patient
was NG lavaged with greater than 2 liters without clearing
(bloody pink fluid was withdrawn), and the Gastroenterology
Service was consulted for emergent endoscopy. The patient's
initial hematocrit was 35.8 and the patient was typed and
screened without initial transfusion.
PAST MEDICAL HISTORY:
1. Status post appendectomy.
2. Status post right shoulder dislocation.
ADMISSION MEDICATIONS: None (the patient denied over the
counter medications).
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is married and lives with his
wife and daughter. The patient reports a 1 [**12-12**] pack per day
tobacco history of 25 years with occasional social alcohol
use. The patient denied intravenous drug use.
FAMILY HISTORY: Without significant history of GI disease
including colon cancer, gastric cancer, no premature coronary
artery disease (father with an MI at the age of 71),
hypertension, or cerebrovascular accidents.
REVIEW OF SYSTEMS: The patient denied chest pain, shortness
of breath, dyspnea on exertion, abdominal pain, easy bruising
or bleeding, fevers, chills, diarrhea, as well as rash.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.1, heart rate 97, blood pressure 142/82, respiratory rate
15, oxygen saturation 100% on 2 liters nasal cannula, weight
76.5 kilograms. General: The patient is a well-developed,
well-nourished male resting comfortably, in no acute
distress. HEENT: Normocephalic, atraumatic. Anicteric
sclerae. Moist mucous membranes. Small dried blood in the
oropharynx. Neck: No jugular venous distention or
lymphadenopathy. Cardiovascular: Regular rate and rhythm
with normal S1, S2, no murmurs, rubs, or gallops. Pulmonary:
Clear to auscultation bilaterally. No wheezes, rales, or
rhonchi. Abdomen: Soft, normoactive bowel sounds,
nontender, nondistended, no hepatosplenomegaly, guarding, or
rebound. Extremities: Warm and well perfuse with no
clubbing, cyanosis or edema.
LABORATORY DATA ON ADMISSION: CBC with a white blood cell
count of 14.9, hematocrit 35.8 (baseline unknown), platelets
162,000 with a normal white blood cell differential. Chem-7
with a sodium of 140, potassium 3.8, chloride 104,
bicarbonate 25, BUN 37, creatinine 1.0, glucose 141. LFTs
with an ALT of 10, AST 12, alkaline phosphatase 47, total
bilirubin 0.4, amylase 61, lipase 33. Coagulations: PT
13.1, INR 1.1, PTT 22.5.
Initial EKG revealed sinus tachycardia at 129 with normal
axis, normal intervals, and isolated Q wave in lead II. No
ST or T wave changes.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit and underwent an emergent upper endoscopy
where he was found to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear in the distal
esophagus as well as a single-cratered 10 mm ulcer in the
proximal duodenum with evidence of recent bleeding. The
ulcer was injected with epinephrine without incident. The
patient received a total of 2.5 liters normal saline
overnight on hospital day number one with a decrease in his
hematocrit from 35.7 to 25.7.
The patient was without further episodes of hematemesis,
however, had several episodes of melenic stool over the
initial night of hospitalization. The patient was transfused
1 unit of packed red blood cells with an appropriate bump in
his hematocrit. The patient had no further episodes of
melena or hematemesis and the patient's hematocrit remained
stable for the remainder of the hospitalization. The patient
was diagnosed with Helicobacter pylori by serum antibody and
was started on PrevPak (amoxicillin, Clarithromycin, and
lansoprazole) for a 14 day course.
The patient was started on a clear liquid diet on hospital
day number two and his diet was advanced without difficulty.
The remainder of the [**Hospital 228**] hospital course was
complicated by several episodes of orthostasis by heart rate
(asymptomatic without change in blood pressure). The patient
received an additional several liters of normal saline with
resolution of orthostasis.
CONDITION ON DISCHARGE: Good, tolerating oral diet without
further hematemesis, stable hematocrit without orthostasis.
DISCHARGE DIAGNOSIS:
1. Duodenal ulcer, Helicobacter pylori positive.
2. Upper gastrointestinal bleed.
MEDICATIONS ON DISCHARGE:
1. Lansoprazole 30 mg p.o. b.i.d. (complete a 14 day
course).
2. Clarithromycin 500 mg p.o. b.i.d (to complete a 14 day
course).
3. Amoxicillin 500 mg p.o. b.i.d. (to complete a 14 day
course).
DISCHARGE INSTRUCTIONS: The patient was discharged to home
with instructions to complete a two week course of
amoxicillin, Clarithromycin, and lansoprazole for the
treatment of H. pylori with duodenal ulcer. The patient was
instructed to follow-up with his primary care physician in
one week postdischarge. The patient was also recommended to
discontinue the use of caffeine, alcohol, as well as tobacco
products. In case of recurrent melena and/or hematemesis,
the patient was instructed to return to the Emergency
Department for further evaluation.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2183-3-23**] 02:36
T: [**2183-3-23**] 18:03
JOB#: [**Job Number 29717**]
ICD9 Codes: 2765, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7378
} | Medical Text: Admission Date: [**2156-12-20**] Discharge Date: [**2156-12-23**]
Date of Birth: [**2108-3-22**] Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Hypoxemia.
Major Surgical or Invasive Procedure:
Thoracentesis.
History of Present Illness:
Mr. [**Known lastname 88321**] is a 48 year old gentleman with a PMH significant
for HCV cirrhosis and a recent admission for a traumatic fall
with multiple IPH requiring bolt placement, multiple orthopedic
fractures s/p surgeries, trach/PEG with hospital course
complicated by Serratia pneumonia treated with pip/tazo now
admitted for hypoxemia. The patient was admitted to [**Hospital1 18**] from
[**Date range (1) 88322**] after a 30 foot fall from height with multiple IPH
s/p intracranial bolt placement for elevated ICP, multiple
orthopedic fractures requiring surgical intervention,
splenectomy, and trach/PEG. He was noted to develop a VAP that
speciated as pan-sensitive Serratia and he completed a course of
pip/tazo, and also had a right-sided pneumothorax requiring
chest tube placement. Per report, the patient was noted at rehab
to have been progressively hypoxemic over the past 2 days with a
outpatient CXR concerning for right-sided pneumonia. He did not
have increased sputum production or fevers. He was then sent to
the [**Hospital1 18**] ED for further evaluation.
In the [**Hospital1 18**] ED, initial VS 98.1 62 92/54 18 95% 40% FM. CXR
notable for right-sided complete opacification, for which the
patient received vanco and pip/tazo. He was placed on volume
cycled assist control, and was sent for a CT chest to rule out
diaphragmatic rupture. While at CT, he received 5 haldol iv and
2 iv ativan for agitation, after which he was arousable to
stimulation. He was then transferred to the [**Hospital Unit Name 153**] for further
management.
Currently, the patient is on mechanical ventilation, minimally
responsive to verbal stimuli.
ROS: Limited given somnolence.
Past Medical History:
Admitted [**Date range (1) 88323**] for 30 foot fall from roof. Multiple
IPH(multiple intraparenchymal petechial, hemorrhages at
[**Doctor Last Name 352**]-white matter junction, as well as involving the right mid
brain, consistent with diffuse axonal injury), facial fractures,
bilateral arm fractures as well as right knee fracture.
Underwent splenectomy, multiple orthopedic surgeries.
- Surgeries [**11-18**] -> ex-lap with splenectomy
- Bolt placed on [**11-19**]
- Trach/PEG on [**11-24**]
- Facial ORIF on [**12-1**]
- IVC filter placed [**12-7**]
- HCAP treated with vanco and pip/tazo, speciated as
pan-sensitive Serratia.
- No evidence of seizure activity during admission, EEG
demonstrating encephalopathy. Arousable to voice and stimulation
with opening of eyes and localization to voice. Intermitently
follows commands.
- Discharged on 35% trach collar.
- Received all appropriate vaccinations
Social History:
Worked as a roofer. Drinks 6-12 pack of beer daily, quit smoking
recently.
Family History:
Non-contributory.
Physical Exam:
VS: 97.5 62 97/66 14 95% AC 550x14, 5, 50%.
Gen: Vented.
HEENT: Pupils 2->1 mm bilaterally. Sclerae anicteric. MM dry.
CV: Nl S1+S2
Pulm: Bronchial breath sounds on right, rhonchorous on left
anteriorly.
Abd: Midline incision healing, no signs of surrounding erythema.
G-tube in place. +bs.
Ext: Right arm, right knee/RLE, LLE in braces. No c/c/e.
Neuro: Opens eyes to verbal stimuli, not following commands.
Pertinent Results:
Labs at Admission:
[**2156-12-20**] 03:30PM BLOOD WBC-15.8* RBC-3.46* Hgb-11.4* Hct-35.7*
MCV-103* MCH-33.0* MCHC-32.0 RDW-15.8* Plt Ct-278
[**2156-12-20**] 03:30PM BLOOD Neuts-56.4 Lymphs-28.2 Monos-5.9 Eos-8.6*
Baso-0.9
[**2156-12-20**] 03:30PM BLOOD PT-13.4 PTT-35.9* INR(PT)-1.1
[**2156-12-20**] 03:30PM BLOOD Glucose-93 UreaN-17 Creat-0.6 Na-132*
K-7.8* Cl-100 HCO3-26 AnGap-14
[**2156-12-20**] 03:30PM BLOOD ALT-51* AST-139* LD(LDH)-646*
AlkPhos-174* TotBili-0.4
[**2156-12-20**] 10:16PM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0
[**2156-12-20**] 03:30PM BLOOD Albumin-2.7*
[**2156-12-20**] 10:16PM BLOOD VitB12-1546* Folate-GREATER TH
[**2156-12-20**] 03:40PM BLOOD Glucose-92 Lactate-1.3 Na-134* K-7.7*
Cl-96* calHCO3-30
[**2156-12-20**] 09:57PM BLOOD Lactate-1.2
Labs at Discharge:
[**2156-12-23**] 06:04AM BLOOD WBC-14.3* RBC-3.66* Hgb-11.7* Hct-37.6*
MCV-103* MCH-32.1* MCHC-31.3 RDW-15.0 Plt Ct-316
[**2156-12-23**] 06:04AM BLOOD Neuts-51.9 Lymphs-29.0 Monos-8.5 Eos-9.8*
Baso-0.8
[**2156-12-23**] 06:04AM BLOOD Glucose-122* UreaN-11 Creat-0.7 Na-141
K-4.1 Cl-104 HCO3-29 AnGap-12
[**2156-12-22**] 04:40AM BLOOD ALT-53* AST-100* LD(LDH)-242 AlkPhos-198*
TotBili-0.5
[**2156-12-23**] 06:04AM BLOOD Calcium-8.9 Phos-2.7# Mg-2.0
Pleural Fluid Analysis:
[**2156-12-21**] 5:37 pm PLEURAL FLUID
GRAM STAIN (Final [**2156-12-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2156-12-22**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso Macro
[**2156-12-21**] 17:37 850* [**Numeric Identifier 3652**]* 21* 17* 3* 56* 2* 1*
PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Cholest Triglyc
[**2156-12-21**] 17:37 4.6 82 272 61 39
OTHER BODY FLUID pH
[**2156-12-21**] 18:04 7.39
Pleural Fluid:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, histiocytes, lymphocytes, and
neutrophils.
Imaging Studies:
Chest CT without contrast ([**2156-12-20**]):
1. No evidence of diaphragmatic hernia.
2. Large right and moderate left simple pleural effusions.
Consolidation and volume loss in the lower lobes bilaterally,
right greater than left, may represent atelectasis however,
aspiration or superimposed infection cannot entirely be
excluded.
3. Healing rib and clavicle fractures, as described above.
4. No pneumothorax.
Chest x-ray ([**2156-12-21**]): In comparison with the earlier study of
this date, there has been removal of a substantial amount of
right pleural effusion with a small residual. No evidence of
pneumothorax. Tracheostomy tube remains in place and there is
again evidence of volume loss at the left base.
Transthoracic echocardiogram ([**2156-12-21**]: The left atrium and
right atrium are normal in cavity size. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
appears bicuspid with mildly thickened leaflets, eccentric
closure point and fused right and left raphe. A gradient could
not be assessed, but there does not appear to be significant
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Probable bicuspid aortic valve with fused right/left
raphe and no significant stenosis or regurgitation. Dilated
ascending aorta. Mild symmetric left ventricular hypertrophy
with preserved global biventricular systolic function. If there
is a clinical suspicion for an aortic dissection - a thoracic
CT/MRI or TEE are suggested.
Brief Hospital Course:
Mr. [**Known lastname 88321**] is a 48 year old gentleman with a PMH significant
for HCV cirrhosis and a recent admission for a traumatic fall
with multiple IPH requiring bolt placement, multiple orthopedic
fractures s/p surgeries, trach/PEG with hospital course
complicated by Serratia pneumonia treated with pip/tazo now
admitted for hypoxemia.
# Hypoxemia/leukocytosis: CTAP demonstrates a new right-sided
pleural effusion with RLL collapse and volume loss throughout
right side. Compressive atelectasis was considered, although
could not rule out HCAP. With regard to new pleural effusion,
LFTs were largely unchanged from prior, making hepatic
hydrothorax unlikely. This may be a parapneumonic effusion with
underlying pneumonia, or could also be from new heart failure.
Would also consider chylothorax given history of trauma. The
patient underwent thoracentesis on the first hospital day and
1.2 liters of exudative fluid were removed from the right
pleural space. Cultures from the fluid came back negative, and
the antibiotics were stopped. Trauma surgery was consulted who
felt that the pleural fluid might be secondary to trauma. They
recommended for repeat imaging in [**2-4**] days to see if the fluid
was reaccumulating. Also, they recommended for repeat imaging if
the patient develops any new respiratory symptoms.
Interestingly, the fluid from the thoracentesis had an
eosinophilic predominance (56% eosinophils). At the same time,
the patient was noted to have a peripheral blood eosinophilia.
This was all felt to be secondary to Depakote, which had been
recently started. The divalproex was therefore stopped.
Notably, after the thoracentesis, the patient's respiratory
status improved markedly and he was able to be weaned back to
the trach mask. With regard to work-up for other causes of
pleural effusion, a transthoracic echocardiogram did not show
any cardiac dysfunction, and infectious studies, as above, all
returned negative. Cytologic analysis showed no malignant cells.
Antibiotics were stopped after the first hospital day.
Due to the calficifications noted on CT scan, a tuberculin skin
test was placed to the right forearm on [**12-22**]. This should be
interpreted on [**12-24**] or [**12-25**]. The spot of the PPD placement is
marked with a bandaid.
# Mental status: His mental status remained at baseline, per
family members and rehab facility notes. He was agitated and
minimally interactive. He required prn doses of Haldol and
Ativan for agitation. With regard to the history of traumatic
brain injury, neurosurgery was consulted during this admission
and did not feel there was any need for intervention. Head CT
was deferred. He was continued on Keppra for seizure
prophylaxis. Divalproex, as above, was stopped due to peripheral
blood and pleural fluid eosinophilia.
# Anemia: Hematocrit was 35.8 on admission, baseline during last
admission 27-33 with macrocytosis. His hematocrit remained
stable.
# Orthopedics: Orthopedics was contact[**Name (NI) **] during this admission.
Follow-up plans are outlined in the discharge orders.
# HCV cirrhosis: LFTs were at baseline.
# Depression: Continue home psychotropic regimen.
# Ulcerative colitis: Not currently treated.
# Nutrition: pnt recieved TF's FEN: TF.
.
# PPx: recieved Heparin SQ.
.
# Access: Double lumen PICC in LAC; this was removed during the
admission as patient was no longer needing antibiotics or
continuous intravenous medicines.
.
# Code: Confirmed FULL [**Telephone/Fax (1) 88324**].
.
# Contact: [**Name (NI) **] [**Name (NI) 88325**] (Sister).
# Dispo: ICU level of care, transferred back to rehab after the
thoracentesis and improvement in respiratory status.
Medications on Admission:
Albuterol nebs
Dulcolax
Chlorhexidine QID
citalopram 20 mg qam
Clonidine 0.1 mg Q12H.
Clotrimazole topical tid
divalproex sprinkles 250 Q8H
Erythromycin eye ointment QID
Famotidine 20 mg [**Hospital1 **]
Ferrous sulfate 300 mg QAM
Folate
Heparin SQ
Levetiracetam 1000 mg Q12H
Methadone 5 mg Q8H
MVI
Quetiapine 25 mg QAM, 50 mg QPM
Thiamine
Trazodone 50 mg qhs
APAP prn
Ativan 0.5 mg prn
quetiapine 25 mg Q6H prn
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation. Tablet, Delayed Release (E.C.)(s)
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levetiracetam 100 mg/mL Solution Sig: Ten (10) PO BID (2
times a day): 1000 mg PO BID.
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
10. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
12. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Agitation.
13. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety or agitaiton.
16. methadone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours: Hold for sedation/ RR<10.
17. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
Drug induced pulmonary infusion
Secondary:
Traumatic brain injury secondary to mechanical fall
Mutliple skeletal fractures secondary to mechanical fall
Hepatitis C Virus Cirrhosis
Depression
Alcoholic Cirrhosis with history of withdrawal
Ulcerative colitis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital due to worsening shortness of
breath. You came to the hospital and had a chest xray which
showed an accumulation of fluid around the right lung. The
fluid around your lung was drained, and your shortness of breath
improved. We felt the fluid accumulation was due to the new
medication you started called "Depakaote". As a result, we
discontinued this medication.
You should follow up with your psychiatrist to make sure your
medications are appropriately controlling your agitation.
CHANGES TO YOUR MEDICATIONS:
DEPAKOTE---> STOP TAKING THIS MEDICATION
Followup Instructions:
Please follow up at the [**Hospital1 18**] orthopedic hand clinic within 2
weeks by Tuesday [**2157-1-4**]. Please call to confimr
appointment.
Hand Clinic - Dr. [**First Name8 (NamePattern2) 951**] [**Last Name (NamePattern1) **]
Department: Orthopedics
Location: [**Hospital Ward Name 23**] 2
[**Hospital1 18**] Phone: ([**Telephone/Fax (1) 32269**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2156-12-23**]
ICD9 Codes: 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7379
} | Medical Text: Admission Date: [**2178-5-4**] Discharge Date: [**2178-5-8**]
Date of Birth: [**2106-11-24**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Tetracycline
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
CC:[**Hospital3 66910**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 71-year-old male who was transfered from NWH for septic
shock with neutropenia, gram negative rod bacteremia, acute DIC,
and multiple organ system dysfunction. He was recently
diagnosed with Stage II Anal Squamous Cell Carcinoma and had
undergone chemotherapy with 5-FU and Cisplatin at NECM in later
[**2178-3-28**]. He was discharged home, but failed at home due
to falls and dehydration so he was sent to a rehab facility. On
[**2178-5-3**] he was sent to NWH for acute onset shortness of breath,
and in the emergency department there he was hypoxic in the 70's
on a non-rebreather and he was hypotensive from septic shock.
He was intubated, IV access was obtained, and he was fluid
rescusitated and started on dopamine. He was admitted to the
ICU where his vasopressors were changed to Levophed and
Vasopressin. His initial lactate was 9, and his pH was 7.04.
.
In addition to fluids, he was treated with Vancomycin,
Metronidazole, Moxifloxacin, and Ceftazidime. Bicarbonate was
administered. He quickly developed anuric renal failure (35 cc
urine output over 24 hours) with evidence for "muddy brown
casts" in his urine. He was also noted to be in DIC with a
platelet count of 19,000, INR of 2.2, and a PTT of 38.2. He was
neutropenic with a WBC of 0.2. He also was noted to have
bilateral leg swelling and LENIs revealed bilateral DVTs with
the left leg occluded from calf to upper thigh, and the right
with clot below the knee. In addition, he was noted to have
700cc's of coffee grounds suctioned from his OG Tube with guaiac
positive stool (he also has radiation injury to the rectum with
some small bleeding). GI was consulted, but he was too unstable
for endoscopy. He was transfused 2 units of PRBCs and one
6-pack of platelets. Due to his anuric renal failure, he was
transfered to [**Hospital1 18**] with the possibility that he may require
dialysis (CVVH).
Past Medical History:
PMHX:
1. GERD
2. Hypertension
3. H/o previous MVA with head trauma and residual right-sided
weakness
4. Right Hemiparesis
5. BPH, s/p TURP
6. Stage II anal squamous cell cancer - s/p 5-FU and Cisplatin
in [**3-/2178**]
Social History:
SOCHX: He is reportedly independent at home and with his ADLs.
He reportedly has not had any contact with family in almost 20
years. His brother, [**Name (NI) **] [**Name (NI) 19219**], is listed as next of [**Doctor First Name **] and
has had no contact with him for the past 18 years.
PCP = [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at [**Hospital1 336**]
Oncologist = Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66911**] at [**Hospital1 336**]
Radiation Oncologist = Dr. [**Last Name (STitle) 66912**] at [**Hospital1 336**] [**Telephone/Fax (1) 66913**]
Family History:
FAMHX: Unknown
Physical Exam:
EXAM: T 96.0, HR 111, BP 98/55, RR 22, O2 sat 96%
VENT: AC/450/5 rate 16, Fio2 = 60%
GEN: Intubated. Unresponsive to pain or voice. Mottled skin.
HEENT: Supple neck. Pupils 3-4 mm and minimally responsive to
light. Dry MM membranes.
CV: Regular tachycardia, no murmurs.
LUNGS: Diffuse rhonchi bilaterally on anterior exam.
ABD: Soft, non-distended.
EXT: Mottled, cool, grey
NEURO: Nonresponsive even to pain. Loss of occulocephalic
reflexes. Pupils minimally reactive.
Pertinent Results:
LABS:
WBC 0.2, HCT 30.8, PLT 19
Na 140, K 3.7, Cl 110, HCO3 11, BUN 83, Creat 2.8
Calcium = 5.90, ALB 1.9
CK 48 -> 643 -> 1159 -> 1293
AST 1446, ALT 828, TB 2.7, DB 2.3, [**Doctor First Name 674**] 157, LIP 11
INR 2.2, PTT 38.2, PT 24.9
.
[**Last Name (un) **] Stim = Baseline 51.2, 30 min 51.78, 60 min 52.63
.
UA: Urine Na <10. Trace LE. Muddy brown casts in urine.
.
CXR: Bilateral patchy airspace opacities, pulmonary edema, ETT
in proper position, left IJ TLC in SVC.
.
ECHO: EF 25%, global HK. Inferior and basal walls are akinetic.
Decreased RV function. No shunts or effusion.
.
MICRO DATA:
[**1-31**] Blood cultures with GNR
Brief Hospital Course:
A/P: 71-year-old male s/p chemotherapy for local anal squamous
cell carcinoma who is now neutropenic in severe septic shock
with multiple organ system dysfunction.
.
1. Septic Shock with neutropenia, gram negative rod bacteremia,
possible acute DIC, and multiple organ system dysfunction - The
presumed source is pulmonary with GNR bacteremia. However,
given his neutropenia he could have multiple sources and could
be fungemic as well. Pt was on vanco, cefepime, flagyl,
caspofungin. He had no signs of reversing his shock, though his
pressor requirement had decreased somewhat.
.
2. Coagulopathy - He has a complicated picture that includes
ischemic hepatitis possibly resulting in synthetic liver
dysfunction. He also has thrombocytopenia that may be due to
sepsis vs. DIC vs. pancytopenia from chemotherapy. Given the
lack of schistocytes acute DIC seems less likely, and hepatic
failure more likely.
The pt remained transfusion dependent to prevent massive
bleeding.
.
3. Anuric Renal Failure - not a HD candidate and no sign of
return of kidney function
.
4. Upper GI Bleed - transfusion dependent with melena and
unstable HCT.
.
5. Respiratory Failure - Possible aspiration plus pulmonary
edema. Vent dependent with very few periods during which he was
overbreathing the vent
.
7. Mental status - He is non-responsive and has lost
occulo-cephalic reflexes. It is possible that he has had an
intracranial/brain stem hemorrhage. CT showed diffuse hypodense
lesions throughout the brain.
.
10. Code Status - CPR not indicated due to the futility of CPR
given his severe critical illness and multi-organ system
dysfunction (including evidence for neurological dysfunction).
Per the legal department, his brother and only family was HCP by
default. He agreed that the pt should be DNR and decided,
ultimately, to withdraw care based on what he knew of the
patient's wishes.
.
.
.
After a complicated hospital course, when the patient's
prognosis appeared very grim, conversations with the patient's
brother regarding end of life care and decision making were
initiated. The patient's brother had conversations with his
brother at the time of their mother's death during which the
patient stated that he would not want to be chronically
maintained on a ventilator. Because the patient was not
expected to ever become liberated from the ventilator, the
patient's brother directed the treating team to withdraw care
and focus on comfort measures.
The patient was seen by the chaplain and had the sacriment of
the sick performed. Thereafter, ventilator and pressors were
discontinued. After a brief period, the patient passed away
quietly.
Medications on Admission:
MEDS on Transfer:
Vancomycin dosed by level
Flagyl 500 mg IV Q8
Moxifloxacin
Ceftazidime
Sodium Bicarbonate
Regular Insulin Sliding Scale
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
death
Discharge Condition:
death
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2178-5-9**]
ICD9 Codes: 0389, 5849, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7380
} | Medical Text: Admission Date: [**2148-5-29**] Discharge Date: [**2148-6-5**]
Date of Birth: [**2079-2-1**] Sex: F
Service: DENTAL
Allergies:
Penicillins
Attending:[**First Name3 (LF) 51674**]
Chief Complaint:
left dental infection
Major Surgical or Invasive Procedure:
1) Tooth extraction, 2)incision and drainage of neck abscess
History of Present Illness:
69yo F with remote hx of breast ca s/p bilateral radical
mastectomy without radiation and h/o sternum osteomyelitis in
'[**23**] s/p resection, who had a tooth extraction and post placement
anticipating for a new implant about 4 weeks ago. She was placed
on an antibiotic which she doesn't recall its name on the day of
dental procedure and was on it for a total of 7 days. After
finishing her abx, she started feeling unwell and total body
achiness. Denies other focal symptoms. Then about 9 days after
the dental procedure, she developed a sore throat and neck
swelling which progressively worsened. She called her PCP who
advised just watchful waiting. Pt tried NSAIDS and mouthwash
with a temporary slight relief.
