Split (1)

train · 498k rows

meta dict	text stringlengths 0 55.8k
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7400 }	Medical Text: Admission Date: [2189-2-25] Discharge Date: [2189-3-2] Date of Birth: [2132-8-16] Sex: M Service: NEUROLOGY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 4583] Chief Complaint: Seizure Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 31523] is a 56 yo healthy man who presents after episode of stiffening and unresponsiveness concerning for tonic seizure. History was obtained from patient's partner. [Name (NI) ] was in bed playing game on iPad, when he began saying "ok" repeatedly. He then raised his arms, internally rotated, and stiffened, and his legs were extended and stiff, there was some shaky movements but not vigorous rhythmic convulsions. He was not responsive during this, and he remains unresponsive after the movement resolved. His partner called 911, and is unclear about how long the event lasted, but states he thinks it was resolving about the time EMS arrived. The patient was intubated in the field for unresponsiveness, with etomodate/succ/versed. His fingerstick was normal. He arrived to [Hospital1 18] sedated and intubated. In ED head CT and labs were normal. He received 1 dose antibiotics (levaquin) for ?aspiration. The patient has never had a seizure before. He was at his baseline yesterday and has not been febrile or ill recently. He does not use drugs, and no EtOH for at least 1 week. Past Medical History: none Social History: lives with male partner, works as systems analyst. No tobacco, rare ETOH, no illicits, no exposures. Family History: non-contributory Physical Exam: VS T (rectal) 99.4 HR 80 BP 152/87 RR 18 intubated 100%02sat Gen: intubated, sedated HEENT: NC/AT, sclera anicteric CV: RRR no m/r/g PULM: CTAB AB: NT/ND EXT: no edema. Has punctate scabs on arms and legs. NEURO: off propofol 5 minutes chewing on tube, coughing. Does not open eyes, does not follow commands. Eyes midline, pupils 3 to 2mm bilaterally. Intially R leg is externally rotated, but later moves all extremities antigravity and symmetrically in response to noxious stim. DTRs: 2+ and symmetric, no clonus, toes mute Pertinent Results: [2189-2-25] 09:32AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.008 [2189-2-25] 09:32AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2189-2-25] 09:32AM URINE RBC-0-2 WBC-[3-21] BACTERIA-FEW YEAST-NONE EPI-0-2 [2189-2-25] 09:32AM URINE HYALINE-0-2 [2189-2-25] 04:16AM TYPE-ART PO2-504* PCO2-48* PH-7.36 TOTAL CO2-28 BASE XS-1 [2189-2-25] 04:16AM LACTATE-1.6 [2189-2-25] 03:38AM VoidSpec-SPECIMEN Q [2189-2-25] 02:00AM URINE HOURS-RANDOM [2189-2-25] 02:00AM URINE HOURS-RANDOM [2189-2-25] 02:00AM URINE GR HOLD-HOLD [2189-2-25] 02:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2189-2-25] 02:00AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.008 [2189-2-25] 02:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2189-2-25] 02:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [2189-2-25] 01:25AM PH-7.17* INTUBATED-INTUBATED COMMENTS-GREEN TOP [2189-2-25] 01:25AM GLUCOSE-208* LACTATE-7.1* NA+-140 K+-4.0 CL--100 TCO2-22 [2189-2-25] 01:25AM HGB-14.7 calcHCT-44 O2 SAT-97 CARBOXYHB-1 MET HGB-0 [2189-2-25] 01:25AM freeCa-1.16 [2189-2-25] 01:17AM UREA N-12 CREAT-1.0 [2189-2-25] 01:17AM estGFR-Using this [2189-2-25] 01:17AM LIPASE-46 [2189-2-25] 01:17AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2189-2-25] 01:17AM WBC-8.3 RBC-5.04 HGB-14.3 HCT-42.3 MCV-84 MCH-28.3 MCHC-33.7 RDW-13.6 [2189-2-25] 01:17AM PT-11.2 PTT-21.2* INR(PT)-0.9 [2189-2-25] 01:17AM PLT COUNT-274 [2189-2-25] 01:17AM FIBRINOGE-330 Brief Hospital Course: 56 yo healthy man p/w generalized tonic seizure followed by unresponsiveness requiring intubation. He had been completely well, no mental status changes, fevers, or illnesses, and has never had a seizure. The report of his seizure includes all extremities stiffening, and extending, with arms internally rotated. There does not sound to have been a clonic component. He was likely postictal when EMS arrived and was intubated for airway protection. Alternatively, there is a much lesser likelihood that he was in status. His neuro exam was initially (before CT) concerning for R sided weakness (R leg ext rotated) but later he demonstrated antigravity movement in all extremities symmetrically. He was admitted to neuro ICU [First Name9 (NamePattern2) 9235] [Doctor Last Name ] and initially started on Keppra 1000 mg [Hospital1 ]. EEG at bedside demonstrated some diffuse slowing but no epileptiform activity. Following the EEG he had another 4 minute generalized tonic event with moderate clonic component as witness by nursing. He was given 2 mg of Ativan. We inreased the Keppra to 1500 mg [Hospital1 ]. MRI brain with and without contrast demonstrated 8 x 6 mm enhancing focus in the right frontal lobe with small amount of adjacent edema. A dedicated CT of sinus demonstrated _no abnormalities. On [2-26] he was extubated and doing well. A lumbar puncture was done which demonstrated 1 WBC, 29 RBCs, 33 Prot, 38 Glucose. Cytology was pending at discharge. A CT of his body demonstrated calcified granulomas in the lungs, liver and spleen and a PPD was placed, for which he was going to return on [2189-3-3] to be read. He was also noted to be hypertensive in the 160s to 180s, and was placed on metoprolol 50 [Hospital1 ] and lisinopril 10 daily which controlled him well in the 120s to 130s. He was maintained on 1500 [Hospital1 ] Keppra, without any further seizure activity. He was seen by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and scheduled for repeat MRI on [2189-3-5] with a biopsy of the lesion scheduled for [2189-3-6]. On discharge he had a normal neurological examination. Medications on Admission: none Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Right Frontal Brain Lesion Seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Exam: normal Discharge Instructions: You were admitted after a first seizure and during your admission you were found to have an abnormality in the right frontal portion of your brain. We remain unsure of what this represents, but hope that a biopsy will provide those answers. You were also hypertensive with blood pressures in the 160's to 180's and you were started on 2 different medications to control your pressure. A CT of your body revealed several calcified areas consistent with a possible remote case of tuberculosis, and you had a PPD placed on your left forearm. Followup Instructions: You will be called by Dr.[Name (NI) 9399] office to come in for a repeat MRI on Thursday ([2189-3-5]). You have a biopsy tentatively scheduled with him for Friday ([2189-3-6]). Please return tomorrow to have your PPD officially read by Dr. [First Name8 (NamePattern2) ] [Name (STitle) ]. ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7401 }	Medical Text: Admission Date: [2145-6-10] Discharge Date: [2145-6-29] Date of Birth: [2065-3-17] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4111] Chief Complaint: RIGHT UPPER ABDOMENAL PAIN Major Surgical or Invasive Procedure: OPEN CHOLECYSTECTOMY History of Present Illness: 80 YEAR-OLD FEMALE WITH 2 WEEKS OF INTERMITTENT RIGHT UPPER QUADRANT PAIN AND LEFT ARM PAIN. PAIN IS SHARP, RADIATING TO THE BACK, AND LASTING 15-20 MINUTES. PAIN WAS CONSTANT ON THE DAY OF ADMISSION, BUT HAD BEEN IMPROVING SINCE HER ADMISSION TO THE EMERGENCY ROOM. SHE TOLERATES ORAL INTAKE AND PASSES GAS FROM BELOW. SHE HAD BOWEL MOVEMENT THE DAY BEFORE ADMISSION. IT WAS SLIGHTLY LOOSE. SHE WAS UNSURE IF THERE HAS BEEN BLOOD IN HER URINE OR STOOL. SHE DENIES SHORTNESS OF BREATH, NAUSEA/VOMITING, FEVERS/CHILLS. SHE HAS NO PERSONAL OR FAMILIAL HISTORY OF GALLBLADDER DISEASE. Past Medical History: 1) TYPE B AORTIC DISECTION S/P REPAIR [10-1] 2) BARRETT'S ESOPHAGUS 3) PEPTIC ULCER DISEASE 4) HYPERTENSION 5) HYPERLIPIDEMIA 6) SPINAL STENOSIS 7) ASTHMA 8) DIVERTICULOSIS 9) CATARACTS AND GLAUCOMA S/P BILATERAL EYE SURGERY [49])S/P HYSTERECTOMY 11)S/P RIGHT KNEE SURGERY Social History: Lives at home with son, who is a teacher.Denies Tobacco or ETOH use.She has a daughter, who is active in her health care and is a nurse [First Name8 (NamePattern2) ] [Last Name (Titles) 9012] Family History: non-contribitory Physical Exam: AT TIME OF SURGICAL CONSULT: TEMP 98.0 PULSE 60 BLOOD PRESSURE 184/81 RIGHT ARM, 188/90 LEFT ARM RESP RATE 16 PULSE OX: 98% ROOM AIR GENERAL: NO ACUTE DISTRESS HEAD AND NECK: ANICTERIC, INJECTED SCLERA, EXTRAOCULO MOTORS INTACT, NO JUGULAR VENOUS DISTENTION, NO LYMPHANOPATHY HEART: REGULAR RATE RHYTHM LUNGS: DECREASED BREATH SOUNDS BILATERALLY ABDOMEN: SOFT, NON-DISTENDED, RIGHT UPPER QUADRANT IS TENDER TO PALPATION, NO REBOUND, NO GUARDING, MIDLINE INCISION IS WELL-HEALED RECTAL: TONE NORMAL, GUIAC NEGATIVE EXTREMITIES: TRACE LEFT LOWER EXTREMITY EDEMA Pertinent Results: [2145-6-27] 05:05AM BLOOD WBC-7.3 RBC-3.70* Hgb-11.1* Hct-33.9* MCV-92 MCH-30.0 MCHC-32.7 RDW-15.1 Plt Ct-229 [2145-6-16] 04:37AM BLOOD WBC-10.7# RBC-4.33 Hgb-12.9 Hct-38.9 MCV-90 MCH-29.8 MCHC-33.2 RDW-15.0 Plt Ct-157 [2145-6-27] 05:05AM BLOOD ALT-29 AST-34 AlkPhos-311* TotBili-0.8 [2145-6-15] 05:45AM BLOOD ALT-48* AST-67* AlkPhos-370* Amylase-44 TotBili-1.4 [2145-6-14] 09:30AM BLOOD ALT-52* AST-78* AlkPhos-379* TotBili-1.5 [2145-6-12] 05:45AM BLOOD ALT-48* AST-60* CK(CPK)-142* AlkPhos-443* Amylase-44 TotBili-1.7* [2145-6-11] 05:45AM BLOOD ALT-53* AST-65* AlkPhos-487* Amylase-43 TotBili-1.6* [2145-6-10] 06:00AM BLOOD ALT-60* AST-82* AlkPhos-513* TotBili-1.0 [2145-6-9] 05:35PM BLOOD ALT-58* AST-86* CK(CPK)-87 AlkPhos-484* Amylase-53 TotBili-0.9 [2145-6-10] 06:00AM BLOOD GGT-665* [2145-6-9] 05:35PM BLOOD Lipase-24 GGT-612* [2145-6-13] 02:23AM BLOOD CK-MB-3 cTropnT-<0.01 [2145-6-12] 04:00PM BLOOD CK-MB-3 [2145-6-12] 05:45AM BLOOD CK-MB-3 cTropnT-<0.01 [2145-6-9] 05:35PM BLOOD cTropnT-<0.01 [2145-6-21] 07:48AM BLOOD calTIBC-241* Ferritn-192* TRF-185* [2145-6-14] 09:30AM BLOOD calTIBC-307 Ferritn-169* TRF-236 Brief Hospital Course: UPON ADMISSION TO THE HOSPITAL, THE PATIENT WAS STARTED ON LEVOFLOXACINQ AND METRONIDAZOLE IV. CARDIAC WORKUP FOR ACUTE CARDIAC CHANGES WAS NEGATIVE. ULTRASOUND AND CT SCAN OF THE ABDOMEN WERE INCONCLUSIVE FOR THE DIAGNOSE OF CHOLECYSTITIS; THE PATIENT'S ABDOMENAL AORTA WAS OBSERVED TO BE STABLE POST-AORTIC DISSECTION REPAIR. FROM CLINICAL SYMPTOMS, A DECISION WAS MADE TO TAKE THE PATIENT TO THE OPERATING ROOM FOR OPEN CHOLECYSTECTOMY. SHE TOLERATED THE SURGERY AND WAS ADMITTED TO THE SURGICAL INTENSIVE CARE UNIT, AND SUBSQUENTLY TO THE SURGICAL FLOOR. POST-OPERATIVELY, SHE HAS BEEN HAVING NAUSEA AND GASEOUS DISTENTION. THE NAUSEA IS NOW RESOLVED, BUT THE GASEOUS DISTENTION IS RELATED TO THE [Hospital ] MEDICAL CONDITION, IN WHICH SHE HAS BEEN TAKING MEDICATIONS FOR AFTER SHE TOLERATED ORAL NUTRITION. HER HOSPITAL STAY WAS COMPLICATED BY DECREASED APPETITE, WHICH RESULTED IN THE NEED FOR TOTAL PARENTAL NUTRITION. SHE HAS STEADYLY IMPROVED SINCE THE SURGERY. HE APPETITE HAS INCREASED. SHE HAS BEEN AMBULATING WITH THE ASSISTANCE OF HER NURSE AND THE PHYSICAL THERAPY TEAM. SHE HAS BEEN AFEBRILE WITH VITALS BEING STABLE AND MOSTLY WITHIN NORMAL LIMITS. SHE WILL BE DISCHARGED TODAY TO A SKILLED NURSING FACILITY ([Hospital ]) IN FAIR/GOOD CONDITON. Discharge Medications: 1. Pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 2. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop Ophthalmic Q 8H (Every 8 Hours). 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for PAIN. Disp:60 Tablet(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). Disp:120 Tablet, Chewable(s) Refills:2 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). Disp:120 Tablet, Chewable(s) Refills:2 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 10. Compazine 5 mg Tablet Sig: 1-2 Tablets PO four times a day: NAUSEA. Disp:60 Tablet(s) Refills:2 11. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: CHOLECYSTITIS; STATUS POST-OPEN CHOLECYSTECTOMY Discharge Condition: FAIR/GOOD Discharge Instructions: PLEASE TAKE MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS CAREFULLY. [Month (only) ] RETURN TO NORMAL ACTIVITIES AS TOLERATED, BUT PLEASE BE AWARE OF ABDOMENAL DRAIN. PLEASE FOLLOW UP WITH DR. [Last Name (STitle) ] ON APPOINTMENT DATE (BELOW) Followup Instructions: PLEASE CALL DR.[Doctor Last Name ] OFFICE FOR A FOLLOW UP APPOINTMENT TO BE SEEN ON [2145-7-5] ([Telephone/Fax (1) 376] ([Telephone/Fax (1) 57851] Completed by:[2145-6-28] ICD9 Codes: 2765
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7402 }	Medical Text: Admission Date: [2148-1-9] Discharge Date: [2148-2-2] Date of Birth: [2106-1-28] Sex: M Service: MEDICINE Allergies: Amoxicillin / Adhesive Bandage / Dicloxacillin Attending:[First Name3 (LF) 10293] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Intubation Diagnostic Paracentesis Therapeutic Paracentesis [Last Name (un) 1372]-jejunal tube placement History of Present Illness: This is 41 year old male with history of cirrhosis secondary to EtOH and hepatitis C virus, obstructive sleep apnea and hypothyroidism, with recurrent episodes of severe enceophalopathy and ascites. Mr. [Known lastname 19420] was re-admitted to [Hospital1 18] [1-9] for worsening encephalopathy. The patient has multiple admits for encephalopathy (5 since [8-27]). He has had 10 MICU admissions/floor transfers and at least 6 intubations since [2147-10-21] as a result of his encephalopathy. He was hospitalized from [Date range (2) 77415], during which time he had recurrent episodes of encephalopathy requiring MICU admissions, w/ one of them to be secondary to possible aspiration with poorly-fitting CPAP mask. He was most recently hospitalized again this month with discharge [1-8]. During this most recent admission, he likewise required MICU level care for encephalopathy and respiratory compromise when even a single Lactulose dose was delayed. He has demonstrated that he is exquisitely sensitive to any decrease in frequency of lactulose administration, and the results of delayed or missed doses lead to severe obtundation. Past Medical History: - HCV and EtOH Cirrhosis with ascites and edema, biopsy diagnosed in [2139], last vl 32,600 copies; last MELD 24. - h/o SBP early [7-27] on cipro prophylaxis - Grade II esophageal varices - Recurrent hepatic encephalopathy of unclear precipitant - Pulmonary HTN - Hypothyroidism - Anxiety disorder - h/o EtOH abuse, IVDU - osteoperosis of hip and spine per pt - Anemia w/ hx of guaiac positive stool. - pulmonary HTN - echo [2146-12-28] unable to assess; EF > 55%, MR slightly increased Social History: Pt lives with his Mother. Pt quit smoking [5-27], was smoking 1/3ppd. Quit drinking etoh 11 years ago. Prior remote hx of IVDU as teen. No current drug use. Family History: Mother with DM and HTN. Father with rheumatic heart disease. Physical Exam: EXAM PRIOR TO MICU TRANSFER ON [2148-1-10] Gen: Nonresponsive, eyes open, HEENT: dry MM, + scleral icterus Pulm: rhonchi BL, no wheezes or crackles CV: S1 & S2 regular without murmur Abd: Distended, tympanitic, + shifting dullness, firm. Unable to determine tenderness. Ext: 2+ edema bilteraly. Neuro: Non-responsive Pertinent Results: ADMISSION LABS: CBC: [2148-1-8] 06:00AM BLOOD WBC-4.8 RBC-2.45* Hgb-8.2* Hct-24.6* MCV-101* MCH-33.6* MCHC-33.4 RDW-19.1* Plt Ct-78* [2148-1-8] 06:00AM BLOOD Neuts-71.0* Lymphs-19.1 Monos-7.6 Eos-2.0 Baso-0.4 COAGS: [2148-1-8] 06:00AM BLOOD PT-23.5* PTT-46.5* INR(PT)-2.3* CHEMISTRIES: [2148-1-8] 06:00AM BLOOD Glucose-119* UreaN-12 Creat-0.8 Na-141 K-3.6 Cl-109* HCO3-25 AnGap-11 LIVER ENZYMES: [2148-1-8] 06:00AM BLOOD ALT-27 AST-66* LD(LDH)-276* AlkPhos-100 TotBili-3.7* [2148-1-9] 01:15PM BLOOD Lipase-46 [2148-1-8] 06:00AM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.3 Mg-1.8 [2148-1-9] 01:15PM BLOOD Ammonia-87* ------- ------- DISCHARGE LABS: [2148-2-2] 05:37AM BLOOD WBC-7.3 RBC-2.72* Hgb-8.5* Hct-26.8* MCV-98 MCH-31.2 MCHC-31.7 RDW-18.9* Plt Ct-67* [2148-2-2] 05:37AM BLOOD Glucose-104 UreaN-10 Creat-0.8 Na-142 K-3.9 Cl-116* HCO3-21* AnGap-9 [2148-2-1] 05:50AM BLOOD ALT-28 AST-71* LD(LDH)-282* AlkPhos-149* TotBili-5.2* MICROBIOLOGY: [2148-1-9] 1:15 pm BLOOD CULTURE FINAL REPORT [2148-1-15] Blood Culture, Routine (Final [2148-1-15]): NO GROWTH ------ [2148-1-11] 3:29 pm PERITONEAL FLUID FINAL REPORT [2148-1-17] GRAM STAIN (Final [2148-1-11]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2148-1-14]): NO GROWTH. ANAEROBIC CULTURE (Final [2148-1-17]): NO GROWTH ------ [2148-1-22] 11:17 am SPUTUM Source: Endotracheal. FINAL REPORT [2148-1-24] GRAM STAIN (Final [2148-1-22]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [2148-1-24]): SPARSE GROWTH OROPHARYNGEAL FLORA. YEAST. SPARSE GROWTH. ------ [2148-1-22] 11:19 am STOOL CONSISTENCY: WATERY Source: Stool. CANCELLED TESTS TO BE PERFORMED PER REQUEST OF PHYSICIAN. FINAL REPORT [2148-1-24] FECAL CULTURE (Final [2148-1-24]): NO SALMONELLA OR SHIGELLA FOUND. NO ENTERIC GRAM NEGATIVE RODS FOUND. CAMPYLOBACTER CULTURE (Final [2148-1-24]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2148-1-23]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: This is a 42 year old gentleman with a history of cirrhosis secondary to EtOH + HCV, history of spontaneous bacterial peritonitis, who has had multiple hospitalizations for encephalopathy who presented with mental status changes again consistent with encephalopathy. # Encephalopathy: The patient was admitted for mental status change secondary to encephalopathy. Within 24 hours of admission patient was transferred to the medical ICU for worsening encephalopathy and witnessed vomiting/aspiration while on CPAP. He was intubated & sedated for airway protection with an NG tube placed for gastric decompression and medicine administration. His chest x-ray and vital signs did not indicated any lung damage. He was extubated approximately 24 hours later. The patient's mental status cleared, he tolerated food and was returned to the Liver-Kidney service. The patient was transferred to the MICU again approximately 24 hours later for repeat altered mental status and unresponsiveness without witnessed aspiration or known cause. He was given lactulose, rifaximin and acidophilus and his mental status cleared within 12 hours. He was kept for 60 hours for monitoring wherein he developed an additional episode of somnolence that resolved with continued lactulose administration. He was again returned to the floor. Patient's encephalopathy remained stable on the floor for nearly 1 week until he became acutely obtunded. He was witnessed vomiting a small amount with subsequent aspiration. He was transferred to the MICU for treatment and intubated again for airway protection. Again lactulose and rifaximin were continued. Patient was again extubated and called out to the liver service. Close attention paid to patient receiving all scheduled lactulose doses while on the floor. In addition patient started on Zinc. He was also switched to a vegetarian diet so as to reduce his intake of animal proteins. This combination of treatments resulted in the patient's encephalopathy remaining stable until discharge. # Aspiration: Two of patient's transfers to the MICU were related to concern for aspitation. Patient felt to develop an aspiration pneumonitis versus pneumonia. Sputum gram stain showed gram positive cocci in clusters, chains and pairs. Cx growing only oropharyngeal flora. Patient was treated with a 7 day course of vancomycin and cefepime. Patient was maintained on aspiration precautions and was evaluated by speech and swallow who recommended thin liquids and ground consistency solids, Pills whole with thin liquids. # Attempt at Spleno-renal Embolization: Patient underwent IR guided spleno-renal embolization in an attempt to embolize shunts in his liver which could be contributing to his encephalopathy. Unfortunately, these shunts could not be embolized during the procedure given team unable to pass into the shunt from the renal vein. # End Stage Liver Disease: Secondary to alcohol and hepatitis C. Patient required two therapeutic paracentesis which yielded 4liters and 3.5 liters respectively. Patient received albumin following each tap. In addition, patient continued on nadolol, though at a decreased dose, and spironolactone. Lasix was held given episodes of hypotension while in the MICU and was not restarted given patient achieved a degree of stability on his medication regimen while lasix held. His liver function tests remained stable. Patient continued on daily cipro for SBP prophylaxis. Patient is currently awaiting a liver [Year/Month/Day ]. He is scheduled to follow up in [Year/Month/Day ] clinic with Dr. [Name (NI) ]. # Anemia: Likely a combination of anemia of chronic disease and mild blood loss anemia given chronically guiac positive stools. It has been unclear what the source of bleed. Hematocrit remained stable during this admission. Would recommend an outpatient colonoscopy to assess for source of GI bleeding. # Thrombocytopenia: Likely secondary to liver disease. Platelets remained stable. # Hypothyroidism: Patient was continued on levothyroxine 88mcg PO daily. # Pulmonary HTN: Patient continued on his outpatient regimen of iloprost. Patient should follow up in pulmonary clinic for further management of this issue. # OSA: He was started on a brief trial of modafinil but this was not continued after he was discharged from the ICU. Patient was continued on CPAP throughout his hospital course. Patient was a FULL code during this admission. Medications on Admission: 1. Ciprofloxacin 250 mg PO Q24H 2. Lactulose Sixty (60) ML PO Q2H as needed for confusion. 3. Rifaximin 400 mg PO TID 4. Levothyroxine 88 mcg PO DAILY 5. Omeprazole 20 mg PO once a day. 6. CALCIUM 500+D 500 PO once a day. 7. Magnesium 400 mg PO once a day 8. Lactulose Forty Five (45) ML PO QID 9. Nadolol 20 mg PO DAILY 10. Home oxygen 2L continuous 11. CPAP 5 - 15 CM H2O 12. Iloprost 10 mcg/mL One (1) nebulizer treatment Inhalation 6x daily. 13. Lasix 20mg PO daily 14. Spironolactone 50mg PO BID 15. Clotrimazole Troche 10mg 5x/day Discharge Medications: 1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 5. Acidophilus Oral 6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. [Hospital ] Hospital Bed: Diagnosis: End stage liver disease complicated by encephalopathy::Patient requires daily tube feeds and aspiration precautions at all times 8. 3 in 1 commode 9. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO twice a day. [Hospital ]:60 Tablet(s) Refills:2 10. Tube Feeding Formula: Fibersource HN Full strength; Rate: At goal rate of 40 ml/hr Flush w/ 100 ml water q6h 11. FiberSource HN Liquid Sig: Forty (40) cc per hour: continuous via post pyloric feeding tube. [Hospital ]#: 120 One hundred and 20 cans Refills: 1 12. Tube feeding supplies Tube fedding supplies supply pump, tubing syringes, pole supply 1 month refill: 1 13. Iloprost 10 mcg/mL Solution for Nebulization Sig: 60mL MLs Inhalation 9 times daily (). 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. [Hospital ]:30 Tablet(s) Refills:2 15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [Hospital ]:60 Capsule(s) Refills:2 16. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [Hospital ]:15 Tablet(s) Refills:2 17. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). [Hospital ]:120 Capsule(s) Refills:2 18. Lactobacillus Acidophilus Capsule Sig: 500 million cell Capsules PO TID (3 times a day). 19. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO Q3H (every 3 hours). [Hospital ]:[Numeric Identifier 16501] qs Refills:2 20. Calcium cholecalciferol 600-40 mg unit TID Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Primary: Hepatic Encephalopathy, Ascites secondary to end stage liver disease Secondary: Pulmonary Hypertension, Obstructive Sleep Apnea, Hypothyroidism Discharge Condition: Stable Discharge Instructions: You were admitted with encephalopathy. Your encephalopathy improved with aggressive and timely administration of Lactulose. During your hospital stay we also performed two therapeutic paracentesis to remove ascites. You have had a tube placed that goes from your nose to your intestines so that you can have tube feeds. The following medications STOPPED: Lasix: please call Dr. [Name (STitle) 23173] if you notice increased leg swelling since this medication may need to be restarted. The following medications are NEW: Zinc: this is for your encephalopathy The following CHANGES were made to your meds: Lactulose is now 45mL q3 hr: in the hospital we had a goal of 700 cc of stool daily Spironolactone is now 50 mg twice a day Magnesium oxide is now 280 mg twice a day Nadolol is now 10 mg daily If you experience changes in your mental status please come to the ED immediately. If you experience shortness of breath, chest pain, fevers or abdominal pain please contact your primary care physician or come to the ED for evaluation. Please let Dr. [Name (STitle) 23173] know if your legs are getting more swollen since you may need to have your lasix restarted. Followup Instructions: You have been scheduled to see Dr. [Last Name (STitle) 1383] ([Last Name (STitle) 1326] Center) on [2148-2-23] at 8:30 am. The office phone number is ([Telephone/Fax (1) 10248]. You should make an appointment to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Location (un) 6330] within the next 7-10 days. The office phone number is [Telephone/Fax (1) 46571]. Completed by:[2148-2-7] ICD9 Codes: 2760, 5070, 4168, 2449, 2859, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7403 }	Medical Text: Admission Date: [2159-3-22] Discharge Date: [2159-3-28] Date of Birth: [2080-7-26] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old male with a past medical history of seizure disorder, found by family at the bottom of the stairs unconscious with seizure activity. Patient failed field intubation and was made an oral airway, bagged with an O2 saturation of 98 percent. Patient was transferred to [Hospital6 2561], where he was intubated and stabilized. Head CT demonstrated bilateral subarachnoid hemorrhage and subdural hematoma. Patient was transferred to [Hospital1 69] Emergency Department as a hemodynamically stable patient. PAST MEDICAL HISTORY: 1. COPD. 2. Seizure disorder. 3. Bladder cancer in [2153] status post urostomy. 4. Status post femoral bypass. ALLERGIES: None. MEDICATIONS: 1. Dilantin. 2. Lamictal. 3. Aspirin. Upon admittance to [Hospital3 ] Medical Center, physical exam showed systolic blood pressure of 218/106, O2 saturation was 99 percent. Respiratory rate was 20. Heart had a regular, rate, and rhythm, S1, S2 present, no murmurs, rubs, or gallops. His abdomen was soft, nontender, nondistended. Bowel sounds times four. His lungs were clear bilaterally, and his extremities had no clubbing, cyanosis, or edema. HEENT: Right eye bruise with swelling. No other lacerations or battle signs. Neurological exam: Patient opens eyes to voice, moves arms to command, squeezed left hand to command. Pupils were 4 to 3 mm reactive bilaterally. Does not blink to visual threat. No facial asymmetry. Positive corneal and gag reflex. His motor activity: He moves upper extremities to antigravity. No lower extremity movement. Sensory: Withdraws to pain in the left lower extremity only. Reflex: Trace. Left lower extremity reflex with muscle, mute toes bilaterally. ASSESSMENT AND PLAN: He is a 78-year-old man with a fall secondary to seizure now with bilateral subdural hematomas and subarachnoid hemorrhage without midline shift. Assessment and plan for this patient at this time was to keep his systolic blood pressure between 100 and 140, hourly neurologic checks. He was given mannitol 50 grams q.4h. Check q.4h. serum sodium and osmolality. He was given Dilantin 500 mg times one. Recheck Dilantin one hour after bolus. Hyperventilated with goal pCO2 between 32 and 35. He was administered Solu-Medrol per Spine protocol. MRI of the spine per trauma protocol with possible MRI of the brain. A stat noncontrast head CT was ordered for four hours. He was given 10 bags of platelets. Held all aspirin and he was at full code at this point. On [2159-3-23], the patient's vital signs were a temperature of 98.8, pulse was 63 and 114, his blood pressure was 100/54, and his respiratory rate was between 22 and 25. He was ventilated, and his O2 saturation was 98 to 100 percent. He was on propofol 50 mcg/kg/minute. At this time, the patient was localizing the pain in the upper extremities only. His pupils were 3 to 2 mm bilaterally. Slight left outward eye deviation. Toes mute. No movement in the lower extremities. No reflex. The assessment and plan at this time: He was under sedation. Plegic in the lower extremities. We wanted to keep his blood pressure between 100 and 140. Hourly neurologic checks. PCO2 between 33 and 35. Keep him euvolemic. Serum osmolality q.4h. If less than 320, given him mannitol. Continue Solu-Medrol times 24 hours, subQ Heparin tonight, serial hematocrits. On [2159-3-27], he spiked a fever at 102.8. His systolic blood pressure was 110-146/51-66. His heart rate was between 73 and 129. His respiratory rate was between 24 and 37. His pupils were trace reactive to ambient light. He was moving his upper extremities spontaneously. No lower extremity movement at this time. His assessment and plan: Neurologically no change. Replaced TC from oral A line. He was to have a full fever workup, chest x-rays, correct the sodium with free water, and the plan was to talk to the family at this time. On [2159-3-28], on Neurosurgery, his temperature was 101.7. His pulse was between 88 and 101. Respiratory rate was between 21 and 36. He was intubated and saturating between 93 and 99 percent. His eyes were closed. He localized to pain on the left. Right arm flexed posture versus localized. Pupils 3 mm reactive to ambient light. Paraplegia of the legs. Assessment and plan: CT of the head shows evolving subarachnoid hematoma with contusions. There is minimal mass effect. Awaiting family discussion regarding CMO status. The goal is to keep his blood pressure below 140. Later on [2159-3-28], attending in the Trauma ICU spoke with the family and explained the developments in his case. They told me that the patient had often expressed a strong desire not to be kept alive if he would be physically impaired. They asked that the patient be removed from mechanical ventilation and made comfort measures only. In light of his grim prognosis, I agree that this is a reasonable course. At 10 p.m., the patient was pronounced dead by Trauma attending physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ] at 10 p.m. He was without spontaneous respirations, no heart activity on telemetry. Exam confirms no breath sounds, heart sounds. Pupils were fixed and dilated. No brain stem functions. DR.[First Name (STitle) ],[First Name3 (LF) 125] 14-118 Dictated By:[Known firstname 55659] MEDQUIST36 D: [2159-3-28] 23:11:14 T: [2159-3-30] 06:51:35 Job#: [Job Number 55660] ICD9 Codes: 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7404 }	Medical Text: Unit No: [Numeric Identifier 77187] Admission Date: [2194-2-19] Discharge Date: [2194-2-24] Date of Birth: [2194-2-19] Sex: F Service: Neonatology HISTORY: [First Name4 (NamePattern1) 14552] [Known lastname ] is a 1.98 kg (4 pounds, 5 ounce) product of a preterm gestation. She was born to a 41-year-old gravida 2, para 1 now 2 mother. The pregnancy was benign with an EDC of [2194-3-31]. Prenatal screens were O+, hepatitis surface antigen negative, rapid plasma reagent nonreactive, rubella-immune, group B Strep status unknown. The infant was delivered by spontaneous vaginal delivery with Apgar scores at 9 at one minute and 9 at five minutes. [Doctor First Name 77188] blood type is B+, Coombs negative. She was born at 35 and 1/7 weeks. PHYSICAL EXAM ON ADMISSION: On admission to the newborn nursery [Doctor First Name 14552] was well-appearing. She had bilateral breath sounds that were clear and equal. The heart rate was regular without murmur and pulses were 2+ and symmetrical. The abdomen was soft and nontender with no hepatosplenomegaly. Her birth weight was 1.98 kg (4 pounds, 5 ounces) in the less than 25th percentile. Her length was 46 cm in the 50th percentile and her head circumference was 30.5 cm in the 25th percentile. She had normal female genitalia. Her hips were stable. Her tone was normal with normal neonatal reflexes. She is tolerating her feedings well. SUMMARY OF HOSPITAL COURSE: Respiratory without issues on this admission. Breath sounds clear and equal. Cardiovascular without issues on this admission. She had a regular heart rate and rhythm, no murmur, and pulses were 2+ and symmetric. Fluids, electrolytes and nutrition. [Doctor First Name 77188] birth weight was 1.98 kg (4 pounds, 5 ounces). [Doctor First Name 14552] is breast feeding every 3 hours and supplemented with 24 calories expressed breast milk or EnfaCare 24. She is feeding well, her discharge weight is 1955kg (4lb 5 oz). Gastrointestinal. [Doctor First Name 77188] bilirubin on [2194-2-20] was 11.4 at which time she was started under double phototherapy. Her bilirubin on [2-21] was 11.2, on [2-22] it was 9.4 and on [2-23] it was 9.3. On [2-24] bili 8.4 at which time phototherapy was discontinued. Rebound bilirubin on [2-25] was 9.1/0.3. Hematology. The hematocrit on [2194-2-23] was 61.1. Her blood type is B+, Coombs negative. Infectious disease. No issues on this admission. Neurologic. The infant has been appropriate for gestational age with normal newborn reflexes. Sensory. Auditory hearing screening was performed with automated brain-stem responses and the infant's right ear was deferred. Followup audiology screening will be recommended. Psychosocial. Family was invested and involved. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. SOURCE OF PRIMARY PEDIATRIC CARE: [Hospital3 44721] at [State 14091], [Location (un) 86], [Numeric Identifier 4809]. Telephone number ([Telephone/Fax (1) 26420]. CARE RECOMMENDATIONS: 1. Continue to feed every 3 hours with expressed milk 24 or EnfaCare 24. 2. Followup with pediatrician at SCCHC on [2194-2-26]. 3. Medications not applicable. 4. Car seat position screening. Mother refused car seat testing and baby will be discharged in car bed. 5. State newborn screens were sent on [2194-2-20] and the results are pending. 6. Auditory. Since the baby's right ear was referred, followup auditory testing is scheduled for [3-21] 9am at [Hospital1 336].. 7. Immunizations received: Hepatitis B vaccine on [2194-2-25]. 8. Immunizations recommended: 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 all household contacts and out of home caregivers. DISCHARGE DIAGNOSES: 1. Preterm 35 and 1/7 weeks, small for gestational age female. 2. Hyperbilirubinemia s/p PTx -- resolved [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD [MD Number(2) 71194] Dictated By:[Name8 (MD) 37128] MEDQUIST36 D: [2194-2-23] 14:27:11 T: [2194-2-23] 18:30:12 Job#: [Job Number 77189] ICD9 Codes: 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7405 }	Medical Text: Admission Date: [2152-9-4] Discharge Date: [2152-9-7] Date of Birth: [2111-11-7] Sex: M Service: MEDICINE Allergies: Ativan Attending:[First Name3 (LF) 30] Chief Complaint: Detox Major Surgical or Invasive Procedure: none History of Present Illness: 40 yo M hx of EtOH abuse on Libirum taper with seizure vs. pseudoseizure disorder on Valproate, admitted to [Hospital1 ] for Librium taper as following: [2152-8-31] libirum 100 [2152-9-1] 75 qid [2152-9-2] 50 mg tid [2152-9-3] 50 mg [Hospital1 ], . On night prior to admission patinet was noticed to be confused and tremulous and was given an addtional dose of Librium 100 STAT amd 2mg Ativan. Paitnet also given Thorazine and Benadryl. . Was started on librium taper at [Hospital1 ] (day 3) and on valproic acid. This AM developed acute delirium, vital signs normal by report. Given higher dose of librium (75 instead of 50 [Hospital1 ]). 30 minutes later was found wondering and confused. He received thorazine, benadryl and ativan IM without improvement at [Hospital1 ]. . Given approximately 50mg IV valium in the ED without improvement. EKG with sinus tach. S/p 3L NS. Was getting daily thiamine, folic acid, MVI at [Last Name (LF) ], [First Name3 (LF) ] no banana bag. . ROS: unable to assess Past Medical History: EtOH abuse Seizure vs. Pseudo-seizure disorder Social History: alcohol and cocaine abuse. Family History: NC Physical Exam: Vitals - T:95 BP:135/100 HR:102 RR:16 02 sat:100RA GENERAL: laying in bed, tremulous, mumbling SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, supple neck, no LAD, no JVD CARDIAC: tachycardic, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: unable to assess Pertinent Results: [2152-9-4] 04:27AM URINE HOURS-RANDOM [2152-9-4] 04:27AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2152-9-4] 04:27AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.004 [2152-9-4] 04:27AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2152-9-4] 03:07AM GLUCOSE-106* UREA N-10 CREAT-0.5 SODIUM-140 POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17 [2152-9-4] 03:07AM estGFR-Using this [2152-9-4] 03:07AM ALT(SGPT)-45* AST(SGOT)-71* LD(LDH)-211 CK(CPK)-933* ALK PHOS-47 TOT BILI-0.5 [2152-9-4] 03:07AM VALPROATE-31* [2152-9-4] 03:07AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2152-9-4] 03:07AM WBC-9.4 RBC-4.18* HGB-14.7 HCT-41.8 MCV-100* MCH-35.1* MCHC-35.1* RDW-14.2 [2152-9-4] 03:07AM NEUTS-75.5* LYMPHS-17.4* MONOS-3.9 EOS-2.9 BASOS-0.3 [2152-9-4] 03:07AM PLT COUNT-114* Brief Hospital Course: 40 yo M presented from Bornewood with altered mental status while undergoing detox. . # Altered mental status. Likely DT's. Urine and serum tox screens negative. No signs of neuroleptic malignant syndrome unlikely with minimally elevated CK. No signs of infection. He required very little benzos per CIWA scale in the MICU. Head CT was negative but showed more atrophy than expected per age. His mental status cleared within the first day. . # EtOH abuse/withdrawal. pt did nor require benzos per CIWA, banana bag and vitamins, thiamine. SW made contact with [Name (NI) 882] nightprogram director, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 75240]) and faxed referral form to sw. . # Psych Some expression of passive SI while in unit. ? of section 12 by [Hospital1 ] facililty prior to arrival to [Hospital1 ]. Psych consult called for issues of safety. Pt had 1:1 sitter but considered to be not suicidal. Haldo PRN for agitation instead of benzos however pt did nor require any administration . # Seizure vs. pseudo-seizure disorder. - continued valproate. PO . # Prophylaxis. Pneumoboots, PPI . # Comm: Sister, [Name (NI) ] [Name (NI) 49478]: [Telephone/Fax (1) 75241] (works here in Legal Dept) # Code: FULL CODE Medications on Admission: Librium taper Valproic acid 250 tid Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please take [11-23] tablet daily for 3 more days and the 1 pill daily. . Disp:90 Tablet(s) Refills:0 6. Naltrexone 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Delirium tremens Alcohol abuse s/p detoxification Secondary diagnoses: Depression Hypertension Discharge Condition: Stable. No Valium requirement >72 hours. Discharge Instructions: Return to emergency room or call your primary care physician if you develop any symptoms of seizures, fevers, chills, agitation, nausea, vomiting, thoughts of harming yourself or others, or any other worrisome symptoms. . Please keep your all your follow-up appointments. . You should call [Hospital6 ] Evening Substance Abuse Program; [Telephone/Fax (1) 31374] for intake (this number and list of AA meetings given to you by psychiatrist) . We recommend you stop smoking. . We restarted all your previous home medications. We did not add any new medications other than vitamins. Followup Instructions: You have an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 28670] (your primary care physician) at 3 pm at [2152-10-9] and discuss with him about being referred to see a psychiatrist. You should call [Hospital6 ] Evening Substance Abuse Program; [Telephone/Fax (1) 31374] for intake (this number and list of AA meetings given to you by psychiatrist) ICD9 Codes: 311, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7406 }	Medical Text: Admission Date: [2185-10-26] Discharge Date: [2185-11-30] Date of Birth: [2105-8-1] Sex: F Service: SURGERY Allergies: Tramadol / Codeine / Kayexalate Attending:[First Name3 (LF) 3223] Chief Complaint: Lower GI bleed Major Surgical or Invasive Procedure: Right Colectomy, Sigmoidectomy Exploratory Laparotomy - ReClosure Fascia sp Pacemaker Placement History of Present Illness: 80F w/ h/o AAA repair admitted to [Hospital 10478] Hosp [10-10] with acute on chronic renal failure following 2-3 days N/D, [1-7] wks diarrhea, increasing weakness, lethargy & SOB. LGIB, C-scope & EGD performed [10-25] "ischemic cecum with diverticulosis & no active bleeding". "Nl EGD". CT prior to transfer showed no AE fistual (clear place, no air around the graft). At the OSH: [10-11] : Treated with insulin, D50, Ca+gluconate, & Kayexalate ??????multiple times?????? Intubated, pressors, renal & pulmonary consults [10-14] extubated Temporary dialysis 2-3x 1st week 10 days getting ready for rehab [10-25] : BRBPR w. clots and drop HCT C-S : ischemic area proximal colon, ulcerated cecum w/ ??????old looking leision??????, normal TI, diverticuli L>R EGD : negative for bleeding sites 6U pRBCs / 24hr HPI cont. [10-26] : acute bleeding episode w/ SBPs 80s, requiring dopamine & levofed; HCT 26.4 Surgery @ OSH consulted for possible Aortoenteric fistula Rec: tx to vascular surgery at [Hospital1 18] & CT w/ contrast Past Medical History: PMH: AFib, sp MI [7-10], CHF, COPD -> steroid & home O2 dependent, PVD, OSA, CRI, PUD, HTN, s/p AAA repair '[75], s/p B/L retinal repair '[78], h/o heavy smoking, moderate AS, 2cm R atrial mass adjacent tricuspid Social History: h/o tobacco occ ETOH Lives w/ daughter Family History: NC Physical Exam: MS/NEURO: A/O, FC, MAE: HEENT: PERRLA, EOMI CVS: RRR Resp: [Month (only) ] BS B Abd: S/+ mild RLQ TTP, + mild distention Ext: +1 Edema, + diffuse skin breakdown Pertinent Results: [2185-10-26] 07:59PM BLOOD WBC-28.8* RBC-4.91 Hgb-15.0 Hct-43.1 MCV-88 MCH-30.5 MCHC-34.8 RDW-14.7 Plt Ct-147* [2185-10-27] 01:50AM BLOOD Hct-34.5* [2185-10-28] 04:06AM BLOOD WBC-14.8* RBC-3.54* Hgb-11.0* Hct-31.2* MCV-88 MCH-31.1 MCHC-35.2* RDW-15.0 Plt Ct-107* [2185-10-30] 01:51AM BLOOD WBC-8.0 RBC-3.17* Hgb-10.1* Hct-28.4* MCV-90 MCH-31.7 MCHC-35.4* RDW-14.8 Plt Ct-148* [2185-10-30] 11:20PM BLOOD Hct-26.3* [2185-10-31] 02:59AM BLOOD WBC-8.6 RBC-2.79* Hgb-8.6* Hct-25.2* MCV-90 MCH-30.9 MCHC-34.3 RDW-15.2 Plt Ct-161 [2185-10-31] 06:13AM BLOOD Hct-23.7* [2185-11-2] 01:44AM BLOOD WBC-15.6# RBC-2.62# Hgb-8.1# Hct-22.9# MCV-87 MCH-30.8 MCHC-35.2* RDW-16.4* Plt Ct-73* [2185-11-2] 10:36AM BLOOD Hct-31.0* [2185-11-4] 02:53AM BLOOD WBC-15.5* RBC-3.43* Hgb-10.5* Hct-29.5* MCV-86 MCH-30.6 MCHC-35.6* RDW-16.8* Plt Ct-48* [2185-11-9] 03:18AM BLOOD WBC-12.8* RBC-3.44* Hgb-10.4* Hct-30.6* MCV-89 MCH-30.2 MCHC-34.0 RDW-16.8* Plt Ct-167 [2185-11-10] 03:19AM BLOOD WBC-9.3 RBC-2.90* Hgb-8.7* Hct-25.9* MCV-90 MCH-30.1 MCHC-33.7 RDW-16.9* Plt Ct-162 [2185-11-12] 03:21AM BLOOD WBC-6.8 RBC-2.69* Hgb-8.1* Hct-24.0* MCV-89 MCH-30.2 MCHC-33.8 RDW-16.5* Plt Ct-212 [2185-11-13] 03:00AM BLOOD WBC-6.3 RBC-2.54* Hgb-7.8* Hct-22.5* MCV-88 MCH-30.7 MCHC-34.8 RDW-16.4* Plt Ct-192 [2185-11-13] 03:54PM BLOOD Hct-28.0* [2185-11-17] 03:00AM BLOOD WBC-11.1* RBC-4.05* Hgb-11.8* Hct-36.4 MCV-90 MCH-29.1 MCHC-32.5 RDW-15.7* Plt Ct-240 [2185-11-19] 03:10AM BLOOD WBC-11.6* RBC-3.66* Hgb-11.1* Hct-31.9* MCV-87 MCH-30.5 MCHC-34.9 RDW-15.8* Plt Ct-202 [2185-11-22] 04:23AM BLOOD WBC-10.7 RBC-3.15* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.4 MCHC-31.9 RDW-16.1* Plt Ct-214 [2185-11-22] 10:24PM BLOOD WBC-13.1* RBC-2.93* Hgb-9.1* Hct-26.2* MCV-89 MCH-31.1 MCHC-34.8 RDW-15.7* Plt Ct-191 [2185-11-27] 02:58AM BLOOD WBC-6.4 RBC-3.03* Hgb-9.3* Hct-28.0* MCV-93 MCH-30.6 MCHC-33.1 RDW-15.9* Plt Ct-203 [2185-11-29] 07:37AM BLOOD Hct-24.7* [2185-11-29] 03:47PM BLOOD Hct-26.2* [2185-11-30] 02:00AM BLOOD WBC-8.3 Hct-26* Plt Ct-225 [2185-10-26] 07:59PM BLOOD PT-13.1 PTT-24.6 INR(PT)-1.1 [2185-10-26] 07:59PM BLOOD Glucose-130* UreaN-43* Creat-2.4* Na-149* K-3.7 Cl-105 HCO3-33* AnGap-15 [2185-11-1] 05:45AM BLOOD Glucose-101 UreaN-34* Creat-2.0* Na-144 K-4.4 Cl-109* HCO3-22 AnGap-17 [2185-11-9] 03:18AM BLOOD Glucose-73 UreaN-103* Creat-2.7* Na-140 K-5.3* Cl-109* HCO3-22 AnGap-14 [2185-11-12] 07:01PM BLOOD Glucose-157* UreaN-111* Creat-2.8* Na-140 K-4.3 Cl-106 HCO3-23 AnGap-15 [2185-11-23] 05:02AM BLOOD Glucose-71 UreaN-59* Creat-1.9* Na-142 K-5.3* Cl-113* HCO3-20* AnGap-14 [2185-11-25] 03:08PM BLOOD Glucose-162* K-5.7* [2185-11-29] 02:21AM BLOOD Glucose-98 UreaN-61* Creat-2.1* Na-141 K-5.0 Cl-108 HCO3-28 AnGap-10 [2185-11-30] 02:00AM BLOOD Glucose-106* UreaN-59* Creat-2.0* Na-140 K-5.4* Cl-108 HCO3-26 AnGap-11 [2185-10-26] 07:59PM BLOOD CK-MB-NotDone cTropnT-0.21* [2185-11-8] 11:03PM BLOOD CK-MB-6 cTropnT-0.21* [2185-11-23] 05:02AM BLOOD CK-MB-NotDone cTropnT-0.18* [2185-11-4] 02:53AM BLOOD calTIBC-118* Ferritn-55 TRF-91* [2185-11-7] 07:04PM BLOOD calTIBC-190* Ferritn-93 TRF-146* [2185-11-21] 03:55AM BLOOD calTIBC-161* Ferritn-214* TRF-124* [2185-10-31] 04:31PM BLOOD TSH-9.8* [2185-11-16] 02:48AM BLOOD TSH-8.9* [2185-11-26] 02:00AM BLOOD TSH-14* . PORTABLE ABDOMEN [2185-10-27] 6:35 AM PORTABLE ABDOMEN Reason: eval bowel gas pattern [Hospital 93] MEDICAL CONDITION: 80 year old woman with distention/bpr IMPRESSION: Mildly dilated loops of small bowel with air in the colon. Likely generalized ileus, although an early and/or partial small-bowel obstruction cannot be entirely excluded. Correlate clinically. . GI BLEEDING STUDY [2185-10-28] GI BLEEDING STUDY IMPRESSION: Focal active GI bleeding originating in the region of the cecum, first seen 29 minutes into the study. . CHEST (PORTABLE AP) [2185-10-31] 6:34 PM CHEST (PORTABLE AP) Reason: sp r cooectomy now intubated [Hospital 93] MEDICAL CONDITION: 80 year old woman with LLL PNA REASON FOR THIS EXAMINATION: sp r cooectomy now intubated CLINICAL HISTORY: 80-year-old female with left lower lobe pneumonia. Status post right lobectomy. Now intubated IMPRESSION: Persistent bilateral pleural effusions and perihilar haziness, consistent with unchanged moderate pulmonary vascular congestion . Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 70733],[Known firstname ] M [2105-8-1] 80 Female [-5/4712] [Numeric Identifier 70734] SPECIMEN SUBMITTED: RT. HEMICOLECTOMY. DIAGNOSIS: Ileocolectomy: 1. Marked necrosis of the cecum with focal loss of the muscularis propria, associated with foreign body crystals consistent with Kayexalate. 2. Adherent segment of sigmoid colon due to peritoneal adhesions. 3. The rest of the right colon, sigmoid colon mucosa, ileal segment and append are within normal limits. 4. No neoplasm. . Cardiology Report ECHO Study Date of [2185-11-1] Conclusions: 1. The left atrium is mildly dilated. 2. A large (2 cm) mass attached to the lateral aspect of the tricuspid valve annulus is seen in the right atrium. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is difficult to assess but is probably low normal (LVEF 50-55%). 4.. The aortic valve leaflets are severely thickened/deformed. There is at least moderate aortic valve stenosis (area 0.8-1.19cm2). Trace aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Trivial mitral regurgitation is seen. . CHEST (PORTABLE AP) [2185-11-3] 4:25 AM CHEST (PORTABLE AP) Reason: eval for interval change IMPRESSION: Unchanged mild pulmonary edema. Decreased right pleural effusion. Suspected pulmonary hypertention. . VIDEO OROPHARYNGEAL SWALLOW [2185-11-17] 1:50 PM IMPRESSION: Penetration with nectar consistency liquids, and aspiration of thin liquids when attempting to swallow barium tablet which became stuck in the vallecula, but cleared with subsequent swallowing. . [Numeric Identifier 70735] NASAL/OROGASTRC TUBE PLMT, PRO FEE ONLY [2185-11-18] 9:26 AM Reason: please place dobbhoff feeding tube IMPRESSION: Uncomplicated placement of weighted 8 French feeding tube, with tip over the antrum of the stomach. . Cardiology Report ECG Study Date of [2185-11-22] 3:55:46 AM Regular bradycardia - probably junctional rhythm Right bundle branch block Consider lateral myocardial infarct, age indeterminate Diffuse ST-T wave changes with prominent T waves - clinical correlation is suggested Since previous tracing of [2185-11-21], junctional rhythm now present and further ST-T wave changes seen Intervals Axes Rate PR QRS QT/QTc P QRS T 39 0 148 544/467.15 0 -23 46 . CHEST (PORTABLE AP) [2185-11-27] 11:39 AM CHEST (PORTABLE AP) Reason: acute desaturation r/o PNA [Hospital 93] MEDICAL CONDITION: 80 year old woman s/p right colectomy in ICU -> w/desat 24 hours prior and brown sputum REASON FOR THIS EXAMINATION: acute desaturation r/o PNA HISTORY: Pneumonia. IMPRESSION: Bilateral pleural effusions and pulmonary edema, unchanged. Support lines unchanged. . Brief Hospital Course: She was transferred on [2185-10-26] on levofed & dopamine, not intubated. Her labs on arrival were: CBC : 28.8 / 42 / 147 Chem : 149/3.7/105/33/43/2.4/130 Coags: 13/24/1.1 Lactate 3.0 [10-26] Resusitated w/ IVF, NGT/NPO/ABX CT : Aortoiliac graft identified, plane between aorta & small bowel, no air around graft ?????? no evidence of fistula; blood in jejunum, ileum, & colon; no retroperitoneal hematoma or soft tissue changes; hyperdense clumped material in multiple segments of colon GI consult > EGD : normal through 4th part duodenum [10-27] : Weaned from pressors; WBC 21.6 HCT 34.9; amio started for Afib, V/Z/F for ?ischemic colitis [10-28] : Bleeding study: Focal active GI bleeding originating in the region of the cecum, first seen 29 minutes into the study. WBC 14.8 HCT 31.2 [10-29]: small maroon stool [10-30] : dark melena; go-lytely for c-s in am [10-31]: BRBPR, SBPs 70s, HCT 23 Got 2U pRBCs [2185-10-31] TO OR: En bloc resection of a portion of sigmoid with a right hemicolectomy for a bleeding cecal mass with adherent sigmoid colon PATH Marked necrosis of the cecum with focal loss of the muscularis propria, associated with foreign body crystals consistent with Kayexalate. Post-op course Pressors for a few days & ventilated for respiratory failure TTE: EF 50-55%, mod AS, 2 cm tricuspid mass vs calcification Wound dehisced on POD 8 requiring take back to OR for facial reclosure & retension sutures. Resp: She had a slow wean from the ventilator complicated by pleural effusion. She still requires Bipap at HS and intermittently through the day. . No further bleeding episodes . CV: She came out in AF with RVR. Has a h/o PAF for a month and probably fully amio loaded there. Has been on pressors this admission (came out on neo from the OR). Intubated. She got IV amio load in the OR followed by IV amio gtt. Currently in sinus. Has prolonged conversion pauses, up to 4.5 seconds and sinus brady low 40s . Echo [11-1] showed normal EF, mild LVH. Now coming off pressors, requiring less O2 on vent. [11-17] had brady to 30's and low BP requiring low-dose dopa which was able to be weaned off [11-18] with HR's 50s. She received a pacemaker on [2185-11-22] and is A-paced at 70. She is on ASA 81 mg daily . Skin: She Pt has multiple partial thickness ulcers(skin tears) on upper and lower extremities. The lower extremities are edematous and ecchymotic and are draining copious amounts of serous fluid from any open area. The right lower leg has a large intact hemorrhagic blister on the lateral aspect and a partial thickness ulcer on the posterior calf. The skin is extremely fragile and thin. The upper extremities also have partial thickness ulcers on the posterior upper arms and the wrists. The drainage there is not nearly as much as lower extremities. Her skin contiued to heal. Bilateral arms/legs with much less fluid,then past week. Decrease amount of clear exudate daily, nurse is only changing dressings daily.(adaptive,softsorb). Two days ago flexi seal fecal management system placed. Sacral area with erythema, approxiately 8x6cm,likely due to increase moisture from stool. Small amount of fecal oozing anal area, this is normal with this system. Nursing applying double guard onitment, and nystatin to site [Hospital1 ]. Sugguest fluff guaze around anal area to wick effluent,and or softsorb. Unble to add banana flakes as patient's K+ is high. Sugguest adding more fiber to diet. All ulcers are clean, without signs of infection. . ID: She will need Meropenem for an additional 7 days for a klebsiella UTI. [11-25] Sputum: rare GNRs. Sensitivities are pending. [2185-11-24] SPUTUM GRAM STAIN-FINAL NEG . Renal: She has a Foley in place, after several void trials, and getting Lasix daily. Her Cr has stablized at 2.0. Her Potassium has been around 5 to 5.8. Do not give Kayexalate. . Endo: Her blood sugars have been well controlled. Her Levothyroxine was increased as the TSH increased. Please continue to monitor and treat her hypothyroidism. . FEN: She continues with a Dobbhoff feeding tube. Please check calories counts and wea from the tube feedings as she increases PO intake. . Code: She is DNI, but does want resuscitation for cardiac arrest (shock, CPR, pressors are OK). Medications on Admission: pred 10', lasix 20, advair, levothryoxine, MVI, vasotec 5, dilt 120 QOD, zocor 10, duonebs, prilosec 20, ASA 81 QOD, home O2 2L MOT: hydrocort 50'', zosyn [10-22], HCTZ 12.5, spironolactone 25, protonix, bactrim [10-18], synthroid 125 po, zocor 20, nystatin s/s, phosLo 667''', amiodorone 200''', cardizem ER 120, colace, mucinex 600'''', ventolin nebs, bipap @ noc, duonebs Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours). 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours). 8. Ascorbic Acid 90 mg/mL Drops Sig: Six (6) PO DAILY (Daily): 500 mg PO daily. 9. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): See sliding scale. 14. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Recheck TSH level in 3 days and adjust dose accordingly. 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 7 days. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Acute on Chronic Renal Failure Lower GI Bleed Ischemic Cecum, Diverticulosis Wound Dehiscence Bowel Necrosis due to Kayexalate Crystals Respiratory Distress requiring intubation Bradycardia requiring Pacemaker Post-op Hypotension / Hypovolemia Skin Tear/breakdown Pleural Effusion Discharge Condition: Fair Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain . Please resume all of your regular medications and take any new meds as ordered. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 519] in 2 weeks. Return on [2184-12-12]. Call ([Telephone/Fax (1) 5323] to schedule an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2185-11-30] ICD9 Codes: 5789, 4280, 486, 2851, 5119, 496, 5185, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7407 }	Medical Text: Admission Date: [2110-9-24] Discharge Date: [2110-9-28] Date of Birth: [2044-10-31] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Lisinopril Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2110-9-24] - CABGx1 (Left internal mammary->Left anterior descending artery) History of Present Illness: Mrs. [Known lastname ] is a 65-year-old woman with hypertension and history of chest pain for the past few months. She was investigated with stress exercise which was positive and she had angiogram which demonstrated single-vessel disease with an occluded left anterior descending artery as well as a left main stenosis. She is now admitted for surgical management. Past Medical History: HTN, Elevated lipids, OA, GERD, Asthma Social History: Retired and lives with husband. [Name (NI) 4084] smoked and drinks 1 glass of wine daily. Family History: Sister and father both died of [Name (NI) 5290] in their early 60's. Physical Exam: HR: 55 BP: 170/90 RR: 20 General: Well developed, no distress Eyes: PERRL, pink conjunctivae, no xanthelasma ENT: Normal dentition, MMM without pallor or cyanosis Neck: Normal carotid upstrokes, no carotid bruits, no jugular venous distention, no goiter Lungs: Clear, normal effort Heart: RRR, normal S1 and S2, no m/r/g, PMI normal, precordium quiet Abd: Soft, NTND, NABS, no organomegaly, normal aorta without bruit Msk: Normal muscle strength and tone, normal gait and station, no scoliosis or kyphosis Ext: No c/c/e, normal femoral and pedal pulses Skin: No ulcers, xanthomas or skin changes due to arterial or venous insufficiency Neuro: A and O to self, place and time, appropriate mood and affect Pertinent Results: [2110-9-26] 05:25AM BLOOD WBC-13.8* RBC-3.01* Hgb-10.0* Hct-27.2* MCV-91 MCH-33.1* MCHC-36.6* RDW-13.4 Plt Ct-212 [2110-9-24] 12:31PM BLOOD WBC-13.3# RBC-2.92# Hgb-9.7# Hct-26.3# MCV-90 MCH-33.0* MCHC-36.7* RDW-13.1 Plt Ct-210 [2110-9-24] 12:31PM BLOOD PT-13.4 PTT-29.4 INR(PT)-1.2* [2110-9-28] 07:10AM BLOOD Glucose-108* UreaN-14 Creat-0.6 Na-141 K-3.9 Cl-103 HCO3-33* AnGap-9 [2110-9-25] 02:01AM BLOOD Glucose-130* UreaN-15 Creat-0.6 Na-137 K-4.1 Cl-105 HCO3-26 AnGap-10 [Known lastname ],[Known firstname 2671] [Medical Record Number 26166] F 65 [2044-10-31] [Year (4 digits) ] Report CHEST (PA & LAT) Study Date of [2110-9-27] 10:22 AM [Last Name (LF) ],[First Name3 (LF) ] R. CSURG FA6A [2110-9-27] SCHED CHEST (PA & LAT) Clip # [Clip Number (Radiology) 26167] Reason: check effusions [Hospital 93] MEDICAL CONDITION: 65 year old woman with REASON FOR THIS EXAMINATION: check effusions Final Report TWO VIEW CHEST COMPARISON: [2110-9-25]. INDICATION: Pleural effusions. Increasing small-to-moderate bilateral pleural effusions are present bilaterally, with adjacent areas of atelectasis. Remainder of the lungs are grossly clear. Heart is enlarged but stable in size. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] Approved: SAT [2110-9-27] 12:49 PM Imaging Lab Brief Hospital Course: Mrs. [Known lastname ] was admitted to the [Hospital1 18] on [2110-9-24] for elective surgical management of her coronary artery disease. She was taken directly to the operating room where she underwent coronary artery bypass grafting to one vessel. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Within 24 hours, she awoke neurologically intact and was extubated. She was then transferred to the step down unit form monitoring. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Beta-blocker optimized, plan to restart valsartan as outpt.when BP can tolerate.The remainder of her postoperative course was essentially uneventful. She continued to progress and was ready for discharge to home with services on POD #4. All follow-up appointments were advised. Medications on Admission: atenolol 100', Flonase 2", HCTZ 25', KCL 10', Simvastatin 40', Valsartan 160', ASA 81", MVI Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:6 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day for 3 days. Disp:12 Tablet Sustained Release(s) Refills:0 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 5. 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:0 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal [Hospital1 ] (2 times a day). Disp:1 1 Refills:0 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO q4hr prn () as needed for pain. Disp:45 Tablet(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: CAD s/p CABGx1 Hyperlipidemia HTN GERD Asthma Osteoarthritis Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up Dr. [Last Name (STitle) ] in 4 weeks. ([Telephone/Fax (1) 1504] Scheduled Appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2385], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2110-10-14] 10:40 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2111-1-16] 1:15 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10491], MD Phone:[Telephone/Fax (1) 142] Date/Time:[2111-2-25] 11:45 Completed by:[2110-9-28] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7408 }	Medical Text: Admission Date: [2173-10-11] Discharge Date: [2173-10-15] Date of Birth: [2125-3-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6701] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: 48 y/o male with history of mild sleep-disordered breathing, nasal congestion, attention deficit disorder, and male sexual partner who was noted to be confused and with altered mental status by his house-keeper today. He was brought in by ambulance. House-keeper reported by phone to the ED that patient was wandering around his house naked. Arrived to the ED agitated saying "I know" and "I want to" repeatedly. History was difficult to obtain in the ED; however, family was temporarily present. They report that he "was fine two days ago." They also report no prior history of alcohol use or drug use. . In the ED, he was not answering questions or following orders. He was noted to have a fever of 100.4 and then 100.8 rectally. VS in ED were 97.9, BP 132/79, HR 123, RR 20, 96% RA. ED called [Hospital1 778] and was told that HIV status negative in [2172]. Neuro exam in ED reported as PERLL, EOMI, moving all extremities, strength wnl. Received total of 5 mg haldol and 4 mg ativan in the ED. CT head with prelim read, "motion artifact, no large ICH." Serum and urine tox screen negative. Labs notable for Na of 122. Received 1.5L fluid in ED. U/A not suggestive of infection. Blood cultures drawn and pending. LP performed and showing WBC 1, RBC 1, polys 8, lymphs 83, protein and glucose pending. . CXR showed no focal infiltrate. EKG was performed later and showed NSR at 68, J point elevation V3-V4, no ischemic changes. . ROS: (+) Per HPI. Unable to obtain additional history given AMS. Past Medical History: attention deficit mild sleep-disordered breathing (previously on CPAP, now discontinued) nasal congestion (on Astelin and Flonase) asthma eczema Social History: He lives with his partner. [Name (NI) ] is employed. He does not smoke. Per family, no history of drugs or EtOH. Per partner pt drinks EtOH occasionally. Occasional use of marijuana and amyl nitrites (poppers). Family History: The patient's mother is healthy but has snoring and asthma. His father has had coronary artery disease, he has two brothers, but he is not sure about their health. Physical Exam: VS: 101.5, 116/65, 77, 14, 100 RA Gen: sleeping, in 4 point restraints, arousable but to noxious stimuli HEENT: MMM, OP clear, no jaundice, PERLL 4mm --> 2mm Neck: supple, no JVD CV: RRR S1 S2 no R/G/M Pulm: clear bilaterally Abd: soft, nontender, non-distended, normoactive bowel sounds, no RUQ tenderness Ext: no edema, pulses 2+ bilaterally Neuro: CNII-XII intact, moving all extremities, withdraws to noxious stimuli, remainder difficult to assess Pertinent Results: [2173-10-11] 04:39PM BLOOD WBC-11.7* RBC-4.67 Hgb-12.8* Hct-37.3* MCV-80* MCH-27.4 MCHC-34.3 RDW-12.9 Plt Ct-208 [2173-10-11] 04:39PM BLOOD Neuts-86.7* Lymphs-9.8* Monos-3.0 Eos-0.2 Baso-0.3 [2173-10-11] 05:10PM BLOOD PT-13.0 PTT-25.4 INR(PT)-1.1 [2173-10-12] 03:00AM BLOOD Fibrino-332 [2173-10-11] 04:39PM BLOOD Glucose-120* UreaN-7 Creat-0.7 Na-124* K-4.4 Cl-90* HCO3-24 AnGap-14 [2173-10-11] 05:10PM BLOOD Glucose-116* UreaN-8 Creat-0.8 Na-122* K-4.5 Cl-86* HCO3-23 AnGap-18 [2173-10-12] 03:00AM BLOOD Glucose-108* UreaN-8 Creat-0.8 Na-127* K-4.3 Cl-94* HCO3-23 AnGap-14 [2173-10-12] 05:40AM BLOOD Glucose-111* UreaN-9 Creat-0.8 Na-129* K-4.2 Cl-97 HCO3-25 AnGap-11 [2173-10-12] 04:46PM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-132* K-3.6 Cl-98 HCO3-25 AnGap-13 [2173-10-12] 10:38PM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-135 K-3.8 Cl-100 HCO3-25 AnGap-14 [2173-10-13] 04:06AM BLOOD Glucose-90 UreaN-12 Creat-0.8 Na-136 K-4.2 Cl-101 HCO3-24 AnGap-15 [2173-10-15] 05:50AM BLOOD Glucose-108* UreaN-10 Creat-1.0 Na-143 K-4.9 Cl-104 HCO3-30 AnGap-14 [2173-10-11] 05:10PM BLOOD ALT-19 AST-30 AlkPhos-61 TotBili-1.8* [2173-10-12] 03:00AM BLOOD CK(CPK)-934* [2173-10-12] 05:40AM BLOOD ALT-20 AST-40 AlkPhos-48 TotBili-1.1 [2173-10-12] 04:46PM BLOOD ALT-36 AST-81* LD(LDH)-307* CK(CPK)-3457* AlkPhos-50 TotBili-1.4 [2173-10-15] 05:50AM BLOOD ALT-40 AST-38 CK(CPK)-810* [2173-10-11] 05:10PM BLOOD Lipase-42 [2173-10-12] 04:46PM BLOOD Lipase-22 [2173-10-11] 05:10PM BLOOD Calcium-8.5 Phos-2.4* Mg-1.5* [2173-10-15] 05:50AM BLOOD Calcium-9.8 Phos-4.5 Mg-2.0 [2173-10-12] 04:46PM BLOOD calTIBC-342 Ferritn-108 TRF-263 [2173-10-12] 05:40AM BLOOD Osmolal-267* [2173-10-12] 04:46PM BLOOD TSH-1.2 [2173-10-13] 04:06AM BLOOD T4-6.7 [2173-10-12] 04:46PM BLOOD Cortsol-14.3 [2173-10-11] 04:39PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2173-10-11] 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2173-10-11] 05:16PM BLOOD Lactate-1.6 K-4.2 [2173-10-11] 05:10PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.013 [2173-10-11] 05:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [2173-10-12] 12:43AM URINE Hours-RANDOM Phos-14.8 [2173-10-11] 07:55PM URINE Hours-RANDOM UreaN-407 Creat-71 Na-136 K-49 Cl-121 TotProt-7 Prot/Cr-0.1 [2173-10-11] 07:55PM URINE Osmolal-527 [2173-10-11] 05:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [2173-10-12] 07:14AM URINE METHYLENEDIOXYMETHAMPHETAMINE-PND [2173-10-11] 08:05PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-8 Lymphs-83 Monos-9 [2173-10-11] 08:05PM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-78 . [2173-10-11] 5:10 pm BLOOD CULTURE Blood Culture, Routine (Pending): . [2173-10-11] 5:10 pm URINE Site: CATHETER FINAL REPORT [2173-10-12] URINE CULTURE (Final [2173-10-12]): NO GROWTH. . [2173-10-11] 5:10 pm BLOOD CULTURE Blood Culture, Routine (Pending): . [2173-10-11] 8:05 pm CSF;SPINAL FLUID #3. R/O HSV. GRAM STAIN (Final [2173-10-11]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2173-10-14]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2173-10-12]): Test cancelled by laboratory. PATIENT CREDITED. For detection of Cryptococcus neoformans, request Cryptococcal Antigen. If questions, contact the Clinical Pathology Resident on-call ([Numeric Identifier 69175]). VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [2173-10-12]): SPECIMEN NOT PROCESSED DUE TO: DUPLICATE SPECIMEN. PLEASE REFER TO RESULT OF VIRAL CULTURE. TEST CANCELLED, PATIENT CREDITED. VIRAL CULTURE (Preliminary): No Virus isolated so far. . [2173-10-12] 4:46 pm SEROLOGY/BLOOD Source: Venipuncture. FINAL REPORT [2173-10-13] RAPID PLASMA REAGIN TEST (Final [2173-10-13]): NONREACTIVE. Reference Range: Non-Reactive. . [2173-10-12] 4:46 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2173-10-15] MRSA SCREEN (Final [2173-10-15]): No MRSA isolated. . [2173-10-12] 4:46 pm SEROLOGY/BLOOD OLD S# [Serial Number 69176]C. FINAL REPORT [2173-10-14] LYME SEROLOGY (Final [2173-10-14]): NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burgdorferi infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of lyme disease should be retested in [3-10] weeks. . Time Taken Not Noted Log-In Date/Time: [2173-10-12] 10:31 pm URINE FINAL REPORT [2173-10-13] Legionella Urinary Antigen (Final [2173-10-13]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. . [2173-10-14] 9:47 pm BLOOD CULTURE x2 Source: Venipuncture. Blood Culture, Routine (Pending): . [2173-10-11] ECG: Sinus rhythm. ST-T wave configuration may be due to early repolarization pattern. Clinical correlation is suggested. No previous tracing available for comparison. . [2173-10-11] CXR: BEDSIDE AP RADIOGRAPH OF THE CHEST: The cardiac, mediastinal and hilar contours are normal. A faint right lower lobe opacity may be normal vasculature, and otherwise the lungs are clear. There is no pleural effusion or pneumothorax. The right lower lobe opacity could be clarified with PA and Lateral views, if clinically relevant. . [2173-10-11] CT Head W/Out Contrast: FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect or recent infarction. The ventricles and sulci are normal in size and configuration. No concerning osseous lesion is seen. There is a small right maxillary mucous retention cyst. IMPRESSION: No evidence of acute intracranial abnormality. Brief Hospital Course: 48 y/o male with history of MSM (reportedly HIV negative in [2172]) who presents with psychomotor agitation and AMS, and is noted to be hyperthermic, hypertensive, tachycardic, and hyponatremic. . # Altered Mental Status: The patient was admitted for severe agitated delirium of unknown etiology. Initial work-up was unremarkable, including normal blood cultures, urine cultures, csf, cxr, head ct, serum tox, and urine tox. Of note, the patient was hyponatremic to 122. He remembers drinking 3 large pitchers of water prior to his confusion, and it is possible that his serum sodium was infact much lower than it was prior to his presentation and that his syptoms reflected symptomatic hyponatremia. His serum sodium corrected with fluid restriction. On the floor continued to be acutely agitated despite use of haldol and ativan. He was transferred to the MICU as he required higher acuity nursing care. He was placed in 4 point leather restraints due to his extreme agitation and combative behavior. He required increasing amounts of sedation, requiring haldol 5mg IV, a total of lorazepam 8mg IV, and olanzapine rapid dissolve 5mg before his agitation resolved and he became somnolent. His ECG showed normal sinus rythm with possible early repolarization. His course improved to spells of alertness and orientation the second day, and he was AAOx3 on awakening his 3rd day in the unit. He did admit to smoking marijuana prior to his becoming agitated; this was obtained from a new source that he had not tried before. At this point the leading cause of AMS is toxic. MDMA va sympathomimetic. There are still toxic and infectious tests that are pending. . Pt was seen by toxicology and they were concerned about a possible ingestion. They recommended fluid for resolving rhabdo and to avoid haldol as it lowers seizure threshhold. Tox also requested a comprehensive urine and serum tox screen using gas chromatography/mass spectroscopy (GC/MS) which might identify a suspected toxic exposure [Doctor Last Name 360] as cause of patient's delta MS. [Name14 (STitle) 498] ([Hospital1 1559], MA) can perform GC/MS screen but our laboratory's screens are already quite broad, and the result of a GC/MS screen will not further affect clinical management. These screens were discussed with the chemistry resident, attending and director of lab medicine (Dr. [Last Name (STitle) ] who felt that the comprehensive screens were not warranted at this point. . The patient was transferred back to the general medical floor after his mental status had cleared. At that time he was alert and oriented x3, able to repeat 3 objects immediately and at 5 and 30 minutes, able to do serial 7s, and follow both simple and complex commands. His speech was fluent and coherent, yet the patient felt it was still slower than usual. He is offered outpatient follow-up for formal neurocognitive evaluation. . # Hyponatremia: The patient's hypnatremia resolved with fluid restriction. . # Elevated CK: The patient's CK peaked at 3500 in the setting of combative behavior and aggresion while in restraints, then started to trend down. Renal function remained at baseline. . # Conjunctivitis: While in the hospital the patient developed a left eye conjunctivitis and was started on ciprofloxacin drops. He will finish a full course as an outpatient. . # Code Status: Full Code. Medications on Admission: AZELASTINE [ASTELIN] - 137 mcg Aerosol, Spray - 2 puffs nostril twice a day BUDESONIDE [PULMICORT] - (Prescribed by Other Provider) - Dosage uncertain FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 puffs intranasal at bedtime SALMETEROL [SEREVENT DISKUS] - (Prescribed by Other Provider) - 50 mcg Disk with Device - 1 spray oral twice daily Discharge Medications: 1. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Puff Inhalation twice a day. 2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 3. Budesonide Inhalation 4. Azelastine 137 mcg Aerosol, Spray Sig: Two (2) Sprays Nasal twice a day. 5. Ciprofloxacin 0.2 % Dropperette Sig: 1-2 drops Otic every four (4) hours for 3 days: Please apply to left eye 1-2 drops, every four hours, for 3 days. Disp:1 bottle Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Altered Mental Status Secondary Diagnosis: Attention Deficit Disorder, Conjunctivitis 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 altered mental status and agitation. You were closely monitored and given sedating medicines to help you remain calm and safe. You were evaluated for infectious and toxic-metabolic causes for your altered mental status, and all tests so far have come back negative. Prior to discharge you were cognitively improved. You may decide to follow-up with cognitive testing in concert with your primary care physician's advice. You were also noted to have a left eye conjunctivitis and started on antibiotic drops. . You should continue on your home medications. You should finish three more days of Ciprofloxacin antibiotics for your conjunctivitis. . It was a pleasure taking care of you. Followup Instructions: You should call your PCP at [Name9 (PRE) 778] for a follow-up appointment in [8-14] days. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 6708] ICD9 Codes: 2930, 2761, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7409 }	Medical Text: Admission Date: [2193-7-2] Discharge Date: [2193-7-26] Date of Birth: [2129-4-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: Placement of PICC line Removal of PICC line History of Present Illness: 64 y/o Male with PMHx sig for Chronic diarrhea w/ hypoalbuminemia, h/o CVA, Hep B, Lymphoma, IDDM, HTN, recent hospitalization in [Month (only) ] for pulmonary embolism w/ DVT who p/w 2 days of nausea, vomiting, diarrhea. Patient had a recent h/o left PICA infarct in [2193-4-8] after which he was started on anticoagulation. He then presented in [2193-5-9] with SOB and was found to have PE based on a high probability VQ scan w/ DVT within superficial femoral vein extending to common femoral origin. He was continued on anticoagulation and sent to [Hospital1 ]. Patient then developed vomiting with nausea and continued intermittent diarrhea with cramping abdominal pain. He had [12-10] episode of vomiting in the weeks prior to admission with intermittent nausea which worsened 2 days prior to admission. There was no change in his frequency of diarrhea. Of note, the patient had been on TPN at [Hospital1 ]. He did not have any hematemesis, [Last Name (un) 15557], hemactoschezia. He denied any chest pain, dizziness, shortness of breath, palpitations. He did have generalized weakness which he has had for several months now. He has a chronic history of diarrhea (likely some kind of protein losing enteropathy) with persistent hypoalbuminemia. Also he has small bowel enteroscopy which showed ersions in stomach/duodenum with ulcerations in jejunum and a mass in the distal bulb. Biopsy of the mass showed extensive gastric foveolar mucous cell metaplasia in duodenum but no evidence of lymphoma anywhere in the GI tract. In the ED, the patient was found to have a pulmonary embolism in the superior branch of the right main pulmonary artery. He also had trop elevation without significant EKG changes. He was given 325 mg Aspirin, started on a Heparin gtt and transferred to MICU. His vitals were stable on presentation to MICU. Past Medical History: 1. Acute left PICA territorial infarct involving the inferior aspect of the left cerebellar hemisphere, with thrombosis of the distal basilar artery [2193-5-3] 2. Reactivation Hepatitis B, on entecavir 3. Complex atheroma in descending aorta seen on TEE in [2-11]. 4. Left-to-right shunt across a small secundum atrial septal defect seen on TEE in [2-11]. 5. Central retinal artery occlusion in right eye - [10-10] likely an embolic event. 6. Lymphoma - lymphoplasmacytoid lymphoma; treated with fludaribine, five cycles in [2187]. Since then has been seen by Dr. [Last Name (STitle) 410] and has not required further therapy. 7. Insulin Dependent Diabetes - has had for many years. Treated with humalog-lente combination 16 u AM, 22 u PM. Has had multiple DM complications including left eye retinopathy, gastroparesis, peripheral neuropathy complicated by several bouts of LE cellulitis. Creatinine at baseline is 0.8-1.0 8. Low albumin - Unclear etiology, has ranged from 1.9-3.5 over last several years. Question of possible nephrotic syndrome; may be related to diabetes but unclear. 9. [Name2 (NI) 167] acoustic schwanoma - treated with gamma knife radiation. 10. Gastritis, duodenitis: significant UGI bleed after received lytics for recent embolic CVA [97]. Peripheral vascular disease status post right below knee amputation [2-11]. 12. Hypertension 13. Anemia that is a combination of iron deficiency and anemia of chronic inflammation. 14. Chronic malnutrition and 2 months of diarrhea, on TPN, multiple GI ulcers, no lymphoma seen on biopsies, but still undergoing work-up. 15. B12 deficiency on IM replacement 16. Depression Social History: He is married with 2 children. Primary language is Russian. He has a remote 35 pack year smoking history. He drinks occasionally. He is a retired dentist. Family History: Father died in [2185] after amputation for gangrene (unclear origin). Mother died [2191] unclear reason, had [Name (NI) 11964]. Physical Exam: Vitals: Temp 96.5, HR 108, BP 119/68, O2sat 95/3L NC Gen: appears confortable, AOx3 HEENT: Glossitis, PERLA, EOMI, MMM Neck: JVD not appreciable Skin: no cyanosis, rash, erythematous changes over knee joints Heart: ditant heart sounds, tachycardic, no murmurs appreciable Lungs: good bilat air movement, CTAB Abdomen: distended, tympanic w/ flank dullness, fluid thrill+, no hepatosplenomegaly appreciated, no caput medusae Ext: R BKA, 2+ pitting edema bilaterally upto knee, R>L GU: guaiac positive Neuro/Psych: mild right facial deviation, 3/5 strength in both UE/LE, mild tremors, mood appears normal . Pertinent Results: [2193-7-1] WBC-8.8 RBC-3.51* Hgb-10.1* Hct-30.1* MCV-86 MCH-28.8 MCHC-33.5 RDW-15.6* Plt Ct-252# Neuts-49.2* Bands-0 Lymphs-47.1* Monos-3.1 Eos-0.1 Baso-0.5 [2193-7-2] WBC-11.8* RBC-3.05* Hgb-8.8* Hct-25.7* MCV-84 MCH-28.8 MCHC-34.2 RDW-15.9* Plt Ct-258 Neuts-54 Bands-10* Lymphs-29 Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [2193-7-3] 02:10AM BLOOD WBC-10.0 RBC-2.83* Hgb-8.1* Hct-24.1* MCV-85 MCH-28.7 MCHC-33.7 RDW-16.1* Plt Ct-238 Neuts-64 Bands-12* Lymphs-21 Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2193-7-4] 01:38AM BLOOD WBC-9.0 RBC-2.30* Hgb-6.6* Hct-19.6* MCV-85 MCH-28.8 MCHC-33.8 RDW-15.8* Plt Ct-197 [2193-7-4] 04:37PM BLOOD WBC-16.7# RBC-3.55# Hgb-10.4# Hct-29.5# MCV-83 MCH-29.2 MCHC-35.1* RDW-15.6* Plt Ct-199 [2193-7-5] 03:45AM BLOOD WBC-11.0 RBC-3.47* Hgb-10.1* Hct-29.1* MCV-84 MCH-29.3 MCHC-34.8 RDW-15.7* Plt Ct-169 Neuts-66 Bands-8* Lymphs-21 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2193-7-6] 02:40AM BLOOD WBC-7.2 RBC-3.19* Hgb-9.4* Hct-26.6* MCV-84 MCH-29.6 MCHC-35.4* RDW-15.6* Plt Ct-135* [2193-7-7] 03:20AM BLOOD WBC-5.1 RBC-3.22* Hgb-9.3* Hct-27.3* MCV-85 MCH-28.8 MCHC-34.0 RDW-15.6* Plt Ct-136* [2193-7-8] 03:10AM BLOOD WBC-5.3 RBC-3.05* Hgb-8.7* Hct-25.9* MCV-85 MCH-28.6 MCHC-33.7 RDW-15.6* Plt Ct-139* [2193-7-8] 09:11PM BLOOD Hct-20* [2193-7-9] 05:00AM BLOOD WBC-8.0# RBC-3.33* Hgb-9.5* Hct-28.2# MCV-85 MCH-28.4 MCHC-33.6 RDW-16.1 Plt Ct-146* [2193-7-9] 03:30PM BLOOD Hct-29.2* . [2193-7-1] 10:26PM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1 [2193-7-7] 03:20AM BLOOD PT-12.0 PTT-71.5* INR(PT)-1.0 [2193-7-8] 03:10AM BLOOD PT-12.5 PTT-67.5* INR(PT)-1.1 [2193-7-9] 05:00AM BLOOD PT-12.2 PTT-50.7* INR(PT)-1.0 . [2193-7-1] UreaN-62* Creat-0.7 Na-133 K-5.3* Cl-108 HCO3-19* AnGap-11 Albumin-1.4* Calcium-7.1* Phos-4.5 Mg-2.2 [2193-7-9] Glucose-109* UreaN-31* Creat-0.5 Na-139 K-4.0 Cl-111* HCO3-22 [2193-7-2] Glucose-109* UreaN-68* Creat-1.1 Na-135 K-5.7* Cl-110* HCO3-17* [2193-7-4] Glucose-125* UreaN-61* Creat-1.1 Na-136 K-4.6 Cl-109* HCO3-18* [2193-7-9] 05:00AM BLOOD Albumin-1.2* Calcium-7.8* Phos-2.9 Mg-1.9 . [2193-7-1] 02:15PM BLOOD ALT-20 AST-22 AlkPhos-172* Amylase-46 TotBili-0.1 [2193-7-5] 03:45AM BLOOD ALT-17 AST-24 LD(LDH)-327* AlkPhos-150* TotBili-0.2 [2193-7-8] 03:10AM BLOOD ALT-13 AST-18 LD(LDH)-210 AlkPhos-432* TotBili-0.2 [2193-7-9] 05:00AM BLOOD ALT-13 AST-16 LD(LDH)-221 AlkPhos-454* TotBili-0.2 . [2193-7-1] 02:15PM BLOOD CK-MB-11* MB Indx-33.3* cTropnT-0.15* [2193-7-1] 11:45PM BLOOD cTropnT-0.13* [2193-7-2] 06:45AM BLOOD CK-MB-11* MB Indx-23.9* cTropnT-0.17* [2193-7-4] 01:38AM BLOOD CK-MB-6 cTropnT-0.17* [2193-7-4] 04:37PM BLOOD CK-MB-NotDone cTropnT-0.12* . [2193-7-2] 06:45AM BLOOD Triglyc-125 HDL-22 CHOL/HD-4.9 LDLcalc-60 . [2193-7-2] 09:44PM BLOOD Type-ART Temp-37.0 FiO2-100 O2 Flow-15 pO2-27* pCO2-37 pH-7.32* calTCO2-20* Base XS--7 AADO2-666 REQ O2-100 Intubat-NOT INTUBA Comment-NEBULIZER . [2193-7-1] 02:25PM BLOOD Lactate-1.4 [2193-7-4] 11:17AM BLOOD Lactate-2.8* [2193-7-5] 12:20AM BLOOD Lactate-1.8 . KUB [7-1] SUPINE AND LATERAL ABDOMINAL RADIOGRAPHS: An NG tube is seen with the tip positioned in the stomach. Air can be seen within the stomach and colon, and scattered loops of small bowel, without any evidence of dilatation. The study is limited secondary to large body habitus; however, no definite free intraperitoneal air is identified. The soft tissue and osseous structures are stable. IMPRESSION: Air is seen within the stomach and colon, without definite evidence for small bowel obstruction. . [7-1] Abd/Pelvis CT: TECHNIQUE: MDCT acquired contiguous axial images were obtained from the lung bases to the pubic symphysis. Multiplanar reconstructions were obtained. CONTRAST: Oral contrast and 130 cc of IV Optiray contrast were administered due to the rapid rate of bolus injection required for this study. CT OF THE ABDOMEN WITH IV CONTRAST: Moderate-size bilateral pleural effusion, increased on the right, new on the left, is accompanied by a small pericardial effusion. Aside from associated relaxation atelectasis, the lungs are clear. A filling defect in the anterior branch of the right main pulmonary artery is a new, likely acute pulmonary embolus. A large amount of ascites and the nodular cirrhotic liver are unchanged. The portal vein is patent. The gallbladder, spleen, kidneys, adrenal glands, and atrophic pancreas are stable in appearance. The bowel is normal, without wall thickening or dilatation. No free intraperitoneal air is seen. Atherosclerotic calcification involves the aorta and its major branches. A stent has not migrated from the origin of the right common iliac artery. Scattered retroperitoneal and periaortic and aortocaval lymph nodes are not appreciably changed. CT OF THE PELVIS WITH IV CONTRAST: A large amount of free fluid is seen within the pelvis. Mild thickening of the sigmoid colon is stable. The bladder is normal. BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. There is spondylolysis of L5. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating the anatomy and pathology. IMPRESSION: 1. Acute right upper lobe pulmonary embolus. 2. No bowel obstruction. 3. Increasing small to moderate pleural and small pericardial effusions probably due to cirrhosis and large volume of ascites. 4. Stable sigmoid colon wall edema or inflammation. . [7-1] CXR: Moderate sized pleural effusion with elevated hemidiaphragm and associated atelectasis. . [7-2] Bilateral Lower Extremity Ultrasound: BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son[Name (NI) 867] of the right and left common femoral, superficial femoral, and left popliteal vein was performed. There is occlusive thrombus, which is hypoechoic and expanding the right common femoral and superficial femoral vein throughout its course. On the left side, there is echogenic nonocclusive thrombus at the origin of the greater saphenous vein at this at the saphenofemoral junction. The left common femoral, superficial femoral, and popliteal veins are patent. IMPRESSION: 1. Occlusive thrombus, which appears acute, within the right common femoral and superficial femoral veins. 2. Nonocclusive thrombus at the origin of the left greater saphenous vein, at the saphenofemoral junction. . [7-5] CXR: 1. New right upper and right middle lobe consolidations, most probably aspiration and/or pneumonia. 2. Mild pulmonary edema, new. 3. Distended stomach. . [7-19] CT Chest 1) Necrotizing pneumonia in right upper lobe posteriorly with foci of gas and probable evolving abscess formation. 2) Moderate right pleural effusion, decreased in size from prior CT. 3) Marked ascites. 4) Resolution of left pleural effusion. 5) Persistent pericardial effusion. . [7-20] ECHO Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is difficult to assess but is normal (LVEF>55%). 3. The aortic root is mildly dilated. 4. The aortic valve leaflets are mildly thickened. 5. The mitral valve leaflets are mildly thickened. 6. There is a small pericardial effusion. 7. No obvious vegetations are seen. 8. Compared with the prior study (images reviewed) of [2193-7-2], there is probably no significant change. . [7-23] IMPRESSION: AP chest compared to [7-17] through 13: Lung volumes remain low marked due to the markedly elevated diaphragm. Longstanding consolidation or atelectasis at the right lung apex and atelectasis at the right lung base are unchanged. Mild pulmonary edema has recurred. Heart size is normal. Mediastinal vascular engorgement is longstanding and stable. Tip of the right subclavian line projects over the junction of the right subclavian and jugular veins. No pneumothorax. Brief Hospital Course: 64 y/o Male with PMHx sig for Chronic diarrhea w/ hypoalbuminemia, recent h/o CVA, Hep B, Lymphoma, IDDM, HTN, recent hospitalization in [Month (only) ] for pulmonary embolism w/ DVT who presented with 2 days of nausea and vomiting, found to have Pulmonary Embolism in Right main PA and troponin elevation likely in setting of PE. . Pulmonary Embolism: Mr. [Known lastname 15558] was at high risk for pulmonary embolism given his history of malignancy, prolonged immobilization, and recent PE w/ DVT. Although the patient was on Coumadin, his INR was subtherapeutic on admission. CT on admission shows PE in superior branch of R PA. He remained hemodynamically stable on presentation. He was placed on Heparin drip and coumadin was started on [7-8]. Bilateral lower extremity ultrasound showed DVT in right lower extremity. IVC filter was placed as pt had PE on anticoagulation. Coumadin and heparin were stopped and the patient was started on lovenox sc. He remained stable on this regimen and his INR trended down. . E coli bacteremia: The patient developed an elevated white count and fevers and blood cultures from [7-3] grew Escherichia coli. Possible sources include either spontaneous bacterial peritonitis vs a pulmonary source given an infiltrate seen in the RUL/RML (see below). Aspiration pneumonia was also considered. He was started on Cefepime on [7-4] and Flagyl on [7-5] (as concern for aspiration). Flagyl was stopped on [7-6] and Cefepime was changed to ceftriaxone. ID was consulted and the patient was restarted on vancomycin and cefepime. IV flagyl was also added for concern for aspiration as above. Patient also has ascites, thought possibly to have predisposed to SBP and subsequent E. Coli sepsis. Surveilance cutures since initial bacteremia have been negative for bacteria. Patient did not receive tap at that time [1-10] to anticoagulation. The patient was doing well and transferred from MICU to floor on [7-11]. . Fungemia: After being tranferred to the floor on [7-11]/2 blood cultures grew [Female First Name (un) ] albicans in the setting of TPN, for which the patient was initially placed on Voriconazole, then ultimately fluconazole. His PICC line was d/c'd and tip cultures was negative, all subsequent cultures were negative and PICC line was replaced on [7-16]. A TTE was performed to r/o endocarditis and showed no vegtations. TEE was not pursued, instead antibiotics will be continued for a total of 4 weeks. Ophthalmology was consulted and found no evidence of fungal infection in the eyes. . Nosocomial PNA: A CXR revealed a necrotizing pneumonia with air fluid level in RUL confirmed by chest CT on [7-19]. He was seen by infectious disease and started on cefipime, vanco, flagyl, and was r/o'd for TB, by 3 negative AFB. Thoracic surgery evaluated him and felt there was not collection to be drained and recommended antibiotics and repeat imaging. . Hypotension: On the morning of transfer to the MICU, patient's SBP dropped to the 60s/40s. He did complain for some chest pain and SOB through the Russian interpreter and he was tachypeneic with ABG 7.51/23/71. He recieved 1 liter NS and appeared more comfortable, was mentating and BPs came up to 80's/50s and then denied CP or SOB. He was afebrile and satting 95-98% on 4.5 L NC. He was tranferred to the MICU for closer monitoring. On admission the patient had a lactate of 2.7 which decreased to 1.6 with volume resuscitation and ongoing abx. The etiology for the patient's hypotension was likely multifactorial including intrasvascular volume depletion given persistent hypoalbunemia and potential sepsis. The patient was noted to have a persistenly elevated white count despite broad spectrum antibiotics. C. Diff has been negative. Sputum cultures are AFB negative x 3. The patient's Hct decreased from 29.6 to 24 in the setting of volume resuscitation without evidence of acute bleeding. The patient was transfused 2U PRBCs to help oncotic pressure given decreased albumin. He reponded to the PRBC well and remained normo to hypertensive for the remainder of his hospitalization. He was transferred back to the floor prior to discharge. . # CVS: CAD: The patient has high risk for CAD, now with elevated Troponins and Ck-MB fraction. No EKG changes. The elevated troponin was likely in the setting of acute PE, due to demand. He was continued on medical management with ASA, restarted on Lipitor. His beta blocker was held after an episode of hypotension which sent him to the MICU. The beta blocker may be restarted once medically stable. . Rhythm: sinus Tachycardia, likely from PE . Pump: ECHO from [2-11] shows EF of 55%, mild sym LVH, no WMA. he seems intravscularly dry. SBP around high 90s. had SBP in 70s. was treated with fluid boluses. SBP responded and remained stable. . HTN: based on previous records, but not on any antihypertensives as outpatient, on [Hospital1 ] metoprolol. BP normal and stable . # GI Bleed: The patient's MICU course was complicated by a GI bleed in the setting of Heparin gtt. The GI bleed resolved, although patient continues to be guaiac positive. likely chronic from stomach/duodenal erosion w/ jejunal ulceration, especially in the setting of anticoagulation. Grossly positive stools early in his hospitalization, but now guaiac positive brown stools. GI was consulted, but given the risks of EGD/colonoscopy in the setting of ulcerations and anticoagulation the decision was made to hold off on this for now. There was a thought to give him IVIg for the ulcerative jejunoileitis but was not given due to lack of enough evidence that it would benefit. The patient's hematocrit trends down slowly and will need to be followed closely. . Anemia: Anemia of chronic disease worsened by GIB. Patient received transfusions to maintain Hematocrit > 28. GI was consulted as above. . Chronic Diarrhea: Consulted GI, but still unclear as to the cause of this. TPN was continued. Albumin was monitored. Stool studies were sent and were negative. Stool negative for C.Diff toxin. TPN was altered to include branched chain amino acids. . Recent h/o line sepsis: Staph epi from [6-15] in [12-10] sets at [Hospital1 ]. repeat Blood Cx from [6-22] w/ 1 set showing staph. Was started on IV Vanco 1 gm until [7-1]. PICC line changed from L to R arm on [6-27]. E. Coli bacteremia as above, but no further cultures growing staph. He was on ceftriaxone for a week and then stopped. was started on IV vanc and cefepime after the CT chest [Last Name (un) ] developing abscess, as above. . ARF: Patient with Creatinine elevated to 1.1 over baseline. It was felt that patient was pre-renal and he was given IVF as needed. Creatinine improved to 0.6. Remained stable. . DM: RISS, tight glycemic control . Gout: Continued Colchicine . Hep B: Continued Entecavir . FEN: Nutrition was consulted for TPN recommendations which was continued during hospitalization. Patient was also taking small amount of PO food. He was evaluated by speech and swallow who felt that the patient was able to take soft solids with thickened liquids. Medications on Admission: Lactinex 1 tab [Hospital1 ] Anusol cream Vit C 500 mg ASA 81 daily Questran 0.4 mg [Hospital1 ] Colchicine 0.6 daily Lomotil 2tabs daily Entecavir 0.5 mg daily Ferrous sulphate Regular insulin SS Prevacid 30 mg [Hospital1 ] Remeron 30 mg QHS Vancomycin 1 gm IV daily (completed on [2193-6-30]) Coumadin 2 mg daily Zinc oxide Octreotide 100 mcg [Hospital1 ] Infantis (Lactic acid prod org) Prednisone 5mg daily Ritalin 5 mg po 9am + 2pm Xenaderm daily to l heel Maalox Zofran PRN Simethicone Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [Hospital1 ] (2 times a day). 3. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). 4. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) 100mcg Injection Q8H (every 8 hours). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 11. Haloperidol 1-2 mg IV HS:PRN agitation 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. Morphine Sulfate 1-2 mg IV Q3-4H:PRN pain 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) per sliding scale Injection ASDIR (AS DIRECTED). 15. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 17. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 18. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for abdominal cramps. 19. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours). 20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 21. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane QID (4 times a day) as needed. 22. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 21 days. 24. Fluconazole in Normal Saline 400 mg/200 mL Piggyback Sig: Four Hundred (400) mg Intravenous Q24H (every 24 hours) for 21 days. 25. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q8H (every 8 hours) for 21 days. 27. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 24H (Every 24 Hours) for 21 days. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: pulmonary embolism deep venous thrombosis E.Coli bacteremia [Female First Name (un) 564] Albicans Fungemia Nosocomial pneumonia GI Bleed Acute renal failure Chronic diarrhea Secondary: PICA infarct Hepatitis B Lymphoma IDDM HTN Gastritis PVD Anemia Depression Discharge Condition: stable Discharge Instructions: Please take all the medications as prescribed. You have a fungus in your blood and a pneumonia which needs to be treated with antibiotics. You must complete the entire course of antibiotics. You need to take 3 more weeks of Cefepime, Vancomycin, Flagyl, and Fluconazole. You need to continue anticoagulation for the diagnosis of pulmonary embolism. Please keep all outpatient appointments as outlined below. Please call your primary care physician or return to the hospital if you experience chest pain, increasing shortness of breath, abdominal pain, fevers, numbness, weakness or other concerning symptoms. Followup Instructions: You have an appointment with Dr. [Last Name (STitle) 8682], [Telephone/Fax (1) 133], on [Last Name (LF) 766], [7-29]. Please be sure to follow up with infectious disease as an outpatient. You have an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [8-19] at 9:30. She will help you to schedule a follow up CT chest at that time. Please follow the result of the anti-Tissue Transglutaminase Antibody, IgA test ICD9 Codes: 7907, 5789, 5849, 2851, 5070, 4280, 2760, 3572, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7410 }	Medical Text: Admission Date: [2107-9-11] Discharge Date: [2107-9-21] Date of Birth: [2042-10-19] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: S/P Cardiac arrest Major Surgical or Invasive Procedure: [2107-9-14] - CABGx3 (left internal mammary-> Left anterior descending artery, Saphenous vein graft (SVG)-> Acute marginal artery, SVG->Posterior descending artery.) [2107-9-12] - Cardiac Catheterization History of Present Illness: Mr. [Known lastname 79067] [Last Name (Titles) ] a 64 yo male with a h/o morbid obesity, OSA, and HTN who presents following a witnessed cardiac arrest. Patient does not recall the events preceding his admission to [Hospital1 18], and history was obtained from OSH record and from wife. [Name (NI) ] report, patient was at a wedding ceremony He was in a seated position when his wife heard a gurgling [Last Name (un) ] and noted him to collapse onto the ground. There were medical personnel present and CPR reported him to have a carotid pulse. EMS arrived and reported him to be in ventricular fibrillation. He was shocked x 1 at 200J and was returned to a perfusing rhythm. No rhythm strips are available. Per report, a piece of chewing gum was suctioned from the oropharynx during resuscitation. There was no report of urinary or fecal incontinence. . He was subsequently brought to the ED at [Hospital 7188] Hospital where he was intubated. Per report, this was a "difficult intubation." He was reported to be hemodynamically stable at time of arrival. CT head was reported as normal. He was admitted to the CCU and supported overnight on a ventilator. He was started on a heparin gtt and amiodarone gtt at 0.5 mg/min. he received ASA 325 mg and Lidocaine 100 mg IV. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, 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 chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. His family did endorse episodes of dyspnea with exertion and diaphoresis. . Past Medical History: Hypertension OSA Morbid obesity Tobacco abuse Social History: Social history is significant for the presence of current tobacco use. Patient states that he currently smokes [1-19] PPD. There is no history of alcohol abuse. He reports that he consumes an average of 1 gin & tonic every night. Family History: His father died in his 50's of an MI. Physical Exam: PHYSICAL EXAMINATION: VS: T 98, BP 156/75, HR 63, RR 18, O2 97% on 4 liters Gen: obese middle aged male in NAD, resp or otherwise. Mood, affect appropriate. Pleasant. NEURO: Oriented to person only. Moving all extremities. CN [3-1] intact. Continues to perseverate and repeat the same questions regarding where he is, what happened. HEENT: NCAT. Ecchymoses over left side of tongue. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Thick, unable to assess JVP. CV: Very distant heart sounds. PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: Scar over left ankle, left knee. Trace lower extremity edema L>R. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: ADMISSION LABS: [2107-9-11] 01:46PM BLOOD WBC-8.8 RBC-3.57* Hgb-12.0* Hct-34.0* MCV-95 MCH-33.7* MCHC-35.3* RDW-19.1* Plt Ct-159 [2107-9-11] 01:46PM BLOOD Neuts-83.4* Lymphs-11.7* Monos-3.9 Eos-0.7 Baso-0.4 [2107-9-11] 01:46PM BLOOD PT-14.2* PTT-58.9* INR(PT)-1.2* [2107-9-11] 01:46PM BLOOD Plt Ct-159 [2107-9-11] 01:46PM BLOOD Glucose-125* UreaN-11 Creat-0.9 Na-136 K-5.0 Cl-100 HCO3-27 AnGap-14 [2107-9-11] 01:46PM BLOOD CK(CPK)-185* [2107-9-11] 01:46PM BLOOD CK-MB-10 MB Indx-5.4 cTropnT-0.07* [2107-9-11] 01:46PM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2 Cholest-159 [2107-9-11] 03:09PM BLOOD %HbA1c-5.1 [2107-9-11] 01:46PM BLOOD Triglyc-240* HDL-41 CHOL/HD-3.9 LDLcalc-70 [2107-9-11] 01:46PM BLOOD TSH-1.1 [2107-9-11] 01:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2107-9-14] 09:41AM BLOOD Type-ART pO2-341* pCO2-44 pH-7.41 calTCO2-29 Base XS-3 Intubat-INTUBATED [2107-9-14] 09:41AM BLOOD Glucose-119* Lactate-1.3 Na-135 K-4.7 Cl-99* [2107-9-14] 09:41AM BLOOD Hgb-11.3* calcHCT-34 EKG demonstrated NSR, HR 60 with normal axis, normal intervals, 1mm ST depression in I. No ST elevations. Q waves present in inferior leads. No prior available for comparison. . TELEMETRY demonstrated: NSR, HR 60's . 2D-ECHOCARDIOGRAM performed on [2107-9-10] at [Hospital ] Hospital demonstrated: depressed left ventricular EF at 35-40% (no official report available) . LABORATORY DATA (from OSH): #1 CK 69, Trop 0.03 #2 CK 176, Trop 0.89 #3 CK 122, Trop 0.85 . RADIOLOGY: CXR ([2107-9-11]): cardiomegaly; left pleural effusion; mild pulmonary vascular congestion without overt pulmonary edema; tortuosity and narrowing of trachea noted [2107-9-13] Carotid Ultrasound Less than 40% stenosis of the internal carotid arteries bilaterally. This is a baseline examination at the [Hospital1 18]. [2107-9-13] Thyroid ultrasound 1. Normal thyroid ultrasound. 2. Mass seen on recent CT not identified due to its retrosternal location. This could be further evaluated with non-contrast enhanced CT or MRI. [2107-9-14] ECHO Pre Bypass: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal for the patient's body size. There is mild regional left ventricular systolic dysfunction with mild septal and mid inferior hypokinesis..The ascending aorta 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. Post Bypass: Preserved biventricular function. LVEF 50-55%. Inferior wall motion slightly improved. Aortic contours intact. Remaining exam unchanged. All findings discussed with surgeons at the time of the exam. [2107-9-11] CTA Chest 1. Superior mediastinal 3 cm mass, immediately contiguous with the inferior aspect of the thyroid gland. Further evaluation with thyroid son[Name (NI) 867] is recommended as clinically indicated. The nodule is substernal and may be difficult to visualize [Name (NI) 79068], however. 2. Intermediate attenuation 4.6 cm bulging along the contour of the right subscapularis muscle. Differential diagnosis would include a mass such as a myxoma or elastofibroma or a cystic structure such as a paralabral cyst or bursitis. As clinically indicated, further evaluation with shoulder MRI is recommended. 3. Extensive coronary artery calcifications. 4. Tiny pulmonary nodules measuring 4 mm at the right lower lobe adjacent to the major fissure and 3 mm in subpleural location overlying the left lower lobe. [2107-9-12] Cardiac Catheterization 1. Selective coronary angiography of this right-dominant system revealed two-vessel coronary disease. The LMCA has no angiographically-apparent stenoses. The LAD has a proximal, hazy, ulcerated 80% stenosis and a calcified 50% mid-vessel stenosis. The LCX has mild diffuse luminal irregularities with no flow-limiting stenoses. The RCA has a proximal chronic total occlusion with brisk collateralization from the LCA. 2. Limited resting hemodynamics demonstrate moderate systemic systolic hypertension. Brief Hospital Course: Mr. [Known lastname 79067] was admitted to the [Hospital1 18] on [2107-9-11] via transfer from [Hospital 7188] Hospital for further management of his cardiac arrest. Cardiac catheterization showed multivessel coronary disease. He was taken to the operating room on [2107-9-14] where he underwent CABG x3. Please refer to Dr[Doctor Last Name ] operative report for further details. He was transferred to CVICU intubated, hemodynamically stable. All lines and drains were discontinued in a timely fashion. He was transferred to the SDU for further tele monitoring and incresaed activity/ambulation. Postoperative anemia was corrected with 1 unit of PRBCs and diuresis. EP study on POD#6 showed VTach was not inducible. EP reccommends to continue further beta-blocker, monitor electrolytes until discharge, and repeat an echocardiogram at 3 months following discharge. During this admission Mr.[Known lastname 79067] had hyperbilirubinemia. Right upper quadrant ultrasound was performed and showed normal gallbladder, fatty liver, and splenomegaly. The patient made excellent progress with physical therapy, showing good strength and balance before discharge. By the time of discharge on POD 7, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. He was discharged to home on POD#7. Medications on Admission: HCTZ 25 mg daily Lexapro 10 mg daily Amoxicillin PRN dental work Ibuprofen 800 mg TID Verapamil 240 XR daily (has not been filled since [Month (only) 116], per CVS) 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(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. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day for 1 months. Disp:30 Capsule(s) Refills:0 9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: CAD s/p CABGx3 HTN OSA Morbid obesity Tobacco use Cardiac arrest 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. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Completed by:[2107-9-21] ICD9 Codes: 496, 4019, 3051, 2859, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7411 }	Medical Text: Admission Date: [2168-11-16] Discharge Date: [2168-11-19] Date of Birth: [2084-5-9] Sex: M Service: MEDICINE Allergies: Amiodarone Attending:[First Name3 (LF) 1515] Chief Complaint: Dizziness Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: 84 year old male with history of A Fib, CAD who presents with dizziness of one day duration. Patient reported feeling dizzy to VNA nurse who found him to be hypotensive 90/50 and bradycardic 40s. Patient describes palpitations and weakness. Patient has history of dizziness - however only positional where today was at rest. He had mild chest discomfort in ED which resolved with no intervention. Patient denies shortness of breath, nausea. Describes baseline lower extremity edema, denies orthopnea and PND. Otherwise patient feels his usual state of health. Denies recent fever or chills. . In the ED, initial vitals were 97.5, BP 107/43, HR 37-44, RR 18, SaO2 100% RA. BP stable from 109-143. Per report HR ranged from 30-50. Patient asymptomatic. Did not require Atropine. . Of note he saw his cardiologist Dr. [Last Name (STitle) ] on [2168-10-14] who decreased his Atenolol from 50 to 25 secondary to bradycardia. Patient was admitted [4-25] through [4-29], with chest discomfort, peripheral edema, and dyspnea and was found to be in atrial fibrillation with a slow response (42 BPM). He was monitored on telemetry where asymptomatic pauses of [4-13] seconds were noted. When his atenolol was discontinued, his heart rate apparently intermittently increased to greater than 100 BPM and he was therefore started on a lower dose of Atenolol. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: CHF (LVEF 60%) PNA [2-/2168] Colon CA (colonoscopy [2162]) Status post hemicolectomy [11/2159] Atrial fibrillation s/p cardioversion x 2 Hypertension Mitral regurgitation Lung nodules (left) noted on CT. Hx of recurrent epididymitis rx'd with cipro, recurrent on L w/ pseudomonas UTI's, followed by urology h/o Indirect right inguinal hernia, pt declined surgery h/o pelvic fracture after MVA 30 years ago Social History: Retired businessman. Lives with his wife in his daughter's house. Grandchildren living with them as well. Smoked 20pack year, but quit 30 years ago. Admits to one serving of alcohol (shot of vodka) daily. Denies IVDU. Family History: NC Physical Exam: On discharge: Tm 98.1 BP 108-134/50-76 HR 44-64, R 16-20, 94-98% on RA-2L GEN: Lying comfortably in bed, NAD HEENT: MMM, JVP at 5 CM CV: RRR, no MRG LUNGS: CTA B ABD: soft, NT, ND,+BS EXT: WWP, no CCE. Pertinent Results: [2168-11-19] 06:00AM BLOOD WBC-5.3 RBC-3.73* Hgb-12.5* Hct-39.1* MCV-105* MCH-33.6* MCHC-32.0 RDW-13.0 Plt Ct-161 [2168-11-19] 06:00AM BLOOD PT-20.4* PTT-31.2 INR(PT)-1.9* [2168-11-19] 06:00AM BLOOD Glucose-113* UreaN-18 Creat-1.1 Na-138 K-4.0 Cl-104 HCO3-28 AnGap-10 [2168-11-18] 07:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2168-11-17] 03:26AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2168-11-16] 03:25PM BLOOD CK-MB-5 cTropnT-<0.01 [2168-11-19] 06:00AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.2 [2168-11-17] 03:26AM BLOOD TSH-2.9 CXR [2168-11-19] Two views of the chest are compared to the prior study from [2168-11-18]. A left subclavian pacer is present with single lead in the right ventricle. The lungs are clear. The cardiomediastinal silhouette is unremarkable. There is minimal atelectasis at the right lung base. The heart is enlarged. Brief Hospital Course: 84 year old male with A Fib, CAD who presented with "dizziness" and bradycardia, s/p pacemaker placement. . # RHYTHM: Atrial fibrillation with intraventricular conduction delay. Patient bradycardiac ranging from 30-50 on admission, now with pacemaker in place. TSH normal. His Atenolol was restarted at 25 mg [Hospital1 ] for control of his afib. He will need a total of 3 days of keflex on discharge (course to be completed end of day on [2168-11-21]). He was also discharged on warfarin and will require f/u in [Hospital3 ], as well as EP f/u one week post-discharge. . # CORONARIES: Chest pain fleeting and resolved without intervention. Troponins negative to date. He was continued on ASA on discharge. . # PUMP: Known diastolic chronic congestive heart failure. No SOB or signs of fluid overload on exam while in the hospital. ACE, statin, Bblocker were continued as pressures would tolerate while in-patient, he was then discharged on all three medications. . # Hypertension: Discharged on atenolol and lasix. Amlodipine held as pressures were WNL without amlodipine, however could re-start on f/u if pressures can tolerate. . # Dyslipidemia: Simvastatin was continued as an inpatient and on discharge. . # BPH: Proscar and doxazosin were held for low BPs, but restarted on discharge when pressures were stable. . CODE: FULL. Medications on Admission: amlodipine 5 mg a day atenolol 50 mg a day, doxazosin 4 mg daily Proscar 5 mg a day fluticasone two puffs twice a day furosemide 40 mg a day gabapentin 600 mg at bedtime lidocaine patch lisinopril 40 mg a day Patanol eyedrops simvastatin 40 mg a day warfarin as prescribed, acetaminophen as needed aspirin 81 mg vitamin B12 1000 mg a day. Discharge Medications: 1. Outpatient Lab Work Please check INR on Tuesday [11-22] and call results to the [Hospital ] clinic at [Telephone/Fax (1) 2173] 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 3. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 3 days. Disp:12 Capsule(s) Refills:0 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QSUN,TUES,THURS,SAT (). 11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QMON,WED,FRI (). 12. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO once a day. 14. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day. 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital6 1952], [Location (un) 86] Discharge Diagnosis: Bradycardia Coronary Artery Disease Chronic Diastolic Congestive Heart Failure Discharge Condition: Good, ambulating. Discharge Instructions: You were admitted for a slow heart rate and had a pacemaker placed. Take all your medications as directed and attend your follow-up appointments. . Medications: STOP: Amlodipine - your blood pressure was well controlled during your hospital stay without this medication. Follow-up your blood pressure with your primary care doctor/cardiologist and re-start if needed. NEW: Antibiotics for 3 days following pacemaker. CONTINUE: All other medications as directed by your cardiologist. . Follow-up: Cardiology: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2169-1-13] 11:40 Primary Care: Provider: [First Name11 (Name Pattern1) 4283] [Last Name (NamePattern4) 4284], M.D. Date/Time:[2169-2-28] 10:10 . Device Clinic: Friday [11-25] on [Hospital Ward Name 23] Clinical center, [Location (un) 436]. Please call [Telephone/Fax (1) 62] on [11-22] for the time of the appt. . Lab work: Please check INR on Tuesday [11-22] and call results to the [Hospital ] clinic at [Telephone/Fax (1) 2173]. A script has been printed for you. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet. . Call your doctor or present to the ED if you are dizzy, have episodes of blacking out, experience chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: Cardiology: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2169-1-13] 11:40 Primary Care: Provider: [First Name11 (Name Pattern1) 4283] [Last Name (NamePattern4) 4284], M.D. Date/Time:[2169-2-28] 10:10 . Device Clinic: Friday [11-25] on [Hospital Ward Name 23] Clinical center, [Location (un) 436]. Please call [Telephone/Fax (1) 62] on [11-22] for the time of the appt. . Lab work: Please check INR on Tuesday [11-22] and call results to the [Hospital ] clinic at [Telephone/Fax (1) 2173]. A script has been printed for you. ICD9 Codes: 4280, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7412 }	Medical Text: Admission Date: [2181-6-26] Discharge Date: [2181-6-29] Date of Birth: [2103-7-24] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: 77 y/o p/w subdural hematoma. Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 77F with a h/o lung cancer s/p lobectomy and PE on lovenox since [1-9] who presented to ED after a CT scan this afternoon at an OSH revealed a SDH. She reports her only symptom is a left sided headache just beside the ear. Of note patient has been taking lovenox since [Month (only) 404] after a diagnosis of a PE. Past Medical History: 1. Hypertension 2.Ao Arch ulceration 3.Knee Arthritis 4. s/p Cataract surgery 5. Thyroid nodule 6. Meningoma 7. lung cancer s/p LUL lobectomy [2181-4-19] 8. Saddle embolus s/p lobectomy, now on lovenox. Social History: Born in [Country 16573], she has 8 children, lives with her daughter, who is a nurse. non-smoker, rare alcohol, no drug use. Prior to the winter she was walking 1.5 to 2 miles to church every day; only stopped because of the cold weather. Family History: She denies h/o of cancer, early MIs, CVAs. Physical Exam: On admission: PHYSICAL EXAM: O: T: 98.3 BP: 148/78 HR:89 RR: 16 O2Sats: 100%RA Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Pupils:PERRL EOMs: intact Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [3-5] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-7] throughout. No pronator drift, no dysmetria Sensation: Intact to light touch, proprioception. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger. Pertinent Results: [2181-6-26] 05:15PM BLOOD WBC-8.3 RBC-4.42 Hgb-12.7 Hct-40.6 MCV-92 MCH-28.7 MCHC-31.2 RDW-16.6* Plt Ct-267 CT [2181-6-26]: FINDINGS: There is a left mixed-density frontal subdural hematoma visualized resulting in shift of midline to the right measuring 8 mm. Represents an acute on chronic subdural hematoma. There is mild effacement of the adjacent sulci visualized. The [Doctor Last Name 352]-white matter differentiation of the brain is well preserved. The ventricles appear normal with no evidence of hydrocephalus. The posterior fossa structures appear unremarkable. No evidence of tonsillar or uncal herniation. No osseous abnormalities visualized. There are bilateral carotid calcifications. The visualized orbits and paranasal sinuses appear normal. IMPRESSION: Left acute on chronic subdural hematoma resulting in subfalcine herniation as described above. No evidence of uncal or tonsillar herniation. MRI [2181-6-26]: FINDINGS: Again visualized is the midline orbital groove hemangioma in close proximity to the crista galli measuring 9 x 5 mm and is unchanged in size. There is a bifrontal subdural hematoma and left parietal subdural hematoma resulting in effacement of the adjacent left frontoparietal sulci, mass effect on the left lateral ventricle and shift of midline to the right, measuring 1 cm to the right. There is no evidence of hydrocephalus. The posterior fossa structures appear unremarkable. The visualized orbits and paranasal sinuses appear normal. The major vascular flow voids are well preserved. There is abnormal pachymeningeal enhancement visualized without evidence of the leptomeningeal enhancement. Differentials to consider would be meningitis. IMPRESSION: 1. Bifrontal subdural and left parietal subdural hematoma resulting in mass effect on the left lateral ventricle and subfalcine herniation to the right as described above. No evidence of tonsillar or uncal herniation. 2. Pachymeningeal enhancement. Differentials to consider would be meningitis. 3. Unchanged orbital groove extra-axial enhancing lesion. This likely represents a meningioma. Brief Hospital Course: Noncontrast head CT in the ED showed a 1 cm left acute on chronic subdural hematoma resulting in subfalcine herniation without evidence of uncal or tonsillar herniation. A brain MRI was also completed to assess for interval changes of her previously diagnosed and treated meningioma, which showed no significant changes. A complete neurological exam was normal. She was admitted to the SICU with neuro checks every one hour. Thoracic surgery attending agreed to discontinue her lovenox at that time as she had been treated for a prior PE for atleast 6 months. Her condition and neurologic exam was stable during her stay in the SICU. On HOD#2 she was transferred to the neurosurgical floor after a repeat head CT on [6-27] showed no significant interval changes. Her exam continued to remain stable during her stay on the floor. Thoracic surgery was consulted to determine her need for anticoagulation or placement of an IVC filter given her prior h/o saddle embolus s/p lobectomy. After consulting her PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] and negative LENIs bilaterally on HOD#2, it was decided that anticoagulation or placement of an IVC filter is not strongly indicated at this time. On HOD#4 PT recommended home services. OT cleared the patient for discharge as she is at her baseline according to her daughter. Neuro exam prior to discharge: orientated x 3 with appropriate responses to direct questions, PERRL, EOMi, CNII_XII intact, motor and sensory exam was normal. She was discharged on [2181-6-29]. Medications on Admission: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours). 4. Lotemax 0.5 % Drops, Suspension Sig: One (1) drop Ophthalmic [Hospital1 ] (2 times a day). 5. Triamterene-Hydrochlorothiazide 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. meds Please continue your home dose of lotemax 0.5% eye drops as prescribed. Please do not take lovenox. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Subdural hematoma Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR HEAD INJURY ?????? Take your pain medicine as prescribed ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) ] TO BE SEEN IN [4-8] WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST. Completed by:[2181-6-29] ICD9 Codes: 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7413 }	Medical Text: Admission Date: [2139-4-10] Discharge Date: [2139-4-13] Service: HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old male with a history of chronic obstructive pulmonary disease admitted to the MICU for increased dyspnea on exertion. The patient was admitted on [4-10] after complaint of increasing shortness of breath for many weeks. In the Emergency Department he had decreased mental status and respiratory failure. He was admitted to the MICU for treatment of this. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Congestive heart failure. Echocardiogram in [2134] revealing an EF of 25%. 3. Coronary artery disease status post coronary artery bypass graft in [2132]. 4. Diabetes. 5. Hypertension. 6. Depression/anxiety. 7. Status post colectomy. ALLERGIES: Penicillin and Haldol, patient is unclear of details. SOCIAL HISTORY: He lives with his son. [Name (NI) ] has VNA several times per week. He denies alcohol. He smokes three packs per day for "many years." MEDICATIONS ON ADMISSION: Elavil 50 q.h.s., Dulcolax prn, Thorazine 100 q.h.s., Zantac 150 q.h.s., Combivent two puffs prn, Colace 100 b.i.d., [Last Name (un) ]-Dur 200 b.i.d., Lasix 80 q.d., glyburide 100 b.i.d., 2 liters of O2 at home, Xanax .25 q.h.s. prn, enteric coated aspirin 325 mg q.d., Albuterol nebulizers q.i.d. and regular insulin sliding scale. PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.1. Blood pressure 120/55. Sating 1% on 2 liters. HEENT was unremarkable. Neck was supple. Cardiovascular regular rate and rhythm. Normal S1 and S2. 1 out of 6 systolic ejection murmur. Lungs had bibasilar crackles. Abdomen was benign. Lower extremity revealed 2+ bilateral edema. HOSPITAL COURSE: The patient was initially admitted to the MICU where he was put on CPAP and diuresed aggressively. By hospital day two he was down to 2 liters by nasal cannula and sating in the 98% range. He was believed to be near his baseline. His lungs sounded course, but he was moving good air. He was called out to the floor. On the floor he continued to do well. He was switched from his Combivent inhaler and given Flovent inhaler and deemed safe to go home. He received steroids for a chronic obstructive pulmonary disease flare in the unit, but on the floor no steroids were required. He had no evidence for pneumonia and was never treated for any antibiotics. We will send him out on a regular daily dose of Lasix and chronic obstructive pulmonary disease medications. We believe the source of his problems included poor medical compliance. On questioning the patient states he always takes his medications, although in speaking with the family there is some doubt about this. Furthermore he states he consumes large quantities of salt and water. He was advised that he needs to comply with his medications and watch his salt and fluid intake. We will send him home with [Hospital6 3429] to evaluate his dietary habits and his home medication compliance. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. FOLLOW UP: With is primary care physician. DISCHARGE MEDICATIONS: Unchanged from admission with only the addition of Flovent two puffs b.i.d. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease flare. 2. Congestive heart failure flare. 3. Uncontrolled diabetes mellitus. [Name6 (MD) 7853] [Last Name (NamePattern4) 7854], M.D. [MD Number(1) 7855] Dictated By:[Last Name (NamePattern1) 1213] MEDQUIST36 D: [2139-4-13] 09:59 T: [2139-4-15] 10:29 JOB#: [Job Number 12972] ICD9 Codes: 4280, 4254, 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7414 }	Medical Text: Admission Date: [2194-5-16] Discharge Date: [2194-6-13] Date of Birth: [2194-4-11] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [Known firstname ] [Known lastname ] was admitted on [5-16] at 35 days of age. He was transferred from [Hospital1 ] NICU for further management. He was born at 27 weeks to a 33-year- old, G4, P2 mother with [Name2 (NI) ] type O+, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, HIV negative, GC negative, chlamydia negative. She had spontaneous vaginal delivery at [Hospital6 ] after preterm labor. HOSPITAL COURSE AT [Hospital6 ] WAS REMARKABLE FOR: RESPIRATORY: Intubation and receipt of 2 doses of surfactant. He was extubated to CPAP on the first day, then to nasal cannula by day 2. CPAP was then changed to BIPAP, then SIMV was started for apnea, as well as respiratory acidosis. He was transferred to [Hospital1 ] NICU on day 11 on pressure support for further management of SVT. CV: SVT developed on day 2. He was treated with adenosine and later loaded with digoxin, which was subsequently discontinued. He was started on esmolol on day 9. The echo showed no structural defect and a tiny PDA. FEN: He was made n.p.o. with [Last Name (un) 37079] drainage for dilated loops. Creatinine was 1.1 on day 11. ID: He was initially treated with amp and gent, and later started on vancomycin, clindamycin, gentamicin because of concerns for NEC. [Last Name (un) ] culture grew gram-negative rods on day of transfer to [Hospital1 ]. NEURO: Head ultrasound was normal on day 11. HOSPITAL COURSE AT [Hospital1 ] NICU WAS NOTABLE FOR: RESPIRATORY: He was extubated on [5-2] after caffeine load. He was initially on CPAP and then transitioned to nasal cannula. He was on low flow at 30 cc/min on the day of transfer to [Hospital3 ] NICU. The baseline for him was intermittent desaturation episodes. CV: He was briefly on a dopamine infusion. The echo at [Hospital1 ] showed a PFO. Esmolol was discontinued. The SVT recurred on [4-30]. He responded to vagal maneuvers and adenosine. He was then started on propranolol at 1.5 mg/kg/D which was adjusted for weight. No further episodes of SVT recurred. He was followed by the [Hospital1 ] EP service. ACCESS: The PICC line was removed on transfer to [Hospital1 ]. His Broviac was placed on [5-1] and then discontinued on [5-13]. FEN: Bowel rest was instituted for 1 week. He was slowly advanced on enteral feeds, and on transfer to [Hospital3 ], he was on breast milk 28 Calories with Neosure and MCT at 140 mL/kg/D. No p.o. feeding had been started prior to transfer to [Hospital3 ]. GI: GI issues were attributed to septic ileus. He had a normal upper GI on [4-24]. A scrotal ultrasound was done on [4-22] because of a left-sided mass which showed a left hydrocele. The hydrocele was aspirated while at [Hospital1 ] NICU. He also had direct hyperbilirubinemia, which was thought to be secondary to sepsis and PN cholestasis. His most recent bilirubin results prior to transfer to [Hospital3 ] on [5-13] was 4.2/3.2. HEME: Multiple transfusions were given at [Hospital1 2177] and [Hospital1 ]. The most recent hematocrit prior to transfer was 25. He was on iron prior to transfer. ID: [Hospital1 ] cultures grew both Staph epi and E. coli. He was treated with meropenem and vancomycin. He was treated for 14 days from the first negative [Hospital1 ] culture on [4-25], and LP on [4-22] was negative. NEURO: Head ultrasound on [5-1] and [5-13] were normal. SENSORY: Due for ROP exam at 6 weeks. No hearing screen yet. HEALTHCARE MAINTENANCE: He received the hepatitis B vaccine on [5-10] prior to transfer. PHYSICAL EXAM ON ADMISSION TO [Hospital3 ] NICU: Well- appearing preterm infant with temp 98.6, pulse 152, respiratory rate 50, [Hospital3 ] pressure 79/52. Pink infant. Soft anterior fontanel. Intact palate. Normal facies. No grunting, flaring or retractions. Clear breath sounds. No murmur. Femoral pulses present. Flat, soft, nontender abdomen without hepatosplenomegaly. Normal phallus, testes and scrotum. Left testis larger than right, nontender. Stable hips. Normal tone and activity. Normal perfusion. A 3-mm nodule with overlying nonerythematous crust in right antecubital area. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: He remained on low-flow nasal cannula until [5-25], at which time he was transitioned to room air. He has had occasional drifts in his O2 saturations, but associated with eating and choking, last occurring on the morning of [6-10]. Otherwise, he has been stable. CARDIOVASCULAR: He remained on propranolol throughout the hospitalization at [Hospital3 ]. He has had no recurrent episodes of SVT. FLUIDS, ELECTROLYTES AND NUTRITION: On transfer to [Hospital3 ], he was on 28 Calorie breast milk. With advancing age, he has been transitioned to breast milk 24 Calories, and continues to gain weight on that. He has been taking full p.o. feeds since [6-9]. Weight on [6-13] is 2530 grams. GI: He is on Actigall for direct hyperbilirubinemia. He was noted to be jaundiced on [5-25] and found to have a bilirubin of 13.6/11.5. Electrolytes at that time: 138/4.8/106/25, alkaline phosphatase 876, SGOT 170, SGPT 94. An abdominal ultrasound was done on [5-27] which showed incidental calcifications in the left lobe of the liver. No biliary atresia or other abnormalities noted. A GI consult was obtained. They recommended a TORCH work-up and the CT of the abdomen. The abdominal CT was done on [6-3] which showed the same calcifications in the left lobe with no other abnormalities. The TORCH work-up has been negative. He was also started on some calcium carbonate and sodium phosphate on [6-9] for increasing alkaline phosphatase to 1468 and concern for metabolic bone disease. His bilirubin has improved to 9.7/7.4 on [6-2]. HEMATOLOGY: His last hematocrit on [6-7] was 26.8 with a retic of 8.8. He is on iron as well as multivitamins. He did not receive any transfusions while at [Hospital3 ]. INFECTIOUS DISEASE: He was noted to have some scrotal edema and erythema on [5-23]. A scrotal ultrasound was done which showed no torsion with the testes in the canals. He was started on vancomycin, gent for concern of infection. CBC: White count 9.4 with 3 bands, 63 neutrophils, hematocrit 35.9, platelets 203. The swelling and edema improved, and he was treated with antibiotics for a full 7 days (four days IV and 3 days of Keflex). The [Month (only) ] culture was negative. During the course of hospitalization, he was also found to have some brief temperature instability, which has resolved. Thyroid function testing was reassuring. NEUROLOGY: No further head ultrasounds have been done here. SENSORY: 1. AUDIOLOGY: Hearing screen passed. 2. OPHTHALMOLOGY: Eye exam on [5-26] showed immature zone II with follow-up recommended in 2 weeks. [6-9] exam showed immature zone III with follow-up recommended in 3 weeks. He has an ophthalmology outpatient appointment scheduled. Upon discharge home, he has been gaining weight on full p.o. feeds, clinically stable. The primary pediatrician will be Dr. [Last Name (STitle) 67310], phone number [Telephone/Fax (1) 67311], fax number [Telephone/Fax (1) 67312] (attention: [Doctor First Name ]). CARE/RECOMMENDATIONS: 1. He will be discharged home on Breast milk made 24 cal/oz with NeoSure which is recommended until 6-9 months corrected age. 2. Medications on discharge: iron (4 mg/kg/day) 0.4 ml daily (of 25 mg/ml) multivitamins 1 ml daily Actigall 24 mg po Q 12 Neutra-Phos 4 mmol po daily calcium carbonate 70 mg of elemental Ca po tid propranolol 1 mg po Q 8 hour 3. Car seat testing was passed. 4. State newborn screen on [4-22] showed low thyroxine, [5-14] was normal, and the one on [6-6] is still pending. 5. He received his first hepatitis B vaccine on [5-10]. His 2 month vaccinations were given [6-11] which included Pediarix, HIB and Prevnar. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: 1) Born at less than 32 weeks; 2) Born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-aged siblings; or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. 7. [Name2 (NI) 269] scheduled for [2194-6-14]. 8. Early intervention recommended. 9. GI recommends repeating bilirubin in the first week of [7-7]. Follow-up appointments: - pediatrician on [6-17] at 3:00 p.m - GI at [Hospital1 ] on [8-5] - Cardiology at [Hospital1 ] on [7-10] - Ophthalmology with Dr. [Last Name (STitle) ] in [Location (un) 3307] on [7-8] - Infant Follow-up Program at [Hospital1 ] DISCHARGE DIAGNOSES: 1. Respiratory distress syndrome. 2. Escherichia coli sepsis. 3. Supraventricular tachycardia. 4. Left hydrocele status post aspiration. 5. Prematurity at 27 weeks. 6. Suspected necrotizing enterocolitis versus septic ileus. 7. Hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Name8 (MD) 67313] MEDQUIST36 D: [2194-6-12] 16:46:31 T: [2194-6-12] 18:01:24 Job#: [Job Number 67314] ICD9 Codes: 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7415 }	Medical Text: Admission Date: [2170-5-31] Discharge Date: [2170-6-3] Date of Birth: [2116-10-28] Sex: F Service: PSYCHIATRY Allergies: Penicillins / E-Mycin / Dilantin / Zoloft / Iodine; Iodine Containing / Percocet / Haldol / Lidocaine (Anest) / Carbamazepine / Sulfonamides / Novocain / Tetracyclines / Latex Attending:[First Name3 (LF) 1678] Chief Complaint: "I feel like I'm a no good person" Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 5700] is a 53 y/o single female with an extensive psych hx and multiple psych dx, including but not limited to borderline personality d/o, anxiety, and depression, who reports taking an overdose of Motrin, Klonopin, Topomax, and insulin last night. The pt says that the medication overdose was an impulsive act after a string of events that left her feeling overwhelmed. She reports that recent stressors include multiple medical illnesses (recurrence of seizures, GI problems, back pain, eating d/o), inability to drive due to seizures, and conflicts w/ neighbors and landlord. Pt also reports feelings of excessive guilt about letting people down. Pt was provocative during questioning about SI/SA, with statements of feeling worthless, but could not confirm or deny current plan or intent. Pt denies HI. Denies AH. Pt says this is her second psych hospitalization in the last three months for OD. Her last hospitalization was at [Hospital1 ], and pt says they discharged her after a weekend and "they said I was hopeless." Pt is concerned that she has no current case worker and no crisis team. But reports that she sees her therapist [First Name5 (NamePattern1) 107802] [Last Name (NamePattern1) ] 1x/wk, and sees her psychopharm psychiatrist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 1x/mo. Pt lives alone w/ cat and has some problems with ADLs, reporting eating only a few crackers in the past day. Unclear if this is d/t c/o N/V or eating disorder (says she has been told by GI she needs g-tube placement because of diarrhea but later says "I feel fat... I won't eat until I lose all this weight"). She reports feeling unsafe at home due to the conflicts w/ neighbors (reports "neighbor's boyfriend ransacked my apartment... my neighbor beat me up when I wouldn't let her boyfriend park in my space."). Few social supports include sister in FL, and local friend [Name (NI) ] who she fought with yesterday. Of note, pt initially dysregulated in ED. Per ED resident, pt pulled out her IV, attempted to milk arm for blood, scratched arm and required soft 2-point restraints. Later able to calm down and participate in interview. Past Medical History: PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT, HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR): (per OMR notes and confirmed w/ pt) -multiple hospitalizations since age 22, last in [3-15] at [Hospital1 ] for reported OD attempt - discharged after a weekend per pt's reprort -several suicide gestures by OD, one by strangulation, though it is unclear that any of these were with intent to kill self -has been adherent on psychiatric meds -h/o DBT treatment -sees therapist [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] and psychiatrist [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], both at Edinburgh Center PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES, OR OTHER NEUROLOGIC ILLNESS): 1) DM2 2) Asthma 3) S/P R TKR 4) OSA on BIPAP 5) GERD 6) Hypercholesterolemia 7) C/o chronic diffuse body pain. H/o dx c fibromyalgia. 8) Insomnia 9) ?Sjogrens Syndrome 10) Numerous psychosomatic presentations (non-epileptic seizures, psychogenic laryngospasm-type episodes culminating in intubation, psychogenic urinary retention) 11) DDD: reports two bulging discs in cervical spine - records in [Location (un) 8985] 12) s/p R knee replacement in [5-12] 13) Chronic Anemia 14) s/p hysterectomy Social History: Ms. [Known lastname 5700] lives in an apartment in [Location (un) 1459] alone. 2nd oldest of 5 daughters. Graduated from college w/degree in early childhood education. Never married, no kids. Section 8 housing, on disability. Volunteer at [Location (un) 2199] Senior Center. Reports h/o sexual assault in '[40]'s and in [2165]. Denies abuse history. Family History: Per OMR depression and EtOH abuse Physical Exam: MENTAL STATUS EXAM (USE FULL, DESCRIPTIVE SENTENCES WHERE APPLICABLE) APPEARANCE & FACIAL EXPRESSION: dressed in hospital gown, facial expressions reactive to content of conversation POSTURE: lying in hospital bed, wearing O2 mask - pulled off frequently when talking animatedly BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS): none noted ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): uncooperative at first b/c "the other psychiatrists left me," was cooperative after est alliance SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC, ETC.): regular volume, rate, rhythm MOOD: "depressed, anxious" AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.): reactive, ranging from teary to irritated to jocular, somewhat childlike at times THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY, CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): linear THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS, DELUSIONS, ETC.): preoccupied w/ guilt regarding disappointing others ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS): none noted NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP, APPETITE, ENERGY, LIBIDO): reports waking every hr or so b/c of "fear", poor appetite SUICIDALITY/HOMICIDALITY (INCLUDE IDEATION, INTENT, PLAN): SI but pt could not confirm or deny intent and plan INSIGHT AND JUDGMENT: poor/poor COGNITIVE ASSESSMENT: SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert ORIENTATION: oriented x3 ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): able to spell WORLD forwards and backwards correctly MEMORY (SHORT- AND LONG-TERM): [1-9] spontaneous recall, final item w/ prompting CALCULATIONS: $1.75 = 7 quarters FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE): PROVERB INTERPRETATION: grass is greener = "other people have something better" SIMILARITIES/ANALOGIES: apple and [Location (un) 2452] = both "fruit" Pertinent Results: No labs since admission to psychiatry Brief Hospital Course: Psychiatric: Upon admission from medicine, the patient voiced numerous complaints. She was upset about the way she had been treated by the psychiatric nursing staff and during admission, was noted to be labile surrounding this issue. She had multiple demands with regards to her care and voiced multiple somatic complaints. Despite this however, the patient did not present a behavioural problem and she denied any intent to harm herself while on the unit. During the initial interview, the patient discussed her suicide attempt/gesture while admitted to medicine. She stated she did not feel heard by the medical team and acknowledged that she wrapped a phone cord around her neck for attention. After addressing numerous medication issues, the goals of the patient were discussed and a plan for discharge was created, which included a short stay on the psychiatric unit and discharge to a partial hospital in [Location (un) 246]. This plan was confirmed through the CL psychiatry notes. For this plan to occur, the patient was encouraged to remain in good behavioural control and maintain her nutrition status, as she had had difficulty tolerating her diet while on medicine. On [2170-6-3], the patient had an episode of acute hyperventilation and a code blue was called. The patient was transferred to the MICU. Please refer to the discharge summary for more details. Psychopharmacology: The patient was started back on the medications she received while she was admitted to medicine. Some of the changes that occurred included Increasing her Olanzapine to 10mg at night, discontinuing her Seroquel, and reducing her Lyrica dose. Several other minor changes to her nonpsychiatric medications, were made per the patient's request. Medical: While admitted to the unit, the patient had two seizures which were felt by the staff to be nonepileptic in nature. She did not lose consciousness, and was not incontinent of urine. She believed these seizures to be "pseudoseizures" and denied they were grand-mal seizures. During her short psychiatric stay, the patient complained of various issues such as swelling in her hands and ankles, difficulty swallowing pills, and a need for ongoing physical therapy for her back. She was seen by nutrition who suggested adding Boost to her meals, and physical therapy was consulted to provide her with continued support for her back. The team felt that listening to the patient and addressing her multiple somatic complaints was beneficial to her overall care. The patient was transferred back to medicine after a code blue was called on [2170-6-3]. Dispo: The patient was transferred to the MICU on [2170-6-3]. Her therapy appts were cancelled. Medications on Admission: Oxcarbazepine 300 mg PO BID Sucralfate 1 gm PO QID before meals and at bedtime Estrogens Conjugated 1 gm VG HS Duration: 3 Weeks Insulin SC (per Insulin Flowsheet) Sliding Scale Olanzapine (Disintegrating Tablet) 2.5 mg PO QAM Lorazepam 2 mg PO Q6H:PRN agitation Olanzapine (Disintegrating Tablet) 5 mg PO Q6H:PRN agitation Max dose of zyprexa is 25mg/24 hours Clonazepam 0.5 mg PO TID Duloxetine 40 mg PO DAILY Pantoprazole 40 mg PO Q24H Fentanyl Patch 25 mcg/hr TP Q72H already on Metoclopramide 10 mg PO QIDACHS Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN pain with eating Maalox/Diphenhydramine/Lidocaine 30 mL PO TID:PRN eating (Medicine team checked with pharmacy, pt. has had this medication in the past, OK to give) Lidocaine 5% Patch 1 PTCH TD DAILY 12 hrs on, 12 hrs off Simethicone 40-80 mg PO QID:PRN GI discomfort Acetaminophen 325-650 mg PO Q4H:PRN pain Pregabalin 75 mg PO TID Olanzapine (Disintegrating Tablet) 5 mg PO qpm Discharge Medications: Oxcarbazepine 300 mg PO BID Sucralfate 1 gm PO QID before meals and at bedtime Estrogens Conjugated 1 gm VG HS Duration: 3 Weeks Insulin SC (per Insulin Flowsheet) Sliding Scale Olanzapine (Disintegrating Tablet) 2.5 mg PO QAM Lorazepam 2 mg PO Q6H:PRN agitation Olanzapine (Disintegrating Tablet) 5 mg PO Q6H:PRN agitation Max dose of zyprexa is 25mg/24 hours Clonazepam 0.5 mg PO TID Duloxetine 40 mg PO DAILY Pantoprazole 40 mg PO Q24H Fentanyl Patch 25 mcg/hr TP Q72H already on Metoclopramide 10 mg PO QIDACHS Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN pain with eating Maalox/Diphenhydramine/Lidocaine 30 mL PO TID:PRN eating (Medicine team checked with pharmacy, pt. has had this medication in the past, OK to give) Lidocaine 5% Patch 1 PTCH TD DAILY 12 hrs on, 12 hrs off Simethicone 40-80 mg PO QID:PRN GI discomfort Acetaminophen 325-650 mg PO Q4H:PRN pain Pregabalin 75 mg PO BID Olanzapine (Disintegrating Tablet) 10 mg PO qpm Discharge Disposition: Home Discharge Diagnosis: Axis I: Somatization d/o, Eating d/o NOS Axis II: Borderline PD Axis III: GERD, OSA on Bipap, seizures (psychogenic), Axis IV: housing issues Axis V: 40 Discharge Condition: Medical transfer Discharge Instructions: Patient transferred to medicine Followup Instructions: Therapist: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 107803] [Telephone/Fax (1) 107804] [2170-6-5] at 2:00pm [Street Address(2) 107805] [Hospital1 ]. Psychiatrist: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 107806] [2170-6-5] at 1:30pm [Street Address(2) 107805] [Hospital1 ]. Case Worker: [First Name8 (NamePattern2) 3692] [Last Name (NamePattern1) 32304] [Telephone/Fax (1) 107807] CBFS *Due to transfer, the patient's above appointments were cancelled. Completed by:[2170-6-5**] ICD9 Codes: 2859, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7416 }	Medical Text: Admission Date: [2101-5-9] Discharge Date: [2101-5-13] Date of Birth: [2032-4-11] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1505] Chief Complaint: Exertional dyspnea Major Surgical or Invasive Procedure: [2101-5-9] Coronary Bypass Graft Surgery x 4 with Left internal mammory artery -> Left anterior artery, Reverse saphenous vein graft-> Diagonal, Posterior descending artery and posterior lateral branch History of Present Illness: Mr. [Known lastname 19130] is a 69 year old male with multiple cardiac risk factors including family history who has undergone extensive workup for worsening exertional dyspnea. Recent cardiac catheterization at MWMC showed 2V CAD. He presents today for cardiac surgical evaluation.PMH also notable for ascending aortic aneurysm measuring approximately 4.0 cm on echocardiogram. There is no record of an outside CT scan. He was referred for coronary revascularization. Past Medical History: Coronary Artery Disease PMH: - Aortic Aneurysm - Type II Diabetes mellitus - Obesity - Dyslipidemia - Hypertension - mild Pulmonary HTN - Diverticular Disease, h/o perforation [2075] Past Surgical History: - Bilateral Knee Replacement [2095] complicated by infection requiring redo operation - Total Hip Replacement [2094] - colon surgery for perforation Social History: Lives with:wife ( RN) Contact: same Phone # Occupation: Works at state board of retirement Cigarettes: Never ETOH: < 1 drink/week [] [3-8] drinks/week [] >8 drinks/week [] Illicit drug use Family History: Father MI at age 55, died at age 64 rupture AAA Mother died at age 68 from MI, heavy smoker Physical Exam: Pulse:77 Resp:18 O2 sat: 98% B/P Right:115/81 Left: 126/85 Height: 5'[99]" Weight: 245 Five Meter Walk Test #1_______ #2 _________ #3_________ General:NAD, obese Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera,OP unremarkable Neck: Supple [x] Full ROM []no JVD appreciated Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur-none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] none Varicosities: B spider veins; mild varicosities R>L Neuro: Grossly intact;nonfocal exam, MAE [6-4] strengths Pulses: Femoral Right:2+ Left:2+ DP Right:NP Left:NP PT [Name (NI) 167]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right: none Left:none Pertinent Results: [2101-5-12] 04:56AM BLOOD WBC-10.2 RBC-3.14* Hgb-9.7* Hct-28.2* MCV-90 MCH-30.8 MCHC-34.3 RDW-13.0 Plt Ct-162 [2101-5-11] 04:45AM BLOOD WBC-10.1 RBC-3.48* Hgb-10.9* Hct-32.1* MCV-92 MCH-31.5 MCHC-34.1 RDW-13.2 Plt Ct-160 [2101-5-10] 02:03AM BLOOD WBC-10.8 RBC-3.75* Hgb-12.0* Hct-34.6* MCV-92 MCH-31.8 MCHC-34.6 RDW-13.3 Plt Ct-181 [2101-5-12] 04:56AM BLOOD Glucose-137* UreaN-20 Creat-0.7 Na-138 K-3.9 Cl-105 HCO3-27 AnGap-10 [2101-5-11] 04:45AM BLOOD Glucose-195* UreaN-18 Creat-0.8 Na-134 K-4.0 Cl-103 HCO3-25 AnGap-10 [2101-5-10] 02:03AM BLOOD Glucose-141* UreaN-14 Creat-0.7 Na-137 K-3.9 Cl-106 HCO3-25 AnGap-10 [2101-5-9] ECHO PRE-BYPASS: The left atrium is normal in size. 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 aorta is mildly dilated. There are focal calcifications in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. [2101-5-13] 08:00AM BLOOD WBC-8.9 RBC-3.40* Hgb-10.4* Hct-30.9* MCV-91 MCH-30.5 MCHC-33.6 RDW-12.9 Plt Ct-256# [2101-5-13] 08:00AM BLOOD Glucose-144* UreaN-17 Creat-0.8 Na-135 K-4.2 Cl-100 HCO3-25 AnGap-14 Brief Hospital Course: The patient was brought to the Operating Room on [2101-5-9] where the patient underwent Coronary Bypass Graft Surgery x 4 with Left internal mammory artery -> Left anterior artery, Reverse saphenous vein graft-> Diagonal, Posterior descending artery and posterior lateral branch. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and increased for hypertension. The patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Oral hyperglycemic medications were initiated with high blood sugars, which were well controlled at the time of discharge. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA in good condition with appropriate follow up instructions. Medications on Admission: Amlodipine 10mg daily Metformin 1000 [Hospital1 ] Glipizide 5 daily Losartan-HCTZ 100-25 daily Pravastatin 40mg daily Niacin 500mg daily Aspirin 81mg daily Vitamin D MV Omega 3 Fluticasone Nasal Spray Urea 40% cream Rogaine 2% cream Amoxicillin prn invasive procedures ( prior staph infection as above) Discharge Medications: 1. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 2. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 6. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:2 8. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:7 Tablet(s) Refills:0 11. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. Disp:14 Tablet Extended Release(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA of Greater [Location (un) 5871]/[Location (un) 6159] Discharge Diagnosis: Coronary Artery Disease PMH: - Aortic Aneurysm - Type II Diabetes mellitus - Obesity - Dyslipidemia - Hypertension - mild Pulmonary HTN - Diverticular Disease, h/o perforation [2075] Past Surgical History: - Bilateral Knee Replacement [2095] complicated by infection requiring redo operation - Total Hip Replacement [2094] - colon surgery for perforation Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Left leg incision clean, dry intact with 2+ left LE edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [Telephone/Fax (1) 170] on [2101-5-19] 10:30a Surgeon Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [2101-6-15] at 1:30p Cardiologist: Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4610] [2101-6-3] at 3:30p Please call to schedule the following: Primary Care Dr. [Last Name (STitle) 8034],[First Name3 (LF) 8035] A. [Telephone/Fax (1) 12295] in [5-5] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2101-5-13] ICD9 Codes: 4168, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7417 }	Medical Text: Admission Date: [2154-6-10] Discharge Date: [2154-6-13] Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1] Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: none History of Present Illness: 87F with multiple surgeries in the past and recurrent SBOs, presenting with epigastric abdominal pain yesterday at noon, up to [9-25], associated with nausea and vomiting x1. It remained centered on the epigastric region and did not radiate.Her last meal was lunch and she has not felt hungry since this pain began.Her last BM was yesterday and was normal. She stopped passing flatus yesterday morning. Had some nausea/vomited x1 upon arrival to the ED. ROS: (+) Pain, N/V per HPI, tinnitus (-) Denies fevers, chills, headache, dizziness, hematemesis, BRBPR, chest pain, shortness of breath, urinary frequency, urgency Past Medical History: Small Bowel obstruction,Polymyalgia Rheumatica, Afib, HTN,hypothyroid, tinnitus Past Surgical History: Cholecystectomy, appendectomy, hysterectomy, sigmoidectomy for diverticulitis, lumbar laminectomy, rectal fissure repair, Left TKA, Left sjoulder hemiarthroplasty, Right shoulder surgery Social History: Lives alone, retired after working for Army, no tobacco, alcohol, drugs Family History: Father died of prostate cancer, mother,HTN, died of a stroke Physical Exam: General: A&O, NAD HEENT:no scleral icterus, mucus membranes moist Cardiac: RRR, No M/G/R Pulmonary: Clear to auscultation b/l, No W/R/R Abdomen:soft, nondistended, nontender tender,normoactive bowel sounds Extremities:no LE edema, LE warm and well perfused Pertinent Results: MICRO: MRSA screen, Urine culture and blood cultures pending ([6-10]) ABX: None IMAGING: Abdominal CT: Preliminary Report: Stomach is markedly distended and fluid filled. Proximal loops of small bowel are dilated up to 4 mm. Distal loops of small bowel are collapsed, compatible with small bowel obstruction. 2. Bilateral consolidations at the lung bases, likely reflect aspiration and/or infection in the appropriate clinical setting. [2154-6-12] 04:35AM BLOOD WBC-10.7 RBC-3.47* Hgb-8.8* Hct-27.5* MCV-79* MCH-25.3* MCHC-31.9 RDW-16.1* Plt Ct-164 [2154-6-11] 12:49AM BLOOD WBC-10.1 RBC-3.51* Hgb-8.9* Hct-28.3* MCV-81* MCH-25.3* MCHC-31.5 RDW-16.5* Plt Ct-158 [2154-6-9] 11:15PM BLOOD WBC-10.1# RBC-4.30 Hgb-11.0* Hct-34.1* MCV-79* MCH-25.6* MCHC-32.2 RDW-16.3* Plt Ct-226 [2154-6-12] 04:35AM BLOOD Glucose-93 UreaN-13 Creat-1.1 Na-141 K-3.3 Cl-108 HCO3-26 AnGap-10 Brief Hospital Course: This is an 87 year old female with history of recurrent SBO who presented to the ED with nausea, vomiting abdominal pain, abdominal imaging was done which was consistent with SBO. Patient was treated conservatively with an NGT,intravenous fluids and bowel rest.Of note patient had developed respiratory issues and was placed on a shovel mask for low oxygen saturations and was transferred to the intensive care unit for further monitoring. Incidentally patient was found to have pneumonia on chest xray and was started on IV antibiotics (Levofloxacin [6-10]). Of note while in the ICU patient was noted to have an episode of agitation during the night and received Lorazepam and Zyprexa with mild improvement. Patient respiratory status continued to improve and her oxygen was weaned and she was transferred from the sicu to the floor. Patient SBO was resolved and she was passing gas and the diet was advanced to clears which was tolerated well.Thus the nasogastric tube was subsequently discontinued and her diet was slowly advanced to clears which was tolerated well. Hospital day 3, the diet was advanced to regular. Patient had no further abdominal pain patient was also restarted on all of her home medications. Hospital day 4, she received a Dulcolax suppository, and bowel regimen (senna and colace). Shortly thereafter patient had a bowel movement. At time of discharge patient was doing well, passing gas, and tolerating a regular diet Patient was discharged home on Levofloxacin PO for 3 days to complete a 7 day course. She had no further respiratory issues and her vital signs were stable. Patient received discharge instructions and will follow-up with Dr. [Last Name (STitle) ] as needed. Medications on Admission: amiodarone 200mg TIW M/W/F amlodipine 5mg daily ammonium lactate lotion atenolol 50mg daily levothyroxine 150mcg morning ompeprezole 20mg daily prednisone 4mg daily ropinirole 1mg bedtime tramadol 1mg PRN pain trazodone 50mg PRN sleep warfarin 3mg 1-2 tabs qd calcium 500+D [Hospital1 ] docusate sodium 100mg [Hospital1 ] Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. prednisone 1 mg Tablet Sig: Seven (7) Tablet PO DAILY (Daily). 5. trandolapril 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 10. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:3 Tablet(s) Refills:0 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for loose stool. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: 1.small bowel obstruction 2.pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with to the hospital with complaints of abdominal pain, nausea, and vomiting. Abdominal imaging was done which showed a small bowel obstruction which was medically managed with bowel rest,nasogastric tube and hydration. Once you started passing gas, your diet was slowly restarted which you tolerated well. You also had some respiratory issues during your hospitalization and a chest xray was done which showed pneumonia and you were started on an antibiotic (Levofloxacin). You will need to continue taking your antibiotic for 3 more days; please take exactly as prescribed even if you are feeling better. You may resume your other home medications. Please call Dr. [Last Name (STitle) ] office if you develop nausea, vomiting, increasing abdominal pain, distention, large decrease in bowel movements or flatus, or any other questions or concerns. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: Please call your PCP to resume coumadin monitoring within the next week. Please follow-up with Dr. [Last Name (STitle) ] as needed [Telephone/Fax (1) 9]. Department: ORTHOPEDICS When: MONDAY [2154-6-24] at 1:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GERONTOLOGY When: THURSDAY [2154-7-4] at 2:00 PM With: [Last Name (un) 3895] [First Name8 (NamePattern2) 3896] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 719] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RHEUMATOLOGY When: WEDNESDAY [2154-7-10] at 2:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 23371], MD [Telephone/Fax (1) 2226] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 861] Campus: WEST Best Parking: [Hospital Ward Name ] Garage ICD9 Codes: 486, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7418 }	Medical Text: Admission Date: [2190-8-16] Discharge Date: [2190-8-20] Date of Birth: [2151-3-24] Sex: M Service: SURGERY Allergies: Cefazolin Attending:[First Name3 (LF) 4691] Chief Complaint: Transferred from So. [Hospital 3844] Med Ctr due to sepsis Major Surgical or Invasive Procedure: I&D Right foot abcess History of Present Illness: Mr. [Known lastname 3321] is a 39 year old paraplegic secondary to severe spinal stenosis who was recently hospitalized at [Hospital1 18] from [Date range (1) 84603] for RLE cellulitis in the setting of taking high dose steroids for Crohn's disease-related uveitis. He underwent operative I&D on [2190-7-19]. Intraoperative wound cultures eventually grew out group A beta-strep. Blood cultures from later in his hospital course grew coag-negative staph. A VAC was applied to his wound, and he was discharged on a 2-week course of Linezolid per ID recommendations. He was re-admitted to [State 20192] Center twice in the interim, once for presumed pneumonia & UTI (treated with Zosyn and Cipro), and the second time for an apparent viral URI (no antimicrobials given). During this time, the patient has been off steroids and completed his course of antibiotics. More recently, the patient reports he has had persistent/worsening pain in his right ankle. He spoke to his VNA about his concerns, who recommended he go to the hospital. He returned to [State 20192] Center, where his RLE was scanned and this reportedly showed evidence of small fluid collections. The patient then developed hypotension requiring pressors and he was therefore transferred to [Hospital1 18] for further mamangement. Past Medical History: PMH: - Crohn's disease (dx'd [2180]) c/b uveitis and scleritis - morbid obesity - degenerative joint disease - CAD s/p MI [2186] - paraplegia due to severe spinal stenosis - recurrent UTI - MRSA cellulitis - hx of pyoderma grangrenosum - chronic R heel ulcer PSH - c-spine decompression [8-19] at [Hospital1 18], c/b quadriplegia with subsequent improvement in function to paraplegia - I&D of RLE [2190-7-19] - excision of cyst from left ear Social History: Smokes 1 ppd. Occasional alcohol use, socially. Denies IV drug use. prio history of opiod addiction Family History: An uncle has epilepsy. There is no family history of multiple sclerosis or other neurologic disorders. Physical Exam: PHYSICAL EXAM: T 98.9, HR 80, BP 123/48, RR 15, O2Sat 94%RA GEN - morbidly obese, NAD, awake/alert, flat affect CVS - distant heart sounds secondary to body habitus PULM - CTAB, no W/R/R, no respiratory distress ABD - obese, nondistended, nontender, no masses or organomegaly EXTREM - significant bilateral non-pitting edema up to the level of the kneees RLE: warm, dry and flaky; triphasic DP and PT pulses; diffuse erythema of the foot and ankle with dusky purple discoloration of the lateral malleolus with some mild fluctuance/bogginess in this area; there are tiny (~2mm) vesicles primarily over the distal shin and dorsum of the foot; there is a ~4x5cm open ulcer of the dorsum of the foot with healthy pink granulation tissue; there is also a ~4x4cm bullae/blister of the heel LLE: warm, dry, triphasic DP and PT pulses, ~4x6cm chronic-appearing ulcer of the heel Pertinent Results: [2190-8-16] 10:34AM WBC-12.3# RBC-3.95 HGB-9.9* HCT-31.0* MCV-79* MCH-25.2* MCHC-32.1 RDW-18.5* [2190-8-16] 10:34AM NEUTS-91.4* LYMPHS-5.7* MONOS-1.1* EOS-1.5 BASOS-0.3 [2190-8-16] 10:34AM PLT COUNT-366 [2190-8-16] 10:34AM PT-13.0 PTT-22.9 INR(PT)-1.1 [2190-8-16] 10:34AM ALT(SGPT)-13 AST(SGOT)-17 CK(CPK)-41* ALK PHOS-60 TOT BILI-0.4 [2190-8-16] 10:34AM GLUCOSE-134* UREA N-11 CREAT-0.6 SODIUM-139 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-27 ANION GAP-1 [2190-8-17] 10:30 am SWAB Source: right lateral malleolus abscess. FINAL REPORT [2190-8-19] GRAM STAIN (Final [2190-8-17]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2190-8-19]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. ANAEROBIC CULTURE (Final [2190-8-17]): SPECIMEN NOT TRANSPORTED ANAEROBICALLY. TEST CANCELLED, PATIENT CREDITED. Brief Hospital Course: Mr. [Known lastname 3321] was admitted to the SICU and evaluated by the Acute Care service. He was on Levophed to maintain a MAP > 60 but that was easily weaned off after fluid resuscitation. His right foot was subsequently I&D'd at the bedside and cultures were obtained. His WBC was 12K. He was placed on Vancomycin and Zosyn and the Infectious Disease service was consulted. He was transferred to the Surgical floor the following day as he continued to be hemodynamically stable. The wound care nurse made recommendations for his left foot ulcers which were improving since his last admission and his right foot was cared for locally with saline damp to dry dressings [Hospital1 ]. His right leg was improving daily in that the cellulitis was contained to the lower leg only and he had much less edema. On [2190-8-19] his antibiotics were changed to oral Linezolid from IV Vancomycin and Zosyn after final wound culture revealed CNS. The ID service felt that the most likely source of his recurrent leg cellulitis was staph or strep both of which he has had in the past and therefore recommended an additional 14 day course of Linezolid. He will be followed closely by the ID service and the ACS service. After showing daily improvement of his wounds he was discharged to home on [2190-8-20] with VNA services for wound care. Medications on Admission: - senna 9.8mg, 1-2tab PO QHS prn constipation - tizanidine 6mg PO QHS - colace 100mg PO BID - nicotine patch TD 21mg/24hrs - baclofen 10mg PO TID - acetaminophen 650mg PO Q6hrs prn pain - oxycodone 10-15mg PO q3hrs prn pain - miconazole nitrate 2% powder TP QID prn rash - gabapentin 800mg PO Q8hrs - camphor-menthol 0.5-0.5% lotion TP TID prn itching Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 5. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:28 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: home health and hospice Discharge Diagnosis: right foot abcess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were admitted to the hospital with an abcess of your right foot and increased cellulitis of your right leg. * The drainage and local care with dressing changed have improved the wound and the cellulitis continues to decrease on antibiotics. * You will need to stay on Linazolid for 2 more weeks and follow up in the [Hospital ] Clinic prior to stopping antibiotics. * You will have VNA services for help with dressing changes. * If you develop any fevers or chills please call the [Hospital 2536] Clinic. Followup Instructions: Call the [Hospital 2536] Clinic at [Telephone/Fax (1) 600] for a follow up appointment in 1 - 2 weeks. Call the Infectious Disease Clinic at [Telephone/Fax (1) 457] for a follow up appointment in [12-12] weeks. Continue to follow up with your physicians at Southern New [Hospital ] Hospital Completed by:[2190-8-20] ICD9 Codes: 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7419 }	Medical Text: Admission Date: [2177-11-24] Discharge Date: [2178-1-2] Date of Birth: [2098-8-2] Sex: M Service: MEDICINE Allergies: Benzodiazepines / Terazosin Hcl / Iodine Attending:[First Name3 (LF) 3283] Chief Complaint: CHF exacerbation and respiratory failure requiring intubation. Major Surgical or Invasive Procedure: Endotracheal intubation with mechanical ventilation PICC placement, removal Right subclavian line Hemodialysis Bronchoscopy History of Present Illness: The patient is a 79 year old Polish speaking man with a history of diastolic CHF (EF 65% in [6-24]), atrial fibrillation (refusing anticoagulation), HTN, DM, CRI who presented with pitting edema and shortness of breath on [2177-11-24]. Per nursing home notes, patient's weight had increased 15 pounds from his baseline (dry weight 265). Prior to early [Month (only) ], patient's urine output was approximately 3-4 liters per day, but had dropped to less than one liter per day, despite lasix dose of 60mg [Hospital1 ] not changing. . In the ED, diuresis was tried with 120mg IV lasix and 250mg diuril. A COPD flare was suspected and IV solumedrol 80mg and azithromycin 500mg was started. Levofloxacin 250 mg IV was added for a positive UA. As the patient's ABG was 7.25/70/242, Bipap was started and the patient was transferred to the MICU. Past Medical History: -Atrial fibrillation: not on anticoagulation because of lack of adherence -Coronary artery disease: refused catheterization -CHF (diastolic dysfunction with last EF 65% on echo [6-24], dry wt 125kg) -CRI (baseline Cr 2.7) -BPH -HTN -DM (diet controlled) -OSA - pulmonary HTN, requiring supplemental night oxygen and BIPAP before intubation -Anemia (baseline hematocrit 23-27) Social History: Married, lives with daugther. Wife lives at [Hospital1 1501]. Polish speaking but understands some English. Per pt's daughter (who is researcher at [Hospital1 18]) no tobacco, alcohol or other drugs; stopped smoking 40yrs ago (smoked a lot while being captain on a ship) At rehab 2 months prior to admission. Prior captain on a ship. Currently lives in [Hospital3 2558]. Family History: No family history of seizures or strokes. Mother died from complications of renal failure. Physical Exam: In MICU: Temp 96.3, BP 102/54; RR 21; O2 93% on 5LNC (off bipap) Gen: increased work of breathing using abdominal accessory muscles on exhalation, responds to commands and moves all 4 extremities. HEENT: PERRLA, NCAT, MM dry Neck: very full, unable to assess JVP, moves neck freely Cor: irreg irreg, s1s2, no r/g/m Pulm: bilateral wheezes, tight sounding throughout lung fields, no crackles Abd; obese, +abd muscle use with each expiration, unable to assess HSM, NT, decreased BS Skin: venous stasis changes in BLE, no rashes Ext: bilateal LE pitting 2+ edema [Date range (1) 8642] up calves, w/w/p, weakly +dp pulses bilaterally . On Transfer to Medicine Floor: T:98.6 BP:100/70 HR:80 RR:24 O2saturation:99% on 4L Gen: Obese man laying in bed. Appears older than stated age. Not responsive to voice or sternal rub, but responded only to deep suctioning. HEENT: No conjunctival pallor. No icterus. Slightly dry mucous membranes. NGT in place. NECK: Supple. Could not appreciate any cervical or supraclavicular lymphadenopathy. CV: Irregularly irregular rate and rhythm. Normal S1 and S2. No murmurs, rubs or [Last Name (un) 549] appreciated. LUNGS: On anterior chest examination, decreased breath sounds in lower lung fields, bilaterally. ABD: Hypoactive bowel sounds in all four quadrants. Soft. Distended. EXT: Warm and well perfused. No clubbing. No lower extremity edema, bilaterally. 2+ dorsalis pedis and radial pulses, bilaterally. NEURO: Somnolent. Could not perform detailed neurological examination. Pertinent Results: Admission Labs: [2177-11-24] 11:07PM TYPE-ART PO2-242* PCO2-70* PH-7.25* TOTAL CO2-32* BASE XS-1 INTUBATED-NOT INTUBA [2177-11-24] 11:07PM K+-5.6* [2177-11-24] 11:07PM freeCa-1.04* [2177-11-24] 09:20PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.011 [2177-11-24] 09:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2177-11-24] 09:20PM URINE RBC-21-50* WBC-[12-8]* BACTERIA-FEW YEAST-NONE EPI-0-2 [2177-11-24] 09:20PM URINE HYALINE-0-2 [2177-11-24] 06:07PM GLUCOSE-142* UREA N-114* CREAT-4.7# SODIUM-135 POTASSIUM-5.9 CHLORIDE-99 TOTAL CO2-28 ANION GAP-14 [2177-11-24] 06:07PM CK(CPK)-15* [2177-11-24] 06:07PM CK-MB-NotDone cTropnT-0.03* proBNP-[Numeric Identifier 10420]* [2177-11-24] 06:07PM CALCIUM-7.6* PHOSPHATE-7.3# MAGNESIUM-3.1 [2177-11-24] 06:07PM WBC-6.5 RBC-2.27* HGB-8.0* HCT-24.5* MCV-108# MCH-35.2 MCHC-32.7 RDW-18.7* [2177-11-24] 06:07PM NEUTS-77.1* LYMPHS-10.4* MONOS-10.4 EOS-1.8 BASOS-0.2 [2177-11-24] 06:07PM HYPOCHROM-3+ ANISOCYT-2+ MACROCYT-3+ [2177-11-24] 06:07PM PLT COUNT-158 . . Microbiology: bronchalveolar ([12-4]): citrobacter Urine Cx ([11-24]): enterococcus, sensitive to ampicillin Urine Cx ([12-6]): negative Tests for MRSA([12-1], [12-8]) and VRE ([12-1]): negative Test for VRE ([12-8]): enterococcus, but sensitive to vancomycin and ampicillin Blood Cx ([11-24], [12-6]): negative catheter tip ([12-13]): pending . Hematocrit: Remained in the 20's. Initially 24, increased to 29. Reticulocyte count: 2.2 on [11-25]. WBC: 6.5 on admission, increased to 14.8 on [12-4], and 11.4 on transfer. Creatinine: 4.7 on [11-24], and increased to 5.0. Following temporary dialysis, 2.3. Urea ranged between 114-->154-->117. Na: Elevated to 151 on [12-8], but trending down to 144 on [12-13]. Troponin: 0.06 on [12-13]. BNP: [Numeric Identifier 10420] on [11-24]. Blood gases: On [11-24].25/242/70. Hypercarbic to 89, requiring intubation between [Date range (1) 10421]. On transfer on [12-13].36/119/54. . STUDIES: Chest Xray([2177-11-24]): Very limited radiograph, small bilateral pleural effusions and mild pulmonary edema cannot be excluded. PA and lateral radiographs with improved suspension of respiration is recommended, if feasible. . Chest Xray([2177-11-28]): There has been interval placement of a right IJ CVL with the tip extending to the cavoatrial junction. Cardiomegaly is stable. Perihilar interstitial opacities have improved in the interval, compatible with improving pulmonary edema. There are likely bilateral pleural effusions, although the study of limited secondary to patient's body habitus. . Chest Xray([2177-12-4]): 1. Standard ET tube placement. 2. Cardiomegaly with no evidence of congestive heart failure on the current chest radiograph. Bilateral atelectasis right more than left, right pleural effusion. . Chest Xray([2177-12-10]): 1. Persistent failure and bilateral pleural effusions. 2. Tip of the nasogastric tube not visualized, but below the level of the diaphragm. . PICC placement ([2177-12-12]): Successful placement of a 40-cm 4 French single lumen PICC via the right brachial vein. The tip is in the central superior vena cava. The line is ready for use. . Brain MRI ([2177-12-13]): No evidence of acute infarct. Moderate brain and medial temporal atrophy. Moderate small vessel disease. . Temporary Catheter Placement([2177-11-27]): Uncomplicated ultrasound and fluoroscopically guided temporary dialysis catheter placement via the right internal jugular venous approach with the tip in the right atrium. . Chest Xray [12-19]: IMPRESSION: Improvement in the appearance of the previously described cardiac failure and bilateral pleural effusions. . Abdominal CT: [12-26] 1. Malpositioned Foley catheter; the balloon is inflated within the penile urethra. 2. Moderate left hydroureteronephrosis to the level of the left ureteovesicular junction without a clear obstructing lesion. No stones are identified within the ureter or bladder. 3. No evidence for diverticulosis or diverticulitis. . Echo: [12-31] Conclusions: 1.The left atrium is moderately dilated. The left atrium is elongated. The right atrium is markedly dilated. 2.There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The ascending aorta is mildly dilated. The aortic arch is mildly dilated. 5.The aortic valve is not well seen. No aortic regurgitation is seen. 6.The mitral valve leaflets are moderately thickened. 7.There is no pericardial effusion. . Labs on discharge: WBC: 5.3 Hct: 27.6 Plt: 265 Na: 138 K: 4.2 BUN: 32 Cr: 2.7 Ca: 8.1 Mg: 2.2 P: 4.1 Brief Hospital Course: Mr. [Known lastname 10422] is a 79 year old man with a history of diastolic CHF, atrial fibrillation, HTN, DM, CRI who presented with CHF exacerbation requiring intubation and subsequently developed citrobacter PNA. After extubation, he was unresponsive to voice and sternal rub. On [12-15] he began responding to questions and following commands. He remained alert, conversant, breathing comfortably on RA. . #) Respiratory Failure: On admission, the patient's ABG was 7.25/70/242, Bipap was started and the patient was admitted to the MICU. Concern for aspiration was noted on [11-29], so an NGT was placed on [11-30]. Unasyn was started on [12-3] for presumed right lower lobe pneumonia. Patient was bronched on [12-4] and large secretions were noted in the right and left lower lobes. With worsening hypercarbia, patient was intubated on [12-5]. Respiratory failure was felt to be secondary to CHF. Meropenem and vancomycin were added for broader antibiotic coverage. On [12-6], citrobacter, sensitive to meropenem, was isolated. Patient was extubated on [12-9], requiring 4L supplemental oxygen. He had initially been given methylprednisolone 40mg IV q8 for question of a COPD flare. He was switched to PO prednisone and tapered over the course of his admission. He was slowly weaned down to room air and maintained oxygen saturations of 94-100%. On [12-13] the patient was transferred to the floor. The patient received tube feedings without incident. His NG tube was d/c'd on [12-14] and could not be replaced after 4 attempts. Speech and swallow evaluated the patient on [12-16] and felt he would be able to tolerate medications and ice chips. They were reconsulted on [12-17] as the patient's mental status was improving. He completed a 14 day course of meropenem as above on [12-21]. He continued to saturate well on RA, requiring 2L NC at night. CPAP was attempted, however the patient refused and repeatedly removed his mask. He was given nebulizers as needed for wheezing. His lung exam at discharge was clear to auscultation bilaterally. . #) Renal Failure: Mr. [Known lastname 10423] creatinine at baseline is approximately 2.6. On admission the patient's creatinine was 4.7 and peaked at 5.0. The acute renal failure was likely due to decreased intravascular repletion in setting of CHF. His woresning renal function led to increased fluid retention which caused worsened cardiac congestion. He was placed on temporary dialysis for several days. Dialysis was initiated on [11-27] and discontinued on [12-5] due to hypotension and tachycardia. On transfer to the floor, he was able to generate sufficient urine output with lasix. On [12-15] the patient triggered for hypotension and his lasix was held. His foley was removed on [12-19], with resultant good urine output. Ins and outs were difficult to obtain secondary to his incontinence and a foley catheter was eventually replaced. His creatinine remained approximately at his baseline. A small dose of lasix 20mg PO was restarted on [12-22]. His medications were dosed appropriately for his creatinine clearance. . #) CHF: Patient's original CHF flare exacerbated by acute renal failure, causing increased fluid retention. He was treated with lasix gtt and nesiritide and even required hemodialysis for management of his volume status. The diuresis was effective and the patient was eventually extubated and was able to be weaned off of oxygen satting well on room air. His lower extremity edema resolved. His dry weight was known to be 265 lbs. On [12-19] his weight was repeated and he was at approximately his dry weight. His beta blocker was continued and once his BP stabilized it was titrated up to his outpatient dose. While he was on lower doses of beta blocker he was noted to have breakthrough tachycardia at night, heart rates to the 140s at night. He remained asymptomatic during these episodes and his heart rate quickly returned to [Location 213]. However, once his beta blocker was titrated back to outpatient dose, these episodes did not recur. . #) Left hydronephrosis: On [12-26] the patient was noted to be hypotensive and complaining of abdominal pain. An abdominal CT was done which revealed a malpositioned foley catheter with the balloon inflated within the prostatic urethra and moderate left hydroureteronephrosis to the level of the left ureteovesicular junction without a clear obstructing lesion. The foley catheter was repositioned with good urine return and he was given a three day course of Ciprofloxacin. He was seen by urology who recommended a catheter for 1-2 weeks until performance status improves, renal imaging in [1-20] months to document resolution of the hydronephrosis and follow up with Dr. [Last Name (STitle) 770]. . #) Episodes of hypotension: He triggered for hypotension on [12-26] PM. Labs and CXR were normal, other vital signs were stable. EKG w/ some deepened ST depressions in I, avL, V5,V6 and flattened T waves in V3, V4. He was noted to be in afib and was put back on telemetry and his cardiac enzymes were cycled and did not change from his baseline mild elevation. He was already on ASA, bblocker. It was felt that this may be related to finally getting up after long hospitalization (pivoted w/ PT 1 hr prior to event), but given his history, 24-36 hrs of "gas pain", and tenderness on abd exam, looked for infectious etiology. Blood cultures and urine cultures remained negative. Abdominal CT with hydronephrosis and traumatic foley placement as above. . #) Mental Status: On [12-8], in anticipation of extubation, patient's sedatives were weaned. At that time the patient was noted to have altered mental status, left-sided weakness. On transfer to the floor he was only responsive to deep suctioning. An MRI was done on [12-13] which did not reveal any evidence of acute infarct. The neurology team was consulted and felt that his mental status changes were likely toxic metabolic superimposed on an atrophic/ susceptible brain. Initially it was felt that the changes were related to medication as he received ativan on [12-13] for MRI scan, and benzodiazepines are known to cause confusion in this patient. However, as his mental status did not resolve for several days the etiology was felt more likely to be increased uremia (renal failure versus steroid) vs. hypernatremia. He was started on D5W to help decrease sodium level. On [12-15] he began responding to yes/no questions and following commands. His mental status continued to improve with improving renal function and improvement of his hypernatremia. On the day of discharge the patient was speaking both English and Polish, was oriented x 3 and was able to express his desire to go home. At that time his Na was within normal limits and his kidney function had improved. . #) CAD: Patient has refused cardiac catheterization in past. He had a hypotensive episode in the MICU requiring phenylephrine and had an additional episode of hypotension (SBP 89) while on the floor. Troponins measured on [12-11] and were negative (0.05-0.06). He was maintained on his aspirin and beta blocker as above. He was not given an ACE-inhibitor due to his renal function. This can be addressed as an outpatient. His lipid panel was checked on [11-25]. There was no evidence of hypercholesterolemia, so statin not needed. The panel was repeated on [12-16] and were notable for elevated triglycerides. No new medication was instituted at this admission, however follow up testing is recommended. . #) Anemia: Patient's hematocrit has remained stable during admission, although he required two units of packed red blood cells on [2177-11-27]. Macrocytic anemia most likely due to patient's chronic kidney disease or due to bone marrow stimulation from epogen. He was continued on ferrous sulfate and epogen 8000 qM,W,F. . #) BPH: The patient's foley was removed on [12-20]. He was initially restarted on flomax and finasteride was added the following day. However, the foley was replaced on [12-24] after he began complaining of abdominal pain and a bladder scan revealed >400cc urine in the bladder. In addition he had episodes of hypotension and as he had a foley catheter in place, flomax was discontinued for the possible effects it would have on his blood pressure. . #) Diabetes: He was maintained on an insulin sliding scale for the majority of his hospitalization. During his stay in the ICU, required insulin gtt for four days. On [12-8], patient weaned from insulin gtt and started on sliding scale insulin. His blood sugars remained moderately well controlled with dietary modifications. . #) UTI: On admission, patient noted to have a UTI. Started on a 7 day course of ampicillin for pansensitive enterococcus. Subsequent antibiotic modifications for presumed pneumonia provided effective coverage. . #) FEN: Mr. [Known lastname 10422] was initially given tube feedings which were continued until his NG tube was removed on [12-14]. After a failed attempt at replacement, he did not receive nutrition for 3 days. Speech and swallow evaluated the patient multiple times during this admission. He was initially restarted on PO meds and ice chips, however as his mental status improved he was advanced to pureed foods and prethickened liquids. On [12-30] he was delivered the incorrect meal tray and ate a [Country 1073] [Location (un) 6002] without difficulty. He will need to be reevaluated by speech and swallow in the near future as he likely can eat solid foods. . #) Prophylaxis: As patient was not ambulating, he was maintained on subq heparin and SCD boots. He was placed on a PPI and given a bowel regimen. [Hospital3 2558] was called and it was determined that Mr. [Known lastname 10422] has received neither his flu shot nor his pneumovax vaccinations. He will be given these prior to discharge. Medications on Admission: Haloperidol 2.5 mg IV HS:PRN anxiety Heparin 5000 UNIT SC TID Acetaminophen (Liquid) 650 mg PO Q4-6H:PRN HydrALAZINE HCl 25 mg PO Q6H Albuterol 6 PUFF IH Q4H Insulin SC (per Insulin Flowsheet) Aspirin 325 mg PO DAILY Ipratropium Bromide MDI 6 PUFF IH Q4H Bisacodyl 10 mg PR HS:PRN Lactulose 30 ml PO Q8H:PRN Calcium Acetate [2172] mg PO TID W/MEALS Meropenem 500 mg IV Q24H Docusate Sodium (Liquid) 100 mg PO BID Epoetin Alfa 8000 UNIT SC QMOWEFR MethylPREDNISolone Sodium Succ 40 mg IV Q8H Ferrous Sulfate 325 mg PO DAILY Metoprolol 25 mg PO BID hold for sbp < 100, HR < 55 Finasteride 5 mg PO DAILY Pantoprazole 40 mg IV Q24H Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] Fluoxetine HCl 20 mg PO DAILY Tamsulosin HCl 0.4 mg PO HS Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) inj Injection QMOWEFR (Monday -Wednesday-Friday). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 5. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) mL PO BID (2 times a day). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Pantoprazole 40 mg IV Q24H 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb IH Inhalation Q4H (every 4 hours) as needed. 14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 15. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed for gas. 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB IH Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 18. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 19. Insulin sliding scale 20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Location (un) 583] house Discharge Diagnosis: CHF, diastolic (EF 75% on echo [12-31] Respiratory failure Chronic renal insufficiency Atrial fibrillation Citrobacter pneumonia BPH Hypertension Diabetes mellitus, type 2, diet controlled Obstructive sleep apnea Anemia Left hydronephrosis, [2-20] traumatic foley Toxic metabolic encephalopathy Coronary artery disease Discharge Condition: Stable. The patient remains hemodynamically stable. Discharge Instructions: You were admitted for congestive heart failure. You had fluid in your lungs which made it difficult for you to breathe. You needed to be mechanically ventilated during this time. The fluid was removed from your lungs by putting you on hemodialysis and through different medications. You are now able to breathe on your own. You were also treated for a pneumonia which you developed while in the hospital. As you have heart failure, you should weigh yourself every morning, and call your doctor if weight > 3 lbs from baseline. You should also adhere to a 2 gm sodium diet It is important that you continue to take all of your medications as prescribed. If you begin to experience any chest pain, difficulty breathing, dizziness, lightheadedness, abdominal pain or any other concerning symptoms please call 911 or your doctor immediately. Followup Instructions: You have the following appointments: 1. Dr. [Last Name (STitle) 770], [Telephone/Fax (1) 10424], on Thursday [2-5] at 230. [Hospital Ward Name 23] building, [Location (un) 470]. 2. [First Name8 (NamePattern2) 1409] [Last Name (NamePattern1) ], [MD Number(3) 1240]:[Telephone/Fax (1) 250] at [2178-1-6] on 850. You will need additional renal imaging, a renal ultrasound, in [1-20] months. You will need a CXR in [2-21] days of discharge to rule out silent aspiration as your diet was advanced on [1-2]. ICD9 Codes: 5845, 5859, 5990, 2760, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7420 }	Medical Text: Admission Date: [2177-11-6] Discharge Date: [2177-11-10] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1234] Chief Complaint: Back pain x 5 days Major Surgical or Invasive Procedure: EVAR [2177-11-6] History of Present Illness: [Age over 90 ] year old female with known aortic abdominal aneurysm of 5.4 cm in size presents with 5 days of back pain. It started out as her feeling lethargic and just not herself. She then had bilateral hip pain that seemed to travel to her back. She has been in constant pain. She denies fever, chills, night sweats, nausea, vomiting, constipation, or diarrhea. She has a known AAA which has been asymptomatic for the last 3 years and followed by Dr [First Name (STitle) ]. She went to [Hospital3 ] where a CT scan showed that there some stranding around the aneurysm and slight increase of size to 5.5 compared to about 1 year and half ago. She denies chest pain and shortness of breath. Past Medical History: Macular degeneration, legally blind, thoracoabdominal aneurism, hypertension, hyperlipidemia, history of colon cancer Past Surgical History: Appendectomy, colon resection for colon cancer, hysterectomy, cataract surgery, tonsillectomy Social History: Lives in an retirement home. Independent of all her activities. She drinks one [Doctor Last Name 6654] a night. She denies tobacco. Family History: N/C Physical Exam: Vital Signs: HR 79 BP 136/66 RR 16 O2 Sat 98% RA General: No acute distress Cardiovascular: regular rate and rhythm Lung: clear to auscultation bilaterally Abdomen: soft, nondistended, nontender Extremities: palpable femoral pulses bilaterally right DP and PT are dopplerable Left DP is dopplerable but PT was not dopperable Wound: Groin sites CDI. No hematoma, no bleed Pertinent Results: [2177-11-9] 06:08AM BLOOD WBC-10.0 RBC-3.65* Hgb-10.8* Hct-31.5* MCV-86 MCH-29.6 MCHC-34.3 RDW-14.9 Plt Ct-175 [2177-11-9] 06:08AM BLOOD Plt Ct-175 [2177-11-9] 06:08AM BLOOD Glucose-103 UreaN-19 Creat-1.1 Na-136 K-4.0 Cl-101 HCO3-27 AnGap-12 [2177-11-7] 01:20AM BLOOD CK(CPK)-71 [2177-11-9] 06:08AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.0 [2177-11-7] 08:44AM BLOOD Type-ART pO2-100 pCO2-32* pH-7.47* calTCO2-24 Base XS-0 [2177-11-7] 08:44AM BLOOD Glucose-133* Lactate-0.6 K-3.3* [2177-11-7] 08:44AM BLOOD O2 Sat-97 Brief Hospital Course: [2177-11-6] Emergently sent by [Location (un) ] from [Hospital1 ] to [Hospital1 18] for symptomatic AAA. Having one week of abdominal and back pain. Esmolol and sodium bicarb gtt initiated. Evaluation by Attending Vascular Surgeon on arrival to ED and CT scan reviewed. Patient was a DNR/DNI and agreed to possible intervention. Taken to the OR for an endovascular AAA repair. Tolerated procedure without complications. Transferred to the CVICU post-op. Propofol and nitro gtts overnight for BP control. Intubated overnight. [2177-11-7] Extubated and weaned off drips. Vitals and labs stable. Transferred to VICU. Diet advanced. OOB to chair. [2177-11-8] No acute events. Labs and vitals stable. Foley DC'ed. PT screened and cleared for home with Physical Therapy. Pain management. Lasix given for fluid overload with symptomatic lung crackles. [2177-11-9] No acute events. Ambulated with PT. Tolerating regular diet. [2177-11-10] Stable overnight. DC home with VNA and Physical therapy. Follow-up with Dr. [Last Name (STitle) ] in [3-18] weeks. Medications on Admission: Lisinopril 10 mg PO Daily, Crestor 10 mg PO Daily, Aspirin 40.5 mg PO Daily, calcium, vitamin D, vitamin C, Multiple vitamins, Omega 3 Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Please call PCP for refills [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 52051]. Disp:30 Tablet(s) Refills:2 6. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: AAA PMH: legally blind hypertension hyperlipidemia DNR/DNI Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [2-16] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [4-20] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2177-12-2] 12:00 Completed by:[2177-11-10] ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7421 }	Medical Text: Admission Date: [2137-5-6] Discharge Date: [2137-6-7] Date of Birth: [2059-1-24] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 2195] Chief Complaint: Left Lower Extremity Ischemia Major Surgical or Invasive Procedure: [2137-5-6] PROCEDURE: 1. Left groin exploration with left common femoral artery arteriotomy and thrombectomy of left superficial femoral artery and profunda femoris artery with bovine pericardial patch angioplasty. 