.
Her symptoms worsened to the point that she couldn't swallow.
She called her PCP [**Name9 (PRE) 96315**] who prescribed Z-pack 10 days prior
to her admission. Despite z-pack, her symptoms worsened but no
fevers.
Past Medical History:
Osteomyelitis of sternum '[**23**] s/p resection- was on pcn for 6
weeks until she developed rash so PCN reported as allergy.
Breast cancer s/p bilateral radical mastectomy in '[**12**] without
radiation and breast implants '[**23**]
Mutliple dental work years ago
HTN
Hypothyroidism
Sciatica, chronic low back pain
s/p tonsillectomy and hemorrhoidectomy
Recurrent cellulitis of L arm in the setting of even slight
trauma as minor cut since lymph node resection during breast
mastectomy.
Social History:
EtOH: {}N {x}Y Amount: occasional social
Tobacco: {x}N {}Y Amount: prior smoker 12year pack year hx. quit
in [**2112**]
Drugs: {x}N {}Y Amount:
Married: {}N {x}Y Divorced {} SO {}
Occupations: Interior design
Exposures: NA
Travel:NA
Pets: NA
Family History:
n/c
Physical Exam:
Vitals: Afebrile, AVSS
Well appearing elderly white female
NAD, A x O x 3
TTP L oral floor with firmness; no TTP L dental implant prep
site; no erythema; soft on Right side.
OP clear; no erythema or exudate
Voice mildly hoarse; no stridor; trachea midline
Significant swelling to submandibular glands B, L>R
No appreciable LAD to ant., post., or supraclavicular chains
SCOPE: Fullness to Left base of tongues, left epiglottis and
extending to false cord left. Bilateral true cords are crisp
and
mobile with widely patent airway.
RRR, no m/r/g
CTA B, no r/r/c, no stridor, no sterdor
ABD soft, NT/ND, NABS
EXT no c/c/e
Pertinent Results:
[**2148-5-29**] 06:35PM PLT COUNT-286
[**2148-5-29**] 06:35PM WBC-11.6*# RBC-3.89* HGB-12.5 HCT-36.2 MCV-93
MCH-32.2* MCHC-34.6 RDW-14.0
[**2148-5-29**] 06:35PM GLUCOSE-95 UREA N-13 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
[**2148-5-29**] 08:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
Patient was admitted on [**2148-5-29**] from the [**Hospital1 18**] ED for left dental
infection with a resulting neck abscess. She was started on IV
clindamycin, but her symptoms did not improve. On [**6-1**] she was
taken to the OR by OMFS for drainage of her abscess and
extraction of tooth #20. She tolerated this well. She was then
taken to the ICU where she remained for airway monitoring. She
was extubated on POD 1 without difficulty. On POD#2 she was
able to be transfered to a regular floor room. ID was consulted
and recommended to keep her on IV clindamycin for at least 14
more days. She was discharged on [**2148-6-5**] after OMFS removed her
drains and she had remained afebrile for several days with
decreasing neck swelling to nearly normal. She was discharged
with clear instructions to follow up with Dr. [**First Name (STitle) **] as well as
her oral surgeon.
Medications on Admission:
Levothyroxine 100 daily, Lisinopril 10 daily, Fosamax weekly
Discharge Medications:
1. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO
every six (6) hours for 10 days.
Disp:*120 Capsule(s)* Refills:*1*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*10 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Neck Abscess
2) Dental Infection
Discharge Condition:
Afebrile with stable vital signs. Tolerating soft diet.
Moderate left neck swelling much improved. No respiratory
distress. No drainage from intraoral or neck wounds.
Discharge Instructions:
1) Rinse with water after each meal
2) Keep neck wound dry for 4 more days
3) Stay on
Followup Instructions:
1) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - oral surgery [**2148-6-10**] (Already arranged)
2) Dr. [**First Name4 (NamePattern1) 10827**] [**Last Name (NamePattern1) **] - otolaryngology [**2148-6-11**] (call [**Telephone/Fax (1) 2349**]
to confirm appointment)
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 925**] DMD [**MD Number(1) 51675**]
Completed by:[**2148-6-5**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7381
} | Medical Text: Admission Date: [**2179-11-28**] Discharge Date: [**2179-12-3**]
Date of Birth: [**2104-5-7**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 75-year-old woman
who was in her usual state of health until 10 p.m. on the day
of admission when she was having a bowel movement in the
rest room and complained of severe headache and spinning
sensation and then vomited.
She was brought to an outside hospital and found to have
pneumonia. She had an INR of 2.5 and a cerebellar hemorrhage
that was seen on head CT. She was given vitamin K and
decadron IV, and transferred to [**Hospital1 188**] for further management.
PAST MEDICAL HISTORY:
1. Breast cancer status post XRT.
2. Pulmonary embolus.
3. Hypertension.
4. Hypothyroidism.
5. Left eye TIA.
6. Incontinent.
ALLERGIES:
1. Penicillin.
2. Sulfa.
PHYSICAL EXAMINATION: Temperature 98.9, blood pressure
153/85, heart rate 75, respiratory rate 18, and sats 98%.
Pupils are equal, round, and reactive to light. EOMs were
full. Lungs were clear. Cardiac: Regular, rate, and
rhythm, S1, S2. GI: Abdomen is soft, nondistended, awake,
alert, and oriented times three. Tends to keep eyes closed.
She has no drift. Speech is somewhat slurred. Cranial
nerves II through XII are intact. Her strength is [**5-3**] in all
muscle groups. Her reflexes are 2+ throughout. Her
sensation is intact. She had no dysmetria and visual fields
were intact.
HOSPITAL COURSE: Patient was admitted to the ICU for close
observation. She had a MRI scan to look for underlying
lesion. No underlying lesion could be detected on MRI scan
due to the amount of hemorrhage present. The patient
remained neurologically stable and was transferred to the
floor to have a heavy vena cava filter placed for protection
against further DVTs and PEs.
She was transferred to the floor on [**2179-12-1**]. She remained
neurologically stable. She was seen by Physical Therapy and
Occupational Therapy and found to be safe for discharge to
home on [**2179-12-3**].
MEDICATIONS ON DISCHARGE:
1. Lisinopril 10 mg p.o. q.d.
2. Metoprolol 50 mg p.o. b.i.d.
3. Hydrochlorothiazide 50 mg p.o. q.d.
4. Levothyroxine 50 mcg p.o. q.d.
5. Lantoprost 0.005 ophthalmic solution one drop O.U. q.h.s.
6. Famotidine 20 mg p.o. b.i.d.
7. Colace 100 mg p.o. b.i.d.
CONDITION ON DISCHARGE: Patient's condition was stable at
the time of discharge.
FOLLOW-UP INSTRUCTIONS: She will follow up with her primary
care doctor early next week for blood pressure check. She
will be sent home with VNA services for blood pressure checks
and home safety evaluation.She also needs to FU with Dr
[**Last Name (STitle) 739**] in [**6-6**] weeks with an MRI of Brain with/without
contrast to R/O tumor.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D.
[**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2179-12-3**] 10:52
T: [**2179-12-3**] 10:58
JOB#: [**Job Number 54132**]
ICD9 Codes: 431, 4019, 2449, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7382
} | Medical Text: Admission Date: [**2194-12-24**] Discharge Date: [**2194-12-28**]
Date of Birth: [**2140-11-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
Patient is a 54 yo M with h/o hypertension and asthma who
presents with BRBPR after colonscopy with biposy yesterday. He
had a repeat colonscopy for the purpose of polypectomy
yesterday. He had a sessile 2 x 3.5 cm polyp in the cecum that
was biopsied. He woke up this morning with some lower abdominal
cramping that was somewhat relieved by passing gas. He had a
normal, brown bowel movement this morning. Then at 4PM, he
developed further abdominal cramping and when he went on the
toilet he noted fresh blood, no clots. Then while he was
driving, he had crampy abdominal pain, felt dizzy, and was
incontinent of blood clots.
.
He presented to Sturdy ED. HCT was 38.1. He was hemodynamically
stable. He was transferred to [**Hospital1 18**] given his procedure here.
.
In the [**Hospital1 18**] ED, initial VS were: 98.8, 98, 134/88, 14, 100% RA.
During his ED visit, he became diaphoretic, nauseous and BP fell
to 67/48. His SBP came up to 120s during a fluid bolus. Bloody
stool was noted on the pad. HCT was 35.9. Coags were normal. He
has received about 2L IVFs and 2 units PRBCs. GI has been
consulted and is requesting a prep (Golytely) for tomorrow. For
access, he has 2 18 and 1 16 PIVS. VS on transfer are: 86,
120/82, 17, 97%.
.
(+) Per HPI + urinary retention
(-) Denies fever, chills, headache, shortness of breath,
wheezing, chest pain, palpitations. Denies dysuria, frequency,
or urgency.
Past Medical History:
1. Hypertension
2. Asthma
3. H/o colonic polyps
Social History:
Patient is a truck driver. He denies any tobacco, etoh, and IVDA
Family History:
Colon cancer and polpys on both sides of the family
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
Orthostatics: supine 81, 152/80; sitting 94, 129/93
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, RLQ tender to palpation, no guarding, no rebound,
non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2194-12-24**] 09:43PM BLOOD WBC-15.4* RBC-4.23* Hgb-12.3* Hct-35.9*
MCV-85 MCH-29.0 MCHC-34.1 RDW-12.6 Plt Ct-285
[**2194-12-25**] 05:47AM BLOOD WBC-16.8* RBC-4.02* Hgb-12.0* Hct-34.0*
MCV-84 MCH-29.9 MCHC-35.4* RDW-12.7 Plt Ct-215
[**2194-12-26**] 04:07AM BLOOD WBC-11.8* RBC-4.02* Hgb-12.2* Hct-34.7*
MCV-86 MCH-30.3 MCHC-35.0 RDW-12.9 Plt Ct-179
[**2194-12-24**] 09:43PM BLOOD PT-12.9 PTT-22.1 INR(PT)-1.1
[**2194-12-24**] 09:43PM BLOOD Glucose-167* UreaN-15 Creat-0.8 Na-138
K-4.6 Cl-106 HCO3-23 AnGap-14
[**2194-12-25**] 05:47AM BLOOD Glucose-130* UreaN-17 Creat-0.7 Na-140
K-3.9 Cl-105 HCO3-23 AnGap-16
[**2194-12-26**] 04:07AM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-139
K-3.6 Cl-105 HCO3-24 AnGap-14
Colonoscopy:
Ulcer in the cecum at the site of previous polypectomy - three
endosocpic clips were applied for hemostasis. Blood in the whole
colon
Brief Hospital Course:
54 yo M who presents with BRBPR after colonoscopy with
polypectomy.
GI Bleed / Acute blood loss anemia.
He was initially admitted to the MICU. He was transfused four
units of pRBCs with stabilization of his hematocrit. GI was
consulted and performed colonoscopy on admission to the ICU; a
large ulcer was found at site of polypectomy with bright red
blood throughout the colon; the ulcer was clipped and hemostasis
was attained.
He had a fever and leukocytosis and this was likely in the
setting of stress but he was placed on emipiric antibiotics x 48
hours to cover GI organisms (amp, cipro, flagyl). These were
quickly peeled off as he defervesed. He was transferred to the
general medical [**Hospital1 **] on hospital day 3 where he remained stable
and his leukocytosis resolved.
HTN, benign: His lisinopril was resumed prior to discharge.
Asthma, without exacerbation: His advair was continued.
Medications on Admission:
Lisinopril 10 mg daily
Advair
Albuterol prn
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Outpatient Lab Work
[**2194-12-31**]: Please check CBC.
Results to: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 275**], [**Location (un) **],
[**Location (un) **],[**Numeric Identifier 6698**], [**Hospital1 **] HEALTHCARE -
[**Location (un) **] phone: [**Telephone/Fax (1) 6699**] Fax: [**Telephone/Fax (1) 84090**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: cecal ulcer secondary to post-polypectomy bleed
Secondary: asthma, benign hypertension
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted because you were bleeding from your rectum.
You had another colonoscopy and you had an ulcer where the polyp
was removed. This was clipped by the endoscopist. You required
blood transfusion due to the bleeding (4 units of red cells);
following the transfusion your counts remained stable.
Do not take any advil, aleve, aspirin or other NSAIDs for 72
hours. You may take Tylenol if needed.
Followup Instructions:
Follow up with your PCP this week. You need to have repeat
blood work at this visit.
Due to the large size of the polyp, you should have a repeat
colonoscopy with Dr. [**Last Name (STitle) **] in 6 months to make sure that there
is no residual polyp at the site where this large polyp was
removed. Please call ([**Telephone/Fax (1) 2306**] to schedule your repeat
colonoscopy with anesthesia.
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7383
} | Medical Text: Admission Date: [**2157-9-23**] Discharge Date: [**2157-10-3**]
Date of Birth: [**2095-10-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin / Erythromycin Base / Latex / Nsaids
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Tracheobronchomalacia, diffuse, and
mucopurulent tracheobronchitis.
Major Surgical or Invasive Procedure:
Dr. [**Last Name (STitle) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]:
1. Right thoracotomy with posterior membranous wall
tracheoplasty with mesh.
2. Right mainstem and bronchus intermedius posterior
membranous wall plasty with mesh.
3. Left main posterior membranous wall bronchoplasty with
mesh.
4. Flexible bronchoscopy.
.
Dr. [**Last Name (LF) **],[**First Name3 (LF) **]:
Bronchoscopy
History of Present Illness:
[**Known lastname 68103**] is a 61-year-old classical singer who developed a
severe cough two
years ago, which has continued to worsen to the point that it is
intractable, severe and debilitating. It was initially felt to
be potentially related to upper respiratory tract infection for
which she has been treated with without any improvement in her
cough. Her cough has become so severe that it results in stress
incontinence and syncopal episodes. She ultimately underwent a
bronchoscopy by Dr. [**Last Name (STitle) 1712**] and was found to have thick
inspissated
secretions throughout the trachea. These were removed and her
breathing improved. Dynamic bronchoscopy was perforemed and she
was diagnosed severe tracheobronchomalacia. Her associated
symptoms have also been
dyspnea on exertion and wheeze. However, she suffers from
postpolio syndrome and therefore does not exert herself
particularly. She has no significant orthopnea although she has
a sleep disturbance. She has had significant colds but has had
no severe infection such as pneumonias. Despite the treatment
for her gastroesophageal reflux disease with proton pump
inhibitors, she has had no improvement in her cough.
She now presents for surgical intervention.
Past Medical History:
HTN, postpolio syndrome, tracheobronchomalacia, s/p lap chole,
TAH-BSO, mult RLE surgeries, and b/l knee replacements
Social History:
former opera singer. non-smoker. Rare ETOH use
Family History:
non-contributory
Pertinent Results:
[**2157-10-3**] 05:36AM BLOOD WBC-9.0 RBC-3.66* Hgb-11.4* Hct-32.8*
MCV-90 MCH-31.2 MCHC-34.7 RDW-13.8 Plt Ct-305
[**2157-10-3**] 05:36AM BLOOD Glucose-109* UreaN-6 Creat-0.8 Na-141
K-4.1 Cl-101 HCO3-27 AnGap-17
[**2157-10-3**] 05:36AM BLOOD Calcium-9.5 Phos-3.8 Mg-1.9
.
[**2157-10-2**] 10:25 pm STOOL CONSISTENCY: WATERY
**FINAL REPORT [**2157-10-3**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2157-10-3**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
[**2157-10-1**] 4:27 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2157-10-2**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2157-10-2**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
CHEST PORT. LINE PLACEMENT [**2157-9-30**] 3:16 PM
REASON FOR THIS EXAMINATION:
please check placement of right median cub. PICC line 50 cm
please page IV nurse [**First Name (Titles) 151**] [**Last Name (Titles) **] [**Location (un) 1131**] thanks [**Doctor First Name **] #[**8-/2590**]
INDICATION: Right PICC placement. Patient is status post
tracheoplasty.
IMPRESSION: Right pleural effusion, unchanged. Right PICC tip in
distal SVC.
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] with respiratory symptoms. She
underwent bronchoscopy on [**2157-9-25**] that showed moderate
tracheomalacia and inspisated sputum. On [**2157-9-26**] she underwent
a right thoracotomy with posterior membranous wall tracheoplasty
with mesh, right mainstem and bronchus intermedius posterior
membranous wall plasty with mesh, left main posterior membranous
wall bronchoplasty with mesh, flexible bronchoscopy. For
operative details, seed dictated report. She was continued on
antibiotics (Zosyn, Nafcillin). She tolerated the procedure well
and was extubated and transferred to the ICU for monitoring.
Chest tube was maintained on suction. Pain was well controlled
with an epidural catheter that was managed by the Acute Pain
Service team.
On POD 1 aggressive pulmonary toilet was begun. Pain was well
controlled and incentive spirometry was encouraged. Diet was
advanced. CXR showed patchy opacity in the right upper lobe and
right lower lobe consistent with a developing air space disease
or atelectasis. Linear atelectasis in the left base, findings
consistent with post-operative changes. There was no evidence of
pneumothorax.
On POD 2, physical therapy service was consulted. She continued
to do well. Diet was advanced.
ON POD 3, chest tube was removed.
ON POD 4, she continued to do well. Antibiotics were continued.
Epidural and IV pain medications were adjusted to achieve better
control. CXR showed a small right loculated air collection most
likely due to loculated pneumothorax. This was unchanged from
previoius study and was thought to be due to post-operative
changes.
POD 5, Bronchoscopy performed and showed a normall right and
left bronchial tree with no airway colapse with expiration,
inspiration or cough. Epidural was removed and patient was
transitioned to PO and IV medications with adequate results.
PICC line was placed for long-term IV antibiotic administration.
Patient developed a significant yeast infection requiring
topical creams as well as Diflucan.
POD 6, patient developed several episodes of loose stool.
C.difficile cultures were negative. Chest PT/physical PT and
incentive spirometry was continued.
POD 7, her C.diff cultures were sent and were negative. She
continued to remain afebrile and her antibiotics was continued,
with empiric flagyl started.
POD 8, she continued to remain afebrile and with return of her
sensitivities, her antibiotics were switched from naficillin to
levofloxacin, and the zosyn and flagyl were continued. She was
deemed stable for discharge and will be discharged home with
VNA. She will continue to zosyn and levofloxacin for 3 weeks,
flsgyl for 4 weeks and was instructed to call Dr.[**Name (NI) 1816**]
office to schedule a follow-up appointment.
Medications on Admission:
Percocet
Atenolol
Nexium
Zantac
Colace
Senna
Amytriptyline
Lamictal
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 21 days.
Disp:*21 Tablet(s)* Refills:*0*
2. Zosyn in Saline 4.5 g/100 mL Piggyback Sig: One (1)
Intravenous every eight (8) hours for 21 days.
Disp:*qs qs* Refills:*0*
3. Heparin Flush 100 unit/mL Kit Sig: Five (5) ml Intravenous
once a day: 5 ml (100unit/mL) heparin to each lumen Daily via
SASH.
Disp:*qs qs* Refills:*2*
4. Normal Saline Flush 0.9 % Syringe Sig: Five (5) mL Injection
once a day: 5 mL NS to each lumen Daily via SASH.
Disp:*qs qs* Refills:*2*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 26 days.
Disp:*78 Tablet(s)* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for 21 days.
Disp:*qs qs* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*30 Capsule(s)* Refills:*2*
8. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lamotrigine 25 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 1* Refills:*2*
13. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D (6
times a day).
Disp:*1 1* Refills:*0*
14. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Tracheobronchomalacia
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Last Name (STitle) 952**]/ Thoracic Surgery office ( [**Telephone/Fax (1) 170**] ) for:
fever, shortness of breath, chest pain, exscessive foul smelling
drainage from incision sites
.
Call to schedule your follow up appointment.
.
Please follow-up with your primary care physician as soon as
possible.
.
*Continue medications as previous to surgery as stated on
discharge instructions. Please discontinue your percocet and
atenolol until follow-up with your primary care physician.
.
*Take new medications as directed and as needed, stated on
discharge instructions.
.
You may shower.
No tub baths or swimming for 3-4 weeks.
Followup Instructions:
Call Dr.[**Last Name (STitle) 68104**]/ Thoracic Surgery office [**Telephone/Fax (1) 170**] to schedule
your follow up appointment.
ICD9 Codes: 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7384
} | Medical Text: Admission Date: [**2185-3-4**] Discharge Date: [**2185-3-11**]
Date of Birth: [**2104-5-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
s/p fall, sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 15138**] is an 80 year old Russian-speaking man with a h/o
colon cancer s/p hemicolectomy, bladder cancer s/p ureterostomy,
HTN, & CKD who presents to the [**Hospital1 18**] after falling out of his
chair at his nursing home. He was found on the floor by the
nursing home personell though he denied hip pain. He was also
noted to be increasingly agitated at rehab.
.
In the ED, his vitals were T 98.8, HR 72, BP 97/59, RR 16, 95%
on RA. He became hypotensive and was not responding to 5L of IV
fluids, so a Right IJ was placed. He got a hip film which
showed no fracture. His labs were notable leukocytosis and
obstructive LFTs. [**Name (NI) 5283**] sono showed no cholecystitis. Surgery
was consulted and recommended ERCP consult.
.
Upon arrival to the [**Hospital Unit Name 153**], patient has dementia and is russian
speaking only so no further history is obtained. Per his
daughter, his appetite decreased over the past few days.
.
Of note, patient was recently admitted to the [**Hospital Unit Name 153**] for
enteroccus sepsis. Given that the source of the sepsis was felt
to be the ampullary tumor which was untreatable and the
likelihood for recurrence, the decision was made to make the
patient DNR/DNI with no central lines. Therefor, EGD/ERCP was
not pursued.
Past Medical History:
#. Saddle pulmanary emboli [**2181-12-3**] s/p IVC filter.
- warfarin therapy eventually discontinued secondary to SDH
[**7-/2182**]
#. Left acoustic neuroma s/p XRT, left cerebello-pontine angle
mass still present on subsequent imaging, stable since [**2173**]
#. colon cancer (per chart, initially dx in [**2172**] with
resection), per daughter was dx in [**12-9**] (GIB while on coumadin),
underwent hemicolectomy [**1-9**] with primary reanastomosis. no
adjuvant chemo/xrt. note, path 13.X6cm mass, adenoca. Margins
clear BUT 2 of 18 LN examined were +cancer (T3N1).
#. Bladder cancer s/p bladder resection [**2166**] s/p ureterostomy
#. recurrent UTIs
#. lower back pain: L3-4 disc bulging, had admission in [**2178**] for
inability to walk
#. Severe DJD
#. HTN
#. OSA
#. Iron deficiency Anemia
#. Hyperlipidemia
# CKD, creat has been around 2.0 since [**11-8**], previously was
1.1, unclear etiology and was never worked up.
Social History:
Patient currently residing in a nursing home. Per his family,
he is alert & oriented x 1 at baseline. He has 2 daughters that
live nearby.
Tobacco: Quit >35 yrs ago after ~15 pack-yrs
EtOH: Rare
Illicits: None
Family History:
No family history of premature coronary artery disease, sudden
cardiac death, thyroid disease, colon cancer, diabetes, or
hypertension.
Physical Exam:
Vitals: T 97.6, HR 77, RR 11, 96% on RA, 97/55
HEENT: dry mucous membranes
CV: RRR, no m/r/g
Pulm: CTA b/l anteriorly
Abd: Soft, NT, ND, + BS, + ureterostomy tube with urine
Ext: 2+ pitting edema bilaterally, cool extremities
Pertinent Results:
[**2185-3-3**] 10:55PM BLOOD WBC-20.9*# RBC-2.96* Hgb-7.4* Hct-25.0*
MCV-85 MCH-25.1* MCHC-29.7* RDW-21.2* Plt Ct-343
[**2185-3-4**] 01:15AM BLOOD WBC-18.9* RBC-2.37* Hgb-6.0* Hct-20.4*
MCV-86 MCH-25.2* MCHC-29.3* RDW-21.2* Plt Ct-292
[**2185-3-10**] 05:07AM BLOOD WBC-20.0* RBC-3.63* Hgb-9.7* Hct-32.7*
MCV-90 MCH-26.7* MCHC-29.7* RDW-21.1* Plt Ct-140*
[**2185-3-3**] 11:42PM BLOOD PT-15.0* PTT-23.3 INR(PT)-1.3*
[**2185-3-10**] 05:07AM BLOOD PT-41.8* PTT-41.0* INR(PT)-4.4*
[**2185-3-3**] 10:55PM BLOOD Glucose-121* UreaN-40* Creat-1.7* Na-135
K-4.9 Cl-101 HCO3-19* AnGap-20
[**2185-3-10**] 05:07AM BLOOD Glucose-65* UreaN-73* Creat-4.0* Na-137
K-6.0* Cl-114* HCO3-12* AnGap-17
[**2185-3-3**] 10:55PM BLOOD ALT-71* AST-108* LD(LDH)-340*
AlkPhos-858* TotBili-4.7*
[**2185-3-8**] 03:31AM BLOOD ALT-80* AST-142* LD(LDH)-397*
AlkPhos-700* TotBili-6.5*
[**2185-3-4**] 12:32PM BLOOD Calcium-7.2* Phos-4.2 Mg-1.9
[**2185-3-10**] 05:07AM BLOOD Calcium-7.2* Phos-7.5*# Mg-2.2
[**2185-3-7**] 05:49AM BLOOD Vanco-27.5*
[**2185-3-9**] 03:45AM BLOOD Vanco-22.8*
[**2185-3-4**] 01:17AM BLOOD Glucose-118* Lactate-3.8* K-4.2
HIP film
IMPRESSION:
1. No fracture.
2. Chronic degenerative changes in the hips, right greater than
left.
[**Year/Month/Day 5283**] US:
1. Multiple isoechoic liver lesions most likely representing
metastatic colon
cancer in the setting.
2. Gallbladder dilation, sludge, and CBD dilation of 14 mm;
concerning for
acute cholecystitis, recommend HIDA.
3. Stent in CBD; not clear if same position or in lower CBD.
Brief Hospital Course:
Mr. [**Known lastname 15138**] is an 80 year old Russian-speaking man with h/o
multiple malignancies including recurrent colon cancer s/p
hemicolectomy and recent metastatic adenocarcinoma with unknown
primary and ampullary mass, HTN, & CKD who presents with septic
shock secondary to cholangitis. He had biliary stent placed in
[**Month (only) 404**]. [**Name (NI) 5283**] sono demonstrates CBD dilitation suggestive of
obstruction (likely from the ampullary mass). Also he was
recently treated for enteroccus endocarditis (finished
Ampicillin course [**3-2**]). He was placed on broad spectrum
antibiotics during this hospitalization; however, no bacteria
isolates were obtained from his blood culture. Patient has
history of several recent bleeds on top of baseline iron
deficiency anemia. He has a baseline Creatinine of 1.4-1.6.
Additionally, he has a history of multiple malignancies
including bladder, colon (with reucurrence), acoustic neuroma,
and new metastatic adenocarcinoma with unknown primary with mets
to the liver, large pericardial effusion, and necrotic ampullary
mass. Oncology was consulted on prior admission and felt that
he was not a candidate for therapy. At baseline, patient A&O x
1. Requires 24 hour assistance for all of his ADL's. Now living
at a rehab facility since prior admission.
Hospital course:
He became cutely agitated, hypertensive, clamp down (cyanosis
perioral and in toes), tachycardic to 120s. He was transiently
placed on nitro gtt and BPs reduced but then hypotensive, nitro
gtt was stopped. EKGs done were without signs cardiac ischemia.
Family consulted and decided only IVF, abx, O2 but no other
interventions. ERCP was deferred. He had worsening renal
function, worsening LFT. Sacral decub was noted - likely from
prior to hospitalization, wound care consulted. IVF boluses
were given for low BP and low UOP, but persistent low blood
pressure, so levophed was started. Patient became very agitated
at night with minimal response to haldol and zyprexa. He
developed arrythemias going in and out of AVNRT repeatly. He
was maintained on medical care geared towards comfort and
eventually became bradycardic and passed away from cardiac
arrest.
Code: DNR/DNI (confirmed with daughter)
Communication: Patient & patient's family (daughter, [**Name (NI) 15139**]
[**Name (NI) 15140**] [**Telephone/Fax (1) 15141**] cell [**Telephone/Fax (1) 15142**] home)
Medications on Admission:
Ferrous sulfate 325 mg daily
Colace prn
Remeron 15 mg qhs
Vicoden prn
Tylenol prn
MOM prn
[**Name2 (NI) 10687**] prn
Bisacodyl prn
Verapamil 80 mg q 8 hours
Metoprolol Tartrate 25 mg q 6 hours
Completed Ampicillin [**2185-3-2**]
.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
septic shock
Ampullary mass with path positive for adenocarcinoma (biliary
stent placed due to prior episode of cholangitis in [**12-22**])
Liver metastases (unknown primary)
Bladder cancer s/p bladder resection & ureterostomy, [**2166**]
Colon cancer s/p resection, [**2172**] with recurrence (T3N1) s/p
hemicolectomy, [**2181**]
L acoustic neuroma s/p XRT, [**2173**]
Saddle PE s/p IVC filter, [**2181**]
h/o SDH, [**2181**]
A-fib s/p cardioversion
Recurrent UTI's
L3-4 disc herniation, [**2178**]
DJD
HTN
OSA
Iron deficiency Anemia
Hyperlipidemia
CKD (baseline Cr 1.2-1.4) from bilateral hydronephrosis
Dementia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 0389, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7385
} | Medical Text: Admission Date: [**2129-3-16**] Discharge Date: [**2129-3-21**]
Date of Birth: [**2051-11-2**] 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:
none
History of Present Illness:
77 y/o male who was admitted at OSH with chest pain. Initial ECG
in ER was suspicious of ACS and he was treated as such. Chest CT
was later done to exclude PE or dissection. The CT revealed a
dissection that started at the aortic arch (just above the left
SCA) and extended to 7 cm long. He was transferred to [**Hospital1 18**]
after starting Esmolol for BP control.
Past Medical History:
Benign Prostatic Hypertrophy, s/p Prostatic surgery
Social History:
Current smoker approx 1-1.5 ppd x 50+ yrs. -ETOH.
Family History:
Non-contributory
Physical Exam:
VS: 130/85 68SR
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD, -Carotid bruit
Pulm: CTAB -w/r/r
Heart: RRR w/ [**12-28**] SM
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -c/c/e
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**3-16**] Chest CT: 1. Extensive type B aortic dissection, not
significantly changed compared to the outside exam of earlier in
the same day. Both studies were reviewed with the Cardiothoracic
Surgery service at 10:30 p.m., [**2129-3-16**]. 2. Emphysema. 3.
Cholelithiasis. 4. Massive enlargement of the prostate gland.
There is an extensive type B aortic dissection extending from
just distal to the take-off of the left subclavian artery
through to just superior to the renal arteries. Contrast is seen
opacifying a 5-cm segment of the false lumen at the level of the
mid-descending thoracic aorta. There is no evidence of
pericardial effusion or hemopericardium, or extension into the
aortic root, coronary arteries or valve apparatus. The celiac
artery and superior mesenteric artery are supplied by the true
lumen. The descending aorta measures up to 3.6 cm in diameter.
[**3-19**] Chest CT: 1. Again seen is extensive type B aortic
dissection extending from the aortic arch to just above the
renal arteries. There is a focal area of outpouching of the true
lumen, which was seen on the prior study, and is smaller
suggesting partial interval thrombosis. There is no increase in
the caliber of the true or false lumen or the extent of
dissection. Intramural hematoma at the aortic arch noted as
before. 2. Pneumobilia, which is increased slightly in
comparison to prior study.
[**2129-3-16**] 08:50PM BLOOD WBC-17.6* RBC-4.28* Hgb-13.2* Hct-39.8*
MCV-93 MCH-30.8 MCHC-33.2 RDW-15.2 Plt Ct-397
[**2129-3-20**] 06:00AM BLOOD WBC-15.3* RBC-4.03* Hgb-12.7* Hct-36.9*
MCV-92 MCH-31.4 MCHC-34.3 RDW-15.3 Plt Ct-378
[**2129-3-16**] 08:50PM BLOOD PT-13.5* PTT-54.5* INR(PT)-1.2*
[**2129-3-20**] 06:00AM BLOOD PT-12.6 PTT-31.1 INR(PT)-1.1
[**2129-3-16**] 08:50PM BLOOD Glucose-91 UreaN-17 Creat-0.8 Na-143
K-3.9 Cl-110* HCO3-24 AnGap-13
[**2129-3-20**] 06:00AM BLOOD Glucose-91 UreaN-21* Creat-0.9 Na-139
K-4.0 Cl-105 HCO3-29 AnGap-9
[**2129-3-20**] 06:00AM BLOOD Calcium-8.1* Phos-1.6* Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the CSRU for tight blood pressure
control and underwent a chest CT on day of admission. CT
confirmed outside results of a Type B aortic dissection just
distal to left SCA and extended to above renal arteries.
Vascular surgery was consulted on day of admission. He remained
in the CSRU for several days receiving blood pressure control.
Beta blockers were started and were titrated throughout hospital
course the maximum BP control. On hospital day three his Foley
catheter was removed and he was transferred to the telemetry
floor for further medical management. He remained on the floor
for several more days and underwent several more CT scans during
hospital course which showed no change of dissection. On
hospital day six he was discharged home with the appropriate
medications and follow-up appointments.
Medications on Admission:
At home: none
On transfer: Esmolol
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Type B aortic dissection
Discharge Condition:
good
Discharge Instructions:
take all of your medications as prescribed
Followup Instructions:
with Dr. [**Last Name (STitle) 26225**] in [**12-25**] weeks
with Dr. [**First Name (STitle) **] in 1 month ([**Telephone/Fax (1) 1504**]
with Dr. [**Last Name (STitle) **] in 1 month ([**Telephone/Fax (1) 2867**]
Please call for appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2129-3-21**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7386
} | Medical Text: Admission Date: [**2163-2-22**] Discharge Date: [**2163-2-24**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
CC:[**CC Contact Info 89949**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F PMH dementia presented to OSH following evaluation at
nursing home for cough, decreased appetite that demonstrated
creatinine increase to 3.6. Patient describes recent cough (per
HCP 1 week duration) but denies fever or chills. Denies
abdominal pain, nausea, vomiting. Denies chest pain or shortness
of breath. Per HCP patient has not been eating well last several
months.
.
Patient presented to OSH found to have T 94.5, creatinine 3.6,
WBC 8.6 (N80%), bilirubin of 8 and an ALP of almost 1400. Her
ultrasound showed some thickening of the GB wall, and did not
comment on her CBD. There were stones and sludge reported. CXR
demonstrated increased opacity right lung base medially and left
retrocardiac region. She was transferred to [**Hospital1 18**] for further
management.
.
On arrival to our ED VS T 97.7, BP 96/54, HR 90, O2Sat 95% 2L.
SBP dropped to 60 which improved to SBP 90s with 3 L of NS. Labs
notable for lactate 2.1, creatinine 3.5 (from baseline of 1.1),
ALT 58, AST 120, AP 1061, Tbili 6.1, Alb 2.9, lipase 13, WBC 7.1
(N 79, L 14), INR 1.3. Gallbladder ultrasound demonstrated
markedly distended GB with sludge/stones but no thickening or
definite [**Doctor Last Name 515**] sign. CBD irregular in appearance measuring up
to 1 cm in diameter. Moderate to large amount of ascites. Patent
main portal vein. Blood and urine cultures sent. Patient given
Levofloxacin (received Unasyn at OSH). Surgery was consulted -
patient's HCP declined surgery but will consider ERCP.
Consequently patient is being admitted to the MICU.
.
On arrival to the ICU, patient overall looks well and is
conversant.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath. Patient
has chronic edema. Describes increase in urinary frequency but
no dysur
Past Medical History:
Dementia
Glaucoma
HTN
Cholelithiasis
GERD
Osteopenia
Spinal stenosis
Lymphedema
Right hip replacement
Social History:
Patient lives in long-term care facility Blueberry [**Doctor Last Name **]. Son is
HCP. [**Name (NI) **] history of tobacco abuse
Family History:
Non-contributory
Physical Exam:
GEN: elderly female, no acute distress
HEENT: Dry mucosa, EOMI, PERRL, sclera icteric, no epistaxis or
rhinorrhea, OP Clear.
NECK: No JVD
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Decreased breath sounds throughout
ABD: Soft, moderately distended, non-tender to light and deep
palpation. No fluid wave. No rebound or gaurding. + BS.
EXT: 3+ pitting edema b/l, no palpable cords
NEURO: alert, oriented to place and season. CN II ?????? XII grossly
intact. Moves all 4 extremities.
SKIN: + jaundice.
Pertinent Results:
[**2163-2-22**] 06:30PM WBC-7.1 RBC-3.82* HGB-11.5* HCT-35.5* MCV-93
MCH-30.0 MCHC-32.3 RDW-16.0*
[**2163-2-22**] 06:30PM PLT COUNT-202
[**2163-2-22**] 06:30PM NEUTS-79.6* LYMPHS-14.1* MONOS-5.4 EOS-0.6
BASOS-0.3
[**2163-2-22**] 06:30PM PT-14.8* PTT-24.6 INR(PT)-1.3*
[**2163-2-22**] 06:30PM GLUCOSE-110* UREA N-110* CREAT-3.5*
SODIUM-141 POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-26 ANION GAP-21*
[**2163-2-22**] 06:30PM ALT(SGPT)-58* AST(SGOT)-120* CK(CPK)-51 ALK
PHOS-1061* TOT BILI-6.1* DIR BILI-5.2* INDIR BIL-0.9
[**2163-2-22**] 06:30PM LIPASE-13
[**2163-2-22**] 06:30PM cTropnT-0.09*
[**2163-2-22**] 06:30PM CK-MB-5
[**2163-2-22**] 06:31PM LACTATE-2.1*
[**2163-2-22**] 07:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2163-2-22**] 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2163-2-22**] 07:00PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2163-2-22**] 09:54PM URINE HOURS-RANDOM CREAT-71 SODIUM-61
POTASSIUM-33 CHLORIDE-54
.
Renal US:
The right kidney measures 9.2 cm and shows cortical thinning but
no
hydronephrosis. The left kidney is only partially seen but it
too shows no
evidence of hydronephrosis.
The spleen is not enlarged. The bowel is predominantly pulled
posteriorly
suggesting that the cause of the ascites is intra-abdominal
spread of
malignancy.Neither pancreas or aorta could be seen.
IMPRESSION: Pancreas and aorta not seen. Extensive ascites that
is probably
malignant.
.
EXAM: Right upper quadrant ultrasound.
COMPARISONS: None available.
FINDINGS:
There is a large amount of intra-abdominal ascites. The liver
demonstrates no
focal or textural abnormalities. There is irregularity of the
common bile
duct which measures up to 10 mm. The gallbladder is distended
containing
layering stones and sludge. There is no appreciable gallbladder
wall
thickening. There was a negative son[**Name (NI) 493**] [**Name (NI) **] sign. The
main portal
vein is patent with appropriate hepatopetal flow. The pancreas
is not well
visualized.
IMPRESSION:
1. Markedly distended gallbladder containing stones and sludge.
No
gallbladder wall thickening or pericholecystic fluid. However,
in the
appropriate clinical setting, acute cholecystitis would be of
concern and
further evaluation with HIDA scan could be obtained.
2. Large amount of intra-abdominal ascites.
3. Irregularity of the common bile duct, which measures up to
10mm.
The study and the report were reviewed by the staff radiologist
.
CXR:
HISTORY: [**Age over 90 **]-year-old woman with cough and hypotension.
IMPRESSION: AP chest reviewed in the absence of any prior chest
imaging:
Pulmonary edema is at least mild in severity. Large region of
opacification in the left lower lobe, seen through the cardiac
silhouette, obscures the left diaphragmatic pleural surface and
could be pneumonia or left lower lobe collapse, but could also
be mediastinal abnormality such as a thoracic aortic aneurysm or
large hiatus hernia. Lateral view would be very helpful. Small
bilateral pleural effusions are presumed. Heart is at least
moderately enlarged if not severely. Elevation of the left main
bronchus suggests substantial left atrial dilatation, and a
ring-like calcification could be in the mitral annulus. Once
again, lateral view would be very helpful. Dr. [**First Name (STitle) 89950**] and I
discussed these findings by telephone.
Brief Hospital Course:
[**Age over 90 **] year-old female with a history of dementia trasnferred from
OSH for obstructive jaundice.
.
# Jaundice: Initial concern for choledocholithiasis and patient
covered with antibiotics. After review, growing concern for
malignant etiology: cholangiocarcinoma vs pancreatic malignancy.
Discussion held with family regarding goals of care. Central
venous line, ERCP and surgery declined. Palliative care
consulted. Decision made to return to [**Hospital3 **] facility
with hospice. Interventions were miniminalized prior to
discharge. Antibiotics were discontinued, pressors were weaned
off.
# Goals of care. Palliative care consulted shortly after
admission. Referral made to Hospice [**Location (un) 1121**] for palliative
care at Blueberry [**Doctor Last Name **]. Family counseled and prepared regarding
likely upcoming events such as continued anorexia secondary to
the natural consequence of aging, cancer, dying process as well
as further inability to ambulate. Palliative care recommended:
trial of pain medication of low dose morphine 2.5 mg prn.
Tylenol avoiding in setting of abnormal liver function tests.
Patient was without complaints of pain at time of discharge.
.
# Hypotension. On admission patient with asymptomatic
hypotension in the 70s. Started on low dose pressor support.
After discussion regarding goals of care decision made to wean
pressors unless symptomatic. All anti-hypertensives medications
held. Patient hemodynamically stable at time of transfer.
.
# Renal failure: Most likely pre-renal versus ATN from shock.
Renal US without hydronephrosis. Creatinine improved with trial
of fluids. Renal function was not trended after goals of care
discussion took place.
.
# Glaucoma: Continue Lumigan.
.
# GERD: Continue prilosec.
.
#. CAD. Continued Aspirin. Held ACE in setting of hypotension
and renal failure.
Medications on Admission:
ASA 81
Colace 100 mg [**Hospital1 **]
Lisinopril 10 mg qd
Prilosec 20 mg daily
Lasix 40 mg daily
Lumigan 0.03% one drop each at bedtime
Robitussin
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
9. morphine 10 mg/5 mL Solution Sig: 2.5 mg PO Q4H (every 4
hours) as needed for pain: Please use if tylenol ineffective.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Blueberry [**Doctor Last Name **] Healthcare - [**Hospital1 **]
Discharge Diagnosis:
Primary
Obstructive Jaundice
.
Secondary
Dementia
Congestive Heart Failure
Lymphedema
Discharge Condition:
Mental status: confused at times
Unable to ambulate
Discharge Instructions:
Dear Ms [**Known lastname 89951**], you were admitted to [**Hospital3 **] Hospital for
further evaluation of your distended belly.
.
Shortly after arrival to the ICU decisions were made to avoid
invasive intervention and refocus goals of care on continued
comfort.
The palliative care team was consulted. The plan is for you to
return to Blue [**Doctor Last Name 3646**] [**Doctor Last Name **] with additional supports in place.
.
CHANGES TO YOUR MEDICATIONS:
Stop take Lisinopril
Hold Lasix given low blood pressure.
Start taking low dose Morphine as needed for pain
Start taking cough suppressants for comfort
Followup Instructions:
Plan to return to Blue [**Doctor Last Name 3646**] [**Doctor Last Name **] with hospice
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2163-2-24**]
ICD9 Codes: 5845, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7387
} | Medical Text: Admission Date: [**2132-8-2**] Discharge Date: [**2132-8-4**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Epistaxis and hypotension
Major Surgical or Invasive Procedure:
L nares cauterized
History of Present Illness:
85 year old man with CAD s/p CABG and CHF who was admitted
with recurrent epistaxis. He was transferred to the MICU for
hypotension. He first had epistaxis one week ago and went to [**Hospital **]
clinic on [**7-24**] where he was cauterized. Five days later, he
presented to [**Hospital1 18**] ENT on [**7-29**] for recurrent epistaxis and was
packed by ENT consult. Two nights ago, he presented to the ED
again for epistaxis and was cautarized. He has not bled since.
In the ED, his vitals were 96.8, HR: 46, BP:167/74, RR:20, O2
95%RA.
He was kept overnight in the ED then admitted to the Medicine
team in the morning. He recieved all his BP meds including
metoprolol, lisinopril, lasix and imdur. At the time, he was
also straining to move his bowels. His SBP dropped from 120's to
80's over the course of the morning. His vitals were: 96.5,
88/40, 50, 94%RA. He remained asymptomatic; making urine,
ambulating and mentating. He recieved 650cc's of NS without
improvement, and given his h/o CHF, he was then transferred to
the MICU for closer monitoring and care. In the MICU the pt
received an additional 1L NS in boluses and 1L NS over 10 hrs
with improvement in his SBPs to the 120-140s. This am, he had an
episode of L sided chest pressure without SOB, diaphoresis, n/v,
lightheadedness, palpitations. Stated this was his anginal
equivalent which occurs 1-2xs/week. EKG was without any new
ischemic changes and pain relieved with SL nitro. Was transfused
2 units pRBC for Hct 23.9 which bumped to 28.7. Transferred to
floor for further care.
Baseline, he can walk 1 flight of stairs and would get SOB.
Baseline [**2-9**] pillow orthopnea. He has occasional chest pain and
relieves it with nitro.
Past Medical History:
-CAD: Severe 3 vessel disease s/p 3v CABG [**2108**](SVG=>D1=>LAD,
SVG=>OM1=>OM3, SVG= >AM). SVG=>D1=>LAD was stented [**2128**]. Repeat
cath [**7-11**] showed inoperable disease. During admit [**10-11**], had CP
a/w some dynamic ST segment depressions in anterior leads,
medically managed with aspirin, plavix, ACE, imdur, and
betablocker. LVEF >55% on Echo done [**12/2131**]
-Incarcerated paraesophageal hernia s/p laparoscopic repair with
fundoplication in [**10-11**]; associated gastric outlet obstruction
resolved with surgical repair
-Lower gastrointestinal bleed secondary to hemorrhoids and
colonic polyps, admit [**2129-11-20**]
-Hypertension with mild symmetric LVH
-Afib, first noted post-op during [**10-11**] admission post op after
paraesophageal hernia repair, converted to NSR on 11/[**2131**]. Off
coumadin [**2-8**] significant bleeding issues.
-Hyperlipidemia
-Diabetes type II
-By MRI/MRA: left posterior parietal infarct, chronic
periventricular microvascular ischemic changes, moderate disease
resulting in 60-70% stenosis of the right precavernous and
cavernous ICA
-s/p bilateral carotid endarterectomy
-Peripheral vascular disease status post left toe amputation
-History of prostate cancer status post radiation therapy
-Cataracts
Social History:
Never smoked
No illicit drugs
He denies alcohol use
Walks with walker at home, recently limited by SOB. Followed by
[**Hospital 119**] [**Name (NI) 2256**] [**Name (NI) 269**], PT, OT. Lives with his wife [**Name (NI) 1446**], has
son [**Name (NI) **] who is active in his care.
Family History:
History of MI in mother (death 89), father (death 67).
Physical Exam:
Vitals
97.5, 145/60, 57, 15, 100% room air
GEN- NAD, pleasant, cooperative
HEENT- MMM, OP clear, pale conjunctiva, no signs of active
bleeding
NECK- JVP 9 cm above sternal notch
CV- Normal S1 and S2. Soft apical holosystolic murmur. No S3.
PULM- Bibasilar crackles at bases, no rhonchi or wheezes
EXT- 1+ edema, 2+ pulses posterior tibialis and dorsalis pedis
bilaterally
Pertinent Results:
HCT 23.9 on [**2132-8-3**] 0600 improving to 28.7 on [**2132-8-3**] [**2055**]. HCT
stable at 27.2 on [**2132-8-4**]
Troponin T negative x two
proBNP 1798 on [**2132-8-2**]
EKG on [**2132-8-2**]
Probable ectopic atrial rhythm. Occasional atrial premature
beats. Right
bundle-branch block. Probable old inferior wall myocardial
infarction.
Prolonged QTc interval. Low QRS voltage in the precordial leads.
Compared to the previous tracing of [**2132-7-29**] atrial ectopy is
new. Otherwise, no significant diagnostic change.
Brief Hospital Course:
Briefly, 85 year old man with CAD s/p CABG and CHF who was
admitted with recurrent epistaxis, transferred to the MICU for
hypotension. He first had epistaxis on one week ago and went to
[**Hospital **] clinic on [**7-24**] where he was caudarized. Five days later, he
presented to [**Hospital1 18**] ENT on [**7-29**] for recurrent epistaxis and was
packed by ENT consult. Two nights ago, he had to come to the ED
again for epistaxis and was cautarized. He has not bled since.
In the ED, his vitals were 96.8, 46, 167/74, 20, 95%RA.
.
He was then admitted to the Med team in the morning. He recieved
all his BP meds including metoprolol, lisinopril, lasix and
imdur. At the time, he was also straining to move his bowels.
His SBP dropped from 120's to 80's over the course of the
morning. His vitals were: 96.5, 88/40, 50, 94%RA. He remained
assymtomatic; making urine, ambulating and mentating. He
recieved 650cc's of NS without improvement, and given his h/o
CHF, he was then transferred to the MICU for closer monitoring
and care. In the MICU the pt received an additional 1L NS in
boluses and 1L NS over 10 hrs with improvement in his SBPs to
the 120-140s. This am, he had an episode of L sided chest
pressure without SOB, diaphoresis, n/v, lightheadedness,
palpitations. Stated this was his anginal equivalent which
occurs 1-2xs/week. EKG was without any new ischemic changes and
pain relieved with SL nitro. Was transfused 2 units pRBC for Hct
23.9 which bumped to 28.7. Transferred to floor for further
care.
.
Baseline, he can walk 1 flight of stairs and would get SOB.
Baseline [**2-9**] pillow orthopnea. He has occasional chest pain and
relieves it with nitro.
[**2132-8-4**]
Patient had episode of bradycardia during the night of [**2132-8-3**].
Went down to 22, patient was aymptomatic and sleeping
comfortably. Heart rate rose back into baseline of 50s, blood
pressure was 140/44. Tele otherwise unremarkable. Decision was
made to continue with metoprolol due to his significant coronary
disease. Blood pressure have held, systolic in the 120s-130s for
the past 24 hours. Patient is not a candidate for
revascularization or surgery, needs optimal medical management.