2. Left lower extremity four compartment fasciotomy History of Present Illness: The patient is a 78 year old male with PMH significant for CAD s/p CABG x 4/MV repair in [1-/2133], 7 cm infrarenal AAA, s/p EVAR in [2129], c/b migration of his Endograft with a large type 1 proximal endo leak found incidentally on CTA at the time of CABG. While awaiting a scheduled repair of the endoleak, in [2-/2133], patient developed rupture of the aneurysm and emergent endovascular repair using a uni-iliac graft with occlusion of the contralateral left iliac artery and subsequent right to left fem-fem bypass graft with 8mm ringed PTFE. In [2133-6-7], the aneurysm sac measured 6.9 cm in maximum diameter which has decreased in size since the last study several months ago. He was transferred from [Hospital3 24768] for an evaluation of painful left lower extremity concerning for ischemia. The LLE became incredibly painful at around noon time on the day of admission. The leg from just above the knee was cool and mottled. There is no dopplerable PT and DP signal or popliteal signal on that side. Patient has decreased sensation to touch on below the knee on the left side. Patient reports significant amount of nausea and persistant severe pain. He received heparin bolus and was on heparin gtt for about 3 hours without any improvement. Past Medical History: PMH: - Coronary Artery Disease s/p CABG x4 ([2132]) - Mitral Regurgitation s/p MV repair ([2132]) - Heart Failure (systolic) - Paroxysmal Atrial Fibrillation - Renal Insufficiency - Peripheral Vascular disease - Hypertension - Chronic Anemia - AAA s/p Endovascular stent [2129], developed Type I endoleak, s/p rupture and emergent endovascular repair in [2132] - Myocardial Infarction [2109] - Gout - Osteoathritis - Venous ligation - GI bleeding - bladder cancer - chronic renal failure PSH: [2130-4-7] (Dr. [Last Name (STitle) ] 1.Endovascular stent graft repair of infrarenal abdominal aortic aneurysm. 2.Femoral artery exposure bilaterally. 3.Two catheters in aorta via both femoral arteries. 4.Modular bifurcated endograft. 5.Left common iliac artery extender cuff. 6.Aortogram in pelvis. 7.Radiologic S&I for endograft. 8.Radiologic S&I for extender piece. [2133-2-4] Coronary artery bypass graft x4; left internal mammary artery to left anterior descending artery and a radial artery sequential grafting to obtuse marginal 1 and 2, and saphenous vein graft to posterior descending artery and mitral valve repair with size 26 [Company 1543] Future Ring. [2133-3-4] (Dr. [Last Name (STitle) ], Dr. [Last Name (STitle) ] Emergent endovascular repair of ruptured abdominal aortic aneurysm using aorta uni-iliac graft (Zenith 32 x125) with occlusion of the contralateral left iliac artery( 18 mm [Doctor Last Name 4726] Excluder) and subsequent right to left fem-fem bypass graft with 8mm ringed PTFE. Extension right CIA with 18X 54 Zenith limb Social History: retired, worked in plastics factory, Married lives with spouse [Name (NI) 1139] - quit 25 years ago, 80 pack year history Denies ETOH Family History: Brother and mother deceased from [Last Name ] problem Physical Exam: Admission PE: VS: 98 83 190/82 21 96% RA CV: RRR pulm: CTA b/l abdomen: obese, + BS, ND/NT extremities: R - normal capillary refil, warm to touch L - mottled to above the knee, painful to touch, decreased sensation in the LLE below the knee pulses: fem-fem fem [Doctor Last Name ] PT DP R dop palp dop dop dop L dop palp - - - Exam on transfer: AVSS CV: RRR pulm: CTA b/l abdomen: obese, + BS, ND/NT extremities: R - normal capillary refil, warm to touch L - warm to knee, incision CDI, pulses: fem-fem fem [Doctor Last Name ] PT DP R dop palp dop dop dop L dop palp - dop dop Exam on discharge: GEN: Resting in bed in NAD, arouses easily to voice. HEENT: NCAT, EOMI. COR: +S1S2, no m/g/r. Irregularly irregular heartbeat. PULM: CTAB, with slight crackles in bases. Improves with cough. [Last Name (un) ]: +NABS in 4Q. Soft, NTND. No peritoneal signs. EXT: Left lower extremity incisions healing well, no erythema or discharge. Lower extremities warm. PT, DP with weak doppler signals NEURO: Awake & alert, MAEE. Pertinent Results: [2137-5-6] 04:15PM BLOOD WBC-19.1# RBC-4.45 Hgb-13.7# Hct-40.0# MCV-90 MCH-30.8# MCHC-34.3 RDW-14.2 Plt Ct-256 [2137-5-18] 03:16AM BLOOD WBC-20.9 RBC-2.58* Hgb-7.7* Hct-24.6* MCV-95 MCH-29.9 MCHC-31.3 RDW-14.2 Plt Ct-518* [2137-5-27] 03:00AM BLOOD WBC-14.7* RBC-3.41* Hgb-10.5* Hct-31.0* MCV-91 MCH-30.9 MCHC-33.9 RDW-15.5 Plt Ct-398 [2137-5-29] 05:03AM BLOOD WBC-10.7 RBC-3.06* Hgb-9.1* Hct-27.4* MCV-90 MCH-29.9 MCHC-33.4 RDW-15.2 Plt Ct-267 [2137-5-7] 05:32AM BLOOD PT-13.3 PTT-46.1* INR(PT)-1.1 [2137-5-9] 01:27AM BLOOD PT-15.9* PTT-58.5* INR(PT)-1.4* [2137-5-17] 12:59AM BLOOD PT-23.4* PTT-102.2* INR(PT)-2.2* [2137-5-22] 02:55AM BLOOD PT-30.0* PTT-28.9 INR(PT)-2.9* [2137-5-23] 03:15AM BLOOD PT-33.5* PTT-30.2 INR(PT)-3.3* [2137-5-27] 06:09AM BLOOD PT-34.5* INR(PT)-3.4* [2137-5-28] 04:56AM BLOOD PT-31.7* PTT-30.1 INR(PT)-3.1* [2137-5-29] 05:03AM BLOOD PT-27.5* PTT-28.7 INR(PT)-2.6* [2137-5-6] 04:15PM BLOOD Glucose-181* UreaN-72* Creat-4.1# Na-140 K-4.2 Cl-104 HCO3-16 AnGap-24* [2137-5-7] 02:56AM BLOOD Glucose-128* UreaN-63* Creat-3.8* Na-139 K-5.5* Cl-107 HCO3-30 AnGap-8 [2137-5-9] 01:27AM BLOOD UreaN-62* Creat-5.3# Na-140 K-4.4 Cl-105 HCO3-22 AnGap-17 [2137-5-11] 12:13AM BLOOD Glucose-147 UreaN-102* Creat-6.5* Na-143 K-5.2* Cl-102 HCO3-30 AnGap-16 [2137-5-22] 02:07PM BLOOD Glucose-116* UreaN-36* Creat-2.6* Na-139 K-4.3 Cl-103 HCO3-23 AnGap-17 [2137-5-27] 05:06PM BLOOD Glucose-95 UreaN-45* Creat-3.5# Na-140 K-3.5 Cl-102 HCO3-23 AnGap-19 [2137-5-29] 05:03AM BLOOD Glucose-111 UreaN-67* Creat-5.7* Na-142 K-3.7 Cl-103 HCO3-27 AnGap-16 Disharge Labs: [2137-6-7] 06:55AM BLOOD WBC-11.0 RBC-2.96* Hgb-9.3* Hct-27.6* MCV-93 MCH-31.3 MCHC-33.7 RDW-14.7 Plt Ct-253 [2137-6-7] 06:55AM BLOOD WBC-11.0 RBC-2.96* Hgb-9.3* Hct-27.6* MCV-93 MCH-31.3 MCHC-33.7 RDW-14.7 Plt Ct-253 [2137-6-7] 06:55AM BLOOD PT-28.4* PTT-30.1 INR(PT)-2.7* [2137-6-7] 06:55AM BLOOD Plt Ct-253 [2137-6-7] 06:55AM BLOOD Glucose-99 UreaN-22* Creat-6.1# Na-134 K-4.1 Cl-94 HCO3-28 AnGap-16 [2137-6-7] 06:55AM BLOOD Calcium-9.7 Phos-5.3* Mg-1.9 Brief Hospital Course: The patient was admitted to the Vascular surgery service on [2137-5-6] and had a Left groin exploration with left common femoral artery arteriotomy and thrombectomy of left superficial femoral artery and profunda femoris artery with bovine pericardial patch angioplasty; Left lower extremity four compartment fasciotomy. He had a dopplerable DP/PT pulse post op and throughout his hospital stay. His fasciotomy sites were primarily closed with nylon sutures once his lower extremity was no longer threatened by compartment syndrome. Those sutures were removed on POD 21. The patient had a complicated hospital course and spent 17 days in the ICU before being transferred to the floor. He was ultimately transferred to the medical service for placement of a tunneled line and initiation of long term dialysis. Neuro: Post-operatively, the patient received fentanyl and propofol until he was extubated on POD before POD 10. When tolerating oral intake, the patient was transitioned to oral pain medications. The patient was A&O x1-2 post extubation. He would become agitated during his ICU stay and was treated w zyprexa and olanzapine. His mentation improved slowly throughout his hospitalization. CV: The patient was anticoagulated postoperatively with a heparin ggt, with a goal PTT of 60-80 until POD 5. During this time coumadin was started and the heparin ggt stopped once the patient was therapeutic on his coumadin. The coumadin was continued throughout his hospitalization to prevent LE thrombosis and to prevent complications from the patient's paroxismal afib. Pulmonary: The patient was thought to have undergone an aspiration event in the OR and vanc/zosyn were started immediately postoperatively. He ended up growing E coli from his sputum and ultimately completed a course of cefepime. His respiratory status improved and his vent settings were weaned until the patient was ultimately extubated. He required supplemental oxygen throughout the rest of his hospitalization and was maintained on an aggresive pulmonary toilet. He was weaned to room air in the VICU which he tolerated well. GI/GU: Post-operatively, the patient was given IV fluids and started on TF on POD2. Due to persistent confusion TF were continued through POD 15. Once extubated the patient's diet was slowly advanced to a renal diet, which he tolerated well. He was also supplemented with Ensure boosts as his nutritional status postop was poor. Immediately postoperatively the bicarbonate was continued, a renal consult was obtained because the patient's Cr was elevated to 4.0. The renal team felt that the elevation was due to [Last Name (un) ] superimposed on chronic renal insufficiency and recommended backing off of the IVF the patient was making good urine. ON POD 2 his urine output dropped off and the patient was given 80mg of lasix with minimal effect. The patient's lasix was titrated to a goal urine output of 1-2L negative daily. Unfortunately his Cr remained elevated and he became oliguric; he was started on HD after placement of a dialysis catheter on POD 14. Dialysis was continued throughout the rest of his hospitalization and ultimately a tunneled line was placed by IR so the patient could continue dialysis as an outpatient. ID: Post-operatively, the patient was started on IV V/Z for a possible aspiration PNA. Pt grew out Ecoli and was switched to a full course og cefepime. The patient had persistent leukocytosis and loose stools during this hospitalization and blood, urine, and stool cultures were checked, all of which were negative. He was briefly given an empiric course of flagyl and his diarrhea ultimately resolved. A C diff PCR was checked and was negative and the flagyl was discontinued. Clinically the patient improved on antibiotics. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received a heparin ggt and then was anticoagulated with coumadin during this stay, he had dopplerable DP/PT pulses postoperatively and his foot while cool was not threatened. At the time of discharge, the patient was doing well, afebrile with stable vital signs, and tolerating a renal diet. He will be discharged on dialysis to a rehabilitation center for further care. Medications on Admission: - aspirin 325 mg daily - diovan 320 mg dialy - furosemide 40 mg daily - citracal - felodipine ER (? 5 or 10 mg) - allopurinol 100 mg daily - folvent - centrum - colcrys 0.6 mg 1-2 times a week - combivent - omeprazole 20 mg daily - zolpidem 5 mg PRN Discharge Medications: 1. aspirin 325 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. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for yeast . 4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO 1-2 TIMES PER WEEK (). 5. warfarin 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Flovent HFA 44 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [12-9] puffs Inhalation four times a day. 8. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO QHS. Discharge Disposition: Extended Care Facility: [Last Name (un) 39721] Health Rehab Discharge Diagnosis: Ischemic Left lower extremity Renal failure Atrial Fibrillation Discharge Condition: Good Discharge Instructions: Mr. [Known lastname 39719], it was a pleasure to help take care of you while you were in the hospital. You came to the hospital because there was an artery in your leg that was blocked. You underwent an operation to remove the obstruction. While you were here, you developed renal failure which required that you start renal replacement therapy (dialysis). You had a catheter placed to allow you to have dialysis when you leave the hospital. You also developed a pneumonia while you were on the ventilator that was treated with with antibiotics. Please follow the instructions below and follow up with your surgeon Dr [Last Name (STitle) ] within 2 weeks of discharge. MEDICATION CHANGES: - Medications ADDED: Nephrocaps 1 cap daily warfarin 0.5 mg daily miconazole powder for rash - Medications STOPPED: You no longer need to take valsartan, lasix, allopurinol, felodipine Followup Instructions: Please follow up with Dr [Last Name (STitle) ] ([Telephone/Fax (1) 10693]) within 2 weeks after discharge to make an appointment. ICD9 Codes: 5856, 5070, 5185, 5845, 2760, 4271, 2851, 4280, 412, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7422 }	Medical Text: Admission Date: [2133-4-7] Discharge Date: [2133-5-12] Date of Birth: [2071-4-27] Sex: M Service: MEDICINE Allergies: Nifedipine Attending:[First Name3 (LF) 3233] Chief Complaint: Pancytopenia Major Surgical or Invasive Procedure: Bone marrow biopsy [2133-4-7] Lumbar puncture with infusion of ara-C [2133-4-9] Lumbar puncture [2133-4-16] Lumbar puncture [2133-4-18] History of Present Illness: 61 year old man with history of Ph+ ALL s/p chemotherapy with DVA, Gleevec and s/p MUD myeloablative allo-SCT [2132-7-9] c/b GVD of liver, CMV viremia, right leg mucormycosis and aspergillus lung infections treated with ambisome/micafungin, presenting with persistent pancytopenia with concern for recurrence of disease. Patient recently admitted with RSV pneumonia treated with IVIG and empiric antibiotics. Course was complicated by seizures leading to encephalopathy, controlled with levetiracetam. Patient was seen in clinic on day of admission and found to have worsening thrombocytopenia in addition to immature cells on peripheral smear. Patient denied worsening fatigue, shortness of breath or fever. He reported abdominal pain, worse with meals, with intermittent nausea. He also complained of cough, with headache, but without rhinorrhea. Headache has been present for past 3-4 weeks occurring at night from 8-9pm. Patient denies visual changes, numbness/weakness/tingling in extremities, or sudden loss of bladder/bowel control. He received 1 unit of platelets in clinic, with improvement in counts from 12 to 57. In addition, patient had a bone marrow biopsy to evaluate for potential recurrence of disease. He was admitted for further management of pancytopenia. Review of Systems: Positive for occasional diarrhea (solid on day of admission). Chills without fever or night sweats. He denies shortness of breath or chest pain. He denies nausea, vomiting, abdominal pain or constipation. He denies dysuria, urgency/frequency of urination or hematuria. Past Medical History: ONCOLOGIC HISTORY - [2132-3-21] bone marrow biopsy c/w ALL, cytogenetic with BCR-ABL translocation - [2132-3-22] started HyperCVAD part A and imatinib - [2132-3-29] febrile neutropenia with MRSA bacteremia, multifocal PNA - [2132-4-13] repeat bone marrow biopsy with no evidence of leukemia, normal cytogenetics indicative of remission - [2132-4-18] RUE DVT at PICC site - [Month (only) 547]/[2132-6-1] IT methotrexate once weekly x 4 weeks - [2132-7-9] matched unrelated donor alloSCT with fludarabine / busulfan / ATG conditioning - [2132-10-22] liver biopsy with evidence of GVHD and infectious cholangitis, in addition, evidence of GVH of gut improved w steroids - [11/2132] aspergillus in lungs - [12/2132] right leg mucor infection (started on ambisome/micafungin) . Other Past Medical History: - Chronic kidney disease - Colon Cancer - s/p R hemicolectomy with anastomosis - Prostate cancer - Sebaceous carcinoma status post removal - Right thigh malignant mass, status post surgery - Muir-[Doctor Last Name ] syndrome - A subset of the [Doctor Last Name ] syndrome which stems from MSH2 deletion - Hypertension - Hypercholesteremia - Left ventricular hypertrophy - Hemorrhoids - ERCP on [10-17] and [10-20] for blocked CBD, s/p sphincterotomy and stent placement - VRE bacteremia on Daptomycin - CMV viremia Social History: Lives in [Location 7661] with his wife, who is his healthcare proxy. [Name (NI) ] 2 adult daughters ([Name (NI) 1356] and [Name (NI) 698]) and 5 grandchildren. Worked as saw operator cutting aluminum, not currently working due to leukemia diagnosis. No history of alcohol intake, no smoking. Denies chemical exposures. Family History: Multiple cancers in family including mother with uterine cancer, father who passed of lung cancer. One of his brothers passed of brain cancer at age 15. Another brother has [Doctor Last Name 89958] syndrome and colon cancer. One of his daughters did test positive for [Name (NI) 89959] mutation. Physical Exam: Admission Physical Exam: VS- T99.0 BP 144/82 HR 76 RR 20 O2 100% RA General- Elderly male in NAD HEENT- PERRL, sclera anicteric, no conjunctival pallor, moist mucous membranes without lesions, exudate or erythema in oropharynx. Adentulous on upper palate. No palpable lymphadenopathy CV- Irregularly irregular rhythm, normal rate, normal S1/S2, no m/r/g appreciated Pulm- Course ronchi in bilateral upper lung fields, clear to ausculation without wheezes, ronchi, rales in lower lung fields. Abd- +BS, soft, nontender, nondistended, no hepatosplenomegaly palpable Ext- Warm and well perfused, 3x3cm eschar overlying right tibial tuberosity with surrounding hyperpigmentation, no erythema or swelling. Trace pedal edema. 1+ DP/PT pulses bilaterally Neuro- Alert and oriented x 2, CN II-XII intact, strength 5/5 bilaterally in upper/lower extremities, sensation intact Access- R PICC c/d/i without tenderness or erythema Discharge Physical Exam: Patient expired during admission. Pertinent Results: Admission Labs: WBC 2.5 Hgb 10.2 Hct 29.3 Plts 12 N:32 Band:1 L:53 M:4 E:1 Bas:0 Atyps:2 Metas:3 Myelos:2 Promyel:1 Nrbc: 6 Other: 1 . 137 106 25 -------------- 4.6 21 1.5 . Ca: 9.0 Mg: 1.7 P: 4.4 ALT: 36 AST: 25 AP: 205 Tbili: 0.7 LDH: 210 . Labs [2133-5-11] - Last labs checked prior to being made CMO: WBC-2.1* Hgb-9.6* Hct-29.3* MCV-97 Plt Ct-28* Glucose-144* UreaN-89* Creat-1.9* Na-150* K-4.3 Cl-115* HCO3-25 ALT-20 AST-33 LD(LDH)-180 AlkPhos-276* TotBili-2.4* DirBili-1.8* . Microbiology: Beta glucan [4-12]- 93 pg/ml Beta glucan [4-15]- 142 pg/ml Beta glucan [4-20]- 67 pg/ml . Galactomannan [4-12]- 0.1 . Adenovirus [4-16]- not detected EBV PCR [4-16]- not detected HHV6 [4-16]- < 500 BK virus PCR [4-20]- 5824 H . CMV viral load [4-7]- CMV DNA not detected Induced sputum [4-11]- NO MYCOBACTERIA ISOLATED (PRELIMINARY) CMV viral load [4-13]- CMV DNA not detected Blood culture [4-15]- no growth Rapid respiratory viral screen [4-16]- POSITIVE FOR RESPIRATORY SYNCYTIAL VIRUS (RSV). Blood fungal/AFB culture [4-16]-negative Urine CMV, adeno [4-16]- no growth on culture, no virus isolated Urine BK virus [Numeric Identifier 89961] H Stool [4-17]- negative for NORO negative for c.diff NO CAMPYLOBACTER FOUND NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND O+P negative x 3 ([4-17], [4-20], [4-21]) C.diff PCR [4-23]- negative . CSF [4-9]: no growth, no malignant cells Chemistry Protein- 84 Glucose- 65 CSF WBC 0 RBC 2 Poly 8 Lymph 28 Mono 24 EOs Macroph- 40 Gram stain- NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN . CSF [4-16]: Protein 57 Glucose 62 WBC 2 PMN-40 Lymph-58 Mono-1 Macro-1 RBC 6050 HSV PCR- NEGATIVE Cryptococcal antigen- not detected GRAM STAIN (Final [2133-4-16]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE: no growth FUNGAL CULTURE: no fungal isolated ACID FAST CULTURE: NO MYCOBACTERIA ISOLATED VIRAL CULTURE: no virus isolated Adenovirus PCR- negative HHV6 PCR- negative EBV PCR- negative VZV PCR- not detected Toxoplasma PCR- negative [Male First Name (un) 2326] virus- negative CMV PCR- not detected . CSF [4-18]: GRAM STAIN- NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. HSV PCR- negative HHV6 PCR- negative EBV PCR- negative VZV PCR- not detected CMV PCR- negative Toxoplasma PCR- negative . Bone marrow core biopsy [4-7]- Relapsed precursor B- acute lymphoblastic leukemia MICROSCOPIC DESCRIPTION Peripheral Blood Smear: The smear is adequate for evaluation. Red blood cells are reduced in number, normochromic with anisopoikilocytosis including occasional macroovalocytes and spherocytes seen. A nucleated red blood cell is seen on scan. The white blood cell count appears decreased. Dysplastic hypogranulated and pelgeroid neutrophils are present. Occasional hypersegmented forms are seen. Large granular lymphocytes are seen. Platelet count appears decreased; large and giant forms are seen. Differential shows 50% neutrophils, 1% monocytes, 47% lymphocytes, 0% eosinophils, 1% basophil, 1% myelocytes. Rare blasts are seen on scan, particularly in the thicker portions of the smear. Aspirate Smear: The aspirate material is adequate for evaluation and consists of hypercellular spicules with sheets of blasts. Erythroid precursors are markedly decreased in number. Myeloid precursors appear markedly decreased in number. Megakaryocytes are present in markedly decreased numbers. Differential (500 cells) shows: 80% Blasts, 1% Promyelocytes, 1% Myelocytes, 1% Metamyelocytes, <1% Bands/Neutrophils, 10% Lymphocytes, 7% Erythroid. Clot Section and Biopsy Slides: The biopsy material is adequate for evaluation. It consists of a 0.6 cm core biopsy of trabecular marrow with focal aspiration artifact with an overall cellularity of 70%. There is an interstitial infiltrate of immature mononuclear cells consistent with blasts occupying 70-80% of overall marrow cellularity. These blasts are medium-sized with small amount of cytoplasm, oval to irregular nuclei with moderately fine chromatin and distinctive nucleoli. In the remaining cellularity, scant trilineage hematopoiesis is noted including occasional dyspoietic erythroids. . Imaging: CXR [4-7]- Right PIC line passes as far as the low SVC. Opacification in the juxtamediastinal region above the right hilus could be due to either mediastinal widening or a new lung lesion. It is best evaluated with conventional radiographs, including a lordotic view if deemed necessary after conventional views have been obtained. There is also a suggestion of consolidation at the right lung base medially. Left lung is grossly clear and there is no pleural effusion. Heart size top normal. . CT Chest [4-8]- 1. Slow progression right middle lobe consolidation over three months, probable low-grade infection, and a different pathogen than multiple small lung nodules, some cavitated, which have not changed over the same period of time. Middle lobe lesions should be accessible to bronchoscopic sampling from a division of the medial segment of the right middle lobe. 2. No gross evidence of malignancy, large goiter, showing less severe tracheal narrowing than previously. 3. Unexplained marrow infiltrative disorder, sternal manubrium, radiographically stable for at least a year. 4. Increased small-to-moderate layering non-hemorrhagic right pleural effusion. Stable small pericardial effusion. No evidence of tamponade. 5. Persistence but continued improvement in widespread bronchocentric infiltrative abnormality, probably viral infection, ascribed to RSV. . Transthoracic echocardiogram [4-13]- The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. 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 mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2132-12-4], no change (very small pericardial effusion was seen on prior). . CT sinuses [4-13]- There is mild to moderate mucosal thickening and aerosolized secretions in the bilateral maxillary, sphenoid, and frontal sinuses. There is also mild mucosal thickening in the ethmoid air cells. There are no air-fluid levels. There is no high-density material. There is no bony erosion or sclerosis. The nasal septum is deviated slightly to the left. The ostiomeatal units are patent. The lamina papyracea are intact. IMPRESSION: Mild to moderate mucosal thickening in all paranasal sinuses. No fluid levels, high-density material or bony erosions to ongoing infection. . Renal ultrasound [4-14]- The left kidney measures 11.5 cm. The right kidney measures 12.3 cm. There is no hydronephrosis. No renal stone identified. There is a small simple cyst in the left kidney measuring 1.4 x 1 x 1.6 cm, unchanged. The urinary bladder appears within normal limits. There is enlarged prostate roughly measuring approximately 4.5 x 4 x 4.8 cm. IMPRESSION: No hydronephrosis. Prostatic enlargement. . MRI right leg [4-14]- No significant interval change in the appearance of the bilateral calves, including the right anterior knee skin lesion. No rim-enhancing collection to suggest an abscess and no evidence of osteomyelitis. . Noncontrast head CT [4-15]- 1. No acute intracranial process. 2. Mild inflammatory disease involving the sphenoid and anterior ethmoidal air cells, and incompletely visualized maxillary sinuses, bilaterally; correlate clinically. . MRI Head [4-16]- 1. No acute abnormality seen within the brain. The previously seen FLAIR and T2 hyperintense foci in the subcortical white matter are unchanged compared to study on [2133-2-15]. 2. Sinus disease is not changed compared to CT yesterday. . 20min EEG [4-16]- This routinely acquired EEG is moderate to moderately severely encephalopathy. There is diffuse background slowing and there is more severe delta frequency slowing seen over frontal central regions. The latter activity often takes on epileptic features with sharp and spike like discharges. Those also tend to be frontal and central in their location. These are seen independently in the two hemispheres as well as in short duration bilaterally synchronous discharges. . EEG [4-17]- The recording showed often rhythmic and very persistent, approximately 2 Hz, generalized sharp wave activity throughout most of the record with brief periods of diminished sharp wave activity, as described above. The background was disorganized. The record indicates an encephalopathy throughout, but the persistent rhythmic 2 Hz sharp wave discharges. There is concern for non-convulsive seizure activity not correlated with clinical signs of seizure. The record did not change appreciably from beginning to end. . EEG [4-18]- The continuous EEG showed rhythmic generalized 2 Hz sharp wave discharges throughout most of the recording. The findings are consistent with generalized nonconvulsive status epilepticus. Nevertheless, there was no evidence of clinical seizure or convulsion. No focal abnormalities were evident. There were a few breaks of several minutes at a time when discharges were far less frequent and an encephalopathic background was more prominent. . EEG [4-19]- The recording showed rhythmic generalized 2 Hz sharp wave discharges through midnight at the end of [4-19]. There were occasional breaks for a second or two with a more slow and disorganized background even during that period. After midnight, there were longer periods of a slower disorganized background with intermittent sharp waves. The earlier parts of the recording indicate non-convulsive status epilepticus. There were shorter episodes after midnight, but the record changed to that of an encephalopathy at about 5:30 in the morning. . EEG [4-20]- The background remained slow, disorganized, and indicative of an encephalopathy throughout. There were no prominent focal findings. There were very frequent and brief periods of rhythmic, generalized sharp wave discharges. These sharp waves were usually blunted and without following slowing and were usually not so rhythmic as to suggest ongoing seizures. No definite electrographic evidence of seizure. . CT chest w/o contrast [4-21]- 1. Peribronchial inflammation, in the lower lungs, left greater than right, increased since [4-9], could be function of aspiration, but I see no pneumonia. Moderate enlarging right pleural effusion is responsible for more right basal atelectasis. 2. Chronic lung infection responsible for small cavitary nodules is unchanged, but a subacute infection responsible for a larger nodule in the right middle lobe is decreasing. 3. Chronic pericardial effusion increased slightly, now moderate in size. No evidence of tamponade. . CXR [4-25]- Right infrahilar consolidation and pleural effusion appear to be even more prominent than on the prior examination. Heart size and mediastinum are stable. Left lung is essentially clear. There is no left pleural effusion. Right pleural effusion is at least moderate. There is no pneumothorax. Narrowing of the proximal trachea due to thyroid enlargement is noted, better appreciated on the CT chest from [2133-4-21]. . CXR [4-28] - There has been interval improvement of the right lower lung consolidation and decrease in size of the right pleural effusion. No left pleural effusion is detected. No pneumothorax or new focal consolidation is seen. Heart and mediastinal contours are within normal limits. Right PICC courses along the expected location of the superior vena cava with tip likely in the region of the cavoatrial junction. Mass effect on the proximal trachea is again noted, better evaluated on prior CT. . Portable Abdomen [5-4] - No evidence of obstruction or perforation. . RUQ ultrasound [5-6] - Gallbladder is distended, contains echogenic material in its lumen and shows some mild wall thickening. Acute cholecystitis cannot be excluded. If this is a clinical concern, HIDA scan is recommended. The gallbladder distention is more pronounced compared to the previous ultrasound examination of [2132-10-20]. No dilated bile ducts. No focal liver lesion. . HIDA scan [5-6] - 1. No acute cholecystitis. 2. Chronic gallbladder dysfunction. . CXR [5-6] - Newly occurred right basal parenchymal opacity, in addition to a right pleural effusion. A reactive pleural effusion and accompanying pneumonia cannot be excluded. A wet read was delivered at the time of image acquisition. Borderline size of the cardiac silhouette. No evidence of pulmonary edema. . CXR [5-10] - Cardiomegaly, pulmonary vascular congestion and mild perihilar edema are present, the latter slightly worse compared to the prior examination. Large partially layering right pleural effusion is again demonstrated as well as a possible small left pleural effusion. Brief Hospital Course: 61 year old man with a history of Ph+ ALL s/p chemotherapy (DVA, Gleevec) and s/p MUD myeloablative allo-BMT [2132-7-9] c/b GVHD of the liver, CMV viremia, R leg mucor infection treated with ambisome/micafungin, PICC line thrombus and CKD presenting with worsening pancytopenia, found to have ALL recurrence. Patient was made comfort measures only following 1 month of admission complicated by multiple medical issues (detailed below) and expired during admission. . # Pancytopenia: Patient has had persistent pancytopenia, but CBC on day of admission was notable for worsening thrombocytopenia and immature white cells in the periphery. Bone marrow biopsy consistent with relapsed ALL with BCR-ABL translocation. See below for management. . # ALL: s/p hyperCVAD and imatinib, s/p MUD allogeneic SCT, admitted with relapse as above. Patient has had complicated course with GVHD, CMV viremia and mucor infection. Patient was started on dasatinib 100mg po daily to target BCR-ABL translocation. In addition, given headaches for several weeks and recent seizures, LP was repeated with infusion of intrathecal araC, and dexamethasone 4mg po BID. Once seizures recurred (see below), dasatanib was held. It was briefly resumed when patient became more awake and alert, but again held as mental status worsened. Given the severity of disease relapse in conjunction with multiple medical issues below, the patient's family transitioned him to comfort measures only. He expired during admission. . # Seizures: On [4-15], patient's mental status was acutely changed, with decreased responsiveness and more irritability. Keppra, which was held due to concern for myelosuppression, was restarted, and on [4-16], when the patient's mental status continued to rapidly decline, a 20 min EEG confirmed non-convulsive seizures. Underlying cause of seizures was not clear. Two LPs were performed with no clear infectious source. Nasopharyngeal RSV was positive so patient received pavalizumab, as this helped during last admission. However, patient is likely colonized with RSV, and seizures did not abate with pavalizumab administration. Patient became less responsive, and per neuro-oncology, he was titrated up on keppra, with addition of lacosamide and eventually valproic acid. Seizure activity was controlled by [4-19], as demonstrated on EEG. Patient was somnolent for several more days, and anti-epileptics were titrated off, leaving valproic acid 750mg QID at therapeutic level (80-100). Once anti-epileptics were reduced, patient slowly became more responsive and interactive. On [2133-5-5], patient again became less responsive. Valproic acid level remained therapeutic, and 24 hour EEG performed did not show further evidence of seizures. The's patient's family refused further EEG monitoring for patient's comfort. . # Upper GIB: On [5-3], the patient was transferred to the ICU for an episode of hematemesis followed by bright red blood per rectum, associated with increasing tachycardia and mild hypotension. The patient was seen by gastroenterology, but did not undergo upper endoscopsy, as decided through a goals-of-care discussion with the family. He was transfused 2 units of PRBCs, and returned to the floor. Following this episode, the patient had multiple episodes of melena, symptomatically managed with transfusion. He was also continued on a PPI drip for gastritis or stress ulcer. . # Pneumonia: As the patient's mental status declined, he suffered from a large right sided aspiration pneumonia. He began spiking high fevers, and was started on broad spectrum antibiotics. The patient was made comfort measures only during the course of his pneumonia, and antibiotics were discontinued. He passed away from fevers of 104 and dehydration in the setting of pneumonia. . # RUQ tenderness: In the setting of ongoing GI bleed and sepsis from pneumonia, the patient began to experience right upper quadrant tenderness associated with worsening LFTs in a cholestatic pattern. RUQ ultrasound and HIDA were without evidence of obstruction. Patient likely had TPN- or sepsis-induced cholestasis. Pneumonia was treated as above. TPN was continued until the patient was made comfort measures only. . # Right leg mucor infection: Stable on ambisome, with no signs of active infection, only eschars remaining. Saw general surgery as outpatient one week prior to admission who felt that debridement of eschars would increase risk of osteomyelitis. MRI performed during admission showed no inflammation to suggest extension of mucor. Patient was continued on ambisome and micafungin during admission. . # Chronic GVHD: Documented GVHD of liver and GI tract. On prednisone and budesonide. LFTs within normal limits. Prednisone was changed to methylprednisolone while patient not taking orals, and budesonide held. Stool was consistently guaiac positive with stable hematocrit. . # Chronic renal insufficiency: During previous admissions, patient has had acute on chronic injury secondary to tacrolimus/ambisome induced tubular toxicity and volume depletion. On admission, there was ongoing concern that ambisome may be worsening renal function following discontinuation of tacrolimus. Patient was continued on ambisome during this admission, and with fluid resuscitation, creatinine improved. Where possible, nephrotoxic medication was avoided. Electrolytes were repleted as necessary, as patient had potassium wasting with elevated transtubular potassium gradient. . # Cavitary lesions in lung: Stable in size over serial imaging. Likely related to mycobacterium kansaii which has been cultured from sputum repeatedly, but not treated due to significant hepatotoxicity associated with RIPE regimen + ambisome. Plan was to transition patient off of ambisome once able to take PO so that he could be treated with the RIPE regimen, but patient was transitioned to comfort measures only. . # History of PICC-associated DVT: Thrombocytopenic throughout admission. Right PICC functioned without issue. . # History of tachycardia: The patient has a history of wide complex tachycardia. On admission, the patient was off of metoprolol secondary to orthostatic hypotension, then restarted early in this admission. Patient was given 5mg IV lopressor as needed for prolonged sinus tachycardia. Late in his admission the patient had many episodes of atrial fibrillation with rapid ventricular response, treated with lopressor 5mg IV q6 hours. Medications on Admission: ALBUTEROL SULFATE 90 mcg HFA INH q4-6h PRN SOB/wheezing and 2 puffs prior to pentamidine AMPHOTERICIN B LIPOSOME 400mg IV q24h BUDESONIDE 3 mg po TOD FINASTERIDE 5mg po daily LEVETIRACETAM 500mg po BID (d/c'ed by Dr. [Last Name (STitle) ] on day of admission) LORAZEPAM 1mg po q8h prn nausea, anxiety, insomnia MAGNESIUM SULFATE 2g IV daily MICAFUNGIN 100mg IV q24h ONDANSETRON 8mg po q8 hours prn nausea OXYBUTYNIN CHLORIDE 5mg po BID prn bladder spasm OXYCODONE 5mg po q4h prn pain PENTAMIDINE 300mg INH qmonth POTASSIUM CHLORIDE 40meq IV daily POTASSIUM CHLORIDE 40meq ER po BID PREDNISONE 10mg po daily URSODIOL 300mg po BID VALGANCICLOVIR 450mg po daily DOCUSATE SODIUM 100mg po BID SENNOSIDES 8.6mg po BID prn constipation MULTIVITAMIN Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: # Recurrent acute lymphocytic leukemia, [Location (un) 5622] chromosome positive # Non-convulsive status epilepticus # Mucor infection of the right leg # Pneumonia # Gastrointestinal bleed # Chronic Graft Versus Host Disease Discharge Condition: Patient expired during admission. ICD9 Codes: 5070, 5849, 486, 5119, 5789, 2760, 2762, 2768, 2851, 5859, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7423 }	Medical Text: Admission Date: [2174-5-22] Discharge Date: [2174-6-21] Date of Birth: [2107-7-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Biliary drain placement Intubation and extubation Central line placement Radial arterial line placement History of Present Illness: 66 year-old gentleman who initially presented on [2174-5-22] from an outside hospital with a 3 day history of abdominal pain and one day history of fever. The pt. was found to have acute hepatitis and pancreatitis at the OSH. He quickly became hypotensive on the floor with systolic blood pressures in the 60s. He was started on pressors, as well as Unasyn and Flagyl for presumed sepsis. He was transferred to [Hospital1 18] for further management. On arrival at [Hospital1 18], he was started on levofloxacin and cefepime. He was intubated and sedated on HD 1 for worsening mental status and acidosis. He was found to be bacteremic with Klebsiella pnuemoniae ([5-24]). Past Medical History: -HTN -alcohol abuse -pulmonic stenosis s/p bovine valve replacement in [2127] -colon polyps s/p open excision Social History: Pt is retired and has a very large and supportive family. His daughter works on the board at [Hospital1 18]. He has a heavy etoh abuse history but did not smoke. Family History: His sister has CAD, mother had breast cancer. Physical Exam: 97.5 HR 108 BP 100/54 RR 26 %Sat 92 on 2L Gen: Tired, jaundiced, slightly labored breathing HEENT: Mild icterus bilateral, O/P dry Neck: Supple, no cervical LAD, RIJ in place, could not assess JVP due to RIJ dressing Chest: Decreased breath sounds bilaterally Cor: Tachy no rubs/m/g Abd: Soft, Distended, tender to deep palpation, no rebound and no guarding Ext: cool, trace edema bilaterally, DP/PT pulses dopplerable Neuro: A+O x 3, grossly non-focal. Garbled voice. No tremor. Pertinent Results: RUQ U/S: 1) Distended gallbladder, with pericholecystic edema and sludge. Common bile duct is not dilated; there is no biliary ductal dilatation. Findings may be consistent with acute cholecystitis, in the appropriate clinical setting. 2) Incidental note of adenomyomatosis. CT Abd/Pelvis: 1) Lack of appropriate contrast in spleen, concerning for splenic infarction or low flow state . 2) Stenotic but patent celiac axis and superior mesenteric artery. 3) Changes of chronic liver disease, with left lobe hypertrophy, chronic portal vein thrombosis, extensive vascular collateralization, and small- moderate amount of ascites. 4) Dilated gallbladder, with gallbladder wall edema, as seen on ultrasound of [2174-5-22]. Gallbladder wall edema may be due to ascites or third spacing of fluid. Repeat RUQ U/S: Transabdominal ultrasound examination was performed. The gallbladder is decompressed with cholecystostomy tube fitted in the gallbladder fossa. The common duct is not dilated and measures five millimeters. Repeat Chest/Abd/Pelvis CT: 1) Moderate bilateral pleural effusions. Nonspecific nodules within bilateral lung bases, as described above. 2) Pigtail cholecytstostomy catheter in place, with tip in gallbladder fossa. 4 mm stone remains in gallbladder neck. 3) Intraabdominal ascites, with no loculated, or drainable fluid collections. No evidence of abscess formation. 2.9 x 1.4 cm hypodense lesion within the interpolar right kidney with mild enhancement possibly a hyperdense cyst, but not clearly characterized on this study. Ultrasound may be helpful for further evaluation. 4) Sigmoid diverticulosis without evidence of diverticulitis. 5) Anasarca. EEG: This is a normal portable EEG. No lateralizing or epileptiform abnormalities were seen. Brief Hospital Course: 66y/o male with htn, etoh abuse, admitted with klebsiella cholecystitis/sepsis, complicated by a altered mental status, difficult vent wean, pancreatitis, ARF, and DIC. Mr. [Known lastname 61944] came into the hospital with Klebsiella sepsis and cholecystitis. The initial management included starting at first empiric antibiotics (then changed to meropenem once sensitivities came back), intubation for hypoxic respiratory failure, and a percutaneous gallbladder drain. His initial ICU course was marked by multiple problems, including persistent hypotension requiring pressors, difficult vent wean, acute renal failure from acute tubular necrosis, hepatitis, pancreatitis, and DIC. However, his hemodynamics improved to the point where he maintained an adequate blood pressure off pressors and he eventually self-extubated himself and did well. He remained in nearly anuric renal failure, dependent on hemodialysis, in DIC, and had delirium. Just prior to being called out to the general medicine floor, blood cultures (drawn for a low grade temperature elevation) came back with 4/4 bottles positive for gram positive cocci in pairs and clusters. His central and arterial lines were all pulled, and he was empirically started and vancomycin. He remained hemodynamically stable and did not require pressors. An surface and esophogeal echocardiograms failed to demonstrate vegetations. He did well for approximatelt 72 hours on the floor when he had a blood bowel movement, became hypotensive, and returned to the ICU. There his hemodynamics were initially stable. Concern for an active GI bleed seemed incorrect as following stools were guaiac negative and his hematocrit remained stable. However, his hemodynamic status began to decline and he was started on first norepinephrine and then vasopressin drips to support his blood pressure. Follow-up blood cultures were negative, he had no fever and but an increased WBC, ECG showed no changes. As there as concern for cholangitis/[Last Name (LF) 61945], [First Name3 (LF) ] MRCP was performed that showed a non-distended GB and was otherwise fairly unremarkable. A U/S was performed to look for ascited and a place to tap; the imaging showed moderate ascites, and a tap was performed that was grossly bloody. With concern for a possible perforation, an abdominal CT was performed that showed extensive bowel ischemia and splenic infarcts. At this point, the patient's hemodynamic status continued to decline and he was reintubated. Discussions were held with the family, who said that this course of treatment would not have been consistent with the patient's wishes and that they wanted to stop treatment and make him comfortable. This was done and the patient died soon thereafter. Discharge Disposition: Expired Discharge Diagnosis: Septic shock Klebsiella sepsis Klebsiella cholescytitis Delirium Hypoxic respiratory failure Ischemic hepatitis Pancreatitis Bowel ischemia/infarction Acute tubular necrosis Acute renal failure Hemolysis Dissemintated intravascular coagulation Secondary: Coronary artery disease Hypertension Alcohol abuse Discharge Condition: Expired ICD9 Codes: 5845, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7424 }	Medical Text: Admission Date: [2147-6-26] Discharge Date: [2147-7-1] Date of Birth: [2102-2-12] Sex: M Service: CME HISTORY OF PRESENT ILLNESS: This is a 45-year-old male with no previously diagnosed coronary artery disease, who is transferred to [Hospital1 69] from [Hospital3 418] Hospital status post acute ST elevation MI. The patient was woken up from sleep early the morning of admission by [9-19] sharp, substernal bilateral chest pain, which was associated with dyspnea, diaphoresis, and possible palpitations. The patient denies any associated nausea or vomiting. The chest pain was nonpleuritic and aside from mild right forearm tingling, did not radiate. At the outside hospital, the EKG showed ST elevations greater than 3 mm at I, aVL, V1 through V5, peaked T's anteriorly, ST depressions inferiorly, poor R-wave progression. This first set of CK and troponin-I were normal. Patient was treated with Heparin, nitroglycerin, aspirin, Lopressor and was transferred here for emergent cardiac catheterization, which revealed an 80 percent stenosis of the mid RCA, 100 percent proximal LAD stenosis, 80 percent proximal left circumflex, and 99 percent stenosis of the OM-1. The left ventricular end diastolic pressure was 31 mm Hg. The LAD was stented and intra-aortic balloon pump was placed, and the patient was enrolled in the Coil MI2 clinical trial. PAST MEDICAL HISTORY: 1. Low back pain. 2. No known diabetes, no known hypertension, no known high cholesterol. CURRENT MEDICATIONS ON TRANSFER: 1. Enteric coated aspirin 325 mg p.o. q.d. 2. Plavix 75 p.o. q.d. 3. Heparin IV drip. 4. Meperidine 25 mg IV prn shivering. 5. Integrelin drip. FAMILY HISTORY: Father: History of CVA at age 72. Mother passed away at age 62 from lung cancer. Patient has three brothers and one sister with no known history of heart disease. SOCIAL HISTORY: The patient works as a roofer. He is married and has three children. He had a one pack per day smoking history x25 years. He has a history of drinking beer, however, he states that he currently only drinks approximately [3-14] glasses of wine every two weeks or so. There is no history of illicit drug use or cocaine use. REVIEW OF SYSTEMS ON TRANSFER TO [Hospital1 18]: Negative for chest pain, dyspnea, or diaphoresis. He had no constitutional symptoms. He was breathing comfortably. He denied a history of syncope or presyncope. He had no known PND, orthopnea, or dyspnea on exertion. PHYSICAL EXAMINATION ON ADMISSION: His temperature was 36.5 C, heart rate 60-84, blood pressure 110-122/90-98, respiratory rate 10-12, and oxygen saturation 100 percent on room air. General: He is awake in bed in no apparent distress. He is calm and comfortable. HEENT: Normocephalic, atraumatic, sclerae are anicteric, pupils are equal, round, and reactive to light and accommodation. Extraocular motions intact bilaterally. Mucous membranes were moist. His oropharynx was clear. His neck was supple. He had 2 plus carotids bilaterally without bruits. His jugular venous pressure was approximately 7 cm up 45 degrees. Cardiovascular exam was regular, rate, and rhythm, normal S1, S2, no murmurs, rubs, or gallops. Chest was clear to auscultation bilaterally with good aeration. Abdomen was obese, soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly, no palpable pulsatile masses. Extremities are warm and dry without clubbing, cyanosis, or edema. He had 2 plus pedal pulses bilaterally. On his skin, a tattoo on the right upper extremity, no rashes. Neurological exam: Alert and oriented times three, speech normal. Cranial nerves II through XII are grossly intact bilaterally. Had a sheath in the right and left groin without hematoma and palpable distal dorsalis pedis pulses bilaterally. His EKG on [2147-6-26] at 11:02 a.m. showed sinus rhythm at 72 beats per minute, poor baseline artifact, anterior ST elevations less pronounced, approximately 1.5 to 2 mm. The patient underwent cardiac catheterization, which showed a normal left main coronary artery, proximally occluded LAD, a proximal 80 percent tubular lesion on the left circumflex. LABORATORIES ON ADMISSION: CK of 5109 with a CK MB of 490. In addition, the patient had a normal Chem-7 with a creatinine of 1.0 at the outside hospital with an initial CPK of 116 and MB 1.0, troponin-I of less than 0.05 at [Hospital3 418] Hospital. He had a normal hematocrit and platelet count prior to catheterization. BRIEF HOSPITAL COURSE: 1. ST elevation MI. This 45-year-old gentleman with no known history of coronary artery disease, diabetes, high cholesterol, or hypertension was transferred to [Hospital1 55251] from [Hospital3 417] with a ST elevation MI. On catheterization, he was noted to have multiple discrete lesions to the RCA, proximal LAD, and left circumflex. The patient had a stent placed in the LAD, which was felt to be the culprit lesion. Postcatheterization, the patient had an intra-aortic balloon pump placed, and was transferred to the Coronary Intensive Care Unit for ICU monitoring. The patient was continued on Heparin drip as well as Integrelin for 18 hours postcatheterization. He was also continued on aspirin and Plavix. His intra-aortic balloon pump was weaned slowly. There was discussion regarding whether the most appropriate course of care would be to perform a CABG or to repeat catheterization with stenting of the other lesions in the RCA and the left circumflex. Given that these lesions appeared to be discrete rather than long tubular lesions, a decision was made that repeat catheterization would be a favorable choice in this patient. The patient underwent repeat cardiac catheterization on [2147-6-29] with a stent to the RCA and the circumflex. The patient tolerated this procedure well without any events. The patient was transferred to the General Cardiology floor following catheterization. He did not experience any chest pain, shortness of breath postprocedure. He did have some mild right groin pain. He did not develop any significant hematomas or bleeding from his catheterization site. Postcatheterization, the patient did have three beats of NSVT. EP was consulted, and felt that given patient has had a recent large anterior myocardial infarction with three vessel intervention, that his three beats of NSVT was likely secondary to reperfusion. Dr. [Last Name (STitle) 284] recommended that the patient have an echocardiogram as well as a Holter monitor prior to following up with her [8-10] at 12:30 p.m. to help discuss possible electrophysiology study and possible ICD placement if needed. The patient was started on Lipitor 80 and Lopressor was titrated up daily for cardioprotective effects. In addition, the patient was started on lisinopril. In addition, the patient was started on Coumadin given that his post-ST elevation MI echocardiogram demonstrated the patient had a depressed ejection fraction of 25 percent with severe left ventricular systolic dysfunction and akinesis of the distal [3-14] of the heart with evidence of mild aneurysm of the apex. The patient was evaluated by Physical Therapy prior to discharge, who felt the patient was safe to be discharged home. DISCHARGE CONDITION: Stable, no further chest pain, or nonsustained VT. DISCHARGE DIAGNOSES: 1. Anterolateral ST segment elevation myocardial infarction. 2. Congestive heart failure. 3. Left ventricular aneurysm. MAJOR SURGICAL PROCEDURES: Cardiac catheterization. DISCHARGE STATUS: To home. DISCHARGE FOLLOW UP: The patient is to followup with Dr. [Last Name (STitle) ], his primary care physician to check his INR and for Coumadin adjustment. His primary care physician should also refer the patient to cardiac rehab. In addition, the patient has follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in Cardiology on [8-10] at 8 a.m. He also has a follow-up appointment on [8-21] with Dr. [First Name4 (NamePattern1) 3692] [Last Name (NamePattern1) 284] at 12:30. Finally, he has an appointment with the Holter Laboratory on [7-31] at 10 a.m. He was advised to avoid all heavy lifting or vigorous exercise. He was advised to take all medications as prescribed, and follow up with appointments listed above. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d. 3. Lipitor 80 mg p.o. q.d. 4. Toprol XL 100 mg SR q.d. 5. Warfarin 5 mg p.o. h.s. 6. Lovenox 100 mg subQ b.i.d. until INR is therapeutic. 7. Lisinopril 10 mg p.o. q.d. As previously stated, the patient will follow up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ] for followup of his INR and advice regarding cessation of the Lovenox injections and adjustment of Coumadin dosing. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [MD Number(2) 13600] Dictated By:[Last Name (NamePattern1) 10641] MEDQUIST36 D: [2147-7-2] 16:11:25 T: [2147-7-3] 11:44:54 Job#: [Job Number ] ICD9 Codes: 4280, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7425 }	Medical Text: Admission Date: [2104-2-19] Discharge Date: [2104-2-26] Date of Birth: [2050-5-8] Sex: F Service: Orthopedic HISTORY OF PRESENT ILLNESS: This is a 53-year-old Hispanic female who presents with progressive scoliosis. The patient states she has had progressive low back pain secondary to her significant thoracolumbar deformity. The patient has failed conservative care consisting of nonsteroidals, rest, and physical therapy. PHYSICAL EXAMINATION: Both lower extremities were warm and neurovascularly intact with good sensation. She had 5/5 strength throughout, with sciatica. X-rays showed a significant thoracolumbar curve, apex to the left. The patient also had significant kyphosis at the thoracolumbar junction. Considering the patient's failure of conservative care, persistent symptoms and radiographic findings the patient's best option consisted of an anterior and posterior thoracolumbar correction and fusion. The risks and benefits of the procedure were explained to the patient. The patient was in complete understanding of these risks and wished to proceed with the aforementioned surgical intervention. HOSPITAL COURSE: On [2104-2-19] the underwent an anterior T11 to L5 fusion with the use of instrumentation, allograft and autograft. The patient tolerated the procedure well. For further details of the procedure please refer to the previously dictated operative report. On postoperative day number one the patient was doing very well. She had adequate pain control. She was tolerating sips of clears. She denied any chest pain or shortness of breath. The patient's chest tube put out 90 cc of serosanguinous fluid. The patient's abdomen remained soft, nontender and nondistended with hypoactive bowel sounds. The patient's hematocrit was stable at 31.4. The patient was maintained on a patient-controlled analgesia pump for pain management. Her chest tube was continued. Her Foley catheter was continued. She was maintained on bedrest. DVT prophylaxis consisted of bilateral sequential compression devices. On postoperative day number two the patient again continued to do very well. Her pain was adequately controlled. She had moderate chest tube output. She was maintained on bedrest. The patient was subsequently prepped for the staged posterior procedure to be performed on [2104-2-21]. On [2104-2-21] the patient underwent a posterior thoracolumbar fusion with the use of instrumentation, autograft and allograft. The patient tolerated that procedure well. For further details of that procedure please refer to the previously dictated operative report. On postoperative day number one from the second procedure the patient remained intubated and was lightly sedated. She was able to move all four extremities upon command. The chest tube continued to put out 90 cc of serosanguinous fluid. Her Hemovac drain put out 120 cc. The patient was maintained on pain management consisting of an epidural. The Hemovac drain was continued, the Foley catheter was continued, her chest tube was continued. She was later extubated on postoperative day number one. Her DVT prophylaxis was maintained with sequential compression devices. On postoperative day number two the patient complained of some right hip iliac crest bone graft slight pain. She had marginal pain control. She also had a significant rash. The patient had minimal p.o. intake. The patient had no chest pain or shortness of breath. The patient did have some flatus. The patient's Hemovac drain put out 0 cc. The patient's abdomen remained soft, nontender and nondistended with positive bowel sounds. The incision was clean, dry and intact. The chest tube was removed. Chest x-ray confirmed no recurrent pneumothorax, slight atelectasis. The patient was transitioned to p.o. analgesia. She was mobilized with the TLSO and physical therapy. Her diet was advanced as tolerated. Her Hemovac drain was discontinued. Her Foley catheter was discontinued. Her DVT prophylaxis was maintained with sequential compression devices. On postoperative day number three the patient was having slight difficulty with mobilization secondary to dizziness. She continued to have no chest pain or shortness of breath. She had flatus but no bowel movement. Her rash was continuing to improve. The patient's Foley catheter was again discontinued. She was slowly mobilized with a TLSO brace. On postoperative day number four the patient was doing much better with pain control. She was eating better. She was tolerating out of bed to the chair. She was urinating without difficulty. X-rays taken showed excellent alignment and correction of her thoracolumbar scoliotic curve. On postoperative day number five the patient again continued to do very well. She was ambulating better with the use of a TLSO. She had flatus but no bowel movement. She was given one unit of packed red blood cells secondary to some dizziness with upright positioning. She was transferred to rehabilitation later on postoperative day number five. CONDITION ON TRANSFER: The patient's pain was adequately controlled with p.o. analgesia. She was eating well. She was urinating without difficulty. She was ambulating with minimal difficulty with the TLSO brace. The patient's incision showed no signs of infection, erythema or fluctuance. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: Thoracolumbar scoliosis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 3863] Dictated By:[Last Name (NamePattern1) 43183] MEDQUIST36 D: [2104-2-26] 09:15 T: [2104-2-26] 09:28 JOB#: [Job Number 43184] ICD9 Codes: 2851, 5990, 5180, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7426 }	Medical Text: Admission Date: [2192-10-12] Discharge Date: [2192-10-12] Date of Birth: [2107-9-4] Sex: M Service: NEUROSURGERY Allergies: atorvastatin Attending:[First Name3 (LF) 14802] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: This is an 85y gentleman who reportedly had a glass of wine then lost his balance and fell down two stairs and hit the back of his head. He was unresponsive and was taken to OSH in NH. There, he was fixed and dilated, flacid. He was moving his lower extremities to pain. He was intubated and CT demonstrated a large L frontal SDH and a L frontal/parietal SDH (13mm) with 8mm midline shift. There was concern for impending uncal herniation. He was transfered to [Hospital1 18] for further evaluation and treatment. Past Medical History: HTN Social History: lives at home with wife. [Name (NI) ] was a PCP [Name Initial (PRE) ] 45years now retired. Family History: non-contributory Physical Exam: PHYSICAL EXAM: GCS E: 1 V: T Motor: 4 O: T: 99.4 BP: 130/69 HR: 115 R 14 O2Sats: 100% intubated Gen: intubated sedated (on propofol) HEENT: 3cm laceration to back of head. Pupils: 4mm fixed bilaterally Neck: Supple. Lungs: scattered rhonchi bilaterally. Cardiac: tachycardic S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Abrasions anterior shins bilaterally Neuro: Mental status: intubated, sedated. Cranial Nerves: I: Not tested II: Pupils fixed and dilated 4mm bilaterally Motor: Normal bulk bilaterally. Posturing on arrival. Moves bilateral lower extremities R>L spontaneously. No movement in upper extremities. Sensation: Withdraws bilateral lower extremity to pain. Reflexes: B T Br Pa Ac Right - - - + + Left - - - + + Toes upgoing bilaterally Pertinent Results: CXR: Endotracheal tube well above the clavicles, 13 cm from the carina and should be advanced. [10-11] CT Head: IMPRESSION: 1. Expanding size of the acute on chronic left frontoparietal subdural hematoma with worsening subfalcine and transtentorial herniation. 2. Diffuse bifrontal subarachnoid hemorrhage similar to prior examination. 3. Enlarging size of the temporal horns of the lateral ventricle suggestive of developing obstructive hydrocephalus. 4. Bifrontal scalp edema, though no underlying skull fracture. [10-11] CT C-spine: IMPRESSION: No acute fracture or malalignment. [10-11] CXR: : Advancement of the endotracheal catheter to the level of the Preliminary Reportthoracic inlet. No other change from recent prior. Brief Hospital Course: Pt admitted to the ICU and was made CMO by the family. Upon arrival of other family members he was extubated per their request. The patient passed at approximately 0931. Medications on Admission: n/a Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: n/a Discharge Instructions: n/a n/a Followup Instructions: n/a Completed by:[2192-10-12] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7427 }	Medical Text: Admission Date: [2127-1-23] Discharge Date: [2127-1-28] Date of Birth: [2055-9-12] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Attending Info 87297] Chief Complaint: Dizziness, weakness, fatigue, nausea, melanotic stool Major Surgical or Invasive Procedure: 1. Endoscopy [2127-1-24] 2. Catheterization of the celiac trunk [2127-1-24] History of Present Illness: 71 year old female with arthritis, osteoporosis, history of duodenal ulcer and recently diagnosed gastric cancer initially treated with chemotherapy c/b nausea/vomiting/lower GI bleed, now presenting with melanotic stool and ten point hematocrit drop. Per the patient, she had been in her usual state of health (limited energy, but independent in ADLs at home) until this morning, when she had three bowel movements with black stool. Her stools were of varying consistency, from very hard to very soft. She did not notice any BRBPR. She sought medical care and her PCP obtained labs, which were notable for Hgb/Hct 6.7/20.0, down from 11.3/32.3 when checked in [Month (only) 359]. She may have felt some dizziness with ambulation for the last couple of days, but denied falls, lightheadedness, dyspnea, chest pain, abdominal pain, or hematuria. Per ED history, patient endorsed an episode of bloody emesis, but she denied this after arriving to the [Hospital Unit Name 153]. . In the ED, initial VS were 97.08, 92, 91/54, 18, 100% RA. Exam was notable for pale sclera and skin, and black stool on rectal exam. ECG revealed normal sinus rhythm at 88 bpm, and no ischemic changes. One unit of RBCs were transfused. A pantoprazole bolus of 80 mg, then 8 mg/hr gtt was started. The patient did not tolerate multiple attempts at NG tube placement for lavage. RBC transfusion was started at [2031]. Foley catheter was placed. GI was consulted, and recommended keeping patient NPO for EGD in AM, and transfusing RBCs for goal Hct > 25. . Per recent radiation oncology notes, the patient has also had significant short-term memory problems and a 40 lb weight loss since starting chemo. The decision was made to defer raditation treatment or further chemo, since the patient was feeling generally well and her PET scan showed general decrease in size of tumor burden. Past Medical History: Past Oncologic History: Carcinoma of GE junction, likely gastric - Presented in [6-10] with dysphagia, initial EGD showed ulcer in cardia and gastritis but no mass and biopsies then negative for malignancy. initally diagnosed in [8-10] after presenting with dysphagia. CT showed showed 5 mm RLL nodule and ulcerated gastric mass at GE junction. A CT scan of the chest, abdomen, and pelvis was performed on [2126-9-13], at [Location (un) 2274]. There was a 5 mm lung nodule noted as well as an ulcerated gastric mass within the fundus near the GE junction extending outside the lumen of the stomach measuring 4.5 x 2.8, without adenopathy. EUS revealed hypoechoic ill-defined mass and biopsy and cytology was suspicious for signet cell tumor. Based these findings, she was initiated on chemo. - She received chemotherapy starting on [2126-10-14], one cycle of EOF (epirubicin, oxaliplatin, and 5-FU). She was hospitalized for dehydration. Second cycle was held and she subsequently received a cycle of EOF on [2126-11-12]. A repeat PET scan was performed, which revealed decreased bilateral hilar and precarinal lymph node FDG uptake. Lung nodule was unchanged, decrease in the size and uptake of the gastroesophageal mass. Because the patient tolerated chemotherapy so poorly, she elected to discontinue chemotherapy at that time. She has not received any chemotherapy since the end of [Month (only) 359]. She was seen by Dr. [Last Name (STitle) ] to discuss surgical options, but thought to be a poor surgical candidate. - Lost 40 pounds since diagnosis. She also has significant short-term memory loss since initiating chemotherapy. She was having some nausea related to mucus production; however, her husband has placed her on a complimentary alternative medicine, which is derived from the mushroom growing on the bark of the white [Doctor Last Name ], which is obtained from [Country 532]. He feels that this has significantly decreased her mucus production and reduced her vomiting. She was prescribed Megace, which she is not taking. She is ambulating without difficulty and her husband says that she is much more alert and does not sleep as much as she did earlier in [Month (only) ]. Other Past Medical History: - Arthritis - per OMR, but patient denies - Osteoporosis - diagnosed many years ago, was on Fosamax, but discontinued this >1yr ago for unclear reasons - Hypercholesterolemia - per OMR, but patient denies, never been on a statin or other medication - Anxiety - Duodenal ulcer - Gastritis - Palpitations Social History: Married, originally from [Location (un) 3156]. She has 2 children, 47 yo and 36yo, who live in the US. Denies tobacco or ETOH use. Family History: Mother died of Leukemia many years ago. Her father died in [Name (NI) 3106] and she is unaware of any medical problems. [Name (NI) ] two children are healthy. Physical Exam: On admission: VS: Temp:97.7 BP:99/59 HR:83 RR:11 O2sat:100% 3L NC GEN: pleasant elderly Russian woman, appears chronically ill and weakened, comfortable, NAD HEENT: + conjunctival pallor, PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits RESP: CTA b/l with good air movement throughout CV: RRR, S1 and S2 wnl, no m/r/g ABD: Flat, NT/ND, +b/s, soft, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: Awake, alert, interactive, oriented to name, place, year, month, but cannot name the date. Cn II-XII intact. 5/5 strength in upper and lower extremities, proximally and distally. No sensory deficits to light touch appreciated RECTAL: Deferred . On discharge: Pertinent Results: ADmission Labs: [2127-1-23] 03:52PM LACTATE-1.1 [2127-1-23] 03:52PM HGB-6.4* calcHCT-19 [2127-1-23] 03:35PM GLUCOSE-130* UREA N-20 CREAT-0.4 SODIUM-135 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-23 ANION GAP-11 [2127-1-23] 03:35PM estGFR-Using this [2127-1-23] 03:35PM cTropnT-<0.01 [2127-1-23] 03:35PM CALCIUM-8.3* PHOSPHATE-3.0 MAGNESIUM-1.9 [2127-1-23] 03:35PM WBC-13.8# RBC-2.04# HGB-6.1# HCT-18.5# MCV-91 MCH-30.0 MCHC-33.0 RDW-14.1 [2127-1-23] 03:35PM NEUTS-83.3* LYMPHS-13.9* MONOS-2.3 EOS-0.1 BASOS-0.5 [2127-1-23] 03:35PM PLT COUNT-406# [2127-1-23] 03:35PM PT-13.9* PTT-36.8* INR(PT)-1.2* . Discharge Labs: . Studies: Imaging: CXR [2127-1-23]: IMPRESSION: No acute intrathoracic process. . Mesenteric study [2127-1-24]: read pending . EGD [2127-1-24]: A large ulcerated friable mass of malignant appearance was found at the gastroesophageal junction. The mass caused a partial obstruction, but the scope traversed the lesion. This was the likely source of bleeding. Normal duodenum, normal stomach Brief Hospital Course: 71 y/o F with gastric adenocarcinoma and history of duodenal ulcers, presenting with one day of black stools and dizziness, found to have ten point hematocrit drop from most recent lab work. . # Melena/anemia: Thought to be upper GIB secondary to gastric malignancy versus possible ulcer. Patient was started on IV Pantoprazole gtt and transfused PRBC X 1 unit in the ED, another 2 PRBC units were transfused in the ICU with appropriate Hct rise from 18.5 on admission to 26 post transfusion. She subsequently remained HD stable and had no significant rebleeding per stable Hct on follow-up. She underwent bedside EGD in the ICU which demonstrated a tumor in the GE junction with no signs of active bleeding and was otherwise unremarkable. Per the high risk of rebleeding from the tumor she was taken to the IR suite for attempted embolization which was unsuccessful d/t a common origin of the left gastric artery and inferior diaphragmatic arteries off the celiac trunk thus the former could not be embolized in isolation. As patient's hematocrit remained stable Heparin were started for DVT prophylaxis. She had a small guaiac positive stool on [1-26], but was asymptomatic without a significant drop in hematocrit. She was discharged on protonix 40mg [Hospital1 ] and sucralfate 1gm po qid. She was discharged with instructions and lab slip to repeat a Hct within 7 days of discharge. . # Gastric CA: She did not tolerate her cycles of chemotherapy well, and was hospitalized each time with nausea/vomiting and bloody diarrhea, thought to be complications from chemo. Since [Month (only) 359], she has been on holiday from either chemo or XRT. Surgery notes indicate that she may have metastatic disease which would preclude her from having curative surgical options. Although percutaneous feeding tubes may be of some palliative benefit, if within goals of care. She had a PET scan to assess size of gastroesphogeal mass and whether there were metatastases to determine further treatment - palliative radiation in setting of gastric mass bleeding vs. surgery or other treatment. The patient went for PET imaging the afternoon of discharge. Patient will continue to follow-up with her primary oncologist, Dr. [First Name (STitle) 2405]. . # Leukocytosis: Likely secondary to stress in setting of GIB. Remained afebrile without localizing symptoms. Was 12.2 on day of discharge. . # Code status: DNI, ok to attempt resuscitation, confirmed with the patient and her husband. . There were no labs pending on the day of discharge. Medications on Admission: Medications per the patient and her husband: NONE, except for natural supplement ([Doctor Last Name ] tree mushroom) for nausea Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [5-7] hours as needed for pain: You may buy this over the counter. Disp:60 Tablet(s) Refills:0 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 4. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:84 Tablet(s) Refills:2 5. Outpatient Lab Work Please have Hematocrit checked in 7 days from day of discharge ([2127-2-4]) and have results faxed to your Primary Care Physician. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Gastric Cancer 2. Upper gastrointestinal bleed 3. Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], It was pleasure taking care of you during this hospitalization. You were admitted because of blood loss from your gastrointestinal tract which was thought to be caused by bleeding from your gastric cancer. You were given blood to make up for your blood loss. You underwent endoscopy which did not demonstrate any active bleeding. You also underwent catheterization with the aim of stopping blood flow to the gastric tumor but this was unfortunately not achieved. Your blood counts stabilized. You are being discharged and will need to go straight to have a PET scan. . The following changes were made to your medications: START Pantoprazole 40mg Tablet, take one tablet twice daily. START Sucralfate 1mg by mouth four times daily START Acetaminophen 325mg 1-2 tablets every 4-6hours as needed for pain START Ondansetron 8mg tablet by mouth every 8 hours as needed for nausea It is important that you not take Ibuprofen, Aleve, or Aspirin, as these can cause bleeding. Followup Instructions: You will need a blood test to check your Hematocrit within 7 days of your discharge and hyave results faxed to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 6808]. . Name: [First Name11 (Name Pattern1) 2890] [Last Name (NamePattern4) ], MD Specialty: Internal Medicine When: Wednesday [2-5] at 11:40am Location: [Hospital1 641] Address: [University/College 2899], [Location (un) ],[Numeric Identifier 2900] Phone: [Telephone/Fax (1) 2115] . Name: [Name6 (MD) ] [Name8 (MD) 87300], MD Specialty: Hematology Oncology When: Thursday [1-30] at 10am Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3468] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 87298*] ICD9 Codes: 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7428 }	Medical Text: Admission Date: [2131-5-25] Discharge Date: [2131-5-30] Date of Birth: [2060-10-6] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 70-year-old male with known coronary artery disease status post coronary artery bypass grafting 11 years ago who presented with one hour of substernal chest pain, 10 out of 10 in severity. He went to [Hospital3 1443] Hospital where electrocardiogram showed acute inferior myocardial infarction. He received ................., intravenous Heparin, intravenous Nitroglycerin, and Plavix. While he was chest pain free after these interventions, he was still noted to have ST elevations on electrocardiogram. He was therefore transferred to [Hospital6 256] for cardiac catheterization. Left heart catheterization showed three-vessel disease with 80% left main, 80% proximal left anterior descending, patent ramus but subtotal circumflex occlusion, and totally occluded right coronary artery. There was a saphenous vein graft to the right coronary artery with diffuse 80% thrombosis and 80% occlusion after the posterior descending artery anastomosis. The LIMA was patent to the left anterior descending. Proximal vein graft thrombus was cleared with an export catheter, and then a stent was deployed. Attention was next turned to the distal vein graft lesion upon which an additional stent was placed. There was no residual stenosis seen, and TIMI3 flow was achieved. Right heart catheterization showed a cardiac output of 3.3 with an index of 1.63, mean wedge pressure of 12, pulmonary artery pressure of 20/9, right atrial pressure of 11. Following the procedure, the patient became bradycardiac and hypotensive requiring Atropine and Dopamine drip and was thus transferred to the Coronary Intensive Care Unit for further management. PAST MEDICAL HISTORY: Coronary artery disease, coronary artery bypass grafting in [2119] at [Hospital1 2025], mild hypertension, hypercholesterolemia. MEDICATIONS ON ADMISSION: Atenolol 50 mg p.o. q.a.m. and 25 mg p.o. q.p.m., Colestipol 5 g p.o. q.d., Zocor 20 mg p.o. q.d., Aspirin 81 mg p.o. q.d. ALLERGIES: PROTAMINE. SOCIAL HISTORY: No tobacco. No alcohol. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 96.6??????, pulse 86, respirations 22, blood pressure 104/63, oxygen saturation 98%. He was on a Dopamine and Integrilin drip. General: He was a pale, elderly male lying in bed complaining of nausea and chest pain, but he was in no acute distress. He was alert and oriented times three. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Normocephalic, atraumatic. Moist mucous membranes. Neck: JVP was not seen. Supple. No lymphadenopathy. Pulmonary: Clear to auscultation bilaterally listening only anteriorly. Cardiovascular: There was a distant S1 and S2. No S3 or S4. Regular, rate and rhythm. No murmurs, rubs or gallops. Abdomen: Soft, nontender, nondistended. Positive bowel sounds. Groin: There was a right venous sheath and a left arterial sheath. There was no hematoma. No oozing. No bruits heard. Extremities: Distal lower extremity pulses were not palpable, but dorsalis pedis and posterior tibial pulses were heard on Doppler. The feet were warm and seem well perfused. There was no clubbing, cyanosis, or edema. Neurological: Cranial nerves II-XII intact. Strength and motor was not tested. LABORATORY DATA: Sodium 141, potassium 3.8, chloride 104, bicarb 26, BUN 17, creatinine 1.0, glucose 136, CK 108, MB 9, troponin T 0.21 at the outside; CBC showed a white count of 8.9, hematocrit 47.2, platelet count 198, differential of the white count was 50% polys, 40% lymphocytes, 5% monocytes, 4% eosinophils; total protein 7.1, albumin 3.9, bilirubin 0.5, alkaline phosphatase 68, ALT 20, AST 50; INR less than 1.0, PTT 26, PT 9.9. Electrocardiogram at the [Hospital3 1443] Hospital showed ST elevations in leads II, III, and AVF. There was ST depression in leads I and AVL. There were Q-waves in leads III and AVF. There were T-wave inversions in leads II, III, and AVF, I, AVL, and V5-V6. There was frequent ectopy. After cardiac catheterization at our hospital, the electrocardiogram showed sinus tachycardia at 127 beats per minute. There was a [Street Address(2) 4793] elevation in lead II and AVF. There was [Street Address(2) 2051] elevations in lead III. There was 1-[Street Address(2) 7093] depression in leads I and AVL, with T-wave inversion in all limb leads, V5 and V6. IMPRESSION: This is a 70-year-old male with coronary artery disease and coronary artery bypass grafting 11 years ago who presented with an ST elevation myocardial infarction, who received .................. Heparin, Plavix, Aspirin, and Lopressor at the outside hospital resulting in persistent ST elevations despite becoming chest pain free. He was transferred here for cardiac catheterization and received two stents to thromboses in the saphenous vein grafts to the right coronary system. HOSPITAL COURSE: 1. Cardiac: The patient was continued on Aspirin, Plavix, and statin. Integrilin was continued for 18 hours after catheterization. Initially given the patient's hypotension, he was continued on Dopamine for approximately 36 hours to keep his mean arterial pressure above 60. He was given aggressive fluid repletion, as well as 1 U packed red blood cells for a hematocrit of 28. The Dopamine was eventually weaned off, and we initiated low-dose beta-blockade, as well as ACE inhibitor. The patient noted some orthopnea and paroxysmal nocturnal dyspnea. Although his lungs were clear, we presumed that he had become hypervolemic from aggressive fluid repletion during his episode of hypotension. We therefore initiated low-dose Lasix with improvement in his symptoms. Finally we performed an echocardiogram on hospital day #3. This showed normal left atrium, normal left ventricular wall thickness and cavity size, an ejection fraction of 40%, with inferior and inferoseptal akinesis, with normal right ventricular chamber size and wall motion. There was no mitral regurgitation or aortic regurgitation seen. We discharged the patient on low-dose beta-blocker and ACE inhibitor. These should be increased as tolerated as an outpatient. Cardiology follow-up was arranged with Dr. [First Name (STitle) 3236] at [Hospital3 1443] Hospital. Hematology: The patient was transfused 1 U of blood cells for a hematocrit of 28. Following this, his hematocrit remained stable at approximately 32. Gastrointestinal: The patient had considerable nausea with his hypotension which was treated with Zofran which provided symptomatic relief. He was also provided with Protonix for GI prophylaxis. DISCHARGE MEDICATIONS: Aspirin 1 p.o. q.d., Zocor 20 mg p.o. q.d., Colestid 5 g p.o. q.d., Plavix 75 mg p.o. q.d., Atenolol 25 mg p.o. q.d., Lisinopril 2.5 mg p.o. q.d., Lasix 20 mg p.o. q.d., this should be taken for 7 days, then stopped. Potassium, BUN, and creatinine should be checked prior to redosing Lasix. FOLLOW-UP: The patient will follow-up with his primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] and with his new cardiologist Dr. [First Name (STitle) 3236]. DISCHARGE STATUS: To home. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSIS: 1. Myocardial infarction. 2. Anemia. 3. Hypotension. 4. Status post two stents to existing saphenous vein graft. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Name8 (MD) 2734] MEDQUIST36 D: [2131-5-30] 14:37 T: [2131-5-30] 14:41 JOB#: [Job Number ] ICD9 Codes: 4019, 2720, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7429 }	Medical Text: Admission Date: [2105-2-12] Discharge Date: [2105-3-8] Date of Birth: [2027-1-11] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: Seizure disorder Major Surgical or Invasive Procedure: Cerebral Angiogram with embolization [2105-2-17] Right Craniotomy for mass resection [2105-2-18] PEG placement on [2105-2-26] tracheostomy [2105-3-5] History of Present Illness: This is a 78 year old woman who was recently on the neurosurgery service for 1 year of memory changes and approximately 3 months of short-term memory decline. She was discovered to have a right spenoid [Doctor First Name 362] meningioma with surronding edema. She was discharged to a rehab facility on [2-5] with plan to return for elective a craniotomy on [2-18]. She then presented to our ED from [Hospital 1319] rehab for decreased movement of her left upper extremity and concern for seizure activity. For 3 days, her son noted that she was not moving the left side of her body and that she had a right gaze preference. Nursing staff felt that she was seizing as well and was not responsive to the examiner. She was sent to [Hospital1 18] for further evaluation. Past Medical History: hypercholesterolemia, basal cell CA removal from Bilateral UE's, bilateral cataract surgery, colon adenoma s/p biopsy Social History: She stopped smoking 35 years ago. She has not had alcohol in years. She has 3 sons and a daughter. She lives alone. She does not drive. Family History: No Ca history Physical Exam: On Admission: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRLA EOMs Unable to track to left side Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech slurred with good comprehension Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light. Visual fields are full to confrontation. III, IV, VI: Right VI nerve palsy 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 [3-26] throughout RUE. Moves left side with good strength but slightly weaker when compared to right. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. On Discharge: Eo to noxious, no commands, localizes briskly with RUE, w/d's bilateral LE R>L, no response to noxious LUE. Pupils [2-22] and brisk Pertinent Results: [2-12] Head CT: IMPRESSION: Known extra-axial right sphenoid [Doctor First Name 362] lesion, likely meningioma, similar in appearance to the prior study. Extensive vasogenic edema in the right cerebral hemisphere, and mass effect, unchanged. No evidence of brain herniation or intracranial hemorrhage. [2-13] EEG: IMPRESSION: This is an abnormal routine EEG, due to the presence of two isolated right posterior frontal epileptiform discharges, suggesting a focal area of potential epileptogenesis. In addition, the presence of more focal left temporal slowing suggesting a region of subcortical dysfunction, while the slow background is consistent with a mild encephalopathy, though it could also be seen in a patient with extensive and bilateral subcortical lesions such as can occur with vascular white matter disease. [2-18] MRI: IMPRESSION: Limited post-contrast MRI images obtained for surgical localization of an extra-axial mass consistent with left sphenoid plane meningioma. [2-18] CT head: Right-sided pneumocephalus with a small subdural hemorrhage causing leftward shift of the normally midline structures by 4 mm. Hypodense appaearance of the right medial temporal lobe and absal ganglia- may relate to edema from recent surgery, tumor or ischemia. Correlate with MR if necessary and not CI. [2-18]: MRI Brain: Limited post-contrast MRI images obtained for surgical localization of an extra-axial mass consistent with left sphenoid plane meningioma. [2-19] MRI Brain 1. Status post partial resection of right middle cranial fossa meningioma. 2. Acute ischemia in the right posterior MCA territory. [2105-2-20] ECHO The TEE probe could not be passed into the esophagus due to mental status, agitation, and marked hypertension in the setting of stroke and recent craniotomy. [2105-2-20] CTA head and Neck 1. Evolving right MCA infarction. 2. Persistent irregularity of the right supraclinoid ICA and proximal MCA. 3. Increased focal narrowing at the bifurcation of the right supraclinoid ICA which is more narrow compared to preoperative CTA. 4. Relative narrowing of the distal MCA suggestive of low flow or spasm. [2105-2-21] CT head Evolving right MCA infarct, with right frontotemporal post-surgical changes. There has been slight increase in midline shift, however, the ventricles remain unchanged in size. [2105-2-22] CT head IMPRESSION: Post-surgical changes of right frontal craniotomy, with residual trace extra-axial hemorrhage and evolving right MCA infarct resulting in continued 8 mm leftward shift, subfalcine herniation, and minimally increased crowding of the basal cisterns. [3-2]: Echo 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. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No cardiac source of embolism identified. Mild mitral regurgitation with mildly thickened leaflets. [3-3]: LENIs Normal bilateral Doppler ultrasounds of both lower extremities. No evidence for DVT. Brief Hospital Course: This is a 78 year old woman who was previously seen by the neurosurgery team for mental status changes and menory issues and was diagnosed with a right sphenoid [Doctor First Name 362] meningioma and she was sent to rehab with plans to reurn for resection on [2105-2-18]. She was thought to have seizure activity and left sided weakness at the facility and she was transfered to the ED on [2-12] and admitted by the Neuromedicine team. On [2-13] the patient was noted to have left neglect and was hemiparetic in the left upper extremity. She was started on dilantin per neurology rec's and an EEG was ordered. She also had a speech and swallow evalaution which she failed and was made NPO including oral medications. On [2-14] her dilantin level was 15.9 and she was noted to have right frontal seziures. On [2-15] she was transferred to the SDU for closer observation and a nutrition consult was ordered after placement of a dobhoff. The dobhoff was removed after it coiled in the esophagus after multiple repositionings. She was scheduled to have a cerebral angiogram with embolization on [2-17] with subsequent OR on [2-18] for resection of her meningioma. She underwent a diagnostic cerebral angiogram on [2-17] which revealed severe narrowing of the right ICA & ACA due to tumor compression. ACA and MCA territories were being filled from the left ICA/posterior circulation. All blood flow to the tumor is via small vessels that were not amenable to embolization. Therefore no intervention was performed. On [2-18] replacement of the NG tube was again attempted but CXR confirmed cioling in the distal esophagus. She was taken to the operating room and underwent a pteroneal craniotomy and subtotal resection of the meningioma. Surgery was without complication. She was extubated and transferred to the ICU. Post op head CT revealed no hemorrhage. On [2-19] the patient remained on a facemask and was not following commands. MRI brain was requested. She continued on decadron 4mg q6hrs and dilantin and keppra for seizure prophylaxsis. Dobhoff tube placement was requested under fluorscopy guidance. On [2-20], patient exam remained unchanged. Dilantin was 11.1 and she was given a 500mg bolus of dilantin and her daily dose was increased to 200mg TID. Neuro stroke requested CTA head and neck as well as a HA1C, lipid panel, blood cxs, and TEE. Her steriods were weaned and EEG was placed. On [2-21] she had a CT showing evolving infarct and mild worsening of her MLS. She remained stable. Mannitol was started with NA and Osm checks and CT [2-22] showed no change in infarct or MLS. She continued in the ICU with EEG leads on and her exam remained stable on [2-23]. Her mannitol began to be weaned to off and her Decadron was written to be weaned to 2mg [Hospital1 ]. EEG was showing breakthrough seizures on [2-23] and Keppra was increased. By [2-25] no further seizures were noted and EEG was discontinued. On 4.7 she remained stable and was intubated for placement of her PEG, which she received. On [2-27] a family meeting was held and patient was extubated after her PEG placement, but was subsequently reintubated on [2-28] when she had difficulty managing her secreations on [2-28]. On [3-2], a trans esophogeal echo was done which did not reveal any vegitations. On [3-3], A bedside tracheostomy was attempted but pulsatile vessel was noted anterior to trachea and the procedure was aborted and ACS team anticipated trach inthe OR. LENIS were negative for DVT [3-4]: Ms [Name13 (STitle) 39798] was hypertensive episodes and received both hydralazine and lisinopril. OR trach was not performed. [3-5]: Ms. [Name14 (STitle) 39798] was febrile overnight and blood cultures sent off. During the day she had a tracheostomy placed. [3-6]: On exam she was slightly brighter with improved eye opening [3-7] patient was trialed off of vent on trach mask for 8 hours, was accepted to vented rehab at [Hospital1 ] with plan for discharge on 4.17 [3-8] patient was again trialed on trach mask with good results. her lone peripheral IV was found to be infiltrated so a new peripheral was placed and she recieved a PICC line. Following this she was discharged to rehab in the afternoon Medications on Admission: Keppra 1 [Hospital1 ], Decadron 4mg q6, Dilantin 400mg q8, protonix 40 daily, simvastatin 40mg daily Discharge Medications: 1. acetaminophen 325 mg Tablet [Hospital1 ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 5. heparin (porcine) 5,000 unit/mL Solution [Hospital1 ]: 5000 (5000) units Injection TID (3 times a day). 6. insulin lispro 100 unit/mL Solution [Hospital1 ]: One (1) Subcutaneous ASDIR (AS DIRECTED). 7. glucagon (human recombinant) 1 mg Recon Soln [Hospital1 ]: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 8. aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 10. levetiracetam 100 mg/mL Solution [Last Name (STitle) ]: Fifteen (15) ml PO QHS (once a day (at bedtime)). 11. levetiracetam 100 mg/mL Solution [Last Name (STitle) ]: Ten (10) ml PO QAM (once a day (in the morning)). 12. magnesium hydroxide 400 mg/5 mL Suspension [Last Name (STitle) ]: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Last Name (STitle) ]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 14. nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ml PO QID (4 times a day). 15. miconazole nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 16. metoprolol tartrate 25 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 17. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [Hospital1 ]: [11-23] Puffs Inhalation Q4H (every 4 hours). 18. lisinopril 5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 19. ferrous sulfate 300 mg (60 mg Iron) Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 20. Ondansetron 4 mg IV Q8H:PRN nausea 21. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 22. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 23. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 24. HydrALAzine 5 mg IV Q6H prn sbp>160 25. Phenytoin Sodium (IV) 200 mg IV Q8H Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: Seizure Disorder Right sphenoid [Doctor First Name ] meningioma CVA Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Medications: ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! ?????? Have a friend/family member check your incision daily for signs of infection. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. Followup Instructions: ??????You will have a follow-up appointment in the Brain [Hospital 341] Clinic on [3-23] at 3pm. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 5074] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain Completed by:[2105-3-8*] ICD9 Codes: 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7430 }	Medical Text: Admission Date: [2198-11-22] Discharge Date: [2198-11-28] Date of Birth: [2136-3-16] Sex: F Service: MEDICINE Allergies: Latex Attending:[First Name3 (LF) 7055] Chief Complaint: Elective cardiac catheterization Major Surgical or Invasive Procedure: Cardiac Catheterization [2198-11-22] R femoral artery pseudoaneurysm repair [2198-11-23] IVC filter placement [2198-11-25] History of Present Illness: Ms. [Known lastname 1924] is a 62 year-old woman with a history of CAD s/p NSTEMI in [9-25] who presented for catheterization on [11-22] and who is now being transferred given worry for hematoma and bleeding. . After NSTEMI in [9-25], she underwent cardiac catheterization which a 90% stenosis of the LMCA and a 70% proximal RCA lesion. On [2197-10-20] she underwent CABG x 3 with a LIMA to the LAD, SVG to the OM and SVG to the RCA. Post operatively she had atrial fibrillation and was started on Amiodarone. In addition she developed a MRSA sternal wound infection/high grade MRSA bacteremia and on [2197-11-25] she underwent exploration of the sternal wound and sternal debridement. Two days later she underwent sternal debridement and bilateral pectoralis flaps. . Approximately 6 months prior to admission, she began to notice that 4-5 minutes into her walks she would have to stop because she was gasping for breath. She has also noticed similar symptoms while doing her water aerobics, at times with associated chest discomfort. . A stress test was done on [2198-11-13] and revealed apical ischemia and septal hypokinesis with an LVEF of 61%. Given this, she was referred for cardiac cath. On [2198-11-22] she underwent cath which showed patent grafts. A POBA was done to the LAD. . Post-cath she had a failed mynx with pressure held. At approximately 6pm, she moved her right leg and felt an acute onset of groin pain. She was given a percocet, after which she felt nauseated. After evaluation by the interventional fellow, decision was made to transfer her to the CCU for observation. . On review of systems, she reports a history of prior [Date Range ] in [2182] at which time she experienced left facial numnbess/tingling. No interventions were performed and this has not recurred. Also reports bleeding after a tubal ligation when she was 25 year-old. She denies any deep venous thrombosis, pulmonary embolism. . She has chronic joint pains, mostly in her knees and elbows. Denies any hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. Reports 20 pound weight gain over last 3 months; for this she was evaluated for hypothyroidism and started on replacement. All of the other review of systems were negative. . Cardiac review of systems is notable for absence paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes (+)Dyslipidemia (-)Hypertension . 2. CARDIAC HISTORY: -CABG ([2197-10-20]): LIMA -> LAD; SVG -> OM1; SVG -> RCA -PCI ([2197-10-17]): LMCA 90% lesion -- no interventions -PACING/ICD: None . 3. OTHER PAST MEDICAL HISTORY: - Remote [Month/Day/Year ] - History of MRSA/bacteremia requiring debridement/flap - Chronic mid sternal chest pain related to prior chest surgeries - GERD - Hypothyroidism - Anxiety/Depression - Arthritis - Recurrent small bowel obstructions due to adhesions requiring multiple surgeries - History of TAH/BSO - History of Laminectomy - History of Resection of pilonidal cyst - History of Cholecystectomy - History of Hernia repair Social History: - Married with four children. - Lives with: husband and daughter in [Name (NI) ] - Occupation: retired; previously worked as a secretary in a [Location (un) 86] school - ETOH: Several glasses of wine per night - Tobacco: Quit in [2196] after 50 pack-years Family History: Brother had CABG in his 40??????s. Father had a stroke at age 58. Physical Exam: VS: BP=110/57 HR=80s RR=16 O2 sat=99% on room air GENERAL: Lying in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Prior sternal wound noted but well-healed. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft. Is TTP over right groin with extension into lower pelvis and to midline. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: Laboratory studies: [2198-11-22] 06:44PM BLOOD Hct-34.9* Plt Ct-240 [2198-11-23] 03:07AM BLOOD WBC-5.7 RBC-3.32* Hgb-10.3* Hct-29.5* MCV-89 MCH-31.1 MCHC-35.1* RDW-12.8 Plt Ct-224 [2198-11-23] 11:24PM BLOOD WBC-6.1 RBC-2.78* Hgb-8.7* Hct-25.1* MCV-90 MCH-31.4 MCHC-34.8 RDW-13.5 Plt Ct-162 [2198-11-25] 04:21AM BLOOD WBC-4.7 RBC-2.41# Hgb-7.4# Hct-21.5* MCV-90 MCH-30.8 MCHC-34.4 RDW-13.8 Plt Ct-170 [2198-11-26] 10:06AM BLOOD WBC-5.9 RBC-3.57# Hgb-11.3# Hct-30.7* MCV-86 MCH-31.6 MCHC-36.7* RDW-14.7 Plt Ct-165 [2198-11-28] 07:30AM BLOOD WBC-5.4 RBC-3.67* Hgb-11.4* Hct-32.1* MCV-87 MCH-31.0 MCHC-35.5* RDW-14.6 Plt Ct-255 . [2198-11-23] 03:07AM BLOOD PT-12.4 PTT-23.9 INR(PT)-1.0 [2198-11-25] 04:21AM BLOOD PT-13.1 PTT-58.2* INR(PT)-1.1 . [2198-11-23] 03:07AM BLOOD Glucose-105 UreaN-14 Creat-0.7 Na-139 K-4.0 Cl-107 HCO3-26 AnGap-10 [2198-11-28] 07:30AM BLOOD Glucose-101 UreaN-12 Creat-0.6 Na-139 K-4.1 Cl-104 HCO3-26 AnGap-13 [2198-11-24] 08:14AM BLOOD Glucose-62* UreaN-10 Creat-0.5 Na-138 K-3.7 Cl-106 HCO3-25 AnGap-11 . [2198-11-23] 03:07AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.9 [2198-11-23] 11:24PM BLOOD Calcium-6.7* Phos-1.8# Mg-1.5 [2198-11-28] 07:30AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.7 [2198-11-24] 08:14AM BLOOD Albumin-3.3* Calcium-7.3* Phos-2.2* Mg-1.8 . [2198-11-22] 06:44PM BLOOD CK(CPK)-61 . [2198-11-28] 06:21AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.005 [2198-11-28] 06:21AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG Microbiology: Nasal MRSA screen negative; BCx pending at time of discharge. Imaging/Studies: Cardiac Catheterization [11-22]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent LIMA and SVG's. 3. Moderate left ventricular diastolic dysfunction. 4. Moderate systemic arterial hypertension. 5. Successful POBA to the distal LAD (immediately post anastomosis) via LIMA. 6. Failed attempt to delived a Mynx closure device to the RCFA. . ECG [11-22]- Sinus bradycardia. Baseline artifact. Non-specific anterior T wave changes. Compared to tracing #1 artifact is new. TRACING #2 Read by: [Last Name (LF) 2889],[First Name3 (LF) 2890] K. Intervals Axes Rate PR QRS QT/QTc P QRS T 54 158 86 446/435 69 -4 88 . CT pelvis/abdomen [11-22]: . IMPRESSION: Moderately large hematoma centered primarily anterior to the bladder, likely with a predominantly intraperitoneal location, also extending into and expanding the right rectus sheath. . ECG [11-23]: Sinus rhythm. Anterolateral ST-T wave changes. Consider myocardial ischemia. Compared to tracing #2 the ST-T wave changes are more pronounced and the baseline artifact is absent. TRACING #3 Read by: [Last Name (LF) 2889],[First Name3 (LF) 2890] K. Intervals Axes Rate PR QRS QT/QTc P QRS T 62 146 88 [Telephone/Fax (2) 100535]12 . [11-23] CT abdomen/pelvis: . MPRESSION: Compared to the study done one day earlier, there has been some improvement in the size of the hematoma within the space of Retzius no new suspicious areas identified i.e., no findings to explain this patient's continued hematocrit drop. . Vascular u/s [11-23]: IMPRESSION: 1. 2.2-cm pseudoaneurysm of the right common femoral artery at the site of puncture. Neck difficult to measure but thought to be very small on the order of [1-21] mm. 2. Right common femoral vein thrombosed near the site of puncture. . U/S LE [11-24]: IMPRESSION: 1. Focal thrombosis of the right common femoral vein as identified on US from [2198-11-23]. 2. No left leg DVT. . CT abdomen/pelvis [11-25]: IMPRESSION: Slight interval increase in size of a hematoma in the space of Retzius associated with a femoral vascular catheter, with increased retroperitoneal component and extension into the right inguinal region. . ECG: . Sinus rhythm. ST-T wave abnormalities with predominantly T wave inversions in the anterolateral leads. Since the previous tracing of [2198-11-24] atrial premature beat is no longer present. Read by: [Last Name (LF) ],[First Name3 (LF) 900] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 74 150 92 396/420 -7 -5 158 Brief Hospital Course: 62 year old woman with known CAD, s/p CABG for severe LM disease, complicated by a MRSA sternal wound infection/bacteremia, who presented for an elective cardiac catheterization (due to recent exertional symptoms and an abnormal ETT) and eventually transferred to the CCU given concern for post-catheterization bleeding. . # HEMATOMA. A failure of the mynx device to deploy during closure s/p cath occured. The sheath was reportedly pulled w/o complications. Post procedure HCT was found to drop from 34 to 29 and a CT pelvis was performed, a 6cm x 8cm pelvic hematoma with no RPB. Patient was thus transferred to CCU for further care. HCTs were checked Q4H. Pt received 2U PRBCs and there was no improvement in HCT. A repeat CT showed no change. Given no response to transfusion and worsening groin pain, in consultation w/ vascular team, it was agreed that exploration of the groin was appropriate. An U/S of R femoral A/V was performed showing 2.2-cm pseudoaneurysm of the right common femoral artery near the site of puncture for catheterization as well as suspicion for a R femoral vein DVT. Plavix was stopped. A pseudoaneurysm repair was performed on [11-23], successfully. A Right femoral DVT was confirmed w/ LENI and heparin gtt was started. With this, HCT began to drop, minimum of 21. A repeat CT showed slight interval increase in size of a hematoma with increased retroperitoneal component and extension into the right inguinal region. At this time a decision with vascular, CCU teams and patient was made to place an IVC filter and d/c heparin. IVC filter was placed on [11-25] and heparin was d/c. Patient received an additional 4 units of blood over next 48hours. HCT eventually stabilized at ~ 30 and patient did not require further transfusions. She remained relatively hemodynamically stable througout this time, with minimum BPs reaching 85mmHg systolic temporarily during dropping HCTs. Episodes of hypotension were asymptomatic. BBK at this time was held. Patient was maintained at bedrest until [11-27]. Hematoma was stabilized w/ above management and HCT at time of discharge was 32. . # CAD: Known 3VD with prior CABG. After ETT showed apical ischemia and a hypokinetic septum, performed for progressive dyspnea, underwent cardiac cath which showed three vessel coronary artery disease, patent LIMA and SVG's, moderate left ventricular diastolic dysfunction and moderate PAH. She underwent POBA to distal LAD. See above for failed mynx device closure complications. She was continued on ASA. BBk was temporarily withheld during episodes of hypotension. Plavix was discontinued as pt. did not have a stent in place and had developed a hematoma. Simvastatin was continued. She was discharged home on ASA, Simvastatin and metoprolol 25mg [Hospital1 ]. These doses should be optimized by outpatient cardiologist upon follow up. Patient did not have chest pain, SOB or other angina equivalent throughout hospitalization. # CHF: EF of 60% on MIBI done last month, 40-50% on Echo from [2196]. Pt. was not in HF throughout hospital stay. . # HYPOTHYRODISIM. Pt. was continued on home regimen of Levothyroxine. . FEN/PPx. Pt. received cardiac diet, pain managment with tylenol PRN and a bowel regimen. . CODE: Confirmed as DNR/DNI; discussed with patient at time of transfer Patient was discharged home in a hemodynamically stable condition, w/ stable HCT and appropriate followup. Contact person upon discharge: [Name (NI) ] [Name (NI) 1924] (husband): [Telephone/Fax (1) 100536] Medications on Admission: 1. Aspirin 81mg daily 2. Simvastatin 40mg daily 3. Metoprolol Succinate 100mg daily 4. Levothyroxine 25mcg daily 5. Fosamax 70mg every Monday 6. Omeprazole 20mg daily 7. Colace 100mg daily 8. MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week: Every Monday. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO once a day as needed for constipation: as needed . Disp:2 bottles Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Coronary artery disease 2. R femoral artery pseudoanerysm 3. R common femoral vein DVT 4. R groin hematoma 5. Retroperitoneal Bleed Secondary Diagnoses 6. Hypothyroidism 7. Depression 8. Hypercholesterolemia 9. GERD 10. Osteoporosis Discharge Condition: Afebrile, hemodynamically stable, hematocrit stable Discharge Instructions: You were admitted to the hospital for cardiac catheterization. After the catheterization you had a hematoma of the right groin. A pseudoaneurysm was seen in the right femoral artery as well as a blood clot in the common femoral vein. You were put on heparin to thin your blood. You had the pseudoaneurysm repaired on [2198-11-23]. You had continued bleeding after this surgery and were found to have bleeding into your thigh and abdomen. You required 6 units of blood in total. You had an IVC filter placed on [2198-11-25] to prevent the blood clot from traveling into your lungs. The heparin was stopped and you had no further bleeding and blood counts were stable. You should follow-up with your cardiologist and PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 10543] in the next 1-2 weeks. You should also follow up with Dr. [Last Name (STitle) 1391] as listed below. You should return to the hospital or seek medical attention with any fevers > 101.4, chills, night sweats, chest pains, shortness of breath, fast breathing or heart rate, sudden onset of dizziness or weakness, arm or jaw numbness, abdominal pain, bleeding in your bowel movements, increased pain, swelling or discoloration of your right thigh or groin, or any other symptoms that concern you. Followup Instructions: You should follow-up with your PCP and cardiologist, Dr. [Last Name (STitle) 10543] in the next week. Please follow up with Dr. [Last Name (STitle) 1391], your surgeon, on [12-3], 9am at [Doctor First Name ], suite 5C in [Last Name (un) 2577] Building at [Hospital1 18], [2197] for staple removal and evaluation of wound. Please call ([Telephone/Fax (1) 4852] with any question. Completed by:[2198-11-30] ICD9 Codes: 2851, 4280, 2449, 311, 2720, 412, 4019, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7431 }	Medical Text: Admission Date: [2143-12-27] Discharge Date: [2143-12-30] Date of Birth: [2085-8-19] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old gentleman with a history of hypertension who presented to [Hospital3 1280] Hospital with a complaint of substernal chest pain and was subsequently found to have transient ST elevations in leads I, aVL, and V2 which resolved after medical therapy; with included aspirin, nitroglycerin, beta blocker, heparin, and Integrilin. At the outside hospital, the patient had a troponin I of 6 and a creatine kinase of 500 to 600. At [Hospital3 1280] Hospital, the patient was taken to the Catheterization Laboratory where trivial serial 90% lesions in the left anterior descending artery and 80% lesions in the right coronary artery were noted. The patient had an intra-aortic balloon pump placed at [Hospital3 1280] Hospital secondary to refractory chest pain and was subsequently transferred to [Hospital1 188] for intervention. PAST MEDICAL HISTORY: 1. Hypertension. 2. Obstructive sleep apnea. 3. Hypothyroidism. 4. Mood disorder. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: (Homes medications included) 1. Celexa 20 mg by mouth once per day. 2. Adderal. 3. Doxazosin. SOCIAL HISTORY: The patient lives with his wife. [Name (NI) ] has a remote tobacco history. He quit smoking 20 years ago. Occasional alcohol use. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient's heart rate was 71 and his blood pressure was 112/74. Head, eyes, ears, nose, and throat examination revealed the oropharynx was clear with moist mucous membranes. Neck examination revealed no jugular venous distention. Cardiovascular examination revealed a regular rate and rhythm. No third heart sound or fourth heart sound. No murmurs. The lungs were clear to auscultation anterolaterally. The abdominal examination was benign. Extremity examination revealed right groin with an intra-aortic balloon pump. No peripheral edema. Dorsalis pedis and posterior tibialis pulses were 2+ bilaterally. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed complete blood count with a white blood cell count of 9.3, his hematocrit was 41.2, and his platelets were 292. The patient's potassium was 4, his blood urea nitrogen was 21, and his creatinine was 0.9. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram, status post percutaneous coronary intervention at [Hospital1 190], revealed a normal sinus rhythm at 68. No ST depressions. There was a 0.5-mm to 1-mm ST elevations in leads I, aVL, and V2 through V4. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. CARDIOVASCULAR ISSUES: (a) Coronary artery disease: The patient was taken to cardiac catheterization which revealed (1) focal medial left anterior descending artery lesion of 90%; (2) tubular distal left anterior descending artery lesion of 90%; and (3) distal right coronary artery lesion of 80%. The patient had percutaneous coronary intervention with drug-eluting stent to both of the left anterior descending artery lesions. The distal right coronary artery lesion was intervened upon at this time. Following the procedure, the patient was chest pain free; however, the intra-aortic balloon pump was left in place, and the patient was transferred to the Coronary Care Unit for further monitoring. The patient did well following the procedure and the intra-aortic balloon pump was removed on the following day. The patient remained chest pain free throughout his stay. The patient's creatine kinase peaked at 617. The patient was to have an outpatient stress test for further evaluation of his 80% right coronary artery lesion. (b) Pump: The patient had transthoracic echocardiogram which revealed left ventricular size, an ejection fraction of greater than 55%, and no clear wall motion abnormalities. (c) Rhythm: The patient remained in a normal sinus rhythm throughout his stay. 2. PULMONARY ISSUES: The patient was continued on his home [Hospital1 ]-level positive airway pressure for obstructive sleep apnea. 3. RENAL ISSUES: The patient's creatinine remained stable status post dye load, and his creatinine was 1.1 at the time of discharge. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. The patient was chest pain free and did not require supplemental oxygen. DISCHARGE STATUS: The patient was to be discharged to home. DISCHARGE DIAGNOSES: 1. Anterior ST-elevation myocardial infarction; status post percutaneous coronary intervention with drug-eluding stent of the left anterior descending artery times two. 2. Obstructive sleep apnea. 3. Hypertension. 4. Mood disorder. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg by mouth once per day. 2. Plavix 75 mg by mouth once per day. 3. Lipitor 10 mg by mouth at hour of sleep. 4. Atenolol 50 mg by mouth once per day. 5. Lisinopril 5 mg by mouth once per day. 6. Doxazosin 0.5 mg by mouth at hour of sleep. 7. Celexa 20 mg by mouth once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to call Dr. [Last Name (STitle) 1295] to arrange appropriate followup. 2. The patient was recommended to have an outpatient stress test for evaluation of the 80% right coronary artery lesion. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], M.D.12.932 Dictated By:[MD Number(1) 97170] MEDQUIST36 D: [2144-1-1] 12:03 T: [2144-1-1] 12:14 JOB#: [Job Number 97171] ICD9 Codes: 2449, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7432 }	Medical Text: Admission Date: [2103-10-16] Discharge Date: [2103-10-18] Date of Birth: [2072-5-28] Sex: M Service: CHIEF COMPLAINT: Coffee ground emesis. HISTORY OF PRESENT ILLNESS: This is a 32-year-old man with multiple comorbidities including end-stage renal disease secondary to type 1 diabetes mellitus since age two, and has been on hemodialysis since [2098]. The patient also has vascular access thrombosis and is currently on anticoagulation. The patient is here with 24 hours of worsening coffee ground emesis, weakness and abdominal pain. The symptoms began at 6 PM on [2103-10-15] with vomiting, diarrhea (watery without mucus or blood), poor appetite, leg cramps and abdominal pain. These symptoms have been present for the past month or so but have intensified over the last 24 hours. The mother reports three to four similar episodes in the past, but none have been as debilitating as this one. The patient reports two episodes of nonbloody emesis yesterday, today dark emesis, two large emesis episodes in the Emergency Department of about 500 cc each. The mother reports variable sugar levels this morning; 6 AM was 476, 10 AM 38, 12 PM 18. The patient reported chills and weight loss. He denied any use of aspirin or ibuprofen, any fevers, shortness of breath, chest pain, palpitations, change in vision or history of irritable bowel syndrome or gallbladder disease. He reports prior alcohol use but would not specify quantity. He denies history of cirrhosis, history of gastric ulcers or varices. EMERGENCY DEPARTMENT COURSE: He was brought to [Hospital1 346] by ambulance this afternoon at around 2 PM. He was initially hemodynamically stable and had two large episodes of emesis, 500 cc each, with coffee grounds and his blood pressure decreased to 70s/50s and his heart rate was in the 120s. A femoral line was placed and the patient refused a nasogastric tube. He was resuscitated with intravenous fluids, one unit of packed red blood cells and one unit of fresh frozen plasma. Just before transfer to the coronary care unit he had another large episode of emesis greater than 600 cc. He was brought to the coronary care unit, stabilized there and he continued to have diarrhea. Prior information from the [Hospital1 756] where he is normally seen shows his last admission there was in [2103-9-16] for diabetic ketoacidosis. He has also had prior admissions for pancreatitis. In [3-17] he had an admission for colitis/coffee ground emesis with a flexible sigmoidoscopy and a colonoscopy which revealed erythematous patches in the descending colon. He had a colon biopsy which was negative and it was unclear if he had an esophagogastroduodenoscopy at that time. In [4-17] he had an angiogram which was negative and an echocardiogram in [2101] which was normal. This was all at the [Hospital1 756]. PAST MEDICAL HISTORY: Type 1 diabetes mellitus since age two, chronic renal failure, end-stage renal disease on hemodialysis since [2098]. He has a history of hypertension with hypertensive crisis in [2089] complicated by a myocardial infarction in [2098]-98. He had three cerebrovascular accidents, one of them reported in [2099]. He has a history of gastrointestinal bleeds and arteriovenous fistula bleeding. He has a history of gastritis and gastroesophageal reflux disease, possible sickle cell trait, pancreatitis, deep venous thrombosis, medical noncompliance, hypoglycemic seizures, superior vena cava syndrome and acquired perforated skin disease. He also has protein S deficiency. PAST SURGICAL HISTORY: He has a stent placed for superior vena cava syndrome. He has a left arteriovenous fistula. He has a left thoracotomy on his back. He has had abscess drainage, as well as laser eye surgery. MEDICATIONS: The medications he was taking as of [2103-1-22] include: PhosLo 660 7 mg p.o. three tablets per day; Dilantin 100 mg t.i.d.; Humalog, NPH and Regular Insulin; Nephrocaps q.d.; thiamine 100 mg p.o. q.d.; Nexium 20 mg p.o. q.d.; magnesium oxide 420 mg p.o. q.d.; quinine 325 mg p.o. q.d.; Tylenol 325-650 mg p.o. q. 8 hours p.r.n.; Benadryl 125 mg q.h.s.; Warfarin 1 mg, he took three tablets on Monday, Wednesday, Thursday, Saturday and Sunday and four tablets on Tuesday and Friday. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: His father had liver cancer/cirrhosis, type 1 diabetes mellitus. There is no history of bleeding diseases in his family. SOCIAL HISTORY: He is currently a smoker. He smokes about one pack every three days. He is a former alcohol user. He lives at home with his mother and he is currently unemployed. REVIEW OF SYSTEMS: On admission in general he reports poor diet, appetite, sleep; no fevers or night sweats, but did report some chills. Head, eyes, ears, nose and throat examination showed no recent head trauma, change in vision, trouble speaking, ulcers or bleeding. Skin: He reports multiple lesions over his entire body with pruritus of lower extremities and preserved sensation. Cardiovascular: His mother reports prior "heart clot with shunt". No palpitations, chest pain or syncope. Lungs: He reported no trouble breathing or shortness of breath. Abdomen: He had positive abdominal pain transversely through his umbilicus. Genitourinary: He was anuric. He had no active infection or symptoms of infection, no urinary symptoms. Extremities: He had preserved motor and sensory functions. PHYSICAL EXAMINATION: On admission his temperature was 98.6, blood pressure 108/70, pulse 87, respiratory rate 18, O2 saturation 98%. General: He was alert and oriented and appropriate, however very cachectic looking. Head, eyes, ears, nose and throat: His head was normocephalic, no lymphadenopathy. Eyes had bilateral scleral icterus and PERRLA bilaterally. His throat examination showed dry mucosa and the palate had purplish petechiae. Neck: Supple, soft without lymphadenopathy. Skin: He had multiple discolored lesions throughout his entire body including his face, back and head. These lesions had no discharge. On his back he had a left thoracotomy scar on the subscapular area. Cardiovascular: He was tachycardic with a regular rhythm; normal S1 and S2. Lungs: Clear. Abdomen: Positive bowel sounds. He had voluntary guarding. It was nondistended but diffusely tender and had no peritoneal signs. Extremities: No edema. His pulses were palpable. Sensation was intact. Motor strength was [5-20] in extremities. He had a right femoral line and a left arteriovenous fistula. Neurological: cranial nerves two through 12 were intact and strength was also intact at the extremities. LABORATORY DATA: Chest x-ray showed that he had mesh overlying his AC but no other acute processes. His electrocardiogram on admission showed sinus tachycardia, decreased T waves in 2, 3 and aVF and aVL with no ST changes. ASSESSMENT: Our overall assessment of him on admission was a 32-year-old male with multiple comorbidities including end-stage renal disease and access issues, here with coffee ground emesis over the past 24 hours. He was hemodynamically stable on admission but deteriorated with repeat episodes of emesis and a consequent drop in blood pressure and tachycardia. He was being resuscitated with blood products and fluids and GI was following. The patient ended up leaving against medical advice and was given a prescription for a proton pump inhibitor and advised to follow up with his nephrologist on Monday morning when he got hemodialysis, to recheck his coagulation studies. HOSPITAL COURSE: GI: After having an upper gastrointestinal evaluation and esophagogastroduodenoscopy he was found to have reflux esophagitis with no active evidence of bleeding. GI recommended a proton pump inhibitor to treat his reflux and an esophageal biopsy was obtained at that time. He was sent home on a proton pump inhibitor and Zofran for nausea. His diarrhea was resolving throughout his course here. Hematologic: He was found to have, per consultation with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 29204] at the [Hospital1 756], a protein S deficiency diagnosed in [2103]. He required one unit of packed red blood cells on admission and his INR over his course here was reversed with one unit of fresh frozen plasma, and vitamin K was currently at 1.3 when he left the hospital. Cardiovascular: He had a history of hypertensive crisis which induced a myocardial infarction in [2098]-98. On admission he was anuric and he was resuscitated with large amounts of volume. He had a labile blood pressure and heart rate throughout his course here but was stable upon leaving the hospital against medical advice. Renal: He is a type 1 diabetic with end-stage renal disease on hemodialysis on Monday, Wednesday and Friday, and he is anuric. He had hemodialysis on his last day at the hospital which was [2103-10-18]. This is the day he left against medical advice. He did not complete that treatment at that time and we could not check his electrolytes any more because we lost access because he insisted on having his femoral line removed. Additionally on that day his femoral line clotted off so we could not draw from it but we could inject things into it. Pulmonary: He did report some pleuritic chest pain overnight but this resolved over the course of the day. Endocrine: He had a long history of poorly-controlled diabetes, which we controlled over his course here and his fingersticks were well controlled by the time he left here. Infectious disease: He had an increased white count but was afebrile over the course here. His white count went up to 22.1. We continued to follow that clinically. He had a chest x-ray which showed no evidence of any active process. The patient was asymptomatic over his course here and left against medical advice. Neurologic: He reported a history of seizures but had no acute issues while in house. Dermatologic: He was seen in dermatology consultation which found his skin lesions to be consistent with acquired perforated skin disorder. He was advised to follow up with a dermatologist for that. Fluids, electrolytes and nutrition: No issues. He was full code while he was in the hospital. His primary care physician is [Last Name (NamePattern4) ]. [Last Name (STitle) 29204] at the [Hospital1 756] [Numeric Identifier 29205]; his nephrologist is Dr. [Last Name (STitle) 29206] at the [Hospital1 756]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4561] Dictated By:[Last Name (NamePattern4) 26613] MEDQUIST36 D: [2103-11-2] 16:54 T: [2103-11-9] 09:33 JOB#: [Job Number 29207] ICD9 Codes: 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7433 }	Medical Text: Admission Date: [2136-8-29] Discharge Date: [2136-9-2] Date of Birth: [2068-4-7] Sex: F Service: CHIEF COMPLAINT: The patient is a 67 year-old female with dizziness, headaches and hand weakness. HISTORY OF PRESENT ILLNESS: This is a 67 year-old female with a history of dizziness, headaches and hand weakness for symptoms including an MRI and MR angiogram of the head and neck was found to have a left supraclinoid carotid aneurysm at the origin of the left ophthalmic artery. There was no evidence of intracranial hemorrhage or brain parenchymal pathology at that time. The patient was therefore seen in consultation by Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1132] and scheduled for elective craniotomy and clipping of the aneurysm. PHYSICAL EXAMINATION ON ADMISSION: Physical examination showed the patient to be a well developed, well nourished, white female in no acute distress. The entire general physical examination including the head, eyes, ears, nose and throat, heart, lungs and abdomen was essentially unremarkable. HOSPITAL COURSE: Due to the clinical findings the patient was taken to the Operating Room on the morning of admission [2136-8-29] where under a general endotracheal anesthetic the patient underwent a right frontal carinal craniotomy with clipping of a right sided P-COMM artery aneurysm. The patient tolerated the procedure well. She went to the Neurosurgical Intensive Care Unit overnight for postoperative care. She was extubated late on the evening of surgery and was noted to be awake, alert and speaking with fluent coherent speech following extubation. She was moving all extremities and had no complaints other then incisional pain. The remainder of her postoperative course was essentially unremarkable. The patient was transferred to the [Hospital 16364] hospital floor on the first postoperative day and remained stable with progressively increasing her ambulation and neurological examination otherwise remaining intact and unchanged. The patient was subsequently discharged home on [2136-9-2]. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: Aneurysm status post clipping. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 1133] Dictated By:[Doctor Last Name 7311] MEDQUIST36 D: [2136-9-2] 10:23 T: [2136-9-4] 07:27 JOB#: [Job Number 16878] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7434 }	Medical Text: Admission Date: [2126-10-15] Discharge Date: [2126-10-25] Date of Birth: [2050-3-7] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2126-10-15] Redo sternotomy, Aortic Valve Replacement (19 [First Name8 (NamePattern2) ] [Male First Name (un) 923] tissue) History of Present Illness: 76 year old female s/p CABG ([2112] at [Hospital1 2025]), critical AS (Valve area 0.6cm) and left carotid endarterectomy who presented to [Hospital3 26615] Hospital the evening of [2126-8-29] with a chief complaint of chest pain. She states the pain started while she was resting in bed and was [7-17] in severity. The pain was associated with diaphoresis and a feeling of impending doom. She states that she can walk 1 flight of stairs before becoming short of breath, but often has to rest midway up the stairs. She recently saw her PCP ([2126-9-23]) for worsening dyspnea and tightness in her chest with exertion. She has had chest pain 1-2x/month, typically when performing housework, for which she takes Nitro with relief of her pain. A TTE [5-/2126] showed: LVEF 45%, hypokinesis of the distal/anterior septum, AV peak gradient 61, mean gradient 37. Given the severity of her current episode of chest pain, she promptly called an ambulance and was brought to the hospital. She underwent a cradiac catheterization which revealed clean coronaries, a patent vein graft and severe aortic stenosis. She is now being referred to cardiac surgery for a redo sternotomy with aortic valve replacement. Past Medical History: Aortic stenosis dyslipidemia Hypertension Left bundle branch block Depression Anxiety Osteoarthritis of hands, shoulders and knees s/p Left carotid endarterectomy s/p Coronary Artery Bypass Graft x 2(LIMA to LAD, SVG to D1)'[12] Social History: Race:Caucasian Last Dental Exam: edentulous Lives with:Significant other [Name (NI) ] Contact:[Name (NI) ] [Last Name (NamePattern1) 3077] (significant other) Phone #[Telephone/Fax (1) 91596] Occupation:retired Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH:has been sober since [2096] Illicit drug use:denies Family History: Premature coronary artery disease- Mom: Died of MI at 72, Dad: Died of MI at 64, Brother: s/p AVR. Physical Exam: Pulse:92 Resp:13 O2 sat:97/RA B/P Right:118/61 Left:125/75 Height:5' Weight:162 lbs General: awake alert oriented Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Left carotid endarterectomy scar Chest: Lungs clear bilaterally [x] Heart: RRR [x] harsh 4/6 systolic ejectin Murmur with radiation to L carotid area Abdomen: Soft [x] non-distended [x] non-tender [x] + bowel sounds Extremities: Warm [x], well-perfused [x] no Edema mild superficial Varicosities bilat Neuro: Grossly intact [] Pulses: Femoral Right: 1 Left:1 DP Right: np Left: np PT [Name (NI) 167]: np Left: np Radial Right: 2+ Left: 2+ Carotid Bruit Right:soft Left: soft (L>R) Pertinent Results: PRE-CPB: 1. The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. 2. The right atrium is moderately dilated. 3. Overall left ventricular systolic function is severely depressed (LVEF= 30 %). There is significant inferoseptal, anterior and anteroseptal hypokinesis. 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. The RCC is severely calcified and immobile. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. 7. Mild (1+) mitral regurgitation is seen. PORTABLE UPRIGHT CHEST: The patient has been extubated, and there has been removal of orogastric tube, pulmonary arterial catheter, chest tubes, and mediastinal drains. A right IJ sheath remains in unchanged position. Sternotomy wires and mediastinal surgical clips are again noted, in unchanged position and alignment. The lung volumes are lower. There are bilateral pleural effusions, left greater than right, with bibasilar atelectasis, worst in the retrocardiac region and increased from prior study. There is no opacity to suggest pneumonia. Prior left pneumothorax has resolved. Mediastinal contours are stable, with expected post-operative widening and stable cardiomegaly. Pulmonary vascular congestion has improved. Calcification of the aortic knob is re-demonstrated. IMPRESSION: Interval removal of numerous supportive and monitoring devices. Decreased lung volumes, with bilateral left greater than right effusions and associated atelectasis. Resolution of prior left pneumothorax. Decreased vascular congestion. [2126-10-24] 06:07AM BLOOD WBC-8.9 RBC-3.50* Hgb-10.2* Hct-31.4* MCV-90 MCH-29.2 MCHC-32.6 RDW-14.0 Plt Ct-333 [2126-10-25] 06:07AM BLOOD PT-14.4* INR(PT)-1.2* [2126-10-24] 06:07AM BLOOD PT-14.4* PTT-20.6* INR(PT)-1.2* [2126-10-25] 06:07AM BLOOD Glucose-108* UreaN-10 Creat-0.9 Na-143 K-4.3 Cl-104 HCO3-30 AnGap-13 [2126-10-21] 04:20AM BLOOD ALT-12 AST-20 LD(LDH)-290* AlkPhos-48 Amylase-50 TotBili-1.0 [2126-10-21] 04:20AM BLOOD Lipase-30 [2126-10-25] 06:07AM BLOOD Calcium-8.5 Phos-4.6* Mg-2.5 Brief Hospital Course: Ms. [Known lastname 6164] was a same day admit and on [2126-10-15] was brought directly to the operating room where she underwent a redo-sternotomy, aortic valve replacement. Please see operative note for surgical details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Pt went into afib post op. Amio was started. pt in afib longer then 24 hrs. Coumadin was iniated, and now on a amio taper with coumadin for new onset afib.The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication.The patient was evaluated by the physical therapy service for assistance with strength and mobility. Gently diuresed toward her preop weight. She proved to be somewhat sensitive to coumadin and was treated with FFP when she was supratherapeutic. By the time of discharge on POD 10 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in stable condition with appropriate follow up instructions.Target INR 2.0-2.5 for A Fib. First blood draw tomorrow [10-26]. Medications on Admission: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 7. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:4 Tablet(s) Refills:0 10. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [Hospital1 ] (2 times a day) for 5 days. Disp:4 Refills:0 11. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): TAPER 400 MG PO BID X 7 DAYS, THEN 400 MG PO QD X 7 DAYS, THEN 200 MG QD UNTILL F/U WITH cardiologist. Disp:60 Tablet(s) Refills:1 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:1 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 9. 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 10. INSULIN Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Breakfast Glargine 10 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 3 Units 3 Units 3 Units 0 Units 160-199 mg/dL 6 Units 6 Units 6 Units 3 Units 200-239 mg/dL 9 Units 9 Units 9 Units 6 Units 240-279 mg/dL 12 Units 12 Units 12 Units 9 Units 280-320 mg/dL 15 Units 15 Units 15 Units 12 Units > 320 mg/dL Notify M.D. 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 12. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 7 days: HOLD FOR POTASSIUM GREATER THAN 4.5. Disp:14 Tablet Extended Release(s) Refills:0 13. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:1 14. Outpatient Lab Work Labs: PT/INR Coumadin for AFib Goal INR 2-2.5 First draw day after discharge Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [Last Name (STitle) 13517] Results to phone [Telephone/Fax (1) 75761] (confirmed with [Doctor First Name ]) 15. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 16. Coumadin 1 mg Tablet Sig: daily dosing per Dr. [Last Name (STitle) 13517] Tablet PO once a day: dose Fri [10-25] is one-half tab ( 0.5mg); all further daily dosing per Dr. [Last Name (STitle) 13517]. Target INR 2.0-2.5 for A Fib . Disp:80 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: partners [Name (NI) ] Discharge Diagnosis: Aortic stenosis s/p Redo sternotomy, Aortic Valve Replacement postop atrial fibrillation Past medical history: Dyslipidemia Hypertension Left bundle branch block Depression Anxiety Osteoarthritis of hands, shoulders and knees s/p Left carotid endarterectomy s/p Coronary Artery Bypass Graft x 2(LIMA to LAD, SVG to D1)'[12] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] on ([Telephone/Fax (1) 170]) on [2126-11-20] at 1:15pm in the [Hospital ] Medical Office Building, [Last Name (NamePattern1) ]., [Hospital Unit Name ]. Wound check in same locale on [2126-10-29] at 10:30am Cardiologist: Dr. [Last Name (STitle) 77919] ([Telephone/Fax (1) 65733]) (recommended by PCP) on [2126-11-11] at 11am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ] [Name (STitle) 13517] ([Telephone/Fax (1) 75761]) in [3-12] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR Coumadin for AFib Goal INR 2-2.5 * very sensitive to coumadin First draw [2126-10-26] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [Last Name (STitle) 13517] Results to phone [Telephone/Fax (1) 75761] (confirmed with [Doctor First Name ]) Completed by:[2126-10-25**] ICD9 Codes: 4241, 9971, 2930, 5119, 4280, 5990, 2859, 4019, 2724, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7435 }	Medical Text: Admission Date: [2101-11-10] Discharge Date: [2101-12-1] Date of Birth: [2021-4-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1115] Chief Complaint: Failure to wean off ventilator, question of tracheobronchomalacia Major Surgical or Invasive Procedure: Arterial line History of Present Illness: HISTORY OF PRESENT ILLNESS: 80 y o Creole-speaking male with PMHx significant for COPD, asthma, HTN, hyperlipidemia, sick sinus syndrome s/p pacemaker placement who presented from [Hospital 107] Hospital in [State 792]for evaluation by interventional pulmonology of tracheobroncheomalacia for possible stenting. Patient admitted to [Hospital 796] Hospital in RI on [2101-9-9] for SOB (and has been in hospital since admission date), treated for COPD exacerbation and URI, required intubation for respiratory failure. Complications during the hospitalization at the OSH included VAP (serratia, pseudomonas) treated with cefepime. Had a CT on [10-4] with BL pleural effusion, with compressive atelectasis. Also had ? sick sinus syndrome s/p pacemaker placement on [10-27], shock liver and DIC secondary to sepsis, severe C.diff colitis now resolved, and anasarca. Underwent tracheostomy on [2101-9-29] and despite this has failed weaning attempts. Per outside hospital notes, he was seen by cardiology consultant on [10-11], because there were several episodes fo bradycardia/PEA during repositioning thought [2-14] mucous plugging. He also had an episode of narrow complex tachycardia that may have been A fib. Patient was transfered from OSH on [11-11] for evaluation by IP for possible stent placement for TBM. Upon transfer from OSH, routine EKG was performed and found to be abnormal. EKG showed 0.5-1mm STD in II/III/AVF, trops 0.4 with normal renal function. Repeat troponins stable (0.41) this AM. Echo this AM, with EF >55%, no focal WMA. Cardiology was consulted on patient, would like to cycle troponins, and if these increase will plan to do cardiac catheterization, otherwise would like to medically manage. Since arrival patient has had antibiotics stopped, and pan-culted; has been afebrile here, MAP 60. Patient is making appropriate urine, 1.4L urine since midnight. Patient was also started on Diamox for alkalosis. For rate control patient was changed from diltiazem to beta blocker, with good rate control. Nutrition was also consulted on the patient, and per their recs tube feeds were started. . Review of systems positive for right eye pain, increased right eye pain with right eye movement, and decreased vision in right eye. 14 point review of systems reviewed and otherwise negative. Past Medical History: Asthma COPD HTN Hyperlipidemia Anasarca Sick sinus syndrome, s/p pacemaker placement [10-27] Ventilator associated PNA (serratia, pseudomonas) Tracheobroncheomalacia Respiratory failure s/p tracheostomy and PEG Shock liver [2-14] sepsis and DIC now resolved Severe C.diff colitis now resolved Social History: Patient [Name (NI) 7979], has been in USA approximately 12 yrs. However, sister reports that patient recently traveled to [Country ] for approximately 9 mos, returned in [2101-4-13]. Reports he used to work as a shoemaker, after that worked in government at a desk job. Only tobacco exposure is intranasal tobacco (snuff). Denies alcohol or illegal drug use. Family History: Noncontributory Physical Exam: On Admission: T=96.8 BP=114/50 HR=90 RR=16 O2= 97% PHYSICAL EXAM GENERAL: Elderly, primarily Creole-speaking elderly gentleman, appears chronically ill, in NAD HEENT: Normocephalic, atraumatic. Right sclera red and injected; area around the eye surrounded by macular rash. MMM. OP whitish exudate on tongue. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. Heart sounds slightly distant LUNGS: CTA anteriorly ABDOMEN: NABS. Soft, NT, ND. No HSM. PEG tube in place EXTREMITIES: Diffuse 2+ pitting edema. Left arm skin weeping. SKIN: Per nursing, multiple ulcerations including sacral ulcer; ulcer stage IV on ear visualized NEURO: Difficult to assess orientation due to language barrier, also patient can only nod, shake head. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. PSYCH: Listens and responds to questions appropriately, pleasant . On Discharge: VS: 98.3 130/104 96 18 100% on 40%TM GEN: NAD, just awoken comfortable HEENT: EOMI, right eye with conjunctival injection NECK: trach mask in place, closed for voice. PULM: wheezing/rhochi bilaterally CARD: Tachycardic, nl S1, nl S2, no audible murmur ABD: PEG tube in place with dressing, clear dry intact. no tenderness to palpation ABS. EXT: 2+ swelling of feet only SKIN: Sacral decubitus ulcer dressing c/d/i Pertinent Results: Labs on admission: WBC 11.8 N60 L18.5 M6.2 E 14.8 B0.4 Hct 32.4 MCV 89 Plts 456 PT 14.3 PTT 26.8 INR 1.2 Fibrino 329 Retic 2.8 146 109 32 ------------------ Glucose 80 4.3 32 0.7 Ca 8.8 Mg 2.0 Phos 3.2 ALT/AST 24/31 CK 25 AlkP 236 --> 179 Tbili 0.5 Dbili 0.2 Ibili 0.3 alb 2.9 prealbumin low CK MB negative x5 Trop 0.4 --> peak 0.61 iron 45 TIBC 137 Ferritin 988 Transferrin 105 cholest 129 Trigly 130 HDL 33 LDL 70 Cortisol random am 1.8 Cortisol stim test 1.0 --> 5.5 Repeat cortisol stim 2.4 --> 5.8 30 mins --> 6.3 60 mins Aldosterone pending x3 Renin x3 pending ACTH normal x3 during [Last Name (un) 104] stim test IgE high 141 Aspergillus negative Labs on discharge: WBC 9.2 Hct 25.0 Plts 392 Coags 13.0/26.9/1.1 139 97 32 -------------- Gluc 102 3.7 35 0.5 Ca 8.8 Mg 1.9 Phos 4.5 Tbili 0.5 IMAGING, siginificant. For full list of images see OMR [2101-11-11] EKG Atrial paced rhythm. Slight inferior ST segment elevation. Clinical correlation is suggested. No previous tracing available for comparison. [2101-11-11] Echo The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 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: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. [11-11] CXR FINDINGS: No previous images. There is hyperexpansion of the lungs with flattening of the hemidiaphragms, consistent with chronic pulmonary disease. Blunting of the costophrenic angles is consistent with pleural effusions. Tracheostomy tube is in place, as is a dual-channel pacemaker device. No evidence of acute pneumonia or vascular congestion. [11-13] EEG IMPRESSION: This telemetry captured no pushbutton activations. Routine sampling and other recordings showed a mildly slow background in wakefulness suggestive of an encephalopathy. Nevertheless, there were no areas of prominent focal slowing. There were no epileptiform features in the recording, whether by routine sampling or by automated detection programs. There were no electrographic seizures. [11-13] CT head without contrast IMPRESSION: 1. Severely limited study secondary to streak artifact from metallic EEG leads rendering the study nearly nondiagnostic. No definite acute intracranial process identified. Repeat exam is highly recommended following removal of metallic leads. 2. Diffuse opacification of the sinuses, which may be related to intubation. Infection cannot be excluded. [2101-11-14] EEG IMPRESSION: This telemetry captured no pushbutton activations. Routine sampling showed a mild to moderately diffusely encephalopathic background consisting of mostly theta activity with occasional periods of slower delta activity. There were no areas of prominent focal slowing and there were no epileptiform features noted. [2101-11-14] CT chest without contrast IMPRESSION: 1)Bilateral pleural effusions which are small to moderate on the right and small on the left side. 2)Diffuse mild bronchial wall thickening and small clusters of centrilobular nodules and peribronchovascular ground-glass opacities suggest recent infection or inflammation possibly due to aspiration. No consolidation or radiological evidence of central airway tracheobronchomalacia. 3)Liver hypodensities are most likely cysts. 4)Small pericardial effusion. [2101-11-15] CXR IMPRESSION: Bilateral small pleural effusions with associated bibasilar atelectasis, with interval increase in the right pleural effusion. Please see attached data with endocrine labs. Brief Hospital Course: Brief Hospital Course By Problem 1. Failure to wean from ventilator: Patient has a history of COPD, per family's report he was able to climb one flight of stairs prior to hospitalization, but was using inhalers and home O2 for month prior to [8-21] hospitalization. Per notes from OSH, it appears that patient had severe COPD requiring intermittent steroids prior to hospitalization. Was sent from OSH for evaluation of tracheobronchomalacia seen during bronchoscopy. Patient found to have elevated troponins and EKG changes on admission, so IP did not do bronchoscopy on admission because they wanted to wait until he was medically cleared. Patient got a CT chest with protocol to assess TBM on [11-14] which showed bilateral effusions, diffuse mild bronchial wall thickening but no TBM, small pericardial effusion. For this reason IP decided not to take the patient for bronchoscopy and stenting. Patient's respiratory status improved slightly over the course of his hospitalization with both a lasix drip for diuresis and steroids. Patient was slowly weaned to trach mask. At discharge the patient was tolerating room air and was talking with passy-muir valve. 2.Elevated troponins: Patient presented with EKG changes and elevated troponins and was seen and evaluated by cardiology. They found no evidence of ACS given that the patient had no chest pain, and felt that most likely the elevation in his troponins was secondary to demand ischemia; they felt there was no indication for cardiac catheterization and that medical management with ASA and beta blockade was most appropriate. Patient had 3 sets of stable troponins. Patient continued to be tachycardic at a rate of 100s-110s, so another troponin was obtained on [11-14], continued to be elevated. This was thought to be due to continued demand ischemia in the setting of most likely worse renal function than his creatinine would indicate given that he has very little overall muscle mass. Patient's beta blocker was increased again to maintain his heart rate around 90s-100s. Patient also recieved an Electrophysiology consult because it was thought that his pacemaker was set at a rate of 90 bpm (atrially paced. EP examined the patient and reported that he had normal pacemaker function; also that the atrial pacing rate above lower rate of 60 seen on [2101-11-11] EKG is due to rate adaptive function, so therefore no changes made to current settings. 3.Right eye injection/macular rash around orbit: Patient had right eye pain on presentation. Patient was seen by ID & opthomology at OSH, initially on Acyclovir, but optho felt that not consistent with herpetic eye involvement, most likely chronic conjunctival chemosis. Patient was seen by ophthomology for further recommendations here, they felt that eye pain may have been secondary to pilocarpine as this can cause pain. Also felt that injection was likely blepheritis, no chemosis, reccomended polysporin ointment q3hrs and vigamox QID and Lacrilube QID as well as hot compresses QID. There was some concern also that he may have early ulcer formation. Ophthomology recommended outpatient follow up. . 4. Anasarca: Patient presented with upper extremity edema much greater than lower extremity edema. Patient was gently diuresed with Lasix drip initially, and then changed to Lasix 40mg IV BID to allow for gentle diuresis. Diuresis was held several times for episodes of hypotension. However, overall we were able to diurese the patient with a significant improvement in his overall edema with upper extremity edema trace pitting edema on day of discharge. Patient also recieved upper extremity doppler out of concern for possible DVT; however, there was no evidence of DVT. 5.Leukocytosis: Patient was transfered on multiple antibiotics for several infections he experienced during 2 months at OSH. All antibiotics were discontinued in the ICU; from that point he remained afebrile. He had a mild leukocytosis which trended down. Sputum culture grew pseudomonas, thought to be a colonizer. Patient was C.diff negative x2. After transfer to the floor, WBC improved. 6. Eosinophilia: Presented to OSH with eosinophilia. [Month (only) 116] be secondary to adrenal insufficiency, may be secondary to parasitic infection given recent travel to [Country 3587]; may be secondary to medication. Stool was negative for O&P x3. Patient was found to have adrenal insufficiency; however, eosinophilia only trended down but did not fully improve with addition of prednisone. Therefore, it was thought that medications may have also played a role and therefore all unecassary medications were minimized. . 7. Adrenal Insufficiency: Patient was thought to be adrenally insufficient secondary to inconsistent prednisone dosing. Cortisyntropin stim test 1.0, 5.5 after 1 mcg cosyntropin: positive for adrenal insufficiency. Given prednisone 5 mg PO daily which improved eosinophilia. Also had multiple labs per endocrine including baseline morning ACTH, cortisol, PRA, [Male First Name (un) ], then give 250mcg Cosyntropin, then the same labs at 30 and 60 mins. Patient requires endocrine follow up as an outpatient. . 8. Anemia: Consistent with anemia of chronic disease per iron studies. . 9. Elevated alk phos: Alk phos elevated at 236 on arrival, trended down to 187 on [11-13] and then 179 on [11-14]. Should be followed as an outpatient. . 10. Decreased albumin: Patient most likely chronically malnourished given long hospital course. Pt was maintained on nighttime tube feeds, and encouraged to take po intake. . 11. Ulcers: Patient has a stage III decubitus ulcer on sacrum/coccyx with minimal amount of serous drainage, and Stage IV ulcer on left ear helix with very scant amount of serous drainage. Patient also has circular healed pressure ulcer to right post acromium process. All present on arrival to [Hospital1 18]. Patient was followed by wound care throughout his stay and received frequent repositioning. He was also seen by nutrition and his nutrition was optimized with tube feedings. . 12. Possible seizure: Patient had a brief episode of altered responsiveness with right sided twitching after pulling the IJ, cleared after several minutes, concern for seizure vs air embolism. EEG was done and showed no evidence of seizure activity. Patient had no other episodes while in the hospital. Medications on Admission: TRANSFER MEDICATIONS : 1) Vigamox NF 0.5 % OU QID 10 minutes prior to ointment 2) Artificial Tear Ointment 1 Appl BOTH EYES Q6H Alternate Q3H with Polysporin. 3) Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl BOTH EYES Q6H Alternate Q3H with Lacrilube 4) PredniSONE 5 mg PO/NG Q0600 5) Metoprolol Tartrate 25 mg PO/NG Q6H 6) Ranitidine 75 mg PO/NG DAILY 7) Montelukast Sodium 10 mg PO/NG DAILY 8) Simvastatin 40 mg NG DAILY 9) Aspirin 325 mg NG DAILY 10) Multivitamins 1 TAB NG DAILY 11) Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] 12) Albuterol-Ipratropium [1-14] PUFF IH Q6H:PRN wheezing 13) Acetaminophen 325-650 mg NG Q6H:PRN fever 14) Heparin 5000 UNIT SC TID Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units units Injection TID (3 times a day). 2. Acetaminophen 160 mg/5 mL Solution Sig: [1-14] teaspoons PO Q6H (every 6 hours) as needed for fever or pain. 3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [1-14] Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): hold for SBP < 100 or HR < 60. 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qAM. 12. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q6H (every 6 hours). 13. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic Q6H (every 6 hours). 14. Moxifloxacin 0.5 % Drops Sig: 1-2 drops Ophthalmic QID (4 times a day). 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: Rehab Hospital Of [Doctor Last Name ] Discharge Diagnosis: primary: respiratory failure due to volume overload secondary: adrenal insufficiency, blepharitis, anasarca, anemia, hypoalbuminemia and malnutrition Discharge Condition: stable, afebrile, O2 sat 98% on 40% TM Discharge Instructions: You were admitted for evaluation of possible softening of the trachea. We did not find that symptoms were consistent with this type of condition per our evaluatioin. During your stay your respiratory status improved and you were making fewer secretions, therefore able to breath comfortably with a trach mask. You were noted to have a condition called adrenal insufficiency for which you were started on a medication called prednisone. Lab work was obtained which needs to be followed up by endocrinology. This is important because if you are to become critically ill, you will require high doses of steroid hormones as your body is unable to as instructed below. During your hospitalization it was also noted that you had redness in your eye which was thought to be due an infection. You were evaluated by opthalmology and you were treated appropriately. It is important that you follow up with an eye doctor early next week. Many of your medications were changed during this hospitalization. Please see attached medication list for new medications. You should continue on your tube feeds atleast until your ulcers heal entirely. After this time you should readress this issue with your doctor. Please call your doctor or go to the emergency room if you develop chest pain, shortness of breath, blood in your stool, fevers >101 or any other concerning symptom. Followup Instructions: Follow with an ophthalmologist early next week. You currently have an appointment with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 3540] on [12-13], 2pm Endocrinology, [Location (un) 453] [Hospital Ward Name 452] Rose Bldg, GI [Location (un) 83825]. [Telephone/Fax (1) 7714]. If you are unable to make this appointment, please call and cancel. However, you will require a follow up appointment with endocrinology to review your lab tests for adrenal insufficiency. Completed by:[2101-12-2] ICD9 Codes: 5119, 2760, 2768, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7436 }	Medical Text: Admission Date: [2185-7-13] Discharge Date: [2185-7-26] Date of Birth: [2130-1-4] Sex: F Service: General Surgery HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old woman with chronic neuronal dysplasia, which is an adult form of Hirschsprung's disease, as well as anxiety disorder and benzodiazepine dependence, depression, irritable bowel syndrome, and sarcoidosis. She presented on [2185-7-13] for an elective rectal dilatation and partial colectomy by Dr. [Last Name (STitle) 957]. The patient on [2185-7-13] underwent a preoperative work-up including chest x-ray, EKG, various blood tests, placement of a peripherally inserted central catheter, and a bowel preparation involving p.o. erythromycin and neomycin. PAST MEDICAL HISTORY: Long history of colorectal procedures by Dr. [Last Name (STitle) 957]. The patient's initial surgery was a total abdominal hysterectomy and bilateral salpingo-oophorectomy in [2149]. Since then she has undergone numerous exploratory laparotomies with lysis of adhesions for obstructive symptoms. She has also undergone repair of a spigelian hernia, pelvic floor reconstruction and a two-part segmental colectomy. On [2185-7-13] the patient complained of continual abdominal pain associated with nausea and a significant amount of weight loss. She described alternating episodes of diarrhea and constipation, but denied any chest pain, shortness of breath, or any other constitutional symptoms. Her prior surgical history was as above, total abdominal hysterectomy, total abdominal hysterectomy/bilateral salpingo-oophorectomy, colon resection, pelvic floor reconstruction, spigelian hernia repair, and five exploratory laparotomies with lysis of adhesions. ALLERGIES: She describes allergies to Zofran, Celexa, Ultram, Benadryl, morphine, Augmentin, and intravenous pyelogram dye. MEDICATIONS AT HOME: 1. Kondremul. 2. Darvocet. 3. Phenergan. 4. Lasix. 5. Valium. 6. Elavil. 7. Vicodin. 8. Anusol. 9. Ambien. 10. K-Lyte. 11. Levsin for nausea. SOCIAL HISTORY: She lives in [Location 4121] with her husband and three daughters. She described no toxic habits, although she does have a history of cigarette and ethanol use. PHYSICAL EXAMINATION: The patient was afebrile, pulse 72, respiratory rate 18, blood pressure 118/60. Her physical examination was benign. Abdomen was soft, nontender, nondistended, with multiple surgical scars that were well healed. LABORATORY DATA: Her admission laboratory studies included white blood cell count of 3.1, hematocrit 36, platelet count 236. Chem-10 showed a sodium of 138, potassium 3.3, chloride 103, bicarbonate 26, BUN 16, creatinine 0.9, glucose 94, calcium 9.2, phosphate 3.7 and magnesium 2.2. Her chest x-ray showed emphysematous changes, osteopenia, no opacifications or effusions. EKG showed normal sinus rhythm at 78 with left atrial enlargement, no ischemic changes. HOSPITAL COURSE: The patient was typed and crossed for two units in the blood bank. Her consent for the procedure was obtained and she was given a bowel preparation overnight. On the morning of [2185-7-14] the patient went to the operating room and once cleared by the anesthesia resident she was taken to the operating room for her procedure. Please refer to Dr.[Name (NI) 6275] previously dictated operative summary for details. In short, the patient underwent an exploratory laparotomy with lysis of adhesions, a rectal sphincter dilatation, a low anterior resection with ileoproctectomy and proctostomy, gastrostomy, tube placement and feeding jejunostomy tube placement. During the procedure the peripherally inserted central catheter was taken out and replaced with a central venous catheter. The patient's postoperative course was significant mostly for pain management issues. The pain was initially treated with a Demerol epidural with bupivacaine instilled into it, but this did not completely control her pain. A Dilaudid PCA apparatus was added on to control her pain. Between these two the patient described better relief. When the PCA was added the Demerol was removed from the epidural and the patient just received a bupivacaine epidural. In addition to this, Toradol was added, 10 mg q. 6 hours p.r.n. for better pain control. On this regimen the patient's pain control was relatively well controlled. Another postoperative problem with the patient's course was low urine output in the first few days after surgery. The patient had low urine output and low blood pressures requiring transfer to the intensive care unit. The patient went to the intensive care unit on [2185-7-16] and was monitored for hypotension via her central venous catheter. In addition her urine output was kept up by fluid boluses and Lasix doses. During this time the patient also received a blood transfusion for chronic blood loss anemia. The patient was in the surgical intensive care unit for two days and came back out onto the floor on [2185-7-13]. By the time she came out to the floor the patient was tolerating p.o. She was advanced to small amounts of clear liquids and cycled tube feeds at 30 cc an hour. On [2185-7-18] the patient was noted to have decreased breath sounds bilaterally as well as low oxygen saturations. She underwent a chest x-ray that revealed signs of aspiration pneumonia and effusions and atelectasis. The patient was started on levofloxacin and IV gentamicin with good results. The patient soon defervesced and became less tachypneic as well as had better oxygen saturations. She was also treated with chest physical therapy every four hours as well as albuterol and Atrovent nebulizer treatment. Over the next few days the patient improved and was slowly advanced to a soft solid diet and p.o. pain regimen as well as her home medications. She continued to complain of nausea following the tube feeds, as well as whenever the gastrostomy tube was clamped, however for the most part she is now able to tolerate the gastrostomy tube being clamped. One [Last Name ] problem following her surgery was a little bit of fluid overload status. She had some edema in the legs as well as some congestive heart failure. She has been getting almost a daily dose of Lasix 5 mg to help diurese her with good results. She has much decreased edema in both of her legs and her lungs today sound much clearer. Today, on [2187-7-26], the patient is being discharged to a [Hospital 3058] rehabilitation center skilled nursing facility for the next week. At the end of this week the patient is scheduled to go for a follow-up appointment with Dr. [Last Name (STitle) 957] on Monday, [2185-8-1], during which Dr. [Last Name (STitle) 957] will remove her gastrostomy and jejunostomy feeding tubes. DISCHARGE DIAGNOSES: 1. Preoperative evaluation and bowel preparation. 2. Chronic neuronal dysplasia. 3. Sarcoidosis. 4. Status post exploratory laparotomy and lysis of adhesions. 5. Status post low anterior resection. 6. Status post rectal sphincter dilatation. 7. Status post ileoproctostomy. 8. Gastrostomy tube placement. 9. Jejunostomy feeding tube placement. 10. PICC line placement. 11. Central venous line placement. 12. Insomnia. 13. Anxiety disorder. 14. Depression. 15. Adjustment disorder. 16. Irritable bowel syndrome. 17. Obsessive-compulsive personality disorder. 18. Narcissistic personality disorder. 19. Benzodiazepine tolerance and dependence. 20. Epidural anesthesia. 21. Chronic blood loss anemia requiring red blood cell transfusions. 22. Volume overload necessitating diuresis. 23. Hypokalemia. 24. Hypocalcemia. 25. Hypophosphatemia. 26. Hypomagnesemia. 27. Jejunostomy feeding tube. 28. PCA pain control. 29. Postoperative fever. 30. Atelectasis. 31. Aspiration pneumonia. 32. Asthma. 33. Chronic obstructive pulmonary disease. 34. Congestive heart failure. 35. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 36. Status post colon resection. 37. Status post pelvic floor reconstruction. 38. Status post spigelian hernia repair. 39. Status post multiple exploratory laparotomies. DISCHARGE MEDICATIONS: 1. Hydroxyzine 25 mg intramuscular every 3-4 hours as needed for itching. 2. Vicodin 1-2 tablets every 4-6 hours as needed for pain. 3. Albuterol nebulizer every 6 hours. 4. Hydrocortisone cream 2.5% once a day applied to rectum. 5. Lasix 20 mg p.o. once a day. 6. Hemorrhoid suppository, one suppository as needed for pain. 7. Valium 5 mg, 1 tablet every 6 hours as needed for anxiety. 8. Levsin 0.25 mg, 1-2 tablets once a day as needed for nausea. 9. Phenergan 25 mg, 1 rectal suppository once a day as needed for nausea. 10. Halcion 0.125 mg q.h.s. p.r.n. as needed for insomnia. 11. Atrovent 1 nebulizer treatment every 6 hours. FOLLOW-UP PLANS: The patient needs outpatient physical therapy. As mentioned before the patient is going to a skilled nursing facility and she has a follow-up appointment with Dr. [Last Name (STitle) 957] on [2185-8-1]. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4007] Dictated By:[Last Name (NamePattern1) 1179] MEDQUIST36 D: [2185-7-25] 09:34 T: [2185-7-25] 10:07 JOB#: [Job Number 48806] cc:[Last Name (NamePattern1) ] ICD9 Codes: 5070, 4280, 5180
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7437 }	Medical Text: Admission Date: [2179-9-14] Discharge Date: [2179-10-7] Date of Birth: [2128-8-14] Sex: F Service: CARDIOTHORACIC Allergies: Zoloft / Tetracyclines / Prozac / Paxil Attending:[First Name3 (LF) 165] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2179-9-15] Cardiac Catheterization [2179-9-21] Cartotid Stent to [Doctor First Name 3098] [2179-9-22] PICC line insertion [2179-9-28] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to RCA), Aortic Valve Replacement (19mm St. [Male First Name (un) 923] Mechanical), Mitral Valve Replacement (27mm St. [Male First Name (un) 923] Mechanical), Aortic Root Enlargement with Pericardial Patch History of Present Illness: 51 y/o F w/hx of HTN and PVD, was in her USOH on Sunday night until she woke up at midnight severely SOB. She was intubated in the filed and brought to [Hospital3 ]. Upon intubation they noted pink frothy sputum coming from the ETT. At the [Hospital1 189] ICU, her bp was controlled and she was diuresed with lasix. She was extubated on Monday [9-13]. She had a CTA to r/o PE, which demonstrated only interstitial opacities c/w CHF (no PE). She had a TTE which showed MR, AR, and an akinetic anterior wall. Her initial ECG upon arrival yest AM showed <[Street Address(2) 4793] depressions in II/III/aVF with 1 mm STE in V1-2. By this AM, her ECG showed deep TWI in I, aVL, II, and V2-6. Her cardiac enzymes showed CK 62-> 278 -> 380, with MB 0.6 ->5 -> 3.7, trop <0.04 -> 0.88 -> 0.94 (from yest at 1 am to 9 am to 5 pm). She was then transferred from OSH to [Hospital1 18] for cardiac cath and further care. Past Medical History: Hypertension, Hypercholesterolemia, Peripheral Vascular Disease, Varicose Veins, Congestive Heart Failure, Congenital hip dysplasia with chronic low back pain, s/p Appendectomy, s/p cholecystectomy, s/p left finger reattached, s/p stents to left leg and angioplasty to right leg, s/p left hip replacement Social History: patient is married with one grown daughter. previously worked as a medical assistant. 1 ppd smoking since age 16, quit 6/[2178]. No alcohol/drug abuse. Family History: Father with Diabetes and CVA in his late 60s, mother with MI at age 53. Physical Exam: T: 98.3 BP: 130/54 P: 77 R: 18 97%RA Gen: alert and oriented pleasant female in NAD HEENT: pupils 2 mm and minimally reactive, eomi, sclerae anicteric, MMM, no OP lesions Neck: supple, bilateral carotid bruits, JVD not elevated Lungs: minimal bibasilar crackles, dullness to percussion at bilateral bases CV: RRR, normal S1/S2, no m/r/g Abd: soft, nt/nd, normoactive bowel sounds Ext: no edema, 2+ dp bilaterally Neuro: CN II-XII intact, MAEW Pertinent Results: Cath [9-15]: 3VD. The LMCA had diffuse 50% stenosis. The LAD had had diffuse proximal disease without critical lesions. The distal LAD was intramyocardial with the distal D2 being the predominant vessel to the apex. The LCx was a non-dominant vessel with 80% stenosis in its origin. The RCA was a dominant vessel with 80% stenosis at its origin. CNIS [9-21]: Significant plaque with bilateral 80-99% carotid stenosis. Of note, the plaque extends fairly high in both cervical internal carotid arteries. Echo [9-28]: PRE-BYPASS: Preserved biventricular systolic function. The intrinsic LV systolic function may be depressed given the degree of mitral regurgitation. Overall LVEF 55%. Thickened mitral leaflets at commisures, no prolapse or flail segments reflecting a probable rheumatic disease in origin. There is shortened chordae and a thickened subvalvular apparatus. There is mild mitral stenosis with moderate to severe mitral regurgitation. The regurgitant jet is mostly central with a vena contracta of 0.57cm and mitral annulus of 30mm and a dilated left atrium. Thickened aortic leaflets especially at commissures with a mild aortic stenosis and a central regurgitant jet c/w with moderate aortic regurgitation. There is no flow reversal of flow in the thoracic aorta. Mild tricuspid and pulmonic regurgitation. POST-BYPASS: Suboptimal images due to double mechanical valves A mechanical prosthesis is seen in the native mitral position, stable and functioning well and regurgitant jets are typical for the type of prosthesis. No mitral stenosis is appreciated. Mean gradient of 3 mm Hg. A mechanical prosthesis is seen in the native aortic position, stable and functioning well and the regurgitant jets are typical of the prosthesis with a mean gradient of 7 mm Hg. CXR [10-2]: Bilateral pleural effusions, worse on the left than the right. There is interval worsening of the left-sided pleural effusion. Bibasilar atelectasis. [2179-9-14] 05:29PM BLOOD WBC-13.6* RBC-4.21 Hgb-13.5 Hct-37.8 MCV-90 MCH-32.2* MCHC-35.8* RDW-12.9 Plt Ct-209 [2179-9-27] 06:45AM BLOOD WBC-5.0 RBC-2.75* Hgb-8.9* Hct-25.5* MCV-93 MCH-32.2* MCHC-34.7 RDW-14.2 Plt Ct-174 [2179-10-5] 07:32AM BLOOD WBC-12.1* RBC-2.99* Hgb-9.4* Hct-27.2* MCV-91 MCH-31.4 MCHC-34.5 RDW-17.0* Plt Ct-262 [2179-9-14] 05:29PM BLOOD PT-12.9 PTT-31.4 INR(PT)-1.1 [2179-9-25] 06:35AM BLOOD PT-12.4 PTT-32.3 INR(PT)-1.1 [2179-10-2] 12:54PM BLOOD PT-64.4* PTT-30.8 INR(PT)-8.1* [2179-10-5] 07:32AM BLOOD PT-16.5* PTT-72.4* INR(PT)-1.5* [2179-9-14] 05:29PM BLOOD Glucose-94 UreaN-14 Creat-0.6 Na-142 K-3.6 Cl-101 HCO3-30 AnGap-15 [2179-9-27] 06:45AM BLOOD Glucose-100 UreaN-7 Creat-0.7 Na-141 K-4.1 Cl-104 HCO3-30 AnGap-11 [2179-10-5] 07:32AM BLOOD Glucose-109* UreaN-9 Creat-0.5 Na-130* K-4.8 Cl-97 HCO3-27 AnGap-11 [2179-9-16] 10:10AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.5 Leuks-MOD [2179-9-16] 10:10AM URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE Epi-0 [2179-9-23] 12:36PM URINE RBC-0-2 WBC-[11-8]* Bacteri-MANY Yeast-NONE Epi-0-2 [2179-9-26] 05:43PM URINE RBC-2 WBC-18* Bacteri-OCC Yeast-NONE Epi-6 Brief Hospital Course: Ms. [Known lastname 104253] was transferred from OSH to [Hospital1 18] and underwent cardiac cath on [9-15] which revealed severe 3 vessel disease. Also on this day she underwent an Echo which revealed moderate MR [First Name (Titles) ] [Last Name (Titles) ]. Pre-operative work-up was performed which first revealed a UTI. She was treated with appropriate antibiotics and then definitive once cultures were completed. She also underwent a carotid ultrasound which revealed bilateral stenosis. On [9-21] she underwent stenting of her [Doctor First Name 3098]. Please see procedure note. On [9-22] she underwent PICC line placement for definitive IV therapy. Please see procedure note. Over the next several days she was medically managed and treated for her UTI. Her operation was cancelled several times due to her UTI. She was finally cleared for surgery and on [9-28] she was brought to the operating room where she underwent a coronary artery bypass graft x 4, aortic valve replacement, and mitral valve replacement. Please see operative report for surgical details. She tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. She remained intubated and on pressors through post-op day one. She also required multiple transfusions for bleeding and low HCT. By post-op day two pressors were weaned and she now required Labetalol for hypertension. This was slowly weaned off and she was then started on beta blockers and diuretics. She was gently diuresed towards her pre-op weight. And beta blocker was titrated for maximum hr and bp control. She was weaned from sedation, awoke neurologically intact and was extubated. Also on this day her chest tubes were removed. She was started on Coumadin (d/t mechanical valves) with a Heparin bridge until INR therapeutic. Epicardial pacing wires were removed on post-op day three and she was transferred to the SDU. On post-op day three her INR dramatically rose to over 8 and Coumadin was stopped. She was treated with FFP and over the next several days her INR trended down and she was again titrated with Coumadin for a goal INR 3-3.5. On post-op day six Amiodarone was started for episode of atrial fibrillation. She was ready for discharge on [2179-10-7]. Medications on Admission: Medications at home: plavix, toprol 50, lisinopril 20, oxycontin 80 mg tid, oxycodone 5 mg prn, aspirin, protonix Medications on transfer: Lasix 40 IV x1, Oxycontin 160mg tid, Toporol 50mg qd, Protonix 40mg qd, Plavix 75mg qd, Aspirin 325mg qd, Reglan prn, lopressor 5 IV x 1, Labetalol 5mg IV x 1, Nitropaste 1 inch, Dilaudid prn, Lipitor 10mg qd, Lisinopril 20mg qd, Lovenox Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:40 Tablet(s) Refills:0 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:1 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): 1 mg alternating with 2 mg. 1 mg today [10-7]. Check INR [10-8] with results to Dr. [Last Name (STitle) ]. Disp:60 Tablet(s) Refills:0 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:14 Tablet(s) Refills:0 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO BID (2 times a day) for 1 weeks. Disp:56 Capsule, Sustained Release(s) Refills:0 14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400 [Hospital1 ] x 4 days, then 400 QD x 7 days then 200 QD ongoing. Disp:120 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Aortic Insufficiency s/p Aortic Valve Replacement Mitral Regurgitation s/p Mitral Valve Replacement PMH: Hypertension, Hypercholesterolemia, Peripheral Vascular Disease, Varicose Veins, Congestive Heart Failure, Chronic low back pain, s/p Appendectomy, s/p cholecystectomy, s/p left finger reattached, s/p stents to left leg and angioplasty to right leg, s/p left hip replacement Discharge Condition: Good Discharge Instructions: [Month (only) 116] take shower. Wash incisions and pat dry. Do not take bath. Do not apply lotions, creams or ointments to incisions Do not drive for 1 month. Do not lift more than 10 pounds for 2 months. If you develop a fever, notice redness or drainage from incision, please contact office immediately. Call to schedule all follow-up appointments. Followup Instructions: Dr. [First Name (STitle) ] in 4 weeks. Dr. [First Name (STitle) ] in [1-22] weeks. Dr. [Last Name (STitle) ] in [12-21] weeks and for coumadin follow up [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2179-10-7] ICD9 Codes: 5990, 9971, 4019, 2720, 4439, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7438 }	Medical Text: Admission Date: [2167-12-10] Discharge Date: [2168-2-9] Date of Birth: [2097-9-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10223] Chief Complaint: LE ulcer and sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 70M CAD s/p CABG, DM , HTN, severe PVD s/p LLE bypass, ESRD on HD, EF 15% who presented to [Hospital3 417] hospital from rehab with R LE nonhealing ulcer, low grade fevers, hypotension with sBP to 50's, and L arm swelling. Was given fluid bolus and responded and started on broad spectrum abx. Was found to have MRSA bacteremia as well as hematuria and was transferrred to [Hospital1 18] for further care and ulcer debridement. Past Medical History: 1. DM2:insulin dependent 2. HTN 3. CRF on dialysis:AV graft first placed [3-18]; s/p graft clotX3 4. CAD s/p MI; CABG X5 -[2160] 5. Bilateral THR - [2157] 6. s/p pacemaker placement 7. PVD 8. LLE bypass - [2167] 9. B heel ulcers (never infected) Social History: Lives at home with long-term girlfriend. [Name (NI) ] tobacco/ethanol Family History: unknown Physical Exam: 97.2 82/42 80 96-100% on RA NAD, lying in bed, frail appearing elderly male. MMM, PERRL, EOMI, no icterus FROM, no LAD, Central line- no surrounding erythema RR with II/VI SEM CTA- anteriorly Soft, NT/ND, +BS Left leg with veous stasis but DP 2+ right leg BKA wrapped in clean/dry bandage. Pertinent Results: Echo ([1-18]): EF 30% (improved from 15% 6 mo ago); new vegetation on mitral valve. . CX: [12-9] R foot: enterobacter, pseudomonas, MRSA, peptostreptococcus [12-9] Blood: MRSA but since then has been Cx negative. [12-10] Urine: enterobact. Brief Hospital Course: The patient expired on [2168-2-9] after a long hospital course managing the problems listed below. On the day of his death, he underwent HD and returned without incident. Later that day he was found pulseless in his room, after having been reported to be fine only 10 minutes before by the nursing staff. A code was run, and then called when he failed to respond. Please see more details of his hospitalization below: # R heel gangrene: R heel wound cultures grew out multiple organisms including psuedomonas, MRSA, and VRE. Pt was seen by vascular [Doctor First Name ] and R BKA was performed (guillotine [12-11], revision [1-3]). He was started on vanc and meropenem. Meropenem was d/c'd after a 36 day course, and vanc will be continued until [2168-2-15] to complete a 6 week course (levels were checked daily after HD and pt was redosed for vanc levels <15). The pt was initially kept on a heparin gtt and then changed to coumadin for target INR of [2-18] for vascular grafts. # Hypotension- multifactorial including low CO, MR due to MV vegitation, failed [Last Name (un) 104] stim test. Pt was supported with levophed throughout his ICU stays. Finally was able to be weaned from pressors and was transferred to the floor. Digoxin was continued for inotropy- goal post HD 1-1.5 (redosed with 0.0625mg). He was continued on steroids since tapering these agents seemed to cause him to relapse with his hypotension. Midodrine was used initially, but the pt responded better to florinef, and this was later able to be tapered to 0.05mg qd for presumed adrenal insuff. His BP's improved and Captopril 3.125 tid was added. # ID/Endocarditis- An echo performed on [2168-1-18] showed a new vegetation on the mitral valve. However, the only blood culture that was positive was that from the day of admission on [2167-12-10] with MRSA. Interestingly no Cx positive since that time. He was continued on Vanc with a plan to continue for 6wks total (would have completed [2168-2-14]) with redosing for levels less than 20 after HD. . #Low grade temps and leukocytosis: Pt had an extensive workup for other sources of infection since WBC remained elevated and pt continued to have low grade fevers even while on IV vanc and meropenem. No other sources of infection were found. . #ESRD- Due to pt's hypotension, he required CVVHD for the first part of his stay, and then was changed to qd ultrafiltration with HD qod once BP improved. . #Chronic LUE edema: Pt was noted to have chronic LUE edema. Workup showed a (-) U/S on [12-29] and [1-31] repeat U/S was also (-). Pt will keep his arm elevated to avoid worsening of the edema. . # Abd pain: Pt continued to c/o epigastric discomfort that was occasionally accompanied by SOB. This was relieved with mylanta. . #Anemia - most likely secondary to ESRD currently on EPO and iron per renal with dialysis. . #[Name (NI) 1568] Pt was continued on SSI and NPH. Steroids exacerbating sugars and supposedly eats food from OSH and non-compliant with diet. . 9. FEN- renal/cardiac diet. Hyperkalemia - adjusting with HD. Nutrition consult for recs re: nutrition supplement other than Boost - i.e. sth with less K. . Medications on Admission: coumadin Vanco at HD Epogen Pravachol 40 qd Nephrocaps 1 qd Lopressor 25 [Hospital1 ] Asa 325 qd Prilosec 30 qd Lactulose 60 qd Levofloxacin 250 qd (for presumed UTI) Colace 100 [Hospital1 ] Reglan 5 qd Lansoprazole Albuterol/Atrovent prn Simvastatin Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: 1. DM2:insulin dependent 2. HTN 3. CRF on dialysis 4. CAD 5. PVD 6. B heel ulcers 7. Endocarditis 8. anemia Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired ICD9 Codes: 4275, 4280, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7439 }	Medical Text: Admission Date: [2175-10-12] Discharge Date: [2175-11-17] Date of Birth: [2151-6-30] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5883] Chief Complaint: Motor vehicle collision. Major Surgical or Invasive Procedure: [10-12]: Patient admitted. Went to OR for ex fix. of right leg. R needle decompression and CT placed for decr BP in OR, no rush of air. In OR w/ ortho/vascular for ex-fix, angiography. [10-13]: [10-15]: new subclavian line. increasing temp. Knee aspirated. New R. sub clav. Vanc/Zosin started (cefazolin/levo d/c) [10-16]: IVC filter placement. Reconstruction of RLE by Ortho. In ICU. [10-18]: Pt. operated on for hand and femur. Extubated. In ICU [2175-10-20] WV placed to R. LE [10-24]: Pt taken to OR for latissimus free flap to R. LE History of Present Illness: 24 y/o male s/p MVC [2175-10-12] - unrestrained, multiple rollover ejecteed 40 feet. Patient transported by lifeflight intubated.(GCS 13 in the field). Gross right leg deformity with a pulseless right. Past Medical History: NIDDM Social History: Musician, +tob, +MJ Family History: non-contributory Physical Exam: VS: 112, 123/73 GEN: intubated, sedated Neuro: E4VtM6 HEENT:pupils 3+ bilaterally CV: tachy, no murmurs Pulm: BS bilaterally Abd/GI: GU/flank: R flank abrasions Ext: gross R leg deformity, bone visible, + R popliteal pulse, no DP pulse on R. laceration on anterior aspect R thigh; R should abrasions Skin: ashen, multiple abrasions Pertinent Results: [2175-10-12] 11:35PM TYPE-ART PO2-124* PCO2-48* PH-7.32* TOTAL CO2-26 BASE XS--1 [2175-10-12] 11:35PM LACTATE-5.1* [2175-10-12] 11:27PM GLUCOSE-133* UREA N-13 CREAT-0.9 SODIUM-142 POTASSIUM-4.9 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14 [2175-10-12] 11:27PM CK(CPK)-9819* [2175-10-12] 11:27PM CK-MB-111* MB INDX-1.1 cTropnT-<0.01 [2175-10-12] 11:27PM CALCIUM-7.3* PHOSPHATE-5.2* MAGNESIUM-2.0 [2175-10-12] 11:27PM WBC-10.1# RBC-3.12* HGB-10.1* HCT-27.4* MCV-88 MCH-32.3* MCHC-36.8* RDW-14.8 [2175-10-12] 11:27PM PLT COUNT-116* [2175-10-12] 11:27PM PT-13.5* PTT-31.9 INR(PT)-1.2* [2175-10-12] 09:21PM TYPE-ART PO2-91 PCO2-42 PH-7.33* TOTAL CO2-23 BASE XS--3 [2175-10-12] 07:54PM TYPE-ART PO2-130* PCO2-46* PH-7.32* TOTAL CO2-25 BASE XS--2 [2175-10-12] 07:54PM LACTATE-4.5* [2175-10-12] 07:54PM freeCa-1.20 [2175-10-12] 07:44PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]->=1.035 [2175-10-12] 07:44PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2175-10-12] 07:44PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [2175-10-12] 07:44PM URINE GRANULAR-0-2 [2175-10-12] 07:36PM GLUCOSE-114* UREA N-13 CREAT-0.9 SODIUM-141 POTASSIUM-5.3* CHLORIDE-111* TOTAL CO2-23 ANION GAP-12 [2175-10-12] 07:36PM CALCIUM-8.1* PHOSPHATE-5.6* MAGNESIUM-2.1 [2175-10-12] 07:36PM HCT-30.7* [2175-10-12] 07:36PM PT-12.5 PTT-29.9 INR(PT)-1.1 [2175-10-12] 05:46PM TYPE-ART PEEP-16 PO2-108* PCO2-44 PH-7.32* TOTAL CO2-24 BASE XS--3 INTUBATED-INTUBATED [2175-10-12] 05:46PM LACTATE-4.6* [2175-10-12] 03:52PM PO2-83* PCO2-30* PH-7.36 TOTAL CO2-18* BASE XS--6 [2175-10-12] 03:52PM LACTATE-3.5* [2175-10-12] 03:52PM freeCa-0.96* [2175-10-12] 03:45PM GLUCOSE-102 UREA N-13 CREAT-0.9 SODIUM-142 POTASSIUM-5.2* CHLORIDE-112* TOTAL CO2-23 ANION GAP-12 [2175-10-12] 01:01PM OTHER BODY FLUID AMYLASE-0 [2175-10-12] 01:01PM OTHER BODY FLUID WBC-0 RBC-3556* POLYS-67* LYMPHS-5* MONOS-23* MACROPHAG-5* [2175-10-12] 12:19PM TYPE-ART PO2-156* PCO2-40 PH-7.34* TOTAL CO2-23 BASE XS--3 [2175-10-12] 12:19PM LACTATE-4.7* [2175-10-12] 12:11PM GLUCOSE-118* UREA N-13 CREAT-1.0 SODIUM-146* POTASSIUM-5.3* CHLORIDE-114* TOTAL CO2-22 ANION GAP-15 [2175-10-12] 12:11PM CALCIUM-7.8* PHOSPHATE-4.6* MAGNESIUM-1.6 [2175-10-12] 12:11PM WBC-4.3 RBC-3.60# HGB-11.6# HCT-31.6# MCV-88 MCH-32.3 MCHC-36.8* RDW-14.6 [2175-10-12] 12:11PM PLT COUNT-130* [2175-10-12] 12:11PM PT-14.0* PTT-35.6* INR(PT)-1.2* [2175-10-12] 09:56AM TYPE-ART PO2-115* PCO2-49* PH-7.24* TOTAL CO2-22 BASE XS--6 [2175-10-12] 09:56AM LACTATE-4.1* [2175-10-12] 09:56AM freeCa-1.07* [2175-10-12] 09:39AM GLUCOSE-134* UREA N-12 CREAT-0.9 SODIUM-144 POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-24 ANION GAP-12 [2175-10-12] 09:39AM ALT(SGPT)-45* AST(SGOT)-98* LD(LDH)-357* CK(CPK)-2794* ALK PHOS-34* AMYLASE-33 TOT BILI-0.5 [2175-10-12] 09:39AM LIPASE-24 [2175-10-12] 09:39AM CK-MB-38* MB INDX-1.4 cTropnT-0.13* [2175-10-12] 09:39AM ALBUMIN-2.2* CALCIUM-8.1* PHOSPHATE-4.6* MAGNESIUM-1.4* [2175-10-12] 09:39AM WBC-3.6# RBC-2.80# HGB-8.9# HCT-24.9# MCV-89 MCH-31.6 MCHC-35.6* RDW-14.9 [2175-10-12] 09:39AM PLT COUNT-142# [2175-10-12] 09:39AM PT-15.3 PTT-42.4* INR(PT)-1.4* [2175-10-12] 08:26AM TYPE-ART PO2-87 PCO2-46* PH-7.29* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED [2175-10-12] 08:07AM HGB-7.8* calcHCT-23 [2175-10-12] 08:07AM freeCa-1.08* [2175-10-12] 07:34AM WBC-9.6# RBC-1.96* HGB-6.3# HCT-17.6# MCV-90# MCH-31.9 MCHC-35.6* RDW-15.4 [2175-10-12] 07:34AM PLT SMR-VERY LOW PLT COUNT-70# [2175-10-12] 07:34AM PT-21.5 PTT-71.3* INR(PT)-2.1* [2175-10-12] 07:34AM FIBRINOGE-81* [2175-10-12] 06:22AM TYPE-ART PO2-297* PCO2-40 PH-7.30* TOTAL CO2-20* BASE XS--5 [2175-10-12] 06:22AM GLUCOSE-89 LACTATE-5.2* NA+-138 K+-3.8 CL--118* [2175-10-12] 06:22AM HGB-8.6* calcHCT-26 [2175-10-12] 06:22AM freeCa-1.07* [2175-10-12] 05:16AM TYPE-ART PO2-241* PCO2-43 PH-7.19* TOTAL CO2-17* BASE XS--11 [2175-10-12] 05:16AM GLUCOSE-116* LACTATE-5.3* NA+-138 K+-3.9 CL--119* [2175-10-12] 05:16AM HGB-9.9* calcHCT-30 [2175-10-12] 05:16AM freeCa-1.20 [2175-10-12] 04:38AM TYPE-ART PO2-279* PCO2-46* PH-7.21* TOTAL CO2-19* BASE XS--9 INTUBATED-INTUBATED [2175-10-12] 04:38AM GLUCOSE-122* LACTATE-5.5* NA+-138 K+-3.9 CL--119* [2175-10-12] 04:38AM HGB-8.7* calcHCT-26 [2175-10-12] 04:38AM freeCa-1.07* [2175-10-12] 03:55AM TYPE-ART PO2-193* PCO2-51* PH-7.16* TOTAL CO2-19* BASE XS--10 [2175-10-12] 03:23AM HGB-8.9* calcHCT-27 [2175-10-12] 03:00AM PT-18.2* PTT-38.3* INR(PT)-1.7* [2175-10-12] 01:57AM GLUCOSE-211* LACTATE-6.2* NA+-140 K+-3.6 CL--109 TCO2-20* [2175-10-12] 01:45AM UREA N-16 CREAT-1.1 [2175-10-12] 01:45AM AMYLASE-35 [2175-10-12] 01:45AM ASA-NEG ETHANOL-161* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2175-10-12] 01:45AM URINE HOURS-RANDOM [2175-10-12] 01:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2175-10-12] 01:45AM WBC-30.7* RBC-2.58* HGB-8.9* HCT-25.2* MCV-98 MCH-34.4* MCHC-35.2* RDW-13.7 [2175-10-12] 01:45AM PLT COUNT-246 [2175-10-12] 01:45AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.004 [2175-10-12] 01:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2175-10-12] 01:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [2175-10-12] 01:45AM URINE AMORPH-FEW [10-12] CT Chest/Abd/Pelvis: 1) Probable injury to the distal right common femoral vein with extensive hematoma tracking along its course proximally into the right paracolic gutter and distally into the right femoral region. The adjacent right common and external iliac arteries appear intact. No evidence of active arterial extravasation on this study. 2) Constellation of findings including hyperenhancing small bowel mucosa and flattened IVC consistent with "shock bowel". 3) No definite solid organ injury. 4) Fractures involving the right femoral diaphysis, sacrum, right inferior pubic ramus, and multiple transverse processes of the lower lumbosacral spine and diastasis of SI joints as described above. Thoracolumbar vertebral bodies are normally aligned and intact. 5) Lung consolidations consistent with massive aspiration with possible coexisting contusion. Tiny right apical pneumothorax. 6) Large thigh intramuscular hematoma. [10-12] CT Cspine: neg fx/disloc. [10-12] CT Head s contrast: No acute intracranial hemorrhage or evidence of other traumatic injury. 9/24 L. Knee: suprapatellar effusion (prelim). [10-15] CXR: Right internal jugular approach central line as above. No radiographic evidence for immediate complication. Small left pleural effusion. Re-expanded left lower lobe. [10-12] CT head: No acute ic. hem or evidence of other injury. [10-12] CT Cspine: No acute cervical spine fracture or malalignment. [10-12] CT pelvis/spine: Minimally displaced fracture off the anterior-inferior endplate of the T2 vertebral body with a small adjacent mediastinal hematoma [10-12] CT torso: R apical bleb, tiny PTX; aorta ok; B/L aspiration/contusion; liver/spleen/panc/kidneys ok; R common iliac vein ? injury w/ surrounding hematoma, no extrav, stable on repeat CT; sacral fx, pubic rami fx RLE: open femur fx, open tib-fib [10-12]: Abdominal and pelvic arteriogram performed today w/ no active extravasation of contrast. Mild arterial spasm in right common femoral artery. mild dissection, intimal flap, in the left ext iliac. [10-26]: L foot -no fracture. [11-5]: Sacrum comminuted fracture of the R sacrum & anterolisthesis of S2 on S3.Bilateral transverse process fractures at L4 [11-6]: R tib/fib- Diaphysial fracture of fibula unchanged Brief Hospital Course: [10-12]: Patient admitted. Went to OR for ex fix. of right leg. R needle decompression and CT placed for decr BP in OR, no rush of air. In OR w/ ortho/vascular for ex-fix, angiography. Not operating on ? iliac vein injury at this time. [10-15]: new subclavian line. increasing temp. Knee aspirated. New R. sub clav. Vanc/Zosin started (cefazolin/levo d/c) [10-16]: IVC filter placement. Reconstruction of RLE by Ortho. In ICU. [10-17]: Recovering from surgery yesterday. Doing well. OR tomorrow for femur/pelvis/L. hand. [10-18]: Pt. operated on for hand and femur. Extubated. In ICU [2175-10-20] WV placed to R. LE [10-23]: Patient transferred to CC6. [10-24]: Pt taken to OR for latissimus free flap to R. LE [11-4]: Began dangle protocol without difficulty. [11-11]: JP drain d/c'd RLE [11-12]: found to have approx 5x5 cm seroma at site of back incision. Overlying skin no erythematous, not warm, not tender, so opted to allow seroma to reabsorb on its own rather than draining it actively. [11-16] : Cleared by PT for d/c home with services. Medications on Admission: klonopin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 2. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical once a day. Disp:qs qs Refills:2 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for muscle spasm. Disp:30 Tablet(s) Refills:0 5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-23] Sprays Nasal TID (3 times a day) as needed. Disp:qs qs Refills:0 6. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3) Tablet Sustained Release 12HR PO Q12H (every 12 hours) as needed for pain. Disp:90 Tablet Sustained Release 12HR(s) Refills:0 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. Disp:60 Tablet(s) Refills:0 8. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Nasal daily (). 9. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 10. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:30 Tablet(s) Refills:0 11. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). Disp:qs qs Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Motor vehicle collision Discharge Condition: Stable Discharge Instructions: Please make sure you keep all your follow-up appointments. Please make sure you continue taking all the medications that you were taking prior to you hospitalization. Please seek medical attention if you experience any fevers, chills, vomiting, nausea or night-sweats. Followup Instructions: Please follow up with plastic surgery. Please call [Telephone/Fax (1) 274] to schedule your appointment in 2 weeks from hospital discharge. Please follow up with orthopedic surgery. Please call [Telephone/Fax (1) 1228] to schedule your appointment in 2 weeks from hospital discharge. Please call the ortho spine [Telephone/Fax (1) 69179] to schedule an [Hospital 6669] clinic appointment in 4 weeks from hospital discharge. Completed by:[2175-11-18] ICD9 Codes: 5185, 2851, 5070, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7440 }	Medical Text: Admission Date: [2107-6-14] Discharge Date: [2107-6-19] Date of Birth: [2107-6-14] Sex: M Service: NEONATAL HISTORY: Baby [Name (NI) ] [Known lastname ] [Known lastname 17562] delivered at 34 weeks gestation, birth weight 2500 grams, and was admitted to the Intensive Care Nursery for management of prematurity. The mother is a 32 year old gravida 1, para 0, woman with prenatal screens that included blood type A positive, antibody screen negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, and Group B Streptococcus unknown. The pregnancy was uncomplicated until the onset of preterm labor on the day of delivery. The membranes were ruptured about four and a half hours prior to delivery. No maternal fever. The mother received intrapartum antibiotics about four and a half hours prior to delivery for unknown Group B Streptococcus status. The infant emerged vigorous and was stimulated given brief free flow oxygen. Apgar scores were 8 and 8 at one and five minutes respectively. PHYSICAL EXAMINATION: On admission, weight 2500 grams, 76th percentile; length 46.5 centimeters which is 50 to 75th percentile; head circumference 32 which is 50 to 75th percentile. On examination, active, non-dysmorphic pink infant, well perfused, well saturated in room air. Skin without lesions. Anterior fontanel soft, open, flat. Ears, Eyes, Nose and Throat within normal limits. Regular rate and rhythm without murmurs. Lungs clear without distress. Abdomen soft, nondistended, no masses; no hepatosplenomegaly. Genitalia: Normal preemie male. Anus patent; spine intact. Hips normal. Neurological is non-focal and age appropriate. SUMMARY OF HOSPITAL COURSE: 1. RESPIRATORY: In no respiratory distress. Has been in room air since admission; no apnea or bradycardia. 2. CARDIOVASCULAR: Has been hemodynamically stable without murmur. Recent blood pressure was 66/37 with a mean of 47. 3. FLUIDS, ELECTROLYTES AND NUTRITION: Started ad lib demand feedings after admission; did not require any intravenous fluid. Has been taking premature [Known lastname 37112] or breast milk or breast feeding every three to four hours. Taking 50 to 55 cc. every three to four hours by bottle when mother is not here. At the time of transfer, will continue to breast feed when mother visits or have [Name (NI) 37112] 20 with iron when mother is not here. Discharge weight 2465. 4. GASTROINTESTINAL: Bilirubin at 24 hours of life was total of 5.3, direct 0.2; bilirubin on [2107-6-19], on day of life five, was up to 15.5, for a total direct of 0.4. He is receiving a phototherapy light and is on a bilirubin blanket with bilirubin level planned for tomorrow. 5. HEMATOLOGY: Hematocrit on admission 48.3 percent. 6. INFECTIOUS DISEASE: Due to preterm labor, a CBC and blood culture was drawn on admission and [Known lastname ] received 48 hours of Ampicillin and gentamicin. The CBC showed a white blood cell count of 11.2 with 39 polys and no bands. Platelets 278,000. The blood culture is negative. Antibiotics were stopped at 48 hours. 7. NEUROLOGY: Examination is age appropriate. 8. SENSORY: Hearing screening has not been performed yet. CONDITION ON DISCHARGE: Five day old former 34 week infant without apnea of prematurity, feeding well with exaggerated physiologic jaundice. NAME OF PRIMARY PEDIATRICIAN: The parents have not decided on a pediatrician yet and are looking into it. CARE AND RECOMMENDATIONS: 1. Ad lib demand feeds or breast feeding. 2. Will need car seat position test prior to discharge. 3. State Newborn Screen was drawn on [2107-6-18]. 4. Has not received Hepatitis B immunization yet; parents have information. 5. Follow-up appointment recommended - the patient will need follow-up appointment with pediatrician after discharge. Transfer to Newborn Nursery care of [Location (un) 13248] Newborn Service. DISCHARGE DIAGNOSES: 1. Appropriate for gestational age 34 week preterm male. 2. Rule out sepsis. 3. Exagerrated physiologic jaundice. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Last Name (NamePattern1) 36138] MEDQUIST36 D: [2107-6-19] 17:44 T: [2107-6-19] 17:59 JOB#: [Job Number 47743] ICD9 Codes: 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7441 }	Medical Text: Admission Date: [2179-5-15] Discharge Date: [2179-5-19] Date of Birth: [2153-8-2] Sex: M Service: MED CHIEF COMPLAINT: Outside hospital ED transfer for heroin overdose and hypoxia. HISTORY OF PRESENT ILLNESS: A 25-year-old male with history of polysubstance abuse including heroin, cocaine, benzodiazepines, marijuana, speed ball, who was found down with aspirated emesis on day of admission with respiratory rate of 4 and incontinence of stool. Patient apparently had done IV heroin and girlfriend and roommate found patient down in bathroom, barely arousable. Patient was brought to [Hospital3 56156] Emergency Department by EMS and given Narcan 6 mg en route, and patient was able to awake and give history of present illness. At outside hospital ED, he was initially alert and then became tachypnea to the 50s with decreased breath sounds and pulse oximetry 80 percent on nonrebreather. Because he did not respond to Combivent nebulizers with decreased O2 saturations, he was intubated. He self extubated and then was reintubated (noted to be traumatic). He was noted to vomit/cough up some questionably bloody secretions. His ABG at the time was 7.30/55/66. His chest x-ray showed bilateral alveolar diffuse pulmonary infiltrates concerning for ARDS. He was aggressively resuscitated with IV fluids, and laboratories drawn at outside hospital revealed a white cell count of 17.3 with 77 neutrophils, 9 bands, 13 lymphocytes, and transferred to [Hospital1 69] ED. At outside hospital, also was noted to have negative EtOH, Tylenol less than 2, TCA negative, and ASA less than 2. In [Hospital1 69] ED, temperature was 102.4, tachycardic to 130s, and repeat chest x-ray showed bilateral interstitial and patchy alveolar infiltrates. Here his serum tox was negative for aspirin, EtOH, Tylenol, benzodiazepines, TCA, barbiturates, and urine tox was positive for benzodiazepines, opiates, and cocaine. PAST MEDICAL HISTORY: Polysubstance abuse (inhaled and IV heroin, EtOH, marijuana, speed ball, benzodiazepines). MEDICATIONS: None. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: About one case of cigarettes a week, drinks twice a week each time seven drinks (mixed drinks/hard liquor), polysubstance use of illegal drugs as above. PHYSICAL EXAMINATION ON ADMISSION: Temperature 102.4, pulse 144, blood pressure 85/43, respirations 19-26, oxygen saturation 96 percent on AC 24 x 450, 60 percent FIO2, PEEP 10. General: Intubated, sedated, and agitated. HEENT: Moist mucous membranes with ETT/nasogastric tube in, PERRLA, soft tissue swelling left eyebrow with erythema. Neck: No JVD. Cardiovascular: Normal S1, S2, tachycardic, regular rate, no murmurs, rubs, or gallops. Pulmonary: Bilateral rales with occasional wheeze. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended. Extremities: 2 plus dorsalis pedis pulses bilaterally, no edema. Neurologic: Minimally responding to voice and following some commands. Skin: Tattoos present on upper extremities bilaterally. Rectal: Soft brown stool, guaiac positive. LABORATORY DATA: White count 18.3, hematocrit 56.2, platelets of 239. BUN 17, creatinine 1.0, bicarbonate 25. ABG on 100 percent FIO2: 7.31/46/126. EKG: At outside hospital, sinus tachycardia at 110 beats per minute, normal axis and intervals, no ST-T wave abnormalities. HOSPITAL COURSE: Respiratory failure: The patient was treated with levofloxacin and Flagyl for presumed aspiration pneumonia given chest x-ray appearance and hypoxia with fevers. He improved rapidly on this regimen and was extubated without complications. He was weaned completely off oxygen within 24 hours and experienced some relief from albuterol/ipratropium MDI. He was discharged on course of levo/Flagyl to complete seven days. Polysubstance abuse: The patient was placed on CIWA and [Doctor Last Name ] scales prn, and received dose of methadone for cold sweats. He also received nicotine patch. Social Work and [First Name8 (NamePattern2) 2411] [Last Name (NamePattern1) 2412] of Addition service evaluated the patient and offered both support and information. He is scheduled to be evaluated by outpatient program for detox. Patient appears to want to quit, but due to that he was not ready for inpatient detox. Neurologic: Because patient was initially noted to have sluggish left dilated pupil, he had a head CT, which showed no hemorrhage, shift, or fracture, and had a MRI, which was normal as well. Hemoptysis/hematemesis: This was likely due to traumatic reintubation at outside hospital. He did not have further episodes of this while hospitalized here, and was noted to have a stable hematocrit. Cardiovascular: A [5-14] troponin was noted 0.04 with elevated CK, but negative MB index, and subsequent negative cardiac enzymes. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: Heroin overdose. Polysubstance abuse. Aspiration pneumonia. DISCHARGE MEDICATIONS: 1. Albuterol/ipratropium MDI prn shortness of breath/wheezing over the next few days. 2. Metronidazole 500 mg p.o. t.i.d. x4 days. 3. Levofloxacin 500 mg p.o. q.d. x4 days. FOLLOW-UP PLANS: The patient was given my card incase he would like to come here for followup, though it was suggested that he may want to followup closer to his home for convenience. [First Name8 (NamePattern2) 2411] [Last Name (NamePattern1) 2412] has made an appointment at APCARE in [Location 21487] for [2179-5-21] at 9:30 a.m. for an intake appointment for outpatient detox/methadone program. Patient was also given her phone number and that of other resource phone numbers as needed. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], [MD Number(1) 5617] Dictated By:[Last Name (NamePattern1) 7193] MEDQUIST36 D: [2179-5-19] 17:11:52 T: [2179-5-20] 06:15:25 Job#: [Job Number 56157] ICD9 Codes: 5070