No signs of epistaxis s/p cautery in the emergency room. Patient
is stable and decision for discharge was made today.
Medications on Admission:
MEDICATIONS ON TRANSFER FROM FLOOR:
# Aspirin 81 mg PO DAILY
# Clopidogrel Bisulfate 75 mg PO DAILY
# Metoprolol 25 mg PO TID
# Lisinopril 20 mg PO DAILY
# Furosemide 20 mg PO DAILY
# Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
# Nitroglycerin SL 0.3 mg SL PRN
# Clindamycin 300 mg PO Q6H
# Sodium Chloride Nasal 2 SPRY NU TID
# Mupirocin Nasal Ointment 2% 1 Appl NU [**Hospital1 **] Duration: 5 Days
# Pantoprazole 40 mg PO Q24H
# Atorvastatin 40 mg PO DAILY
# FoLIC Acid 1 mg PO DAILY
# Ferrous Sulfate 325 mg PO DAILY
# Insulin SC (per Insulin Flowsheet)
# Atropine Sulfate 1 mg IV ASDIR
Discharge Medications:
1. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day).
Disp:*2 bottles* Refills:*2*
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Mupirocin 2 % Ointment Sig: One (1) application Topical
twice a day for 2 days.
15. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 3 days.
Disp:*24 Capsule(s)* Refills:*0*
16. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
17. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 2256**]
Discharge Diagnosis:
CAD- severe 3 vessel disease s/p CABG in [**2108**], LAD stent placed
[**2128**], repeat cath [**7-/2131**] showed inoperable disease
Diastolic heart failure- EF 65-70%
Hypertension
Atrial fibrillation- converted, off coumadin due to bleeding
problems
Paraesophageal hernia- s/p fundplication
Epistaxis
chronic anemia
Chronic lower GI bleed
Diabetes type 2
Hyperlipidemia
PAF
h/o CVA
s/p bilat CEA
h/o prostate ca s/p radiation
cataracts
PVD- s/p left toe amputation
Discharge Condition:
Good
Patients blood pressures holding in the 120-130s systolic
Heart rate in the 50s, baseline
No active bleeding
Discharge Instructions:
You were admitted to the hospital to monitor your blood
pressure which was found to be low during the event of a
prolonged nosebleed.
Continue to use Ocean nasal spray to both nares 4 time a day.
Just allow the fluid to drip into your nose to keep your nose
moist.
Clindamycin is an antiboitic. Please continue for 2 more days.
Continue all medicines as prior to this admission.
Contact Dr [**First Name (STitle) **] [**Telephone/Fax (1) **] if you have nose discomfort or
concerns about bleeding.
Followup Instructions:
Dr [**First Name (STitle) **] on Wednesday [**8-6**] 2:15 at [**Location (un) 55**] Office
[**Telephone/Fax (1) **]
Please follow up with you primary care doctor Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1609**]
within 1-2 weeks. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1609**]. Her phone number is [**Telephone/Fax (1) 2740**]
ICD9 Codes: 2851, 5789, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7388
} | Medical Text: Admission Date: [**2132-1-30**] Discharge Date: [**2132-2-2**]
Date of Birth: [**2077-2-8**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Procardia
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Colonoscopy
Right femoral line
History of Present Illness:
54 year old woman with past medical history significant for
diverticulosis, hypertension, hyperlipidemia, rhythm controlled
afib not on coumadin and chronic diastolic CHF who now presents
with
bright red blood per rectum for the past 12 hours.
.
Patient states her symptoms began last night about 8:15pm. She
had lower abd cramps and an episode of dark colored stool. She
had nausea with no emesis. Since then has had about 20 bloody
BMs, dark red in color, with some clots. She states she had
undercooked red meat and steamed vegatable for dinner last night
at Friend's home. Her friend had severe diarrhea overnight, but
no rectal bleeding. Pt denies fever/chill, NSAIDs use, but she
is on ASA 81mg daily. She complaints of dizziness last night.
Pt's abdominal pain is much improved now.
.
In the ED, initial vs were: T 96.4 P 97 BP 82/27 R 15 O2 sat
100% RA. Patient was given 1 liter NS and her BP improved. On
exam she had lower abdominal tenderness. She has dark red blood
on rectal exam but no more BMs in ER. GI and surgery were
called. NG lavage was negative for blood. Hct was 26 from
baseline of 43, so she was given 2 unit of blood (emergency
unit) and 6 units were cross matched. She was alert during these
encounter. Intravenous Protonix given and Cipro and flagyl were
also given. Access of PIV 18 gauge x 2 was established. At the
time of transfer to the ICU were 73 97/52 15 100%2L.
.
During her MICU course, GI and Surgery followed. She received
total of 6 U PRBC (last one at 8 AM today) 1 U FFP and her last
Bloody BM was 4:30 PM on [**1-30**]. Access was difficult, so despite
having 2 18G, a femoral line was placed and will be kept until
the morning. GI convinced her to have colonoscopy and so started
bowel prep tonight.
.
REVIEW OF SYSTEMS:
No fevers, chills, weight loss, headache, visual changes, sore
throat, chest pain, shortness of breath, nausea, vomiting,
abdominal pain, constipation, pruritis, easy bruising, dysuria,
skin changes, pruritis.
Past Medical History:
#. pAfib - maintained on Propafenone
- CHADS1, on aspirin
#. Chronic Diastolic CHF, EF 55%
#. Diverticulosis
#. Adrenal Adenoma
#. Chronic rhinitis
#. Bladder cancer
- dx'ed 3 yrs ago s/p resection, no chemo
- Single papillary tumor at the left dome.
#. Hypertension
#. Chronic bronchitis (normal spirometry in [**2129**])
#. Hyperlipidemia
#. Osteoarthritis
#. Tenosynovitis
#. Low Back Pain
Social History:
The patient currently lives in [**Location **] alone. She is single, 1
son. The patient has no HCP. The patient is currently on
disability for arthritis. She previously worked in food
services, bartending, catering. Tobacco: [**1-5**] PPD x 40 years
ETOH: Prior heavy use, has since quit Illicits: None
Family History:
Mother with DM, HTN, diverticulitis, angina at the age of 38 and
CVA at age 48 from which she passed away.
Physical Exam:
On transfer out of MICU to floor:
VS: T96.7 HR86 BP124/88 RR18 98% RA
GEN: No apparent distress, alert and oriented, comfortable
SKIN: Erythema and excoriations of bilateral upper extremities
HEENT: EOMI, normal oro/nasopharynx, moist mucus membranes, no
JVD/LAD. Neck soft and supple.
PULM: CTAB, no wheezing/rhonchi/rales
CARDIAC: Regular rate and rhythm; no murmurs/gallops/rubs
ABDOMEN: No apparent scars. Non-distended, non-distended, soft,
+BS (slightly hyperactive)
EXTREMITIES: Trace peripheral edema, warm and well perfuse,
+DP/PT pulses, right femoral line in place - c/d/i
Pertinent Results:
Chem 10
141 111 28 93 AGap=13
4.1 21 1.0
Ca: 7.7 Mg: 1.5 P: 3.6
ALT: AP: Tbili: Alb:
AST: LDH: 129 Dbili: TProt:
[**Doctor First Name **]: Lip:
.
FDP: 0-10
.
CBC
11.7 9.8 175
28.8
N:72.7 L:22.1 M:3.4 E:1.5 Bas:0.2
.
PT: 12.6 PTT: 26.7 INR: 1.1
Fibrinogen: 259
.
Trop-T: <0.01
.
ECHO ([**2130-11-10**])
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a fat pad.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2129-4-22**],
the patient is now in atrial fibrillation. Mild pulmonary
hypertension is identified. The other findings appear largely
similar. LV function is difficult to compare directly between
the studies given the current degree of tachycardia.
.
COLONOSCOPY:
Findings: ([**2131-1-12**])
Contents: Red blood was seen in the rectum and sigmoid colon.
Excavated Lesions Multiple diverticula were seen in the sigmoid
colon. Diverticulosis appeared to be severe, with no
identifiable single bleeding diverticulum.
Impression: Blood in the rectum and sigmoid colon Diverticulosis
of the sigmoid colon Otherwise normal colonoscopy to proximal
sigmoid colon
Recommendations: Unable to pass sigmoid due to spasm, dicomfort
and blood contents. No identifiable bleeding lesion in this
limited exam. If bleeding persists, please obtain bleeding scan,
contact IR. Consider surgical consult.
.
[**2132-2-1**]: Mutiple diverticuli throughout the colon. Able to get
to ileocecal valve this time with general sedation.
Brief Hospital Course:
54 year old woman with past medical history of diverticulosis
with past GI bleeds, atrial fibrillation (CHADS1, not on
coumadin) who presented with acute bright red blood per rectum,
hypotension and 20 point hematocrit drop. Patient was initially
in the MICU and then transferred to the floor where she
tolerated bowel preparation and underwent colonoscopy showing
diffuse diverticular disease but no more active bleeding.
.
# Bright red blood per rectum: Gastroenterology and General
Surgery followed the patient closely in-house. Hematocrit
stabilized after 6 units pRBC, 1 unit FFP. Etiology likely
diverticular bleed given her long-standing history of
constipation and history of significant diverticular bleeds.
Also on the differential but lower include ischemic colitis
given atrial fibrillation (without coumadin) and lactate 4.2
initially. Repeat colonoscopy revealed extensive diverticular
disease throughotu patient's colon. Her IV pantoprazole was
discontinued and patient started on clears diet which she
tolerated well; her diet was eventually advanced. Patient was
educated on dietary/bowel management for diverticuli and
discharged with close follow-up in GI and Gen [**Doctor First Name **] clinics.
Patient is to discuss surgical option, such as bowel resection,
given her significant history of dangerous diverticular bleeds
in the past (X3-4?)
.
# PRURITIC RASH: Slightly erythematous and excoriated. Responded
to Sarna lotion. Patient felt the IV pantoprazole caused her
rash.
.
# PAROXYSMAL ATRIAL FIBRILLATION: Patient remained in sinus
rhythm. Given her GI bleed, aspirin was held, to be restarted
upon discharge. She was continued on Propafenon short acting, to
resume her home long acting version upon discharge.
.
# CHRONIC DIASTOLIC HEART FAILURE: Well compensated, although
likely tolerates rapid ventricular response very poorly. No
crackles and trace lower extremity edema on exam. After her
colonoscopy, patient's home Diltiazem dose was restarted in
short-acting form. Her enalapril was held to be restarted when
patient was discharged home.
.
# OSTEOARTHRITIS: Stable and pain well controlled with tylenol
and oxycodone PRN
.
# BLADDER TUMOR: No clinical evidence of recurrence and was
stable.
.
# Right Femoral line: Difficult access and initial IJ was
attempted unsuccessfully. Patient had two peripheral IVs as well
and after colonoscopy, had the right femoral line removed
without issues. Site remained clean, dry and intact until after
discharge.
.
# CODE: Full, discussed and confirmed in ICU
Medications on Admission:
DILTIAZEM HCL - 240 mg Capsule
ENALAPRIL MALEATE - 20 mg Tablet [**Hospital1 **]
FUROSEMIDE - 40 mg Tablet daily
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg q6H:PRN Pain
PROPAFENONE [RYTHMOL SR] - 225 mg Capsule [**Hospital1 **]
DOCUSATE SODIUM - 100 mg Capsule
ASPIRIN 81mg daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for back pain.
2. Propafenone 225 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
3. Cartia XT 240 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
4. Docusate Sodium 250 mg Capsule Sig: One (1) Capsule PO twice
a day.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diverticular bleed
Secondary: Paroxysmal atrial fibrillation, chronic diastolic
CHF, hypertension/hyperlipidemia, osteoarthritis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
-You were admitted with bright red blood in your bowel
movements. You were briefly in the ICU but stabilized well with
6 units of red blood cells. Colonoscopy showed you likely had a
bleed from the many diverticuli (outpouchings) you have in your
colon.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> HOLD Furosemide 40mg daily until you discuss with your
primary care doctor
--> RESUME Aspirin 81mg daily
--> RESUME Rhythmol SR 225mg twice daily
--> RESUME Enalapril 20mg twice daily
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Appointments:
.
** Please call the General Surgery Clinic to make an appointment
to be seen in [**1-5**] weeks. You should discuss with them surgical
options for managing your significant diverticulosis. Their
phone number: ([**Telephone/Fax (1) 30009**]
.
* Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2-6**]
at 11am. Her number is [**Telephone/Fax (1) 17826**] if you need to reschedule.
She should check your blood counts and blood pressure. Please
discuss with her about re-starting Furosemide (aka Lasix).
.
* Gastroenteroloy - Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2132-2-12**] 2:00pm
.
* Urology - [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**]
Date/Time:[**2132-2-14**] 3:20pm
.
* Cardiology - DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2132-10-2**] 10:40am
ICD9 Codes: 2851, 4280, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7389
} | Medical Text: Admission Date: [**2102-3-28**] Discharge Date: [**2102-4-7**]
Date of Birth: [**2049-7-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Arm pain, left lung empyema
Major Surgical or Invasive Procedure:
1. left video-assisted thoracoscopic converted to left
thoracotomy, decortication of lung
History of Present Illness:
This is a 52 year old male who presents for management of
cervical osteomyelitis. He was healthy up until he went on an
alcohol binge [**12-24**] mos ago, leading to an admisison to [**Hospital1 **]. There, he had withdrawal seizures, and was intubated
with aspiration pneumonia and bacteremia, treated for blood
cultures growing MSSA which was treated with oxacillin and then
cefpodoxime. He also had a left pleural effusion that was
tapped, and a left knee effusion that was tapped (results not
present). He was discharged to rehab after a 3 week admission,
and has since been discharged back home. He has remained
abstinent of EtOH since that admission (7 weeks). He notes
losing 20 lbs over the course of these recent events.
.
Today, he saw his PCP for [**Name Initial (PRE) **] few days of neck pain and right
posterior upper arm pain, associated with numbness and tingling
in the right fingertips. He notes generalized, but not focal,
weakness. C-spine plain films were abnormal so he had an
outpatient MRI showing C6-7 osteomyelitis (although some parts
of the record indicate C2-3). He went to [**Hospital3 **] ED where
he was afebrile, with labs showing WBC 15, plt 677, CRP 153. He
was given vancomycin 1gm, ceftriaxone 2gm, and morphine 12mg
total. He was transferred to the [**Hospital1 18**] ED, where his vitals
were: 99.1 80 115/85 16 98RA, with a generally benign exam.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations. Denies cough, shortness of breath, or
wheezes. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No black or bloody stools. No dysuria. Denies
arthralgias or myalgias. Denies rashes.
Past Medical History:
EtOH abuse, hypertension, left knee surgery, HTN, HLD
Social History:
Lives with girlfriend. [**Name (NI) 1403**] as a national accounts manager for
a [**Location (un) **] manufacturer.
- EtOH abuse, reported sober since [**2102-1-23**]
- tobacco: 30pk-yr history, quit [**11-30**]
- illicits: none
Family History:
non-contributory
Physical Exam:
On admission:
VS: 98.9 147/90 75 18 97RA
GEN: Alert, pleasant, NAD
HEENT: MMM
NECK: C-collar in place
CV: RRR no m/r/g
PULM: CTA B
ABD: NABS. S/NT/ND.
EXT: WWP, 2+ PT and radial pulses, no edema.
NEURO: 5/5 strength in all ext, except [**3-27**] in R forearm
extension and abd at shoulder (limited by pain). Sensation
intact to lt touch in all ext.
.
upon initial consult
General: NAD, AOx3
Chest: no egophony, absent BS LLL, dull to percussion
CV: RRR, S1/S2 appreciated, no R/M/G
Abdomen: soft, NT/ND
Ext: no C/C/E
Pertinent Results:
CT c-spine [**3-28**]:
1. Mixed lytic/sclerotic destruction of endplates at multiple
levels of the
cervical spine consistent with chronic osteomyelitis.
2. Multilevel degenerative changes and mild spinal canal
stenosis at the
level of C6.
.
CXR [**3-28**]: No previous images. There is a moderately large left
pleural
effusion with underlying compressive atelectasis. No evidence of
acute focal
pneumonia.
.
[**3-28**]: MRI thoracic/lumbar spine-1. Anterior and posterior
epidural abscesses extending from the thoracic into
the lumbar spine as described above, with abnormal thickening
and enhancement
of the dura as well as several nerve roots in the cauda equina.
2. Incompletely assessed abnormal signal and enhancement within
the C6-7
intervertebral disc and C7 vertebral body, better seen on the
recent MRI of
the cervical spine, compatible with the known
discitis/osteomyelitis. Probable
hemangioma in the T11 vertebral body anteriorly; continued
attention to this
area on follow up is recommended to exclude any superimposed
infection.
3. Abnormal signal within the thoracic cord at T10-11 without
abnormal
enhancement. This could represent edema or ischemic change
resulting from the
surrounding abnormalities. No thoracic or lumbar cord
compression.
4. Abnormal signal in the posterior soft tissues of the lumbar
spine
suggestive of inflammation. Abnormal enhancement within the
right psoas
muscle without discrete fluid collection. Left L4-5 facet
effusion.
5. Loculated fluid collection within the left lower lobe of the
lung.
6. Dark bone marrow signal diffusely on T1 weighted images
suggestive of
chronic anemia versus bone marrow replacement.
.
ECHO [**3-30**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 60%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. 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 regurgitation. No masses or vegetations
are seen on the aortic valve. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: no vegetations seen
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
.
[**3-30**]: fluoro aspiration: Successful epidural aspiration at L4-5
and L2-3.
.
[**3-31**] CT head:
1)Moderate sized left pleural effusion with smooth pleural
thickening and
probable loculation is incompletely evaluated in the absence of
IV contrast.
2)Diffuse tiny centrilobular nodules are predominantly in the
left lower lobe,
suggesting a diffuse bronchiolitis, possibly due to a viral
infection.
3)Mediastinal and epicardial lymph node enlargement is most
likely reactive.
4)A left side PICC line is directed into the left IJV and should
be
repositioned. The PICC will be repositioned by IR today
.
[**3-31**] UE US: Thrombophlebitis involving the distal aspect of the
left cephalic
vein. No evidence of deep venous thrombus.
.
[**4-2**]: cp-spine: Unchanged sequelae of cervical spine
osteomyelitis.
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**2102-3-28**] for evaluation and
treatment of cervical osteomyelitis as well as aspiration
pneumonia and bacteremia, after having recently received
treatment at an outside hospital for aspiration pneumonia and
bacteremia. On [**2102-4-4**], the patient underwent a left
video-assisted thoracoscopic converted to left thoracotomy and
decortication of lung, which went well without complication
(please refer to Operative Note for details). Post-operatively,
the patient was transferred to the thoracic surgery service and
the patient remained intubated for positive pressure to maintain
lung inflation and was transferred to the TSICU for
post-operative care.
.
-Osteomyelitis: pt was admitted for evaluation of his cervical
osteomyelitis. He was seen by orthopedics who recommended no
immediate surgical intervention and c-collar for 6 weeks.
Pain: He was treated with oxycodone, acetaminophen, tramadol and
neurontin for pain control with good effect. Blood cxs remained
negative throughout the admission, however several were pending
on discharge and will require follow up.
.
-Epidural abcesses: pt was noted to have multiple
thoracic/lumbar epidural abcesses which were drained by
interventional neurology. Fluid was sent for gram stain/cx with
no evidence of organisms or growth. Neuro exam was normal
throughout the admission.
.
-pleural effusion: known from prior admission, without any
evidence of respiratory compromise. Given his history of
bacteremia, an attempt at thorocentesis was made but was
unsuccessful, necessitating thoracotomy and decortication
procedure.
.
-anemia - Pt with a history of heavy EtOH use and has a
normocytic anemia. Iron studies are indicative of an anemia of
chronic disease.
*monitor Hct
.
-leukocytosis-likely due to osteomyelitis, epidural abcesses and
surgical intervention. Initially improved with abx.
.
-thrombocytosis - likely reactionary, secondary to cervical
osteomyelitis
.
-htn - pt was continued on his home dose of atenolol
.
-hyperlipidemia - pt was continued on his home statin
.
-Thrombophlebitis-noted in LUE after treatment with vanco. US
showed no clot.
.
Neuro: No issues
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The patient's
osteomyelitis and epidural abscess was determined to be
non-operative and to be to be treated with a course of IV
antibiotics. Blood cxs remained negative throughout the
admission. He was followed by infectious disease recommended 6
week course of Vancomycin [**Date range (1) 86699**] in the setting of
osteomyelitis, epidural abcesses and hx of MSSA bacteremia as
well as MRSA growth in endotracheal tube at last admission and
in the nares. Goal Vancomycin trough 15-20. His Vancomycin
trough on [**2102-4-7**] was 9.0 his dose was increased to 1.5g.
Repeat trough level will be checked on Monday [**4-10**] and results
will be faxed to the ID whom will make further recommendations.
PICC line: Single lumen placed [**2102-3-31**] left basilic 47 cm
terminated in SVC.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Disposition: He was discharged to home with Critical Care Systms
in [**Location (un) 8985**].
Phone [**Telephone/Fax (1) 86700**], fax [**Telephone/Fax (1) 86701**]. He will follow-up with
ID, Spine and Dr. [**First Name (STitle) **] as an outpatient.
Medications on Admission:
Atenolol 25, Ferrous sulfate 325'', Folic acid 1, Protonix 40,
Simvastatin 40, Tamsulosin 0.4, MVI, Percocet 2 tabs q4H
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Atenolol 25 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. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
scoop PO DAILY (Daily).
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
8. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Disp:*90 Tablet(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. Vancomycin 500 mg Recon Soln Sig: 1500 (1500) mg Intravenous
every twelve (12) hours for 5 weeks: Goal Trough 15-20.
Disp:*qs solution* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
1. left-sided loculated pleural effusion
2. cervical spine osteomyelitis w/spinal epidural abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101 chills, or shakes
-Increased shortness of breath, cough or sputum production
-Chest pain
-Difficulty or painful swallowing, nausea, vomiting
-You may shower. No tub bathing or swimming for 4 weeks
-Incision develops drainage: staples remain until seen by Dr.
[**First Name (STitle) **]
[**Name (STitle) 86702**] bandaid over left chest tube site and change daily until
healed
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] [**4-20**] 9:00am on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Chest X-Ray 30 minutes before your appt on the [**Location (un) 861**]
Radiology
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2102-4-17**] 10:00 in the [**Last Name (un) 2577**] Building Ground Floor [**Last Name (NamePattern1) 10357**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3736**] Spine
Center Date/Time:[**2102-5-8**] 10:45 ortho [**Hospital Ward Name 516**] [**Hospital Ward Name 23**]
Clinical Center [**Location (un) **]
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16976**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2102-5-15**] 9:30 infectious disease [**Last Name (un) 2577**] Building
Ground floor [**Last Name (NamePattern1) **]
Weekly labs: Please fax results to ID RN [**Telephone/Fax (1) 432**]
Completed by:[**2102-4-11**]
ICD9 Codes: 5119, 2859, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7390
} | Medical Text: Admission Date: [**2145-7-6**] Discharge Date: [**2145-7-11**]
Date of Birth: [**2145-7-5**] Sex: M
Service: NBB
[**Doctor Last Name 5045**] [**Known lastname 63127**], boy #1, was born at 32 and 4/7 weeks
gestation by cesarean section for worsening maternal
pregnancy induced hypertension. The mother is a 34 year old
gravida I, para 0, now II woman. Her prenatal screens are
blood type A positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis surface antigen negative and group B
strep positive. This pregnancy was complicated by pregnancy
induced hypertension, gestational diabetes and cervical
shortening with cerclage placement. The mother received a
complete course of betamethasone prior to delivery. Rupture
of membranes occurred at the time of delivery. Meconium
stained amniotic fluid was noted for twin #1. He was
intubated in the delivery room. There was no meconium noted
below the cord. The infant's birth weight was 2450 grams. The
infant remained at [**Hospital **] Hospital in the special care
nursery on continuous positive airway pressure and was
transferred to [**Hospital1 **] due to worsening
respiratory distress syndrome and lack of available bed space
at [**Hospital **] Hospital.
On admission to the [**Hospital3 **] NICU on [**2145-7-6**], the
infant was a premature infant, active, with moderate work of
breathing on continuous positive airway pressure. Anterior
fontanelle soft and flat. Palate intact. Neck supple and
without mass. Chest with moderate aeration, moderate
grunting, flaring and retracting. The heart was regular rate
and rhythm, no murmur. Abdomen soft, nontender and
nondistended, no hepatosplenomegaly. Testes descended
bilaterally, Patent anus. Stable hip exam and age appropriate
tone and activity.
NICU COURSE BY SYSTEMS: Respiratory status: He was intubated
soon after admission. He received 2 doses of Surfactant and
then weaned to nasopharyngeal continuous positive airway
pressure on day of life #2 and weaned to room air on day of
life #3 where he has remained. On exam, he has some very mild
subcostal retractions. Lung fields are clear and equal. He
has had 1-4 episodes of apnea and bradycardia in a 24 hour
period. He has not been treated with caffeine.
Cardiovascular status: He has remained normotensive
throughout his NICU stay. On exam, his heart has a regular
rate and rhythm and no murmur.
Fluid, electrolyte and nutrition status: At the time of
discharge, his weight is 2275 grams. Enteral feeds were begun
on day of life #3 and advanced without difficulty to full
volume feeding on day of life #6. At the time of discharge,
he is eating on full feeds of total fluids 140 ml/kg per day
of preemie Enfamil 20 calories per ounce by gavage. He has
remained euglycemic throughout his NICU stay with adequate
amounts of urine and passing meconium stool.
Gastrointestinal status: Phototherapy was begun on day of
life #4 for his peak bilirubin which was total 12.2 and
direct 0.4. A bilirubin is being done on the day of
discharge.
Hematology status: He has received no blood product
transfusions during his NICU stay. His hematocrit on
admission at [**Hospital **] Hospital was 44, platelets 232,000.
Infectious disease status: He was started on ampicillin and
gentamicin at the time of admission for sepsis risk factors.
Antibiotics were discontinued after 48 hours when the blood
cultures were negative and the infant was clinically well.
His white count at the time of admission was 12.2 with a
differential of 50 polys and 0 bands. The blood cultures
remained negative.
Sensory: Audiology hearing screen has not yet been performed.
It was recommended prior to discharge.
Psychosocial: The parents have been involved in the infant's
care throughout the NICU stay. The mother was transferred to
[**Hospital1 **] on day of life #2. The infant is
discharged in good condition.
The infant is transferred back to [**Hospital **] Hospital Special
Care Nursery.
Primary pediatric care will be provided by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44793**] of
[**Location (un) 37540**] Pediatrics. Address [**Last Name (un) **], [**Hospital1 **],
[**State 350**]. Telephone number [**Telephone/Fax (1) 63128**].
RECOMMENDATIONS AFTER DISCHARGE:
1. Feedings: Total fluids of 140 ml/kg/day of preemie Enfamil
20 calories per ounce, increasing calories as needed.
2. The infant is discharged on no medications.
3. Car seat position screening test is recommended prior to
discharge.
4. A State newborn screen was sent on [**2145-7-8**].
5. The infant received his first hepatitis B vaccine on the
day of delivery at [**Hospital **] Hospital.
DISCHARGE DIAGNOSES: Prematurity at 32 and 4/7 weeks
gestation.
Twin #1.
Status post respiratory distress syndrome.
Sepsis ruled out.
Hyperbilirubinemia of prematurity.
Apnea of prematurity.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2145-7-11**] 03:00:13
T: [**2145-7-11**] 09:59:25
Job#: [**Job Number 63129**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7391
} | Medical Text: Admission Date: [**2150-7-2**] Discharge Date: [**2150-7-4**]
Date of Birth: [**2150-7-2**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 43174**], [**Name2 (NI) 37336**] #3,
was born at 35 weeks gestation to a 28 year old Gravida 6,
Para 4, now 6 woman. Her prenatal screens are blood type 0
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis surface antigen negative and group B Streptococcus
negative.
Her prenatal course was significant for this [**Name2 (NI) 37336**] in [**Last Name (un) 5153**]
fertilization, pregnancy-induced hypertension with normal
laboratory values and no medication required except for
magnesium on the day of delivery.
Obstetrical history is remarkable for pregnancy-induced
hypertension with pregnancy in [**2139**] requiring a primary
cesarean section. Repeat cesarean section at 36 weeks
gestation in [**2141**] and [**2148**], a tubal ligation in [**2148**] and a
failed reversal of a tubal ligation in [**2150**]. She was
therefore treated with in [**Last Name (un) 5153**] fertilization which resulted
in this [**Last Name (un) 37336**] pregnancy.
Maternal history is remarkable for history of a seizure
disorder requiring no medications during pregnancy and the
last seizure occurring 1 1/2 years ago.
Due to contractions noted and maternal hypertension,
the infants were delivered by cesarean section.
This infant emerged active with good respiratory effort.
Apgars were 8 at one minute and 9 at five minutes.
The birthweight was 1,985 gm, 25th to 60th percentile and
head circumference was 31 cm in the 25th percentile.
PHYSICAL EXAMINATION: The admission physical examination
reveals an active vigorous preterm infant. The anterior
fontanelle is open and flat, mild intercostal and subcostal
retractions. Breathsounds were clear. Normal S1 and S2
breathsounds. Pink and well perfused. Soft abdomen,
nontender and nondistended. Appropriate and symmetric tone
and reflexes. Stable hip examination, patent anus, fine
intact and normal preterm external female genitalia.
HOSPITAL COURSE: Respiratory status - The respiratory
distress resolved within a few hours of admission to the
Nursery Intensive Care Unit. The infant has always remained
in room air. Lungsounds are clear and equal.
Cardiovascular status - The infant has remained normotensive
throughout her Nursery Intensive Care Unit stay. She has a
normal S1, S2 heartsound and no murmur. There are no
cardiovascular issues.
Fluids, electrolytes and nutrition - Her weight at the time
of transfer is 1,910 gm. She is eating Enfamil 20 or
breastfeeding on an ad lib schedule. She has kept her
glucoses in the 60s to 70s range during her Nursery Intensive
Care Unit stay.
Gastrointestinal status - The bilirubin drawn on [**2150-7-4**]
is a total of 5.2, direct 0.3. She has passed meconium
stool.
Hematological status - Her hematocrit at the time of
admission was 48, platelets 340,000. She has received no
blood products during this Nursery Intensive Care Unit stay.
Infectious disease status - Blood culture was sent at the
time of admission for sepsis suspect, the infant is
clinically well and blood culture remains negative at the
time of transfer to the Nursery Intensive Care Unit.
Social status - The mother was transferred here to [**Hospital6 1760**] from [**State 1727**].
The infant is in good condition on transfer to the Newborn
Nursery for continuing care. Primary pediatric care will be
provided in [**State 1727**] by Dr. [**Last Name (STitle) 43178**], telephone [**Telephone/Fax (1) 43179**].
CARE RECOMMENDATIONS: (At the time of transfer)
1. Feedings - The infant is eating Enfamil 20 or
breastfeeding with PC formula until the mother's milk is well
established on a three hour schedule.
2. Medications - The infant is transferred on no
medications.
3. Carseat screening - A carseat position screening test has
not been done but will need to be done prior to discharge.
4. State newborn screen - Needs to be sent prior to
discharge.
5. The infant has received no immunizations.
6. Newborn hearing screening should be performed prior to
discharge to home.
DISCHARGE DIAGNOSIS:
1. Prematurity 35 weeks gestation
2. [**Telephone/Fax (1) **] #3
3. Status post transitional respiratory distress
4. Rule out sepsis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2150-7-4**] 20:20
T: [**2150-7-4**] 20:56
JOB#: [**Job Number 43181**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7392
} | Medical Text: Admission Date: [**2175-4-14**] Discharge Date: [**2175-4-25**]
Date of Birth: [**2115-2-26**] Sex: M
Service: CCU
CHIEF COMPLAINT: Dyspnea, respiratory failure.
HISTORY OF PRESENT ILLNESS: This is a 63-year-old male with
long tobacco use history, known coronary artery disease,
severe chronic obstructive pulmonary disease, status post
myocardial infarction in [**2170**], and restenosis in [**2172**], now
transferred from [**Hospital6 2910**] for cardiac
catheterization.
Patient of Dr. [**Last Name (STitle) **], presented to Dr. [**Last Name (STitle) **] earlier this month
with a complaint of increased dyspnea and stress test showed
severe reversible inferior ischemia. The patient was taken
to cardiac catheterization on [**2175-4-11**] at [**Hospital6 1322**] which showed RA pressure of 6, PA pressure of 46/20,
LV pressure of 112/26, RV pressure of 46/6, and pulmonary
capillary wedge pressure of 14. Patient had a cardiac index
of 2.05, and a SVR of 1494. He was also shown to have
moderate luminal irregularities in the mid RCA. There was
99% stenosis of the prior stent in the RCA distally. The
left circumflex artery was patent, as was the left main and
the left anterior descending artery. Ejection fraction of
30-40% with global hypokinesis, no MR, there was a question
of a 60% stenosis of the external iliac.
Status post catheterization, patient went into hypoxic
respiratory failure. He was suctioned without improvement,
and was transferred to [**Hospital6 2910**] MICU,
where he was intubated. He was thought to be in congestive
heart failure and was diuresed and extubated on [**2175-4-12**]. He
was also given steroids for presumed chronic obstructive
pulmonary disease exacerbation. Postintubation, the patient
again became dyspneic and tachypneic, and had to be
reintubated.
There is a question of a right lower lobe infiltrate. The
patient was bronched with mucus plug aspirate from the right
lower lobe and left lower lobe. Of note, the patient's
systolic blood pressure at [**Hospital6 2910**]
decreased into the 70s to 80s when he was sedated. Nutrition
evaluation revealed moderate malnutrition.
Patient was transferred to [**Hospital1 188**] for PTCA and brachytherapy of instent restenosis.
Cardiac catheterization on [**2175-4-14**] at [**Hospital1 190**] revealed 99% right coronary artery lesion,
successfully PTCA with brachytherapy. His pressures were RA
43/13, RV 45/14, PA 44/27, pulmonary capillary wedge was 20,
and aortic outflow was 118/76.
PAST MEDICAL HISTORY:
1. Ankylosing spondylitis.
2. Status post gastrectomy.
3. Peripheral vascular disease.
4. Paget's disease.
5. Chronic obstructive pulmonary disease, on home O2 through
trache.
6. Coronary artery disease, status post inferior and anterior
myocardial infarction in [**2170**] with cardiogenic shock
requiring intra-aortic balloon pump. LAD, LCX, RCA stented.
Restenosis and PTCA in [**4-/2173**]
7. MRSA, two years ago.
8. Congestive heart failure with ejection fraction of 25-30%
in [**2170**].
TRANSFER MEDICATIONS:
1. Percocet prn.
2. MS Contin 100 mg po q8h.
3. [**Last Name (un) **]-Dur SR 100 mg po q day.
4. Aldactone 25 mg po q day.
5. Zestril 5 mg po q day.
6. Plavix 75 mg po q day.
7. Propofol.
8. Protonix 40 mg po q day.
9. Flovent.
10. Reglan.
11. Prednisone at home, discontinued.
12. Solu-Medrol 50 mg IV q6h.
13. Zithromax 500 mg po q day taken from [**4-12**] through [**4-14**].
14. Zoloft 50 mg po q day.
15. Lopressor 2.5 mg IV q4h.
16. Lasix 40 mg IV q day.
17. Ativan prn.
LABORATORIES FROM [**Hospital6 **] ON [**2175-4-13**]:
white count 13.3, hematocrit 30.2, platelets 472. PTT 66.8,
INR 1.0. Sodium 140, potassium 4.1, chloride 104, bicarb 21,
BUN 22, creatinine 0.7, glucose 194. Albumin 2.3, total
protein 5.6, total bilirubin 0.3, direct bilirubin 0.1.
Alkaline phosphatase 282, ALT 16, AST 45, Theophylline 308.
CK trended from 42 to 106 to 76, troponin trended from 2.4 to
2.7 to 1.5.
Electrocardiogram: Precath shows Q waves in leads II, III,
and aVF which are old, low voltage, T-wave inversions in aVL.
Postcatheterization electrocardiogram from [**Hospital1 346**] shows low voltage, old Q waves in
II, III, and aVF, and T-wave inversion in V2.
PHYSICAL EXAMINATION: Vital signs: Temperature 99.0, blood
pressure 127/82, heart rate 109, respiratory rate 20, vent
sating is AC at 60%, tidal volume of 600, respiratory rate of
14, and a PEEP of 5. In general, the patient is emaciated
appearing, older than his age. HEENT: Jugular venous
pressure at 10-11 cm. Chest: Crackles at the right base
laterally. Cardiovascular: Tachycardic, no murmurs, rubs,
or gallops. Abdomen is soft, nontender, nondistended, chest
wall is severely hyperexpanded. Extremities: 2+ dorsalis
pedis pulses bilaterally. Neurologic: Intubated, following
commands.
HOSPITAL COURSE: In short, this is a 60-year-old male with
history of severe chronic obstructive pulmonary disease,
coronary artery disease, who presents with instent
restenosis, status post PTCA and brachytherapy with
respiratory failure.
1. Coronary artery disease: After his catheterization
in-house, the patient did not complain of any kind of chest
pain or discomfort. He was placed on a good cardiac regimen.
He was continued on aspirin, started on Plavix. He was also
continued on Lopressor 25 mg po bid. Patient's lisinopril
dose was titrated up to 10 mg po q day as his pressure
tolerated. Patient did not receive Integrilin
postcatheterization as per Dr. [**Last Name (STitle) **].
2. Pump: Patient's echocardiogram from [**4-14**] shows an
ejection fraction of 30% with inferior akinesis and a
hypokinetic RV. During the patient's hospitalization, he did
have an episode of hypoxia, and it was thought that there was
a contribution from failure. His regular Lasix dose was not
sufficing. Patient received 40 of IV Lasix which led to good
diuresis, but the patient was quite sensitive in terms of his
blood pressure. Otherwise, the patient's lisinopril dose was
able to be titrated up to 10 mg po q day over several days as
his hemodynamics improved.
3. Blood pressure: The patient had an episode of
hypertension while on the vent, going down to 75/48. This
was thought to be secondary to Lasix.
4. Rhythm: Patient did not have any arrhythmias while
in-house.
5. Pulmonary: Patient was overall difficult to wean, which
extended his hospital stay. This was thought to be due to a
combination of his chronic obstructive pulmonary disease and
developing pneumonia in his lower lung bases. The Pulmonary
team was consulted. Patient was initially on AC mode
ventilation. While he tolerated this, he was quite easily
able to transition to pressure support mode, and it was not
felt that the patient was tiring out. However, at one point,
the patient may have received too much in terms of narcotics,
which elevated his pCO2. This is still unclear as the
patient has a very high narcotic threshold. While in-house,
the patient received bronchoscopy. This revealed clean
bronchial tree. There was very little that was suctioned
out. Once the infection was under control with the proper
antibiotics, we were able to lower his PEEP enough that he
could be extubated. Patient was extubated on [**Last Name (LF) 2974**], [**4-21**]. Overall, his chest x-ray was consistent with bilateral
atelectasis versus pneumonia, with varying degrees of
pulmonary edema.
Once the patient was extubated, he was placed on 6 liters of
O2 through his trache stoma, and 12 liters of shovel mask as
needed. Given his pulmonary improvement, the patient did not
need any revision of his trache stoma as it had originally
been thought during his stay here.
Patient's gas from [**4-22**] after he was extubated was 7.42, 51,
50. We believe that the patient generally has a very low
pAO2 baseline around 45-50. We have been targeting his O2
saturation to high 80's to low 90's. Patient was also
weaned off of his steroids as he was not really thought to be
in chronic obstructive pulmonary disease exacerbation.
Patient is currently on 5 mg of prednisone. That will be
continued for one week, through [**2175-4-30**].
6. ID: During the patient's hospitalization, he spiked up to
102. Blood cultures from [**4-19**] showed 1/2 bottles that
eventually grew Serratia marcescens, sensitive to
ceftazidime, which was the antibiotic with the lowest MIC
other than meropenem. In addition, the patient's sputum from
[**4-19**] grew MRSA, sensitive to Vancomycin and clindamycin.
Patient was started on ceftazidime and Vancomycin for a two
week course. A single lumen PICC line was placed without
difficulty. After commencing antibiotics, the patient no
longer had any spikes. Patient's white blood cell count
remained stable.
7. Pain control: The patient is normally on MS Contin for
his ankylosing spondylitis. He was converted to MSIR while
intubated. He was placed back on MS Contin at 60 mg po q8h.
This is lower than his normal dose. He was also given prn
oxycodone. He may need to have his MS Contin dose raised.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg po q day.
2. Alprazolam 0.25 mg po tid.
3. Lopressor 25 mg po bid.
4. Protonix 40 mg po q day.
5. Theophylline SR 100 mg po bid.
6. Lisinopril 10 mg po q day.
7. MS Contin 60 mg po q8h.
8. Xanax 0.25 mg po tid prn.
9. Prednisone 5 mg po q day.
10. Oxycodone 5-10 mg po q4-6h prn.
11. Digoxin 0.125 mg po q day.
12. Vancomycin 1 mg IV q12h, through [**2175-5-4**].
13. Atrovent MDI four puffs IH [**Hospital1 **].
14. Insulin-sliding scale.
15. Lactulose 30 mL po q8h prn constipation.
16. Ceftazidime 1 gram IV q8h through [**2175-5-4**].
17. Heparin 5,000 units subQ q12h.
18. Aspirin 325 mg po q day.
19. Albuterol two puffs IH q6h and 1-2 puffs IH q2h prn.
20. Zoloft 50 mg po q day.
21. Colace 100 mg po bid.
22. Salmeterol two puffs IH [**Hospital1 **].
23. Fluticasone 110 mcg, six puffs IH [**Hospital1 **].
24. Aldactone 25 mg po q day.
25. Tylenol 325-650 mg po q4-6h prn.
26. Plavix 75 mg po q day, duration 30 days.
DISCHARGE INSTRUCTIONS: Patient will followup with Dr. [**Last Name (STitle) **]
for his cardiac needs. Otherwise, he will complete the two
week course of Vancomycin and ceftazidime for presumed
pneumonia.
DISCHARGE DIAGNOSES:
1. Severe chronic obstructive pulmonary disease, with
difficulty weaning from ventilator.
2. Pneumonia.
3. Coronary artery disease, status post percutaneous
transluminal angioplasty and brachytherapy of right coronary
artery stent.
4. Ankylosing spondylitis with chronic pain.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2175-4-25**] 07:02
T: [**2175-4-25**] 07:28
JOB#: [**Job Number 96297**]
ICD9 Codes: 486, 496, 7907, 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7393
} | Medical Text: Admission Date: [**2145-12-28**] Discharge Date: [**2146-1-14**]
Date of Birth: [**2064-8-10**] Sex: F
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:
[**2145-12-30**] Coronary Artery Bypass Graft x 4 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
Diagonal, Saphenous vein graft to Ramus, Saphenous vein graft to
Obtuse Marginal)
[**2145-12-29**] Cardiac cath
History of Present Illness:
Ms. [**Known lastname 102405**] is a 81 female with multiple coronary artery
disease risk factors and previous strokes with dementia who
presented with acute onset chest pain. ED initially was not
concerned as patient had negative MIBI [**4-17**] and was originally
going to be ruled out and scheduled for a stress test. However
her troponin returned elevated at 0.21 so patient was started on
a heparin drip, got Aspirin 325mg, and was transferred to the
floor without plavix load.
Past Medical History:
Stroke w/ residual left sided weakness, Hypertension,
Hyperlipidemia, Diabetes Mellitus, Dementia, Gastroesophageal
Reflux Disease, Recurrent urinary tract infections, Iron
defiency anemia, Recurrent falls, s/p Hysterectomy
Social History:
Lives at [**Hospital3 **]- Country Club Heights in [**Location (un) 246**]. Has
daughter lives close by in [**Name (NI) 2436**]. She needs assitance with
showers. She is independent in ambulating with a walker, eating
and toileting
IADLS: Need assitance with shopping, bills, daughter does meds,
food preparation. She is independent with telephone use
Quit smoking 30 to 40 years ago. Occasional ETOH.
She has pre-existent home care services
+ H/o fall within 3 months
+ Unsteady gait?
+ Visual aides
Family History:
father had afib and CVA in 70s.
Two cousins with [**Name2 (NI) 499**] cancer.
Physical Exam:
Admission
VS - 97.0 162/77 86 18 100% on RA
Gen: elderly F in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 3 cm at 45' angle.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: slight crackles at the bases.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: wwp, no edema. slight brawny stasis dermatitis.
Discharge
VS T 97.4 HR 72SR BP 130/75 RR 18 O2sat 96%-RA
Gen NAD
Neuro A&Ox3, residual left sided weakness. Able to ambulate with
walker.
Pulm CTA-bilat
CV RRR, no M/R/G. Sternum stable, incision CDI
Abdm soft, NT/+BS
Ext warm well perfused. 1+ pedal edema bilat. Small rt arm
phlebitis- improving over last few days
Pertinent Results:
[**2145-12-28**] 09:30PM CK(CPK)-78
[**2145-12-28**] 09:30PM PT-12.4 PTT-32.8 INR(PT)-1.0
[**2145-12-28**] 01:00PM GLUCOSE-135* UREA N-19 CREAT-0.9 SODIUM-138
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2145-12-28**] 01:00PM cTropnT-0.21*
[**2145-12-28**] 01:00PM WBC-9.9 RBC-3.98* HGB-11.8* HCT-34.6* MCV-87
MCH-29.7 MCHC-34.2 RDW-13.6
[**2145-12-28**] 01:00PM PLT COUNT-336
[**2145-12-28**] 01:00PM PT-11.7 PTT-22.2 INR(PT)-1.0
[**2146-1-14**] 05:06AM BLOOD WBC-11.5* RBC-3.48* Hgb-10.8* Hct-31.1*
MCV-89 MCH-31.1 MCHC-34.8 RDW-15.0 Plt Ct-688*
[**2146-1-14**] 05:06AM BLOOD Plt Ct-688*
[**2146-1-7**] 12:08PM BLOOD PT-12.6 PTT-28.6 INR(PT)-1.1
[**2146-1-14**] 05:06AM BLOOD Glucose-141* UreaN-25* Creat-1.3* Na-137
K-4.4 Cl-100 HCO3-28 AnGap-13
[**2145-12-29**] 10:10AM BLOOD %HbA1c-7.2*
[**2145-12-29**] Cardiac Cath: 1- Selective coronary anguiography of
this left-dominant system demonstrated severe diffuse three
vessel coronary artery disease with markedly calcific vessels.
The distal LMCA/ostial LCX had 80% stenosis and the mid and
distal LCX had each 70% stenosis serially. The LAD had 70%
diffuse bifurcation stenosis at mid vessel with 60% stenosis in
the ostial major diagonal brancg. There was a small high
diagonal vessel(RI) with 30% stenosis. The RCA was a diminutive
vessel with 40% diffuse stenosis throughout. 2- Limited resting
hemodynamic assessment revealed normal systemic arterial
pressure (121/60 mmHg). The left-sided filling pressures were
normal at baseline (LVEDP 11 mmHg, increased to 16 mmHg after LV
gram). 3- Left ventriculography revealed normal LVEF (60-65%)
without regional wall motion abnormalities or mitral
regurgitation.
[**2145-12-29**] Carotid U/S: Less than 40% stenosis of the internal
carotid arteries bilaterally.
[**12-30**] Head CT:1. No significant interval change from prior MR
examination from [**2142-5-20**] with no acute infarction or hemorrhage
identified. 2. Multiple old lacunar infarctions of the bilateral
cerebellar hemispheres and pons, and changes consistent with
chronic small vessel ischemic disease.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 102406**] (Complete)
Done [**2145-12-30**] at 10:02:05 AM FINAL
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: [**2064-8-10**]
Age (years): 81 F Hgt (in):
BP (mm Hg): 108/65 Wgt (lb):
HR (bpm): 75 BSA (m2):
Indication: intraoperative management of CABG.
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2145-12-30**] at 10:02 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.8 cm
Left Ventricle - Fractional Shortening: *0.24 >= 0.29
Left Ventricle - Ejection Fraction: 60% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - LVOT diam: 1.8 cm
Aortic Valve - Valve Area: *1.4 cm2 >= 3.0 cm2
Aortic Valve - Pressure Half Time: 738 ms
Mitral Valve - Pressure Half Time: 77 ms
Mitral Valve - MVA (P [**2-10**] T): 2.8 cm2
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.11
Findings
LEFT ATRIUM: Moderate LA enlargement. Elongated LA.
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 diameter of aorta at the sinus, ascending and arch
levels. Complex (>4mm) atheroma in the aortic arch. Normal
descending aorta diameter. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Results were
Conclusions
PREBYPASS
1. The left atrium is moderately dilated. The left atrium is
elongated. No atrial septal defect or PFO is seen by 2D or color
Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are complex (>4mm) atheroma in the aortic arch. There
are complex (>4mm) atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
7. There is no pericardial effusion.
8. Dr.[**Last Name (STitle) 914**] was notified in person of the results in the OR at
the time of surgery
POSTBYPASS
1. Patient is on XX infusions.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2146-1-3**] 14:46
Radiology Report CHEST (PA & LAT) Study Date of [**2146-1-12**] 9:13 AM
[**Hospital 93**] MEDICAL CONDITION: 81 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
EVALUATE EFFUSIONS
Provisional Findings Impression: MLKb WED [**2146-1-12**] 10:50 AM
Decrease in amount of pleural effusion.
Final Report
HISTORY: 81-year-old female, status post CABG. Evaluate
effusions.
COMPARISON: Prior study, [**2146-1-10**].
FINDINGS: Status post sternotomy with surgical clips post-CABG.
There is
decreasing amount of pleural effusion seen on the lateral views.
Right-sided PICC line is again seen with the tip in the SVC.
Unchanged appearance of the cardiomegaly and bilateral bibasal
atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 75229**] [**Name (STitle) **]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: WED [**2146-1-12**] 12:20 PM
Brief Hospital Course:
As mentioned in the HPI, Mrs. [**Known lastname 102405**] was admitted from the
emergency room after she was found to have a non-ST segment
elevation myocardial infarction. She was appropriately medically
managed and worked up for cardiac surgery. On [**12-30**] she was
brought to the operating room where she underwent a coronary
artery bypass graft x 4. The procedure was performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]. Please see operative report for surgical
details. In summary she had CABG x4 with LIMA-LAD, SVG-Diag,
SVG-Ramus, SVG-OM. She tolerated the operation well and
following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. She remained intubated for three
days after surgery secondary to a difficult airway and fluid
overload. She was weaned from her pressors and her chest tubes
were removed. She was fed via a dobhoff tube after surgery
secondary to somnolence. She was noted to be confused after the
surgery, but also has a baseline history of dementia. Her beta
blockade was titrated up as tolerated. On post-operative day
seven she was transferred to the surgical step down floor. She
had intermitant episodes of atrial fibrillation with hypotension
and was returned to the surgical intensive care unit, where she
converted to sinus rhythm after adjustment of Bblockers and
initiation of amiodarone. Her mediastinal incision was noted to
have some purulent drainage and she was started on Vancomycin
and ciprofloxacin. She was transferred back to the step down
floor on post-operative day nine. Sternal drainage subsided and
her sternum remained stable. As discussed with Dr.[**Last Name (STitle) 914**], Cipro
was discontinued and upon discharge, Vancomycin will be
continued for 7 days. She was seen by phyisical therapy. On
post-operative day 15 she was discharged to rehabilitation at
[**Hospital6 **].