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7442 }	Medical Text: Admission Date: [2130-5-21] Discharge Date: [2130-7-7] Date of Birth: [2130-5-21] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname 61256] is a 1665 gram product of a 32 week gestation, born to a 37 year-old, Gravida II, Para 0, now I Mom. PRENATAL SCREENS: 0 positive, antibody negative, hepatitis surface antigen negative. RPR nonreactive. Rubella immune. GBS unknown. This pregnancy was notable for a cystic fertilization and early marginal placenta previa, subsequently resolved. Normal amniocentesis, 46XX and normal 16 week fetal ultrasound. Mother presented on [4-18] with premature rupture of membranes. She was treated with a full course of Betamethasone and approximately 5 days of antibiotics at that time. She has been hospitalized since and with reassuring fetal monitoring, although ultrasounds have shown oligohydramnios. The evening of delivery, she was noted to develop a fever, chills, uterine contractions, and fetal tachycardia. Mother was given Ampicillin and Gentamycin and then taken for Cesarean section for presumed chorioamnionitis. Infant emerged with decreased tone and respiratory effort, requiring brief positive pressure ventilation with good response. Apgars were 6 and 8. PHYSICAL EXAMINATION: Birth weight 1665 grams. Head circumference 30 cm. Length 42 cm. Anterior fontanel open and flat with significant molding and shaping of head, not distinctly dysmorphic. Fontanel soft and flat. Palate intact. Bilateral red reflexes. Ears and nares normal. Neck supple, no lesions. Full passive range of motion. Chest with poor aeration, coarse bilaterally, positive retractions and flaring, moderately tachypneic. Regular rate and rhythm. No murmur or gallop. Abdomen: Soft, no hepatosplenomegaly, no masses, quiet bowel sounds. Three vessel cord. Normal female genitalia. Femoral pulses 2+. Anus patent. No edema. Hips and back normal. Mildly decreased tone and activity. Positive grasp and weak suck/moro. HOSPITAL COURSE: 1. Respiratory: [Known lastname ] was admitted to the newborn Intensive Care Unit with mild respiratory distress. She was placed on C-Pap at 12 hours of age. She was intubated and received two does of Surfactant and extubated within 24 hours. She has been stable in room air since that time. She did not require muscle vamping for management of apnea and bradycardia of prematurity. She did demonstrate mild apnea and bradycardia. Her last documented episode was on [2130-7-1]. Cardiovascular: She has been cardiovascularly stable thorughout her hospital course with no concerns. 1. Fluids, electrolytes and nutrition: Birth weight was 1665 grams. She was initially started on 80 cc/kg/day of D-10- W. Initial D-sticks were low requiring D-10 boluses. Enteral feedings were initiated on day of life number two. She advanced to full enteral feedings by day of life number 7. Maximal enteral intake was 150 cc/kg/day of breast mild 30 with ProMod and she is currently ad lib feeding breast milk 24 calorie, concentrated with Similac powder. Her discharge weight is . 1. Peak bilirubin was on day of life number 4 of 9.7 over 0.3. She required phototherapy. Rebound bilirubin was 5.6 over 0.2 on day of life 7. This issue has been resolved. 1. Hematology: Hematocrit on admission was 46.5. She has not required any blood transfusions during this hospital course. She is currently receiving Ferrous sulfate supplementation. Her most recent hematocrit was 27.3 with a reticulocyte count of 3.7% on [2130-6-27]. 1. Infectious disease: A CBC and blood culture obtained on admission, in light of clinical course and clinical presentation of mother with increased concern of chorioamnionitis. Infant received a total of 7 days of Ampicillin and Gentamycin, although blood cultures remained negative and initial and repeat CBC's were within normal limits. Lumbar puncture was obtained and was within normal limits. The infant had no further issues with sepsis. 1. Neurology: Infant has been appropriate for gestational age. 1. Audiology: Hearing screen has been performed with automated auditory brain stem responses and the infant passed both ears. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 174]. Telephone number is [Telephone/Fax (1) 41277]. CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk concentrated to 24 calories with Similac powder. MEDICATIONS: Continue Ferrous sulfate supplementation and Vi- Day-[Doctor First Name ] 1 ml p.o. q. day. CAR SEAT POSITION SCREENING: NEWBORN SCREENS: Newborn screens have been sent for protocol and have been within normal limits. Infant has not received any immunizations as parents requested to have pediatrician provide them. DISCHARGE DIAGNOSES: 1. Premature female, born at 32 weeks, corrected at 38 and 5/7 weeks. 2. Mild respiratory distress syndrome, rule out sepsis with antibiotics. 3. Mild hyperbilirubinemia. 4. Mild apnea and bradycardia of prematurity. 5. Anemia of prematurity. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2130-7-7] 00:19:39 T: [2130-7-7] 05:29:34 Job#: [Job Number 61257] ICD9 Codes: 769, 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7443 }	Medical Text: Unit No: [Numeric Identifier 76101] Admission Date: [2159-10-22] Discharge Date: [2159-12-17] Date of Birth: [2159-10-22] Sex: F Service: NB SERVICE: Neonatology. HISTORY: This infant was admitted to the NICU for prematurity and respiratory distress. This infant was born at 30 and 0/7 weeks' gestation to a 37-year-old, G8 P2 mother with [Name2 (NI) ] type [Name (NI) 57108], antibody negative, HBsAg negative, RPR nonreactive, GBS unknown. Maternal history is remarkable for GERD treated with Zantac and Reglan, as well obesity status post abdominoplasty. The mother is a cigarette smoker. Maternal obstetric history was notable for two prior deliveries, one at term and one near-term, one in [Country 9362] and the other in [Location (un) 4551]. This pregnancy was notable for spontaneous di-di twinning and was complicated by cervical shortening which was followed with serial scans. The mother was admitted on [2159-10-17] with cervical dilatation. Betamethasone was given at that time. The decision was made to deliver several days later due to continued cervical dilatation. Delivery was done under spinal anesthesia and it was a C-section. The infant emerged with a vigorous cry. The infant required PPV and intubation in the delivery room due to respiratory distress, and was then [Last Name (un) 4662] to the NICU. The infant's Apgars were 5 and 8. Of social note, the family has recently moved from [State 3706] and are new to the area. They are originally from [Country 9362]. They have a 15-year-old son who was born at 36 weeks and has behavioral issues. MEASURES AT BIRTH: A birth weight of 1710 grams which is 75th to 90th percentile, length of 41 cm, which is 50th to 75th percentile, head circumference of 29 cm, which is 50th to 75th percentile. PHYSICAL EXAMINATION AT DISCHARGE: GENERAL: Shows an infant who is pale-pink, skin warm and dry. HEENT: Anterior fontanelle open and flat. Normal facies, intact palate. Normal ears. Bilateral red reflexes. NECK: Supple. RESPIRATORY: Breath sounds clear and equal with no retractions, comfortable breathing. CARDIAC: Soft systolic murmur, heard best laterally, pale-pink, well-perfused. Normal pulses. GI: Abdomen soft and rounded. Good bowel sounds. No masses. Cord healed. GU: Normal female genitalia. MUSCULOSKELETAL: Normal extremities. Moves all extremities well. Straight spine. No dimple. Intact hips. NEURO: Good tone. Normal reflexes. Physical exam at discharge also shows a weight of 2980 grams, length of 49.5 cm and a head circumference of 35 cm. SUMMARY OF HOSPITAL COURSE BY SYSTEM: 1. Respiratory: Initially, the infant was given two doses of surfactant while intubated and weaned to CPAP on day- of-life two. From CPAP went to room air on day-of-life four and has remained stable on room air since that time, but did develop some apnea of prematurity requiring methylxanthine therapy of caffeine citrate which was started just prior to extubation. The infant remained on caffeine citrate until [2159-11-19], at which time it was discontinued. Rare apneic spells were noted subsequently which gradually resolved. At the time of discharge, the infant is breathing comfortably in room air, without any apneic episodes noted for over one week. Occasional mild desaturations during feedings persisted, but by the time of discharge, infant had been feeding well for 48 hours without difficulty. 2. Cardiovascular: The infant has maintained cardiovascular stability while in the NICU and has required no cardiac evaluations, has had normal heart rates, [Year (4 digits) ] pressures. A soft systolic murmur was noted during hospitalization that is persistent at discharge; exam is otherwise unremarkable and multiple x-rays have shown normal heart size and clear lung fields. Murmur is most consistent with peripheral pulmonic stenosis, and can be followed clinically. 3. Fluid, electrolytes and nutrition: UVC was placed on admission to the NICU for IV fluid administration. The infant was NPO at that time. Enteral feedings were started on day two of life and advanced to full enteral feedings at day seven by one week of age. The infant began having frank [Year (4 digits) ] in the stool on [2159-11-29], at which time the infant was made NPO and a KUB was done with questionable area of pneumatosis. The infant was treated for 10 days for necrotizing enterocolitis at which time the enteral feedings were reestablished and the infant achieved full enteral feedings again by [2160-12-13]. Due to presence of elevated eosinophils at time of episode of colitis, it was decided to restart feedings with breast milk with mother encouraged to limit dairy intake or nutramigen. At this time, the infant is all p.o. feeding, Nutramigen or breast milk, 24 cal per ounce with Nutramigen powder for supplementation, all p.o. taking approximately 170 mL per kilo per day. The infant is showing steady weight gain and good growth, is voiding and stooling normally with an occasional heme- positive stool, no frank [Year (4 digits) ]. The infant was started on supplemental iron and multivitamins once full feedings were achieved on [2159-12-14]. The infant remains on supplemental iron and multivitamins at discharge. 4. GI: The infant had hyperbilirubinemia which was treated with phototherapy. The peak bilirubin level was 10.8/0.3 and the infant received a total of eight days of phototherapy. This is now a resolved issue. The infant was treated with medical NEC as mentioned above from [2159-11-29] to [2159-12-8]. 5. Hematology: The infant's [Year (4 digits) ] type is A-positive, DHE negative. The infant has required no [Year (4 digits) ]-product transfusions while in the NICU. The most recent hematocrit was done on [2159-12-14], and was notable for anemia with a level of 24.1 with a reticulocyte count of 5.9%, decreased from 26.5 eight days earlier. Infant is being treated with 4 mg per kilogram per day of supplemental iron in addition to the feeding, which is 0.5 mL p.o. daily. 6. Infectious disease: A CBC and [Year (4 digits) ] culture were done on admission to the NICU. The CBC was benign at that time. The infant received 48 hours of ampicillin and gentamicin which were subsequently discontinued and the [Year (4 digits) ] culture remained negative at that time. Again, the infant was treated for medical NEC starting on [2159-11-29] at which time the infant presented with bloody stools. The CBC at that time was benign. The infant was treated with 10 days of Zosyn which was subsequently discontinued on [2159-12-8]. The infant was also given 48 hours of miconazole powder for a diaper rash from [2159-11-29] to [2159-12-1]. There have been no other infectious disease issues. 7. Neurology: The infant had head ultrasounds done at one week and one month of age which were normal. Otherwise, the infant has maintained normal neurologic exams for gestational age. 8. Sensory: a. Audiology: A hearing screen was performed with automated auditory brainstem responses and the infant passed in both ears. b. Ophthalmology: The infant had two ophthalmologic exams. The initial showed immaturity to zone three on [2159-11-19]. A follow-up ophthalmologic exam was done on [2159-12-10] which showed mature retinas at that time with the recommended ophthalmologic followup at nine months of age. The ophthalmologist was O'[First Name9 (NamePattern2) ] [Doctor Last Name ]. 9. Psychosocial: The family is involved and intact. The twin was discharged prior to this twin and is home doing fine. The family visits and appears appropriate while here. The social worker has been in contact with the family. There are no active issues at this time, but if there are any concerns, she can be reached at ([Telephone/Fax (1) 64591]. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parent. NAME OF PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 38676], M.D., telephone number ([Telephone/Fax (1) 67162]. CARE RECOMMENDATIONS: Ad lib p.o. feedings of breast milk supplemented with Nutramigen powder for an additional four calories per ounce or Nutramigen powder when not breast-fed, p.o. ad lib. MEDICATIONS: 1. Ferrous sulfate 0.5 mL p.o. daily and Goldline multivitamin 1 mL p.o. daily. 2. Iron and vitamin D supplementation. a. Iron supplementation is recommended for preterm and low-birth-weight infants until 12 months corrected age. b. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 International Units which may be provided as multivitamin preparation daily until 12 months corrected age. CAR SEAT: This infant has passed in the car seat position screening. NEWBORN SCREEN: State newborn screens were sent on [2159-10-25] which showed an abnormal amino acid profile. Repeat was done on [2159-11-7] which was within normal limits. IMMUNIZATIONS RECEIVED: The infant received the hepatitis B vaccine on [2159-11-20]. The infant also received Synagis on [2159-12-7]. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants meeting any of the following four criteria: a. Born less than 32 weeks' gestation. b. Born between 32 and 35 weeks with two of the following: Either daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school-age siblings. c. Chronic lung disease. d. Hemodynamically significant congential heart defects. 2. Influenza immunization is recommended annually in the fall for all infants once they reach six months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. This infant has not received the 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 six weeks, but fewer than 12 weeks of age. FOLLOW-UP APPOINTMENTS: Scheduled for the pediatrician on [2159-12-19], and that is with [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 38676]. An early intervention referral has been made on [2159-12-17] with [Location (un) 15953] EIP in [Location (un) 620], telephone number ([Telephone/Fax (1) 76102]. VNA referral was made. DISCHARGE DIAGNOSES: 1. Prematurity, born at 30 and 0/7 weeks' gestation, twin infant. 2. Respiratory distress syndrome, resolved. 3. Apnea of prematurity, resolved. 4. Hyperbilirubinemia, resolved. 5. Necrotizing enterocolitis, treated and resolved. 6. Possible milk protein intolerance. 7. Anemia of prematurity, ongoing. 8. Murmur consistent with peripheral pulmonic stenosis, ongoing. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Name8 (MD) 75423] MEDQUIST36 D: [2159-12-17] 21:28:02 T: [2159-12-17] 22:25:27 Job#: [Job Number 76103] ICD9 Codes: 769, 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7444 }	Medical Text: Admission Date: [2151-2-3] Discharge Date: [2151-2-15] Date of Birth: [2095-12-25] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 158] Chief Complaint: nausea, vomitting, abdominal pain Major Surgical or Invasive Procedure: [2151-2-8]: ex lap, sigmoid colectomy, left salpingo-oophorectomy, diverting loop ileostomy [2151-2-10]: washout and closure History of Present Illness: 55 year old female with no known past medical history who was admitted for abdominal pain and N/V, found to have new large colonic mass causing bowel obstruction, now s/p resection. The patient had been previously well until 2 weeks ago, when she started having constipation and was started on colace. A stool guaiac was obtained and it was positive. She underwent an EGD and colonoscopy on [2151-2-2], during which a mass in splenic flexure was found and biopsied. She then presented the following day on [2151-2-3] with sudden-onset nausea and vomiting after prep for colonoscopy. . On admission, she was found to have a partial large bowel obstruction at the sigmoid colon with the transition point at the location of her mass. She was also found on CT scan to incidentally have four pulmonary nodules consistent with metastatic disease. She was made NPO, given IV fluids, and NG tube placed for decompression. Remained obstructed and distended, so a family meeting was held regarding her prognosis, and they opted for surgical intervention. Past Medical History: Hemorrhoids 20 yrs ago Social History: She lives with her husband, daughter and son, she works as a cook in a local restaurant. She denies drinking, tobacco, or illicit drugs. Family History: Non-contributory, no family hx of cancer Physical Exam: Discharge Physical Exam: VS: Tm 98.4, Tc 97.6, HR 79, BP 105/68, RR 18, SO2 98% RA GEN: NAD Cards: RRR, no RMG Pulm: CTAB Abd: soft, nt, nd, normal bs, incision without erythema/tenderness Extrem: CCE Pertinent Results: WBC: 3.8, hgb 14.4, hct 45.2, plt 273 Na+137, K3.3, Cl 108, Bicarb22, BUN 11, Cr 0.3, Gluc 149, Ca+6.4, Mg1.5, Phos 2.6 PT 11.2, PTT 31.6, INR 1.0 ABG: pH 7.49 pCO2 27 pO2 371 HCO3 21 BaseXS 0, K+ 2.8 (repleted), lactate 1.5 CEA 3.0 UA: Neg Leuk, Neg Nitr, WBC 10, Bact Few, 0 Epi . Micro: Urine culture [2151-2-8] pending . Images: [2-3] CT abd/pelvis with contrast: 1. 1-cm nodule in the left lung base should be further evaluated with a dedicated chest CT on a non-emergent basis. 2. Dilated fluid-filled loops of small bowel with relative transition point at the level of the sigmoid colon. Distended large bowel. 3. Segment of the descending colon appears thickened and irregular which may be related to recent colonoscopy. No free air seen. 4. Ascites. [2-4] KUB: Large bowel obstruction. Severe cecal dilatation to 10.9 cm. No free air or pneumatosis. [2-4] CT chest: 1. Four pulmonary nodules measuring up to 11 mm within the lungs bilaterally are most consistent with metastatic disease. None of these are located centrally and would probably not be amenable to endobronchial biopsy. 12 mm right hilar lymph node, immediately anterior to the right mainstem bronchus at the level of the right pulmonary artery. 2. Marked distention of proximalsmall bowel loops up to 5.3 cm in diameter, unchanged. 3. Trace bilateral pleural effusions. Mild cardiomegaly. [2-7] KUB: As compared to prior examination, there is interval slight decrease in the distention of the bowel loop still substantially dilated, up to 5.5 cm for the small bowel and up to 6 cm for the large bowel. Again is noted paucity of the bowel gas in the pelvis with only minimal amount of air questionably located in the rectum. This might correspond to fluid-filled bowel loops as opposite to air-filled. The NG tube tip is in the stomach. The right pleural effusion is noted, appears to be slightly increased since [2151-2-3]. . EKG: [2151-2-8] rate 91, sinus rhythm, nonspecific twave changes Brief Hospital Course: 55 year old female with no known PMH who was admitted for abdominal pain, N/V, new large colonic mass causing bowel obstruction. She underwent open left colectomy and diverting loop ileostomy, and subsequent washout and closure of abdomen. She tolerated this well. Her hospital course by systems is as such: Neurovascular: Patient required paralytics postoperatively from her ex.lap on [2151-2-8], however this was weaned. While on mechanical ventilation she was transitioned to fentanyl and versed. After extubation, she was still quite sedated, but this resolved within 24 hours and was thought to be secondary to persistent effects of sedating medication. Respiratory: Following her colectomy and ileostomy on [2151-2-8], she required mechanical ventilation. After her washout on [2-10]/2 she passed her spontaneous breathing trial on [2151-2-11] and was extubated. She was weaned to room air and transferred to the floor where she was stable on room air until discharge. Cardiovascular: Patient had minimal pressor requirement after initial surgery on [2-8]. This was weaned down and the patient started autodiuresing. GI/Nutrition: Patient was maintained on TPN for nutrition while unable to take POs. By 36 hours after extubation, the patient was tolerating clears. Her diet was subsequently advanced once she was moved to the floor. Her ostomy had excellent output postoperatively. Electrolytes: Repleted prn Medications on Admission: Calcium 500mg QD Vit D 1 tab Q day Colace 100mg TID Ferrous sulfate 1 tab Q day Discharge Medications: 1. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). Disp:120 Capsule(s) Refills:1 2. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 3. Vitamin D Oral 4. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours: Please take this medication if the tylenol is not controlling your pain. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: Colonic Adenocarcinoma Large Bowel Obstruction Respiratory Failure Hypotension Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to the [Hospital1 18] Colorectal surgery service where you underwent a procedure to remove an obstructing mass in your large bowel. At this time we feel you are safe to go home and continue your recovery at home. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. In particular, be sure to take the newly prescribed loperamide 4 times daily. Please take the prescribed analgesic medications as needed. You may not drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician so they may further direct your care. Incision Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. You have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. You must measure your ileostomy output for the next few weeks as the ostomy nurses have taught you. The output from the stoma should not be more than 1200cc or less than 500cc. If you find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if you notice your ileostomy output increasing, take in more electrolyte drink such as gatoraide. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If you notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. You may eat a regular diet with your new ileostomy. However it is a good idea to avoid spicy foods. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. The stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as you have been instructed by the wound/ostomy nurses. You will be able to make an appointment with the ostomy nurse in the clinic for this week. You will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until you are comfortable caring for it on your own. Thank you for letting us participate in your care. We wish you a speedy recovery. Followup Instructions: Please call tomorrow to schedule an appointment in clinic with Dr. [Last Name (STitle) ] at ([Telephone/Fax (1) 3378] for 10 days from now. Please also call the ostomy clinic to make an appointment with the Ostomy Nurses: ([Telephone/Fax (1) 34123] for this week. Completed by:[2151-2-16*] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7445 }	Medical Text: Admission Date: [2132-3-11] Discharge Date: [2132-4-14] Date of Birth: [2057-6-14] Sex: F Service: MEDICINE Allergies: Talwin Nx / Heparin Agents Attending:[First Name3 (LF) 898] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Liver Biopsy--> no complications Central line placement. History of Present Illness: Patient is a 74 yo woman with PMH of rheumatic heart disease, breast cancer, DM2, AFib who was transferred to [Hospital1 18] on [2132-3-11] from [Hospital ] Hospital for semi-elective valve replacement. Patient had been in her USOH until couple years ago, when her son noticed DOE. She had not noticed this as a problem at the time. The patient began noting more concerning symptoms in [Month (only) ]/[2131-10-23] when began noticing she would become SOB on more minimal exertion. She presented to her cardiologist re: these concerns in [2131-11-22], at which time he did an ECHO that demonstrated LVH, EF=55-60%, mod-severe MR, mod AR, ?pulm valve stenosis, mild TR. At this time, per patient, she was urged to consider valve replacement surgery, but the patient initially refused. Over the past couple months, pt has noted worsening of her SOB so that she now feels some SOB at rest. A couple weeks ago she also noted some swelling in her ankles and orthopnea. ROS also negative for CP/pressure, TIA sxs. Therefore, pt re-presented to her cardiologist, now requesting surgery for her sxs. Pre-op w/u prior to presentation included cardiac cath at [Hospital 47] hospital on [2132-3-10], which demonstrated no significant CAD, severe AS, mod-severe MR, elevated filling pressures, decreased CO at 3.24 (Fick), decreased CI at 1.56 (Fick), PCWP 24, RA mean 18, PA 49/26, RV 53/6. Patient was admitted to CT surgery service on [2132-3-11] and transfered to CCU for optimization of clinical status prior to surgery after developing fever to 101.5. Started on vanc and zosyn for empiric coverage. Found to have enterococcus in urine and treated with Zosyn-->levaquin for 10 day course. Course them complicated by dropping HCT. GI consulted and pt found to have gastic varicies. Pt anticoagulated with heparin for Afib and anticipating surgery. course again complicated by rising LFT's. Pt had liver bx on [3-31] for elevated LFT's. path pending. HF service consulted for CHF, volume overload in setting of elevated creat and decreased Na. Pt started on Niseritide with goal of taking off 10 lbs prior to surgery. Past Medical History: 1.) Rheumatic heart disease 2.) DM2 - on oral hypoglycemics 3.) Breast cancer - initially dx in [2117], s/p mastectomy and placed on tamoxifen. Then recurred in [2123], s/p surgical resection, chemo, radiation. Since that time mammograms have been negative. 4.) AFib - ?dx 1 month ago, on atenolol for rate control 5.) HTN 6.) TAH Social History: No tobacco, EtOH, drug use. Lives alone, son lives nearby. Husband just died of heart problems in [2131-11-22]. Had a daughter that died of cancer. 2 other children. Family History: NC Physical Exam: VS T:97 P:84 BP:99/66 (leg) RR:16 O2Sat:100%2L GENERAL: Anasarca, pleasant and talkative, speaking in full sentences. NAD HEENT: MMM, pupils equal NECK: supple, no LAD, elevated JVD. CARDIOVASCULAR:irreg, irreg, [3-27] blowing systolic murmur. LUNGS:Diffuse rales to 2/3 up. Decreased BS at bases. ABDOMEN: Obese, edema, soft, NT, NABS EXTREMITIES:Anasarca, pale, non-palp pulses, warm. NEURO:A&Ox3. Non-focal. Pertinent Results: [2132-3-11] 08:57PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2132-3-11] 01:15PM GLUCOSE-167* UREA N-30* CREAT-1.3* SODIUM-136 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14 [2132-3-11] 01:15PM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-69 AMYLASE-65 TOT BILI-0.6 [2132-3-11] 01:15PM LIPASE-33 [2132-3-11] 01:15PM WBC-9.2 RBC-3.72* HGB-10.3* HCT-30.8* MCV-83 MCH-27.7 MCHC-33.5 RDW-16.7* [2132-3-11] 01:15PM PLT COUNT-186 [2132-3-11] 01:15PM PT-14.5* PTT-26.2 INR(PT)-1.3* . Carotid u/S: IMPRESSION: Minimal plaque with a left less than 40% carotid stenosis. The right carotid was not evaluated due to the central line. . ECHO: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is mildly depressed. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular systolic function is normal. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Moderate to severe (3+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . LENI: IMPRESSION: No evidence for DVT. . CT abd: IMPRESSION: 1. Left pleural effusion, without right pleural effusion. Etiology of this is unclear and a chest x-ray is recommended for further evaluation. 2. Right groin hematoma. No drainable fluid collection is seen. 3. No evidence for retroperitoneal hemorrhage. . CXR: The cardiac silhouette is markedly enlarged but stable. There remains a moderate-sized left pleural effusion with adjacent atelectasis in the left lower lobe. A small right pleural effusion is also noted and is not seen on the previous study. Note is made of prior left mastectomy and axillary lymph node dissection as well as asymmetrical apical thickening on the left, possibly related to prior radiation therapy. . CTA abd: IMPRESSION: 1. Multiple splenic hilar varices extending to the proximal greater curvature of the stomach becoming gastric varices with splenorenal shunt. No evidence for splenic vein thrombosis or splenomegaly. No evidence for esophageal varices. The combination of these findings, along with a large inferior vena cava with contrast reflux into the hepatic veins, bilateral pleural effusions, and pericardial effusions suggest right heart failure and volume overload. 2. Low-density left adrenal lesion consistent with an adrenal adenoma. . Brief Hospital Course: Given severity of mitral and aortic valve disease, pt expressing CHF sxs, progressive over past 6 months plan was for valve replacement with MVR and AVR once medically stable. Pt had cath at OSH prior to surgery which showed normal coronaries. Pt was diuresed intially in the CCU with swan guidance. However, prior to surgery pt found to have a UTI which was treated with 7 days of Levaquin. Pt cleared the UTI but her HCT slowly began to drop and she was found to be GUIAC positive. Pt was on a heparin gtt at this point in anticipation of surgery. Gi service was consulted and felt that pt should have a colonoscopy and EGD prior to the surgery to assess risk. Colonoscopy revealed hemorroids and the EGD revealed large gastric varicies. There was concern to severe liver damage given the secondary findings. Therefore the patient underwent a liver biopsy on [2132-3-31] to, again, asses for risk of surgery. The biopsy showed grade III fibrosis while would put her at 30-50% mortality risk for this surgery. This made the patient no longer a condidate for this surgery. Lipitor was also discontinued for hepatic dysfunction. The patient was fluid resuscitated during the GI bleed and subsequently became markedly fluid overloaded and anasarcic. She was started on smal doses of IV lasix and transfered to the medicine service. At this point her Na was gradually dropping with a nadir of 120 due to CHF and volume overload. In addition, the pt was going into worsening reanl fialure with her creatinine of 3 from a baseline of 1.3. The CHF service was consulted and recommended starting Niseritide as pt did not seem to be responding to this. The patient was aslo started on Amiodarone for her afib and a low dose BB for better rate control to improve cardiac output. The patient had gained 10kg as well. The pt continued to gain wgt on the Niseritide with no improvement in her sodium. The renal service was consulted for assitance with diuresis, hyponatremia and worsening renal failure. They recommended an aggressive regimen of Lasix 160 IV qd abd Diuril 250 IV QD. The patient received this regimen for approximately one week with very good response. She lost 15kg of fluid and was diuresing 2L per day. The Diuril was discontinued and the pt was placed on an IV Lasix taper with the goal of finding an oral regimen that she could be discharged on. Her creatinine came back down to baseline after the diuresis as well. The patient was converted to Lasix 80mg PO BID with good response. Plan would be to address afterload reduction with ACE-I or Imdur and hydralazine after consultation with Dr. [Last Name (STitle) 1290] on [4-17]. Pt has DM2 and was maintained on a sliding scale during this admission but added back oupt glyburide on 2 days prior to discharge with good response and FS<180 but will likely need a second [Doctor Last Name 360] since we cannot use metformin any longer with her chronic renal failure. While the patient was on the Heparin gtt awaiting surgery she developed thrombocytopenia. A heparin antibody was checked and was positive. The patient was switch to argatroban for anticoagulation and the pt was diagnosed with HIT. Hematology was consulted for assistance with furture anticoagulation. The patient remained on the argatrogan for 10 days and was started on coumadin therapy towards the end of her admission for continued anticoagulation given her afib and risk of thrombosis after HIT. Thrombocytopenia resolved as coumadin was restarted and INR increased to INR 2.0 on admission. Plan is to maintain INR 2.0-3.0 on doses of coumadin 7.5-10mg per Heme/Onc and she will follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2148] on [4-25] in [Hospital ] clinic. During this admission the patient was noted to be somewhat depressed at times. She did note that her husband had recently passed away and she was having difficulty dealing with the extent of her admission. Psychiatry was consulted and the patient was started on Remeron. She had confusion with this and was given Haldol for agitation. She seemed to have symptoms of akethesia with this so Haldol was avoided for the remainder of the admission. Pt was then started on Seroquel at night. Within 3 days she developed a Leukopenia which resolved after stopping this medication. After this, the patient decided that she did not want to try any other medications and would deal with her depression through talk therapy when able. The patient did have further episodes of frustration and at one point reversed her code status to DNR/DNI and wanted to return home as CMO. However, after further discussion with psychiatry and the palliative care service the patient stated that she was just very uncomfortable and if efforts such as removing foley and getting better food were met she was very pleased and requesting full medical treatment. A family meeting was held with the patients son and brother and goals of care discussed. The patient is a FULL CODE. Medications on Admission: Medications: At Home: ASA 81mg QD Synthroid 100mcg QD Atenolol 50mg QD Lipitor 10mg QD Glyburide 10mg [Hospital1 ] Metformin 500mg [Hospital1 ] Triamterene/HCTZ 37.5/25mg QD On Transfer: Insulin SC Levothyroxine Sodium 100 mcg PO DAILY Lorazepam 0.5 mg PO Q8H:PRN Acetaminophen 325-650 mg PO Q4-6H:PRN Metoprolol 12.5 mg PO BID Amiodarone HCl 200 mg PO TID Milk of Magnesia 30 ml PO Q6H:PRN Aspirin EC 81 mg PO DAILY Mirtazapine 15 mg PO HS Atorvastatin 10 mg PO DAILY Nesiritide 0.015 mcg/kg/min IV INFUSION Bisacodyl 10 mg PO/PR DAILY:PRN Pantoprazole 40 mg PO Q24H Docusate Sodium 100 mg PO BID Simethicone 40-80 mg PO QID:PRN Guaifenesin [4-30] ml PO Q6H:PRN Tucks Hemorrhoidal Oint 1% 1 Appl PR DAILY Heparin IV TraZODONE HCl 50 mg PO HS:PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal DAILY PRN (). 10. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday). 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection Injection 2X/WEEK (WE,SA). 13. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO DAILY (Daily). 18. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 ] Rehab, [Hospital 1110] Campus Discharge Diagnosis: Aortic Valve stenosis Mitral valve stenosis Congestive Heart Failure Atrial Fibrillation Hepatic congestion Heparin induced thrombocytopenia diabetes type II Discharge Condition: Stable. Discharge Instructions: Please return to the hospital if you experience chest pain, shortness of breath, nausea/vomiting/diarrhea or any other severe symptoms. Please call your doctor if you have any questions about your symptoms. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 1290] at 9:30am on [4-17]. Please have your son accompany you to this appointment. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9561], M.D. Phone:[Telephone/Fax (1) 457] Date/Time:[2132-4-25] 1:00 Please follow-up with your primary care doctor in [12-24] weeks. ICD9 Codes: 5715, 5990, 5849, 2761, 4019, 311, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7446 }	Medical Text: Admission Date: [2166-5-25] Discharge Date: [2166-6-1] Date of Birth: [2091-3-22] Sex: F Service: [Location (un) 259] HISTORY OF PRESENT ILLNESS: This is a 75-year-old female status post fall down two flights of stairs with loss of consciousness confirmed. She suffered a C1 fracture during the fall which is evident on CT scan of the cervical spine. She is also noted to have a 4 cm thoracic aorta aneurysm on CT scan of the chest. There is no evidence of dissection on the CT scan of chest. The patient complains of chest pain today, but that pain has resolved. She denies any nausea, vomiting, abdominal pain, or shortness of breath. She is transferred from the outside hospital [Hospital3 ] complaining of back, chest, and right elbow pain. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease with home O2 on 2 liters nasal cannula. 2. Peptic ulcer disease. 3. Hypertension. 4. Status post cholecystectomy. 5. Status post aortobifemoral graft bypass in [2163]. 6. Status post CEA. MEDICATIONS AT HOME: 1. Lopressor 50 mg po bid. 2. Atrovent and albuterol nebulizers. 3. Centrum. 4. Prilosec 20 mg po q day. 5. Calcium. 6. Vitamin D. ALLERGIES: None. SOCIAL HISTORY: The patient lives with son and daughter. She smoked two packs a day for the past 60 years, but quit a few years ago. She rarely drinks alcohol. She denies any IV drug use. She is a DNR/DNI for her code status. EXAMINATION UPON ADMISSION: Temperature of 98.8, pulse of 101, blood pressure 95/58, respiratory rate 28, and 93% on 2 liters. HEENT: Right eye ecchymosis. Cardiovascular: Tachycardic, regular rhythm, normal S1, S2. Chest was clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Back is tender to palpation in the lower back. Extremities: Right elbow skin abrasion. Neurologically: She is alert and oriented times three, moving all four extremities. LABORATORIES UPON ADMISSION: White count of 12 with 88% neutrophils, hematocrit 35.3. Sodium 126, potassium 4.7, chloride 87, bicarb 26, BUN 26, creatinine 0.8, 156 glucose, CK 128, MB 6, troponin less than 0.3. INR is 1. PTT is 25.3, PT is 12.4. The patient is transferred to the Medical floor on [2166-5-29] given her numerous medical problems. Upon transfer, patient's laboratories were white count 9, hematocrit 31.3, platelets 419, potassium 4, sodium 136, chloride 95, bicarb 33, BUN 22, creatinine 0.7, glucose 151, calcium 9.3, phosphate 3.5, magnesium 1.7, INR 1, PTT 27.6, PT 12.6. Urinalysis shows trace blood, 100 protein, 1 urobilinogen, 0-2 red cells, [3-12] white cells, no bacteria, [6-17] squamous epithelial cells. Arterial blood gas done on [5-28] showed pH of 7.31, pCO2 34, and pO2 of 64, on 2 liters nasal cannula sating 89% with a lactate of 0.7. Free calcium 1.31. A [5-28] chest x-ray showed signs of congestive heart failure and bibasilar atelectasis with left sided pleural effusion. A [5-28] video swallow showed that she can do puree and nectar liquid foods and aspirates with thin liquids. Electrocardiogram upon transfer is normal sinus rhythm at 112 beats per minute. There is a S in lead I, a Q wave, inverted T wave in lead III, there is normal axis and interval. There is T-wave inversion in V1 and V3. 1. Tachycardia: Patient's tachycardia was of unknown etiology. Given her electrocardiogram findings of a right heart strain, it would suspect that she may have a pulmonary embolism, congestive heart failure, or bronchospasms. She was sent for a CTA of the chest which showed no evidence of pulmonary embolism. She continued to be tachycardic, so she was given Lasix to help diurese her. She was also sent for echocardiogram which showed ejection fraction of 80% with left ventricular hypertrophy. She did suffer a non-ST elevation myocardial infarction (by troponin, with negative CK's) during her tachycardia, so she was put on aspirin, beta blocker, and IV Heparin. Also her bronchospasm can be contributing to her tachycardia especially with the albuterol treatments, so all beta agonists were discontinued on this patient. 2. Chronic obstructive pulmonary disease: Patient was continued on her Flovent and Atrovent MDIs with Atrovent nebulizers prn. Her oxygen saturation was maintained between 90-92% with 2-4 liters of oxygen. Again her hypoxia is most likely secondary to chronic obstructive pulmonary disease given that the CTA was negative for any pulmonary embolism. 3. C1 fracture: Given that she did have a C1 fracture, her hematocrit was monitored closely while she was on the Heparin. Also a CT scan of the head was obtained which showed no bleed from the fall. Three days prior to the patient's demise, she did have an episode where she became hypotensive with a systolic blood pressure in the 80's and a desaturation to the 70's on 4 liters. CCU was given, given that she had some ST depressions and elevation on the electrocardiogram, that it was felt that she can be medically managed with the current regimen of aspirin, beta blocker, and Heparin. She then began to also desaturate, so she was put on a nonrebreather, and her oxygenation did improve. She was also given 500 cc normal saline bolus and her blood pressure came up to 120/80. Unfortunately, her heart rate continued to be in the 110's to 120's, and so she was given beta blocker which only worsened her breathing. She was then tried with some pain control with Morphine and that helped to decrease her tachycardia and shortness of breath. A venous gas was obtained during this time showing a pH of 7.4, pCO2 64, and pAO2 of 30. The MICU was called, but she did not require transfer given that she was saturating well on the nonrebreather. The MICU was made aware that she may possibly need BiPAP for her breathing difficulties. She remained tachycardic, so she was transferred to the Cardiac floor, where a central line was placed, and the patient was started on IV diltiazem. Her heart rate was controlled in the 80's, and her blood pressure did maintain about the systolic of 100's. However, on [2166-6-1], she went into asystole. So she was DNR/DNI. No CPR was done per the patient's wishes. She died on the morning of [2166-6-1]. THE DIAGNOSIS OF HER LAST HOSPITAL STAY OF HER LIFE: 1. Non-ST elevation myocardial infarction. 2. Hypertension. 3. Congestive heart failure. 4. Chronic obstructive pulmonary disease. 5. C1 fracture. DATE OF DEMISE: [2166-6-1]. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Last Name (NamePattern1) 4270] MEDQUIST36 D: [2166-6-3] 13:44 T: [2166-6-5] 12:32 JOB#: [Job Number 47901] ICD9 Codes: 4280, 496, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7447 }	Medical Text: Admission Date: [2161-5-20] Discharge Date: [2161-5-26] Date of Birth: [2105-12-20] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11415] Chief Complaint: S/P MVA with right wrist pain/injury and left leg pain/injury. Major Surgical or Invasive Procedure: S/P ORIF right distal radius on [2161-5-20]. S/P ORIF left distal femur on [2161-5-20]. History of Present Illness: 55 YO male transported via EMS to [Hospital1 18] ED S/P MVA at 70 mph on [2161-5-20]. Found to have right distal radius fracture and left distal femur fracture. No other injuries and no LOC. [Year (4 digits) 5498] consulted and admitted to Dr. [Last Name (STitle) 18191], MD [First Name (Titles) 767] [Last Name (Titles) ]. Patient taken to operating room for ORIF of both fractures on [2161-5-20]. Past Medical History: 1. Gout 2. GERD Social History: Patient lives with wife, daughter and son. Family History: N/A Physical Exam: Gen: distressed upon arrival, non-toxic, and alert. HEENT: abraison on head. EOM intact b/l. Nose and throat clear. Neck: Supple, non-tender with full range of motion, no lymphadenopathy. Lungs: CTAB Heart/CV: RRR, no M/R/G, pulses 2+ b/l UE and LE. ABD: Soft, NTND, no masses, no HSM. Extremities: Tenderness right distal radius, motor and sensation intact. Tenderness left distal femur, motor and sensation intact distally. Pertinent Results: [2161-5-20] 08:59PM HCT-34.9* [2161-5-20] 02:37PM HCT-35.3* [2161-5-20] 01:15PM PT-12.8 PTT-24.4 INR(PT)-1.1 [2161-5-20] 11:07AM GLUCOSE-134* UREA N-16 CREAT-0.8 SODIUM-146* POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-25 ANION GAP-15 [2161-5-20] 11:07AM WBC-11.3* RBC-3.58* HGB-12.2* HCT-34.0* MCV-95 MCH-34.1* MCHC-35.9* RDW-15.6* [2161-5-20] 11:07AM PLT COUNT-168 [2161-5-20] 11:07AM PT-ERROR* PTT-ERROR* INR(PT)-ERROR* [2161-5-20] 08:55AM WBC-14.7* RBC-3.55* HGB-12.3* HCT-33.8* MCV-95 MCH-34.8* MCHC-36.6* RDW-14.8 [2161-5-20] 08:55AM PLT COUNT-253 [2161-5-20] 08:14AM TYPE-ART PO2-132* PCO2-38 PH-7.39 TOTAL CO2-24 BASE XS--1 INTUBATED-INTUBATED VENT-CONTROLLED COMMENTS-UNABLE TO [2161-5-20] 08:14AM GLUCOSE-135* LACTATE-3.5* NA+-142 K+-4.2 CL--110 [2161-5-20] 08:14AM freeCa-1.10* [2161-5-20] 07:55AM COMMENTS-SPECIMEN C [2161-5-20] 06:01AM GLUCOSE-139* UREA N-18 CREAT-0.8 SODIUM-142 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-26 ANION GAP-12 [2161-5-20] 06:01AM ALT(SGPT)-63* AST(SGOT)-61* ALK PHOS-70 AMYLASE-43 TOT BILI-1.1 [2161-5-20] 06:01AM LIPASE-35 [2161-5-20] 06:01AM ALBUMIN-4.1 CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-1.9 [2161-5-20] 06:01AM WBC-12.0* RBC-3.75* HGB-12.5* HCT-36.1* MCV-97 MCH-33.5* MCHC-34.7 RDW-14.6 [2161-5-20] 06:01AM PLT COUNT-185 [2161-5-20] 06:01AM PT-12.5 PTT-23.0 INR(PT)-1.1 [2161-5-20] 03:58AM PT-12.7 PTT-22.6 INR(PT)-1.1 [2161-5-20] 03:46AM TYPE-MIX PO2-35* PCO2-50* PH-7.33* TOTAL CO2-28 BASE XS-0 [2161-5-20] 03:46AM GLUCOSE-145* LACTATE-2.8* NA+-145 K+-4.3 CL--109 [2161-5-20] 03:46AM O2 SAT-69 CARBOXYHB-0 MET HGB-0 [2161-5-20] 03:46AM freeCa-1.12 [2161-5-20] 03:35AM UREA N-20 CREAT-0.9 [2161-5-20] 03:35AM AMYLASE-45 [2161-5-20] 03:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2161-5-20] 03:35AM URINE HOURS-RANDOM [2161-5-20] 03:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2161-5-20] 03:35AM WBC-13.1* RBC-3.61* HGB-12.6* HCT-35.0* MCV-97 MCH-34.9* MCHC-36.1* RDW-13.8 [2161-5-20] 03:35AM PLT COUNT-219 [2161-5-20] 03:35AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.021 [2161-5-20] 03:35AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2161-5-20] 03:35AM URINE RBC-[2-15]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 Brief Hospital Course: Patient brought to operating room date of accident from ED and underwent an ORIF of his right distal radius and ORIF of his left distal femur without complications. Transferred to PACU in stable condition. Patient transferred to floor in stable condition. Pt placed in [Doctor Last Name 6587] brace on floor and OT consulted to make orthomoldable volar right wrist splint. PT consulted for NWB left LE and right UE with platform crutch. Pt. spiked fever at 103.9 on [2161-5-23] with low BP and increased HR, CXR unremarkable, urine culture showed no growth, blood cultures showed no growth. Temp stabilizd. Pt. given 2 units PRBCs [2161-5-23] for low Hct. Hct stabilized at 31.6 by [2161-5-25]. Pt given lovenox 30mg [Hospital1 ] for anticoagulation and Kefzol 1gram q 8 hours for prophylaxis. Pt had good pain management with morphine then switched to percocet 5/325 PO [12-15] q 4-6 hours/prn. Pt. had difficulty with ambulation with Physical Therapy. PT reported poor home safety eval with NWM status for left LE and right UE with platform crutch and recc. Rehab facility prior to going home. Pt discharged to rehab facility. Medications on Admission: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mg Subcutaneous Q12H (every 12 hours) for 4 weeks. 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mg Subcutaneous Q12H (every 12 hours) for 4 weeks. 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [Hospital 5503] Health Care Center Discharge Diagnosis: Left distal femur fracture and right distal radius fracture s/p motor vehicle accident on [2161-5-20]. S/P ORIF right distal radius on [2161-5-20]. S/P ORIF left distal femur on [2161-5-20]. Discharge Condition: Good Discharge Instructions: Keep incisions clean and dry. Keep splint on rt wrist and brace on left leg at all times and keep dry. Keep [Doctor Last Name 6587] brace locked in extension at all times except when in bed, which you can do passive range of motion with Physical Therapist supervision. Do not bear weight on left leg. Keep left leg and right arm elevated to reduce swelling as much as possible when at rest. Do not bear weight on right arm when pushing off from bed or chair. Use platform crutch when walking to keep weight of right arm. Take all medications as directed. Physical Therapy: NWB left LE and NWB right UE with push off from bed or chair. Use platform crutch for ambulation. CPM as tolerated to left knee in [Doctor Last Name 6587] brace. Lock brace for ambulation. Treatments Frequency: Keep incisions clean and dry. Sutures and staples can be discontinued on post-op day 14. Date of surgeries [2161-5-22]. Keep right upper extremity elevated and left lower extremity elevated to reduce swelling. Followup Instructions: Dispo to rehab facility and follow-up with Dr. [Last Name (STitle) 2637] in clinic 1 week after discharge from rehab. Call [Telephone/Fax (1) 1228] for appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2161-5-26] ICD9 Codes: 5180, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7448 }	Medical Text: Admission Date: [2107-8-2] Discharge Date: [2107-8-7] Date of Birth: [2038-12-4] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Ace Inhibitors Attending:[First Name3 (LF) 1267] Chief Complaint: Dyspnea on exertion, chest pain Major Surgical or Invasive Procedure: [2107-8-2] Four Vessel Coronary Artery Bypass Grafting(left internal mammary artery to left anterior descending, with vein grafts to diagonal, obtuse marginal, and right coronary artery) History of Present Illness: Mrs. [Known lastname 32289] is a 68 year old female with progressive dyspnea on exertion and exertional chest discomfort. She also admits to shortness of breath at night with 2 pillow orthopnea. She underwent persantine MIBI in [2107-4-5] which was positive for chest pain and negative for ischemic EKG changes. Imaging revealed severe perfusion defect in the apex, distal anterior wall and apical inferior wall. There was severe HK at the apex, and LVEF was estimated at 58%. She subsequently underwent cardiac catheterization in [2107-7-6] which showed severe three vessel coronary artery disease. She was subsequently referred for surgical intervention. Past Medical History: Coronary Artery Disease, History of MI Hypertension Hyperlipidemia Menieres Disease/Vertigo Questionable History of Hepatitis Chronic Pruritis Hemorrhoids - History of BRBPR s/p Polypectomy Social History: Denies ETOH and tobacco. She is not employed. She lives alone. Family History: Denies premature coronary artery disease. Physical Exam: Vitals: 110/60, 63, 18 General: WDWN elderly female in NAD HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally, no carotid bruits Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [2107-8-7] 04:45AM BLOOD Hct-25.6* [2107-8-6] 05:35AM BLOOD Hct-25.3* [2107-8-5] 06:45AM BLOOD WBC-10.5 RBC-2.96* Hgb-8.7* Hct-25.8* MCV-87 MCH-29.3 MCHC-33.6 RDW-15.9* Plt Ct-263 [2107-8-5] 06:45AM BLOOD Plt Ct-263 [2107-8-4] 02:35AM BLOOD Plt Ct-205 [2107-8-4] 02:35AM BLOOD PT-12.9 PTT-32.7 INR(PT)-1.1 [2107-8-7] 04:45AM BLOOD UreaN-10 Creat-0.6 K-4.5 [2107-8-6] 05:35AM BLOOD UreaN-12 Creat-0.5 K-4.4 [2107-8-5] 06:45AM BLOOD Glucose-115* UreaN-12 Creat-0.6 Na-143 K-4.3 Cl-106 HCO3-34* AnGap-7* Brief Hospital Course: Ms. [Known lastname 32289] was admitted and underwent coronary artery bypass grafting by Dr. [Last Name (STitle) ]. For surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. On postoperative day one, she awoke neurologically intact and was extubated without incident. She weaned from intravenous therapy and otherwise maintained stable hemodynamics. Her CSRU course was uneventful and she transferred to the SDU on postoperative day two. She did well postoperatively and was ready for discharge [Last Name (un) ] eon POD #4. Medications on Admission: Aspirin, Calcium, Celebrex, Fosamax, Imdur, Pravastatin, Toprol XL, Valsartan, Vitamin D Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:28 Tablet(s) Refills:0 3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:120 Capsule, Sustained Release(s) Refills:2 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:40 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Coronary Artery Disease - s/p CABG Hypertension Hyperlipidemia Menieres Disease/Vertigo Questionable History of Hepatitis Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [Last Name (STitle) ] in [3-10] weeks, call for appt Dr. [Last Name (STitle) ] in [1-8] weeks, call for appt Dr. [Last Name (STitle) 11528] in [1-8] weeks, call for appt [Hospital Ward Name 121] 2 Wound Check in 2 weeks Completed by:[2107-8-9] ICD9 Codes: 4280, 2724, 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7449 }	Medical Text: Admission Date: [2125-7-19] Discharge Date: [2125-7-25] Date of Birth: [2084-2-27] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 348] Chief Complaint: altered mental status fever acute renal failure Major Surgical or Invasive Procedure: mid-line IV History of Present Illness: 41yo woman w/ PMH hypothyroidism, s/p laparoscopic cholecystectomy and umbilical hernia repair [2125-6-27] at [Hospital1 89097] transferred to [Hospital1 18] with fever, acute renal failure and mental status changes. . She was originally admitted [6-26] with recurrent biliary colic and had a laparascopic cholecystectomy with concurrent repair of an umbilical hernia. Intraoperatively she had a bile leak that was controlled with small clips and a JP drain was left in place. During that admission she apparently had malignant hypertension thought to be due to self-induced hyperthyroidism (?). She had ERCP showing peripheral bile leak, with sphincterotomy and placement of a stent. She then improved and was discharged home [7-1]. . She was seen as an outpatient [7-8] when she was doing well, except for pain at the JP site. [7-12] she was readmitted b/c of persistent abdominal pain. Repeat ERCP and MRCP showed no leak, though a HIDA scan showed pooling of small amounts of bile in the peripheral of the liver. [7-14] and [7-15] she spiked fevers. She was thought to have cellulitis around the JP site, and the bile grew [Last Name (LF) 8974], [First Name3 (LF) ] she was started on oxacillin with removal of the JP drain. She subsequently developed a small biloma. She began to develop acute kidney injury with rising creatinine. [7-18], she had WBC 13.3, BUN 8, Cr 4.8, total bili 4.3. She also had R UQ pain. CVL was placed. CT scan of the abd and pelvis showed the small biloma and severe right sided colitis. No biliary duct obstruction. The decision was made to transfer her to the [Hospital1 18] SICU. . On arrival to the SICU, the surgery team did not feel that her biloma was her primary issue and that she did not require surgical intervention. They requested transfer to the medical team. The patient is intermittently oriented to place and year. She is confused and agitated and unable to provide further history. It is unclear when her confusion began as it is not mentioned in the OSH notes. Past Medical History: - anxiety - hypothyroidism - cesarean section x2 - alcohol abuse Social History: Unknown at this time. - Tobacco: - Alcohol: reports of EtOH abuse, unknown amount. - Illicits: Family History: Unknown Physical Exam: At admission: Vitals: T: 99.1 BP:157/85 P: 77 R: 18 O2: 100% 2L NC General: Alert, but confused and agitated HEENT: Sclera anicteric, dry mucous membranes with dried blood in the oropharynx Neck: supple, JVP not elevated, no LAD, R IJ clean and in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, right-sided tenderness with some guarding, non-distended, bowel sounds present, no rebound tenderness, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema At discharge: Vitals: T:97.9 BP: 133/72 P: 80 R: 18 O2: 99 on RA General: Alert and oriented, in NAD HEENT: Sclera anicteric, MMM 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, obese, not TTP, BS+ Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: At admission: [2125-7-19] 02:45PM BLOOD WBC-7.5 RBC-2.92* Hgb-9.3* Hct-27.3* MCV-94 MCH-31.8 MCHC-34.0 RDW-13.8 Plt Ct-321 [2125-7-19] 02:45PM BLOOD Neuts-85.2* Lymphs-10.1* Monos-3.2 Eos-1.3 Baso-0.2 [2125-7-19] 02:45PM BLOOD PT-13.9* PTT-30.7 INR(PT)-1.2* [2125-7-19] 02:45PM BLOOD Glucose-135* UreaN-17 Creat-3.7* Na-142 K-3.6 Cl-107 HCO3-24 AnGap-15 [2125-7-20] 03:03AM BLOOD Lipase-93* [2125-7-19] 02:45PM BLOOD Albumin-2.7* Calcium-8.5 Phos-4.3 Mg-2.2 [2125-7-19] 02:45PM BLOOD TSH-0.11* [2125-7-20] 03:03AM BLOOD Free T4-0.81* [2125-7-20] 07:45AM BLOOD Type-[Last Name (un) ] pO2-38* pCO2-43 pH-7.39 calTCO2-27 Base XS-0 [2125-7-20] 07:45AM BLOOD Lactate-0.9 [7-20] Abd U/S IMPRESSION: 1. Small collection in the gallbladder fossa, which has decreased in size compared to ultrasound [2125-7-18]. No free fluid within the abdomen. 2. Moderate pleural effusions, right greater than left. [7-19] CXR IMPRESSION: Increased pulmonary vascular pattern most likely representing perioperative fluid overload.As no previous chest examination is available for comparison, consider followup examination within a few days. [2125-7-19] Urine Cx: no growth WOUND CULTURE - catheter tip (Final [2125-7-22]): No significant growth. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST X3 (Final 06/25-28/11) [2125-7-20]: blood cx: no growth [2125-7-23] Stool culture: no O/P, no campylobacter Discharge: WBC 9.0 hgb 10.1* hct 29.8* Plt 557* Chem 7 glucose 112 BUN 14 Cr 1.8* Na 137 K 3.3 Cl 100 HCO3 28 Brief Hospital Course: 41 yo female s/p lap CCY/bile leak transferred from OSH. Hospitalization notable for fevers, transient cholestasis (resolved), [Month/Day/Year 8974] recovery from biliary drainage, AMS, ARF (attributed to AIN). Showed significant Right sided colitis on recent abdominal CT. Pt's course was complicated by HAP. AMS: Mental status changes were worked up for toxic, metabolic and infectious etiologies. It was determined that her mental status changes were due to accumulation of benzodiazepines and narcotics in the setting of acute renal failure. When the offending substances were removed and pt's renal function improved, her mental status returned to baseline. Pt does have history of alcohol abuse, but had not drank within past week prior to admission and she never showed signs of EtOH withdrawal. Acute renal failure: Pt was admitted with creatinine of 3.7. In outside hospital, injury was attributed to nafcillin AIN. On admission, pt was found to be hypovolemic and was resuscitated with fluids in the ICU. Her kidney function improved, but she began putting out large volumes of urine when she arrived on the floor. Based on urine lytes with FeUrea consistent with intrinsic failure it was determined that she was experiencing post ATN diuresis. During this time, she was found to be hypokalemic from the copious diuresis. K was replaced, urine output decreased and creatinine continued to improve by time of discharge. She was discharged with Cr of 1.8, and pt had good urine output. Baseline creatinine was unknown. Hyperkalemia: In ICU pt was found to be hyperkalemic. EKG showed no signs of hyperkalemia, was given kayexalate and K trended down as kidney function improved. Hospital acquired PNA: In SICU, pt was found to have right lobar PNA, was febrile with leukocytosis and cough with SOB. She could not produce sufficient sputum sample for culture and all blood cultures were negative, so she was treated empirically for HAP with cefepime and vancomycin for a 10 day course. She was discharged with a midline IV to complete the final four days of ABX therapy with VNA services. Colitis: In ICU pt developed watery diarrhea. On admission she had abdominal pain and outside CT showed pericolic stranding. An infectious process associated with previous cholecystectomy and JP tube was ruled out in the ICU with U/S and neg cultures from JP site. Pt also had leukocytosis and was suspected to have c. diff and started on empiric PO vancomycin and flagyl. She had three negative c diff toxin assays and diarrhea and abdominal pain resolved. Symptoms were likely caused by intra-abdominal inflammation secondary to bile leak and small biloma. Hypertension: On floor, the pt was found to be consistently hypertensive with systolic pressures in the 160s. She reported that her PCP has diagnosed her with HTN but she has refused medication. We treated her with amlodipine 10 mg qday and pressures became normotensive. She was discharged on Amlodipine 10mg qday. Hypothyroidism: Pt was found to have a low TSH (0.11) in ICU indicating that her dose of synthroid might be too high. Pt's renal failure could have contributed to accumulation of synthroid and suppression of TSH. As condition improved, she did not show any signs of hyperthyroidism and she was discharged with home dose of synthroid. Depression/anxiety: Pt's depression was stable on duloxetine and she was discharged on home dose. On the floors, when pt's renal function improved and mental status returned to baseline, she was restarted on her home dose of xanax qHS. There are no outstanding results that need to be followed up at time of discharge. Pt will follow up with PCP after course of abx. Midline IV will be removed by VNA after abx course. Medications on Admission: Medications (home): - Synthroid 0.2mg daily - Cymbalta 90 daily - Xanax 2mg PO QHS - Vicodin after surgery . Medications (on transfer from OSH): - Tylenol 650mg PO PRN - Xanax 1mg PO PRN - Cefazolin 1gm IV Q8hrs - Benadryl 25mg Q6hrs PRN pruritus - Cymbalta 90mg PO daily - lovenox 40mg SQ daily - Vicodin 1 tab Q8hrs PRN - Synthroid 200mcg PO daily - Reglan 10mg IV Q6hrs PRN nausea - Flagyl 500mg IV Q8hrs - Morphine 1mg IV Q2hrs PRN - Narcan 0.1mg IV PRN - Protonix 40mg IV daily Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Xanax 2 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain for 4 days. Disp:30 Tablet(s) Refills:0 5. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) for 3 days. Disp:3 Recon Soln(s) Refills:0 6. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every other day for 3 days. Disp:1 1g Refills:0 7. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush for 4 days. 8. Outpatient Lab Work please check a potassium on friday [2125-7-27] and fax to primary care doctor [Month/Day/Year 89098] at fax number [2125]. 9. potassium citrate 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day for 4 days. Disp:4 Tablet Extended Release(s) Refills:0 10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: 1. Right sided colitis 2. hospital acquired pneumonia 3. acute mental status changes 4. Acute kidney injury from acute tubular necrosis 5. hypertension 6. hyperkalemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname ], It was a pleasure taking care of you. You were admitted to [Hospital1 18] because of suspicion of an abdominal infection secondary to your previous gallbladder surgery. It was determined that you did not have an infection from the surgery. Infectious diarrheal disease was also ruled out. It was determined that you had a colitis secondary to irritation from the bile leak from your surgery. While you were in the hospital, you were diagnosed with a kidney injury that was treated with IV fluids and electrolyte replacement. You also experienced mental status changes which resolved as your kidney function improved. Finally, you were diagnosed with a pneumonia, which we have been treating with IV antibiotics which will be continued at home for three days. During your hospital stay, your blood pressures were elevated and you were diagnosed with hypertension. You will be going home with a mid-line IV and a visiting nurse will come to administer medications and will remove the line. When you leave the hospital, continue with your home medications and add the following. - START amlodipine 5mg by mouth every day - START Vancomycin 1 gram intravenous every other day - START cefepime 2g intravenous every 24 hours Followup Instructions: Please follow up with your primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) 89098] within one week. Please follow up with your surgeon, Dr. [Last Name (STitle) 89099] at [Hospital 487] hospital on your scheduled appointment date, [7-31]. ICD9 Codes: 486, 5845, 4019, 2449, 2767, 2859, 2768, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7450 }	Medical Text: Admission Date: [2151-5-14] Discharge Date: [2151-5-21] Date of Birth: [2084-11-24] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: A 66-year-old male presenting with left arm tingling and neck pain. The patient has been seen by his physician. [Name10 (NameIs) ] has been having left shoulder pain and an outpatient workup showed that he had a spinal cord tumor, and he also has thyroid cancer not associated to the spinal vertebral body, and the patient admitted for resection of the tumor. PAST MEDICAL HISTORY: Significant for hypertension, kidney cancer, and also renal cell cancer and thyroid CA (he is SP radiation therapy in [2147]). Hypothyroidism. He had an appendectomy and also had a left nephrectomy and left thyroidectomy in [2147]. PREOPERATIVE MEDICATIONS: Levoxyl 150 mcg, Norvasc 5 mg once a day, folic acid 1 mg once a day, lorazepam 1 mg at bedtime. PHYSICAL EXAMINATION: In general, in no acute distress. His vital signs are a temperature of 98.6, blood pressure 149/76, heart rate of 78, respirations 16, and saturation is 97% on room air. He weighs 160 pounds and height of 5 feet 7 inches. Chest is clear to auscultation AP bilaterally. Heart regular rate and rhythm. No murmur. No gallop or bruits. Abdomen soft, nontender, and nondistended. Bowel sounds positive. Extremities with no edema. No cyanosis. Neurologic exam reveals patient is oriented. No cervical tenderness. Muscle strength is [6-10] in all extremities, and toes are upward. His DTRs are 1+ on the right brachial radialis; otherwise 2+ throughout. No sensory deficits. LABORATORY DATA: White count is 7.6, hematocrit is 29.9, platelets are 104. His PT is 14, PTT is 31, INR is 1.2. His chemistries reveal sodium is 142, potassium is 4.1, chloride is 104, bicarbonate is 25, BUN is 13, and creatinine is 1.1. Blood glucose is 137. His ABG is 7.38, PCO2 is 44, PO2 is 157. RADIOLOGIC STUDIES: The patient's preoperative chest x-ray showed no acute cardiopulmonary process identified. BRIEF SUMMARY OF HOSPITAL COURSE: This 66-year-old male underwent a C7 vertebral body embolization on [2151-5-14]. On [5-15] he underwent resection of a T1 tumor with a posterior fusion from C5 to T2 which was separate from his thyroid cancer which was resected in [2147]. After his procedure he reported some radicular pain down to his fingers but denied any headache, nausea, vomiting. No double vision. No ataxia or urinary incontinence. Postoperatively, he did well. Neurologically, he was alert and oriented x 3. His motor function was [6-10] throughout. Sensation remained intact. The patient stayed overnight in PACU and then transferred to the unit on the 10th. He remained neurologically stable, and his labs remained stable. He was able to be extubated on [5-16] and remained well. He was on Kefzol postoperatively. The patient was transferred to [Hospital Ward Name 121] 5 which is the neurosurgery floor. On postoperative day 1, try to increase activity, ambulate with PT. Also, check postoperative x-rays plain AP and lateral which were on the lateral radiograph really limited due to inadequate under-penetration and only showed C1 through C4. On the AP radiograph there has been fusion of C5 through T2 via posterior pedicle screws and rods. An additional horizontal metallic construct connects the posterior fixation device at T1. Patient evaluated by PT for safety for home needs and felt the patient was able to go home without any services, and he is able to tolerate diet well and ambulate independently and did well throughout hospital course. Patient discharged on [2151-5-21] without any complications postoperatively. MAJOR SURGICAL AND INVASIVE PROCEDURES: He had a T1 tumor resection and C5 to T2 posterior fusion, and prior to that he had spinal tumor embolization on the 8th. DISCHARGE STATUS: The patient neurologically stable. DISCHARGE MEDICATIONS: Acetaminophen 325 mg 1 to 2 tablets q.4-6 hours as needed for pain, Levoxyl 150 mcg once a day as preoperative, Norvasc 5 mg once a day, folic acid 1 mg once a day, Prilosec 20 mg once a day, Colace 100 mg twice a day, Keflex 500 mg p.o. q.i.d. for 7 days, oxycodone/acetaminophen 5/325 mg tablets 1 to 2 tablets q.4-6 hours for pain. FOLLOW-UP PLANS: Follow up with Dr. [Last Name (STitle) 1132] on [2151-5-25] for removal of staples. Change dressing Xeroform gauze twice a day and wound check for redness or any swelling or any other concerns. [Name6 (MD) ] [Last Name (NamePattern4) 1359], [MD Number(1) 1360] Dictated By:[Last Name (NamePattern1) 20397] MEDQUIST36 D: [2151-8-4] 12:15:43 T: [2151-8-4] 13:09:45 Job#: [Job Number 20398] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7451 }	Medical Text: Admission Date: [2201-6-15] Discharge Date: [2201-6-16] Date of Birth: [2168-1-8] Sex: M Service: MEDICINE Allergies: Clindamycin Attending:[First Name3 (LF) 2297] Chief Complaint: Malaise, abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 33 year old male with seronegative arthritis on immunomodulating agents and multiple infectious complications (MRSA, VRE, Klebsiella UTI) presenting with malaise and abdominal pain x 2 days associated with decrease in ostomy output. Was recently treated w/Cipro/Flagyl, d/c'd on [5-27] after completing 10 day course. Pt denied fever, chills, nausea, vomiting. Tolerating PO well per rehab nurse. [First Name (Titles) 21843] [Last Name (Titles) 21844] decrease in BM's per rectum x 1 month. Pt felt pain at the site of ventral hernia and thought abdominal pain was related to hernia. Pt was previously admitted in [March 2201] w/fevers and joint pain concerning for possible chronic osteomyelitis of L knee. Per pt and [Name (NI) ], pts joint pain stable; however rheumatology increased Prednisone on Friday to 80mg daily with taper q2 days. Also had recent prednisone burst 1 week ago. Pt has had low grade temps 99-100 consistently over past month while at NH, HR 100s. At NH, C.diff sent and negative x1 and U/A sent which was negative. . In the ED: afebrile (Tmax 100.7), BP 128/97. HR 100-130. CXR negative, Urine negative, abdominal CT with stool per wet read, has ventral wall hernia, abdominal Xray with no free air or air-fluid levels on wet read. Surgery evaluated in ED, did massive disimpaction, but no concern for surgical process at this time. Guaiac negative on exam. Patient was started on empiric Vancomycin and Piperacillin-Tazobactam due to h/o MRSA/VRE and new leukocytosis. 4 L NS, Zofran, Dilaudid, given in ED. BCx, UA/UCx sent. Past Medical History: Past medical history: Seronegative arthritis, possibly ankylosing spondylitis, of hips, knees, wrist, on steroids/immunosuppressants since [2190] (methotrexate, sulfasalazine, Enbrel, Humira, Remicade, prednisone) L prosthetic knee infection with C. albicans and CoNS - now with spacer Citrobacter fasciitis of abdominal and chest wall - required skin grafting Multiple abdominal abscess - citrobacter, VRE Right lower extremity DVT requiring IVC filter anemia of chronic disease MRSA infection PUD anabolic steroid abuse (16 months in early 20s) -Recent MRI knee suggestive of osteomyelitis PSH: [2200-8-28] radical debridement of soft tissues of R chest wall, abdominal wall, flank, groin; step incisions in abdominal wall fascia & musculature with drainage of peritoneal abscess [2200-8-29] repeat debridement of necrotic soft tissues of R chest, abdominal wall, b/l groins, additional step incisions in abdominal wall fascia & musculature with drainage of peritoneal abscess -[2200-9-4] tracheostomy with 8-0 cuffec Portex tube, irrigation & debridement of wounds with further drainage of periappendiceal abscess, placement of 26Fr mushroom-tipped catheter into appendiceal stump within cecum -[2200-9-17] IVC filter placement -[2200-9-26] vac dressing change under general anesthesia -[2200-9-30] vac dressing change under general anesthesia -[2200-10-2] preparation of wound bed with debridement & excision of scar, meshed skin graft (16/1000" meshed at 1.5, total surface area 40x55 cm) -[2200-10-7] removal of bolster, skin graft, replacement of wound dressing with DuoDerm gel & Xeroform gauze ... -L TKR [3-1] c/b wound dehiscence & septic arthritis in [3-2] -R THR [10-30] -L THR [1-26] -R TKR [4-28] -L tibial osteotomy -L4-L5 laminectomy [2193] (s/p MVA with traumatic disc herniation) . Current hardware: spacer left knee, prosthesis right knee, bilateral hips Social History: Disabled, prior to last hospitalizations lived with mother in [Name (NI) ], MA. Was a semiprofessional body builder in early 20s with h/o anabolic steroid abuse x 16 months. Tobacco 1 pack/day x 10 years. Denies alcohol use. Most recently at Rehab--came from rehab via St V's. Family History: noncontributory Physical Exam: PE: vitals: T100.1 ; BP 112/40; HR 119; RR 18 98%RA general: obese, young, male, NAD heent: anicteric sclearae, EOMI, O/P clear, no oral lesions neck: Supple, No JVP, no adenopathy car: normal S1 S2. Tachycardic. no murmurs/rubs/gallops resp: CTAB. No wheeze/crackles anteriorly abd/GI: Skin grafts intact over L. Abdominal wall, Multiple abdominal scar sites; c/d/i. left lower midline ventral hernia noted, ostomy in place with nl green output. Soft, Non-tender, non-distended, +BS in all 4 quadrants. No rebound/guarding. SKIN: multiple skin graft harvest sites over bilateral upper thights. ext: L. knee: No warmth, erythema, non-tender to palpation, no open wounds. R. Knee no warmth/erythema. Range of motion limited [12-27] chronic pain. Sensation intact. No LE Edema. NEURO: Alert and Oriented x3. CN 2-12 grossly intact. Sensation intact throughout. Pertinent Results: CBC: WBC max 20, down to 8.1 on discharge [2201-6-14] 06:30PM BLOOD WBC-20.7# RBC-4.59# Hgb-9.9* Hct-34.5* MCV-75# MCH-21.5 MCHC-28.7* RDW-17.2* Plt Ct-638* [2201-6-15] 09:45AM BLOOD WBC-17.0* RBC-4.22* Hgb-9.0* Hct-32.1* MCV-76* MCH-21.4* MCHC-28.1* RDW-17.3* [2201-6-16] 03:42AM BLOOD WBC-8.1# RBC-3.60* Hgb-8.0* Hct-27.2* MCV-75* MCH-22.1* MCHC-29.3* RDW-17.2* Plt Ct-471* [2201-6-14] 06:30PM BLOOD Neuts-93.0* Bands-0 Lymphs-3.9* Monos-2.8 Eos-0.1 Baso-0.2 [2201-6-15] 09:45AM BLOOD Neuts-78.7* Bands-0 Lymphs-14.7* Monos-6.1 Eos-0.2 Baso-0.4 . Coagulation Studies (INR subtherapeutic on admission) [2201-6-14] 06:30PM BLOOD PT-19.2* PTT-26.6 INR(PT)-1.8* [2201-6-15] 09:45AM BLOOD PT-18.5* PTT-26.3 INR(PT)-1.7* [2201-6-16] 03:42AM BLOOD PT-19.6* PTT-29.9 INR(PT)-1.8* . Inflammatory Markers [2201-6-16] 03:42AM BLOOD ESR-71* [2201-6-16] 03:42AM BLOOD CRP-193.9* . CBC: [2201-6-14] 06:30PM BLOOD Glucose-135* UreaN-18 Creat-0.6 Na-137 K-5.8* Cl-99 HCO3-23 AnGap-21* [2201-6-16] 03:42AM BLOOD Glucose-85 UreaN-7 Creat-0.5 Na-142 K-3.5 Cl-106 HCO3-28 AnGap-12 . LFTs/AP/Bili [2201-6-14] 06:30PM BLOOD ALT-66* AST-47* AlkPhos-437* TotBili-0.4 [2201-6-15] 09:45AM BLOOD ALT-48* AST-25 LD(LDH)-282* AlkPhos-344* TotBili-0.4 [2201-6-16] 03:42AM BLOOD ALT-34 AST-10 LD(LDH)-101 AlkPhos-257* TotBili-0.4 [2201-6-14] 06:30PM BLOOD Lipase-16 GGT-1044* [2201-6-15] 09:45AM BLOOD GGT-840* [2201-6-16] 03:42AM BLOOD GGT-651* . Thyroid function studies [2201-6-15] 09:45AM BLOOD TSH-2.0 . Microbiology: urine cx ([6-14]): - pending blood cx's ([6-14], [6-15]): pending stool cx's: c. diff unquantifiable (not enough stool) O&P pending, yersenia/vibrio cholera pending . Imaging: CXR: INDICATION: 33-year-old man with diffuse abdominal pain with history of necrotizing fasciitis. Please evaluate for free air. PA and lateral radiograph of the chest are obtained. Cardiomediastinal silhouette and hilar contours are normal. Unchanged mediastinal widening is compatible with mediastineal fatty deposition. Right hemidiaphragm is elevated. The lungs are clear with no focal consolidation, pleural effusion or pneumothorax. No free intra-abdominal air is visualized. IVC filter is in place. IMPRESSION: 1. No free intra-abdominal air. 2. Elevated right hemidiaphragm. . KUB:IMPRESSION: 1. No free intraperitoneal air and no air fluid levels. Mildly distended small bowel loop is noted in the left upper quadrant area. 2. Status post bilateral total hip replacement, with possible periprosthetic lucency about the left femoral stem. Dedicated femur radiographs may be pursued per clinical concern. . CT ABD/PELVIS IMPRESSION: 1. Extensive colonic fecal loading rectosigmoid more than left colon. 2. Mildly prominent small bowel loops measuring upto 3 cm, may reflect partial obstruction, not completeobviously with a functioning colostomy. 3. Mild left renal collecting system fullness to the UPJ is new without cause evident. Correlate with urine analyses. 4. Small upper abdominal fluid collections in the gastrohepatic and gastrosplenic space are significantly smaller than prior study, nearly resolved. . RUQ U/S: FINDINGS: The liver shows no focal or textural abnormality. There is no biliary dilatation and the common duct measures 0.4 cm. Several small gallstones are seen within the gallbladder measuring less than 1 cm and there is a small amount of sludge present. There are no signs of cholecystitis. The visualized portion of the pancreas is unremarkable however the pancreas is partially obscured by overlying bowel gas. There is no ascites seen in the right upper quadrant. IMPRESSION: Subcentimeter gallstones and small amount of sludge but no signs of cholecystitis. No biliary dilatation. . Brief Hospital Course: A/P: 33 year old male with seronegative arthritis on immunosuppressants and extensive infectious history presenting with malaise and abdominal pain. . # Abdominal Pain: Likely etiology 2' to constipation leading to temporary partial bowel obstruction, as pt had improvement of pain after disimpaction in ED, and was abdominal pain free during his ICU stay. He is also on a very heavy opiate regimen for pain that may also have contributed to his constipation. He had an extensive surgical history concerning for SBO, but KUB did not show air-fluid leves, and CT was negative for strangulatation of his ventral hernia, and his lactate was normal. His RUQ US was also negative for acute cholecytitis: he may have had transient choledocholithiasis with a passed stone, as small subcentimeter stones and GB sludge were noted on U/S, and he transiently elevated AP and LDH that decreased over 24 hours while in the ICU. . # Leukocytosis: Pt had an elevated WBC 20 on admission, but he did have recent Prednisone burst started by rheumatology on [6-13], so may be related to steroids. His WBC resolved to 8.1 on discharge. His CT showed no evidence of abdominal abscess. [Month (only) 116] have had transient choledocholithiasis (see above, abd pain.) His CXR showed no evidence of PNA. He has a h/o VRE, MRSA, ESBL Klebsiella, and has a history of osteomyelitis, given bilateral hip and knee hardware. These are chronic problems and unlikely completely causative of his leukocytosis. His stool was sent for C. difficile toxin assay, but not enough stool was present for proper quantification. He was afebrile during his hospital course. His blood, urine, and stool cx's o/w showed no growth at the time of discharge. . # Sinus Tachycardia- In [Name (NI) ], pt has had history of sinus tachycardia at baseline with rates in the 100s. Etiology unclear. EKG showed sinus tachycardia, no evidence of arrhythmias. His TSH was WNL (2.0). He was monitored on telemetry and had no chest pain or SOB. . # Seronegative Arthritis: Pt was on a prednisone taper per rheumatology. He was continued on a baseline dose of prednisone at 20 mg. He was continued on bactrim ppx for PCP, [Name10 (NameIs) ] his long-term steroid treatment. He was continued on his home pain control regimen as it was carefully managed on previous admissions; MS Contin, Oxycodone and MS IR. It was supplemented with IV dilaudid for now as he had abdominal pain, which was tapered off prior to discharge. . # History of DVT, s/p IVC filter.: His INR was subtherapeutic on admission (1.7); He was given an addition 5mg coumadin on [6-15], and can return to his home dose once INR is therapeutic ([12-28]). . # PUD: He was continued on omeprazole. . # Hypoandrogenism: He was continued on his testosterone patch. . # FEN: He was kept on a regular diet. His electrolytes were checked daily. He was kept on a bowel regimen as needed. # Access: 2 large bore peripheral IVs . # PPx: continued on coumadin, omeprazole. . # Disp: returned to rehabilitation center. Medications on Admission: #. Morphine SR 120mg TID at 9 am, 12pm, 9pm. #. Oxycodone 10mg q4H PRN #. Morphine 30 q4H PRN #. Testosterone 2.5mg/24hr q24H - #. Docusate Sodium 100mg [Hospital1 ] - #. Prednisone 20mg daily - #. Clonazepam 2mg q8H PRN anxiety - #. Quetiapine 400mg po QHS - #. Warfarin 2mg qPM #. Dulcolax 10mg daily PRN constipation - #. Magnesium Hydroxide 400mg/5mL 30mL PO Q6H PRN - #. Diphenhydramine 25mg q4H PRN - #. Omeprazole 40mg PO daily - #. Reglan 10mg QID PRN nausea - #. Multivitamin po daily - #. Aspirin 81mg daily - #. Trimethoprim-Sulfamethoxazole 160-800mg PO Monday, Wednesday, Friday - #. Calcium Carbonate/vitamin D - #. Ferrous Sulfate 325mg daily - #. Tylenol 650 mg Q6H prn - Discharge Medications: 1. Quetiapine 100 mg Tablet Sig: Four (4) Tablet PO QHS (once a day (at bedtime)). 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). 5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed. 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed. 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: One (1) PO every six (6) hours as needed for indigestion. 16. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 17. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [11-26] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. 18. Morphine 15 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain: can be given at same time as other opiod medications. 19. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain: can be given at same time as other opiod medications. 20. Morphine 30 mg Tablet Sustained Release Sig: Four (4) Tablet Sustained Release PO Q8H (every 8 hours) as needed for pain: can be given at same time as other opiod medications. Discharge Disposition: Extended Care Facility: [Hospital1 ] for sandalwood Discharge Diagnosis: Constipation . Secondary Diagnosis Seronegative Arthritis (Ankylosing Spondylitis) Osteomyelitis MRSA infection Necrotizing Fasciitis Abdominal Abcesses Anemia of Chronic Disease Deep Vein Thrombosis Discharge Condition: Good Discharge Instructions: You were admitted to the [Hospital1 18] with a diagnosis of constipation leading to temporary bowel obstruction. Your bowel obstruction has resolved, and you were discharged in good health. You were also on a prednisone taper when you came into the hospital that was started last Friday ([6-12]). However, the steroids were making your white blood cell count high, and was clouding you lab tests and making it difficult for us to treat you. We discharged you on a Prednisone dose of 20 mg daily. Please continue this dose for now. We will leave the re-initiation of the taper to your outpatient rheumatologist at this point. Please contact your primary care physician or have your care facility send you to the nearest emergency department if you experience any of the following symptoms. Temperature greater than 102 F, worsening abdominal pain, increased vomiting, severe constipation/lack of stool output from your colostomy tube, severely decreased urine output, or extremely low blood pressure. Please also return if you experience worsening chest pain, pain in your extremities, diarrhea, loss of consciousness, or any other symptoms that are concerning to you. Followup Instructions: Please follow up with your primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. His contact information is: [Name (NI) ] [Last Name (NamePattern4) 21845] MD [Location (un) 21846] [Location (un) 19707] ,[Numeric Identifier 21847] . Please follow up with orthopedics for care of your osteomyelitis. . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2201-7-13] 2:10 Please follow up with your infectious diseases physician as you have been. Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2201-7-15] 1:30 . Please also follow up with your primary rheumatologist for re-initiation of your prednisone taper. Completed by:[2201-6-16] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7452 }	Medical Text: Admission Date: [2159-9-16] Discharge Date: [2159-9-21] HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old gentleman, oxygen dependent from COPD who was admitted twice last month at [Hospital3 27946] for pneumonia, discharged two days prior to admission on Cipro for pneumonia and presents states he has not improved and his status is worsening. Shortness of breath, tachypnea, no fevers, no chills, no cough, positive dark sputum positive weight loss about 30 lbs over the last year, positive exposure to asbestos, positive tobacco and pipe exposure 25 years ago, quit. In the Emergency Room respiratory rate of 32 with 80% oxygen saturation on room air, 90's on a 50% face mask. Given 80 mg gm times one. PAST MEDICAL HISTORY: Two recent admissions to [Hospital3 31084] for pneumonia. COPD vs asbestosis on home O2 two liters. Coronary artery disease status post small MI years ago, hypertension, questionable atrial fibrillation, benign prostatic hypertrophy status post TURP years ago and blindness due to macular degeneration. MEDICATIONS: Current medications include Lanoxin .25 mg po Monday, Wednesday, Friday, Saturday, Lanoxin 0.125 mg po Sunday, Tuesday, Thursday, Flovent 4 puffs [Hospital1 ], Serevent 2 puffs [Hospital1 ], Protonix 40 mg po q day, Levaquin 500 mg po q day times 21 days, Diltiazem 60 mg po q 6 hours, Humibid DM one po bid, Flomax 0.4 mg po q day, Captopril 12.5 mg po tid, Albuterol 2 puffs each qid, Atrovent 2 puffs qid, Prednisone taper, 20 mg q day times two, then will go to 10 mg q day times two, then to 5 mg q day times two, to 2 mg q day times two, to 1 mg q day times two. Also receiving prn Haldol 0.5 mg po prn q h.s. ALLERGIES: Ativan. He just does not tolerate it well. PHYSICAL EXAMINATION: On admission, generally he was tachypneic, ill appearing, in no apparent distress. He was febrile with a temperature of 102.4, heart rate 110-130 in atrial fibrillation. Blood pressure 110-140/42-81. Mucus membranes were dry. He has a right surgical pupil, left was 2 mm and reactive, no JVD, irregularly irregular heart rate, no murmurs, diffuse rhonchi, decreased breath sounds in the left upper lobe, no wheezes. Abdomen soft, nontender, non distended, positive bowel sounds. Extremities, no edema with ecchymoses. Neuro, alert and oriented to hospital and name, not date. Able to move all extremities. LABORATORY DATA: White count 30.9. Chest x-ray, left upper lobe infiltrate, no CHF. EKG showed atrial fibrillation. HOSPITAL COURSE: The patient first stayed in the unit for a day and a half, treated for his pneumonia, had a CT scan. The CT results, without contrast, he had diffuse emphysema, severe, with bullous changes in the left space, patchy ground glass in consolidation involving the right lower lobe, the left upper lobe, the left lower lobe and the lingula. He had lymphadenopathy in the mediastinum and no plaque or effusion. Chest x-ray at this time showed two left infiltrates with hyperinflated lung fields with bronchiectasis, pneumonia overlying COPD. Throughout his stay after day 2 transferred to a regular floor, continued to improve, his white count went to 14.9, still with a left shift, was being treated on Levaquin and Vancomycin. His heart was being treated with Diltiazem and Digoxin. Saturations continued to improve where he got up to 50% face mask and now is satting well on a 4 liter nasal cannula. Pulmonary evaluated patient and plan was continued to treat pneumonia and decided Vancomycin was unnecessary at that time because there is no evidence for MRSA. Outside cultures grew Pseudomonas and patient continued to be covered by Levaquin and improved. Before discharge patient had a swallow study which showed minor aspiration with thick barium and a little bit more risky aspiration with thin barium. Speech and swallow recommended to keep the patient on thick nectar liquids and to use the chin tuck position in swallowing. The patient will be discharged to rehab and we expect his pulmonary status to improve from this pneumonia although he does have severe COPD. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Much improved. Will be going to rehab. DISCHARGE DIAGNOSIS: 1. Pneumonia. 2. Chronic obstructive pulmonary disease. 3. Coronary artery disease. 4. Hypertension. 5. MAT. 6. Benign prostatic hypertrophy. 7. Blindness. 8. Hard of hearing. [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Last Name (NamePattern1) 9018] MEDQUIST36 D: [2159-9-21] 09:01 T: [2159-9-21] 09:36 JOB#: [Job Number 31085] ICD9 Codes: 5070, 412, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7453 }	Medical Text: Admission Date: [2139-2-11] Discharge Date: [2139-2-17] Date of Birth: [2063-4-26] Sex: F Service: MEDICINE Allergies: Vioxx / Compazine / Phenergan Attending:[First Name3 (LF) 398] Chief Complaint: AMS/sepsis Major Surgical or Invasive Procedure: Lumbar Puncture Tunnel Cath Placement History of Present Illness: This is a 75 yo F with a history of HTN, CAD, ulcerative colitis, ESRD nearing HD initiation, and h/o recurrent UTIs including multiresistent organisms who is admitted from [Hospital1 ] with hypothermia, altered mental status, sepsis. The patient was admitted on [2-1] with a chief complaint of weakness. She had been unable to ambulate and had progressive decreased PO intake, inability to even ambulate to the bathroom. She was initially started on ctx for a presumed UTI from [Date range (1) 24729], switched to unasyn from [Date range (1) 24730]. On the 4th was obtunded, bradycardic and hypothermic, and was transfered to the ICU. Changed abx on 4th to ceftaz, got IVF, on the 6th, went from 4L NC to 80% FM and was intubated. CXR on [2-9] showed new effusions (few CXR there). Abx - ctaz, ctx, acyclovir (concern for CNS infection), 1x dose for tobramycin, then got one time dose of vanc on 5th, ? linezolid at least on the day of transfer. Of note, patient was admitted to [Hospital1 18] from [2139-1-5] to [2139-1-8] with mental status changes likely [3-9] a Klebsiella UTI treated with a 10 day course of Ciprofloxacin. She was also admitted to the ICU in early [Month (only) ] with severe metabolic acidosis requiring bicarb gtt and worsening renal failure. On arrival, the patient is intubated, and continues to be hypothermic to around 95 degrees. She is unresponsive, appears to decorticate with noxious stimuli. On minimal pressor support with levophed. ROS: Unobtainable Past Medical History: - Chronic UTIs, been on suppressive therapy in the past, last abx course was Cipro, completed on [1-17], followed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7443]/[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in ID - History of VRE - End Stage Renal Disease: Stage V. C/b renal osteodystrophy. Patient states that she is heading toward HD. Has plans for AVF, but was initially postponed until infection-free. Followed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10083] at [Last Name (un) ] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816] with Transplant Nephrology - History of Nephrolithiasis - GERD with esophageal strictures and dysphagia, last balloon dilatation [12-12] - Ulcerative colitis status post colectomy and ileostomy - Cervical spondylosis with chronic low back pain - Hypertension - S/p thyroid resection - Vitamin D deficiency - Macrocytic Anemia: B12 deficiency and CKD, baseline range 23-29 - Hypercholesterolemia - CAD: last echo [3-15]. LVEF 70%. no h/o MI - Pulmonary hypertension (mild PSH on ECHO [3-15]) - Venous insufficiency - Sleep apnea: uses CPAP at night. - Chronic LE cellulitis - treated with bilat unaboot Social History: Patient married. Lives in [Location 3915], MA with husband; daughter and son-in-law live on different level of same house. 2 children, 3 grandchildren. Never a smoker. Denies EtOH use. Pt not very ambulatory. Sleeps in chair with commode nearby. Husband helps with her medications, has VNA but no home health aide. Family History: Mother died of MI at age 62, father died of stroke in 70s. Sister with HTN and DM. Physical Exam: On Presentation: Vitals: T: 94.9 BP: 112/56 HR: 57 Intbated on AC satting 100% , Vt 500, RR 10, PEEP 5, FiO2 35% GEN: Obese, unresponsive HEENT: Pupils constricted, minimally reactive, sclera anicteric, mild proptosis bilaterally, epistaxis from R nares, ETT in place NECK: No JVD, no bruits, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses diminished bilaterally PULM: Lungs clear anteriorly, + rhonchi ABD: Soft, NT, ND, +BS, no masses, ostomy in RLQ with guaiac + watery output EXT: Significant stasis dermatitis, multiple ecchymosis with scabbed areas of skin, erythema without warmth NEURO: Unresponsive, minimal reaction of pupils, responds to noxious stimuli with grimace and internal rotation of arms Pertinent Results: ADMISSION LABS: -[2139-2-11] 04:08PM WBC-8.4 RBC-2.56* HGB-9.4* HCT-28.8* MCV-112* MCH-36.7* MCHC-32.6 RDW-15.6* -[2139-2-11] 04:08PM CALCIUM-8.0* PHOSPHATE-4.3# MAGNESIUM-1.9 -[2139-2-11] 04:08PM GLUCOSE-195* UREA N-25* CREAT-2.1* SODIUM-141 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-16* ANION GAP-26* -[2139-2-11] 04:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [2139-2-11] 04:08PM PT-12.7 PTT-48.6* INR(PT)-1.0 IMAGING: CT HEAD: No acute intracranial abnormalities or hemorrhage. Sinus fluid level and soft tissue changes could be related to intubation but clinical correlation recommended. CT NECK: No focal fluid collection is seen in the neck. Mild stranding of the soft fat is identified bilaterally. Degenerative changes are seen in the cervical spine. Opacity seen in partially visualized right upper lung, for which correlation with torso CT is recommended. CT TORSO: 1. No evidence of retroperitoneal bleed. 2. Large bilateral pleural effusions with complete left lower lobe and near complete right lower lobe collapse. Patchy opacities in the right upper lobe in a bronchovascular distribution consistent with an infectious vs inflammatory process. 3. Findings suggestive of chronic dissection within the distal abdominal aorta without aneurysmal dilatation. Evaluation of the abdominal aorta is incomplete given lack of IV contrast administration. 4. Inferiorly oriented aneurysm of the aortic arch not fully evaluated without contrast administration. 5. Mildly enlarged mediastinal lymph nodes which are nonspecific. 6. Mild coronary artery calcifications. 7. Anasarca. 8. Small amount of ascitic fluid surrounding the liver. 9. Small atrophic kidneys suggesting chronic renal insufficiency with osseous findings suggesting renal osteodystrophy. 10. Extensive lower lumbar degenerative changes as described above. MRI may be obtained for further evaluation as indicated. CARDIAC ECHO: The left atrium is mildly dilated. 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 valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen (best appreciated on cine loop #63). There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Pleural effusions. EEG: Read pending Brief Hospital Course: MICU COURSE: Ms. [Name13 (STitle) ] is a 75 yo F with a history of HTN, CAD, ulcerative colitis, ESRD nearing HD initiation, and h/o recurrent UTIs including multiresistent organisms who was transferred from [Hospital3 7362] with hypothermia, altered mental status, and suspected urosepsis. # Sepsis: On admission, patient met SIRS criteria with hypothermia, elevated WBC, Likely sources are sputum growing GNR, urine culture growing pseudomonas (though less than 100,000 colonies), all at OSH. [Last Name (un) ] stim done at OSH, >9 point increase in cortisol level. Pt was started on Vancomycin, Zosyn and Flagyl, vasopressors. Prior to admission pt was noted to be responsive only to painful stimuli with some witnessed decortication posturing. Neurology was consulted for her altered mental status, an LP was performed which showed no sign of meningitis. HD was also administered for 3 sessions and showed no improvement in mental status. A family meeting was held after pt's mental status failed to improve, after in depth discussion family decided on comfort measures only. Mrs. [Known lastname 7474] was extubated and placed on a Morphine drip. During the evening she developed asytole on the telemetry monitor. On exam she was nonresponsive to voice or touch, she had no spontaneous breathing or breath sounds present, and had no heart sounds present. She was pronounced dead at 5:58 pm. Her cause of death were listed as respiratory failure, urosepsis. Her husband, son were at the bedside at time of passing, they declined an autopsy. Medications on Admission: Home medications (per OSH discharge summary): Folic acid 1 mg daily Ditropan 5 mg [Hospital1 ] Protonix 40 mg [Hospital1 ] Sodium bicarb 650 [Hospital1 ] Lopressor 100 mg [Hospital1 ] Cardizem 60 mg QID Norvasc 5 mg daily Phoslo 667 mg [Hospital1 ] Tigan 300 mg daily Lasix 20 mg daily ASA 81 mg Zyrtec 10 mg daily Ferrous Sulfate 325 mg daily Medications on transfer: Miconazole powder 2% [Hospital1 ] Ceftaz 2 gm IV Q12H Thiamine 100 mg daily Hydrocortizone 50 mg IV Q8H Linezolid 600 mg IV Q12H Heparin 5000 u SQ Q12H Protonix 40 mg IV Qday Ativan 2 mg IV q2H prn Morphine 2 mg IV q2H prn Albuterol MDI 4 puff Q2H prn Ipratropium MDI 17 mcg 4 puffs Q2H prn Levophed gtt Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A ICD9 Codes: 0389, 5990, 5849, 4168, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7454 }	Medical Text: Admission Date: [2168-3-4] Discharge Date: [2168-3-8] Date of Birth: [2108-9-12] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: +ETT Major Surgical or Invasive Procedure: CABGx5 with LAD patch angioplasty LIMA->LAD, SVG->d1->om1->om2, SVG->PAD Social History: Married, working as a plumber. Family History: +CAD Mother with CABG at age 76 Physical Exam: On discharge: Neuro Non focal Lungs with coarse breath sounds t/o Cardiac RRR Sternal incision without redness or drainage, sternum stable Abdomen benign Extremities with trace edema LLE EVH incision clean and dry with ecchymosis Pertinent Results: [2168-3-8] 07:05AM BLOOD WBC-11.9* [2168-3-7] 06:30AM BLOOD Plt Ct-140* [2168-3-7] 06:30AM BLOOD Glucose-102 UreaN-16 Creat-0.9 Na-135 K-4.1 Cl-98 HCO3-28 AnGap-13 Brief Hospital Course: On [2168-3-4] he underwent a CABG x 5 (LIMA->LAD, SVG->D1->OM1->OM2, SVG->PDA) with Dr. [Last Name (STitle) 914]. He was transferred to the ICU in critical but stable condition on neosynephrine and propofol. He was extubated, weaned from his drips and transferred to the floor by POD1. He had no complications post operatively, he had no problems with dysrhythmias and was easily diruesed. He was seen in consultation by physical therapy, and was ready for discharge home on [2168-3-8]. Medications on Admission: wellbutrin, Toprol, [Last Name (LF) 17339], [First Name3 (LF) ] Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:40 Capsule, Sustained Release(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills: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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:qs qs Refills:2 8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:50 Tablet(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: CAD hyperlipidemia HTN PVD h/o Rib Fx Discharge Condition: good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions. Call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: follow up with Dr. [Last Name (STitle) 914] in four weeks [Telephone/Fax (1) 170] follow up with Dr. [Last Name (STitle) ] in two weeks [Telephone/Fax (1) 3183] follow up with cardiologist per Dr. [Last Name (STitle) ] in two weeks Completed by:[2168-3-8] ICD9 Codes: 4111, 4019, 2720, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7455 }	Medical Text: Admission Date: [2129-8-16] Discharge Date: [2129-8-24] Date of Birth: [2060-1-7] Sex: M Service: SURGERY Allergies: Betadine Attending:[First Name3 (LF) 2597] Chief Complaint: AAA Major Surgical or Invasive Procedure: endovascular AAA repair c/b nasal bleed History of Present Illness: This 69-year-old gentleman with severe heart disease, and thought to be a high risk for aneurysm repair has a 6.7-cm infrarenal aortic aneurysm. His anatomy is reasonable for endovascular repair. Past Medical History: CAD, DMII, hyperthyroid, Neuropathy of LE's, MI ([2100]) PSH: CABG [2102], rev [2102], rev [2118] Pacemaker: [2118],[2123],[2128] RFA ablation [2123] Social History: lives with wife in [Name (NI) 41179] Family History: non contributory Physical Exam: GEN: NAD HEENT: nose improved, still has some clotted blood in it, mild difficulty breathing through nose; neck has dressing on R from CVL; otherwise normal HEENT, carotids palpable no bruits. CV: RRR no MRG appreciated RESP: lungs CTA B/L no RRW ABD: soft, NT, mildly protuberant, ND, no masses, no palpable AAA pulse, no bruits, liver and spleen not palpable. EXT: Groin incisions healing well, femoral pulses palpable B/L. [Name (NI) ] PT's B/L, Palpable DP's B/L. no CCE. Pertinent Results: [2129-8-16] 10:37PM PT-14.3* PTT-23.3 INR(PT)-1.3* [2129-8-16] 10:37PM WBC-3.5* RBC-3.60* HGB-12.0* HCT-33.5* MCV-93 MCH-33.3* MCHC-35.7* RDW-15.3 [2129-8-16] 10:37PM GLUCOSE-203* UREA N-23* CREAT-1.4* SODIUM-141 POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16 CTA [8-23] - no report yet, no leak appreciated preliminarily Brief Hospital Course: Pt admitted on [8-16] for scheduled endovascular AAA repair [8-17]. operation c/b nasal bleeding whcih required ENT nasal and oropharyngeal packing. Endovascular AAA repair uncomplicated, pt did well p/op but was taken to SICU for management of nasal bleed. On POD 1 oropharyngeal packing was removed, without complications, and pt tolerated PO's. Femoral, Popliteal and Dorsalis pedis pulses were palpable, Posterior Tibial arteries were [Month/Year (2) 17394] B/L. No pulsatile masses could be palpated post/op. On POD 4 Nasal packing was removed, without recurrence of bleed. Pt's post operative course was uncomplicated and CTA on POD 5 showed no leak into aneurysmal sac. Pt was stable and prepared for discharge on POD 6 with scheduled Follow up. Medications on Admission: Amio 200', Cozaar 50', Lopid 600', Lanoxin 0.125', Metoprolol 100", Lasix 20", Indur 120', Warfarin 2.5/5 QOD, Levoxyl 75', Amaryl", Crestor ' HS, Vytorin [9-16]', Nitrostat 0.4 PRN, ASA 81', Colace 200" Discharge Medications: 1. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 14. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours for 10 days. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: AAA Discharge Condition: good Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [12-31] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [3-3] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Dr. [Last Name (STitle) ] in 2 weeks - call office for appointment [Telephone/Fax (1) 3121] ICD9 Codes: 2851, 3572, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7456 }	Medical Text: Admission Date: [2178-4-21] Discharge Date: [2178-4-27] Date of Birth: [2122-12-10] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 7760] Chief Complaint: Mental status changes, hypotension and hypothermia Major Surgical or Invasive Procedure: Central line placement Peripherally inserted central line placement History of Present Illness: 55F s/p lap ventral hernia repair ([1-29]) s/p ex-lap, LOA & SBR for two enterotomies and primary closure of one enterotomy [2-5] s/p (Removal of temporary abdominal wall closure device, repair of enterocutaneous fistula, and ventral hernia repair with Vicryl meshon [2-17]) now having hypotension and hypothermia concerning for line sepsis Past Medical History: HTN Diverticulitis s/p L hemi-colectomy, cholecystectomy [9-16] s/p lap ventral hernia repair [9-17] s/p lap ventral hernia repair [2178-1-29] s/p exlap, enterotomy repair, draiange [2178-2-6] Social History: No ETOH, Tobacco Family History: Non-contributory Pertinent Results: [2178-4-21] 06:32PM TYPE-[Last Name (un) ] [2178-4-21] 06:32PM O2 SAT-78 [2178-4-21] 03:11PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.018 [2178-4-21] 02:19PM LACTATE-1.2 [2178-4-21] 12:54PM LACTATE-1.2 [2178-4-21] 12:52PM GLUCOSE-75 UREA N-37* CREAT-0.6 SODIUM-138 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13 [2178-4-21] 12:52PM ALT(SGPT)-112* AST(SGOT)-75* ALK PHOS-347* AMYLASE-25 TOT BILI-0.4 [2178-4-21] 12:52PM LIPASE-35 [2178-4-21] 12:52PM CALCIUM-8.5 PHOSPHATE-2.8 MAGNESIUM-2.0 [2178-4-21] 12:52PM WBC-9.1 RBC-3.97* HGB-11.6* HCT-34.4* MCV-87 MCH-29.4 MCHC-33.9 RDW-13.5 [2178-4-21] 12:52PM NEUTS-76.0* LYMPHS-15.4* MONOS-4.8 EOS-3.4 BASOS-0.4 [2178-4-21] 12:52PM PLT COUNT-250 [2178-4-21] 12:52PM PT-12.9 PTT-23.8 INR(PT)-1.1 Brief Hospital Course: Ms. [Known lastname ] was admitted to Dr. [Last Name (STitle) 17477] service at [Hospital1 18] on [2178-4-21]. Upon admission, she was found to have mental status changes, hypothermia and hypotension--she was taken to the SICU for concerns of line sepsis. Her PICC line was removed, the tip sent for culture and a left subclavian central line placed. She was given warm IVF, kept NPO and started on Vanc/Levo/Flagyl/Fluconazole. On HD3, she was hemodynamically stable and she was transferred from the ICU to the floor and re-started on TPN but kept on maintenance IVF. On HD 4, an infectious disease consult recommended the patient be continued on Vanc/Levo but that Flagy and Fluconazole be discontinued. Of note, her blood cultures were all negative as was her PICC line tip; although, her urine culture was positive for Enteroccus and Coag neg. Staph. On HD 4, the patient noted some erythema on right upper extremity near old picc line site--an ultrasound of the area was negative for DVT. On HD 7, the patient was doing well, ambulating without difficulty, stable with good glucose control on her TPN regimen. She then had a new PICC line placed and her subclavian line removed. She was deemed fit enough to return home and was so discharged in good condition in the care of her husband. She is to have her fistula output (which has had a rel. constant output of 300cc per day) replaced with lactated ringer's solution in a 1cc:1cc ratio. Home VNA is aware and will be monitoring the patient until her follow-up in the next 1-2 weeks with Dr. [Last Name (STitle) ]. [Doctor Last Name 6633]. Medications on Admission: 1. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Paroxetine HCl 10 mg/5 mL Suspension Sig: One (1) PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours). 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation TID PRN (). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation TID PRN (). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Percocet Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Docusate Sodium 50 mg/15 mL Syrup Sig: Two (2) PO BID (2 times a day). Disp:qs 1 Refills:6 3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QD (). Disp:30 Tablet(s) Refills:2 4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:qs 1 Refills:4 6. picc line PICC Line Care per protocol 7. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous twice a day for 8 days. Disp:qs 1 Refills:0 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 8 days. Disp:8 Tablet(s) Refills:0 9. lactated ringers Lactated Ringers solution: Please replace each cc of fistula output with 1cc of Lactated Ringers solution Discharge Disposition: Home With Service Facility: [Location (un) 511] Home Therapies Discharge Diagnosis: Line sepsis versus urinary tract infection 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. 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 all of your previously prescribed medications. You may take showers. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 2998]. Call to schedule appointment ICD9 Codes: 0389, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7457 }	Medical Text: Admission Date: [2126-10-21] Discharge Date: [2126-10-31] Date of Birth: [2056-6-25] Sex: M Service: CSU CHIEF COMPLAINT: Recurrent dyspnea on exertion. HISTORY OF PRESENT ILLNESS: A 70-year-old man with dyspnea on exertion times several years with no chest pain. Exercise tolerance test done in [Month (only) 216] showed an EF of 30-35 percent with global hypokinesis and large fixed inferior defect. Referred for cardiac catheterization. Initial evaluation was prompted by preoperative cataract surgery exam. Patient denies chest pain. Cardiac catheterization done on the [6-12] shows EF of 25-30 percent with global hypokinesis, inferior akinesis, LAD 70 percent lesion, circumflex 70 percent lesion, RCA 100 percent lesion. Echocardiogram done on [2126-7-18] showed an EF of 30 percent with LVH, mild MR, and dilated aortic root to 3.9 mm. PAST MEDICAL HISTORY: Hypertension. Diabetes mellitus type 2. Obesity. Carpal tunnel repair. Stomach surgery for questionable duodenal ulcer complicated by peritonitis. Bilateral knee replacements. Broken right femur with an ORIF. Cataract surgery. Pilonidal cyst removal as a teenager. MEDICATIONS: 1. Lisinopril/hydrochlorothiazide 20/25 every day. 2. Atenolol 25 every day. 3. Glyburide 5 twice a day. 4. Metformin 500 twice a day. 5. Aspirin 81 every day. 6. Multivitamins every day. 7. Vitamin E 400 every day. ALLERGIES: 1. Celebrex, which causes swelling. 2. Feldene, which causes "a hole in my stomach." FAMILY HISTORY: Mom had CAD in her 50's. Lived to be 80. Brother with a MI at age 46, died at age 56. Multiple uncles also with CAD. OCCUPATION: Retired truck driver. SOCIAL HISTORY: Lives with his wife. Remote tobacco. Quit 30 years ago. Had a 50 pack year history prior to that. Alcohol: Remote, quit in [2092]. PHYSICAL EXAMINATION: Height is 5'[32]", 240 pounds. Heart rate 70. Blood pressure 99/53, respiratory rate 20, and O2 saturation 98 percent on room air. General: Sitting in bed in no acute distress. Skin is warm and dry. No obvious lesions. HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Mucous membranes are moist with no lesions. Neck is supple with no carotid bruits, no lymphadenopathy, and no JVD. Chest was clear to auscultation. Cardiovascular: Regular rate and rhythm, S1, S2 with a 2/6 systolic ejection murmur. Abdomen is soft, nontender, and nondistended with normoactive bowel sounds. Extremities are warm and well perfused with no edema, no varicosities. Neurologic: Alert and oriented times three, nonfocal examination. Pulses: Dorsalis pedis 2 plus bilaterally. Posterior tibial 2 plus bilaterally. Radial 2 plus bilaterally. Carotids are 2 plus with no bruits. HOSPITAL COURSE: As stated, the patient was a direct admission to the operating room. Previous history and physical and physical exam were done in preadmission testing. On [10-21], the patient was admitted into the operating room for coronary artery bypass grafting x4. Please see the OR report for full details. In summary, he had a CABG x4 with a LIMA to the LAD, saphenous vein graft to the PDA, saphenous vein graft to the OM, saphenous vein graft to the diag. His bypass time was 92 minutes with a cross-clamp time of 64 minutes. He tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was in sinus rhythm at 94 beats per minute with a mean arterial pressure of 69. He had Levophed at 0.03 mcg/kg/minute and propofol at 20 mcg/kg/minute. Patient did well in the immediate postoperative period. His sedation was discontinued. His anesthesia was reversed. He was weaned from the ventilator. However, following weaning, the patient had periods of apnea. Therefore, his breathing tube was left in place to give the patient little additional time to recovery from his anesthesia. Ultimately, the patient was successfully extubated on the day of his surgery. He remained hemodynamically stable throughout that day with Levophed to maintain an adequate blood pressure on postoperative day one. Patient remained hemodynamically stable. His Levophed infusion was weaned to off. He was begun on beta-blockade. His Swan-Ganz catheter was discontinued. He was noted to have periods of atrial fibrillation, and was therefore started on amiodarone infusion. On postoperative day two, the patient continued to be hemodynamically stable, although he was in atrial fibrillation that was rate controlled with this ventricular response in the 90s. His chest tubes were discontinued and he was transferred to the floor for continued postoperative care and cardiac rehabilitation. Once on the floor, the patient had a slow recovery from his surgery. On postoperative day three, his temporary pacing wires were removed. His amiodarone infusion was switched to oral amiodarone. His activity level was increased with the assistance of the nursing staff and Physical Therapy. Over the next several days, the patient's beta-blockade was gradually increased. He continued to be diuresed, and he was begun on anticoagulation with Heparin as well as Coumadin. On postoperative day four, the patient converted to a normal sinus rhythm. However, he did continue to have periods of being in and out of atrial fibrillation. By postoperative day seven, the patient's atrial fibrillation was in better control. However, he remained somewhat fluid overloaded with bilateral pedal edema and scattered rales. Therefore, his diuresis was increased with good effect. Over the next several days, the patient's shortness of breath resolved. On postoperative day 10, it was decided that patient was stable and ready to be discharged home. At the time of this dictation, the patient's physical exam is as follows: Vital signs: Temperature 97, heart rate 88, atrial fibrillation, blood pressure 100/56, respiratory rate 20, and O2 saturation 96 percent on room air. Weight at discharge is 116.4 kg. Preoperatively, 100 kg. Neurologic: Alert and oriented times three, moves all extremities, follows commands, and nonfocal examination. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Irregularly, irregular. Sternum is stable. Incision with Steri-Strips, open to air clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused with 1 plus edema bilaterally. Bilateral endoscopic vein harvest sites with Steri-Strips open to air clean and dry. Laboratory data: White count 10.6, hematocrit 30, platelets 567. PT 19.9, INR at 2.5. Sodium at 141, potassium 4.9, chloride 101, CO2 29, BUN 19, creatinine 1.1, glucose 77, magnesium 2.2. CONDITION ON DISCHARGE: Stable. DISPOSITION: He is to be dislocation home with visiting nurses. FO[Last Name (STitle) ]P INSTRUCTIONS: He is to followup in the [Hospital 409] Clinic in two weeks. Follow up with Dr. [Last Name (STitle) ] to have an INR check on [11-1]. Follow up with Dr. [Last Name (STitle) 5874] in [2-19] weeks and follow up with Dr. [Last Name (Prefixes) ] in four weeks. DISCHARGE DIAGNOSES: Coronary artery disease status post coronary artery bypass grafting times four with a left internal mammary artery to the left anterior descending artery, saphenous vein graft to the obtuse margin, saphenous vein graft to posterior descending artery, and saphenous vein graft to diagonal. Hypertension. Diabetes mellitus type 2. Status post exploratory laparotomy complicated by peritonitis. Arthritis. DISCHARGE MEDICATIONS: 1. Colace 100 mg twice a day. 2. Aspirin 81 mg every day. 3. Glyburide 5 mg twice a day. 4. Coumadin as directed to maintain goal INR of [2-18].5. Patient is to take 1 mg on the day of discharge, then as directed by Dr. [Last Name (STitle) ]. 5. Ferrous sulfate 325 mg every day. 6. Dilaudid 2-4 mg every four to six hours as needed. 7. Amiodarone 400 mg twice a day times one week, then 400 mg every day times one week, then 200 mg every day. 8. Lasix 40 mg every day times two weeks. 9. Metoprolol 25 mg twice a day. 10. Metformin 500 mg twice a day. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2126-10-31] 19:38:45 T: [2126-11-1] 08:20:39 Job#: [Job Number 57527] ICD9 Codes: 9971, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7458 }	Medical Text: Admission Date: [2195-5-19] Discharge Date: [2195-5-23] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2569] Chief Complaint: decreased responsiveness Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ]yo woman with history of breast cancer s/p rigth mastectomy on arimidex, hypertension, presents with aphasia and right sided weakness. She was in her USOH the night prior to presentation, which is when she was last seen well. Her family found her this morning, not speaking and not responding to them. EMS was called and she was brought to [Hospital1 18] ED. Past Medical History: breast cancer s/p right mastectomy, on arimidex hypertension Social History: per OMR, no tobacco or EtOH, retired teacher, son in [Name (NI) ]. Family History: not elicited Physical Exam: VS: T 100.4, HR 69, BP 162/90, RR 29, saO2 96%/RA, FS 116 Genl: sitting in bed, rhonchorous HEENT: NCAT Neck: supple CV: RRR, nl S1, S2, but difficult to auscultate over rhonchi Chest: diffusely rhonchorous Abd: soft, NTND, BS+ Ext: warm and dry Neurologic examination: MS: Regards examiner on left, does not track past midline to right. Does not follow commands. Does not speak. CN: Pupils equal and reactive, 4->2, no blink to threat on right, left gaze deviation, does not pass midline, b/l corneals present, nasal tickle present b/l but R facial palsy. Motor: Antigravity spontaneously in RUE, moves less than LUE; RUE drifts down immediately, LUE without drift. RLE triple flexes to noxious, no antigravity movement but moves with gravity on the bed. LLE antigravity. Sensory: responds to noxious in all extremities DTRs: hyperreflexic on right; not elicited in achilles b/l; right plantarstim -> triple flexion, left downgoing. Pertinent Results: 143 107 26 ------------< 117 4.3 25 1.7 estGFR: 28/34 (click for details) CK: 72 MB: Notdone Trop-T: 0.02 Ca: 9.9 Mg: 2.0 P: 3.5 9.6 > 41.0 < 201 N:71.6 L:20.4 M:5.5 E:1.8 Bas:0.6 PT: 12.3 PTT: 27.8 INR: 1.0 U/A negative CXR: Limited study demonstrating no evidence of pneumonia or CHF. <br> Head CT [5-19]: IMPRESSION: 1. Findings concerning for early infarct in the left frontal lobe. MRI may be performed for further evaluation. No hemorrhage. 2. Hyperdense appearance of the left ACA, worrisome for thrombosis. 3. Chronic small vessel ischemic disease. 4. Age-related parenchymal atrophy. <br> Head CT [5-20]: FINDINGS: Evolving hypodensity and associated cortical sulcal effacement is noted of the left frontal lobe in the left middle cerebral artery territory consistent with new infarction. Also noted is a small area of developing hypodensity involving the genu of the left internal capsule consistent with infarction. There is no evidence of intracranial hemorrhage, mass effect, shift of normally midline structures or hydrocephalus. There is mild hypodensity of the periventricular white matter consistent with chronic small vessel infarction. Mucosal thickening and a fluid level is noted within the left maxillary sinus. Bilateral lens replacements are present. There are age-related involutional changes. IMPRESSION: 1. Evolving infarction of the left middle cerebral artery territory, including a portion of the left frontal lobe and genu of the left internal capsule. No evidence of intracranial hemorrhage or significant mass effect. 2. Fluid level within the left maxillary sinus. Brief Hospital Course: Ms. [Known lastname 73624] was admitted to the Neuro ICU for close monitoring following her large Left MCA stroke. She continued to have a dense aphasia, right side neglect, and right hemeplegia. She was kept euthermic with Tylenol and euglycemic with an insulin sliding scale. On her first night in the ICU, she was found to go into rapid atrial fibrillation. This was previously unknown and is the likely mechanism for her stroke. Her rapid ventricular rate caused some hemodynamic instability with hypotension; she was rate controlled with a diltiazem drip. This was turned off the next night when she converted back to sinus and had bradycardia to the 50s. Echo was not obtained as her family did not feel she would want to have been anticoagulated. After two days in the ICU, based on clinical findings and imaging results, it was clear that she was not going to have a significant recovery and in the long-term would need a PEG for feeding and round-the-clock care. Her family were all in agreement that this is not something she would want at the end of her life, especially the PEG. Therefore, all involved agreed that it was appropriate to make her code status CMO (Comfort Measures Only). She was placed on a morphine drip and transferred to the floor. Two days later, she passed comfortably and quietly with family at the bedside. Medications on Admission: lisinopril metoprolol HCTZ KCl arimidex ASA All: NKDA Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cerebral Infarct (Stroke) Discharge Condition: Expired. Discharge Instructions: N/A Followup Instructions: N/A [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2195-5-23] ICD9 Codes: 5070, 4019, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7459 }	Medical Text: Admission Date: [2109-6-7] Discharge Date: [2109-7-10] Date of Birth: [2080-11-11] Sex: F Service: OBSTETRICS HISTORY OF PRESENT ILLNESS: This is a 28-year-old G5 P2 with expected date of delivery of [2109-9-16] by last menstrual period who presents at 25 weeks and 4 days with a complete previa, bleeding since previous night, with small clots, and soaked through one full pad. At the time of admission, the patient denied any vaginal bleeding. She denied any abdominal pain, contractions or leakage of fluid and had good fetal movement. The patient's last episode of bleeding was in [3-6]. PRENATAL COURSE: Expected date of confinement is [2109-9-16] by last menstrual period consistent with early ultrasound. Laboratory examination, she was A positive. Ultrasound of [2109-3-14] showed a posterior placenta with a complete previa, and a 14-week ultrasound showed size equal to date. On [2109-6-16], she had anterior placenta, complete previa with a 4-cm of the placenta along the posterior wall, otherwise a normal survey. Cervix was 29 mm in length and expected fetal weight was 242 g in the 34th percentile. Her triple marker screen was within normal limits. PAST OBSTETRIC HISTORY: TAB x 1. In [2104], a primary cesarean section secondary to breech presentation, baby boy, 7 pounds 7 ounces, 38 weeks and no complications. Ectopic pregnancy x 1, status post laparoscopy, salpingostomy, and methotrexate. In [2107], a repeat cesarean section, baby girl weighing 6 pounds 3 ounces, full-term, no complications. PAST GYNECOLOGICAL HISTORY: History of abnormal pap, but no cervical biopsies. Repeat Pap was within normal limits and no other gynecological problems. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: C-section x 2 and laparoscopy, status post salpingostomy. MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Denies tobacco, alcohol or drugs. PHYSICAL EXAMINATION: Her temperature was 98.4 degrees, pulse 97, respiratory rate 20, blood pressure 112/54. In general, she was in no apparent distress. Her abdomen was soft, gravid, nontender, nondistended. Sterile vaginal exam was deferred. There was no external bleeding. Extremities, no clubbing, cyanosis, or edema. Tocodynamometer showed no contractions, external fetal monitor in 150s, appropriate gestational age, no decelerations. A bedside ultrasound, baby was in vertex presentation. Biophysical profile was [9-8] with normal fluid and no placental clot was seen. HOSPITAL COURSE: Previa and accreta. The patient had an ultrasound on [2109-6-7], which showed an anterior placenta with the tip of the external os to the left of the midline, an accreta, bladder varices representing a possible percreta. A repeat transabdominal and transvaginal ultrasound by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 410] on [2109-6-24] showed anterior placenta with areas of irregularity of the uterine contour with the placenta extending through the myometrium consistent with a placenta accreta. The largest area was 7 cm low and anterior just above the bladder. There was one area of placental vascularity, which was unclear with extents beyond the confines of the uterus. The uterovesical junction was seen bilaterally at real time and jets of flow were documented. There were no definite areas of bladder wall involvement. The patient was typed and crossed x 2 units. Initially, she did not have any vaginal bleeding. Her hematocrit remained stable at 30 percent. The patient was remained on bedrest. Gynecology, Oncology, Interventional Radiology, High Risk Obstetrics, and Anesthesia were all consulted and involved in her care. On [2109-6-28], the patient had an urge to void and had a large clot and vaginal bleeding. The patient was brought up to Labor and Delivery once typed and crossed x 2 units. Once again, her coags were all within normal limits, and her hematocrit remained at 31 percent. The patient was observed overnight. A large clot, thumb sized, was expressed by the obstetrician on call. She did not have any signs or symptoms of bleeding at that time. The baby was monitored as well as contraction monitoring. She did not have any signs or symptoms of labor. When the patient was stable, she was brought back down to the Antepartum Floor and remained stable from the bleeding standpoint. After this, the patient had trace RBCs in her urinalysis and some pinkish discharge while she urinated; otherwise, she did not have any vaginal bleeding up until [2109-7-9] at 1:35 a.m. when the patient had a sudden gush of vaginal bleeding. Coags were sent, and the patient was immediately transferred to Labor and Delivery. Her coags at that time were within normal limits. Her PT was 13, PTT was 26.6, and INR was 1.1 and a fibrinogen of 335. Her hematocrit was at 33.3 percent and her platelets at 260. An emergent central line was placed for IV access. The patient was typed and crossed x 8 units and brought back to the Labor and Delivery Operating Room. The patient was transfused 11 units of packed red blood cells, 6 units of FFP, and 500 of Hespan during her cesarean section. She had a classical cesarean section via a vertical incision and a supracervical hysterectomy at 30 weeks and 1 day gestational age. The patient was left with abdominal packing and 6 laparotomy sponges. She was under general anesthesia. Dr. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 1022] from Gynecological Oncology, Dr. [First Name11 (Name Pattern1) 402] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ], and Dr. [First Name (STitle) 34301] [Name (STitle) 34302] were all involved in her surgery. At the time of the cesarean section, a baby female was in vertex presentation with Apgar's 3 at 1 minute, 6 at 5 minutes, and 7 at 10 minutes. Cord gases, a pH was 7.3, 17, 49, 25, minus 4. The placenta was adherent to the lower uterine segment, and there was increase in bleeding with detachment. There was increase in vascularity at the bladder and uterine junction. Please see the operative note for further details. Her total EBL was 4000 cc. Immediately, after her cesarean section, the patient went into DIC. Her hematocrit had nadired at 18.0 percent as well as her platelet count at 32 percent. Her coagulations also demonstrated a consumptive coagulopathy with her PT being 16.6 and PTT peaking at 61.4 with an INR of 1.8. After multiple transfusions, her coagulopathy had subsided at the time of this dictation. Please see the next dictation on discharge summary for further details. Fetal well-being. The patient had a reassuring fetal testing throughout her pregnancy. Her last fetal weight showed a baby at the 40th percentile with size equal to date and appropriate interval growth. Weekly biophysical profiles were obtained, all of which showed a biophysical profile of [9-8]. Her last fluid level was 11.7 centimeters. At the time of her cesarean section, the baby was [Name2 (NI) ] at 30 weeks and 1 day with Apgar's as described above, 3 at 1 minute, 6 at 5 minutes, and 7 at 10 minutes. The baby was brought up to the NICU, and at the time of this dictation, is currently doing well. The NICU was consulted during her hospital stay. The patient also received 12 mg IM of betamethasone on [7-8] and [7-9] for fetal lung maturity. The patient tolerated this medicine well without any complications. DISCHARGE DIAGNOSES: An asymmetric previa, accreta, and percreta. Intrauterine pregnancy, status post betamethasone. Status post supracervical hysterectomy and cesarean section on [2109-7-9]. [Name6 (MD) 34301] [Name8 (MD) 34302], [MD Number(1) 34303] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2109-7-9] 10:05:00 T: [2109-7-9] 21:38:32 Job#: [Job Number 34304] ICD9 Codes: 2851, 5070, 5185
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7460 }	Medical Text: Admission Date: [2175-2-28] Discharge Date: [2175-3-6] Date of Birth: [2152-11-19] Sex: M Service: TRAUMA SURGERY CHIEF COMPLAINT: Status post motor vehicle collision. HISTORY OF PRESENT ILLNESS: The patient is a 22 year old male, status post motor vehicle collision, the patient fell asleep at the wheel, was an unrestrained driver. The motor vehicle had turned over and the patient arrived with a GCS of 15. On arrival, the patient was tachycardic and hypotensive and given six liters of crystalloid and brought to the CT scanner after response to fluids. The patient sustained a grade III/IV splenic laceration, small left pneumothorax, pulmonary contusions, left rib fractures of ribs eight, nine and ten, small pelvic rami superior and inferior fracture with intramuscular hematoma. The patient's official CT read showed a splattered spleen with hemoperitoneum, grade III/IV splenic laceration, the hilum appeared to be intact. PAST MEDICAL HISTORY: Testicular cancer, status post orchiectomy. SOCIAL HISTORY: The patient drinks three to four drinks two to three times per week and denies tobacco. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Wellbutrin 200 mg p.o. twice a day. 2. Zoloft 50 mg p.o. once daily. 3. Ambien p.r.n. PHYSICAL EXAMINATION: On admission to the Emergency Department, the patient's temperature was 99.4, blood pressure 82/palpable initially and heart rate was 90 to 115, respiratory rate 24, oxygen saturation 100% on nonrebreather. LABORATORY DATA: The patient's white blood cell count was 19.4, hematocrit 42.4, platelet count 236,000. Electrolytes were within normal limits. Lactate was 2.9. Amylase was 76. The patient's arterial blood gas was 7.34, 49, 209, 28, 0. The patient's INR was 1.2. Partial thromboplastin time was 24.2. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9325], M.D. [MD Number(1) 10637] Dictated By:[Last Name (NamePattern1) 45743] MEDQUIST36 D: [2175-3-9] 16:25 T: [2175-3-11] 12:18 JOB#: [Job Number 53218] ICD9 Codes: 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7461 }	Medical Text: Admission Date: [2156-4-1] Discharge Date: [2156-4-13] Date of Birth: [2086-7-24] Sex: M PRINCIPAL DIAGNOSIS: Residual basal tongue squamous cell carcinoma. ASSOCIATED DIAGNOSES: 2. Depression. 3. History of tobacco and alcohol abuse. PRINCIPAL PROCEDURE: Base of tongue resection with primary closure. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old the tongue, status post chemoradiation therapy with residual disease. Thus, the patient now presents for salvage surgery. PAST MEDICAL HISTORY: (Past medical history is remarkable for) 1. Hypercholesterolemia. 2. Depression. 3. Tobacco and alcohol use. PAST SURGICAL HISTORY: Past surgical history is remarkable for tonsillectomy as well as hemorrhoidectomy. MEDICATIONS ON ADMISSION: Trazodone 100 mg p.o. q.h.s., Celexa 40 mg p.o. q.d., simvastatin 20 mg p.o. q.h.s. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient has a past alcohol use history. He has a significant past history of tobacco. He still uses some. The patient has strong support from his family; mostly daughter. FAMILY HISTORY: Family history was noncontributory. REVIEW OF SYSTEMS: Review of systems was unremarkable. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination the patient's was found to have a pulse of 72, a blood pressure of 110/70, with a weight of 157 pounds. The patient was afebrile. In general, the patient was alert and oriented times three. He was in no acute distress. Head and neck examination revealed him to have normal ears bilaterally. Examination of the nose was unremarkable. The oropharyngeal examination revealed approximately a 2-cm firm mass at the right base of the tongue. Otherwise, no other lesions on his tongue. Tongue mobility was good. No oropharyngeal or oropharyngeal mucosal lesions were appreciated. Examination of the patient's nasopharynx, hypopharynx, and larynx revealed these to be normal. Examination of the patient's neck did not reveal evidence of lymphadenopathy. Examination of the chest revealed the patient to have lungs that were clear to auscultation bilaterally. The patient had a normal first heart sound and second heart sound with a regular rate and rhythm. No murmurs, rubs or gallops were appreciated. The abdominal examination was found to be soft, nontender, and nondistended. There was evidence of a previous open G-tube. Examination of the extremities was benign. ASSESSMENT AND PLAN: In summary, the patient is a 69-year-old with residual squamous cell carcinoma of the base of the tongue, status post chemoradiation therapy. After discussion of all risks and benefits, the patient opted to pursue surgical salvage. HOSPITAL COURSE: Thus, the patient presents to the hospital for a same day admission for surgery. The patient presented to the hospital on [2156-4-1]. At this time he underwent a right selective neck dissection including levels I through IV with a lateral pharyngotomy approach to the base of the tongue. The latter was resected. Closure was performed primarily by Plastic Surgery without any issues. The patient's immediate postoperative course was benign except for new onset intermittent persistent headaches. The headaches were generally minimally responsive to morphine. After a CT scan was performed, which was found to be entirely normal as well as laboratory evaluation which also was found to be normal, a Neurology consultation was obtained for this issue. In summary, they found the headaches to likely be of little concern and suggested muscle contraction and spasm as the likely source. Based on their recommendations, the patient was treated with a 3-day of Neurontin 300 mg b.i.d. with good resolution of the headaches. Otherwise, the patient's postoperative course was without acute complications. The patient was evaluated by Speech and Swallow with a video swallow assessment approximately on postoperative day seven. At this time the patient was found to have some evidence of aspiration. Based on this recommendation, the patient was kept n.p.o. and an open G-tube was obtained by General Surgery. Thereafter, the patient was able to tolerate tube feeds to goal without issue. Furthermore, the patient was successfully decannulated. DISCHARGE STATUS: The patient was discharged to home with visiting nurse services in stable condition; ambulating and tolerating bolus tube feeds. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE INSTRUCTIONS: The patient was discharged to home with instructions to remain n.p.o. He was to continue nutrition per G-tube in the form of eight cans of ProMod with fiber q.d.; the latter to be delivered at 3 a.m., 3 at noon, 2 q.p.m. MEDICATIONS ON DISCHARGE: Furthermore, the patient was discharged with prescriptions for Colace 100 mg per G-tube b.i.d., Roxicet 5 cc to 10 cc per G-tube q.4-6h. as needed for pain, Zocor 40 mg per G-tube q.h.s., Celexa 40 mg per G-tube q.d., Nystatin 10 cc swish-and-spit q.i.d. times 10 days, Keflex 500 mg per G-tube q.i.d. for seven days. DISCHARGE ACTIVITY: The patient had no activity restrictions. DISCHARGE FOLLOWUP: He was to follow up with Speech and Swallow for continuing swallowing rehabilitation with hopes of eventually being able to tolerate a full diet by mouth and concomitant discontinuation of the G-tube. The patient was to follow up with Dr. [Last Name (STitle) 1837] one week after discharge. [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 6152], M.D. [MD Number(1) 6153] Dictated By:[Last Name (NamePattern1) 41760] MEDQUIST36 D: [2156-4-12] 10:36 T: [2156-4-14] 12:04 JOB#: [Job Number ] ICD9 Codes: 3051, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7462 }	Medical Text: Admission Date: [2145-3-12] Discharge Date: [2145-3-18] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: cholangitis Major Surgical or Invasive Procedure: endotracheal intubation central line placement ERCP History of Present Illness: 83M with COPD, Waldenstrom's presented to OSH on [2-26] with abdominal pain and distension as well as LE edema. His hospital course was notable for hypoxia and hypotension on [2-28] in the setting of blood transfusion, with Klebsiella pneumoniae in [5-14] blood culture bottles. He was noted to have guiac positive stools. He was empirically treated with levofloxacin and flagyl. He did experience an elevation of his cardiac enzymes thought c/w NSTEMI vs demand ischemia; this was medically treated with beta blocker/ASA/statin. A RUQ ultrasound was obtained on [2-27] which showed dilatation of the CBD with stones. ERCP was delayed until [3-11] as he was not felt to be stable enough for the procedure prior to that time. At ERCP, the CBD was cannulated with pancreatogram showing distal filling defects c/w stones. He became hypotensive to the 70's and hypoxic to the 70's during the procedure. Subsequently he was intubated and transferred to the CCU. His antibiotics were changed to vancomycin and Zosyn per the OSH ID consultant's recommendations. He was transferred to [Hospital1 18] on [3-12] for ERCP and further management of his biliary sepsis. Current vent settings AC 400x20, PEEP 5, FiO2 0.5. Currently c/o mild right sided abd pain. Past Medical History: COPD with "severe bullous disease" Waldenstrom's macroglobulinemia Paget's disease Temporal arteritis s/p cholecystectomy [72] years ago h/o PUD s/p gastrectomy, s/p hand surgery Social History: Lives alone but daughter lives in downstairs apt. Former 60 pack year h/o smoking. Occ EtoH. Family History: noncontributory Physical Exam: T36.9C P 82 BP 95/46 CVP 15 PA 67/32 RR 27 O2 96% on FiO2 50% General Elderly man in no acute distress HEENT Sclera anicteric, conjunctiva pink, ET and NGT in place Neck No JVD Pulm Lungs with few crackles at left base and decreased breath sounds right base CV Regular rate S1 S2 no m/r/g Abd Soft, mild discomfort right abdomen without rigidity or guarding, no masses appreciated Extrem Legs warm with tr bilateral pitting edema Neuro Alert awake and communicative via head movements and hand gestures Derm No jaundice Lines/tubes/drains R PA line, foley Pertinent Results: [Hospital1 18] labs [3-12] Chem 146/3.5/116/19/19/1.5<104 Ca 6.5 Mag 2.2 Phos 3.0 Alb pending CK 41 MB pending Tropn pending ALT 29 AST 67 ALKP 167 Tbil 0.8 [Doctor First Name ] 130 Lip 39 pro-BNP pending CBC 5.5>8.9/28.7<176 N 83.1 L 11.9 M 4.6 E 0.2 Baso 0.1 INR 1.7 PTT 18.8 ABG 7.28/43/89/21/-6 on PSV 31x390 PEEP 5 lactate 0.8 . [Hospital3 ] labs (select) [3-12] WBC 6.9, Hb/Hct 8.9/28.8, Plts 162 Na 145 K 3.9 Cl 114 Co2 19 Bun 19 Cr 1.7 (Cr 1.3 on [3-11].4 on [2-26]) Mg 1.9 Phos 2.1 PT 1.9, PTT 37.8 ALT 47, AST 126, ALKP 205, Tbil 0.6, Dbil 0.2, amylase 131, lipase 73, alb 2.8, tprot 7.1 ABG 7.29/42/92/21 on FiO2 0.5 [2-28] CK 241 MB 8.6 Tropn 7.41 (peaks, on [3-12] CK 48 MB 2.6 Tropn 0.06) [2-27] lactate 0.9 [3-12] UA 1.013 5.0 leuk- nitr- blood 3+, [3-16] wbc, 50-100 rbc . . MICRO [Hospital1 18] [3-16] catheter tip cx negative [3-13] sputum >25 polys cx with MRSA 2/1,2/4,2/5,[3-17] blood cx NGTD [3-12] blood a line * [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) ] * [3-12] urine cx negative . [Hospital3 ] [3-12] sputum >25 polys, "many" GPCs on gram MRSA [3-12] urine cx NGTD [3-12] blood cx [3-13] NGTD [3-10] blood cx [2-10] GPC in clusters [3-7] blood cx NGTD [3-6] C diff negative [3-3] blood cx no growth [2-28] sputum no polys, few bacteria on gram, rare growth oral flora *** [2-28] blood cx [5-14] Klebsiella pneumoniae * S to augmentin, unasyn, cefazolin, cipro, gent, levo, zosyn, bactrim; I to amp, tetracycline [2-27] urine cx <10k skin flora [2-27] strep pneumoniae urinary antigen negative, legionella urinary antigen negative . [3-13] ERCP report Impression: 1. Short Billroth II segment 2. The major papilla was noted to be bulging. 3. Successful cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. 4. Cholangiogram showed multiple large filling defects consistent with stones in the CBD. 5. Successful placement of a 7cm by 7Fr Cotton [Doctor Last Name ] biliary stent, with draiange of dark, infected looking bile. . [3-15] TTE The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Right ventricular cavity enlargement with free wall hypokinesis. Pulmonary artery systolic hypertension. Normal left ventricular cavity size and systolic function. This constellation of findings is suggestive of a primary pulmoanry process (COPD, pulmonary embolism, etc.). . [3-18] CXR Minimal interval improvement in pulmonary edema is noted with unchanged left retrocardiac atelectasis and bilateral pleural effusions. Borderline cardiomegaly is stable. IMPRESSION: Slight improvement in pulmonary edema still accompanied by large bilateral pleural effusions. Left retrocardiac atelectasis. Most likely underlying emphysema. Brief Hospital Course: 1. Biliary sepsis with Klebsiella bacteremia The patient was transferred to [Hospital1 18] on [3-12] for planned ERCP. He was continued on vancomycin and zosyn for coverage of the Klebsiella and MRSA isolated at the OSH. His dopamine was weaned off, but by [3-13] he again required pressor support despite aggressive fluid resuscitation so he was started on levophed. He underwent the planned ERCP on [3-13] with stenting of the biliary duct and drainage of dark bile. Subsequent to the ERCP he required additional ventilatory support and addition of vasopressin for additional blood pressure support. He was started on Xigris on [3-14] which was initially complicated by some hematuria and heme positive stools. Xigris was discontinued by [3-15] in anticipation of central line change. By [3-17] he developed grossly bloody stools. Labs on [3-18] showed evidence of low level DIC. After discussion with the family regarding the patient's extremely poor prognosis in setting of respiratory failure, candidemia, cholangitis, and transfusion dependent GI bleed the decision was made to make the patient CMO. He was extubated and pressors were discontinued. He died at 6:18pm on [2145-3-18]. 2. Candidemia (non-albicans) The patient's blood culture drawn on [3-12] from the arterial line placed at the OSH grew C. [Month/Day (4) 29361]. He was empirically started on caspofungin on [3-16] when this positive result returned. Opthalmology exam showed no evidence of fungal retinitis. 3. Respiratory failure, ARDS The patient remained ventilatory dependent during his hospitalization with P/F ratios less than 200 and bilateral infiltrates c/w ARDS. 4. Gastrointestinal bleeding GI bleeding as above. The GI service was consulted and offered to perform EGD to evaluate for source of bleeding. The family declined the procedure given the patient's extremely poor prognosis by the time gross GI bleeding had developed. 5. Acute renal failure The patient's creatinine remained essentially stable at 1.8 above his recent baseline, with elevation thought likely due to ATN in setting of hypotension. 6. COPD We continued the patient on his bronchodilators. 7. CAD By report he had a NSTEMI versus demand ischemia at the OSH prior to transfer. His troponin was mildly elevated at admission but remained flat on serial check. EKG showed diffuse T wave inversions. Echocardiogram showed RV free wall HK c/w prior infarct. 8. Pulmonary hypertension The patient underwent a brief trial of sildenafil to assess whether this would improve cardiac output, but BP did not tolerate the trial. Medications on Admission: Medications at home: Lasix 20 mg daily Fosamax 70 mg qweek Spiriva daily Albuterol inhalations prn Medications on Tx: levofloxacin/Flagyl ([Date range (2) 95072]) Vancomycin 1g IV daily Zosyn 2.25g IV q6 Dopamine Lipitor 20mg QHS Combivent q6 Nexium 40 daily Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: primary 1. cholangitis 2. septic shock 3. ARDS 4. gastrointestinal bleeding 5. acute renal failure 6. fungemia 7. coagulopathy suspected DIC secondary 1. pulmonary hypertension 2. CAD s/p NSTEMI Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292**] ICD9 Codes: 5789, 5849, 496, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7463 }	Medical Text: Admission Date: [2138-12-24] Discharge Date: [2138-12-31] Date of Birth: [2070-3-19] Sex: M Service: Cardiothoracic Surgery CHIEF COMPLAINT: Stable exertional chest discomfort relieved with rest. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 11089] MEDQUIST36 D: [2138-12-31] 08:14 T: [2138-12-31] 08:18 JOB#: [Job Number 24665] ICD9 Codes: 9971, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7464 }	Medical Text: Admission Date: [2125-10-4] Discharge Date: [2125-10-12] Date of Birth: [2040-1-27] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2125-10-8] - Coronary bypass grafting x4 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to the distal right coronary artery; reverse saphenous vein graft from the aorta to the first diagonal coronary; reverse saphenous vein graft from aorta to ramus intermedius coronary artery. [2125-10-4] - Cardiac Catheterization History of Present Illness: Mr. [Known lastname 107057] is an 85 year-old male with history of hypertension, hypercholesterolemia, colorectal cancer s/p hemicolectomy in [2125-7-8] admitted following cardiac catheterization for left main disease where patient was found to have 80% blockage of left main. The patient was admitted for cardic surgery evaluation and further managment. . For more than three months, Mr. [Known lastname 107057] has experienced exertional substernal chest pain for more than three [Last Name (un) 94303], that is worse after eating a large meal. He initially attributed his symptoms to indigestion because his symptoms were relieved by burping and he did not seek out medical treatment. He underwent an exercise tolerance test on [2125-9-24] where he exercised for four minutes achieving 89% of his predicted max heart rate without anginal symptoms. The resting EKG showed voltage for LVH. There was also 2-[Street Address(2) 79078] depression noted. The nuclear portion shows a fixed perfusion abnormality at the inferolateral wall with mild hypokinesis of the inferior wall and an LVEF of 54%. . Of note, he had a post surgery chest CT recently that revealed a right upper lobe lung mass and a 1cm hilar adenopathy. He is now referred for a cardiac catheterization with a possible radial approach given the possibility of a future pulmonary diagnostic procedure. . On the floor the patient feels well post catheterization. He denies chest pain, shortness of breath, bleeding from the catheterization site. . On review of systems, he denies any prior history of stroke, TIA, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: multiple skin cancers cataract surgery bilaterally arthritis in right knee cervical disc disease hypertension hypercholesterolemia glaucoma Coronary artery disease Social History: Married, worked as an engineer at Polaroid, does not smoke, drinks alcohol very occasionally Family History: Brother died of MI in late 50s. No family history of arrhythmia, cardiomyopathies; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=97.6, BP=163/68, HR=64, RR=18, O2 sat= 96% on RA GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no elevated JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Patient with multiple scars over head and neck consistent with prior diagnosis of cancer. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: [2125-10-8] ECHO Pre CPB: 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 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. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. There is calcification of the aortic valve resulting in incomplete opening between the LEFT and NON coronary cusps, although this does not result in significant stenosis, there is mild aortic insufficiency which originates at this same location and has a central component. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Dr. [Last Name (STitle) 914] was notified in person of the results. Post CPB: Left ventricular systolic function continues to be normal. Trivial mitral regurgitation and mild aortic regurgitation persist. The thoracic aorta is intact. [2125-10-5] Carotid Ultrasound Significant plaque with a right 70-79% carotid stenosis. On the left there is less than 40% stenosis. [2125-10-4] Cardiac Catheterization 1. Selective coronary angiography in this right dominant system demonsratrated left main and three vessel coronary artery disease. The LMCA had a distal 80-90% stenosis that extended into an 80% stenosis of the proximal LAD. The LCX was 100% stenosed proximally. The RCA was 100% stenosed in the proximal vessel with a network of bridging right to right collaterals providing distal blood flow. There were also right to left collaterals. 2. Limited resting hemodynamics revealed moderate systemic arterial systolic hypertension with SBP 153 mmHg. The left ventricular filling pressure with elevated with LVEDP 15mmHg. 3. There was no evidence of aortic stenosis on careful pullback of the JR catheter from the left ventricle to the ascending aorta. [2125-10-4] 05:08PM BLOOD WBC-5.6 RBC-4.54* Hgb-13.7* Hct-39.7* MCV-87 MCH-30.2 MCHC-34.5 RDW-13.3 Plt Ct-178 [2125-10-10] 04:12AM BLOOD WBC-8.0 RBC-3.19* Hgb-10.0* Hct-28.6* MCV-90 MCH-31.5 MCHC-35.1* RDW-13.5 Plt Ct-123* [2125-10-4] 05:08PM BLOOD PT-13.7* PTT-24.3 INR(PT)-1.2* [2125-10-12] 05:10AM BLOOD PT-12.5 INR(PT)-1.1 [2125-10-4] 05:08PM BLOOD Glucose-82 UreaN-18 Creat-0.9 Na-138 K-4.2 Cl-100 HCO3-31 AnGap-11 [2125-10-12] 05:10AM BLOOD UreaN-27* Creat-1.1 Na-134 K-4.2 Cl-96 [2125-10-4] 05:08PM BLOOD Glucose-82 UreaN-18 Creat-0.9 Na-138 K-4.2 Cl-100 HCO3-31 AnGap-11 [2125-10-12] 05:10AM BLOOD UreaN-27* Creat-1.1 Na-134 K-4.2 Cl-96 [2125-10-4] 07:05PM BLOOD ALT-21 AST-21 AlkPhos-102 TotBili-0.4 [2125-10-4] 05:08PM BLOOD Calcium-9.5 Phos-4.1 Mg-2.1 Brief Hospital Course: Mr. [Known lastname 107057] was admitted to the [Hospital1 18] on [2125-10-4] following his cardiac catheterization which revealed severe left main disease. Heparin was started as he had a known pulmonary embolism. Given the severity of his disease, the cardiac surgical service was consulted for surgical evaluation. He was worked up in the usual preoperative manner including a carotid ultrasound which revealed a 70-79% right internal carotid artery stenosis and a less then 40% stenosis on the left. On [2125-10-8], Mr. [Known lastname 107057] was taken to the operating room where he underwent coronary artery bypass grafting to 4 vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. On postoperative day one, he was transferred to the step down unit for further recovery. Mr. [Known lastname 107057] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. The patient developed rate controlled atrial fibrillation. Amiodarone was started, and beta blocker titrated as tolerated. Coumadin was initiated as well. He continued to make steady progress and was discharged to home with PT on POD 4. Coumadin will be followed by Dr. [Last Name (STitle) ] with INR draws by VNA the day after discharge. And then on Monday, Wednesday and Friday. Results to be sent to Dr. [Last Name (STitle) ]. Medications on Admission: Simvastatin 20 mg Daily Finasteride 5 mg daily Timolol maleate 0.5% 1 drop both eyes every other day Medications - OTC GLUCOSAMINE &CHONDROIT-MV-MIN3 [GLUCOTEN] - (Prescribed by Other Provider) - 375 mg-300 mg-25 mg-68.75 mg-0.5 mg-100 mcg-5 mcg-3.75 mg Tablet - 1 Tablet(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain PEG 400-PROPYLENE GLYCOL [SYSTANE] - (Prescribed by Other Provider) - 0.3 %-0.4 % Drops - 1 drop in each eye as needed Multivitamin Ascoric Acid 500 mg daily Colace 100 mg [Hospital1 ] PRN Tylenol 500 q6 PRN Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take to two 200 mg tablets twice daily for 1 week. Then one 200 mg tablets twice daily for 1 week. Then 1 200 mg tablet daily until stopped by cardiologist. Disp:60 Tablet(s) Refills:2 8. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Coumadin for atrial fibrillation. Goal 2-2.5. Take two 2 mg tablets initially with first INR draw the day after discharge. INR draw then on Monday, Wednesday and Friday. Dr. [Last Name (STitle) ] will follow INR/Coumadin dosing. VNA to call results to Dr. [Last Name (STitle) ]. Disp:60 Tablet(s) Refills:2 9. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 2 weeks. Disp:28 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass Hypertension Hypercholesterolemia benign prostatic hypertrophy s/p Sigmoidcolectomy for cancer [7-/2125] S/p Skin cancer excisions - basal & Squamous (head, face, neck, ears) h/o pulmonary embolism Cervical disc disease s/p bilateral Cataract surgery with lens implants Glaucoma osteoarthritis of right knee Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg 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) 914] ([Telephone/Fax (1) 170]) on [2125-11-6] at 1PM Cardiologist: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2125-11-13] at 11:30AM Please call to schedule appointments with: Primary Care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [3-12] weeks ([Telephone/Fax (1) 3858]) Dr. [Last Name (STitle) ] will follow INR/coumadin dosing, VNA to call results to Dr. [Last Name (STitle) ] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours scheduled Appointments: Provider: [Name10 (NameIs) ] [Last Name (NamePattern5) 21185], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2125-11-7] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 23551], MD Phone:[Telephone/Fax (1) 447] Date/Time:[2125-11-7] 3:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2125-12-18] 2:15 Completed by:[2125-10-12] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7465 }	Medical Text: Admission Date: [2110-11-28] Discharge Date: [2110-12-4] Date of Birth: [2052-7-26] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2195] Chief Complaint: alcohol intoxication, altered mental status Major Surgical or Invasive Procedure: Intubation and then extubation for respiratory compromise and airway protection during episode of acute severe alcohol intoxication History of Present Illness: Mr. [Known lastname 24642] is a 58-year-old male with past medical history significant for ETOH abuse and anemia who presented with unresponsiveness and found to be significantly intoxicated with ETOH level of 516 on admission in the emergency room. He was intubated in the ER for airway protection. Patient had limited recollection of events leading up to his emergency room course. . In the emergency department initial vital signs were T: 97.1 BP: 130/70 HR: 84 RR:20. He received 2L NS IVFs and he was placed on fentanyl and midazolam drips. Initial review of systems was unable to be obtained. He was intubated for airway protection and admitted to the medical ICU for airway management and monitoring for alcohol withdrawal. Labs were also notable for hypernatremia with Na of 150. . He was given free water boluses to help resolve hypernatremia while in ICU and he was successfully extubated and placed on a CIWA scale with valium on [11-30] prior to transfer from MICU to general medical floor. . Vital signs per medicine resident note upon arrival to medical floor on [12-1] were T 100.1, HR 95, BP 152/95 and RR 20 with O2 saturation 97% on room air. . Past Medical History: -Alcohol abuse -Right bimalleolar ankle fracture s/p ORIF [2-16] -longstanding anemia Social History: Patient was homeless at time of admission and states he moves from shelter to shelter in the colder weather. Consumes about [12-15] to [12-14] pint vodka per day, sometimes "other" alcohol. Denies having seizures in the past. Smokes 1 PPD. Denies other illicit drug use / IVDU. Family History: Not able to convey, not cooperative with questioning. Physical Exam: ADMISSION EXAM: Vitals: T 95.2F, BP 116/82, HR 78, intubated with RR 18 GEN: intubated and sedated, not responding to commands HEENT: NC/AT, Pupils pinpoint bilaterally, OP clear, ETT in place NECK: supple, no LAD PULM: CTAB, no wheezes or crackles appreciated CARD: bradycardic, no murmurs appreciated ABD: +BS, soft, non-tender, non-distended EXT: no LE edema SKIN: intact, no lesions appreciated NEURO: sedated, pupils constricted and minimally responsive, not withdrawing to painful stimuli, babinski equivocal bilaterally . DISCHARGE EXAM: Vitals: T 99.6F, BP 107/67, HR 102, RR 20 and O2 Sat 100% RA. General: well appearing male, walking with cane in hallway, NAD HEENT: NC/AT, PERRLA and EOMI. Poor dentition but OP clear of any erythema, exudates. Nares clear. NECK: no JVD, no LAD, supple PULM: poor aeration at bases with decreased lung sounds, otherwise clear to auscultation CARD: RRR, no murmurs/rubs/gallops ABD: NT/ND, normoactive bowel sounds in all quadrants, non-distended, no CVA tenderness and no suprapubic area tenderness NEURO: CNs [1-24] grossly in tact, no resting tremor noted, slow speech at times but appropriate, sensation to light touch in tact, gait slow with cane and shuffles at times EXT: 2+ pedal pulses, no edema SKIN: No rashes . Pertinent Results: ADMISSION LABS: [2110-11-28] 07:20PM ASA-NEG ETHANOL-516* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2110-11-28] 07:20PM WBC-6.6 RBC-4.12* HGB-13.2* HCT-41.0 MCV-100* MCH-32.1* MCHC-32.3 RDW-17.6* [2110-11-28] 07:20PM PT-13.3 PTT-20.9* INR(PT)-1.1 [2110-11-28] 07:20PM FIBRINOGE-348 [2110-11-28] 07:24PM GLUCOSE-102 LACTATE-5.3* NA+-150* K+-3.2* CL--102 TCO2-26 [2110-11-28] 08:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2110-11-28] 08:44PM TYPE-ART PO2-517* PCO2-40 PH-7.34* TOTAL CO2-23 BASE XS--3 IMAGING STUDIES: . [12-3] CXR: In comparison with the study of [12-2], there are continued atelectatic changes at the left base. No evidence of acute focal pneumonia or vascular congestion. . [12-2] CXR: The patient is rotated to the right. There has been interval removal of the endotracheal tube. The lungs are well expanded and clear without focal consolidation, pleural effusion or pneumothorax. The stomach is distended. The cardiac and mediastinal silhouettes and hilar contours are stable allowing for rotation. IMPRESSION: No acute cardiopulmonary process. No evidence of pneumonia. . [12-1] ABD Ultrasound: Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. . CT head [11-28]: Global atrophy, slightly advanced for stated age of 58 years. Otherwise, no acute intracranial process identified. The patient is intubated with pooling of secretions in the oropharynx. . CXR [11-28]: Presumed left lower lobe atelectasis. There is prominence and poor definition in the right hilar region. It is difficult to exclude underlying mass lesion with potential downstream atelectasis. Consider CT scan if indicated once clinically feasible. Endotracheal tube in satisfactory position. . CARDIAC /EKGs: [11-28] EKG - rate mid 50s, sinus bradycardia. Baseline artifact. Non-specific intraventricular conduction delay. Possible left ventricular hypertrophy. Non-specific ST-T wave changes could be due to left ventricular hypertrophy, although cannot exclude ischemia or a metabolic/drug effect. Poor R wave progression in leads V1-V3 could be due to left ventricular hypertrophy or lead placement. No previous tracing available for comparison. . . MICROBIOLOGY DATA: [12-2] Urine Culture -8:30 pm URINE Source: CVS. FINAL REPORT [2110-12-3] URINE CULTURE (Final [2110-12-3]): BETA STREPTOCOCCUS GROUP B. >100,000 ORGANISMS/ML.. [12-2] Blood Culture pending x2 [12-4] Blood Cultures pending x2 [11-29] Blood Cultures pending x2 . DISCHARGE LABS: [2110-12-4] 05:05AM BLOOD WBC-7.3 RBC-3.81* Hgb-12.3* Hct-37.2* MCV-98 MCH-32.2* MCHC-32.9 RDW-17.3* Plt Ct-395 [2110-12-4] 05:05AM BLOOD Plt Ct-395 [2110-12-4] 05:05AM BLOOD [2110-12-4] 05:05AM BLOOD Glucose-119* UreaN-10 Creat-0.9 Na-135 K-3.2* Cl-98 HCO3-28 AnGap-12 [2110-12-4] 05:05AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.3* Brief Hospital Course: In summary, Mr. [Known lastname 24642] is a 58 year old male with longstanding history of alcohol abuse who was brought to emergency room after being found unresponsive in the setting of ETOH intoxication and required urgent intubation for airway protection and close monitoring. Patient was successfully extubated ~36 hours after presentation and followed closely with as-needed dosing of valium for ETOH withdrawal. Initial hypernatremia, hypothermia and lactic acidosis all resolved slowly but he continues to have intermittent hypokalemia, low magnesium and lasting mild anemia. Patient had notable hospital course for fevers and thorough workup with multiple labs, microbiology studies and chest/abdominal imaging in search of fever source. Ultimately, patient grew out over 100k colonies of Group B Streptococcus bacteria from urine culture which was felt to be the most likely cause for his recent fevers and he was discharged on antibiotics as outlined below. Please see below for detailed problem list based summary of hospitalization. . #. ETOH INTOXICATION/INTUBATION FOR AIRWAY PROTECTION: Patient significantly intoxicated on admission. Extubated after <36 hours. He scored on CIWA for hypertension and tachycardia, requiring 3 doses of valium on [11-29] and two doses on [11-30] with scattered doses over the following few days. By [12-3] patient was stable enough so that he had not scored any CIWA scale points for over 24 hours and his CIWA monitoring and valium both discontinued. Telemetry discontinued [12-4]. Social work and nursing addictions were consulted and followed patient closely during his admission. Patient was given gentle IVFs initially and slowly transitioned to a regular diet which he tolerated well. Given anemia and longstanding ETOH use he was also started on daily 100mg thiamine, 1mg folate supplement and a daily multivitamin. Also counseled on ETOH avoidance at time of discharge. Fortunately, two follow-up CXRs on [12-2] and [12-3] showed no evidence of any infiltrates associated with recent intoxication and intubation/extubation. . #. LACTIC ACIDOSIS: Likely secondary too dehydration in setting of ETOH intoxication. No high fevers or signs of infection initially when he had elevateed lactate level, trended down to normal after generous IV fluid resuscitation in the ICU setting. . #FEVERS: Spiked to 102F range on [12-2] and again overnight on [12-4] after over 24hrs no fevers. CXR from [12-3] was negative for any infiltrates and he denied any cough or shortness of breath. Recent RUQ US negative for any biliary process and he denied any nausea, vomiting or diarrhea symptoms. Urine and Blood Cultures re-sent again overnight but early morning urine culture data returned positive for >100k Group B Strep growth which suggested UTI as most probable source. Recent foley placed and male so will plan to treat x 7 days for complicated course. Will plan to follow-up final blood cultures pending at time of discharge as well as the urine culture sensitivity data. He was discharged with plan for Amoxicillin 500mg TID coverage x 7 days for UTI given very limited side effect profile and excellent GBS [Doctor Last Name 360]. This information conveyed to the Pine Stree Inn nurse at time of discharge to shelter. . #GAIT IMBALANCE: Noted mild gait imbalance soon after arrival to medical floor but after several days his reassessed gait improved, especially with use of cane. Seen and evaluated by physical therapy who felt patient was safe for discharge to shelter setting. He may have been more challenged when patient was post-intoxication stage and on CIWA actively. Walks with cane at baseline. [Month (only) 116] be from long term ETOH use as well. . #HYPERNATREMIA: Noted at time of admission with sodium high of 150 which slowly resolved after several free water boluses in the MICU. This was attributed to severe dehydration in setting of intoxication and ETOH. At time of discharge Na was in normal range at 135. . #HYPOTHERMIA: Noted at time of initial admission on [11-28] after patient found outside with altered mental status. Felt to be from environmental exposure and his body temperature regulated within less than 24 hours of admission with gentle warming with blankets. . #Fluids, electrolytes and nutrition: Given alcoholism he was continued on supplements with thiamine, folate and daily multivitamins. Followed his Mg and potassium closely given tendency for hypomagnesemia and hypokalemia. Regular diet, gentle IVFs given PRN but very good PO intake at time of discharge. . #Prevention: Heparin SC for DVT prevention . #Code Status: Discussed twice with patient by medical housestaff and patient desired to be full code status. . Medications on Admission: None Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) as needed for UTI for 7 days. Disp:42 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: . 1. Alcohol Withdrawal 2. Respiratory distress 3. Fevers 4. Urinary Tract Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 24642], . You were admitted to the hospital with alcohol intoxication and put on a breathing machine because you were not awake enough. You were taken off the breathing machine and given valium to prevent alcohol withdrawal symptoms such as anxiety and rapid heart rates or palpitations. After several days this valium medication was tapered and stopped. By the time of discharge now you demonstrated no active signs that were felt to be concerning for acute alcohol withdrawal. . You also had an evaluation of your fevers with a chest x-ray and you did not have any evidence of pneumonia. You had additional abdominal imaging studies which showed no evidence of any gall bladder infections. Blood and urine samples/labs were collected to continue to search for a source of your fevers and a urine culture was ultimately positive for Group B Streprococcus bacteria so you were started on a 7 day course of antibiotics to treat this infection. The medical team will continue to monitor your pending blood cultures after your discharge to ensure you do not have to be treated for any other infections. . During your hospital stay you had some low potassium levels and low magnesium levels which were repleted. It is very important that you have these labs followed on an outpatient basis. . As discussed, please follow up with your new primary provider at the [Name9 (PRE) 778] Health Clinic. Appointment details are listed below. You need to have your electrolytes (potassium, magnesium) evaluated and you need to be seen to monitor for improvement in your urinary tract infection symptoms. . . MEDICATION INSTRUCTIONS / NEW MEDICATIONS: -PLEASE continue taking a daily Thiamine supplement (100mg daily) -PLEASE continue taking a daily Folic Acid supplement (1 mg daily) -PLEASE continue taking a daily Multivitamin -PLEASE continue taking Amoxicillin 500mg tablets every 8 hours (or three times daily) over the next 7 days to effectively treat your urinary tract infection . As explained, if you have any recurrent fevers, confusion or feel ill please return to the hospital emergency room or contact your new primary care provider listed below. . The social work team here has counseled you on the harms of ongoing alcohol use, please continue your efforts to abstain from alcohol use as an outpatient. You were set up for discharge to [Street Address(1) ] Inn in [Location (un) 86] and given a cab voucher for transportation there at time of discharge. The nurse at the shelter was also notified of your arrival. Followup Instructions: Please see your new primary care provider for [Initials (NamePattern4) ] [Last Name (NamePattern4) 702] appointment which has been set up for you for Monday [12-8] at 1:30pm with [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 24643] N.P. (works with Dr. [Last Name (STitle) ]. Office location is [Location (un) ], [Location (un) 86] MA. Office is on [Location (un) 470]. Phone #[Telephone/Fax (1) 798]. Completed by:[2110-12-4] ICD9 Codes: 2760, 2762, 5990, 2768, 3051, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7466 }	Medical Text: Admission Date: [2167-5-7] Discharge Date: [2167-5-11] Date of Birth: [2112-5-3] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Nausea Major Surgical or Invasive Procedure: [2167-5-7] CABGx4(LIMA->LAD, SVG->OM, PDA, RCA) History of Present Illness: Mr. [Known lastname 73144] is a 55 year old male who presented to his PCP with nausea. EKG was abnormal and he was sent to the ER for further evaluation. He ruled in a for a myocardial infarction and referred for cardiac catheterization which revealed severe three vessel disease including a tight left main lesion. Due to his critical anatomy, he was transferred to the [Hospital1 18] for urgent coronary surgical revascularization surgery. Past Medical History: Coronary Artery Disease Acute Myocardial Infarction Hypertension Hypercholesterolemia Cerebrovascular Disease - prior CVA Obstructive Sleep Apnea Glucose Intolerance Social History: Quit tobacco over one year ago at the time of his stroke. He does admit to occasional ETOH. Family History: Denies premature coronary artery disease Physical Exam: Vitals: T 97.6, BP 136/63, HR 58, RR 16, SAT 98 on room air General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [2167-5-9] 04:10AM BLOOD WBC-10.5 RBC-3.19* Hgb-9.8* Hct-29.9* MCV-94 MCH-30.8 MCHC-32.9 RDW-13.9 Plt Ct-304 [2167-5-7] 07:40PM BLOOD PT-14.3* PTT-35.6* INR(PT)-1.3* [2167-5-9] 04:10AM BLOOD Glucose-135* UreaN-14 Creat-0.9 Na-135 K-4.3 Cl-101 HCO3-28 AnGap-10 [2167-5-10] CHEST (PA & LAT): Small left-sided pleural effusion and bibasilar atelectasis. Intraop TEE: 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 systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) 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. Post_bypass: Preserved biventricular global systolic function. LVEF 55%. There is a mild mid inferior segmental wall motional abnormalitiy . No valvular lesions. Aortic contour is intact. Brief Hospital Course: Mr. [Known lastname 73144] was admitted and underwent emergent coronary artery bypass grafting by Dr. [First Name (STitle) ]. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and weaned from intravenous therapy without difficulty. On postoperative day one, he transferred to the SDU for further care and recovery. He tolerated beta blockade and remained in a normal sinus rhythm. Beta blockade was slowly advanced as tolerated. Over several days, he continued to make clinical improvements with diuresis and was eventually cleared for discharge to home on postoperative day four. Medications on Admission: Benicar Zocor Aspirin Gabapentin Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills: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. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:50 Tablet(s) Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 9. Benicar 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: Coronary Artery Disease - s/p CABG Recent Myocardial Infarction Hypertension Hypercholesterolemia Cerebrovascular Disease - prior CVA Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for sternal drainage, temp>101.5 Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 43672] for 1-2 weeks. Make an appointment with Dr. [First Name (STitle) ] for 4 weeks. Make an appointment with Dr. [Last Name (STitle) 20222] for 2-3 weeks. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2167-5-12] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7467 }	Medical Text: Admission Date: [2173-8-9] Discharge Date: [2173-8-26] Date of Birth: [2107-5-2] Sex: F Service: HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 102099] is a 66-year-old woman with past medical history significant for symptoms consistent with neuromuscular disorder. Her symptoms began approximately six months prior to admission and were significant for lower extremity weakness which progressed to the point where she was unable to ambulate. Three weeks prior to admission, she developed upper extremity weakness and dysphagia. She is admitted to outside hospital where workup included equivocal EMG studies, positive P/Q voltage-gated calcium channel antibody, and negative acetylcholine receptor antibody. She was subsequently transferred to [Hospital1 69] for further evaluation and management. PAST MEDICAL HISTORY: 1. Coronary artery disease status post non-Q-wave myocardial infarction in [2173-3-23]. 2. Congestive heart failure with ejection fraction of 25%. 3. History of atrial fibrillation status post cardioversion in [2173-3-23]. 4. Hyponatremia, question secondary to SIADH. 5. Depression. 6. History of deep venous thrombosis. 7. Obesity. 8. Hepatitis C. 9. History of osteomyelitis of the skull status post craniotomy which is complicated by a grand mal seizure. 10. Chronic low back pain. 11. History of compression fractures. 12. Type 2 diabetes mellitus, diet controlled. 13. Hypothyroid. MEDICATIONS ON ADMISSION: 1. Lasix 80 mg q day. 2. Potassium chloride 30 mEq po q day. 3. Lopressor 50 mg [Hospital1 ]. 4. Aspirin 81 mg po q day. 5. Flovent two puffs [Hospital1 ]. 6. Lipitor 40 mg q day. 7. Phenobarbital 30 mg tid. 8. Prilosec 20 mg q day. 9. Imodium. 10. Multivitamin. 11. Ambien 5 mg q hs. 12. Darvocet prn. 13. Coumadin 3 mg q day. 14. Colace. 15. Zinc sulfate. 16. Sodium chloride. 17. Vitamin C. 18. Rhinocort. 19. Neurontin 100 tid. 20. Levoxyl 50 q day. 21. Zoloft 75 q day. 22. [Doctor First Name ] 60 q day. 23. Water restriction to 1 liter q day. ALLERGIES: Morphine which causes a rash. She is allergic to codeine which causes a rash. SOCIAL HISTORY: She is married and denies alcohol or tobacco use. She formally worked as a nurse. She currently lives in a rehabilitation facility. EXAMINATION: Temperature 98.8, heart rate 70, blood pressure 120/70, respiratory rate 22, and oxygen saturation is 96% on 3 liters. She is a morbidly obese woman lying motionless in bed. She is in no apparent distress. Pupils are equal, round, and reactive to light and accommodation. Sclerae are anicteric. Moist mucous membranes. Neck was supple with no lymphadenopathy. There were several palpable nodules in the thyroid. Lungs had bibasilar rales going 1.5 up the posterior lung field. Heart was regular with normal first and second heart sounds. No murmurs, rubs, or gallops. Abdomen is obese, soft, nontender, nondistended. There are active bowel sounds and no abdominal bruits. The extremities showed 2+ pitting edema at the knees. There were 2+ palpable peripheral pulses. Neurological examination was notable for a disoriented woman with slurred speech. She was also to close her eyes, but she is not able to hold them closed against resistance. Her motor strength was [1-25] in the upper extremities bilaterally. Motor strength is 0/5 in the lower extremities bilaterally. There was no clonus or vesiculations. Her tone was flaccid in the lower extremities. Her upper extremities were mildly rigid. Deep tendon reflexes were absent in all four extremities. DATA: White count 15.6, hematocrit 35.4, platelets 271. INR 2.2, PTT 32.2. Sodium 142, potassium 4.0, chloride 103, bicarb 24, BUN 38, creatinine 1.5, glucose 138. Sed rate 172. ALT 20, AST 40, alkaline phosphatase 211, total bilirubin 0.6, albumin 2.4, total protein 6.3. HOSPITAL COURSE: Ms. [Known lastname 102099] was admitted to the hospital for further management of her neuromuscular disease. Due to impending respiratory failure, she was transferred to the Medical Intensive Care Unit soon after she arrived in the hospital. 1. Pulmonary: Ms. [Known lastname 102099] was subsequently intubated secondary due to her respiratory muscle weakness. At the time of intubation, she had a decreased vital capacity and decreased NIF. Her pulmonary issues were complicated by progressive fluid overload leading to cardiogenic pulmonary edema. She did not demonstrate any significant improvement in her respiratory mechanics for the remainder of her hospital stay. She did have a diagnostic therapeutic thoracentesis, which resulted with a removal of 1 liter of fluid, however, this did not improve her respiratory mechanics. 