Medications on Admission:
Alendronate 70 mg PO qweekly, Imipramine 20 mg PO QHS,
Lisinopril 10 mg PO qAM, Metoprolol XL 50 mg PO QHS, MVI (noon),
Nitrofurantoin 100 mg PO 3x/week MOWFri, Prilosec 20 mg PO
[**Hospital6 **], Simvastatin 20 mg PO [**Last Name (LF) **], [**First Name3 (LF) **] 81 mg PO daily, Calcium
Carbonate 750 mg PO TID, Vitamin D3 800 PO [**First Name3 (LF) **], Ferrous
Sulfate 325 mg PO [**First Name3 (LF) **], Aggrenox 200-25 mg PO BID, Simethicone
80 mg PO QID, Glyburide 1.25 mg PO QAM, Metformin 500 mg PO QAM,
Glucovance 5-500 PO BID before breakfast and supper)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
4. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
Disp:*60 Cap(s)* Refills:*0*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Glyburide Micronized-Metformin 5-500 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day for 7 days.
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
15. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Myocardial Infarction, Postop atrial fibrillation
PMH: Stroke w/residual left sided weakness, Hypertension,
Hyperlipidemia, Diabetes Mellitus, Dementia, Gastroesophageal
Reflux Disease, Recurrent urinary tract infections, Iron
defiency anemia, Recurrent falls, s/p Hysterectomy
Discharge Condition:
Stable
Discharge Instructions:
Please shower daily , no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 100.5
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 one month and off [**Doctor Last Name **] narcotics
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) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in [**3-14**] weeks
Dr. [**Last Name (STitle) **] in [**2-10**] weeks
Completed by:[**2146-1-14**]
ICD9 Codes: 5185, 9971, 2851, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7394
} | Medical Text: Admission Date: [**2120-1-8**] Discharge Date: [**2120-1-13**]
Date of Birth: [**2060-1-28**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
The patient is a 59 yo F with a psychiatric history, colectomy
s/p anastamosis, A fib recently started on dabigutran, COPD and
hepatitis C who presents with several weeks of BRBPR. The
patient came to the ED yesterday complaining of 2 weeks of
bloody stools, which have been intermittent since [**12-25**].
The patient reports that she began taking Dabigutran at the end
of [**Month (only) 1096**], without evidence of any bleeding until mid-[**Month (only) 404**].
Since that time, she has been having approximately [**4-12**] stools
per day, which she describes as red liquid and clots. No fever,
chills, nausea, vomiting or abdominal pain. She initially came
to the ED over the weekend and was admitted for monitoring and
possibly colonoscopy, but left AMA after being told that she
could not leave the hospital to smoke a cigarette. According to
the patient, she went home last night, ate fish filet, Ziti and
milk, and then had a BM that consisted of blood mixed with stool
this AM. She spoke to her PCP today and was advised to return to
the ED for further workup.
.
In the ED, initial vitals were: 0 98.9 88 86/57 22 98%. Patient
triggered for hypotension on arrival, received 1.5 L IVF and BP
improved to 90s/50s. Her rectal exam was notable for maroon
stool. Labs were significant for a leukocytosis to 14 (down from
17.5 yesterday) with a mild neutrophilia and a Hct of 40.2
(stable >24hrs). U/A and CXR were unremarkable and the patient
was admitted to the medical service for further monitoring.
Vitals on transfer were HR low 100s in atrial fibrillation, rr
18, BP 91/54 and 96% RA.
.
On the floor, patient reports feeling excellent, and being
annoyed with her liquid diet. She denies any chest pain,
worsened SOB (patient has baseline chronic SOB [**1-10**] COPD),
dizziness, abdominal pain, fever, chills, nausea or vomiting.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Has chronic cough and SOB. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, constipation
or abdominal pain. No recent change in bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
s/p colectomy for unclear reasons
AFib
back pain
COPD
? Hepatitis C
? paranoid schizophrenia and borderline personality disorder -
as told to psychiatry to the patient over the weekend
Social History:
Has a longstanding relationship with her boyfriend, [**Name (NI) 1169**]
[**Name (NI) **] (w[**Telephone/Fax (1) 14520**], c[**Telephone/Fax (1) 14521**]). Lives independently with
7 animals. Currently, her son lives with her as well. Also has
an extensive trauma history. Currently smokes > 1.5 ppd, sober
from EtOH > 16 years, smokes marijuana regularly. Denies other
illicits.
Family History:
Son with Bipolar disorder, DM on mother's side of family,
psychiatric illness on father's side of family.
.
Physical Exam:
Admission Exam:
Vitals: T: 98 BP: 106/71 P: 50-140s in afib/flutter R: 18 O2:
100% on RA
General: Alert, extremely agitated, swearing, shaking and
shouting throughout interview.
HEENT: NCAT, Sclera anicteric, MMM, oropharynx clear, very poor
dentition
Lungs: Coarse breath sounds throughout, otherwise no discrete
wheezes, rales, ronchi
CV: irregularly irregular and tachycardic, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Rectal: Several small nonbleeding external hemorrhoids, no stool
in vault
Psych: labile, tangential with pressured speech and extremely
agitated to the point of shaking bed and self during interview
Discharge Exam:
VS: 99 122/89 100s AFib 22 99% RA
GEN: hyperalert and oriented, pleasant
HEENT: PERRL, EOMI, anicteric, dry MM, OP without lesions
RESP: decreased breath sounds throughout, no wheezes
CV: irregular rhythm, tachycardic, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm and well-perfused, good distal pulses
SKIN: no rashes, jaundice or ecchymosis
Pertinent Results:
Admission Labs:
[**2120-1-8**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2120-1-8**] 11:05AM GLUCOSE-111* UREA N-22* CREAT-1.0 SODIUM-137
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15
[**2120-1-8**] 11:05AM PT-12.5 PTT-28.8 INR(PT)-1.1
[**2120-1-8**] 11:00AM WBC-14.0* RBC-4.36 HGB-13.9 HCT-40.2 MCV-92
MCH-31.8 MCHC-34.6 RDW-15.0
[**2120-1-8**] 11:00AM NEUTS-78.7* LYMPHS-17.8* MONOS-2.3 EOS-0.8
BASOS-0.4
[**2120-1-7**] 10:51AM WBC-13.2* RBC-4.32 HGB-13.5 HCT-40.1 MCV-93
MCH-31.2 MCHC-33.6 RDW-14.8
[**2120-1-7**] 02:23AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2120-1-7**] 01:11AM ALT(SGPT)-29 AST(SGOT)-33 LD(LDH)-280* ALK
PHOS-69 TOT BILI-0.4
[**2120-1-7**] 01:11AM LIPASE-42
[**2120-1-7**] 01:11AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2120-1-7**] 01:11AM WBC-17.4* RBC-4.43 HGB-13.7 HCT-40.9 MCV-93
MCH-31.0 MCHC-33.5 RDW-14.6
Discharge Labs:
[**2120-1-13**] 06:30AM BLOOD WBC-7.2 RBC-4.22 Hgb-13.5 Hct-39.2 MCV-93
MCH-31.9 MCHC-34.3 RDW-16.2* Plt Ct-183
[**2120-1-13**] 06:30AM BLOOD Plt Ct-183
[**2120-1-13**] 06:30AM BLOOD PT-13.0 PTT-28.8 INR(PT)-1.1
[**2120-1-13**] 06:30AM BLOOD Glucose-87 UreaN-15 Creat-0.6 Na-142
K-3.6 Cl-111* HCO3-21* AnGap-14
[**2120-1-13**] 06:30AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.8
Imaging:
CXR: IMPRESSION:
5-mm right granuloma. Dense opacity projecting over the left
heart may
reflect costochondral calcifications, however a parenchymal
opacity is
possible and a PA and lateral chest radiograph is recommended to
further
assess initially.
CXR: FINDINGS: A single upright AP view of the chest was
obtained. The
cardiomediastinal silhouette is stably enlarged. A streaky
retrocardiac
opacity likely in the left lower lobe is new compared to the
prior study
possibly representing a developing pneumonia. A calcified
granuloma is again noted inferior to the right minor fissure.
Calcification projecting over the lower left heart border likely
represents mitral annular calcifications.
There are no pleural effusions or pneumothorax. No osseous
abnormalities are identified.
Colonoscopy Findings:
Protruding Lesions: Non-bleeding grade 1 internal hemorrhoids
were noted.
Excavated LesionsL: End to side small bowel to colon anastomosis
at about 20 cm from anal verge. At the anastomosis there was a
large area of ulceration with stigmata of recent bleeding (red
spots). No active bleeding. No intervention performed. No
biopsies secondary to anticoagulation and bleeding.
Impression: Ulcer in the colon
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to 30 cm
Recommendations: End to side small bowel to colon anastomosis at
20 cm from anal verge with ulceration with stigmata of recent
bleeding (red spots) at site. Recommend repeat colonoscopy with
biopsies in 2 weeks. If continued bleeding recommend surgical
evaluation as likely result of ischemia at site of anastomosis.
Brief Hospital Course:
This is a 59 yo F with A fib on dabigutran, COPD, hx of
colectomy and bipolar d/o who presented with several weeks of
BRBPR which is attributed to an ulcer at the site of a previous
colonic anastamosis.
.
# LGIB: The patient was immediately transferred to the MICU upon
admission for brisk LGIB and tachycardia. She was intubated for
a colonoscopy which revealed a ulcer at the site of her
anastamoses from a previous colonic anastamosis ([**Hospital1 2025**] records
obtained, and colectomy was apparently performed for severe
constipation). She received 2 units PRBCs and HCT remained
stable. Patient's HCT was stable for 3 days upon discharge and
without recurrent rectal bleeding. GI recommmended a followup
colonoscopy in 2 weeks which they will schedule during a
followup appointment. Upon their recommendation, her
anticoagulation will be held until then. This was discussed with
her outpatient cardiologist, Dr. [**Last Name (STitle) 14522**] who agreed to holding
anticoagulation until after colonoscopy in two weeks.
.
# Afib with RVR: The patient had a history of atrial
fibrillation prior to admission. She developed RVR in the MICU.
This was thought to be secondary to hypovolemia secondary to
bleeding and she was rate controlled with an esmolol gtt and
diliazem gtt; she was subsequently transitioned back to PO
medication. The patient had one episode of afib with RVR after
being transferred to the floor, but was well rate controlled in
the HR 80s before discharge. She was discharged on her home dose
of Diltiazem with increased dose Metoprolol.
.
# Cardiomyopathy: The patient's cardiac history was discussed
with her cardiologist Dr. [**Last Name (STitle) 14522**], who reported that a recent
Echo showed LVEF 40-45%, Mod MR, Asymmetrical septal
hypertrophy, LA 5.2cm. She has a question of non-obstructive
hypertrophic cardiomyopathy. He also reported that she has no
history of CAD on Cath. He had started her on Dabigatran for
anti-coagulation for afib because she had variable INRs on
Coumadin.
.
# Schizophrenia/borderline personality d/o: Upon transfer to the
MICU, the patient became agitated and required risperdal and
haldol. She was seen by psychiatry who did not feel she had
capacity at that time to make decisions regarding code status,
etc. She was much more calm upon transfer to the floor, but was
started on Risperdal and Clonazepam upon discharge per
Psychiatry reccs. Psychiatry spoke to her PCP who states that
she is willing to follow the patient on these new medications.
.
# COPD: Continue inhalers
.
# Tobacco: Nicotine patch daily
Medications on Admission:
metoprolol XR 100 mg qd
MgO 400 mg qd
diltiazem 240 mg qd
furosemide 20 m qd
advair 250/50 [**Hospital1 **]
Spiriva daily
Tylenol 1000 gm q4-6 hr prn
Albuterol inh prn
prednisone 10 mg qd as part of a steroid taper since [**12-28**]
Bactrim recently finished a 10 day course "for COPD"
Dabigitran/Pradaxa 150 mg daily since end of [**Month (only) 1096**]
Discharge Medications:
1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Take
with 50mg Tablet for total daily dose of 150mg once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day.
4. diltiazem HCl 240 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
10. clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
11. Risperdal 2 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
12. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Take
with 100mg tablet, for total daily dose of 150mg each day. .
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 185**],
You were admitted to the hospital because you were bleeding from
you GI tract. You were treated in the ICU and we performed a
colonoscopy that showed the location of the bleeding. The blood
thinner darbigatran likely caused the bleeding. You will have
to stay OFF this medication until your next endoscopy. Please
speak with your cardiologist about restarting the darbigatran.
You were also treated for atrial fibrillation with a rapid heart
beat while you were here. On discharge, your heart rate had
decreased back to your baseline.
We have made the following changes to your medications:
STOP Dabigatran. This medication contributed to your bleeding.
You will need to stay off this medication until you have an EGD
in 2 weeks. Thereafter, you should talk to your primary
provider and cardiologist about when to restart this or other
anti-coagulation.
START Clonazepam 0.5 mg by mouth twice daily and Clonazepam 1 mg
at night daily
START Risperidone 2 mg by mouth at night daily
INCREASED Metoprolol XL to 150 mg once daily - 100 mg XL Daily
and 50 mg XL daily
Please go to the scheduled followup appointments with GI and
your primary care doctor.
Followup Instructions:
1. GI followup: Department: GASTROENTEROLOGY
When: TUESDAY [**2120-1-30**] at 9:00 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
You have an appointment to see you primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 14523**], on Monday [**1-15**] at 8AM. She will followup your
new psychiatric medications and make decisions about when to
restart your anticoagulation.
ICD9 Codes: 4254, 4589, 5789, 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7395
} | Medical Text: Admission Date: [**2149-6-3**] Discharge Date: [**2149-6-13**]
Date of Birth: [**2091-10-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea x 3 days
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
57 year old man with history of DMII, IPF on prednisone 20,
chronic MRSA osteomyelitis since [**9-17**] after ankle fracture, PAF
on coumadin presents to [**Hospital3 **] ED on [**2149-6-3**] after 3
days of worsening dyspnea. The patient has a long and
complicated hospital course neatly outlined in previous
discharge summary. In brief, the patient was recently discharged
from [**Hospital1 18**] on [**2149-5-23**], admitted on [**2149-5-21**] for failed
osteomyelitis treatment on vanc and switched to daptomycin. His
bactrim PCP [**Name9 (PRE) **] was also discontinued for concern of worseing
CKD and after a 5 day gap was switched to dapsone on [**2149-5-27**].
The patient started noticing dyspnea on exertion, fatigue, and
increasing O2 requirement on [**2149-5-31**] up to 6LNC from his
baseline of 1-2LNC. On the day prior to admission he developed
an increasingly productive cough of clear/white sputum. He
decided to present to the ED.
.
In the [**Hospital3 **] ED he initially presented with the
following VS: 98 87 28 181/67 98% on NRB. He was switched
off to 6LNC, desated to 87% and replaced on NRB. Sent set of
blood cx and gave him Duonebs and Solumedrol 125mg IV ONCE. HCT
came back at 23. Pt then taken off NRB and satting 90-93% on
6LNC. Vitals at transfer were 98.4 81 182/69 22 93%6LNC. His
labs were notable for CO2 of 36, creatinine of 2.5, BUN of 91,
WBC 14.9, HCT of 23.3 (MCV 84), K 5.4, INR 3.2, Troponin <0.015.
Rectal exam was guiac negative.
.
In the ED, his vital signs were 97.8 84 160/80 20 92% 6L RA
initially. He was given gabapentin 400mg PO ONCE, vancomycin 1gm
IV ONCE, cefepime 2mg IV ONCE, azithromycin 500mg IV ONCE.
Past Medical History:
1) Interstitial lung disease on prednisone 20 daily
2) Diabetes II
3) Osteomyelitis of right ankle on daptomycin (s/p vanc failure)
4) HTN
5) HLP
6) PAF on coumadin
7) Provoked DVT in remote past
8) Obesity Hypoventilation syndrome on BIPAP
Social History:
Former businessman, on disability at present. Does not smoke,
drink, or use drugs. Good social support from wife.
Family History:
No family hx of lung disease. Mother with MI at age 48.
Physical Exam:
Admission Physical Exam
GEN: pleasant, morbidly obese, unable to complete full sentences
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions,
RESP: CTA b/l with good air movement throughout except bibasilar
rales
CV: RR, S1 and S2 wnl, no m/r/g
ABD: obese nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c 3+ edema bl
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Discharge Physical Exam
VS: 98.2 142-150/68-75 80-83 22-24 94%2LNC
I/O: 1500/3400
CBG:152/130/61/182
GEN: pleasant, morbidly obese, able to complete full sentences
HEENT: PERRL, EOMI, anicteric, MMM, OP clear without lesions
NECK: supple, unable to evaluate JVD given habitus
RESP: CTAB. No crackles or wheezing noted
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: +BS, obese, soft, nontender, nondistended, no masses or
hepatosplenomegaly, +pitting edema of skin
EXT: wwp, DP 2+ bilaterally, 3+ LE edema to the thighs
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.
Pertinent Results:
[**2149-6-3**] 07:35PM BLOOD WBC-13.9* RBC-3.20* Hgb-8.6* Hct-27.9*
MCV-87 MCH-26.8* MCHC-30.8* RDW-17.1* Plt Ct-266
[**2149-6-6**] 03:32AM BLOOD WBC-14.9* RBC-3.04* Hgb-8.2* Hct-26.0*
MCV-86 MCH-26.9* MCHC-31.4 RDW-16.0* Plt Ct-274
[**2149-6-9**] 05:43AM BLOOD WBC-11.7* RBC-3.26* Hgb-9.0* Hct-28.2*
MCV-87 MCH-27.7 MCHC-32.0 RDW-16.9* Plt Ct-250
[**2149-6-12**] 05:59AM BLOOD WBC-12.8* RBC-3.23* Hgb-8.8* Hct-28.3*
MCV-87 MCH-27.2 MCHC-31.1 RDW-17.2* Plt Ct-244
[**2149-6-6**] 03:32AM BLOOD PT-28.2* PTT-27.3 INR(PT)-2.7*
[**2149-6-7**] 05:57AM BLOOD PT-21.4* PTT-25.4 INR(PT)-2.0*
[**2149-6-8**] 06:07AM BLOOD PT-18.9* PTT-23.7 INR(PT)-1.7*
[**2149-6-9**] 05:43AM BLOOD PT-16.5* PTT-23.2 INR(PT)-1.5*
[**2149-6-11**] 06:12AM BLOOD PT-17.5* PTT-22.6 INR(PT)-1.6*
[**2149-6-12**] 05:59AM BLOOD PT-20.0* INR(PT)-1.8*
[**2149-6-13**] 04:57AM BLOOD PT-22.4* INR(PT)-2.1*
[**2149-6-4**] 01:49AM BLOOD Ret Aut-2.7
[**2149-6-3**] 07:35PM BLOOD Glucose-139* UreaN-85* Creat-2.2* Na-141
K-5.2* Cl-96 HCO3-35* AnGap-15
[**2149-6-5**] 03:38AM BLOOD Glucose-321* UreaN-68* Creat-1.9* Na-142
K-4.2 Cl-94* HCO3-37* AnGap-15
[**2149-6-7**] 05:57AM BLOOD Glucose-191* UreaN-71* Creat-1.6* Na-141
K-4.4 Cl-96 HCO3-39* AnGap-10
[**2149-6-8**] 02:56PM BLOOD Glucose-216* UreaN-64* Creat-1.6* Na-139
K-4.4 Cl-95* HCO3-37* AnGap-11
[**2149-6-10**] 04:18AM BLOOD Glucose-217* UreaN-53* Creat-1.4* Na-140
K-4.9 Cl-97 HCO3-39* AnGap-9
[**2149-6-12**] 05:59AM BLOOD Glucose-297* UreaN-47* Creat-1.6* Na-138
K-4.8 Cl-96 HCO3-35* AnGap-12
[**2149-6-13**] 04:57AM BLOOD Creat-1.4* Na-141 K-4.5 Cl-96
[**2149-6-3**] 07:35PM BLOOD ALT-20 AST-16 LD(LDH)-390* AlkPhos-93
TotBili-0.3
[**2149-6-4**] 01:49AM BLOOD proBNP-1356*
[**2149-6-4**] 01:49AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.2 Iron-22*
[**2149-6-4**] 01:49AM BLOOD calTIBC-244* Ferritn-253 TRF-188*
[**2149-6-4**] 03:34PM BLOOD B-GLUCAN-Test negative
TTE ([**2149-6-6**])
There is mild symmetric left ventricular hypertrophy with normal
cavity size. 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 are mildly thickened (?#). There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. No mitral regurgitation
is seen. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Preserved left ventricular
function. No pathologic structural valvular disease identified,
but views are limited.
CT Chest
1. The appearance of the lungs, while significantly obscured by
motion
artifact and extensive multifocal consolidations, is not typical
for
idiopathic pulmonary fibrosis as there is no evidence of basilar
reticulation
or honeycombing. The appearances are more in keeping with a
multifocal
pneumonia rather than an acute flare of pulmonary fibrosis. When
the patient's
clinical condition has improved, a HRCT may then be performed to
assess for
subtle pulmonary fibrosis.
2. Moderately severe pulmonary enlargement suggesting pulmonary
hypertension.
Brief Hospital Course:
57 year old man with history of DMII, IPF on prednisone 20,
chronic MRSA osteomyelitis since [**9-17**] after ankle fracture, PAF
on coumadin presents to [**Hospital3 **] ED on [**2149-6-3**] after 3
days of worsening dyspnea.
# Hypoxia/respiratory failure: Patient on home 2L 02 and
admitted with hypoxic respiratory distress and required full
face bipap (failed nasal CPAP) for the first 24-36 hours.
Etiology was unclear but felt likely multifactorial IPF (history
of this, on 20mg po prednisone) vs. Pneumonia (increased cough,
sputum production and leukocytosis) vs. CHF (bnp . He was
treated with high dose IV steroids (125 q6 for 48 hours) for ?
IPF flare, Vanc/Cefepime/Levoflox for HAP and he was diuresed
with IV lasix. Over the course of 3 days his respiratory status
improved so that he was satting 90-95% on 3-4L by NC, though he
desatted to the 80s every time he moved. He was net negative
almost 10 Liters over this time. His prednisone was decreased
to 60 then 50 then 40mg po. His antbiotics were continued for
an 8 day course. He was continued on full face Bipap overnight
rather than nasal Bipap. He was eventually transitioned to po
bumetamide and discharged home with physical therapy as he was
able maintained good oxygen saturation with ambulation on 3LNC.
# History of IPF: Patient's pulmonologist was on vacation when
he was admitted, but OSH records showed that patient was
initially admitted on [**4-/2148**] with bilateral pneumonia, and
during this admission he was bronch'd and infectious etiologies
were ruled out and he had a transthoracic biopsy which was used
to get the diagnosis of IPF. Since then the patient's steroid
requirement was as low as 10mg po daily but the he was
hopsitalized in [**State **] last [**Month (only) 205**] with respiratory failure and
since then has remained on 20mg prednisone and home 02.
Patient's CT scan here was not consistent with IPF and it is not
the usual standard here to diagnose IPF on transbronchial biopsy
(typically transthoracic). Patient was continued on Dapsone for
PCP [**Name Initial (PRE) 1102**] (concern at an earlier admission that he had
renal failure from Bactrim). Vitamin D, Calcium, and a PPI were
initially for his steroid course.
# [**Last Name (un) **]: Patient's creatinine 2.2 on admission, up from 1.6
recently. After significant diuresis the kidney function
improved to baseline at 1.6, likely poor forward flow from CHF.
# Anemia: HCT down to 25 from baseline 30, normocytic, guiac
negative. Hemolysis unlikely with nl bili and other hemolysis
labs normal. Initially concerned for GI bleed still in ddx esp
with INR of 3.5 but patient guiac negative and had no BRBPR.
Patient's iron studies showed iron deficiency.
# PAF: Anticoaggulated for remote DVT, PAF, and immobility with
osteo. INR supratherapeutic, so his warfarin was initially held
which led to it being subtherapeutic. Coumadin was increased to
7.5 mg to maintain goal INR [**3-13**].
# Chronic osteomyelitis: Patient on Daptomycin, which was held
when he was treated for HAP. Daptomycin was subsequently
restarted after he completed 8 days of his HAP regimen.
# DM: Exacerbated by steroids at present. He was maintained on
Lantus 70 QAM, 60 QPM plus SSI. [**Last Name (un) **] was consulted with
eventual lantus of 75 qam and 55 qpm upon discharge.
# HTN: His home antihypertensives were initially held and were
subsequently restarted.
Follow up for PCP
1. Please check electrolytes and kidney function at the next
visit and decide whether to decrease bumetamide to qdaily
instead of [**Hospital1 **] based on volume status and kidney function.
2. Please discuss with pulmonologist regarding further
evaluation of IPF
3. Please check INR and adjust coumadin dose according.
Follow up for ID
1. Please check kidney function and ajdust Daptomycin dose
frequency accordingly.