2. Cardiac: She has a history of coronary artery disease, congestive heart failure, and atrial fibrillation. She was in atrial fibrillation while she was in the MICU. This was complicated by worsening congestive heart failure and decreased urine output. She became more fluid overloaded during the course of her hospital stay. She required fluid to maintain her blood pressure. She was unable to diurese with Lasix drip and dopamine drip. She was cardioverted back into normal sinus rhythm with improvement of her blood pressure. However, this did not effect her urine output at all. 3. Renal: She developed acute renal failure during her hospital stay. It was thought that part of her acute renal failure were due to contrast induced ATN. However, she did not develop any improvement in her renal function, perhaps due to inadequate tissue perfusion. She was dialyzed several times during her MICU course to remove fluid in an attempt to improve her hemodynamic status. 4. Neurology: Her differential diagnosis of her neuromuscular disease included myasthenia [Last Name (un) 2902] and [Location (un) ]-[Location (un) ] myasthenic syndrome. Her serologic tests were thought to be more consistent with [Location (un) ]-[Location (un) ]. She underwent seven rounds of plasmapheresis with minimal improvement in her clinical status. 4. I&D: She developed a methicillin-resistant Staphylococcus aureus pneumonia, and a methicillin-resistant Staphylococcus aureus sacral decubitus ulcer. Her sacral decubitus ulcer also grew Pseudomonas. She received Vancomycin for treatment of her infections. Her sacral decubitus ulcer was debrided by Surgery. Due to her hematologic issues, however, she had problems clotting after the debridement, and she continued to ooze from her decubitus ulcer for the remainder of her hospital stay. 5. Hematology: Her course is complicated by both anemia and thrombocytopenia. It is thought that the thrombocytopenia might be due to Heparin, so the Heparin was discontinued, and she was started on lepirudin. She remained coagulopathic for the rest of her hospital stay. Despite aggressive measures in the Intensive Care Unit, Ms. [Known lastname 102099] continued to get worse. After further discussion with her family, decision was made to shift the focus of our care for comfort measures for Ms. [Known lastname 102099]. She expired on [2173-8-26]. DISCHARGE STATUS: Expired. DISCHARGE DIAGNOSES: 1. [Location (un) ]-[Location (un) ] myasthenic syndrome versus myasthenia [Last Name (un) 2902]. 2. Hypercarbic respiratory failure requiring mechanical intubation. 3. Methicillin-resistant Staphylococcus aureus pneumonia. 4. Atrial fibrillation status post DC cardioversion. 5. Congestive heart failure. 6. Acute renal failure requiring hemodialysis. 7. Sacral decubitus ulcer complicated by infection of methicillin-resistant Staphylococcus aureus and Pseudomonas. 8. Anemia. 9. Thrombocytopenia, question Heparin-induced thrombocytopenia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 7512] Dictated By:[Last Name (NamePattern1) 7787] MEDQUIST36 D: [2174-12-29] 16:59 T: [2175-1-2] 06:15 JOB#: [Job Number 102100] ICD9 Codes: 4280, 5849, 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7468 }	Medical Text: Admission Date: [2130-7-18] Discharge Date: [2130-7-18] Date of Birth: [2071-7-2] Sex: M Service: SURGERY Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 1384] Chief Complaint: HCC/Hep-C Major Surgical or Invasive Procedure: none History of Present Illness: 59 M w/ hep C cirrhosis and HCC who presented to [Hospital3 2568] Hosp w/ dyspnea and vague abdominal pain. A right thoracentesis was performed by the ED staff, [Last Name (un) 26734] 3 liters. His pain worsened and he became progressively hypotensive (SBP 130 to 80) and oliguric. A CT scan demonstrated a large liver mass (9x13cm) and contrast extravasation. His right common hepatic artery was then embolized by IR. He became combative in the ICU and was intubated. He has recieved 11 units of RBCs, 2 of FFP, and 4 amps of bicarb for a pH of 6.7. His INR was initially 1.3 but then became 4.5. He has been on and off Neo. He has a R SC line, an A line, a foley and an ETT. Past Medical History: HCV, HCC, HTN, NIDDM Social History: NC Family History: NC Physical Exam: PE: T 94.8, HR 98, BP 85/51, RR 28, SO2 100% Vent- AC 100%, 650x22, PEEP 5 Gen- intubated, sedated Heart- RRR Lungs- CTA b/l Abdomen- no BS, distended, soft Extremities- no c/c/e Brief Hospital Course: 59 M with known hepatitis C cirrhosis and HCC (for which he was treated w/ INF in [State 108] about 1-2 years ago for 5 months and declined surgery) who presented to [Last Name (un) 1724] last night with dyspnea and vague abdominal pain for 1 month. A right thoracentesis was performed by the ED staff, [Last Name (un) 26734] 3 liters of effluent (1275 WBC, [Numeric Identifier 29564] RBC, cytology pending). His pain then worsened from a [2-11] to a [10-11] and he became progressively hypotensive (SBP 130 to 80). He also became oliguric, making 45 cc of urine over 12 hours. His hematocrit dropped from 37 to 27. His createnine was 1.4. ALT was 71, AST 170, AP 180, TB 3.5. On exam at [Last Name (un) 1724], he had RUQ tenderness and no peritoneal signs. A CT scan demonstrated a large liver mass (9cm) and blood in the abdominal cavity. A repeact CT scan with IV contrast showed an area of contrast extravasation on the HCC, portal vein thrombosis, and esophageal varicies. His right common hepatic artery was then embolized by IR. He became combative in the ICU and was intubated. He has recieved 11 units of RBCs, 2 of FFP, and 4 amps of bicarb for a pH of 6.7. His INR was initially 1.3 but then became 4.5. The thought was that was is in DIC. He was on Neo briefly but has responded somewhat to resussitation. He has a R SC line, an A line, a foley and an ETT. CXR- RML collapse, R pleural effusion This patient was made CMO after lengthy discussion w/ family members. It was made clear that he is not a surgical candidate, he is not a transplant candidate because of his cirrhosis and the size of his tumor. Patient was pronounced of his death on [2130-7-18] @ [2080]. Discharge Disposition: Expired Discharge Diagnosis: pt expired on [2130-7-18] @[2080] Discharge Condition: pt expired in house Completed by:[2130-7-18] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7469 }	Medical Text: Admission Date: [2139-3-9] Discharge Date: [2139-3-16] Date of Birth: [2065-2-4] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: The patient is a 74 year old male with known history of aortic stenosis and hypertension. He was admitted to the [Hospital3 3583] on [2139-3-7] with 10 out of 10 chest pain. The patient was transferred to [Hospital6 256] for further evaluation and treatment. PAST MEDICAL HISTORY: 1. Hypertension; 2. Aortic stenosis. PAST SURGICAL HISTORY: Unremarkable. MEDICATIONS ON ADMISSION: 1. Maxzide [1-9] tablet p.o. q. day 2. Captopril 12.5 mg p.o. t.i.d. 3. Isobutyl 400 mg p.o. q. day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient quit smoking in [2095]. Drinks occasionally, approximately one beer per day. PHYSICAL EXAMINATION: On physical examination the patient was afebrile with vital signs stable. Head was normocephalic, atraumatic, no scleral icterus noted. Neck was soft and supple. No carotid bruits. Heart was regular rate and rhythm, Grade IV/VI systolic ejection murmur. Chest was clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended with positive bowel sounds. Extremity examination was significant for trace bilateral pedal edema with palpable pulses. LABORATORY DATA: Admission laboratory data were white count 9.6, hematocrit 46.0, platelets 205. Sodium 140, potassium 3.5, chloride 99, bicarbonate 31, BUN 24, creatinine 1.2, and glucose 102. INR 1.3. HOSPITAL COURSE: The patient is a 74 year old male with aortic stenosis and known history of hypertension, transferred to [Hospital6 256] from the outside hospital for further assessment and treatment of 10 out of 10 chest pain. On [2139-3-9], the patient was taken to the Cardiac Catheterization Laboratory which demonstrated moderate to severe aortic stenosis, three vessel coronary artery disease, with severe left anterior descending stenosis arising from a complex aneurysm. Left ventricular function was normal. Immediately following cardiac catheterization, Cardiac Surgery was consulted, and the patient was evaluated and assessed by Dr. [Last Name (STitle) 1537] and thought to be a good candidate for coronary artery bypass graft surgery and aortic valve repair. On [2139-3-10], the patient was taken to the Operating Room where coronary artery bypass graft times four was performed and an aortic valve replacement with a Porcine valve. For more details, please see operative report. Postoperatively, the patient was transferred to the Cardiac Surgery Recovery Unit. The patient was extubated at 8 PM on postoperative day #0. The patient was on an Amiodarone drip for brief ventricular fibrillation coming off pump and Neo-Synephrine at .2 for blood pressure. On postoperative day #2, the patient required atrioventricular pacing to maintain a heart rate in the 80s and blood pressure 115/59. Electrophysiology was consulted. Electrophysiology had no new recommendations. The patient was back into sinus rhythm and was later transferred to the floor on postoperative day #2. On postoperative day #3, the patient was doing well, 79 in sinus. Chest tubes were discontinued on postoperative day #3. The patient was started on Metoprolol 12.5 mg b.i.d. Post chest tube pull, chest x-ray demonstrated a .5 cm apical pneumothorax on the right and 1 cm apical pneumothorax on the left. Chest x-ray following initial chest x-ray showed that these pneumothoraces were not changing. On postoperative day #4, Toprol was increased to 25 mg b.i.d. Pacing wires were discontinued and repeat chest x-ray showed no evolution of the pneumothorax. On postoperative day #5, another repeat chest x-ray showed no evolution of pneumothoraces. Lopressor was increased to 50 mg b.i.d. The patient was able to achieve physical therapy level 5. On postoperative day #6, the patient was doing well, physical therapy level 5 and another repeat chest x-ray showed no evolution of the pneumothorax. The patient was deemed well enough to go home. DISCHARGE DISPOSITION: To home. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Hypertension. 3. Aortic stenosis. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. q. 12 hours times 10 days. 2. Potassium chloride 20 mEq p.o. q. 12 hours times 10 days. 3. Colace 100 mg p.o. b.i.d. and prn for constipation. 4. Aspirin 325 mg p.o. q. day. 5. Percocet 1 to 2 tablets p.o. q. 4-6 hours prn for pain. 6. Metoprolol 75 mg p.o. b.i.d. FOLLOW UP: The patient is to follow up with the Wound Care Clinic in one week, primary care physician and cardiologist in two to four weeks and Dr. [Last Name (STitle) 1537] in four weeks. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 7190] MEDQUIST36 D: [2139-3-16] 09:26 T: [2139-3-16] 09:40 JOB#: [Job Number 55261] ICD9 Codes: 4241, 9971, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7470 }	Medical Text: Admission Date: [2123-7-13] Discharge Date: [2123-7-17] Date of Birth: [2062-3-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: recent mild angina with exertion Major Surgical or Invasive Procedure: emergency CABG X 3 ([2123-7-13])(LIMA to LAD, SVG to ramus, SVG to OM) History of Present Illness: 61 yo African-American male had abnormal EKG found as part of pre-op eval. for ventral hernia repair. Had subsequent abnormal stress test and pefusion imaging showed EF 38% with perfusion defects. Echo prior to scheduled cath showed mild LVH, inferior HK, EF 40%, mild MR, mild LAE. Cath at [Hospital1 ] today showed 80% LM lesion with normal LAD, CX, RCA. Severe systolic HTN also noted. Transferred in urgently for cabg with Dr. [Last Name (STitle) 1290]. Past Medical History: ventral hernia HTN elev. chol. right facial droop with metal plate secondary to GSW to face right nephrectomy Social History: current smoker Family History: not given Physical Exam: Not done, taken to OR direct from ambulance transfer. Pertinent Results: [2123-7-14] 02:06AM BLOOD WBC-9.4 RBC-3.61* Hgb-10.4* Hct-29.9* MCV-83 MCH-28.8 MCHC-34.8 RDW-14.3 Plt Ct-154 [2123-7-17] 05:14AM BLOOD Hct-25.2* [2123-7-14] 02:06AM BLOOD Plt Ct-154 [2123-7-13] 08:05PM BLOOD PT-13.6* PTT-33.3 INR(PT)-1.2* [2123-7-17] 05:14AM BLOOD UreaN-25* Creat-1.0 K-3.9 [2123-7-15] 02:02PM BLOOD Mg-2.1 FINAL REPORT TWO VIEW CHEST, [2123-7-17] COMPARISON: [2123-7-14]. INDICATION: Status post coronary bypass surgery. There has been removal of a Swan-Ganz catheter and placement of a right internal jugular vascular catheter, with the tip terminating in the proximal right atrium just below the junction with the superior vena cava. Cardiac and mediastinal contours are stable in the postoperative period. Previously reported interstitial edema has resolved. There has been interval improvement in left basilar atelectasis. Right basilar atelectasis has slightly worsened. Bilateral pleural effusions are unchanged. IMPRESSION: 1. Vascular catheter tip terminates in proximal right atrium. 2. Bibasilar minor atelectasis, worse on the right and improved on the left. Persistent pleural effusions. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] Approved: SAT [2123-7-17] 8:20 PM Procedure Date:[2123-7-17] PRE-CPB: The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. No left ventricular aneurysm is seen. There is mild regional left ventricular systolic dysfunction. Overall left ventricular systolic function is mildly depressed. There is no ventricular septal defect. Resting regional wall motion abnormalities include mild inferior hypokinesis. Right ventricular chamber size and free wall motion are normal. The right ventricular cavity is mildly dilated. There are simple atheroma in the aortic root. 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. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST-CPB: Preserved LV systolic function on phenylephrine. LVEF now 50%. Trace MR, AI as described. Normal aortic contours. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD, Interpreting physician Brief Hospital Course: Admitted directly to OR from ambulance transfer and underwent cabg x3 with Dr. [Last Name (STitle) 1290] on [7-13]. Transferred to the CSRU in stable condition on phenylephrine and propofol drips. Extubated early the next morning and chest tubes removed. Gentle diuresis and beta blockade started, and he was transferred to the floor to begin increasing his activity level.Foley removed on POD #2 and had scattered rales with temp 101.2. Afebrile the next day and pacing wires removed without incident. He made excellent progress and was discharged to home with VNA services on POD #4. He is to follow up with providers as per discharge instructions. Medications on Admission: bisoprolol 5 mg daily crestor 20 mg daily HCTZ 25 mg daily lisinopril 40 mg daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 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:2 6. 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 7. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA carenetwork Discharge Diagnosis: CAD HTN ventral hernia right nephrectomy s/p right facial plating Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no driving for 1 month no lifting > 10 # for 10 weeks [Last Name (NamePattern4) ] Instructions: with Dr. [First Name (STitle) ] in [2-19] weeks with Dr. [Last Name (STitle) 6254] in [2-19] weeks with Dr. [Last Name (STitle) ] [Last Name (Prefixes) 53724] in 4 weeks Completed by:[2123-7-29] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7471 }	Medical Text: Admission Date: [2178-3-12] Discharge Date: [2178-3-20] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: diarrhea and ICD fire Major Surgical or Invasive Procedure: none History of Present Illness: HPI: This is a [Age over 90 ] yo M with a PMH of CAD s/p CABG, s/p ICD in [2173], who p/w 1 week of diarrhea, fevers, and ICD firing x4 yesterday. The pt states that over the past week, he has had many (<10) brown, watery stools, associated with lower abdominal cramping prior to bowel movements. The abdominal cramping is alleviated with bowel movements, and he is often incontinent of stool at this time. He states that his wife has told him he has had a temp over 100 F over the past week. He also notes that his ICD fired 4 times yesterday as he was walking out of the bathroom, which has never happened to him before. He has had decreased po intake of foods and fluids over the past 3-4 days. He denies any palpitations, LOC, chest pain, shortness of breath, dysuria, nausea, vomiting, headaches, cough, leg swelling, rashes, or chills. . Of note, the pt was hospitalized at [Location (un) ] [Location (un) 1459] from [Date range (1) 75564]/08 for probable urosepsis and positive blood cultures for E Coli (grown in bottle from [2-13]). His E Coli was pansensitive. He was treated with CTX while inpatient, and then discharged to [Hospital 76713] rehab where he was treated with Avelox for his positive blood culture. The pt was discharged from rehab 1 week ago, which is when he started to have diarrhea. . In the ED, the pts vitals were: Tm 100.4, HR 102-128, BP 86-107/32-56, R 20-26, Sat 96% 2L NC. He received 3 L NS, 2 L of LR, flagyl 500 mg IV x2, Levofloxacin 500 mg IV x1, Vanc 1 gm IV x1. Blood cultures and urine cultures were drawn. Because he was hypotensive to the 80s and tachy to the 120s, a right subclavian central line was placed. He was responsive to fluid boluses in the ED. He was seen by EP and ICD interrogation revealed underlying AF with RVR. Initially he had rapid AF, then regular ventricular rate CL 290: shock with 29J into rapid AF, but still in VF detection zone: 5 more shocks. Then another episode AD--> rapid regular tachycardia CL 260 msec: teminated while charging but therapy not aborted due to a few short coupled beats while in AF. His VF detection range was changed to CL 320 msec. . He was given a total of 7.5L of fluid in his roughly 2 day stay in the MICU and his blood pressure responded. He continued to be tachycardic, though was documented to be in sinus tach by EKG. His metoprolol was restarted on [2178-3-15]. . Upon transfer, he denied CP, palpitations, SOB, lightheadedness. Past Medical History: CAD s/p CABG in [2169] for L main disease ischemic cardiomyopathy with h/o CHF TTE [4-15]: EF 15-20%, RV dilation,LV global hypokinesis cardiac cath [5-14]: patent grafts to LAD, OM1, and OM2 s/p ICD in [2173] for compromised LV function and recurrent syncope BPH h/o elevated PSA h/o renal insufficiency--baseline Cr 1.2 DJD of neck and spine NSTEMI in [2169] HTN hyperlipidemia Gout h/o DVT Social History: The pt denies any alcohol, tobacco, or illicit drug use. He lives at home with his wife. [Name (NI) ] recently was discharged from rehab 1 week ago. He is a retired postal worker. He has no children. Family History: non-contributory Physical Exam: VS: Temp: 98.0 Tm 98.8 BP: 119/55, 94-157/53-95 HR: 102, 102-138 O2sat 99, 92-100%3L NC GEN: pleasant, comfortable, NAD HEENT: NCAT, EOMI, MMM, +dentures RESP: decreased breath sounds at BL bases, mild bibasilar crackles bilaterally. o/w ctab. CV: irreg irreg, S1 and S2 wnl, no m/r/g ABD: mildly distended, mild tenderness to palpation in bilateral lower quadrants, no rebound or guarding, NABS EXT: 2+ LE bilaterally, no c/c NEURO: AAOx3. CN 2-12 intact grossly. Moving all 4 extrem equally. Pertinent Results: [2178-3-20] 06:00AM BLOOD WBC-12.0* RBC-3.88* Hgb-12.2* Hct-38.5* MCV-99* MCH-31.5 MCHC-31.7 RDW-15.4 Plt Ct-371 [2178-3-20] 06:00AM BLOOD Glucose-147* UreaN-27* Creat-1.3* Na-140 K-3.9 Cl-112* HCO3-17* AnGap-15 [2178-3-13] 08:20AM BLOOD ALT-14 AST-15 CK(CPK)-47 AlkPhos-70 TotBili-1.1 [2178-3-13] 02:59PM BLOOD CK-MB-NotDone cTropnT-0.16* [2178-3-13] 08:20AM BLOOD CK-MB-NotDone cTropnT-0.20* [2178-3-12] 09:20PM BLOOD CK-MB-NotDone cTropnT-0.19* [2178-3-13] 08:20AM BLOOD TSH-3.1 [2178-3-20] 06:00AM BLOOD Digoxin-0.3* [2178-3-20] 06:00AM BLOOD WBC-12.0* RBC-3.88* Hgb-12.2* Hct-38.5* MCV-99* MCH-31.5 MCHC-31.7 RDW-15.4 Plt Ct-371 [2178-3-20] 06:00AM BLOOD Glucose-147* UreaN-27* Creat-1.3* Na-140 K-3.9 Cl-112* HCO3-17* AnGap-15 [2178-3-20] 06:00AM BLOOD Calcium-7.6* Phos-2.5* Mg-2.1 [2178-3-13] 08:20AM BLOOD TSH-3.1 [2178-3-13] 08:20AM BLOOD Cortsol-49.7* [2178-3-16] 12:12AM BLOOD Lactate-2.4* [2178-3-14] 04:12AM BLOOD freeCa-1.15 . MICRO: CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2178-3-15]): REPORTED BY PHONE TO [Last Name (LF) 4174],[First Name3 (LF) 2671] @ 07:36, [2178-3-15]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. [3-13] Blood Cx x4 NGTD [3-13] Urine Cx NGTD . IMAGING: CXR [3-13]: No acute pulmonary process. Hypertensive cardiomediastinal configuration. Small left pleural effusion. Indwelling AICD. . TTE [3-14]: The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. There is mild global left ventricular hypokinesis (LVEF = 40-50 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with depressed free wall contractility. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. A mitral valve annuloplasty ring may be present. An eccentric, anteriorly directed jet of Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is a trivial/physiologic pericardial effusion. . CXR [3-16]: 1. Slight decrease in the left small pleural effusion. 2. Otherwise there is essentially no significant interval change. . ECG Study Date of [2178-3-16] 12:05:52 AM Probable sinus tachycardia with atrial premature complexes but may be multifocal atrial tachycardia Consider left ventricular hypertrophy Delayed R wave progression - is nonspecific but could be due in part to left ventricular hypertrophy Nonspecific ST-T abnormalities Since previous tracing of [2178-3-15], probably no significant change Brief Hospital Course: A/P: [Age over 90 ] yo M with a PMH of CAD s/p CABG, h/o atrial fibrillation, s/p ICD in [2173], who p/w 1 week of diarrhea, fevers, ICD firing x4, found to be in afib with RVR and hypotensive. . # Hypotension: Initially thought due to sepsis from GI source. Covered with levo/flagyl/vanc/zosyn, last antibiotic d/c'd on [2178-3-14], now just on flagyl for cdiff as below. Hypotension responded to fluid. UCx negative. BCx pending x 4, and CXR shows only a small L pleural effusion. No other clear focus of infection is evident. Lactate improved. BCx were negative x 4, UCx negative x 1. Home lisinopril and diuretics were held, and should be restarted as blood pressure allows. . # arrhythmia: originally afib by device detection/firing, now looks like MAT by EKG, likely related to volume depletion vs. sepsis upon admission. He is not on anticoagulation. Will defer to outpatient physician for decision about anticoagulation given age and comorbidities. TSH wnl. EP consulted and recommended digoxin 0.0625, which was increased to 0.125 daily based on dig level. He will need a repeat dig level on [2178-3-27]. His lisinopril was held as above, and continued to be held to allow blood pressure room for beta blocker. Will defer to rehab/primary care physician [Last Name (NamePattern4) ]: restarting lisinopril, titrating digoxin. . # Diarrhea: cdiff positive, other fecal studies pending. cont to have diarrhea. WBC much improved. On flagyl day 7 of 14, cont until [2178-3-27]. Started on loperamide and opium tincture prn after WBC began to trend down. . # volume overload: bilateral basilar crackles, suggestion of vascular congestion by CXR, and bilateral dependent edema. Also has an oxygen requirement. He received prn lasix. His home lasix and aldactone was held as above. Will defer to rehab/primary care physician [Last Name (NamePattern4) ]: restarting diuretics. Please wean O2 as tolerated. . # Low UOP: likely from dehydration from diarrhea. Responded to boluses. He should be encouraged to take PO fluids, IVF prn, though gently given dependent edema. . # hypernatremia: Briefly had hypernatremia with Na 146. Likely related to NS IVF. He was given D5W and LR. Hypernatremia resolved. . # CAD: s/p CABG. No current issues. ICD shocks were due to rapid afib. Pt has 0.[Street Address(2) 1755] depressions in precordial leads, no prior EKG to compare to. Elevated troponin, but CKs flat x 3. [Month (only) 116] be demand ischemia from RVR and also with renal failure. He was continued on aspirin 325, simvastatin. Lisinopril as above. . # Acute Renal Failure: Bl Cr 1.2. Admission Cr is 1.8, likely due to dehydration. Improved and stable at 1.3 to 1.4, near baseline. Held scheduled lasix and aldactone as above . # HTN: restart lisinopril when pressures tolerate. . # BPH: terazosin held for BP, restarted upon discharge. . # F/E/N: IVF. Replete lytes PRN. reg diet. He may benefit from a speech/swallow study, though had no witnessed aspiration here. . # PPx: no bowel regimen given pt's diarrhea, sq Heparin. . # Code Status: DNR/DNI . # Communication: wife, [Name (NI) 730] [Name (NI) ], [Telephone/Fax (1) 76714] . # Follow-up: with Dr. [Last Name (STitle) 76715] and Dr. [Last Name (STitle) 76716] as above. Medications on Admission: ASA 325 mg daily Lisinopril 10 mg daily Allopurinol 100 mg dily Terazosin 2 mg at night Metoprolol 200 mg daily Lasix 40 mg daily Aldactone 25 mg daily Tylenol 1 g q h8hr ultram 50 mg q 6 hr prn Simvastatin 20 mg daily Discharge Medications: 1. Outpatient Lab Work Digoxin level [2178-3-27]. Titrate digoxin accordingly. Please fax to Dr. [Last Name (STitle) 76715]. Phone [Telephone/Fax (1) 9219], Fax [Telephone/Fax (1) 76717]. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for arthritis pain. 8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days: Continue through [2178-3-27]. 11. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 12. Opium Tincture 10 mg/mL Tincture Sig: Five (5) Drop PO Q6H (every 6 hours) as needed for diarrhea. 13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY AT 6 AM (). 14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Terazosin 2 mg Capsule Sig: Two (2) Capsule PO at bedtime. Discharge Disposition: Extended Care Facility: [Hospital 169] Center - [Location (un) ] Discharge Diagnosis: Hypotension due to presumed sepsis; source never isolated C.dif colitis Atrial fibrillation with RVR MAT Inappropriate ICD firing s/p adjustment by the EP service Acute on Chronic RF . CAD s/p CABG in [2169] for L main disease ischemic cardiomyopathy with h/o CHF TTE [4-15]: EF 15-20%, RV dilation,LV global hypokinesis cardiac cath [5-14]: patent grafts to LAD, OM1, and OM2 s/p ICD in [2173] for compromised LV function and recurrent syncope BPH h/o elevated PSA h/o renal insufficiency--baseline Cr 1.2 DJD of neck and spine NSTEMI in [2169] HTN hyperlipidemia Gout h/o DVT Discharge Condition: Stable for discharge to rehab Discharge Instructions: You were seen at [Hospital1 18] for diarrhea, rapid heart rate, and your defibrillator firing. You were found to have a heart arrhythmia. Your defibrillator was recalibrated. You have a gastrointestinal infection for which you will need to continue antibiotics as prescribed. . You should discuss with your primary care provider about possibly started coumadin or another anticoagulation drug to thin your blood given you have an arrhythmia. . Your diuretics were also held during your stay. Please discuss with your primary care provider about restarting those. . You should return to the emergency department or call your primary care provider if you experience chest pain, worsening shortness of breath, wheezing, fevers/chills greater than 101.5 degrees F, your defibrillator firing, or any other symptoms that concern you. Followup Instructions: SCHEDULED APPOINTMENTS: Dr. [Last Name (STitle) 76716], Thursday [2178-4-2], 1:45pm. Phone:[Telephone/Fax (1) 9219] . Dr. [Last Name (STitle) 76715], Thursday [2178-4-2], 2:00pm. Phone:[Telephone/Fax (1) 9219] . Please call if you need to cancel. ICD9 Codes: 0389, 5849, 5119, 2760, 4589, 5859, 2724, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7472 }	Medical Text: Admission Date: [2146-9-13] Discharge Date: [2146-9-22] Date of Birth: [2089-1-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 8388] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 57 year old male with a pmh of hepatitis C cirrhosis c/b refractory ascites s/p TIPs in [Month (only) 958] on Lasix and Aldactone, hepatic encephalopathy on lactulose and Rifaximin, and 3 cords of grade II varices in the lower third of the esophagus, bipolar, and DJD who presents with altered mental status after a fall. Today he was found by his landlord on the floor, when water started leaking into the apartment below him. He was confused, and vaguely remembered hitting his head, but had doesn't remember any events surrounding the event. He denies any symptoms of fever, chills, nausea, vomiting, incontinence, diarrhea, cough, chest pain, shortness of breath, myalgias or dysuria. In the ED He was initially AAOx1. Head CT showed acute on chronic subdural hemorrhage with 2mm shift. Neurosurgery was consulted and felt this was encephalopathy, and not related to the ICH. His VS were stable with BPs in the 90s-100s. Pulse was in the 70s, and he was 99% on RA. HCT was at 27.9, creatinine 2.6, ALT/AST: 199/566, INR 1.8. He was given 2 units FFP, vitamin k 10mg IV, typed and crossed x 4 units, 800mg of ibuprofen, started on a Protonix bolus and gtt. Access, 18 and a 20g. 2L IVF, vanc and cefipime with blood and urine cultures done. Ibuprofen for pain, percocet. On the floor, he is uncomfortable where he hit his head and elbow. Otherwise oriented x3 and current events. He has gross asterixis without any other gross neurologic abnormalities. Review of systems: (+) Per HPI; all others negative Past Medical History: 1) HCV genotype 1 and cirrhosis s/p Pegylated interferon and Ribavirin treatment x 2 without total viral load suppression. 2) History of alcohol excess - discontinued [2145] 3) Refractory ascites s/p TIPS [2146-4-14] 4) Bipolar disorder 5) Degenerative disc disease Social History: Lives alone. Currently on disability. Has a brother-in-law/sister that live in [Name (NI) 86]. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies (only prescribed pain medication) Family History: No history of liver disease. Family history of bipolar disease. Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally scant bibasilar crackles, no wheezes, rales, ronchi CV: Normal rate and regular rhythm Abdomen: soft, non-tender, mildly distended, + ascites, bowel sounds present, no rebound tenderness or guarding, palpable liver tip 3FB below the costal margin GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+ edema to the midshin Neuro: AAOx3, CN2-12 intact, no gross deficits. + Asterixis. DISCHARGE PHYSICAL EXAM: 98.2 114/60 89 20 98% net neg 300 GEN: well-appearing, NAD, A+O CV: RRR no MRG LUNGS: CTA b/l ABD: soft, non-tender, distended with ascites, large umbilical hernia is reducible EXT: 2+ pitting edema Pertinent Results: Admission Labs: [2146-9-13] 10:20AM BLOOD WBC-6.1 RBC-2.68* Hgb-10.1* Hct-27.9* MCV-104* MCH-37.8* MCHC-36.2* RDW-18.6* Plt Ct-107* [2146-9-13] 11:20AM BLOOD PT-19.5* PTT-43.7* INR(PT)-1.8* [2146-9-13] 10:20AM BLOOD Glucose-87 UreaN-91* Creat-2.6# Na-137 K-3.7 Cl-102 HCO3-23 AnGap-16 [2146-9-13] 10:20AM BLOOD Glucose-87 UreaN-91 Creat-2.6# Na-137 K-3.7 Cl-102 HCO3-23 AnGap-16 [2146-9-13] 10:20AM BLOOD ALT-199 AST-566* LD(LDH)-867* CK(CPK)-5045* TotBili-2.0* [2146-9-13] 10:20AM BLOOD Albumin-2.5* Calcium-7.7* Phos-3.8 Mg-3.1* DISCHARGE LABS: [2146-9-22] 04:40AM BLOOD WBC-3.1* RBC-2.18* Hgb-8.0* Hct-22.9* MCV-105* MCH-36.8* MCHC-35.1* RDW-16.2* Plt Ct-112* [2146-9-22] 04:40AM BLOOD PT-19.6* PTT-61.0* INR(PT)-1.8* [2146-9-22] 04:40AM BLOOD Glucose-96 UreaN-15 Creat-1.3* Na-131* K-4.3 Cl-100 HCO3-24 AnGap-11 [2146-9-22] 04:40AM BLOOD ALT-19 AST-35 AlkPhos-102 TotBili-1.1 [2146-9-22] 04:40AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.7 Tox Screen: [2146-9-13] 10:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG. . [9-14] Liver/GB US IMPRESSION: 1. Patent TIPS shunt with stable velocities. 2. Small stable right hepatic lesion unchanged from prior abdominal imaging. No new liver lesion identified. No biliary dilatation is seen. 3. Splenomegaly. . [9-13] CT head IMPRESSION: 1. Moderate-sized left subdural likely acute on subacute hemorrhage. 2 mm rightward shift of midline structures. 2. Ovoid occipital subcutaneous lesion likely a sebaceous cyst but correlation with exam is recommended. . [9-16] CT head IMPRESSION: ??????1. No change versus comparison study three days ago. ??????2. Stable subdural collection along the left frontal convexity layering dependently. Stable shift of midline structures and ventriculomegaly. No evidence of new hemorrhage or hydrocephalus. PARACENTESIS #1: [2146-9-14] 02:54PM ASCITES WBC-40* RBC-3770* Polys-17* Lymphs-12* Monos-6* Mesothe-11* Macroph-54* PARACENTESIS #2: (SBP) [2146-9-18] 03:00PM ASCITES WBC-1100* RBC-[Numeric Identifier 36711]* Polys-38* Lymphs-6* Monos-0 Eos-4* Mesothe-2* Macroph-50* PARACENTESIS #3: [2146-9-20] 02:17PM ASCITES WBC-110* RBC-860* Polys-0 Lymphs-7* Monos-0 Mesothe-1* Macroph-92* Brief Hospital Course: 57 year old male with pmh of decompensated Hep C cirrhosis with multiple metabolic derangements and AMS s/p fall, now with an acute on chronic SDH and ARF. . . AMS: Was determined to be secondary to hepatic encephalopathy. Possible precipitants included medications (opiates and depakoate), and medication non-compliance (though patient denies). Infectious etiologies and GIB were ruled out. Paracentesis was initially negative for SBP on admission. Given potential hepatic toxicity, depakote was held and pt was ultimately started on valproate. Abd ultrasound was checked to evaluate the patency of his TIPs and it was determined that TIPS was shunting too much blood from gut resulting in worsening encephalopathy. A TIPS reduction was done and pt's encephalopathy improved. Serial ammonia levels remained low after reduction. His lactulose was uptitrated and his Rifaximin was continued. ICH: This could have been contributing to AMS on presentation though certainly not the cause given pt was encephalopathic when he fell. Head CT showed an acute on chronic SDH with 2mm rightward shift. Neurosurgery evaluated and felt there was no component contributing to his AMS. He was monitored with Q4 neuro checks which were stable. Repeat head CT revealed stable lesion. Neurosurgery signed off and pt will follow up with neurosurgery in 4 weeks time with repeat head CT. Until that time he will continue on seizure prophylaxis with keppra ARF: CK came back at 5045 contributing to the ARF as well as volume depletion. Hepatorenal syndrome was considered though thought to be less likely given improvement with IVF and clearance of his CK. His baseline creatinine was 0.8 to 1.0. CK trending down to normal within 3 days. Pt's creatinine trended down and at time of discharge it was 1.3. Resumed diuretics at lowered dose of lasix 40mg and spironolactone 100mg daily Transaminitis: Possibly in the setting of ischemia, or myolysis from being found down. Seizure thought unlikely given no recent alcohol use and his negative serum EtOH. Possible medication effect with opiates and valproic acid. His valproic acid was held and an ultrasound was performed to evaluate the patency of his TIPS. TIPS was reduced as mentioned above. transaminitis improved, but still had impaired synthetic fxn at time of discharge [2-23] underlying cirrhosis. Depakote was restarted. Anemia: Baseline 32-36, HCT on admission 27.9 with drop to 25 with hydration. FOBT positive with brown stool in the ED. No hematemesis. Denied any blood in his stool or urine. Denies any increasing abdominal distension. Most recent tap was on [2146-9-8]. Hemolysis labs were + for low hap to, elevated lactate dehydrogenase, and [Doctor First Name ]. Could have had some underlying hemolysis from high velocities in TIPS. Pt's crit remained stable, and will need endoscopy/c-scope after discharge. Liver decompensation: Continued his lactulose and rifaximin. Initially held his diuretics given ARF and elevated CK. Ascites continued to increase throughout hospitalization and a large volume paracentesis was performed on [2146-9-20] with removal of 3 liters of fluid Spontaneous Bacterial Peritonitis: A diagnostic para performed on [2146-9-18] revealed SBP with ~330 neutrophils. Started on 5day course of ceftriaxone and albumin with repeat albumin 3 days later. Paracentesis performed on [9-20] was also sent for diagnosis, revealing resolution of SBP. Patient started on ciprofloxacin 500mg for SBP prophylaxis BPAD: pt's mood stabilizer was d/ced in setting of transaminitis and AMS. He was started on valproate, but will need close psychiatric follow up. His outpatient psychiatrist was called numerous times by psychiatry and the primary team but he did not return calls. Psych consult reported that pt is not threat to self or others. Also reported that he will not be able to get close enough follow up with a [Hospital1 18] psychiatrist and will need to follow up with outpt psychiatrist or find a new one before discharge. Transitional: # Pt needs follow with psychiatry # follow up with NSG in four weeks with repeat CT of head Medications on Admission: - carvedilol 25mg [Hospital1 ] - hydralazine 25mg TID - atorvastatin 80mg daily - plavix 75mg daily - ASA 325mg daily - coumadin 5mg daily - 15 units insulin NPH & regular human (70-30) [Hospital1 ] - lasix 80mg daily - spironolactone 50mg TID - folic acid 1mg daily Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): titrated to [3-25] bowel movements per day. 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:2 7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:120 Tablet(s) Refills:0 10. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every twenty-four(24) hours. Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) ] Discharge Diagnosis: Subdural hematoma Hepatic encephalopathy Cirrhosis bipolar affective disorder Spontaneous bacterial peritonitis Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 36712], It was a pleasure taking care of you. You were admitted to the hospital for confusion and a fall. When you fell, you hit your head and this caused a small bleed inside your skull called a subdural hematoma. The neurosurgeons here examined you and we did two CT scans of your head and it was determined that the bleeding had stopped. Your were started on Keppra for seizure prophylaxis. During your hospitalization we also performed a procedure called a TIPS reduction. Your TIPS was shunting too much blood away from your liver and this was contributing to your confusion (ie. hepatic encephalopathy). After the procedure your encephalopathy improved. You also underwent a paracentesis to remove fluid from your abdomen, and there was an infection so you were started on antibiotics. A repeat tap removed about 3L of fluid and showed that the infection had resolved. We have made the following changes to your medications: START: ciprofloxacin 500mg daily on [2146-9-23] to prevent recurrence of spontaneous bacterial peritonitis START: keppra 500mg twice daily DECREASE: spironolactone to 100mg daily DECREASE: lasix to 40mg daily Followup Instructions: Please call to find a psychiatrist. This is extremely important and will be a prerequisite to being placed back on the liver transplant list Department: TRANSPLANT When: WEDNESDAY [2146-10-12] at 2:20 PM With: TRANSPLANT [Hospital 1389] CLINIC [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RADIOLOGY When: THURSDAY [2146-10-20] at 10:15 AM With: CAT SCAN [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: NEUROSURGERY When: THURSDAY [2146-10-20] at 11:00 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 7746], MD [Telephone/Fax (1) 3666] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage ICD9 Codes: 5849, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7473 }	Medical Text: Admission Date: [2196-2-5] Discharge Date: [2196-2-9] Date of Birth: [2164-10-29] Sex: M Service: [Location (un) ] Medicine HISTORY OF PRESENT ILLNESS: This is a 31-year-old gentleman with HIV with recently undetectable viral load and CD4 greater than 200, which is complicated by HIV nephropathy and HIV cardiomyopathy and a remote [Doctor First Name ] infection as well as the [November 2195] admission for lactic acidosis and fulminant hepatic failure secondary to Stavudine, who was well following his discharge until [2196-2-2], when he noted productive cough with yellow sputum. Cough improved, but then worsened again the day prior to admission. Patient also noted feeling warm in the morning of admission, temperature to 102, rechecked later in the evening with a temperature to 103, and came into the Emergency Room at [Hospital1 18]. He had no dyspnea at rest only with a significant exertion. He is able to cook and clean without dyspnea. He has been compliant with his HAART and Bactrim therapy without missing any doses. In the Emergency Room received 2 liters of IV fluids, levofloxacin 500 mg p.o., Combivent nebulizer, and acetaminophen. PAST MEDICAL HISTORY: 1. HIV with undetectable viral load, CD4 greater than 200, diagnosed in [2194-3-31] complicated by nephropathy, collapsed focal segmental glomerulonephritis on biopsy with end-stage renal disease on hemodialysis 3x a week, also complicated by HIV cardiomyopathy with a last ejection fraction of 20-25% in [2195-12-29]. 2. History of [Doctor First Name ] infection. 3. Hepatitis C carrier. 4. Anemia of chronic disease. 5. History of G-6-P-D deficiency. 6. Left upper extremity A-V fistula placed [2194-5-31], revised in [2195-4-30]. 7. HAART-induced hepatic failure and lactic acidosis in [2195-11-30]. 8. Acute renal failure with hypocalcemia. 9. Uremic coagulopathy. 10. Inflammatory arthritis of the left knee. ALLERGIES: Stavudine to which he has lactic acidosis. MEDICATIONS ON ADMISSION: 1. Cyanocobalamin 100 mg q.d. 2. Bactrim single strength one p.o. q.d. 3. Lisinopril 10 mg p.o. q.d. 4. Metoprolol 12.5 mg p.o. b.i.d. 5. Sevelamer. 6. Pantoprazole. 7. Tenofovir. 8. Efavirenz. 9. Lamivudine. SOCIAL HISTORY: He lives with his mother and three nephews. [Name (NI) ] smokes about one pack per week x10 years. Alcohol every 1-2 weeks, no illicit drugs. FAMILY HISTORY: Hypertension. PHYSICAL EXAMINATION: Vitals on admission: Temperature 101.8, pulse of 119, blood pressure 159/90, respiratory rate of 16, and sats of 89% on room air with 97% on 2 liters. In general, he is very pleasant and nontoxic appearing. HEENT: No sinus tenderness. Pupils are equal, round, and reactive to light. Oropharynx and conjunctivae are clear. Moist mucous membranes. Neck was soft, supple, no lymphadenopathy. No JVD. Cardiovascular is tachycardic, normal S1, S2, [2-5] holosystolic murmur throughout. Pulmonary: Diffuse rhonchi, scattered wheezes expiratory greater than inspiratory, right bibasilar crackles, no egophony, no fremitus. Abdomen is soft, nontender, nondistended, positive bowel sounds. No hepatosplenomegaly. Back: No CVA or paraspinal tenderness. Extremities: 2+ dorsalis pedis pulses bilaterally. Trace bipedal edema. Skin: No rashes or lesions. Neurologic is nonfocal, alert and appropriate. LABORATORIES ON ADMISSION: White count 5.8 with 65% neutrophils, 25% lymphocytes, hematocrit 35, platelets of 233. Chem-7 with a sodium of 135, potassium of 5.9, which is hemolyzed, chloride 92, bicarb 29, BUN 21, creatinine 8.4, glucose 89, lactate of 2.7, ALT of 18, AST 72 hemolyzed. Alkaline phosphatase 75, total bilirubin 0.9, amylase 209 hemolyzed, LDH 584 hemolyzed corrected to 241 nonhemolyzed. Blood cultures sent x2. Chest x-ray with enlarged cardiac silhouette consistent with a bibasilar infiltrative process. Urinalysis with small blood, 100 protein, 100 glucose. HOSPITAL COURSE: This is a 31-year-old gentleman with HIV admitted with pneumonia. 1. Pneumonia: Patient had chest x-ray and history which were consistent with community acquired pneumonia initially started on levofloxacin. Initially not concerned for PCP as had been compliant with his medicines and stable CD4 count, and on prophylaxis, although on single strength Bactrim, G-6-P-D deficiency, and nonelevated LDH. Patient was admitted initially for his pneumonia because of hypoxemia. Was eventually treated with levofloxacin to complete a two week course. However, was also hydrated in the Emergency Room secondary to presumed insensible loss with a fever, and was transferred to the floor, where he completed his fluids, and had stable gas of 7.48, 58, 72 on the floor on room air, which was stable. However, patient was then taken to hemodialysis day of admission for his scheduled dialysis and went into acute respiratory distress. Patient had a blood gas taken at that time, which showed gas of pH of 7.36, CO2 of 42, and pO2 of 61. Chest x-ray at that time showed asymmetric right sided pulmonary edema. Patient also at that time was noted to be tachycardic into the 140s, had a blood pressure up to 202/128 and was concerned for flash pulmonary edema. Was eventually ultrafiltrated via dialysis and then was transferred to the MICU for further observation. Patient also received one dose of prednisone for concern for acute PCP, [Name10 (NameIs) ], as patient was improving with diuresis via ultrafiltration, the patient was not continued on treatment doses for PCP, [Name10 (NameIs) ] was back to his home regimen of prophylaxis. Over the course of his MICU stay, the patient had 6 kg of weight ultrafiltrated, and otherwise remained stable throughout the rest of his stay. His oxygenation improved after some nebulizer treatments and was nonrebreather and essentially weaned back down to room air. By the time of discharge, had been ambulating and not requiring oxygen for 36 hours prior to discharge without any desaturations. Patient also had two induced sputums sent for PCP, [Name10 (NameIs) 6643] were negative, and patient was continued on his levofloxacin to complete a two week course and this was stable. 2. End-stage renal disease with HIV nephropathy: This was stable and patient after his MICU stay continued on his [Name10 (NameIs) 766], Wednesday, Friday regimen, and will follow up with his renal nephrologist, Dr. [Last Name (STitle) 1860] as an outpatient. 3. For patient's CHF, known ejection fraction of 20-25% secondary to his HIV. Was continued on his ACE inhibitor and beta blocker, which were tolerated well and no further signs of overload throughout the rest of his stay, and will follow up with the CHF team as an outpatient. 4. HIV: Stable with a CD4 count greater than 200 and undetectable viral load. Will continue HAART and continue Bactrim prophylaxis. Continue to monitor for concerns for toxicity from HAART with history of MICU admission for lactic acidosis and hepatic failure on Stavudine. This will be continued to be followed by patient's nephrologist and PCP. 5. Anemia: This is secondary to his renal disease. No evidence of hemolysis. Reticulocytes normal. Patient was continued on his Procrit at hemodialysis. 6. GERD: Patient's abdominal symptoms were stable over the course of his stay, and was continued on his proton-pump inhibitor. 7. Nutrition: Patient was continued on renal diet, and continued to follow electrolytes. He did have evidence of hyperkalemia on day of flash edema, which improved with dialysis of 0 K dialysis. This was determined to be secondary to acid-base changes. 8. Prophylaxis: Patient was ambulating throughout his stay and continued on his proton-pump inhibitor. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Pulmonary edema. 3. End-stage renal disease. 4. Congestive heart failure with ejection fraction of 20-25%. 5. Human immunodeficiency virus. DISCHARGE MEDICATIONS: 1. Levofloxacin 250 mg p.o. q.48h. for four more doses. 2. Lamivudine 10 mg p.o. q.d. 3. Efavirenz 600 mg p.o. q.d. 4. Tenofovir 300 mg p.o. q Friday. 5. Metoprolol XL 12.5 mg p.o. q.d. 6. Lisinopril 10 mg p.o. q.d. 7. Cyanocobalamin 100 mcg p.o. q.d. 8. Pantoprazole 40 mg p.o. q.d. 9. Sevelamer 400 mg p.o. t.i.d. 10. Dextromethorphan [5-9] mL p.o. q.6h. as needed for cough. 11. Nephrocaps 1 mg p.o. q.d. 12. Bactrim SS one p.o. q.d. 13. Albuterol 1-2 puffs inhaled q.i.d. as needed for shortness of breath or wheezing. FOLLOW-UP PLANS: Patient is to followup with his PCP on [2-18] at [Hospital1 778], Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Patient is to call [Hospital 1902] Clinic and setup a repeat evaluation with Dr. [First Name (STitle) 2031]. Patient is to keep his follow-up appointment with Dr. [First Name (STitle) ] in [Month (only) 958]. DISCHARGE CONDITION: Good. Patient is ambulating without difficulty. Not requiring oxygen and otherwise stable. DISCHARGE STATUS: Discharged to home. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2667], M.D. [MD Number(1) 2668] Dictated By:[Name8 (MD) 264] MEDQUIST36 D: [2196-2-10] 10:07 T: [2196-2-10] 10:17 JOB#: [Job Number 100378] ICD9 Codes: 486, 4254, 4280, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7474 }	Medical Text: Admission Date: [2141-5-4] Discharge Date: [2141-5-10] Date of Birth: [2082-7-4] Sex: F Service: SURGERY Allergies: Metformin / Metoprolol Succinate Attending:[First Name3 (LF) 301] Chief Complaint: Cholecystitis Major Surgical or Invasive Procedure: Open Cholecystectomy with liver biopsy [2141-5-4] History of Present Illness: The patient is a 58-year-old woman who was complaining of attacks of epigastric pain for the last 2 months. She has been seen in the hospital, and she has known about her gallstones for the last 5 years but has tried to avoid surgery. Ultrasound confirms gallstones and a contracted gallbladder. Liver function tests were normal and repeated within normal limits with a total bilirubin of 1.6. The patient has had a decreased appetite and reports a 10- pound weight loss. She has been previously evaluated by her report with a CAT scan which has been normal. She was seen in my office this weekend with persistent right upper quadrant pain and we proceeded with a laparoscopic cholecystectomy. . Past Medical History: Cholecystitis Pulmonary Hypertension (primary vs. rheum condition vs undiagnosed cardiac dz DMII CAD. Cath [9-/2136] severe LM with 50% ostial stension. Hypothyroidism ?pan-hypo pit: partially empty sella on MR [2131], though has not required hormone replacement.anemia Hypertension Social History: The patient is from [Country 480]. She lives with her husband and has supportive children. Family History: noncontributory Physical Exam: ON admission: v/s 97.2, 60, 133/76, sat 97% on room air, RR 20 Gen: elderly female in no acute distress, partial english-speaking, slightly mal-nourished appearing HEENT: MMM, EOMI, no icterus Neck: supple, no masses CV: RRR, no murmur Pulm: coarse BS Abd: soft, NT/ND, normoactive BS, no masses Extr: warm, well-perfused Pertinent Results: [2141-5-4] 04:28PM BLOOD WBC-12.1# RBC-4.08 Hgb-10.7* Hct-35.2* MCV-86 MCH-26.2* MCHC-30.4* RDW-13.9 Plt Ct-275 [2141-5-5] 02:00AM BLOOD WBC-9.0 RBC-3.98* Hgb-10.5* Hct-33.8* MCV-85 MCH-26.4* MCHC-31.1 RDW-14.1 Plt Ct-233 [2141-5-5] 04:56PM BLOOD WBC-11.1* RBC-3.88* Hgb-10.2* Hct-33.0* MCV-85 MCH-26.2* MCHC-30.7* RDW-13.9 Plt Ct-232 [2141-5-6] 03:57AM BLOOD WBC-8.5 RBC-3.62* Hgb-9.4* Hct-30.4* MCV-84 MCH-26.0* MCHC-31.0 RDW-14.1 Plt Ct-199 [2141-5-6] 11:45AM BLOOD WBC-8.8 RBC-4.01* Hgb-10.5* Hct-34.0* MCV-85 MCH-26.3* MCHC-31.0 RDW-14.0 Plt Ct-193 [2141-5-7] 06:00AM BLOOD WBC-7.6 RBC-3.75* Hgb-9.8* Hct-31.2* MCV-83 MCH-26.1* MCHC-31.3 RDW-13.9 Plt Ct-190 [2141-5-8] 05:45AM BLOOD WBC-5.0 RBC-3.61* Hgb-9.6* Hct-29.7* MCV-82 MCH-26.5* MCHC-32.2 RDW-13.8 Plt Ct-206 [2141-5-8] 05:45AM BLOOD PT-14.5* PTT-34.3 INR(PT)-1.4 [2141-5-4] 04:28PM BLOOD Glucose-164* Creat-0.9 Na-143 K-3.2* Cl-106 HCO3-28 AnGap-12 [2141-5-5] 02:00AM BLOOD Glucose-114* UreaN-19 Creat-0.9 Na-141 K-4.9 Cl-108 HCO3-27 AnGap-11 [2141-5-5] 04:56PM BLOOD Glucose-93 UreaN-16 Creat-0.8 Na-141 K-4.5 Cl-107 HCO3-25 AnGap-14 [2141-5-6] 03:57AM BLOOD Glucose-68* UreaN-14 Creat-0.8 Na-141 K-4.3 Cl-106 HCO3-25 AnGap-14 [2141-5-6] 11:45AM BLOOD Glucose-72 UreaN-13 Creat-0.8 Na-141 K-4.6 Cl-106 HCO3-26 AnGap-14 [2141-5-7] 06:00AM BLOOD Glucose-73 UreaN-15 Creat-0.6 Na-138 K-4.0 Cl-103 HCO3-27 AnGap-12 [2141-5-8] 05:45AM BLOOD Glucose-155* UreaN-7 Creat-0.5 Na-139 K-3.7 Cl-102 HCO3-31* AnGap-10 [2141-5-4] 04:28PM BLOOD CK(CPK)-78 [2141-5-5] 02:00AM BLOOD CK(CPK)-250* [2141-5-6] 03:57AM BLOOD ALT-18 AST-48* AlkPhos-41 Amylase-27 TotBili-1.9* [2141-5-7] 06:00AM BLOOD ALT-19 AST-41* AlkPhos-40 Amylase-22 TotBili-2.2* [2141-5-8] 05:45AM BLOOD ALT-14 AST-26 AlkPhos-34* Amylase-16 TotBili-1.0 DirBili-0.4* IndBili-0.6 [2141-5-6] 03:57AM BLOOD Lipase-9 [2141-5-7] 06:00AM BLOOD Lipase-11 [2141-5-8] 05:45AM BLOOD Lipase-17 [2141-5-4] 04:28PM BLOOD Calcium-8.5 Phos-5.2# Mg-1.3 [2141-5-5] 02:00AM BLOOD Calcium-8.2* Phos-4.7* Mg-1.7 [2141-5-6] 03:57AM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.1# Mg-1.6 [2141-5-8] 05:45AM BLOOD Albumin-2.7 Calcium-8.0* Phos-1.7* Mg-1.4* [2141-5-5] 05:07PM BLOOD Lactate-1.1 [2141-5-5] Chest Xray: no acute cardiopulmonary process MICRO [2141-5-4] Intraoperative Swab culture: gram stain, culture negative [2141-5-6] Urine culture: negative [2141-5-6] Blood culture: negative [2141-5-7] Sputum culture: negative Brief Hospital Course: This is a 58 year old female who was admitted for elective laparoscopic cholecystectomy for cholecystitis. Intraoperatively the case was converted to an open cholecystectomy (please see the operative note of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for full details). During the case she was noted to have bradycardia with bigeminy and hypotension requiring lidocaine for conversion to sinus rhythm. She was transferred to the ICU setting post-operatively for close monitorring and remained there for 4 days. Cardiology was consulted and recommended close monitoring and repletion of electrolytes. She essentially did well in her post-operative course with no further cardiologic events . On post-op day 3 she had some tachypnea and an ABG demonstrated mild hypoxia; she was treated with chest PT and nebulizers with resolution of her symptoms. She was started on a clear diet on post-op day 4 which was advanced to a regular diet on post-op day 5 which she tolerated well. She was weened off of her morphine to oral narcotics by post-op day 4 with good pain control. She worked with physical therapy and was cleared for home safety. Her JP drain was removed on post-op day 6. She was discharged to home on post-op day 6 with planned follow-up with Dr. [Last Name (STitle) ] in [11-20] weeks. All questions were answered to her satisfaction upon discharge. Medications on Admission: Levothyroxine 175 mg oral qd MSContin 15 mg oral [Hospital1 ] Meclizine 25 mg oral TID prn Protonix 40 mg oral QD Viagra 25 mg oral TID Toprol XL 25 mg oral QD Avandia 4 mg oral QD Aspirin 325 mg oral QD Discharge Medications: 1. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 levothyroxine 175', mscontin 15", meclizine 25"' prn, protonix 40', toprol xl 25', cortisporin [Hospital1 ] to ears, avandia 4', asa 325', . Levothyroxine 175 mg oral qd MSContin 15 mg oral [Hospital1 ] Meclizine 25 mg oral TID prn Protonix 40 mg oral QD Viagra 25 mg oral TID Toprol XL 25 mg oral QD Avandia 4 mg oral QD Aspirin 325 mg oral QD Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Cholecystitis Secondary: pulmonary hypertension, coronary artery disease, Diabetes Mellitus Discharge Condition: Good. Tolerating POs. Ambulating without assistance. Good pain control Discharge Instructions: You may continue your pre-admission medications (including aspirin) in addition to the medications we have prescribed for you. Do not drive while taking narcotics. Call the office or come to the ER with any abdominal pain not improved with your oral narcotics, nausea/vomitting, drainage from your incision, or fever to 101. You may shower and resume you regular activity but no heavy lifting or baths for 2 weeks. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], Minimally Invasive Surgery, Call to schedule an appointment within 1-2 weeks [Telephone/Fax (1) 2723] Provider: [Name10 (NameIs) ],[First Name8 (NamePattern2) ] [Hospital1 7975] INTERNAL MEDICINE Where: [Hospital1 7975] INTERNAL MEDICINE Phone:[Telephone/Fax (1) 7976] Date/Time:[2141-5-24] 2:00 Provider: [Name10 (NameIs) 1571] BREATHING TEST Where: [Hospital6 29] PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 612] Date/Time:[2141-5-30] 9:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 5265], M.D. Where: [Hospital6 29] REHAB SERVICES (DYSPNEA) Phone:[Telephone/Fax (1) 612] Date/Time:[2141-5-30] 10:00 Completed by:[2141-5-10] ICD9 Codes: 4019, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7475 }	Medical Text: Admission Date: [2173-5-1] Discharge Date: [2173-5-3] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Stroke Major Surgical or Invasive Procedure: t-PA and cerebral angiography History of Present Illness: 85 yo woman of unknown handedness, presented as a code stroke, transferred from [Hospital3 4107]. She has a history of afib, not on coumadin due to noncompliance with INR checks, and around 12:30pm she had an "audibly witnessed" collapse. Per daughter, she lives at home with her 2 children and was well this AM. She sneezed violently several times, and then fell to the ground. She had no complaints after falling, and was "semiconscious" per son, but slowly began to "fade", close her eyes become less responsive. [First Name8 (NamePattern2) ] [Hospital1 ] notes, she was poorly responsive, RR 4/min. She was bagged by EMS and taken to [Hospital3 ]. She was found to have a BP of 122/84 and HR 161, in rapid afib, placed on a dilt drip. SHe was intubated. NCHCT was negative for bleed and she was transferred to [Hospital1 18] for further workup. She is noted to be guaiac positive, otherwise workup was unrevealing (neg CE x1, lytes, CBC). INR 1.17. FS 120's. Please see my exam below. Pt is intubated and unable to provide history. Of note, coumadin was just discontinued 2 weeks ago. Past Medical History: - right fronto-parietal stroke with residual left neglect and walks with a cane, [2169-3-3], she was diagnosed with afib at this time - afib off coumadin x 2 weeks secondary to noncompliance with INR checks - HTN - left eye surgery "collapsed retina", blind right eye, decreased visual acuity left eye s/p left cornea transplant - breast cancer [2142] s/p lumpectomy and radiation, no chemo Social History: SHx: lives at home with 2 kids, widowed, no tob/etoh/drugs, home maker and did other small part time jobs. Family History: daughter died of lupus at age 50. Physical Exam: ADMISSION EXAM Vitals: 98.8, 101 (was 161 at OSH afib), 153/60 (was 122/84 at OSH), 97% RR 12 (at set rate) intubated. Was overbreathing the vent earlier at 15 bpm. GEN: intubated elderly woman HEENT: NC/AT, anicteric sclera, right eye is completely [Last Name (un) 57454] out, mmm NECK: supple, no carotid bruits CHEST: CTA bilat CV: RRR without mur at this time ABD: soft, NT/ND, +BS, no HSM EXTREM: no edema, warm limbs NEURO: MENTAL STATUS: unresponsive to sternal rub, only withdrawls legs to painful stim. CRANIAL NERVES: Pupil exam: no pupil on right, left pupil is irregular in shape and displaced vertically but IS reactive EOM exam: no dolls Corneal reflex: absent Facial symmetry: unable, obscured from ETT Gag reflex: absent to suction MOTOR: spontaneously moves bilateral left>right LE just a bit SENSORY: withdrawls legs to painful stim minimally, not arms REFLEXES: brisker on the left, upgoing toe on the left, mute on the right. Pertinent Results: [2173-5-1] 09:50PM TYPE-ART PO2-128* PCO2-33* PH-7.41 TOTAL CO2-22 BASE XS--2 [2173-5-1] 09:34PM GLUCOSE-198* UREA N-7 CREAT-0.5 SODIUM-138 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14 [2173-5-1] 09:34PM WBC-14.5* RBC-3.90* HGB-12.7 HCT-35.9* MCV-92 MCH-32.5* MCHC-35.3* RDW-13.0 [2173-5-1] 09:34PM PLT COUNT-204 [2173-5-1] 04:30PM GLUCOSE-153* UREA N-8 CREAT-0.7 SODIUM-142 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16 [2173-5-1] 04:30PM CK(CPK)-42 [2173-5-1] 04:30PM CK-MB-NotDone cTropnT-<0.01 [2173-5-1] 04:30PM WBC-11.6* RBC-4.72 HGB-14.8 HCT-43.9 MCV-93 MCH-31.4 MCHC-33.8 RDW-13.0 [2173-5-1] 04:30PM PLT COUNT-195 [2173-5-1] 04:30PM PT-12.5 PTT-23.2 INR(PT)-1.1 [2173-5-1] 04:30PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 [2173-5-1] 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG Brief Hospital Course: The patient was emergently brought to the Neurointerbeventional Suite for cerebral angiogram, attempte thrombolysis, and angioplasty. t-PA was given intra-arterially. There was little change in her exam. Neurosurgery was consulted and agreed that the prognosis was very poor. Patient noted to have ocular bobbing, preservation of coneals, gag reflexes but was not over breathing the ventilator. The family made the decision to withdraw her from the ventilator machine and she was extubated. Comfort care was administered. A morphine drip was administered. The patient expired at 1:25PM [2173-5-3]. Discharge Disposition: Expired Discharge Diagnosis: Basilar Artery Thrombosis Discharge Condition: Deceased [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7476 }	Medical Text: Admission Date: [2162-1-4] Discharge Date: [2162-2-2] Date of Birth: [2108-11-18] Sex: F Service: TRANSPLANT HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 28181] is a 53 year-old female who is status post cadaveric renal transplantation in [2161-8-3] for end stage renal disease and polycystic kidney disease who had an uneventful postoperative course, but developed increasing shortness of breath and dyspnea on exertion with abrupt worsening at the end of [2161-12-3]. She also expressed concern about weight gain and pedal edema. She was eventually diuresed at outside hospital, but was found to have elevated creatinine and was subsequently transferred to the [Hospital1 69] for management. At the tine of transfer the patient's creatinine was elevated at 3.0. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus. 2. Hypertension. 3. Polycystic kidney disease. 4. Hypercholesterolemia. 5. Uterine fibroids. 6. Nasal polyps. 7. Status post cadaveric renal transplant [2161-8-3]. 8. Status post total abdominal hysterectomy. 9. Status post tubal ligation. 10. Asthma. MEDICATIONS AT HOME: 1. Tacrolimus 8 mg po b.i.d. 2. Rapamycin 5 mg po q.d. 3. Prednisone 5 mg po q day. 4. NPH insulin 30 units subq q.a.m. and 12 units subq q.p.m. 5. Lasix 20 mg po q day. 6. Atovaquone 1500 mg po q day. 7. Advair 1 mg inhaler b.i.d. 8. Aciphex 20 mg po q day. 9. Epogen 10,000 units subcutaneously q week. 10. Lipitor 10 mg po q day. 11. Albuterol inhaler prn. 12. Iron 325 mg po q day. ALLERGIES: 1. Zestril. 2. Sulfa. 3. Environmental. FAMILY HISTORY: Polycystic kidney disease. SOCIAL HISTORY: The patient denies tobacco use and states that she uses alcohol occasionally. PHYSICAL EXAMINATION: Vital signs temperature 98.8. Blood pressure 122/64. Heart rate 94. Oxygen saturation 95% on 3 liters nasal cannula. In general, the patient is an obese African American female who appears to be in mild distress. HEENT clear oropharynx. Mucous membranes are moist. Neck supple, nontender without lymphadenopathy. Heart regular rate and rhythm. No murmurs. Lungs decreased at the bilateral bases. Abdomen soft, obese, nontender, nondistended. Extremities 2+ pedal edema bilaterally. LABORATORY STUDIES: White blood cell count 4.5, hematocrit 27.2, platelet count 276, PT 13.6, PTT 30.6, INR 1.2, sodium 140, potassium 5.5, chloride 103, bicarb 27, BUN 31, creatinine 3.1, glucose 223, AST 23, ALT 11, alkaline phosphatase 93, amylase 49, total bilirubin 0.2, lipase 30. IMAGING: Chest x-ray performed on admission demonstrated a globular appearing cardiac silhouette with small bilateral effusions and an overall picture concerning for pericardial effusion. HOSPITAL COURSE: After the patient was transferred to the [Hospital1 69] on [2162-1-4] a pericardial drain was placed to treated the pericardial effusion. This drained approximately 1 liter in the immediate period and she therefore underwent a pericardial window procedure on [2162-1-8] for persistent fluid reaccumulation. The patient tolerated this procedure well and was admitted to the Coronary Care Unit postoperatively for close observation. She was extubated on postoperative day one with two chest tubes in place and was transferred to the [Hospital3 ] floor on postoperative day two in stable condition. The patient did well, but developed a temperature spike on postoperative day six along with increased shortness of breath. A chest x-ray at this time demonstrated hydropneumothorax. This was treated without intervention and subsequently resolved. The patient did have another temperature spike to 103.6 and was subsequently found to have MRSA bacteremia. This was treated with intravenous Vancomycin. A transesophageal echocardiogram was done to evaluate the heart valve given the recent procedure and persistent bacteremia. This finding was consistent with endocarditis. The infectious disease team was therefore consulted for management. Per their recommendations, the patient was treated with Levofloxacin for gram negative coverage along with Vancomycin for MRSA bacteremia and presumed endocarditis. She was also on Valcyte for a positive CMV antibody titer. Around this time the patient developed severe right hip pain permitting her from ambulating. An MRI was performed, which was negative for infection, but did show mild degenerative joint disease. The patient was focally tender over the greater trochanter area and an orthopedic consultation was therefore obtained for possible trochanteric bursitis. Per their recommendations given that the patient was already on steroids they felt that it would be unuseful to treat her with additional steroid medications as it might potentiate her dependence on steroids. The patient was therefore treated with aggressive physical therapy and was seen by the acute pain service. An MRI was obtained to rule out radiculopathy, which was negative. She was treated with Tylenol #3 with Percocet for breakthrough pain and is scheduled to see the pain service as an outpatient. During her hospitalization, a biopsy of the transplant kidney was performed, which was negative for rejection. After remaining afebrile for greater then 48 hours the patient was discharged to rehab for physical therapy and intravenous antibiotics. DISCHARGE DIAGNOSES: 1. Insulin dependent diabetes mellitus. 2. Hypertension. 3. Polycystic kidney disease status post cadaveric renal transplant. 4. Hypercholesterolemia. 5. Uterine fibroids. 6. Nasal polyps. 7. Status post total abdominal hysterectomy. 8. Status post tubal ligation. 9. Asthma. 10. MRSA bacteremia. 11. Endocarditis. 12. Pericardial effusion status post pericardial window procedure. 13. CMV infection. DISCHARGE MEDICATIONS: 1. Tylenol prn. 2. Tylenol #3 one to two tablets po q 4 to 6 hours prn pain. 3. Advair inhaler q 12 hours prn. 4. Albuterol inhaler prn. 5. Lipitor 10 mg po q day. 6. Atovaquone 1500 mg po q day. 7. Clotrimazole one lozenge po q.i.d. prn. 8. Colace 100 mg po b.i.d. 9. Erythropoietin 10,000 units subcutaneously q Friday. 10. Iron 325 mg po q day. 11. Lasix 10 mg po q day. 12. Neurontin 300 mg po q.h.s. 13. Sliding scale and NPH insulin as directed. 14. Prevacid 30 mg po q day. 15. Levofloxacin 500 mg po q day times three days for a total of a 14 day course. 16. Montelukast 10 mg po q day. 17. Multivitamin one tablet po q day. 18. Nifedipine CR 30 mg po q day. 19. Zofran 2 mg intravenously q 6 hours prn nausea. 20. Oxycodone 5 mg po q 4 to 6 hours prn pain. 21. Prednisone 5 mg po q day. 22. Senna one tablet po b.i.d. prn. 23. Tacrolimus 4 mg po b.i.d. 24. Vancomycin 1000 mg intravenously q day times four weeks. 25. Valganciclovir 450 mg po q day times six weeks. 26. Ambien 10 mg po q.h.s. prn insomnia. FOLLOW UP PLANS: The patient was instructed to follow up with the [Hospital 1326] Clinic in approximately one week. She should have a CBC, chem 7, calcium, magnesium, phosphate, albumin, AST, ALT, alkaline phosphatase, T bilirubin, D bilirubin, and FK506 levels drawn every Monday and Thursday in the morning while at rehab. These results can be faxed to [Telephone/Fax (1) 697] for dosing changes. The patient was instructed to follow up with the [First Name4 (NamePattern1) 1193] [Last Name (NamePattern1) 1194] Service at the [Hospital1 346] as needed for her right hip pain. The patient was also instructed to follow up if she had fevers greater then 101.5 degrees Fahrenheit, intractable vomiting or any other questions or concerns. [Name6 (MD) 1344] [Name8 (MD) 1345], M.D. [MD Number(1) 1346] Dictated By:[Last Name (NamePattern1) 26023] MEDQUIST36 D: [2162-2-2] 11:11 T: [2162-2-2] 11:20 JOB#: [Job Number 28182] ICD9 Codes: 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7477 }	Medical Text: Admission Date: [2133-5-27] Discharge Date: [2133-6-15] Date of Birth: [2070-2-22] Sex: M Service: SURGERY Allergies: Tetracycline / Dicloxacillin Attending:[First Name3 (LF) 1384] Chief Complaint: HBV cirrhosis/hepatomas Major Surgical or Invasive Procedure: [2133-5-30] liver [Month/Day/Year ] History of Present Illness: 63 M with HIV, chronic Hep B, cirrhosis on [Month/Day/Year ] list recently treated for SBP. On coumadin for PV thrombosis and PE -PV thrombosis not seen on recent U/S. Listed for [Month/Day/Year ] this admission, listed yesterday, accepted today. Past Medical History: Chronic cirrhosis from hepatitis B infection with likely HCC HIV diagnosed in [2111] with undetectable viral load ([2133-2-7] CD4 101,HIV VL <48 copies/ml) Hepatitis B diagnosed in [2093] with undetectable viral load ([2133-2-7] HBVL <40) Herpes simplex HPV Peripheral neuropathy (feet) secondary to Stavudine Nephrolithiasis Left sided kidney stones surgical removal in the early [2103]'s and had lithotrypsy 3 times in the [2103]'s. Pancytopenia Depression Benign prostatic hypertrophy Basal cell carcinoma with Moh??????s surgery Gonorrhea Hypogonadism [2133-5-30] Liver [Month/Day/Year 1326] Social History: Patient is retired restaurant/bar manager (on disability since [2126] due to neuropathy). Homosexual male. He is the primary caregiver for his mother who has dementia. Patient is not married. Never smoked and no current alcohol. No illicit drug use. Family History: Mother with [Name2 (NI) 499] cancer. Father had brain tumor. Physical Exam: 98.8 57 130/60 20 98% RA AAOx3 NAD + icterus or jaundice no signs of skin infections RRR CTAB soft, moderate distension, tympanitic, non-tender, no obvious scars, no hernias, no edema, extrem warm rectal deferred Labs: 135 108 40 89 AGap=13 4.5 19 1.6 Ca: 9.7 Mg: 2.0 P: 2.0 ALT: 39 AP: 58 Tbili: 5.8 Alb: AST: 47 LDH: Dbili: TProt: [Doctor First Name ]: Lip: Other Blood Chemistry: AFP: Pnd 1.6>24.1<52 PT: 23.8 PTT: 33.8 INR: 2.3 Rads: [5-27] Liver U/S: 1. Cirrhotic liver with grossly normal portal hepatic venous as well as hepatic arterial vasculature and no evidence of portal venous thrombus. 2. Splenomegaly. [5-27] CXR - neg [2133-5-2] CT 1. Nonocclusive right lower lobe pulmonary embolism in the distal and subsegmental branches. This study was not optimized for evaluation of pulmonary embolism, however there is no apparent thrombus in the main pulmonary arteries. 2. Nonocclusive thrombus in the main portal vein which is new. Clot previously described in the splenic vein is less apparent on today's study. The hepatic arterial vasculature remains patent. 3. Large volume ascites in the abdomen and pelvis, which appears to have increased since the prior examination. Splenomegaly with splenic varices from portal hypertension. 4. Hypodense lesions in the liver corresponding to site of prior RF ablation. 5. Multiple hyperenhancing foci subcentimeter in size throughout the liver which appear stable concerning for hepatocellular carcinoma in this cirrhotic liver. No clear new areas of disease. 6. Nonobstructive 9 mm left lower pole renal calculi. 7. Stable pancreatic cysts. 8. Possible bladder stone, recommend correlation with patient's symptoms. Pertinent Results: [2133-6-15] 05:30AM BLOOD WBC-5.2 RBC-3.32* Hgb-10.1* Hct-30.8* MCV-93 MCH-30.6 MCHC-32.9 RDW-17.7* Plt Ct-122* [2133-6-15] 05:30AM BLOOD PT-14.7* PTT-21.9* INR(PT)-1.3* [2133-6-14] 06:10AM BLOOD PT-13.0 INR(PT)-1.1 [2133-6-15] 05:30AM BLOOD Glucose-210* UreaN-43* Creat-1.3* Na-134 K-4.5 Cl-103 HCO3-23 AnGap-13 [2133-6-15] 05:30AM BLOOD ALT-102* AST-46* AlkPhos-166* TotBili-2.6* [2133-6-15] 05:30AM BLOOD Albumin-3.1* Calcium-7.6* Phos-3.1 Mg-2.3 [2133-6-15] 05:30AM BLOOD tacroFK-8.8 Brief Hospital Course: On [2133-5-30], he underwent piggyback orthotopic liver [Date Range ] for end-stage liver disease secondary to hepatitis B. He also has HIV. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. Please refer to operative note for details. He received induction immunosuppression (solumedrol,simulect,and cellcept) as well as HBIG 10,000 units during the anhepatic phase of surgery to protect against HBV recurrence. Of note, there was a significant size mismatch, with the recipient artery being much smaller than the donor artery. There was a good anastomosis with good thrill present. The liver was quite large for the patients size. Closure was successfully obtained and two drains were placed. He was transferred to the SICU intubated immediately postop for management where he received blood products to maintain hemostasis. LFTs trended up initially then started to trend down. An u/s of the liver was obtained on postop day 1 revealing patency and normal flow in all vessels. There was mildly increased liver echogenicity, with no intra- or extra-hepatic biliary duct dilatation. No focal liver lesions were identified. He was extubated. LFTS continued to slowly trend down. HBIG (10,000units each dose)was given daily for 7 days with HBsAb levels greater than 450 and negative HBsAg. Diet was started and advanced. PO meds were started with ARVs resumed on [6-3]. Prograf was started on [5-30]. He received intermittent doses based on trough levels that varied between 5.5 and 16.7 due to the interaction between ARVs. Prograf 1mg was given on [6-1], [6-2]. Prograf 0.5mg was given on [7-9] and [6-9]. Based on trough levels and doses given the plan was to give 0.5mg every Monday pm with trough levels every Monday, Thursday and Friday. Given preop condition of malnutrition and insufficient dietary intake postop to meet his caloric needs, a postopyloric feeding tube was placed. He was started on Nutren 2.0. This was changed to Fibersource due to diarrhea, but he continued to have diarrhea. Stools were negative for c.diff. Fibersource was switched to Peptamen 1.5 at 40cc/hr continuous with improved tolerance. Imodium was started on [6-10] and given x3. Stooling decreased to once a day, but he then developed hyperkalemial. He experienced hyperkalemia on [6-10] with potassium of 5.9. Kayexalate 30grams was administered with potassium decreasing to 4.9 and diet was changed to low potassium. On [6-13], he again required treatment for hyperkalemia. This was treated with decreased repeat potassium. Lasix 10mg daily was started for the hyperkalemia. The tube feeding was switched back to a renal formulation, but loose stools continued, therefore, Novasource Renal was diluted on [6-15] to 3/4 strength with goal of 55cc/hour. Physical therapy worked with him extensively recommending rehab. He was screened and accepted at [Hospital1 ]. Of note, PT noted left foot drop, a problem that he had experienced preop as a result of prior ARVs. He wore a multipodis splint and an AFO was ordered. On [6-13], it was noted that he had some asymmetrical leg/foot swelling. LENIS were done showing bilateral DVTs. There was extensive occlusive thrombus within the left mid-to-distal superficial femoral vein extending to the left calf veins. In addition, there was occlusive thrombus within the right popliteal vein extending to the calf veins. There was normal color flow within the more proximal bilateral common femoral veins and superficial femoral veins. There was some swelling of the dorsum of the left foot. An xray demonstrated a substantial soft tissue prominence about the dorsum of the foot. No evidence of acute bone or joint space abnormality was noted. Of incidental note there was a small posterior calcaneal spur. He was started on coumadin 3mg daily on [6-13] for the bilateral DVTs and h/o segmental PE known preop. INR was 1.3 on [6-15]. Daily INRs were to be drawn at [Hospital1 ] until INR stable between 2-2.5. He developed a small stage 2 decubitus on his sacrum (1cmx0.5cm x 3mm). Critic Aide barrier cream was applied and he was encouraged to turn frequently. Medications on Admission: 1. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Darunavir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Entecavir 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Megestrol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pregabalin 50 mg Capsule Sig: One (1) Capsule PO three times a day. 10. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. 13. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 15. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia. 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 17. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:90 Tablet(s) Refills:2 19. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day: Please start [2133-5-14]. Disp:30 Tablet(s) Refills:2 20. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days: To complete [2133-5-13]. Disp:16 Tablet(s) Refills:0 21. Outpatient Lab Work Please have INR checked twice weekly unless otherwise specified by your primary care doctor. Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): follow taper per [Month/Day/Year ] protocol . 2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day) as needed for hypocalcemia. 5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours): last [6-10]. 10. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Darunavir 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for diarrhea. 13. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime. 14. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day: see printed scale. 15. HBIG Sig: 10,000 units once a month: 1 month from liver [Month/Year (2) ] ([5-30])-due [6-29] GIVE IV form. 16. Outpatient Lab Work Every Monday, Thursday and Friday trough prograf levels Call Result to [Hospital1 18] [Hospital1 1326] Center [Telephone/Fax (1) 673] 17. Outpatient Lab Work Labs every Monday and Thursday; cbc, chem 10, ast, alt, alk phos, t.bili, albumin Call results to [Hospital1 18] [Hospital1 1326] Center 18. Outpatient Lab Work Labs: Monthly: HBsAntibody titer and Hepatitis Surface Antigen prior to monthly infusion of Hepatitis B Immune globulin (HBIG) 19. Left AFO for left foot drop 20. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 21. Tacrolimus 0.5 mg Capsule Sig: 0.5 Capsule PO once a week: Give every Monday 6pm. Trough level every Monday, Thursday and Saturday am [Hospital1 1326] Center to adjust dose ONLY Tacrolimus interacts with Ritonivar and Darunavir therefore only need once a week dose . 22. Outpatient Lab Work Daily INR Call results to [Hospital1 18] [Telephone/Fax (1) 673] 23. Outpatient Lab Work Every Monday and Thursday CBC ,chem 10, ast, alt, alk phos, t.bili and albumin Fax results to [Hospital1 18] [Hospital1 1326] Office [Telephone/Fax (1) 697] 24. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): for hyperkalemia. 25. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: HIV HBV malnutrition depression peripheral neuropathy Hyperglycemia related to steroids Discharge Condition: stable Discharge Instructions: Please call the [Hospital1 1326] Office [Telephone/Fax (1) 673] if fever, chills, nausea, vomiting, increased abdominal pain/distension, increased JP drainage or if drain output stops, incision redness/bleeding/drainage or jaundice. Daily prograf levels Labs every Monday and Thursday Record JP output and send record of drain outputs to next appointment at [Hospital 1326] Clinic Followup Instructions: Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2133-6-18] 8:30 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2133-6-25] 9:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2133-7-2] 2:20 Completed by:[2133-6-15] ICD9 Codes: 5849, 5715
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7478 }	Medical Text: Admission Date: [2140-3-22] Discharge Date: [2140-4-8] Service: TRA ADMISSION DIAGNOSIS: Status post fall. DISCHARGE DIAGNOSES: 1. Subarachnoid hemorrhage. 2. Bilateral frontal lobe contusions. 3. Right cerebellar hemispheric bleed. 4. Subdural bleed. 5. Right occipital bone fracture, nondisplaced. 6. Left lung collapse requiring bronchoscopy with persistent left lower lobe collapse. 7. Question of ligamentous injury of the cervical spine of C3, C4. 8. Methicillin-resistant Staphylococcus aureus pneumonia. PROCEDURES DURING ADMISSION: Bronchoscopy for left lung collapse. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old female, who suffered a mechanical fall from a standing position on [2140-3-22]. She was transferred from [Hospital 1474] Hospital for further trauma management. The patient was hemodynamically stable. She was never hypoxic. Her GCS was 7 on arrival. She underwent further imaging evaluation by the Trauma Team after she was seen and evaluated in the Trauma Bay. PAST MEDICAL HISTORY: 1. Gout. 2. Osteoarthritis. 3. Hypertension. 4. Cataracts. 5. Question of CHF. PAST SURGICAL HISTORY: Not available. OUTPATIENT MEDS: 1. Vioxx. 2. Lasix 40 4x a day. 3. Prevacid 30 once a day. 4. Atenolol 25 twice a day. 5. Allopurinol 100 once a day. 6. Iron. 7. Tylenol. 8. Eyedrops. PHYSICAL EXAMINATION: On exam the patient had a GCS of 7. The patient was intubated for airway control given her GCS of 7. Her pupils were equal and reactive bilaterally. Heart was regular. Chest was clear. Abdomen was soft, nontender, nondistended. Her lower extremities revealed no deformity. Her right upper extremity had a small laceration that was not bleeding. RADIOLOGY FILMS: 1. Chest x-ray was negative. 2. A-P pelvis was negative. 3. CT head revealed contusion to the frontal lobes with a hematoma on the right cerebellar hemisphere, a subdural hematoma, and subarachnoid blood, a nondisplaced single fracture of the right occipital bone as well as a probable chronic subdural fluid collection in the right frontoparietal area with some brain atrophy. 4. Her CT of the abdomen and pelvis was negative. 5. TLS negative. 6. Right humerus negative. HOSPITAL COURSE: The patient was seen and evaluated in the Trauma Bay by the Trauma Team, and was admitted to the Intensive Care Unit for q1h neurological checks and hemodynamic monitoring. The [Hospital 228] hospital course by systems is as follows: 1. Neurologic: The patient had the above mentioned findings on head CT and was seen and evaluated by the Neurosurgery team. She had several repeat head CT scans, which were stable, and her neurologic exam slowly improved over the hospital course to the point where she was following commands and was able to be extubated. The patient's C spine was attempted to be cleared when she was extubated, however, she did have some probable ligamentous instability at C3-C4, therefore she was kept in a C collar. 1. Cardiovascular: The patient did have some episodes of tachycardia during her hospital stay. It was thought to be sinus tachycardia with PAC's given her EKG findings. Her Lopressor dose was increased and her heart rate reduced into the low 100s. 1. Respiratory: The patient was extubated initially midway throughout her hospital course, and given the fact that she was having difficulty breathing after extubation, and was tachypneic and tachycardic, she was reintubated. Upon reintubation, she had copious increase in thick secretions and was started on Levaquin empirically for a pneumonia. Her secretions did improve to the point that she was able to be extubated with aggressive pulmonary toilet. She did have a total collapse of her left lung and underwent an x- ray on [2140-4-2]. She underwent a bronchoscopy and awake bronchoscopy, and the patient's left lung, did improve, but she did have some persistent left lower lobe collapse. Her sputum did grow out on [2140-4-1] MRSA and the patient was started on vancomycin for this. Her respiratory status improved greatly with pulmonary toilet. 1. GI: The patient was started on tube feeds initially during her stay. These were continued and most recently she was started on a diet as her speech and swallow evaluation revealed that she was able to tolerate nectar- thickened liquids and a soft puree diet. As her nutrition is not optimized yet, she is continuing on her tube feeds until she is at goal nutrition. 1. GU: The patient does have a Foley catheter. She has had no issues with urine output. Has received Lasix intermittently for diuresis. Of note, she was on Lasix at home, however, this was not restarted during her hospital stay. She appeared to be fairly euvolemic. She may require Lasix to be restarted during her rehab stay. 1. Heme: The patient did not have any significant drops in her hematocrit. She was started on subcutaneous Heparin 5000 b.i.d. when cleared by Neurosurgery, and should continue on this. 1. ID: The patient is now on vancomycin day nine. She is going to get five more days of vancomycin for a 14 day course for her MRSA pneumonia. She had no other positive blood cultures, and does have a persistent left lower lobe collapse with secretions. 1. Endocrine: The patient is on a sliding scale with her tube feeds and receiving insulin per the sliding scale with q.i.d. fingersticks. 1. Prophylaxis: The patient is on Prevacid with Venodyne boots and subcutaneous Heparin. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Tylenol 325 p.o. q.4-6h. prn. 2. Heparin 5000 units subQ b.i.d. 3. Dulcolax prn. 4. Regular insulin-sliding scale. 5. Acetylcysteine 20 percent q.2h. prn for thick secretions. 6. Albuterol nebulizers q.4h. 7. Ipratropium bromide two puffs q.i.d. 8. Lopressor 50 mg p.o. t.i.d. 9. Nystatin swish and spit p.o. q.i.d. prn. 10. Vancomycin 1000 mg q.24h. for five more days. DISCHARGE INSTRUCTIONS: Patient's discharge instructions are to followup with Dr. [Last Name (STitle) 26803] in one month at [Telephone/Fax (1) 56306] with a head CT and flex-x films of her C spine prior to followup. She is to followup in the Trauma Clinic in [12-29] weeks. She continued receiving Impact with fiber at 60 cc an hour, to get chest PT q.6h. with nasogastric suction q.6h. She needs a Xeroform dressing and dry dressing to her right upper arm q.d. She does need aggressive physical therapy and pulmonary toilet. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5732], MD 2211 Dictated By:[Last Name (NamePattern1) 55418] MEDQUIST36 D: [2140-4-8] 10:13:57 T: [2140-4-8] 10:59:38 Job#: [Job Number ] ICD9 Codes: 5180