Medications on Admission:
1) Daptomycin 1300mg Q48H since [**6-2**]
2) Neurontin 400mg PO TID
3) Nortryptaline 50 PO BID
4) Prednisone 20mg PO daily
5) Coumadin 5mg PO daily
6) Norvasc 10 daily
7) Coreg 25mg PO BID
8) Paxil 40mg PO daily
9) Bumex 3mg PO BID
10) Lantus 70 units QAM, 60 units QPM
11) SSI
12) Dapsone 100mg PO daily
13) Metolazone 5mg PO BID
14) Pantoprazole 40mg PO Daily
Discharge Medications:
1. daptomycin 500 mg Recon Soln Sig: 1300 (1300) mg Intravenous
once a day.
Disp:*30 doses* Refills:*0*
2. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. nortriptyline 50 mg Capsule Sig: One (1) Capsule PO twice a
day.
4. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
Disp:*30 Tablet(s)* Refills:*2*
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
8. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
9. bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. insulin glargine 100 unit/mL Solution Sig: Seventy Five (75)
units Subcutaneous qam.
11. insulin glargine 100 unit/mL Solution Sig: Fifty Five (55)
units Subcutaneous qpm.
12. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary Diagnosis: Multilobar pneumonia, Acute on chronic
diastolic heart failure, Acute on chronic kidney injury
Secondary Diagnosis: OSA, obesity hypoventilation syndrome,
Hypertension, Type 2 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted for shortness of breath and increasing oxygen
requirements. CT scan revealed a multilobar pneumonia. You
were started on IV antibiotics for a total eight day course.
In addition, you had an exacerbation of your diastolic heart
failure. Your heart is slightly stiff as a result of high blood
pressure. It is not as effective at pumping the fluid through
your body. You were given IV diuretics to help remove this
fluid and eventually transitioned to bumetanide orally.
Your steroids were increased while in the ICU, but a taper was
initiated thereafter. Please discuss your steroid course with
your outpatient lung doctor.
The following changes were made to your medication regimen:
INCREASE PRENDISONE to 40 mg by mouth once a day. Please discuss
your steroid course with your outpatient lung doctor.
INCREASE COUMADIN to 7.5 mg by mouth once a day. Please discuss
with your primary care doctor next week about continuing on
current dose or decreasing the current dose.
START BUMETANIDE 2 mg by mouth twice a day. Please discuss with
your primary care doctor next week about continuing on current
dose or decreasing the current dose.
STOP METALOZONE 5 mg by mouth once a day
INCREASE your morning lantus to 75 units while DECREASING your
pm lantus to 55 units
Followup Instructions:
Name: BROWN,[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: FAMILY MEDICINE ASSOCIATES
Address: [**State 90014**], [**Location **],[**Numeric Identifier 14085**]
Phone: [**Telephone/Fax (1) 14086**]
Appointment: Tuesday [**2149-6-17**] 9:45am
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2149-7-10**] at 12:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2149-7-10**] at 12:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**You have also been placed on a cancellation list. The office
will contact you if a sooner appointment becomes available.
Department: INFECTIOUS DISEASE
When: [**Hospital Ward Name **] [**2149-6-23**] at 9:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PODIATRY
When: [**Hospital Ward Name **] [**2149-6-23**] at 11:10 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2149-7-10**] at 12:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 486, 5849, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7396
} | Medical Text: Admission Date: [**2195-8-28**] Discharge Date: [**2195-9-8**]
Date of Birth: [**2142-7-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
acute left lower extremity ischemia and hypotension
Major Surgical or Invasive Procedure:
[**2195-8-29**] Mesenteric arteriogram, SMA stent, thrombectomy of left
limb or aortobifemoral graft, endarterectomy of left
CFA/SFA/PFA, left lower leg fasciotomy
History of Present Illness:
52 year-old gentleman with a complicated h/o peripheral vascular
disease s/p aorto-bifemoral bypass in [**2191**], pancreatic mass s/p
Whipple in [**2192**], and esophageal cancer s/p esophagectomy with
colonic interpostion 4 months ago complicated by necrosis of the
neoesophagus and development of an enterocutaneous fistula who
presents with altered mental status. Pt was found by his wife
to have altered mental status this AM and presented to an OSH.
He was found to be hypotensive, hypernatremic and
hyperchloremic, abd was fluid resuscitated, and started on
levophed. He had a CXR which showed a right middle lobe
pneumonia. Pt was started on abx prior to being transferred to
[**Hospital1 18**]. His left leg was found to be acutely ischemic with no
dopplerable signals in the left foot with coolness up to the
left mid-thigh.
Past Medical History:
Aorto-bifemoral bypass [**8-19**]
MI
HTN
R CEA ([**7-19**])
Knee athroscopy
Whipple operation ([**Doctor Last Name 468**]) in [**2192**] for benign pancreatic mass
Esophagectomy with colonic interposition complicated by
neoesophagus necrosis requiring resection and spit fistula
creation ([**2195-4-22**])
Social History:
Pt lives with family. He works on an assembly line at a
brickyard. He formerly smoked 2 PPD x 40 years.
Family History:
Father with liver cirrhosis from ETOH use
Physical Exam:
Afebrile/VSS
No distress, alert and oriented x 3
PERLA, EOMI, anicteric
Neck with spit fistula draining to ostomy appliance
RRR, no murmurs, lungs clear
Abdomen soft, nontender, midline wound healing by secondary
intention with good granulation tissue in place; known ECF in
right aspect of wound drainge brown fluid
Left groin incision C/D/I, left lower leg fasciotomy incisions
C/D/I
.
Pulses: palpable femorals, dopplerable PTs bilaterally
Pertinent Results:
Admission:
[**2195-8-28**] 07:55PM BLOOD WBC-12.9*# RBC-4.19*# Hgb-11.9*#
Hct-39.8*# MCV-95# MCH-28.5 MCHC-30.0* RDW-17.2* Plt Ct-170
[**2195-8-28**] 07:55PM BLOOD Neuts-78.4* Lymphs-16.0* Monos-5.2
Eos-0.2 Baso-0.3
[**2195-8-28**] 08:08PM BLOOD PT-14.4* PTT-24.9 INR(PT)-1.2*
[**2195-8-28**] 07:55PM BLOOD Glucose-247* UreaN-42* Creat-1.1 Na-177*
K-2.7* Cl-GREATER TH HCO3-17*
[**2195-8-28**] 07:55PM BLOOD CK(CPK)-1423*
.
CK trends:
[**2195-8-29**] 12:10PM BLOOD CK(CPK)-3334*
[**2195-8-30**] 12:59AM BLOOD CK(CPK)-4913*
[**2195-8-30**] 04:25PM BLOOD CK(CPK)-7135*
[**2195-8-30**] 10:13PM BLOOD CK(CPK)-7338*
[**2195-8-31**] 12:20PM BLOOD CK(CPK)-6963*
[**2195-9-1**] 04:47AM BLOOD CK(CPK)-5514*
[**2195-9-1**] 12:07PM BLOOD CK(CPK)-4823*
.
Discharge:
[**2195-9-7**] 05:05AM BLOOD WBC-4.7 RBC-3.19* Hgb-9.4* Hct-28.9*
MCV-91 MCH-29.4 MCHC-32.5 RDW-16.7* Plt Ct-308#
[**2195-9-8**] 04:13AM BLOOD PT-17.5* PTT-74.0* INR(PT)-1.6*
[**2195-9-7**] 05:05AM BLOOD Glucose-219* UreaN-13 Creat-0.4* Na-136
K-4.2 Cl-104 HCO3-25 AnGap-11
[**2195-9-8**] 04:13AM BLOOD Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname 60925**] was admitted on [**2195-8-28**] with hypotension and an
acutely ischemic left leg. A CT revealed a SMA stenosis with
concerns for acute mesenteric ischemia given the patients
hypotension requiring a vasopressor. It also revealed that the
left limb of his previous aorto-bifemoral graft was thrombosed
causing his left leg to be ischemic. On [**2195-8-29**] he was taken
emergently to the operating room where an arteriogram and SMA
stent were performed. Simultaneously, his left groin was
explored and a thrombectomy performed of the left limb of his
aortobifemoral graft. An endarterectomy was performed of his
left CFA, SFA, and PFA. Due to concerns for ischemia and
potential compartment syndrome formation, a left lower leg
fasciotomy was performed. He was taken to the CVICU and
continued on broad spectrum antibiotics post-operatively.
.
Pulses: He left foot had no dopplerable signals and his femoral
was weakly dopplerable. Post operatively his exam was notable
for a palpable femoral pulse and a strong dopplerable left PT
signal. Initially, in the post-operative period, his left PT
signal was weak, but this was due to global hypoperfusion and
vasopressors. Once his pressors were weaned down, his PT signal
became very strong. His fasciotomy incisions are healing
nicely.
.
Neuro: Post-operatively he required propofol and then fentanyl
and versed to maintain adequate sedation and pain control while
intubated. His neuro exam remained intact and these were
discontinued when he was extubated. He is currently on prn
dilaudid for pain control. He does have left drop foot
requiring a multipodis boot.
.
Cardiovascular: He required vasopressor support post-operatively
and aggressive resuscitation. He remained in vasodilatory shock
for a number of days and the neosynephrine was finally able to
be weaned off on [**2195-9-4**]. He remained hemodynamically stable
and was able to be transferred out of the CVICU and into the
VICU. He is stable.
.
Pulmonary: He remained intubated until POD4. On POD zero, he
was noted to have increased opacification of his right
hemithorax. He underwent a bronchoscopy where copious
secretions were encountered and suctioned. His post-bronch CXR
showed improved aeration of his lungs. He was continued on
broad spectrum antibiotics with double coverage for Pseudomonas
due to his recent hospitalization being complicated by resistant
Pseudomonal pneumonia. His BAL specimen never grew any
organisms and his antibiotics were discontinued by one
antibiotic daily.
.
Gastrointestinal: He was able to be started on trophic tube
feeds while in the CVICU. Once he was off pressors and stable,
these were able to be advanced to goal. He continues to have a
spit fistula that drains to an ostomy appliance. His known
enterocutaneous fistula started to have feculent drainage.
General and Thoracic surgery were consulted and a wound vac was
placed in attempts to isolate the fistula. The was continued
leakage of fistula output and the vac was only functioning part
of the time. Thoracic surgery is managing his fistula and
recommended discontinuing the wound vac and starting moist to
dry dressing changes to his abdominal wound.
.
Genitourinary: He had more than adequate urine output beginning
in the immediate post-operative period. His foley catheter was
able to be removed once he was out of the ICU and he voids
without difficulty.
.
Heme: He was maintained on a heparin gtt to maintain patency of
his circulation. He is currently being transitioned to
coumadin. His did require transfusion of 3 units of PRBC in the
early post-operative period, but his hematocrit has remained
stable since transfusion.
.
Endocrine: His blood sugars have been well controlled on sliding
scale insulin.
.
Infectious Disease: Due to his septic physiology on admission he
was placed on broad spectrum antibiotics empirically. On POD
zero there were concerns for pneumonia based on CXR and
bronchoscopy so double coverage was started for his history of
Pseudomonas pneumonia. Infectious disease was consulted. All
of his culture date returned negative so his antibiotics were
discontinued one at a time. He is currently on no antibiotics
and his WBC is normal.
.
He is discharged in good condition to rehab. He will need
physical therapy and nursing care for his spit fistula,
enterocutaneous fistula, and healing midline abdominal wound.
Medications on Admission:
Atenolol 50mg daily, Simvastatin 40mg daily, Diovan 160-25mg
daily, percocet prn
Discharge Medications:
1. Acetaminophen 650 mg Suppository [**Date Range **]: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever/pain.
2. Clopidogrel 75 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily)
for 30 days: For 30 days only.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: per sliding scale
units
units Subcutaneous ASDIR (AS DIRECTED): glucose dose
121-140 2 units
141-160 4 units
161-180 6 units
191-200 8 units
201-220 10 units
221-240 12 units
241-260 14 units
261-280 16 units
281-300 18 units.
5. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
6. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain
7. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4
PM: Goal INR of [**2-17**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Acute left leg ischemia
Mesenteric ischemia
Enterocutaneous fistula
Discharge Condition:
Good
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-If you have staples, they will be removed during at your follow
up appointment.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* 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.
* Continue to ambulate several times per day.
* No heavy ([**10-29**] lbs) until your follow up appointment.
.
* Continue tube feeds
* Continue coumadin with a goal INR of [**2-17**], adjust dose
accordingly
* Continue spit fistula care
* Continue abdominal wound and enterocutaneous fistula care
* Continue physical therapy daily
* Continue to wear multipodis boots
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2195-9-24**] 11:00
ICD9 Codes: 0389, 2762, 2760, 2875, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7397
} | Medical Text: Admission Date: [**2113-5-4**] Discharge Date: [**2113-5-8**]
Date of Birth: [**2036-5-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Right IJ sepsis triple lumen placed
History of Present Illness:
76 year old woman with h/o Myasthenia [**Last Name (un) 2902**], atrial
fibrillation was well until one week prior to admission when she
developed runny nose, fatigue, and malaise. She then noted a
cough with green sputum. She originally was afebrile, but a few
days prior to admission, developed chills and subjective fevers.
She was so weak, she was confined to her bed. At that point, her
family took her to the ED.
In the ED, 102.7, 75, 133/66, 18, 95% RA. CXR with RML PNA.
Lactate 4.4. Code sepsis was called and Right IJ line placed.
She was given levofloxacin, ceftriaxone, flagyl, hydrocortisone
(stress dose), and tylenol. She was then admitted to the MICU.
She was given levophed per protocol, but this was quickly weaned
off.
Past Medical History:
Myasthenia [**Last Name (un) 2902**] on chronic prednisone
atrial fibrillation
hyperlipidemia
Social History:
Lives with her husband, she has a 25 pack year smoking history,
but quit 25 years ago. No alcohol or drug use.
Family History:
brother with DM
Physical Exam:
on admission:
V/S: 102.7, 133/66, 75, 18, 95% RA
GEN: in NAD
HEENT: PERRL, conjunctiva normal, nasal mucosa wnl, oropharynx
dry. neck supple without JVD
COR: irreg, irreg, II/VI systolic murmer\
LUNGS: coarse breath sounds right base
Abd; Soft, mild RUQ tenderness, nd, +BS
ext: no LE edema
Pertinent Results:
[**2113-5-4**] 04:00PM WBC-15.2* RBC-4.90 HGB-15.4 HCT-44.6 MCV-91
MCH-31.5 MCHC-34.6 RDW-13.4
[**2113-5-4**] 04:00PM PLT SMR-NORMAL PLT COUNT-276
[**2113-5-4**] 04:00PM NEUTS-86.2* BANDS-0 LYMPHS-10.2* MONOS-3.1
EOS-0.2 BASOS-0.2
[**2113-5-4**] 04:00PM CORTISOL-35.0*
[**2113-5-4**] 04:08PM LACTATE-4.4*
[**5-8**]: urine sodium 85
Brief Hospital Course:
1) pneumonia complicated by sepsis: patient was seen in the ED
and a "code sepsis" was called based on fever, tachycardia, and
a lactate of 4.4. She had a chest x ray demonstrating a right
middle lobe pneumonia. She had transient hypotension and was on
Levophed. She was admitted to the MICU and placed on ceftriaxone
and azithromycin. She had received a dose of levofloxacin in the
ED, but this was stopped due to potential reaction with
myasthenia. Her Levophed was quickly weaned off and she was
quickly hemodynamically stable. She remained on O2, but this was
also stopped after a couple of days. Her NIFs and vital
capacities were monitored to ensure no myasthenic crisis. These
remained stable. She was called out to the floor and did well.
Her d/c NIF was -22 and vital capacity was -1100. She was
discharged home and will complete a course of cefpodoxime and
azithromycin. She will follow her respiratory status as
azithromycin can also provoke a myasthenic crisis. She was also
given a dose of Pneumovax prior to her discharge. No organism
was identified as the etiology of her pneumonia.
2) myasthenia [**Last Name (un) 2902**]: patient was maintained on prednisone and
Mestinon at her home doses. Dr. [**Last Name (STitle) **] and neurology followed
her initially. She did well and had no complications from her
myasthenia. She will be followed as an outpatient. She was
started on Bactrim for pneumocystis prophylaxis given her
chronic steroid use.
3) mineralocorticoid deficiency: Ms. [**Known lastname 12289**] had persistently
low blood pressures upon leaving the intensive care unit. SBP in
the 80s when sitting, improved to low 100s when lying in bed.
These were minimally responsive to fluid boluses. She also did
not appear volume depleted. Given her chronic prednisone
use(relatively glucocorticoid specific), a urine sodium was
checked. This was >80. It was thought that she had a
mineralocorticoid deficiency and was started on Florinef. Her
blood pressure appeared to rise following it use. She will be
discharged on this medication.
4) atrial fibrillation: the patient remained in atrial
fibrillation as an inpatient. She had several runs of rapid
ventricular response to 140s-150s. Initially her b blocker was
held due to low blood pressure. A smaller amount was restarted
in order to control her heart rate. This was effective and she
was discharged home on a lower dose of b blocker as well as
coumadin. INR at time of d/c was 2.
Medications on Admission:
atenolol 50 mg po daily
coumadin
prednisone 35 mg po daily
metinon 30 mg po daily
protonix 40 mg po daily
fosamax 70 mg po qsunday
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
2. Prednisone 10 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily).
Disp:*105 Tablet(s)* Refills:*0*
3. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO
3X/WEEK ([**Doctor First Name **],TU,TH).
Disp:*90 Tablet(s)* Refills:*0*
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO EVERY OTHER DAY (Every Other Day).
5. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO QAM
(once a day (in the morning)).
6. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QSUN
(every Sunday).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): As directed by PCP. [**Name10 (NameIs) 357**] have your INR checked
regularly.
11. Outpatient Lab Work
Please check INR.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pneumonia complicated by sepsis
2. Myasthenia [**Last Name (un) **] on chronic steroids
3. Atrial fibrillation
4. Mineralocorticoid deficiency
Discharge Condition:
Good, oxygenating well on room air and ambulating without
assistance. NIF -22
Discharge Instructions:
You are discharged to home and should continue all medications
as prescribed. Please contact your physician or present to the
ER if you experience fevers, chills, night sweats, cough,
shortness of breath, chest pain or other concerns. Please make
a follow-up appointment with your primary care physician.
Followup Instructions:
Please make a follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3329**]) within one week after
discharge. It is important that you have your INR (Coumadin
level) checked regularly. These results should be available to
Dr. [**Last Name (STitle) **] who will adjust your Coumadin dose accordingly.
ICD9 Codes: 0389, 486, 2762, 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7398
} | Medical Text: Admission Date: [**2148-11-27**] Discharge Date: [**2148-12-5**]
Date of Birth: [**2092-1-16**] Sex: F
Service: OMED
CHIEF COMPLAINT: Pain.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 56 year-old
female with no past medical history who presented for an
initial visit with outpatient oncologist on [**2148-11-27**]. Her
pertinent oncologic history began eight months ago when she
noticed a lump in her right breast. She did not seek medical
attention until [**Month (only) 1096**] due to desire to spare her family
pain of dealing with cancer. The patient's family recently
lost a son to [**Name (NI) **] sarcoma six years ago. The patient
finally sought medical attention when her back pain became
too severe to ignore. The patient's back pain had begun in
[**Month (only) 216**] and waxed and waned over the fall. The patient saw
her primary care nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7749**] at the
[**Hospital 14840**] Health Center and was referred to a surgeon. The
patient underwent excisional breast biopsy on [**2148-11-18**]
revealing an infiltrating carcinoma grade 3 out of 3 with a
lobular component, ER positive, HER-2/neu negative. Bone
scan done one week ago shows uptake in multiple ribs and
vertebral bodies as well as lighter areas of uptake in the
right femur and right hip. Formal report of this study is
not available. The patient's family reports that her pain
control had been very inadequate and they had been up with
her q one hour giving her breakthrough liquid Oxycodone in
addition to a Fentanyl patch, which has been up from 25 to 75
over the last two weeks. They also report that her breathing
has become labored and she has not eaten anything and taking
only liquids for two weeks as well. The patient has had
sweats, but no fevers, headache, no bowel movements for one
week. The patient has been essentially bedridden since last
Thursday.
PAST MEDICAL HISTORY: Benign breast biopsy twenty years ago.
MEDICATIONS: Fentanyl patch 75 micrograms, Oxycodone for
breakthrough pain, Zantac liquid b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Married with three living children. Son
died six years ago from [**Doctor First Name **] sarcoma. The patient has a 100
pack year history of tobacco. Previously drank three to four
beers per day, but none since [**2148-11-2**]. The patient
worked as a teacher and then stayed home with the kids.
Recently was working as a retail store manager.
PHYSICAL EXAMINATION: Temperature 99.2. Pulse 100. Blood
pressure 112/84. Respiratory rate 24. O2 sat 94% on 4
liters. Cachectic, ill appearing female in mild respiratory
distress. HEENT temple wasting, anicteric sclera.
Oropharynx dry with no thrush. No cervical adenopathy.
Lungs decreased breath sounds bilaterally. Cardiac regular.
Normal S1 S2. No murmurs, rubs or gallops. Breast
examination fresh surgical biopsy on the right with extensive
ecchymosis. Left breast unremarkable. Abdomen flat with
hypoactive bowel sounds. Nontender, nondistended. No
organomegaly. Extremities no clubbing, cyanosis or edema.
Neurological lethargic with poor recalls. Cranial nerves II
through XII are intact. Strength 4 out of 5 throughout.
Decreased sensation to light touch in right arm and left leg.
Reflexes 2+ throughout. Down going Babinski.
LABORATORY: White blood cell count 8.4, hematocrit 39.3,
platelets 328, PT 13.9, INR 1.3, PTT 27.7, sodium 126,
potassium 4.4, chloride 83, bicarb 32, BUN 13, creatinine
0.3, ALT 15, AST 31, LDH 479, alkaline phosphatase 132,
total bilirubin 0.6, albumin 2.9, calcium 9.3, CEA 24,
CA27-29 pending.
IMAGING: Head CT from [**2148-11-29**] showed no intracranial
metastases with possible cystic lung lesions. Chest CT from
[**2148-11-29**] showed bolus emphysema, small bilateral pleural
effusions. No metastasis. Spinal MR from [**2148-12-1**] showed
multiple areas of metastatic disease in the cervical,
thoracic and lumbar spine. No evidence of cord compression.
Mild pathologic compression fracture of T3 and T6, bilateral
small pleural effusions.
HOSPITAL COURSE: 1. Pulmonary: The patient was in moderate
respiratory distress on arrival with an O2 sat of 80% on room
air that increased to 94% on 4 liters. The patient was also
given significant amount of narcotics as well as
benzodiazepines for pain and anxiety. The patient became
more lethargic and arterial blood gases showed hypercarbic
respiratory failure. The patient was intubated on the floor
and taken to the _________ Intensive Care Unit. The patient
initially got a single dose of Azithromycin in the Intensive
Care Unit and remained on the ventilator until she self
extubated on [**2148-12-1**]. The patient did well with multiple
Atrovent and Albuterol nebulizers. Flovent was added to her
pulmonary regimen. The patient remained extubated and did
well and was transferred to the floor. Pulmonary function
tests will be obtained on [**2148-12-5**] to assess her emphysema.
A chest CT showed large bolus emphysema. The patient has a
long significant history of smoking. Will schedule Ms. [**Known lastname **]
with outpatient follow up with Dr. [**Last Name (STitle) 575**] in the Pulmonary
Department. Tolerated O2 sat at 92% given patient's tendency
to retain CO2. Also need to avoid increasing her narcotics
or giving her any benzodiazepines given her propensity to
retain CO2.
2. Oncologic: The patient has significant skeletal
metastases of her breast cancer. The patient was started on
Arimidex and given pamidronate in the Intensive Care Unit.
The patient will continue on Rumidex for hormonal treatment
of her breast cancer and will receive monthly doses of
pamidronate. The patient will follow up with her Dr. [**Last Name (STitle) 26065**]
her oncologist in one month for dose of Pamidronate and to
assess the effectiveness of the Arimidex.
3. Pain: The patient's pain was better controlled after her
Intensive Care Unit stay when her Fentanyl patch was
increased to 100. She was on low dose NSIR for breakthrough.
In addition, will add NSAIDS for breakthrough pain Ibuprofen
600 mg t.i.d. Any changes in her narcotics should be
discussed with Dr. [**Last Name (STitle) 26065**] her primary oncologist. Should
avoid increasing her narcotics due to her demonstrated
ability to retain CO2 and develop hypercarbic respiratory
failure. If the patient's pain again becomes difficult to
manage will consider palliative radiation therapy, but at
this time there is no acute indication for radiation therapy
given no evidence of sinal cord compression.
DISCHARGE MEDICATIONS: Multiple vitamin one tab po q.d.,
Atrovent MDI two puffs meter dose inhaler q 6 hours,
Albuterol MDI two puffs q 2 hours prn, Albuterol Atrovent
nebulizers q 4 hours prn, heparin subQ 500 units b.i.d.,
Arimidex 1 mg po q day, Fentanyl patch 100 micrograms po q 72
hours, Colace 100 mg po b.i.d., Boost one po b.i.d., Flovent
110 micrograms per puff four puffs b.i.d., Ibuprofen 600 mg
po q 8 hours prn should be used initially prior to using
narcotics for breakthrough. NSIR 10 mg po q 4 hours prn if
NSAIDS do not relieve pain. Dulcolax 10 mg po pr q day prn.
Senna one tab po q.h.s.
DISCHARGE STATUS: To rehab.
DISCHARGE CONDITION: Fair.
DISCHARGE DIAGNOSES:
1. Breast cancer with skeletal metastasis.
2. Bolus emphysema.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 26066**], M.D. [**MD Number(1) 26067**]
Dictated By:[**Last Name (NamePattern1) 16516**]
MEDQUIST36
D: [**2148-12-4**] 12:02
T: [**2148-12-4**] 13:05
JOB#: [**Job Number 37309**]
ICD9 Codes: 2765, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7399
} | Medical Text: Admission Date: [**2151-1-27**] Discharge Date: [**2151-3-23**]
Date of Birth: [**2071-8-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
placement of gallbladder drain
Central venous line
Hemodialysis
Percutaneous jejunostomy tube placement
PICC line
History of Present Illness:
79M with CAD s/p recent CABG & AVR, CHF (EF 20%), DM2,
hyperlipidemia, and HTN who has been at [**Hospital **] Rehab for the
past 2 weeks following a prolonged hospitalization at [**Hospital1 112**] for
CHF, CABG, AVR c/b difficulty weaning and trach placement (since
removed), G-tube placement, line infection, ileus, oral
candidiasis, and sacral decub ulcer. On day of admission, pt was
in an ambulance on his way to a scheduled cardiology appt when
his SBP was noted to be in the 60s and he was instead brought to
the ED for further evaluation.
<br>
Of note, pt had increased sputum at [**Hospital1 **] and was started on
[**First Name9 (NamePattern2) 64983**] [**1-26**] for presumed bronchitis vs PNA. This AM,
covering rehab MD [**First Name (Titles) 8706**] [**Last Name (Titles) 7968**] UOP, elevated HR, and "low but
unchanged SBP in 100-120 range." In addition, pt's lisinopril 5
mg daily was held due to creatinine 2.2 (up from 1.3 per
report).
<br>
Upon arrival to [**Name (NI) **], pt's BP 67/44, HR 110s, temp 101.2, Sat 97%
2L NC. SBP improved to 90s within ~ 2 hours after IVF given. In
addition, patient was found to have RUQ tenderness so CT
abd/pelvis was obtained & showed "sludge within a distended
appearing gallbladder. There may also be pericholecystic fluid
or wall edema that is concerning for acute cholecystits." CT
also revealed pericardial and bilat pleural effusions, moderate
ascites, and R-inguinal hernia with nonobstucted small bowel.
Surgery was consulted & recommended IV antibiotics and urgent
percutaneous GB drainage catheter placement by IR. Labs were
signif for WBC 15 w/88% neut, 0% bands, Hct 24, K+ 5.7, proBNP
30,000. Lactate 1.5, INR 2.2 on coumadin. Pt rec'd [**Name (NI) 64983**],
flagyl, vancomycin, 2U PRBC, 1L NS, and Tylenol PR. Two sets
blood Cx sent.
<br>
Upon my eval in the ED, he denies any abdom pain, F/C, N/V, or
diarrhea (in fact is slightly constipated). He has noted
increased sputum production (yellow, thick) over the past few
days. Pt also c/o pain in his buttocks at the site of skin
breakdown. Denies CP, SOB, palpitations. Pt also denies any
lightheadedness, visual changes, or known confusion when his BP
was low. Also denies BRBPR, melena, hematuria, or new bruises.
No known aspiration or choking episodes.
Past Medical History:
-CAD s/p stents in [**2146**]; s/p CABG, AVR(bioprothetic),
pericardial stripping on [**2150-12-16**] at [**Hospital1 112**]. On coumadin.
-DM2 x ~40 yrs on oral hypoglycemics at home
-hyperlipidemia
-HTN (although SBP 100-120 & only on lisinopril 5 @ rehab)
-Atrial fibrillation
-GERD
Social History:
-transferred from [**Hospital **] Rehab
-remote TOB: ~10 pack-yrs; quit >40 yrs ago.
-HCPs is son & daughter
Physical Exam:
-VS: temp 101.2->96.3 (after Tylenol in ED), HR 75-85, BP 106/30
(in ED), repeat BP 83/55 with MAP 67 (in ICU), RR 20, Sat 100%
NC. Pulsus <10 mmHg.
-Gen: cachectic elderly M sitting in stretcher in NAD
-Skin: former trach site w/thick, yellowish mucus; sacral
dressing over known decub; G-tube site without erythema;
sternotomy site intact, nonerythematous.
-HEENT: OP clear, dry MM, poor dentition. [**Name (NI) 3899**], [**Name (NI) 64984**] ptosis
(per family, has been like this x years). ~1 mm pupils
bilaterally.
-Neck: JVD to mandible, supple, full ROM
-Heart: S1S2, irreg irreg, II/VI SM
-Lungs: coarse upper airway sounds anteriorly. Posteriorly:
[**Name (NI) 7968**] B.S. R-lower [**12-29**] and L-base. Crackles 1/2 up on right
and 1/3 up on left. Fair air movement. No wheezes appreciated.
-Abdom: mild tenderness to palp in RUQ; somewhat tense muscles
but no rebound or guarding. +B.S.
-Extrem: thin; 1+ pitting edema bilat LEs up to knees; 1+
pitting sacral edema; trace DP pulses bilat; 1+ radial pulses
bilat.
-Neuro/Psych: A&Ox3, answers ?s in [**12-28**] word phrases, speech
fluent but difficult as former trach site still open. [**4-30**]
strength in upper extrem. 2/5 strength in lower extrem. CN2-12
intact.
Pertinent Results:
Admission labs
<BR>
[**2151-1-27**] 01:45PM GLUCOSE-174* UREA N-77* CREAT-2.1* SODIUM-137
POTASSIUM-5.7* CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
[**2151-1-27**] 01:45PM ALT(SGPT)-27 AST(SGOT)-26 CK(CPK)-17* ALK
PHOS-141* AMYLASE-22 TOT BILI-1.0
[**2151-1-27**] 01:45PM CK-MB-4 cTropnT-0.31* proBNP-[**Numeric Identifier 64985**]*
[**2151-1-27**] 01:45PM ALBUMIN-2.5*
[**2151-1-27**] 01:45PM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.8*
[**2151-1-27**] 01:45PM HAPTOGLOB-268*
[**2151-1-27**] 01:45PM DIGOXIN-2.2*
[**2151-1-27**] 01:45PM WBC-15.0* RBC-2.69* HGB-8.1* HCT-23.9* MCV-89
MCH-29.9 MCHC-33.7 RDW-20.1*
[**2151-1-27**] 01:45PM NEUTS-88.8* BANDS-0 LYMPHS-6.7* MONOS-4.2
EOS-0.1 BASOS-0.2
.
Discharge Labs:
WBC 8.9, Hct 34, plt 156
inr 1.3, ptt 34
na 143, k 5.2, cl 109, bicarb 26, bun 51, creat 2.8
ca 9.2, phos 3.2, mag 1.8
alt 14, ast 19, ap 171, Tbili 0.4, amylase 18, lipase 7
PTH 52
Vanco (random, [**2151-3-16**]) = 33.2
Digoxin ([**2151-3-17**]) 0.8
ABG 7.46/40/95 ([**2151-3-11**])
<BR>
CT OF THE ABDOMEN WITHOUT IV CONTRAST: There is a small
pericardial effusion. There are coronary artery calcifications.
A metallic clip is seen in the region of the pericardium. There
are moderate large bilateral pleural effusions, right greater
than left. There is bibasilar atelectasis/consolidation, as well
as consolidation/collapse within the right middle lobe. There is
a 4-mm calcified nodule in the left lower lobe. There is also
fluid in the left major fissure. On the unenhanced scan, the
liver, adrenal glands, kidneys, and pancreas are unremarkable.
Multiple calcifications are seen within the spleen. There are
multiple vascular calcifications within the abdomen. There is
atherosclerotic calcification of the descending aorta, including
at the major branch points of the celiac axis, and inferior
mesenteric arteries, as well as bilateral renal arteries. There
is high attenuation layering within the gallbladder consistent
with sludge. There is a small-to-moderate amount of ascites seen
adjacent to the liver, spleen, and pancreas. There also appears
to be fluid in the gallbladder fossa, some of which may
represent wall edema or pericholecystic fluid. The gallbladder
itself is distended. Lymph nodes are seen within the mesentery
measuring approximately 7-8 mm. There are similar appearing left
paraaortic lymph nodes. There is a G-tube in place. There is
also stranding of the mesentery. There are no dilated loops of
large or small bowel.
<BR>
CT OF THE PELVIS WITHOUT IV CONTRAST:
1 Pericardial effusion, and moderate bilateral pleural
effusions. Bibasilar atelectasis/consolidation. 2 Moderate
ascites. 3 Sludge within a distended appearing gallbladder.
There may also be pericholecystic fluid or wall edema. This is
concerning for acute cholecystits in the appropriate clinical
setting. 4. Right inguinal hernia containing nonobstructed small
bowel and fluid.
<BR>
PORTABLE CHEST RADIOGRAPH: The patient is status post median
sternotomy with sternal wires seen. The patient is status post
mitral valve replacement. There are bibasilar opacities which
could be secondary to pulmonary edema and/or overlying
consolidation. There are bilateral pleural effusions, left
greater than right. IMPRESSION: Developing pulmonary edema with
possible underlying consolidations.
<BR>
[**2-12**] NON-CONTRAST CT SCAN OF THE NECK: An endotracheal tube is
in place. Contrast is visualized around the upper aspect of the
endotracheal tube and in the cervical esophagus. No definite
sizeable masses are identified in the neck. No definite free
fluid collections within the neck are identified. There is a
right subclavian catheter.
<BR>
IMPRESSION: Contrast material visualized within the upper airway
perhaps secondary to reflux from placement of contrast material
for CT of the torso obtained at the same time. No definite
evidence of pathologic fluid collection in the neck.
<BR>
EKG (admit): Atrial fibrillation with rapid ventricular
response, Multifocal PVCs, Poor R wave progression, Nonspecific
ST-T wave changes, No previous tracing available for comparison
Rate PR QRS QT/QTc P QRS T
117 0 98 [**Telephone/Fax (2) 64986**] 157
<BR>
ECHO: The left atrium is moderately dilated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (ejection fraction 40 percent), mainly due to abnormal
left ventricular electrical/mechanical activation sequence. No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. A bileaflet aortic valve prosthesis
is present. The aortic prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion. Impression: ventricular dyssynchrony with
reduced left ventricular ejection fraction
<BR>
FINDINGS T-tube cholangiogram: Appropriate position of
cholecystostomy tube. Normal opacification of gallbladder,
common bile duct, and intrahepatic bile ducts with drainage into
the duodenum. Small amount of retrograde flow of contrast along
the cholecystostomy tube likely of little clinical significance
in the absence of the patient's symptoms.
<BR>
RENAL ULTRASOUND: The right kidney measures 10.7 cm, the left
kidney measures 10.7 cm. There are no renal stones, masses or
hydronephrosis. A Foley catheter is within the bladder. A small
amount of ascites is seen within the right upper quadrant.
IMPRESSION: No hydronephrosis.
<BR>
CHEST (PORTABLE AP) [**2151-3-13**] 10:17 AM:
The right pleural effusion has [**Month/Day/Year 7968**] since the previous
exam, however, there is suggestion of larger effusion on the
left extending along the lateral chest wall. Overall the
parenchymal opacities remain stable with compressive atelectasis
in the left lung base. The degree of the pulmonary edema shows
no change since the previous exam.
<BR>
There is a right PICC line with the tip in SVC and left
subclavian dialysis catheter. A tracheostomy tube is in place.
The patient is status post CABG and AVR.
<BR>
[**2151-2-5**] 11:01 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2151-2-5**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
<BR>
RESPIRATORY CULTURE (Final [**2151-2-7**]):
OROPHARYNGEAL FLORA ABSENT.
ENTEROBACTER CLOACAE. HEAVY GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
<BR>
[**2151-2-2**] 2:56 pm SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS
(Final [**2151-2-6**]): ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
<BR>
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- 8 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R
<BR>
[**2151-2-8**] 10:52 am BRONCHIAL WASHINGS
GRAM STAIN (Final [**2151-2-8**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
<BR>
RESPIRATORY CULTURE (Final [**2151-2-11**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
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.
Please contact the Microbiology Laboratory ([**6-/2451**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
<BR>
[**2151-3-14**] 2:36 am SPUTUM Source: Endotracheal.
<BR>
GRAM STAIN (Final [**2151-3-14**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM AND
PROPIONIBACTERIUM SPECIES.
<BR>
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
Please contact the Microbiology Laboratory ([**6-/2451**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
STAPH AUREUS COAG +. SPARSE GROWTH. 2ND STRAIN.
Please contact the Microbiology Laboratory ([**6-/2451**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
<BR>
SENSITIVITIES: MIC expressed in
MCG/ML
_<BR>________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
PENICILLIN------------ =>0.5 R =>0.5 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ <=1 S <=1 S
Brief Hospital Course:
79M with CAD s/p CAGB, AS s/p AVR, DM2, Afib admitted to MICU
for hypotension, suspected cholecystitis, likely PNA, and ARF.
Hospital course outlined by problem.
.
HYPOTENSION: Initially BP stabilized after NS and PRBCs, but
intermittently became hypotensive during the begining of his
hospital stay thought to be related to sepsis. Blood cultures
remained persistently sterile. [**Last Name (un) **] stim showed preservation of
adrenal function with baseline at 21.9 and a rise to 38 after 1
hour after cosyntropin. Regardless was transiently placed on
hydrocort. Continued to be hypotensive during CVVH only, but
later was able to maintain his BP during HD sessions as time
went on. Blood pressure meds should be held on his HD days for
more effective ultrafiltration. Over the latter part of his
hospital course, he has maintained systolic blood pressures
greater than 90. He was able to tolerate small doses of
hydralzyine 10 q 6 hours (holding for sbp than 90) and was
recently started on toprol 12.5 mg qd. He has been aggressively
dialyzed and bp meds should be held during hd days.
.
POSSIBLE ACUTE CHOLECYSTITIS: noted on CT abd/pelvis. RUQ
tenderness but no peritoneal signs. Percutaneous gallbladder
drain placed by IR on Febuary 3 & drained well, and initially
covered on levo/flagyl/amp. IR study showed good drainage
contrast into duodenum, so drain was clamped and LFT's/AlkP were
followed with the surgery team. After the labs remained stable,
this drain was pulled. Remained afebrile without abdominal pain
after his course of antibiotics was completed.
.
RECURRENT PNA: he initially noted increased sputum, fever, and
some infiltrates on CXR (CHF vs infiltrate) c/w PNA. Initially
on levo/flagyl/amp and vanco for empiric coverage for
cholecystitis, pneumonia, and skin flora. Sputum Cx grew back
MRSA and enterobacter, changed to CTX after sensitivity panel.
He later was treated for 2 full courses Vanc and Meropenem for
PNA which was completed on [**3-6**]. There was evidence of aspirated
contrast by CT initially, so pt's PEG was changed to PEJ to help
prevent aspiration. Approximately 6 days prior to his hospital
discharge he began having copious secretions. His CXR showed no
evidence of a new pulmonary infiltrate. His WBC count rose
slightly. Sputum grew MRSA and he was started on a 10 day
course of vancomycin for MRSA tracheobronchitis. His vanc
levels were dosed at 1g to keep levels >25 for good pulmonary
penetration. His last vanco course will be completed on
[**2151-3-20**].
.
RESPIRATORY FAILURE: With his worsening respiratory difficult a
trach was re-placed at the site of his prior trach site and he
was vented as tolerated in the setting of CHF and PNA. Attempts
were made to wean his from the trach, but were difficult in the
setting of CHF, PNA, and severe deconditioning. He was
gradually weaned off the vent with removal of fluid through
hemodialysis / ultrafiltration and treatment of his pneumonias.
He was on trach mask for >1 week prior to his discharge. He was
speaking with a passy muir valve, however care must be taken to
suction his secretions intermittently while the valve is on. He
is able to cough some of his secretions into his mouth and has a
good gag.
.
CHF: EF reportedly ~20% pre-CABG. ProBNP markedly elevated in ED
but O2 sat stable on NC even after 2U PRBC in ED. JVD and
crackles. Digoxin was held for serum level 2.2 and evidence of
dig toxicity on EKG (accelerated junctional rhythm). He
required two doses of digibind before his rhythm improved.
Repeat EF showed EF of 30%. His bioprosthetic aortic valve was
noted to be well seated. His CHF is complicated by severe
malnutrition and low albumin, creating for marked third spacing.
He has improved with aggressive ultrafiltration as alluded to
above but still requires ultrafiltration at least 3 days per
week. Hydralzyine was started in hopes of providing afterload
reduction for improved forward flow - given his marginal
pressures, he does not have much room to titrate up. In
consultation with cardiology and given his atrial fibrillation,
he was restarted on digoxin. However, near the end of his
course, there were again concerns about av block and as such dig
has been d/c'd. Finally, he was started on low dose
beta-blocker, metoprolol 12.5 [**Hospital1 **] to help w/ ventricular
remodeling. As mentioned below, pending renal function, an ACEI
may be considered.
.
ARF: creat was 2.1 in ED, but apparently creat was 1.2 in recent
past per rehab note. Initially thought to be ATN given prolonged
hypoTN in ambulance and initially in ED. He later became anuric,
and underwent CVVH for fluid removal. A tunned HD line was
placed by renal, and he later tolerated full HD sessions without
difficulty. He continues to require hemodialysis and hasn't
made any signs of renal recovery. The etiology of his renal
function remains unclear. [**Name2 (NI) **] did have renal u/s demonstrating
normal blood flow and no evidence of obstructive physiology. As
such, he continues w/ UF on Tuesday, Thursday, and Saturday.
Recently, he has been able to tolerate as much as 4L removal
during these sessions. Nephrology feels that he may regain his
renal function and have recommended that he not be placed on an
ACEI. This will need to be readdressed over time as he will
benefit from an ACEI from a CHF and blood pressure standpoint.
.
AFIB/CAD: it was initially unclear if pt is chronically in Afib
or paroxysmal, however he remained in AFIB throughout his entire
hospital stay. Upon talking w/ daughter later in hospitlization,
it appears that pt may chronically be in afib. It was presumed
he was on coumadin for AVR & Afib. While here he had a GIB with
an episode of hypotension in the setting of a supratherapeutic
INR. Coumadin was stopped and was not be restarted during his
stay. GI was consulted who recommended an outpatient coloscopy.
In the setting of his acute renal failure, he developed dig
toxicity with EKG changes (accelerated junctional rhythm). He
required two rounds of digibind before this resolved and dig was
discontinued. He was started on IV amiodarone (load) and was
tolerating PO amio but maintained in atrial fibrillation. Later
in his hospitalization, cardiology (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**]) was
reconsulted regarding the utility of continuing amiodarone in
the setting of likely chronic afib w/ enlarged atria, chf, and
respiratory failure (making conversion to SR unlikely). It was
recommended to d/c amiodarone and to restart his digoxin at a
low dose 0.625 qod while checking dig levels frequently to keep
his dig level <1.5. Dig was contineud but recently there were
concerns about ?AV block on dig. Given his history of dig
toxicity and renal failure, it was decided to d/c dig on [**3-19**].
Subsequent rate control will be through beta-blockade,
metoprolol 12.5 [**Hospital1 **]. His rates have generally been well
controlled although occasionally noted to be in low 100's during
HD and during pain. As mentioned above, given his recent
bleeding, it was elected not to anti-coagulate pt. He will be
maintained on ASA. Future discussions regarding
re-anticoagulation could be revisited by cardiologist or PCP. [**Name10 (NameIs) **]
was initiated on metoprolol for CHF and rate control. He was
s/p CABG 1 month ago prior to admission w/ bioprosthetic aortic
valve placed during [**11-30**]. He was continued on an ASA and
statin.
.
GIB/ANTICOAGULATION: he was restarted on Coumadin and then began
to have bright red blood per rectum, and hypotension in the
setting of supratherapeutic INR. Coumadin was stopped, vitamin K
IV, FFP, and PRBCs administered. GI consulted and reluctant to
scope patient in tenous clinical situation. Despite this
reversal, his INR continued to be elevated for unclear reasons.
It was questioned what his true need for Coumadin is since he
has a bioprosthetic valve with Afib. After his GIB is was felt
that Coumadin should be held during this hospitalization, and
that he should continue an ASA and re-address risks of Coumadin
after discharge. He has no further bleeding during the last [**1-29**]
weeks of hospitlization and no further transfusion requirements.
.
DECUB: he has significant sacral decub ulcers that were
evaluated by the wound care team, as well as a L-heel pressure
ulcer that was followed as well. He continues to have SEVERE
pain in the buttock region. We have been increasing his
fentanyl patch and using morphine IV for breakthrough pain.
Zinc and vitamin C were given orally daily. His wound has been
slowly improving. He requires frequent turning and an air
mattress. His fentanyl patch was increased to 200mcg/hr on [**3-17**].
It will be important to titrate this medication upwards but
mindful not to avoid oversedation. In fact, pt was found heavily
sedated on [**3-18**] - this was attributable to this increased
narcotic dosage and subsequently has been reduced to 125 mg
every 3 days (last changed [**3-18**]). His mental status has
subsequently returned to baseline. Nutrition will be important
in hopes of improving decub.
Diabetes: He was maintained on sliding scale insulin and Lantus
10. Given chronic tube feeds, this dose may be titrated
according to sliding scale measurements.
Malnutrition: Pt did have PEG placed for nutrition. Earlier in
hospital course, it was demonstrated that pt was in fact
aspirating and as such, PEG was converted to PEJ to reduce risk
for aspiration. He did have repeat swallow study which continued
to demonstrate high risk for aspiration. As such, he should
continue on current tube feeding recommendations. There is mild
erythema at site of PEJ that is felt to represent inflammation
rather than infection. This should be followed closely.
Access: He has double lumen PICC placed earlier in [**Month (only) 958**]. Only
one port is flushing at this point but not clear that pt
requires a great deal of IV medications so this will suffice. In
the future, it could be decided to remove PICC. Finally, he does
have left subclavian dialysis port.
.
GOALS OF CARE: it was addressed several times about the goals of
care, and the family repeatedly insisted that all aggressive
measures should be taken. They have been advised about the
severity of his many illnesses and the chance for recurrent
complications or repeat hopsitilzations. There was question if
the patient had expressed wished to withhold aggressive care,
but was unclear if he truly understood scenario and this goes
against his family's wishes. Communication with his son [**Name (NI) **]
[**Telephone/Fax (1) 64987**] and daughter [**Name (NI) **] who is the HCP. This will need
to be reevaluated now that he is speaking with his Passy Muir
valve.
Medications on Admission:
-lasix 40 daily
-coumadin 5 mg daily
-digoxin 0.125 mg daily
-lisinopril 5 daily (held starting today at [**Hospital1 **] due to K+)
-aspirin daily
-simvastatin 40 daily
-sucralfate 1 gm [**Hospital1 **]
-Epo qWed
-insulin SS
-nystatin TID
-iproatrop neb prn
-albut neb prn
-artificial tears prn
-zinc sulfate 220 mg daily
-Mg hydroxide 30 mL daily
-lansoprazole 30 daily
-lactulose 20 daily
-Na bicarb 10 cc daily
-MVI
-ferrous sulfate 300 daily
-oxycodone 5 mg q4h prn
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
Disp:*90 injection* Refills:*2*
13. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): hold for sbp less than 90 and during HD days.
14. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) unit Transdermal
Q72H (every 72 hours): last change was on [**3-18**].
15. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) patch Transdermal
every seventy-two (72) hours: last patch of 125 on [**3-18**].
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous DAILY (Daily) as needed.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): please hold on HD days and for sbp less than 85
and hr less than 60.
19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
21. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
22. Insulin Glargine 100 unit/mL Cartridge Sig: 10 units units
Subcutaneous once a day.
23. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale units Subcutaneous every six (6) hours: Sliding Scale
Sugar Insulin
0-60 1 amp d50
61-150 0 units
151-200 2 units
201-250 4 units
251-300 6 units
301-350 8 units
351-400 10 units
>401 12 units.
24. Outpatient [**Name (NI) **] Work
Pt should have chemistry 7 w/ ca/mag/phos checked every other
day - please fax to covering nephrologist
25. ultrafiltration
Please continue w/ ultra-filtration every monday, wednesday, and
friday
Please call Dr. [**Last Name (STitle) 174**] at [**Telephone/Fax (1) 60**] for questions with regards
to dialysis
26. Outpatient Speech/Swallowing Therapy
Pt is deemed to be aspiration risk and should be maintained NPO
from mouth.
A repeat swallow eval could be performed in [**12-28**] weeks to
determine if improved.
27. PICC line
One port of LUE PICC not flushing. Pt has minimal IVF needs and
could consider removal of PICC line as condition continues to
improve.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Acute Renal Failure now on hemodialysis
GIB in setting of coumadin
pneumonia with MRSA
aspiration pneumonia
sepsis
MRSA tracheobronchitis
sacral and heel decubitus ulcers
secondary:
CAD s/p cabg
aortic stenosis s/p AVR
Discharge Condition:
fair
Discharge Instructions:
When the patient's clinical status improves, he needs a
colonoscopy for his GIB. If he has no lesions, anti-coagulation
with coumadin could be considered. Patient is to be out of bed
to chair at least once per day. He should have labs (chem 7 w/
calcium, mag, phos and digoxin) checked atleast every other day
(with HD).
Followup Instructions:
Follow up with his PCP [**Name9 (PRE) 6983**] [**Name9 (PRE) **] (see phone above) within 7
days of his discharge.
Hemodialysis/Ultrafiltration three times weekly Monday,
Wednesday, and Friday
ICD9 Codes: 0389, 5845, 4280, 5070, 5789 |
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