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7479 }	Medical Text: Admission Date: [2163-8-30] Discharge Date: [2163-9-2] Date of Birth: [2137-10-22] Sex: M Service: MED Allergies: Penicillins Attending:[First Name3 (LF) 3326] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: 25 yo male with a hx of AML s/p failed BMT x2 admitted for worsening shortness of breath x 1 day. Pt was recently d/c from [Hospital1 18] for shortness of breath and pleuritic chest pain, productive cough with sputum, thrombocytopenia, and low-grade temperature. He was treated for community acquired pneumonia and atypical pneumonia w/ vancomycin, cefepime, levofloxacin, caspofungin, and pentamidine. He was d/c to home on vanco/levo/caspofungin. All culture data in the hospital was negative. Pt was also started on serevent w/ symptomatic improvement. He had been improving until [8-31] when his previous symptoms returned acutely and worsened throughout the day. Pt was seen in clinic [8-29] where his white blood cell count had increased from 8.0 to 26.0. Past Medical History: AML Aspergillosis HTN [2-21] cyclosporine Social History: Pt's family is quite supportive of his condition. He has a girlfriend. [Name (NI) ] does not smoke, drink alcohol or do drugs. He is much less physically active than in the past Family History: No cancer/leukemia. Physical Exam: Gen - skin dry and pale, cachectic, mild distress HEENT - PERRL dry mucus membranes Neck - no JVD Chest - rhonchi b/l . CV - tachy, Normal S1/S2 no murmurs, rubs, or gallops Pulses - + pulsus paradoxus Abd - Soft, nontender, nondistended, with normoactive bowel sounds. No HSM. Extr - 2+ bipedal edema to ankles. Neuro - Alert and oriented x 3, cranial nerves [3-3] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact. Pertinent Results: [2163-8-30] 08:50PM GLUCOSE-157* UREA N-16 CREAT-1.1 SODIUM-135 POTASSIUM-5.9* CHLORIDE-104 TOTAL CO2-19* ANION GAP-18 [2163-8-30] 08:50PM ALT(SGPT)-55* AST(SGOT)-29 LD(LDH)-506* CK(CPK)-40 AMYLASE-20 TOT BILI-0.6 [2163-8-30] 08:50PM LIPASE-12 [2163-8-30] 08:50PM CK-MB-NotDone cTropnT-<0.01 [2163-8-30] 08:50PM CALCIUM-9.1 PHOSPHATE-3.8 MAGNESIUM-2.1 [2163-8-30] 08:50PM WBC-32.7# RBC-3.37# HGB-10.1# HCT-28.6 MCV-85 MCH-30.0 MCHC-35.3* RDW-14.2 [2163-8-30] 08:50PM NEUTS-7* BANDS-1 LYMPHS-10* MONOS-25* EOS-0 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 BLASTS-55* [2163-8-30] 08:50PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL [2163-8-30] 08:50PM PLT SMR-RARE PLT COUNT-14# LPLT-2+ [2163-8-30] 08:50PM PT-14.2 PTT-39.9* INR(PT)-1.3 [2163-8-30] 11:57AM WBC-18.6* RBC-2.64* HGB-8.0* HCT-24.0* MCV-91 MCH-30.4 MCHC-33.5 RDW-14.6 [2163-8-30] 11:57AM PLT COUNT-60# [2163-8-30] 11:57AM GRAN CT-1420 [2163-8-29] 04:54PM PLT COUNT-34* [2163-8-29] 11:58AM GLUCOSE-105 UREA N-14 CREAT-0.8 SODIUM-139 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15 [2163-8-29] 11:58AM ALT(SGPT)-72* AST(SGOT)-28 LD(LDH)-218 ALK PHOS-72 TOT BILI-0.4 DIR BILI-0.2 INDIR BIL-0.2 [2163-8-29] 11:58AM ALBUMIN-3.6 CALCIUM-8.7 MAGNESIUM-1.4* [2163-8-29] 11:58AM WBC-28.4# RBC-3.38 HGB-10.2* HCT-28.9* MCV-86 MCH-30.1 MCHC-35.3* RDW-13.9 [2163-8-29] 11:58AM NEUTS-5* BANDS-3 LYMPHS-20 MONOS-21* EOS-0 BASOS-0 ATYPS-4* METAS-3* MYELOS-0 BLASTS-44* [2163-8-29] 11:58AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL FRAGMENT-OCCASIONAL [2163-8-29] 11:58AM PLT COUNT-<5*# Brief Hospital Course: 25 yo male w/ refractory AML, now in blast crisis tachycardic w/ large pericardial effusion Blast crisis - bone marrow transplant attending was following the patient. It was deemed that his condition was not amenable to any treatment at this time. He was given hydroxyurea as a palliative measure. Cadiac Tamponade - was thought to arrive most likely source is a malignant effusion from tumor on the pericardium. The pericardium was likely fibrosed and treatment would involve pericardial stripping which was deemed too invasive for the patient and the family at the point of his disease. Palliative pericardiocentesis was offered to the patient but he declined. Dyspnea - He has several etiologies for his shortness of breath. leukostasis vs aspergillus vs pna. The patient was continued on levofloxacion, vancomycin, bactrim, caspofungin, and acyclovir. These were eventually dicharged as he was made palliative care. He was also maintained on Bipap in order to keep him comfortable from a respiratory standpoint. Pain control - The patient was eventually placed on a morphine drip as his code status was DNR/DNI. He was made comfort measures and passed away surrounded by his family. Discharge Disposition: Expired Discharge Diagnosis: AML Discharge Condition: deceased ICD9 Codes: 486, 2875, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7480 }	Medical Text: Admission Date: [2127-7-10] Discharge Date: [2127-7-15] Service: UROLOGY Allergies: Tylenol / Advil Attending:[First Name3 (LF) 6157] Chief Complaint: kidney stone Major Surgical or Invasive Procedure: cystoscopy with retrograde placement of a ureteral stent History of Present Illness: HPI: This is a [Age over 90 ]M with h/o of prostate hyperplasia s/p TURP x2, presents from home c/o diffuse abd pain that radiated to the RLQ. A CTU revealed and 4mm obstructing R ureteral stone + hydro. On review of systems, the pt. denied recent fever or chills. No night sweats or recent weight loss or gain. Denied headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: TURP 5 years ago at JPVA and reTURP on [2124-9-15] Bladder stone HTN R femoral hernia H/O levo resistent enterococcus uti BPH ? of PNA on CXR + tob use On CXR, appears to have COPD although no documented PFT's. Social History: live alone, not married, smokes cigars, no drug use, some EtOH Family History: n/c Physical Exam: In the ED, VS 96.6, HR 90, BP 210/92, RR16, 92% RA. . General: Elderly Male, mild distress HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: LCTA Cardiac: RR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: AAOX3, responds to questions and follows commands. Pertinent Results: [2127-7-13] 04:30AM BLOOD WBC-4.4 RBC-3.78* Hgb-11.3* Hct-33.2* MCV-88 MCH-30.0 MCHC-34.2 RDW-13.9 Plt Ct-122* [2127-7-12] 03:11AM BLOOD WBC-5.2# RBC-3.90* Hgb-11.8* Hct-34.0* MCV-87 MCH-30.2 MCHC-34.7 RDW-14.2 Plt Ct-122* [2127-7-11] 06:40AM BLOOD WBC-12.9* RBC-4.41* Hgb-13.3* Hct-37.1* MCV-84 MCH-30.1 MCHC-35.7* RDW-13.8 Plt Ct-170 [2127-7-10] 10:15PM BLOOD WBC-17.2* RBC-4.30* Hgb-12.9* Hct-37.1* MCV-86 MCH-29.9 MCHC-34.6 RDW-14.1 Plt Ct-189 [2127-7-9] 06:45PM BLOOD WBC-13.1# RBC-4.91 Hgb-14.5 Hct-41.4 MCV-84 MCH-29.5 MCHC-34.9 RDW-13.4 Plt Ct-271 [2127-7-13] 04:30AM BLOOD Plt Ct-122 [2127-7-13] 04:30AM BLOOD PT-12.7 PTT-26.3 INR(PT)-1.1 [2127-7-13] 04:30AM BLOOD Glucose-104 UreaN-39* Creat-1.1 Na-145 K-4.3 Cl-112* HCO3-24 AnGap-13 [2127-7-12] 04:29PM BLOOD Glucose-140* UreaN-40* Creat-1.2 Na-142 K-4.1 Cl-109* HCO3-25 AnGap-12 [2127-7-12] 03:11AM BLOOD Glucose-127* UreaN-43* Creat-1.4* Na-141 K-3.7 Cl-109* HCO3-22 AnGap-14 [2127-7-11] 01:26PM BLOOD Glucose-117* UreaN-44* Creat-2.0* Na-141 K-3.7 Cl-106 HCO3-23 AnGap-16 [2127-7-11] 06:40AM BLOOD Glucose-139* UreaN-43* Creat-2.4* Na-139 K-3.7 Cl-105 HCO3-21* AnGap-17 [2127-7-10] 10:15PM BLOOD Glucose-152* UreaN-37* Creat-2.2# Na-138 K-3.7 Cl-105 HCO3-21 AnGap-16 [2127-7-9] 06:45PM BLOOD Glucose-135* UreaN-18 Creat-1.1 Na-143 K-3.8 Cl-107 HCO3-25 AnGap-15 [2127-7-13] 04:30AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.2 . MICRO [2127-7-11] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; ANAEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)} INPATIENT [2127-7-10] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; ANAEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)} INPATIENT . Imaging: CT abd/pelvis [7-9] 1. 4-mm obstructing right ureteral stone with right-sided hydronephrosis and stranding around the right kidney. 2. 5-mm right lower lobe pulmonary nodule. In the absence of a known malignancy, followup in one year is recommended to ensure stability. 3. Markedly enlarged and heterogenous prostate. 4. Normal-appearing appendix within a right femoral hernia. 5. Cholelithiasis, without evidence of cholecystitis. Brief Hospital Course: In the ED, patient received CXT 1gm IV, Toradol 30mg IV, Pepcid, morphine and admitted to urology. Patient received IV hydation during HD#1, with plan for going to OR for cystoscopy. During that day, patient was noted to be increasingly tachypnic and hypoxic, Sats 96% on 2L NC. Medical consultation was obtained but patient declined further evaluation since he didn't wnat, "anymore pills." Was noted to be speaking in full sentences, and ambulating to BR without significant distress. VS at that time: TM99.5, Tc 98.1, RR27, and noted to have L>R bibasilar crackles. no CVAT. . Patient taken to the OR in am HD2 for cysto and stenting. No complications, but given the tachypnea, patient remained intubated and transfered to the [Hospital Unit Name 153]. . He spent two days in the ICU, extubating on POD1. On POD2 pt was transferred to the floor where the remainder of his hospital course was unremarkable. Pt's cultures grew out probable coag negative staph 4/4 bottles from the evening of HD1 and the morning of HD2/POD0. No other blood cultures were positive. An ID consult was obtained and a PICC was placed for a total of 14d of vancomycin. On POD3 pt failed a void trial. Pt was transferred to rehab on POD4, afebrile, tolerating a regular diet on room air. He is to finish a total of 14 days of vanco and return to Dr. [Last Name (STitle) 4229] in the clinic for follow up. Medications on Admission: Milk of Magnesia 30 ml PO Q6H:PRN Codeine Sulfate 15-30 mg PO Q4H:PRN pain Morphine Sulfate 2-4 mg IV Q4H:PRN Docusate Sodium 100 mg PO BID Pantoprazole 40 mg IV Q24H Ipratropium Bromide Neb 1 NEB IH Q6H Levofloxacin 500 mg IV Q24H Tamsulosin HCl 0.4 mg PO HS Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation: Do not give within 6 hours (before or after) the dose of Levofloxacin. Disp:qs ML(s) Refills:0 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day): take while an inpatient at rehab. Disp:90 syringe Refills:2 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. Disp:60 Capsule(s) Refills:2 6. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) piggyback Intravenous Q 12H (Every 12 Hours) for 10 days: Please check a trough in 3 days. Disp:20 piggyback Refills:0 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 MDI Refills:2 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation QID (4 times a day). Disp:1 MDI Refills:2 11. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for 2 days. Disp:6 Tablet(s) Refills:0 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. Bacitracin 500 unit/g Ointment Sig: One (1) application Topical twice a day: Please apply to glans of penis while pt has foley [Last Name (un) ] or prn. Disp:qs Refills:2 Discharge Disposition: Extended Care Facility: [Hospital ] - [Location (un) ] Discharge Diagnosis: Obstructing stone of the R ureter with sepsis secondary to UTI with obstruction. Discharge Condition: stable Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. 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. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 4229] in his office in two week's time. His office number is: [Telephone/Fax (1) 4230]. You also have an appointment with Dr. [Last Name (STitle) ] as follows: [Name6 (MD) 1037] [Name8 (MD) 5647], MD Phone:[Telephone/Fax (1) 1971] Date/Time:[2127-7-17] 1:30 Completed by:[2127-7-15] ICD9 Codes: 5990, 5849, 486, 496, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7481 }	Medical Text: Admission Date: [2148-12-7] Discharge Date: [2149-1-2] Date of Birth: [2085-7-5] Sex: F Service: SURGERY Allergies: Iodine; Iodine Containing / Trileptal / Dilantin Attending:[First Name3 (LF) 668] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: [2148-12-10]: Simultaneous liver and kidney [Month/Day/Year ] [2148-12-11]: Bronchoscopy [2148-12-24]: Ultrasound-guided right thoracentesis [2148-12-25]: Ultrasound-guided left thoracentesis. History of Present Illness: 63 yo female with polycystic kidney/liver with ESLD and ESRD on HD, h/o budd chiari, h/o ICH from ruptured [Doctor Last Name ] aneurysm, discharged on [12-5] after a prolonged hospitalization for anemia, SBP, now presents from rehab after a witnessed episode of aspiration this morning during breakfast leading to tachypnea and dyspnea. She was transported to ED and was intubated in ED because she respiratory rate was 40-50. Meanwhile, she had 100 degree in her rectum temp. ROS:: unobtainable because of sedation Past Medical History: - [Month/Day (4) 18048] (autosomal dominant w renal/liver involvement, c/b [Doctor Last Name ] aneurysmal bleed and ESRD) - ESLD with recent MELD in high 20s - multiple liver cysts - ESRD [12-31] [Month/Day (2) 18048] now s/p bilateral nephrectomies -Liver & Kidney [Month/Day (2) 1326] [2148-12-10] - subarachnoid hemorrhage 2/2 L MCA [Doctor Last Name ] aneurysm s/p surgical clipping c/b peri-operative hemorrhagic stroke resulting in right hemiparesis([2136]) - HTN - secondary hyperparathyroidism - anemia - acidosis - nephrolithiasis - stress fracture of the right ankle. - seizure disorder Social History: Had been at rehab prior to admission. At baseline, she lives with her husband in [Name (NI) 86]. Ambulates with a cane (more recently from rehab with walker). Worked as a city planner. She was transferred directly from rehab today. Smoking: denies EtOH: 1 glass of wine/day Drugs: denies Family History: Father and son with [Name (NI) 18048]. F - died in his 80s, [Name (NI) 18048] and prostate cancer M - died at [Age over 90 ] yrs of old age Sister w [Name (NI) 11398]. Physical Exam: Pt is sedated and intubated and on pressers T99 P105-119 R 16-17 BP 62-69/39 SaO2 96%40% HEENT: PREEAL, oral dry NECK: supple, no JVD, no LN Chest: clear, no wheezing CVS: regular, no murmur Abd: distent, I was unable to appreciate if pt has tender or not because pt is sedated. BS present. liver enlarged significantly. The skin in her low abd was significant red. Ext: pitting edema Lab: 129 93 51 86 AGap=19 5.6 23 2.9 CK: 65 96 16.1 8.8 321 29.8 N:84.9 L:6.2 M:6.8 E:1.6 Bas:0.5 PT: 37.9 PTT: 39.3 INR: 3.9 Pertinent Results: [2149-1-2] 07:15AM BLOOD WBC-10.6 RBC-3.40* Hgb-10.3* Hct-31.7* MCV-93 MCH-30.4 MCHC-32.5 RDW-17.3* Plt Ct-428 [2148-12-30] 05:49AM BLOOD PT-10.8 PTT-26.2 INR(PT)-0.9 [2148-12-31] 07:57AM BLOOD Glucose-119* UreaN-91* Creat-2.0* Na-135 K-4.9 Cl-101 HCO3-23 AnGap-16 [2149-1-1] 05:40AM BLOOD Glucose-95 UreaN-95* Creat-1.9* Na-135 K-5.1 Cl-102 HCO3-23 AnGap-15 [2149-1-2] 07:15AM BLOOD Glucose-95 UreaN-95* Creat-1.8* Na-140 K-5.6* Cl-107 HCO3-22 AnGap-17 [2149-1-1] 05:40AM BLOOD ALT-11 AST-16 AlkPhos-111* TotBili-0.9 [2149-1-2] 07:15AM BLOOD ALT-9 AST-17 AlkPhos-110* TotBili-0.9 [2149-1-2] 07:15AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.9 [2148-12-30] 05:49AM BLOOD calTIBC-166* Ferritn-GREATER TH TRF-128* [2148-12-19] 02:15AM BLOOD TSH-27* [2148-12-19] 02:15AM BLOOD T4-3.0* T3-61* Brief Hospital Course: Hypotension and respiratory distress were most likely 2nd to aspiration vs sepsis vs pulmonary edema. Pt was intubated and on started on antibiotics. She was treated with improvement in the MICU. On [2148-12-10], a liver and kidney donor became available. She was cleared for surgery. On [12-10], a liver was transplanted by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Attempt was made to do a splenectomy prior to the renal [Last Name (NamePattern1) ], but this was too difficult secondary to the extremely large polycystic liver wrapped around the spleen. She was very coagulopathic. Bleeding was controlled then a renal [Last Name (NamePattern1) ] was performed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] with a 6-French double-J stent inserted into the ureter and a JP drain. Drains were also placed posterior to the liver and at the hilum as well as in the splenic bed. Induction immunosuppression was administered consiting of ATG, cellcept and steroids. Postop, she was transferred to the SICU for management. Postop course was complicated requirining CVVH for delayed renal graft function. LFTs trended down immediately. Duplex of the liver was appropriate. Renal duplex US demonstrated lack of diastolic flow of the interpolar arteries, with an RI of 1. There was flow within the main renal vein. She experienced ATN. She failed to extubate and a trache was considered, but eventually with improving renal/liver function, she managed to extubate on ***. Of note, on [12-19], TSH was noted to be 27, T3 61 and T4 3.0. Levothyroxine was increased. She remained tachypneic and short of breath. On [12-11], a bronchoscopy was performed as she has aspirated bilious appearing emesis. BAL was performed in the anterior segment of the left upper lobe. Twenty ml of greenish aspirate was obtained. Culture grew 10-100,000 colonies of Enterobacter Cloacae. She was treated with Cipro for 14 days from [Date range (1) ]. Vancomycin was administered from [12-10] thru [12-17]. Micafungin was administered from [12-11] trough [12-25] for antifungal coverage per [Month/Year (2) ] protocol. On [12-15], a CVL was removed to simplify lines. Tip was sent for culture and grew VRE. Linezolid was started on [12-18] until stop date [12-30]. CXR demonstrated bilateral pleural effusions with right greater than left. On [12-24], a right thoracentesis was done removing 1.5 liters. This fluid was cultured and had no growth. A left thoracentesis was done on [12-25] for 1100ml. This also had no growth on culture. Respiratory status improved with room air sats of 99%. Respiratory rate averaged 20 bpm. BP ranged between 130/90-145/100. She was mantained on lopressor. CVVHD was continued during most of her SICU stay. As urine output increased, CVVHD was stopped on [12-26]. Creatinine averaged 0.6 on dialysis. Once off CVVHD, creatinine increased to 2.0 on [12-30]. By [1-2], creatinine had decreased to 1.8 with daily urine output averaging 2.9 liters/day on Lasix. A daily dose of oral Lasix was prescribed. Florinef was added on [12-30] for hyperkalemia. On [12-30], she was transfused with 2 units of PRBC for a hct of 23.3. Immunosuppression consisted of ATG (75mg each dose x3 doses), cellcept and steroid taper. Prograf was initiated on postop day 2 and adjusted daily per trough levels with goal achieved. Goal prograf was 10. On [12-28], she transferred out of the SICU to the Med [Doctor First Name ] Unit. Preop, she was very debilitated with muscle wasting. Postop, she was more so and required PT. A [Doctor Last Name ] lift was recommended for transfers. Rehab was recommended. Diet was poorly tolerated and nasojejeunal tube feedings were administered using Novasource Renal. She did have some diarrhea. Stools were negative for C.diff. Cellcept dosing was adjusted to qid with decreased GI side effects. On [12-26], a speech and swallow evaluation was completed without s/sx of aspiration at bedside. She appeared safe for initiation of regular diet, thin liquids, pills whole with thin. Energy level improved overall although she is still very debilitated. She will transfer to [Hospital3 ] in [Hospital1 8] with twice weekly lab monitoring. Tunnelled HD line should be flushed with saline/heparin every 2-3 days as she is currently off dialysis. Immunosuppression should be managed only by the [Hospital1 1326] Service at [Hospital1 18]. A TSH should be repeated in [3-4] weeks as Levoxyl was increased on [12-19]. Medications on Admission: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for diaper rash. 10. Clotrimazole 1 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for diaper rash . 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours): Must give standing, and even wake out of bed for this overnight. 12. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO DAILY (Daily): Please titrate to [1-31] bowel movements daily. 15. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO Once Daily at 4 PM: Monitor INR at least once weekly while taking this medication. 17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 18. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q 8H (Every 8 Hours): Must give standing, and even wake out of bed for this overnight. 19. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours): Patient has been receiving this standing in the days prior to discharge, as has been frequently SOB. Must give standing, and even wake out of bed for this overnight. 20. Heparin (Porcine) 1,000 unit/mL Solution Sig: One (1) flush Injection PRN (as needed) as needed for line flush: Withdraw 4 ml prior to flushing with 10 mL NS followed by heparin as above. 21. Medication Critic-Aid - apply in morning to buttocks and prn throughout the day as needed to maintain seal Discharge Medications: 1. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. 2. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. 3. Florinef 0.1 mg Tablet Sig: One (1) Tablet PO Monday-Weds-[Month/Day (1) 2974]. 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 7. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection ASDIR (AS DIRECTED): see printed scale. 8. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing/SOB. 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 12. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): follow taper. 15. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for sbp <110 or HR <60. 19. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea/vomiting. 20. Dextrose 50% in Water (D50W) Syringe Sig: 12.5 gm Intravenous PRN (as needed) as needed for hypoglycemia protocol. Discharge Disposition: Extended Care Facility: [Hospital1 ] - [Hospital1 8] Discharge Diagnosis: [Hospital1 18048] s/p liver/kidney txp Delayed renal graft function [12-31] ATN Hypothyroidism Pleural effusions Discharge Condition: Stable/Fair A+Ox3 Ambulatory status: requires intensive rehab Discharge Instructions: Please call the [Month/Day (2) ] clinic at [Telephone/Fax (1) 673] for fever, chills, nausea, vomiting, diarrhea, constipation, inability to take or keep down food, fluids or medications, jaundice, decreased urine output, weight gain of 3 pounds in a day, pain over liver/kidney [Telephone/Fax (1) ]. Call if there are problems with the post pyloric feeding tube or intolerance to the tube feeds such as diarrhea Labwork every Monday and Thursday with results faxed to [Telephone/Fax (1) ] clinic at [Telephone/Fax (1) 697]. Monitor the incision for redness, drainage or bleeding Monitor urine output daily and keep record to send with patient to clinic. Followup Instructions: [Last Name (LF) ],[First Name3 (LF) 156] [First Name3 (LF) ] SOCIAL WORK Date/Time:[2149-1-9] 2:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2149-1-9] 3:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2149-1-16] 3:40 Completed by:[2149-1-2**] ICD9 Codes: 5070, 5856, 5845, 2761, 5119, 2449, 5715
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7482 }	Medical Text: Admission Date: [2111-10-16] Discharge Date: [2111-10-20] Date of Birth: [2051-12-5] Sex: M Service: MEDICINE Allergies: Codeine / Percocet Attending:[First Name3 (LF) 1145] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization with stenting History of Present Illness: Mr. [Known lastname 24214] is a 59 yo man with history of HTN and s/p renal transplant for polycystic kidney disease who presenting with substernal crushing chest pressure that began while building a gazebo. When the pain failed to subside with rest, he went to [Hospital1 18] ED. In the emergency room, he was diaphoretic with blood pressure 114/70, pulse 70, respiratory rate 16, and oxygen saturation 100% on room air. He was given full dose aspirin and EKG showedhyperacute t-waves, questionable ST changes. Repeat EKG showed ST elevations V3-V5, and the patient was taken to cath lab. In the cath lab, Mr. [Known lastname 24214] was found to have 90% lesion of LAD with thrombus at D1, and a 70% lesion with filling defect after D2. He was stented with 2 overlapping Diver bare metal stents with normal flow. Subsequently, he did have marked oozing around femoral sheath; the sheath was upsized and integrilin was stopped with good effect. The patient was admitted to the CCU for further care. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Does note slightly increased DOE over the past few weeks. He does note feeling lightheaded over the past few days, and attributed this to working in the heat. Past Medical History: 1. polycystic kidney disease, s/p R-sided transplant in [2103] 2. HTN 3. Anemia- prior to kidney transplant Social History: Mr. [Known lastname 24214] is a prior smoker of 44 pack years. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. His mother died from brain cancer, and his father died from cirrhosis. Physical Exam: Exam in CCU Vital signs Gen: Lying flat, appears well, NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, unable to assess JVP secondary to positioning CV: PMI non-displaced, normal s1/s2, no murmurs, rubs, or gallops Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: soft, NTND, no tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: mild stasis dermatitis, no ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [2111-10-16] 02:00PM WBC-9.6 RBC-3.81# HGB-8.5# HCT-27.5# MCV-72# MCH-22.3# MCHC-30.8 RDW-17.6* [2111-10-16] 02:00PM NEUTS-76.3* LYMPHS-15.6* MONOS-6.7 EOS-1.2 BASOS-0.2 [2111-10-16] 02:00PM PLT COUNT-361# [2111-10-16] 02:00PM PT-13.5* PTT-26.8 INR(PT)-1.2* [2111-10-16] 02:00PM RET AUT-1.7 [2111-10-16] 02:00PM calTIBC-333 HAPTOGLOB-207* FERRITIN-17* TRF-256 [2111-10-16] 02:00PM CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-2.1 IRON-15* [2111-10-16] 02:00PM CK-MB-4 [2111-10-16] 02:00PM cTropnT-<0.01 [2111-10-16] 02:00PM LD(LDH)-187 CK(CPK)-140 TOT BILI-0.8 [2111-10-16] 09:23PM CK(CPK)-3349* [2111-10-16] 09:23PM CK-MB-387* MB INDX-11.6* [2111-10-16] 02:54PM TYPE-ART O2 FLOW-3 PO2-122* PCO2-32* PH-7.45 TOTAL CO2-23 BASE XS-0 COMMENTS-NASAL [Last Name (un) 154] . CATH [2111-10-16]: 90% lesion of LAD with thrombus at D1, 70% lesion with filling defect after D2. 60% stenosis of RCA. . TTE [2111-10-17] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 11-15mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with septal, anterior, distal LV/apical akinesis. The remaining segments are hyperdynamic. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. EF 30% . CXR [2111-10-16] Left costophrenic sulcus is excluded from the radiograph, precluding assessment of small left pleural effusion. Right cardiophrenic angle is clear. The heart is mildly enlarged and there is mild CHF with vascular engorgement and minimal interstitial pulmonary edema. . Lower extremity ultrasound [2111-10-19] IMPRESSION: No evidence of DVT on the left or right legs. . CXR [2111-10-19] 1. No evidence of CHF. 2. Small focal patchy opacity in the anterior aspect of one of the lower lobes seen only on lateral view. This may be due to atelectasis or early focus of infection. Followup radiographs may be helpful in this regard. . Microbiology [2111-10-18] urine culture: NEGATIVE [2111-10-18] blood culture: no growth as of [2111-10-20] Brief Hospital Course: 1. STEMI - The patient underwent bare metal stent placement of his LAD. He continued his beta blocker and was started on high dose statin, plavix, and aspirin. We added a low dose ACE inhibitor as well after discussion with his outpatient nephrologist Dr. [First Name (STitle) 805]. He will follow up with cardiology clinic on [2111-11-2]. A repeat TTE to assess LV function should be done in [5-15] weeks from discharge. . 2. Fever - Mr. [Known lastname 24214] developed a fever to 102 with chest film showing question of retrocardiac infiltrate. Although he had minimal symptoms, given his immunosuppression his team felt that he should receive empiric treatment for pneumonia. He was started on ceftriaxone and azithromycin, and will complete a 7 day course of cefpodoxime and azithromycin. He knows to seek medical attention should he develop worsening fevers, chills, or coughing at home. He did also have lower extremity ultrasound studies to assess for DVT as the cause of his fevers; this study showed no evidence of DVT. His urine culture from [10-18] was negative, and his blood culture from [10-18] was negative as of the date of discharge [10-20]. . 3. CRI s/p renal transplant - The patient continued his home immunosuppressants. . 4. Microcytic anemia - The patient had iron studies suggestive of iron-deficiency anemia. He was started on iron supplements. He will need followup endoscopy as an outpatient to assess for sources of gastrointestinal bleeding. . Code: The patient was full code Medications on Admission: cellcept [Pager number ] mg PO BID cartia 300 mg PO daily gengraf 75 mg PO BID prednisone 5 mg PO daily metoprolol 50 mg PO BID lasix 40 mg PO daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gengraf 25 mg Capsule Sig: Three (3) Capsule PO twice a day. 7. CellCept [Pager number ] mg Tablet Sig: One (1) Tablet PO twice a day. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 11. Azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 12. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 13. Outpatient Lab Work Please have blood drawn for a complete metabolic panel (including potassium, creatinine, and BUN) in one week and have the results sent to your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 24215] ([Telephone/Fax (1) 24216]) and Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 4022]) Discharge Disposition: Home Discharge Diagnosis: 1. Myocardial infarction 2. Iron deficiency anemia 3. Pneumonia Discharge Condition: good Discharge Instructions: You came to the hospital after developing chest discomfort. This was caused by a heart attack. You had a stent placed in one of the arteries supplying your heart. Please be sure to take all of your medicines as directed and follow up with both your primary care doctor and your cardiologist. Please do not stop taking aspirin or Plavix unless told to do so by your cardiologist. While in the hospital, you had some fevers and sweats that may have been due to pneumonia. Please continue to take the entire course of antibiotics as directed even if you are feeling well. You have an iron-deficiency anemia. It is very important that you let your doctor know about this. You will need a colonoscopy as an outpatient to further address this anemia. Call your doctor or seek medical attention at once if you develop: Recurrent chest discomfort that is severe or persistent, shortness of breath, lightheadedness, fevers, shaking chills, sweats, worsened cough, or other symptoms that worry you Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD Phone:[Telephone/Fax (1) 4022] Date/Time:[2111-11-2] 1:40 Please follow up with your primary care doctor [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 24215] at [Hospital ] Medical Group ([Telephone/Fax (1) 24217] on Monday [10-26**] at 2pm. Please bring all new medications with you, so that they can be entered into the Caritas records. ICD9 Codes: 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7483 }	Medical Text: Admission Date: [2145-10-27] Discharge Date: [2145-11-13] Date of Birth: [2082-10-25] Sex: M Service: MEDICINE CHIEF COMPLAINT: Fever. HISTORY OF PRESENT ILLNESS: This is a 63 year old primarily Spanish speaking male with a history of end-stage renal disease secondary to diabetes mellitus on dialysis. The patient also has a history of coronary artery disease, chronic obstructive pulmonary disease, recurrent Methicillin resistant Staphylococcus aureus/VRE dialysis catheter infection and status post Methicillin resistant Staphylococcus aureus epidural abscess of L2 to 3, status post incision and drainage in [2144-7-15]. The patient is now here from his outpatient hemodialysis center with a fever up to 103.3 F., lethargy and back pain. Per the hemodialysis center notes the patient had a temperature the previous night at home, however, he was afebrile at the beginning of his hemodialysis session. The patient was given Tylenol for his back pain which did not help. The patient also complained of increased back pain. His pain was mostly between the shoulders. Temperature came down to 101.8 F. Blood cultures were drawn times two. The patient was given one gram of Kefzol and 80 mg of intravenous Gentamicin and sent to the [Hospital1 69] Emergency Department. At [Hospital1 69], the patient was given 1 gram of Vancomycin and 2 grams of ceftriaxone. A lumbar puncture was performed. A head CT scan was performed and was negative. The patient received about a liter of intravenous fluids. Initially, the patient was only minimally responsive and could only open his eyes, however, he quickly perked up and after the antibiotics, he was alert and oriented times three. He complained of mild headache, mostly bifrontal and mild neck pain as well as the thoracic back pain. The patient denied any chest pain or shortness of breath. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis. 2. Diabetes mellitus, non-insulin dependent. 3. Chronic obstructive pulmonary disease. 4. One vessel coronary artery disease, status post catheterization in [8-/2145]; status post left circumflex percutaneous transluminal coronary angioplasty and stent. 5. Congestive heart failure. 6. History of Methicillin resistant Staphylococcus aureus L2 to 3 epidural abscess with incision and drainage in [2144-7-15]. 7. Recurrent line infections with Methicillin resistant Staphylococcus aureus, VRE and Klebsiella. 8. Thrombosis in right internal jugular, right subclavian and right brachiocephalic veins in 10/[2144]. 9. Peptic ulcer disease. 10. Hypertension. 11. History of medication noncompliance. MEDICATIONS ON ADMISSION: 1. Epogen. 2. Coumadin 4 mg p.o. q. day. 3. Ambien 5 mg q. h.s. 4. Amitriptyline 25 mg p.o. q. day. 5. Protonix 40 mg p.o. q. day. 6. Aspirin 325 mg p.o. q. day. 7. Plavix 75 mg p.o. q. day. 8. Norvasc 10 mg p.o. q. day. 9. Enalapril 20 mg p.o. q. day. 10. Metoprolol 25 mg p.o. three times a day. 11. Tylenol p.r.n. 12. Senna p.r.n. 13. Colace p.r.n. 14. Tums with meals. 15. Regular insulin sliding scale. SOCIAL HISTORY: The patient is married and is a nonsmoker and nondrinker. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Temperature 103.2 F.; blood pressure 128/44; pulse 88; respiratory rate 14; O2 saturation 100% on two liters. In general, the patient is alert and oriented times three in no apparent distress. HEENT: Oropharynx clear; anicteric. Pupils equally round and reactive to light and accommodation. Extraocular movements are intact. Neck supple; no lymphadenopathy. Generalized plethora and edema of neck. Cardiovascular: Regular rate and rhythm, no murmurs, gallops or rubs. Lungs are clear to auscultation bilaterally. Chest: Left sided Quinton dialysis catheter without any surrounding erythema or exudate, nontender. Back with no costovertebral angle tenderness. Minimal paraspinal thoracic tenderness to palpation. Extremities: Cachectic; no cyanosis, clubbing or edema. Left sided AV fistula with positive thrill. Abdomen soft, nontender, nondistended. Normoactive bowel sounds. No hepatosplenomegaly, masses or bruits. Neurologic: Alert and oriented times three. No focal signs. LABORATORY: White blood cell count 14.7 with a differential of 92% neutrophils, 11% lymphocytes, hematocrit 34.3, platelets 127, sodium 141, potassium 3.5, chloride 99, bicarbonate 27, BUN 25, creatinine 3.5, glucose 224. CK 22, PT 16.4, PTT 42.7, INR 1.8. Lumbar puncture tube #1, 9 white blood cells with 6% polys, 48% lymphocytes, 46% monocytes, 18 red blood cells. Glucose 173. Tube #2, white blood cells 9 with a differential of 2% polys, 51% lymphocytes, 47% monocytes, 3 red blood cells and a protein of 37. Chest x-ray with poor inspiration, diffuse haziness but no focal infiltrates. Head CT scan with no evidence of bleeding or masses. EKG with normal sinus rhythm at 99 beats per minute. T wave inversions in I and AVL, [Street Address(2) 4793] depressions with T wave inversions in V4 through V6. Biphasic T waves in V2 to V3. No old electrocardiograms accessible for comparison. HOSPITAL COURSE: In short, this is a 63 year old Spanish speaking male with a history of end-stage renal disease on hemodialysis, diabetes mellitus, coronary artery disease status post left circumflex stent, chronic obstructive pulmonary disease, history of recurrent dialysis catheter infections with Methicillin resistant Staphylococcus aureus and VRE, and history of Methicillin resistant Staphylococcus aureus epidural abscess, who now presents with fever, lethargy, back pain and headache. 1. INFECTIOUS DISEASE: The patient did not have any further high spikes after being admitted. He had only low spikes for a couple of days and then was afebrile afterwards. The patient had blood cultures drawn in the Emergency Department. These were negative without any growth. The patient's fever was presumed to be secondary to his left sided Quinton catheter, even though it did not show any obvious signs of infection. The patient was kept on a regimen of Vancomycin and Gentamicin for broad coverage. Of note, the patient's blood cultures from his dialysis center were found to be positive, growing four out of four tubes of Methicillin sensitive Staphylococcus aureus. This was found to be overall pan sensitive, only resistant to penicillin, Ampicillin and tetracycline. However, the MIC was only low for oxacillin at a level of 0.25. For this reason, the patient was switched from Vancomycin and Gentamicin to intravenous Oxacillin at a dose of 1 gram q. four hours. His Quinton dialysis line was pulled after dialysis was started with his left AV fistula. The Quinton tip also grew Methicillin sensitive Staphylococcus aureus. The patient was unable to have a right sided PICC line placed because of the extensive network of clots in his right internal jugular, subclavian and brachiocephalic veins. However, a midline catheter was successfully placed on [11-4]. The patient was continued on intravenous Oxacillin. Because the patient was also having back pain, and given his history of an epidural abscess, there was a concern that he might have seeded his vertebrae, thus causing osteomyelitis. The patient received an MRI of the spine. This was negative for an epidural abscess, but did show increased signal and paravertebral swelling anterior to C3 through 5, suspicious for osteomyelitis. Even though this is not the area where the patient was having pain, it was decided that the patient should be treated for presumed osteomyelitis for a total of six weeks on antibiotics. Given that the patient was bacteremic with Methicillin sensitive Staphylococcus aureus, there was also concern that he may have seeded his heart valves. The patient had a transthoracic echocardiogram a couple of days after admission. This showed low normal left ventricular ejection fraction, small ASD, but only mild mitral regurgitation and no change in his valves. A transesophageal echocardiogram was planned for [11-4], but during the procedure, the patient was unable to tolerate the tube and therefore it was aborted. 2. ACCESS: As already noted, the patient came in with a left sided Quinton catheter. He also had an AV fistula with a positive thrill that had been placed in [2145-7-15], but had not been used yet. The Quinton catheter was taken out after the AV fistula was tested and found to be usable. A midline catheter was placed in the right side for intravenous antibiotics. Unfortunately, after a couple of sessions of dialysis, it was realized that there was not good blood flow going through the left sided AV fistula. The patient initially had an AV fistula ultrasound and then an AV fistulogram. This revealed the stenosis between the arterial and venous components. The patient had an angioplasty to open up the AV fistula. This was performed by Transplant Surgery. As a temporary measure, the patient received a central line for dialysis through his left sided EJ. Transplant Surgery's recommendation was to leave the AV fistula alone for one to two weeks following the angioplasty and then to retest it. 3. CARDIOVASCULAR: The patient's initial presentation had some concerning T wave and ST changes on his EKG even though an old EKG was not accessible. The patient was ruled out by serial cardiac enzymes. He had no episodes of chest pain or shortness of breath. The patient was kept on his regimen of aspirin, Plavix, Lopressor, and Enalapril for cardiac health. The patient also received a Nitroglycerin patch. 4. HEMATOLOGIC: The patient has a history of right sided clots in his internal jugular, subclavian, brachiocephalic veins; for this reason, he is on anticoagulation. Because of all the interventional procedures performed, the patient was mostly off of Coumadin, but was kept on a heparin drip towards the end of his stay. We were just waiting for his Coumadin to become therapeutic. He was placed on 7.5 mg of Coumadin. His INR on [2145-11-12], was 1.6. It was expected to become therapeutic by [2145-11-13], with a goal range of probably between 2.0 to 3.0. 5. RENAL: The patient is followed closely by the Renal Team. He received hemodialysis every Monday, Wednesday and Friday. There were no further complications during hemodialysis including fever, hypotension, or volume overload. CONDITION AT DISCHARGE: Good. DISCHARGE MEDICATIONS: 1. Coumadin 7.5 mg p.o. q. day. 2. Calcium carbonate 1000 mg p.o. three times a day, taken with meals. 3. Oxacillin 1 gram intravenous q. four hours, to be taken until [2145-12-13]. 4. Sarna lotion, one application topically twice a day p.r.n. 5. Nitroglycerin Ointment 2%, 0.5 inches topically q. six hours. 6. Ambien 5 mg p.o. q. h.s. p.r.n. 7. Percocet one tablet p.o. q. four to six hours p.r.n. back pain. 8. Nitroglycerin 0.3 mg sublingually p.r.n. chest pain. 9. Milk of Magnesia 15 to 30 ml p.o. four times a day p.r.n. 10. Bisacodyl 10 mg p.o./p.r. q. day p.r.n. 11. Lopressor 100 mg p.o. three times a day; hold for systolic blood pressure less than 100, pulse less than 60. 12. Norvasc 10 mg p.o. q. day. 13. Enalapril 20 mg p.o. q. day. 14. Plavix 75 mg p.o. q. day. 15. Enteric coated aspirin 325 mg p.o. q. day. 16. Protonix 40 mg p.o. q. 24 hours. 17. Amitriptyline 25 mg p.o. q. h.s. 18. Colace 100 mg p.o. twice a day. 19. Senna two tablets p.o. q. day. 20. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n. 21. Lantus 15 units subcutaneously q. a.m. 22. Regular insulin sliding scale. DISCHARGE INSTRUCTIONS: 1. The patient is to be discharged to East Point Rehabilitation once his INR is within therapeutic range. 2. The patient will follow-up with his renal doctors. 3. The patient will continue to receive hemodialysis every Monday, Wednesday and Friday. 4. The patient will also need to be seen for removal of his temporary external jugular dialysis catheter once his AV fistula is retested and working again. DISCHARGE DIAGNOSES: 1. Methicillin sensitive Staphylococcus aureus bacteremia, now resolved. 2. Osteomyelitis. 3. End-stage renal disease on hemodialysis. 4. Diabetes mellitus. 5. Coronary artery disease, status post left circumflex stent. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Name8 (MD) 3839] MEDQUIST36 D: [2145-11-12] 13:40 T: [2145-11-12] 13:49 JOB#: [Job Number 34027] ICD9 Codes: 7907, 496, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7484 }	Medical Text: Admission Date: [2157-11-13] Discharge Date: [2157-11-25] Date of Birth: [2105-6-23] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: hypotension and hypoxia Major Surgical or Invasive Procedure: VATS History of Present Illness: 52yo man with history of Rheumatoid arthritis on gold injections, hepatitis C, and pulmonary fibrosis was trasferred from [Hospital6 204] for worsening dyspnea/hypoxemia and for potential lung biopsy. He was admitted there on [2157-11-7] where he presented after one to two weeks of chills and low grade fevers with progressive shortness of breath. This is in the setting of previously asymptomatic chest CT findings dating back to [8-28] with nodules, scarring, and chest/abdominal lymphadenopathy. His initial ABG was 7.49/34/65/94% on 4L nc. His CT chest demonstrated multiple abnormal findings with evidence of bullous disease, honeycombing in the bases and a mosaic pattern of interstitial infiltrates. He reportedly was presented options of going for lung biopsy or having an empiric course of corticosteroids at that time. He opted for empiric steroid treatment. . His hospital course was notable for worsening dyspnea to the point of not being able to speak in sentences and progressive hypoxemia. He was admitted on room air, and steadily progressed to 40% mask -> 100% NRB with oxygen saturation of 95%; ABG demonstrated 7.53/27/65. Throughout his hospital course, he remained afebrile. He was initially treated with ceftriaxone and azithromycin. This was later tapered down to only azithromycin. Chest films did not show any evidence of focal consolidation. Rather, they demonstrated bilateral ground glass opacities. . In [Hospital Unit Name 153] respiratory status was monitored and intubated yesterday for progressive hypoxia and in anticipation of VATS for lung biopsy and bronch today. While in OR today developed increasing hypoxia and difficulty oxygenating, Swan was attempted unsuccessfully and Right IJ cordis was placed. Eventually thick secretions were noted in ETT which was pulled and a LMA was placed for airway support. He was then transferred to ICU for further management. Here is ventilated on AC 600/30/10/100%FiO2. Preliminary pathology on biopsy results is consistent with dense fibrosis. He is currently on Propofol gtt and appears comfortable. . Past Medical History: 1. Rheumatoid arthritis - on gold treatments; last was few weeks ago 2. Hepatitis C 3. Pulmonary fibrosis 4. Epilepsy - first diagnosed as a child; ? trauma 5. h/o Lyme disease 6. h/o anal fissure repair 7. distant etoh abuse 8. right knee surgery 9. By report, normal pulmonary function tests and TTE in [7-30]. Social History: Notable for smoking history and occupational exposure to concrete (works in swimming pool business). About 50pack year smoking history. . Family History: NC Physical Exam: gen: sedated, nad heent: perrl, MMM, LMA in place neck: right IJ cordis in place cv: RRR, tachy, no murmurs resp: CTAB with diffuse bilateral crackles abd: soft, NT/ND, +BS extr: no edema Pertinent Results: [2157-11-14] 01:54AM BLOOD WBC-10.1 RBC-3.69* Hgb-10.8* Hct-32.3* MCV-88 MCH-29.3 MCHC-33.4 RDW-12.7 Plt Ct-439 [2157-11-14] 01:54AM BLOOD Neuts-83.7* Lymphs-12.5* Monos-2.6 Eos-1.2 Baso-0.1 [2157-11-14] 01:54AM BLOOD PT-12.9 PTT-24.4 INR(PT)-1.1 [2157-11-14] 01:54AM BLOOD Glucose-107* UreaN-17 Creat-0.8 Na-140 K-4.4 Cl-103 HCO3-28 AnGap-13 [2157-11-17] 05:15PM BLOOD ALT-93* AST-40 LD(LDH)-385* AlkPhos-109 TotBili-0.2 [2157-11-14] 01:54AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.4 [2157-11-15] 04:45AM BLOOD calTIBC-165* Ferritn-277 TRF-127* [2157-11-17] 05:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2157-11-17] 05:15PM BLOOD ANCA-NEGATIVE B [2157-11-17] 05:15PM BLOOD C3-171 C4-39 [2157-11-17] 05:15PM BLOOD RheuFac-101* [2157-11-19] 04:26AM BLOOD HIV Ab-NEGATIVE [2157-11-18] 06:36PM BLOOD Glucose-172* Lactate-1.6 Na-133* K-4.8 Cl-95* Brief Hospital Course: 52yo man with history of RA, hepatitis C, and pulmonary fibrosis of uncertain etiology admitted to MICU with progressive hypoxia after VATS. Progressive hypoxia secondary to pulmonary fibrosis and worsening hypoxia despite maximum oxigenation. Pt was continued on supportive O2 ventilation with paralysis. Complicating matters. patient with growing pneumothorax after VATS requiring re-initiation of chest tube to suction. Biopsy pathology demonstrated change consistent with organizing stage of diffuse alveolar damage, possibly complicating a bacterial/viral infection, over a background of chronic interstitial lung disease. In workup echo remarkable for right to left interatrial shunt; which under consultation from cardiology felt to be of little clinical significance as well as Pt not being a candidate for closure. Given patient's disease process, only potential "cure" would be heart lung transplant but patient a poor candidate, contributing to very poor prognosis. Family meeting held where goals of care were discussed. Pt made CMO and transplant service consulted for possible candidancy. Pt was taken off ventilatory support and died shortly thereafter. Patient subsequently taken to the OR for organ harvest. Medications on Admission: Medications on transfer: Humibid DM 1 po BID Tolmetin 600mg po BID Lovenox 40mg daily protonix 40mg daily Zithromax 250mg qD Prednisone 60mg daily Regular insulin sliding scale . Medications from [Hospital Unit Name 153]: Methylprednisolone Na Succ 50 mg IV BID Midazolam HCl 0.5-2 mg/hr IV DRIP TITRATE TO sedation Acetaminophen 325-650 mg PO Q4-6H:PRN Morphine Sulfate 0.5-2 mg IV Q3-4H:PRN Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Pantoprazole 40 mg IV Q24H Heparin 5000 UNIT SC TID Ibuprofen 400 mg PO Q8H:PRN Sodium Chloride Nasal [11-28] SPRY NU QID:PRN Insulin SC Sliding Scale Sulfameth/Trimethoprim 370 mg IV Q8H Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Pulmonary fibrosis Hepatitis C Rheumatoid arthritis Discharge Condition: deceased Discharge Instructions: N.A. Followup Instructions: N.A. ICD9 Codes: 486, 4168, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7485 }	Medical Text: Admission Date: [2199-11-17] Discharge Date: [2199-11-26] Date of Birth: [2120-3-31] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Called by Emergency Department to evaluate ICH Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 79-year-old right-handed man with a history of Left CEA on [2199-11-12] who presents with acute onset language impairment, found to have a left occipital hemorrhage. The history begins on the weekend before [Holiday 1451], about 3 weeks prior to this. He was at that time driving alone on the [Location (un) 81675] and went off the road. Apparently, it's thought that he lost consciousness, causing him to lose control. When EMS found him, he was awake, but reportedly "confused" and has no memory of the events for several hours after the event. Based on this, he was apparently diagnosed with a TIA. In the work-up for the TIA, he was found to have 98% stenosis of his right carotid and at least 90% of the left. He underwent RIGHT CEA shortly thereafter, and had a LEFT CEA performed on [2199-11-12], both at [Hospital1 ]. After this second CEA he was doing well except for some constipation. This afternoon, he told his wife he was not feeling well (not further elaborated on) and went quickly to the bathroom. He apparently had a bowel movement, but was in the bathroom for a while. His wife called for him, but initially got no answer. He then flushed the toilet and came out of the bathroom on his own, but said nothing to his wife, only [Name2 (NI) 27723] at her. His wife believes he did not understand what she was saying to him, as he was not doing as she asked. She led him to bed. She noted that he was "wobbling" back and forth, but did not run in to anything. She called her daughter, his doctor, and then EMS. EMS found his initial BP in the field to be 240/110. He was taken by EMS to [Hospital1 ], where a head CT showed a hyperdensity in the left occipital lobe about 1 cm x 0.5 cm, surrounded by hypodensity. HIs maximum BP was 270/150, and he received 10 mg labetalol. He was seen by a neurologist, who noted right eye deviation and thought he was having a seizure, so the pt received Dilantin 1.6 g IV. He developed "son[Name (NI) 7884] respirations" and was intubated, receiving Ativan 0.5 mg, Etomidate 20 mg/Succ 80 mg/Lidocaine 100 mg/Vecuronium 12 mg at [2100], 2 mg Versed, and 2 mg Morphine. After administration of all this medication, his BP dropped into the 80s systolic, coming up when propofol was held for a few minutes. In our ED, he received propofol gtt and Tylenol 650 mg PR for fever to 101.4. Formal ROS is not possible; per his wife, he was not complaining of anything other than constipation Past Medical History: Motor vehicle accident ~[2199-10-26] due to LOC Diagnosed with "TIA" after losing consciousness while driving (no known focal features, so unclear what this diagnosis was based on) s/p RIGHT CEA late [2199-10-5] s/p LEFT CEA [2199-11-12] HTN DM2 Gout Report by family that he has a renal cyst(?) seen on torso CT at time of MVA trauma work-up. Social History: Former smoker but quit many years ago. No EtOH use. Former jewelry salesman. Family History: NC Physical Exam: Vitals: T: 99.3 (101.4 max) P: 91 R: 16 BP: 157/80 (83/50-175/93) SaO2: 100% AC General: Intubated, off propofol for 10 minutes. HEENT: Anicteric. Surgical wound on left neck with surrounding edema and erythema, tense to palpation. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Neurologic: -Mental Status: Opens eyes to voice, follows one-step commands, but grossly inattentive, requiring frequent stimulation. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1.5mm. Appears not to blink to threat. III, IV, VI: EOMI without nystagmus. V: Not tested. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to voice. IX, X: Intubated, gag intact. [Doctor First Name 81]: Not tested. XII: Not tested. -Motor: Normal bulk throughout. Slightly spastic tone in B LEs. Does not cooperate with FST but moves all extremities antigravity with apparently equal vigor. -Sensory: Withdraws from light touch in all 4 ext. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 1 1 1 0 R 2 1 1 1 0 Plantar response was flexor bilaterally. -Coordination & Gait: Could not be tested due to patient's somnolence. Pertinent Results: [2199-11-17] 07:39AM GLUCOSE-211* UREA N-23* CREAT-1.2 SODIUM-142 POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-33* ANION GAP-14 [2199-11-17] 07:39AM CK(CPK)-64 [2199-11-17] 07:39AM CK-MB-NotDone cTropnT-0.11* [2199-11-17] 07:39AM CALCIUM-9.1 PHOSPHATE-4.3 MAGNESIUM-1.9 CHOLEST-162 [2199-11-17] 07:39AM %HbA1c-6.3* [2199-11-17] 07:39AM TRIGLYCER-160* HDL CHOL-42 CHOL/HDL-3.9 LDL(CALC)-88 [2199-11-17] 07:39AM OSMOLAL-300 [2199-11-17] 07:39AM PHENYTOIN-4.8* [2199-11-17] 07:39AM WBC-10.5 RBC-3.35* HGB-11.4* HCT-30.8* MCV-92 MCH-34.1* MCHC-37.0* RDW-13.5 [2199-11-17] 07:39AM PLT COUNT-256 [2199-11-16] 10:46PM GLUCOSE-187* UREA N-21* CREAT-1.4* SODIUM-137 POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-31 ANION GAP-14 [2199-11-16] 10:46PM estGFR-Using this [2199-11-16] 10:46PM CK(CPK)-72 [2199-11-16] 10:46PM CK-MB-NotDone cTropnT-0.17* [2199-11-16] 10:46PM CALCIUM-9.3 PHOSPHATE-4.6* MAGNESIUM-2.0 [2199-11-16] 10:17PM TYPE-ART RATES-/16 TIDAL VOL-500 PEEP-5 O2-100 PO2-445* PCO2-47* PH-7.41 TOTAL CO2-31* BASE XS-4 AADO2-244 REQ O2-47 -ASSIST/CON INTUBATED-INTUBATED [2199-11-16] 09:05PM URINE HOURS-RANDOM [2199-11-16] 09:05PM URINE GR HOLD-HOLD [2199-11-16] 09:05PM WBC-13.0* RBC-3.72* HGB-12.7* HCT-34.8* MCV-94 MCH-34.3* MCHC-36.6* RDW-13.6 [2199-11-16] 09:05PM NEUTS-89.6* LYMPHS-6.3* MONOS-3.3 EOS-0.7 BASOS-0.2 [2199-11-16] 09:05PM PLT COUNT-250 [2199-11-16] 09:05PM PT-12.8 PTT-21.4* INR(PT)-1.1 [2199-11-16] 09:05PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.010 [2199-11-16] 09:05PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0 LEUK-NEG [2199-11-16] 09:05PM URINE RBC-[5-14]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 MRI brain with and without contrast: Markedly motion degraded study. Subacute hematoma in the left occipital lobe with mild leptomeningeal enhancement which may reflect hyperemia secondary to subacute hematoma. No convincing underlying mass lesion is noted; however, recommend followup imaging after resolution of acute blood products for better assessment. CTA head with and without contrast: No convincing evidence for an AVM. There is very slight hyperemia in the region of the prior hemorrhage. Recommend attention on followup imaging. Irregularity and diminutive appearance of the basilar artery may reflect a combination of atherosclerotic disease and fetal type PCA distribution on the left. ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a very small inferolateral pericardial effusion without evidence for hemodynamic compromise. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. EEG: This is an abnormal routine EEG due to the presence of diffusely slow background and periodic left temporal sharp activity. There was also an electrographic seizure seen broadly over the left hemisphere with no associated clinical correlate. NCHCT: There is a small focus of intraparenchymal hemorrhage in the left occipital lobe adjacent to an area of edema involving the posterior watershed of the left cerebrum. Compared to the earlier study, the involved area of predominantly vasogenic edema is less well defined and less extensive. The findings do suggest a hypoperfusion pattern considering the distribution and given history of recent carotid endarterectomy. Therefore the small focus of hemorrhage must be presumably hemorrhagic conversion. MRI with diffusion-weighted sequence is recommended to assess for elements of acute ischemia. EKG: Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 93 172 94 360/417 66 -29 44 Brief Hospital Course: Mr. [Known lastname ] is a 79-year-old right-handed man with a history of Left CEA on [2199-11-12] who presented with acute onset language impairment, found to have a left occipital hemorrhage. His exam neurological exam was non focal. The hemorrhage was most likely due to a hyperperfusion syndrome conversion although an an underlying mass can not be ruled out. Given the recent CEA, a hyperperfusion syndrome is indeed most likely (patient was also found to have a fetal PCA on head CTA). Patient was intubated in ICU for a few days. Because of his fever on admission and change in behavior, he was treated empirically with acyclovir. Because there was a history suggestive of a seizure at the OSH and here EEG showed diffusely slow background and periodic left temporal sharp activity, patient was loaded with dilantin and had levels checked regularly. He will need to have his dilantin level followed-up as outpatient. When extubated and transferred to the wards, patient was agitated, requiring olanzapine. His mental status improved over time, being alert and oriented to time and place upon discharge. He is also being treated for hospital acquired pneumonia with vancomycin and ceftriaxone (he will need another week of antibiotics to complete 14 day-course). Medications on Admission: ASA 81 mg po daily Lisinopril 40 mg po daily Metformin 1000 mg po daily Allopurinol 100 mg po daily Amlodipine 2.5 mg po daily Janumet 50-500 mg po qpm Discharge Medications: 1. Dilantin Extended 100 mg Capsule Sig: Two (2) Capsule PO three times a day: You should have your levels checked with PCP [Name Initial (PRE) ] [9-23]. Disp:180 Capsule(s) Refills:2 2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 7 days. 6. Ceftriaxone 1 gram Piggyback Sig: One (1) Intravenous once a day for 7 days. 7. Janumet 50-500 mg Tablet Sig: One (1) Tablet PO qpm. 8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. Haldol 5 mg/mL Solution Sig: 0.5 mg Injection qpm MRx1 as needed for sundowning, agitation. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: - small left occipital intracranial hemorrhage; probably due to hyperperfusion - left lower lobe pneumonia - abnormal electroencephalogram Discharge Condition: Stable Discharge Instructions: You were transferred to this hospital with confusion, difficulty speaking. You had recently undergone a left carotid endarterectomy Your head CT showed a small left occipital intracranial hemorrhage thought to be due to hyperfusion syndrome. You are being treated with a 2 week course of IV vancomycin and ceftriaxone for a retrocardiac opacity and presumed hospital acquired pneumonia. You are also on dilantin due to left temporal spikes and an electrographic seizure seen on long term monitoring by electroencephlogram. You should continued on dilantin until your follow-up in [Hospital 4038] clinic. You should follow-up in [Hospital 878] clinic. Further brain imaging may be necessary. You should have your dilantin level checked with your PCP (level goal [9-23]). Please take medications as prescribed. Please keep your follow-up appointments. If you have any worsening or worrying symptoms, please contact your PCP or return to the emergency room. Followup Instructions: PCP: [Name6 (MD) ] [Name8 (MD) ], M.D. Phone: [Telephone/Fax (1) 60170] Please follow-up with your PCP [Name Initial (PRE) 176] 1-2 weeks of discharge. Neurology: [Name6 (MD) ] [Name8 (MD) ], M.D. ([Hospital 4038] clinic) Phone:[Telephone/Fax (1) 2574] Date/Time:[2199-12-31] 1:30 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2199-11-26] ICD9 Codes: 486, 4019, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7486 }	Medical Text: Admission Date: [2167-9-8] Discharge Date: [2167-9-16] Date of Birth: [2108-7-6] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 922] Chief Complaint: known Mitral Regurg-eval for Mitral Valve repair/Replacement Major Surgical or Invasive Procedure: [2167-9-8] Radical mitral valve repair with posterior leaflet P1/P2) triangular resection with ring annuloplasty using [Last Name (un) 3843]-[Doctor Last Name ] Physio II 30-mm ring. Resection of left atrial appendage. History of Present Illness: 59 year old male with a long standing history of asymptomatic severe mitral regurgitation secondary to posterior flail leaflet. A recent echocardiogram demonstrates interval progression of mildly enlarged left ventricle, moderate left atrial enlargement with preserved systolic function, EF 65%. The patient denies shortness of breath or chest discomfort. He states he will occasionally take a 45 minute walk without any shortness of breath or difficulty. He presents today for elective cardiac cath. Cardiac surgery consulted for evaluation of Mitral Valve repair vs.Replacement. Past Medical History: Severe Mitral Regurgitation,Esophageal Reflux,Trigger Finger Social History: Last Dental Exam:[2167-5-3]-Dr.[Last Name (STitle) 90537] at [Last Name (NamePattern4) 75882] Community Health Lives with:Lives with wife and daughter Contact: Phone # Occupation:Works fulltime as a signs fabricator/installer Cigarettes: Smoked no [] yes [x] -occasional cigar Other Tobacco use: ETOH: < 1 drink/week [] [2-9] drinks/week [x] >8 drinks/week [] Illicit drug use-denies Family History: Uncle died of an MI, grandfather had DM Physical Exam: Pulse:61 Resp:20 O2 sat: 98% B/P 106/94 Height: 5 ft 9inches Weight: 200lbs Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x]intermittent (R)exp wz Heart: RRR [x] Irregular [] Murmur [] grade _IV/VI SEM_____ Abdomen: Soft [x] non-distended [x] nonx-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema []none appreciated at this time _____ Varicosities: (R)LE Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right: 2+ Left:2+ PT [Name (NI) 167]: Left: Radial Right: Left: Carotid Bruit-none appreciated, pulse Right:2+ Left:2+ Pertinent Results: [2167-9-11] 05:49AM BLOOD WBC-11.8* RBC-3.44* Hgb-11.1* Hct-30.0* MCV-87 MCH-32.3* MCHC-37.0* RDW-12.5 Plt Ct-151 [2167-9-8] 01:08PM BLOOD WBC-17.1# RBC-4.51 Hgb-13.9* Hct-39.0* MCV-87 MCH-30.8 MCHC-35.6* RDW-12.9 Plt Ct-190 [2167-9-8] 01:08PM BLOOD PT-14.3* PTT-44.6* INR(PT)-1.2* [2167-9-11] 05:49AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-138 K-3.9 Cl-102 HCO3-28 AnGap-12 [2167-9-8] 01:08PM BLOOD UreaN-10 Creat-0.8 Na-142 K-4.1 Cl-112* HCO3-25 AnGap-9 [2167-9-15] 06:30AM BLOOD WBC-8.5 RBC-3.50* Hgb-11.0* Hct-29.7* MCV-85 MCH-31.4 MCHC-37.1* RDW-12.9 Plt Ct-349 [2167-9-14] 06:00AM BLOOD WBC-7.4 RBC-3.55* Hgb-11.1* Hct-30.3* MCV-85 MCH-31.3 MCHC-36.6* RDW-12.9 Plt Ct-271 [2167-9-15] 06:30AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-139 K-4.3 Cl-104 HCO3-26 AnGap-13 [2167-9-14] 06:00AM BLOOD Na-144 K-4.5 Cl-107 [2167-9-13] 08:57AM BLOOD UreaN-13 Creat-0.7 Na-141 K-4.3 Cl-103 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Diastolic Dimension: 7.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Annulus: 2.5 cm <= 3.0 cm Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV cavity. Normal regional LV systolic function. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall hypokinesis. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Eccentric MR jet. Severe (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. REGIONAL LEFT VENTRICULAR WALL MOTION: PREBYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. Regional left ventricular wall motion is normal. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. An eccentric, anteriorly directed jet of Severe (4+) mitral regurgitation is seen. POSTBYPASS LV function now appears borderline normal (LVEF ~ 50%). The LV is now moderately dilated. The RV appears less dilated and its function is improved compared to prebypass. There is a ring prosthesis in the mitral position. The MR is now trace. The remaining study is unchanged from prebypass Brief Hospital Course: 59 year old whose preoperative transesophageal echo showed severe mitral regurgitation, and his preoperative cardiac cath showed normal coronaries. The patient was felt to be a good candidate for mitral valve repair. The patient was admitted to the hospital and brought to the operating room on [2167-9-8] where the patient underwent a radical mitral valve repair with posterior leaflet (P1/P2) triangular resection with ring annuloplasty using [Last Name (un) 3843]-[Doctor Last Name ] Physio II 30-mm ring and resection of left atrial appendage. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. POD #2 the patient spiked a temperature to 102 and was pan cultured. Central line was removed and tip culture came back negative. He did have some nausea and liver function tests and abdominal ultrasound were both negative for a source of fevers. He was started on Kefzol and continued with fevers over the next several days. He had multiple blood cultures drawn - all of which are no growth to date. He was switched to Vancomycin and infectious disease service was consulted. They recommended switching to Keflex for a 10 day course. On POD 8 he had been afebrile x greater than 24 hrs and sternum was without erythema or draiange. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 8 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: OMEPRAZOLE -20 mg Capsule Q AM Zantac 75mg QPM Medications - OTC HORSE CHESTNUT Dosage uncertain BilBERRY- Dosage uncertain MULTIVITAMIN -Dosage uncertain SAW [Location (un) ] - Dosage uncertain VITAMIN E -Dosage uncertain ZINC - Dosage uncertain Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s)* Refills:0 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q3hours as needed for pain. Disp:50 Tablet(s) Refills:0 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:1 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 6. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:1 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 10. sodium chloride 0.65 % Aerosol, Spray Sig: [1-4] Sprays Nasal QID (4 times a day). 11. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. Disp:40 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Severe mitral regurgitation. 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 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] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) 914] on [10-20] at 1:15pm Cardiologist: Dr. [First Name (STitle) 1975] [Name (STitle) 66687] on [9-24] at 1:00pm Wound check in cardiac surgery office [Telephone/Fax (1) 170] [Hospital ] medical building on Thrus [9-24] at 10:15 am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 29117] in [4-7] weeks [Telephone/Fax (1) 70698] 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:[2167-9-16] ICD9 Codes: 4240, 4280, 4019, 2724, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7487 }	Medical Text: Admission Date: [2166-12-22] Discharge Date: [2167-2-3] Date of Birth: [2088-3-22] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3918] Chief Complaint: Abdominal distention Major Surgical or Invasive Procedure: [2166-12-24] Pericentesis R IJ CVL placement PICC line placement [2167-1-26] Bronchoscopy History of Present Illness: [Known firstname ] [First Name4 (NamePattern1) ] [Known lastname ] is a 78-year-old G4P30013 Taiwanese female with history of aortic stenosis and HTN, who initially presented to [Hospital1 ] [Location (un) 620] on [2166-12-16] with complaint of worsening fatigue, early satiety, increasing abdominal distention and discomfort, and constipation alternating with diarrhea. The patient denied any associated fevers, chills, cough, shortness of breath, dyspnea on exertion or headaches. On [2166-12-16], the patient underwent a CT scan of the abdomen and pelvis. This study revealed moderate diffuse abdominal and pelvic ascites. In addition, the omentum was noted to be thickened and somewhat nodular. There was an asymmetric fullness of the left adnexa. The patient was admitted to the medical service for further evaluation. On [2166-12-17], the patient underwent a diagnostic paracentesis. 1.5 liters of cloudy, yellow fluid was removed and sent for the appropriate studies. Serum CA 125 level was found to be elevated at 746. CEA is 1.8. Cytology from the peritoneal fluid is pending. On [2166-12-19], the patient underwent a second paracentesis. She noted a mild improvement of her symptoms after the paracentesis, however now reports increasing discomfort due to further abdominal distention. The patient is transferred to [Hospital1 18] for further management. Past Medical History: PAST MEDICAL HISTORY: 1. Hypertension. 2. Mild to moderate aortic stenosis; mild aortic regurgitation; moderate tricuspid regurg; moderate pulmonary artery hypertension (TTE done [2166-12-19]). 3. Patient hospitalized twice ([2162], [2165]) with CP which resolved with SL NTG; see most recent stress test below. 4. Osteoporosis. 5. History of tuberculosis. 6. History of Hep B. Cleared infection. HBsAg non-reactive; HBsAb <5; HBcAb reactive. PAST GYN HISTORY: Denies history of abnormal pap smear. Pap smear negative for malignancy [2160-3-7]. Denies history of sexually transmitted infections. Denies postmenopausal vaginal bleeding. PAST OBSTETRICAL HISTORY: SVD x 3, TAB x 1 PAST SURGICAL HISTORY: Right eye surgery Social History: The patient lives in [Location ], [State 350], with her son, [Name (NI) ] and her daughter-in-law [Name (NI) 43425]. The patient has not smoked cigarettes and denies use of alcohol. Family History: Per [Name (NI) ], the patient's son, the patient's mother had gastric cancer. The patient's sister also had an unknown type of malignancy. The patient's daughter had breast cancer. Physical Exam: VS: T 98.3 BP 110/60 HR 92 RR 16 O2Sat 97% RA General: Elderly Asian female, A&O x 3 Cardiac: RRR, no murmurs, rubs, gallops Lungs: CTAB, no rales, wheezes or crackles Abdomen: Moderate abdominal distention, shifting dullness c/w ascites, no tenderness to palpation, no masses, no HSM Ext: 1+ edema bilaterally, non tender Pertinent Results: LABS ON ADMISSION [2166-12-22] 08:00PM BLOOD WBC-8.5 RBC-3.32* Hgb-11.3* Hct-32.8* MCV-99* MCH-33.9* MCHC-34.4 RDW-13.5 Plt Ct-257# [2166-12-22] 08:00PM BLOOD Plt Ct-257# [2166-12-22] 08:00PM BLOOD PT-13.9* PTT-67.6* INR(PT)-1.2* [2166-12-22] 08:00PM BLOOD Glucose-101 UreaN-16 Creat-1.0 Na-136 K-4.2 Cl-101 HCO3-26 AnGap-13 [2166-12-22] 08:00PM BLOOD ALT-46* AST-130* AlkPhos-41 Amylase-32 TotBili-0.3 [2166-12-22] 08:00PM BLOOD Lipase-21 [2166-12-22] 08:00PM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.8 Mg-1.9 [2166-12-22] 08:00PM BLOOD CA125-696* LABORATORY DATA: CA-125: 696 . [2166-12-17] Peritoneal fluid: Albumin was 1.8, LDH was [Telephone/Fax (1) 43426] nucleated cells of which on preliminary analysis many appeared malignant. Final cytology pending. . [2166-12-19] Cell block, peritoneal fluid: Mesothelial cells, lymphocytes, neutrophils, histiocytes and red blood cells. Cytology pending. . [2166-12-24] Pathology report from mesenteric biopsy: Burkitt's. . [2166-12-26] Bone Marrow: Peripheral Blood Smear: The smear is adequate for evaluation. Erythrocytes demonstrate anisopoikilocytosis. They appear to have increased central pallor, with scattered polychromatophils present. Abnormal forms including target cells, ecchinocytes, and elliptocytes are also present. The white blood cell count appears normal. Platelet count appears normal with rare clumping. Large forms are seen. Differential count shows 69% neutrophils, 5% monocytes, 2%lymphocytes, 1% basophils, 3% atypical mononuclear cells with cytoplasmic vacuoles within deep blue cytoplasm. . Aspirate Smear: The aspirate material is adequate for evaluation and shows several cellular spicules with many stripped nuclei. The M:E ratio is 0.9:1. Erythroid precursors are present in mildly megaloblastoid maturation. Myeloid precursors appear normal in number and show left shifted maturation. Megakaryocytes are present in decreased numbers. Differential shows: 3% Blasts, 1% Promyelocytes, 12% Myelocytes, 14% Metamyelocytes, 14% Bands/Neutrophils, 13% Plasma cells, 16% Lymphocytes, 35% Erythroid. There are foamy hemosiderin laden macrophages present in the smear. There are large cells with intensely blue cytoplasm with vacuoles. . Biopsy Slides: The biopsy material is adequate for evaluation and demonstrates a fragmented cellular core (overall cellularity of 20-30%). There are increased plasma cells and mast cells. There is an eosinophilic background. The M:E ratio estimate is decreased. Erythroid precursors are increased in number and show normoblastic maturation. Myeloid elements are relatively decreased in number and exhibit full spectrum maturation. Megakaryocytes are present in normal number. There is an interstitial infiltrate of plasma cells occurring in small clusters occupying 20% of marrow cellularity. Marrow clot section is not submitted. Touch prep is not submitted. . Special Stains: Iron stain is adequate for evaluation. Storage iron is increased. Sideroblasts are present. Ring sideroblasts are absent. . EKG: sinus rhythm, HR 80, normal axis, normal intervals, non pathologic q-waves in II, III, aVF. [Street Address(2) 4793] depression in III. . RADIOGRAPHIC DATA: CXR [2166-12-22]: There is some hyperexpansion of the lungs with coarseness of interstitial markings consistent with chronic pulmonary disease. Apical pleural thickening bilaterally, more prominent on the right, consistent with old granulomatous disease. No evidence of acute focal pneumonia, vascular congestion, or pleural effusion. Loss of height of a mid dorsal vertebra, most likely on a postmenopausal basis. . CT CHEST [2166-12-19]: 1. CALCIFIED SCARRING AT THE LUNG APICES. CALCIFIED MEDIASTINAL LYMPH NODES. CALCIFICATIONS IN THE LIVER AND SPLEEN. THESE FINDINGS ARE SUGGESTIVE OF CHRONIC TUBERCULOSIS OR ANOTHER CHRONIC GRANULOMATOUS INFECTION. 2. BILATERAL CALCIFIED PLEURAL PLAQUES, WHICH ARE MOST LIKELY ALSO RELATED TO A CHRONIC GRANULOMATOUS INFECTION. HOWEVER, ASBESTOS EXPOSURE [Month (only) ] ALSO BE CONSIDERED, AND CLINICAL CORRELATION IS SUGGESTED. 3. SMALL BILATERAL PLEURAL EFFUSIONS. 4. ABDOMINAL ASCITES, WHICH WAS BETTER ASSESSED ON THE [2166-12-16] ABDOMINAL CT SCAN. 5. 9 MM LUCENT LESION IN THE LEFT GLENOID WITHOUT AGGRESSIVE FEATURES, WHICH MOST LIKELY REPRESENTS A SUBCHONDRAL CYST. HOWEVER, A METASTASIS CANNOT ENTIRELY BE EXCLUDED, AND A BONE SCAN [Month (only) ] BE CONSIDERED. 6. MODERATE COMPRESSION DEFORMITIES OF THE VERTEBRAL BODIES OF T7 AND T12, OF UNKNOWN CHRONICITY. . [2166-12-16] CT ABDOMEN ([Hospital1 ] [Location (un) 620]): ASCITES. OMENTAL THICKENING THAT [Month (only) ] REFLECT PERITONEAL CARCINOMATOSIS. THERE IS ASYMMETRIC FULLNESS OF THE LEFT PELVIC ADNEXA BUT NO DEFINITE MASS IS IDENTIFIED. SMALL PLEURAL EFFUSIONS. OLD GRANULOMATOUS DISEASE. . [2166-12-27] ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. The study is inadequate to fully assess aortic valve, however mild stenosis is suggested based on two-dimensional images. Mild (1+) aortic regurgitation is seen. No mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Calcific aortic valve disease with mild regurgitation and probable mild stenosis. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the report of the resting portion of the prior stress study (images unavailable for review) of [2163-9-9], tricuspid regurgitation and pulmonary hypertension are now seen. Aortic valve is not fully assessed on the current emergency study. The other findings appear similar. . [2167-1-2] LE Ultrasound: The examination was negative for DVT in the lower extremities. . [2167-1-12] Chest CT: 1. Diffuse ground-glass opacity and more focal left upper lobe subpleural opacity. Findings most likely reflect an infectious process or drug-related alveolitis. 2. Right PICC line lies at the level of the tricuspid valve. 3. Moderately-severe aortic valve calcifications of uncertain physiologic significance. . [2167-1-25] Chest CT: 1. Interval progression of diffuse ground-glass opacity, which remains most consistent with an infectious process such as a viral or atypical pneumonia, or drug-reaction. 2. No pleural effusion. 3. Calcified pleural plaques and interstitial lung disease, may represent asbestos-related disease. . [2167-1-25] Shoulder film: Three views of the right shoulder demonstrate some mild degenerative changes with small osteophytes but no fracture is identified. As seen in the chest CT from the prior day there is right apical pleural plaque and increased interstitial markings on the right. . [2167-1-26] Bronchoscopy: preliminary negative . . Brief Hospital Course: [Known firstname ] [First Name4 (NamePattern1) ] [Known lastname ] is a 78-year-old female transferred to [Hospital1 18] with CT findings of ascites, omental thickening, and left adnexal fullness, as well as an elevated CA-125, concerning for ovarian cancer versus primary peritoneal cancer, found to have Burkitt's lymphoma as well as likely peritoneal TB. . # Burkitt's Lymphoma: Patient was originally admitted to the gynecologic service for possible ovarian cancer. Patient underwent CT guided mesenteric biopsy which demonstrated high proliferation fraction and lack of Bcl-2 expression consistent with Burkitt's Lymphoma. The patient was transferred to BMT service and on [2166-12-28] started Day 1 modified CODOXM ([Last Name (un) 43427]). Also started on Prednisone 100 mg for 7 days. Bone marrow biopsy demonstrated MILDLY HYPOCELLULAR ERYTHROID DOMINANT BONE MARROW WITH MATURING TRILINEAGE HEMATOPOIESIS AND REACTIVE (POLYCLONAL) PLAMACYTOSIS, but did not show evidence of lymphoma. Bone marrow acid-fast stain was negative for microorganisms. MRI demonstrated no discrete lymphadenopathy and findings consistent with anasarca. Pt completed part A of [Last Name (un) 43427] but was complicated by sepsis requiring ICU admission. Pt was then switched to a more easily tolerated regimen called [Hospital1 ]. She started [Hospital1 ] cycle 1 on [2167-1-15]. She will need to continue cycle 2 on [Last Name (LF) 766], [2167-2-9]. The pt was discharged with a follow up appointment with hematology/oncology for counts on [Last Name (LF) 2974], [2167-2-6]. . # Volume overload: The patient presented with ascites, lower extremity edema and pulmonary edema. The patient underwent two diagnostic and therapeutic paracenteses. The patient was aggressively diuresed on Lasix 40 mg IV BID with improvement. Ms. [Known lastname ] was euvolemic at the time of discharge. . # Hypoxia: Initially, on the floor the patient required NRB for O2 sat 90-94%. Pulmonary and cardiac shunt essentially negative: LENI negative, ECHO bubble no intra-cardiac shunt, V/Q scan indeterminate secondary to volume overload (unable to do CTA in setting of renal failure with lysis). EKG showed no acute changes. Thought to be secondary to fluid overload and atelectasis. Hypoxia improved significantly with diuresis. . However, hypoxia returned days later without significant evidence of volume overload and concurrent fevers. CT chest was performed showing diffuse ground glass opacities. Pt was started on several antibiotics. Pt became hypotensive, hypoxic, and febrile. She was sent to the ICU before stabilizing. Sputum culture grew stenothrophomonas. Pt underwent a broncoscopy on [1-26] for evaluation of persistant ground glass opacities. BAL preliminary was negative. The pt was also treated with vancomycin and meropenem which were eventually removed. Pt is now completing a a course of bactrim to be completed [2167-2-10] per the infectious disease service. On discharge the pt was able to breathe comfortably on room air. . # Peritoneal TB: The patient had a history of active TB (demonstrated on CT chest) without adequate treatment. She ruled out for pulmonary TB with > 4 sputum samples negative for AFB. The infectious disease service was concerned for peritoneal TB due to + [Doctor First Name ] peritoneal fluid ([Doctor First Name ] of 96.7 with a reference range of <7.6 U/L) despite negative TB PCR. The pt was started on 4 drug therapy with ethambutol, INH, rifabutin, and pyrazinamide. The pt was followed by Infectious Disease for the duration of her admission, and they recommended that the pt continued the four-medication regimen for two months. The pt will follow up at the infectious disease clinic in [Month (only) 404], [2167]. . # Risk of Strongyloides: As the patient was from an area where strongyloides is endemic, she was felt to be at high risk prior to starting a course of steroids. Per ID recommendations the pt received two doses of Ivermectin therapy. . # Hep B exposure: Patient surface antibody positive, viral load negative. Patient was started on Lamivudine prophylaxis and was discharged on lamivudine. . # Access: The pt was discharged with PICC in place as she will return for scheduled admission on [Last Name (LF) 766], [2167-2-9] for second cycle of [Hospital1 ]. Medications on Admission: Fosamax Atenolol Calcium MVI Discharge Medications: 1. 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:2 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 3. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Isoniazid 300 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK (TU,TH,SA). Disp:270 Tablet(s) Refills:2 5. Rifabutin 150 mg Capsule Sig: Two (2) Capsule PO 3X/WEEK (TU,TH,SA). Disp:180 Capsule(s) Refills:2 6. Ethambutol 400 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK (TU,TH,SA). Disp:270 Tablet(s) Refills:2 7. Pyrazinamide 500 mg Tablet Sig: Six (6) Tablet PO 3X/WEEK (TU,TH,SA). Disp:540 Tablet(s) Refills:2 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 9. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 12. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours) for 7 days. Disp:21 Tablet(s) Refills:0 14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous once a day as needed for line flush. Disp:qs ML(s) Refills:0 15. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection once a day as needed for line flush. Disp:qs Refills:0 16. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:90 Tablet(s) Refills:2 17. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:6 Tablet(s) Refills:0 18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Caregroup Home Care Discharge Diagnosis: Burkitt's lymphoma Pneumonia Peritoneal tuberculosis Discharge Condition: Good, able to climb stairs with assistance, ambulate without the use of nasal canula oxygen. Discharge Instructions: You were admitted to the hospital for increased abdominal girth. During your hospitalization you were diagnosed with Burkitts lymphoma. You were started on chemotherapy treatment immediately. Your hospitalization was complicated by inflammation of your mouth and throat which limited your ability to eat and required intravenous nutrition. You also had a significant infection in your lungs. You were treated with antibiotics and recovered well. You will need to continue with further cycles of chemotherapy in the future. . The following changes were made to your medications: - Your atenolol has been changed to metoprolol. - Many medications have been added to your medication regimen. The following are new medications: Omeprazole: for heartburn Senna: as needed for constipation Pyridoxine: to take with tuberculosis medications Isoniazid: tuberculosis medication Ethambutol: tuberculosis medication Pyrazinamide: tuberculosis medication Docusate Sodium: for constipation Fluconazole: to prevent fungal infection Rifabutin: tuberculosis medication Metoprolol Tartrate: for blood pressure Acetaminophen: for pain Lamivudine: to prevent infection Trimethoprim-Sulfamethoxazole: to prevent infection Acyclovir: to prevent infection Hydromorphone: as needed for pain Lorazepam: as needed for nausea . Please continue all other home medications as previously directed. . Please follow up with your doctors as detailed below. It is very important that you follow up with your doctors as listed below. . Please notify your physician or return to the hospital if you experience fever, chills, abdominal pain, diarrhea, nausea, vomiting, cough, sore throat, shortness of breath, rash or any other symptom that is concerning to you. Followup Instructions: Hematology/Oncology follow up: [Last Name (LF) ],[First Name3 (LF) 674] H. [Telephone/Fax (1) 38619] Provider: [Name Initial (NameIs) 455] 5-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[2167-2-6] 9:00 . Infectious disease follow up: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13447], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2167-2-24] 9:30 . Please call to arrange a follow up appointment with you primary care doctor: Dr. [Last Name (STitle) ],[First Name3 (LF) ] J. [Telephone/Fax (1) 4775] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 3922] ICD9 Codes: 311, 0389, 2762, 4280, 2859, 4241, 4019, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7488 }	Medical Text: Admission Date: [2121-5-2] Discharge Date: [2121-5-6] Date of Birth: [2038-3-2] Sex: M Service: UROLOGY Allergies: Toprol Xl Attending:[First Name3 (LF) 6736] Chief Complaint: fevers, tachycardia Major Surgical or Invasive Procedure: lithotripsy right ureteral stent placement x 2 History of Present Illness: Mr. [Known lastname 108020] is an 83 year old man with Stage V CKD, h/o multiple malignancies including bladder cancer s/p resection, bilateral nephrolithiasis, and non-ischemic cardiomyopathy (EF 25-30%) here with fevers, rigors, hypotension, and tachycardia after right ureteral stent placement today for chronic kidney stones. The patient underwent lithotripsy with right ureteral stent placement x 2 today with Dr. [Last Name (STitle) ], but approximately 90 minutes after the procedure, while recovering in the PACU, he began experiencing rigors and a temperature at that time was 101. He then became hypotensive to the 90's systolic and tachycardic to 116, so he was given Vancomycin & Ceftriaxone x 1 and transferred to the ICU for further monitoring. In the [Hospital Unit Name 153], initial vs were: T100.9 P114 BP127/48 R15 O2 sat 94% 3L. Patient denied any subjective fevers, chills, abdominal/flank pain. He further denied any nausea, vomiting, or shortness of breath. He did endorse several weeks of solid food dysphagia and a 25 pound weight loss over the past year, including approximately 15 pounds in the last 2 weeks. Past Medical History: - HTN - Non-ischemic cardiomyopathy (EF 25-30%) - Chronic renal insufficiency (Baesline 5.5-6. [Doctor First Name ] positive. Possibly secondary to tubular interstitial disease.) - Nephrolithiasis (first kidney stone at the age of 25 which he passed with a lot of pain. Asymptomatic since then. Back CT [2-/2120] revealed bilateral renal stones that were quite large (>1.0 cm). The patient had laser lithotripsy in [2120-4-14] on the right side and in [Month (only) 116] on the left side by Dr. [Last Name (STitle) 365]. This was repeated on last admission in [2121-4-14].) - Chronic back pain since [2114] secondary to ankylosing spondylitis, DDD and facet degeneration (MRI L spine on [2119-2-10]: mild L45 central, mod/sev R and mild L foraminal stenosis, moderate L34 central and mod L L3 foraminal stenosis. Spine survey on [2119-5-22] at NEBH: ossification of PLL c/w ankylosing spondylitis. CT L spine on [2119-5-22]: L34 and L45 advanced degenerative disc disease. On TENS for mobility.) - Memory difficulties - NHL [2091] (initially thought to have Crohn disease, went for surgery that revealed lymphoma, involving bladder. He was further treated with 9 cycles chemotherapy, radiation and bowel resection. No recurrence.) - Short gut syndrome after bowel surgery. Takes monthly B12 injections. ([2091]) - Urinary frequency - Papillary urothelial carcinoma of the bladder s/p partial bladder resection - SCC L ear ([2118]) - BCC L nose ([2117]) - Femoral neck fracture s/p internal stabilization - Left partial lateral knee meniscectomy ([2118]) - Secondary Hyperparathyroidism - Anemia [3-18] ESRD & B12 deficiency Social History: SOCIAL HISTORY: Professor [First Name (Titles) ] [University/College 15564]and is teaching [University/College 34011] History. He has insignificant history of smoking when he was much younger and experimented with tobacco but nothing really significant. He has no history of alcohol abuse or illicit drug use. He lives with his wife, [Name (NI) ]. Family History: FAMILY HISTORY: His father died of MI age 57. His brother died of multiple sclerosis at the age of 40. His sister is 86 and in very good health. His mother died after falling down the stairs but his maternal aunts lived over the age of 100. Otherwise non-contributory. Pertinent Results: [2121-5-6] 08:50AM BLOOD Calcium-7.5* Phos-4.5# Mg-2.1 [2121-5-6] 08:50AM BLOOD WBC-11.4* RBC-3.12* Hgb-9.7* Hct-30.9* MCV-99* MCH-31.1 MCHC-31.4 RDW-13.1 Plt Ct-353 Brief Hospital Course: 83 year old man with CKD (Cr 5.5-6 baseline), h/o multiple malignancies including bladder cancer s/p resection, bilateral nephrolithiasis, and non-ischemic cardiomyopathy (EF 45%) transferred to [Hospital Unit Name 153] s/p bilateral ureteral stent placement for fevers, rigors, hypotension, and tachycardia with concern for sepsis. Stabalized in [Hospital Unit Name 153] with fluid resusitation, broad spectrum empiric antibiotics started. Patient transferred to floor when stable. Cultures followed and antibiotic narrowed to ampicillin. Foley was removed POD3 and patient passed a voiding trial. Creatinine returned to baseline, WBC returned to [Location 213] range. Renal was informed of his admission, specifically Dr. [Last Name (STitle) ] who visited the patient in house on the day of discharge. He was discharged home in stable condition, on POD4, voiding without difficulty, ambulating without assistance, tolerating a regular diet. He was given a 7 day course of Ampicillin, and istructed to contact Dr. [Last Name (STitle) ] [Last Name (STitle) ] arrange/confirm follow up. He is also advised to contact Dr. [Last Name (STitle) ] and his PCP upon discharge to arrange follow up. Medications on Admission: AMLODIPINE 5 mg PO daily CALCITRIOL 0.25 mcg qOD CYANOCOBALAMIN 1,000 mcg/mL qmonth TESTOSTERONE CYPIONATE 200 mg Q3 weeks TRAMADOL 50mg PO BID ACETAMINOPHEN 650mg PO daily ERGOCALCIFEROL 400 unit PO daily MVI daily Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Sepsis following bilateral ureteral stent placement Discharge Condition: Stable Discharge Instructions: -You may shower and bathe normally. -Tylenol should be used for pain -Resume all of your home medications at their usual dose, please follow up with your PCP and Renal specialist to inform them of your recent hospital stay. - If you develop fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. General Instructions and information for the patient post procedure Definitions: Ureter: the duct that transports urine from the kidney to the bladder: Stent: a plastic hollow tube that is placed into the ureter, from the kidney to the bladder to prevent the ureter from swelling shut. Despite the fact that no skin incisions were used, the area around the ureter and bladder is irritated. The stent is required in order keep the ureter open and urine flowing from the kidney to the bladder. Because one end of the ureter is in the bladder, it can cause irritation to the bladder. Therefore, it is normal to feel that you need the urge to urinate frequently when the stent is in place. Although the stent can be uncomfortable, it is important to have the stent to avoid damaging the kidney and ureter after your procedure. You may see some blood in your urine while the stent is in place and a few days afterward. Drink lots of fluid - this will help clear up your urine.   Diet: You may return to your normal diet immediately. Because of the raw surface of your bladder, alcohol, spicy foods, acidy foods and drinks with caffeine may cause irritation or frequency and should be used in moderation. To keep your urine flowing freely and to avoid constipation, drink plenty of fluids during the day (8 - 10 glasses) Activity: Your physical activity doesn't need to be restricted. However, if you are very active, you may see some blood in the urine. We would suggest to cut down your activity under these circumstances until the bleeding has stopped Bowels-It is important to keep your bowels regular during the postoperative period. Straining with bowel movements can cause bleeding. A bowel movement every other day is reasonable. Use a mild laxative if needed, such as Milk of Magnesia [3-19] Tablespoons, or 2 Dulcolax tablets. Call if you continue to have problems. If you had been taking narcotics for pain, before, during or after your surgery, you may be constipated. Take a laxative if necessary Medication-You should resume your pre-surgery medications unless told not to. In addition you will often be given an antibiotic to prevent infection. These should be taken as prescribed until the bottles are finished unless you are having an unusual reaction to one of the drugs. Problems [Name (NI) ] Should Report to Urology Service a. Fevers over 100.5 Fahrenheit b. Heavy bleeding, or clots (See notes above about blood in urine). c. Inability to urinate. d. Drug reactions (Hives, rash, nausea, vomiting, diarrhea). e. Severe burning or pain with urination that is not improving. f. You have and internal stent and it is important to have a follow-up appointment to remove your stent. Call your doctor for this appointment when you get home Followup Instructions: 1. Please contact Dr.[Name (NI) 10529] office to arrange/confirm follow up appointment. 2. Please contact your PCP to inform him/her of your recent hospital stay Completed by:[2121-5-6] ICD9 Codes: 0389, 5849, 4254, 2762, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7489 }	Medical Text: Admission Date: [2124-6-20] Discharge Date: [2124-7-4] Date of Birth: [2056-3-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 759] Chief Complaint: Neck and left arm numbness and tingling Major Surgical or Invasive Procedure: Cervical laminectomy and fusion, ACDF C3-6 History of Present Illness: Mr. [Known lastname 1968] is a 68 y/o male with hyperlipidemia, HTN, cervical radiculopathy, who was admitted to the orthopedics service on [2124-6-20] for a cervical laminectomy and C3-C6 anterior/posterior fusion. He underwent the procedures successfully and was recovering on the ortho service, when on [6-26] he had an episode of hypotension with SBP's in the 60's and tachycardia with confusion. This resolved spontaneously, work-up was initiated, and his opiate dose was decreased. However, a similar episode of hypotension occured again at approximately 10 pm on the same day, resulting in a Code Blue, intubation for airway protection and transfer to the tramua ICU on [6-26]. He was started on vancomycin and zosyn and levophed. CXR was significant for infiltrates. He underwent a bronchoscopy and BAL on [2124-6-27] and was noted to have copious secretions in LUL and LLL. He had a bump in his troponin on [2124-6-27] with peak to 0.37. He was extubated successfully on [2124-6-28]. . Of note, his course was complicated by a troponin leak from 0.04 to >0.39. Cardiology was consulted and felt that the patient likely sustained an NSTEMI in the setting of his hypotension, recommendation was for medical management. . Past Medical History: 1. Cervical radiculopathy s/p cervical laminectomy and C3-C6 fusion [6-20] 2. HTN 3. Hyperlipidemia 4. Remote history of stroke with residual mild left-sided hemiparesis 5. gout Social History: He lives alone. Previously worked at a meat cutter. Smokes about half pack per day for over 40 years. History of heavy alcohol use in the past. Denies drug use. Family History: N/C Physical Exam: NAD RRR CTA B Abd soft NT/ND BUE- good strength at right biceps, triceps, wrist extension and flexion, finger extension and flexion and intrinsics, Left sided weakness 4/5 from previous stroke; sensation diminished in left arm C5-7 dermatomes; hyperreflexic at biceps, triceps and brachioradialis; + [Doctor Last Name 937] bilaterally BLE- good strength at hip flexion and extension/abduction/adduction, knee flexion and extension, ankle dorsiflexion and plantar flexion, [Last Name (un) 938]/FHL; sensation intact distally; reflexes diminished at quads and Achilles; + clonus; equivical Babinski . On transfer out of the MICU: PHYSICAL EXAM: VS:T 98.6 122/80 HR 92 RR 18 84% RA -> 88% 2L -> 94% 3L General: Awake, alert, resting comfortably in bed, NAD HEENT: NC, AT, EOMI no scleral icterus Neck: supple, no LAD, steri-strips in place on left anterior neck and posterior neck, no erythema or exudate at operative sites CV: RRR s1 s2 no appreciable murmur Chest: coarse crackles diffusely, loudest at bases, no wheezes Abd: soft, NT ND BS hyperactive Ext: no LE edema, DP's 2+ Bilaterally . Pertinent Results: WBC-23.8* RBC-3.31* Hgb-10.0* Hct-28.2* MCV-85 MCH-30.1 MCHC-35.3* RDW-13.6 Plt Ct-316 PT-15.5* PTT-29.4 INR(PT)-1.4* Glucose-71 UreaN-19 Creat-0.9 Na-136 K-3.8 Cl-99 HCO3-25 AnGap-16 CK(CPK)-208* <- 304 <- 467 CK-MB-6 <- 9<- 15 TropnT-0.27* <-0.39 <- 0.37 CT neck and chest: Status post C3-6 laminectomy and anterior cervical fusion with large low- attenuation fluid collection anterior to this region with thin enhancing rim, likely representing post-operative change; however, superimposed infection cannot be excluded. The fluid collection extends into the superior mediastinum at the thoracic inlet. 2. Multiple lymph nodes are noted in the neck, mediastinum, and hila. 3. Air space opacity in the left upper lobe suggestive of pneumonia. Bilateral subsegmental atelectasis noted. 4. Left upper lobe 3-mm pulmonary nodule. Comparison with prior imaging is suggested if available to establish stability; otherwise, follow-up imaging with Ct Chest to assess for stability in a few months can be considered based on risk for thoracic malignancy. 5. Opacification of left maxillary sinus and air- fluid level in the sphenoid sinus may relate to recent endotracheal tube placement. 6. 1-cm enhancing soft tissue nodule in right axilla of uncertain etiology; this may represent a node; however, clinical correlation is recommended. echo: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. CT head: No evidence of acute intracranial hemorrhage. MRI with diffusion-weighted images is a more sensitive evaluation for acute ischemia/infarct and for vascular detail. lung scan, perfusion images only: Low likelihood ratio for recent pulmonary embolism. Heterogeneous perfusion is compatible with the pulmonary congestion. intraoperative Cspine XR: Two intraoperative radiographs of the cervical spine were obtained without a radiologist present. These demonstrate localization of C5-C6 and subsequent anterior spinal fusion. For additional details, please consult the operative report. Brief Hospital Course: Mr. [Known lastname 1968] is a 68 yo M with PMH HTN, Hyperlipidemia who was initially admitted to the service of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for an anterior/posterior cervical decompresion and fusion C3-6. #. Cspine sponylosis s/p anterior/posterior cervical decompresion and fusion C3-6: He was consented for the procedure and elected to proceed with Dr. [Last Name (STitle) 363]. Please see operative note for procedure in detail. Post-operatively he was administered antibiotics and pain medication. He was afebrile and his incisions were clean and dry. His post op course was complicated by the details below, however he was ultimately seen by physical therapy, cleared for discharge to rehab, and should wear brace when out of bed at all times until his follow up appoitnment with Dr. [Last Name (STitle) 363] in one month. #. Pneumonia: postoperatively, he became confused and experienced hypotension. A stat EKG was performed which was unchanged from previous. His confusion cleared and hypotension resolved after a 500mL blous of fluid. A second episode of hypotension and difficulty breathing occurred and a code was called. He was subsequently intubated and transferred to the T/SICU. In the T/SICU he required pressors for his hypotension and continuous mechanical ventilation. An echo was performed which was unchanged from that [2120]. V/Q Scan revealed a low likelihood ratio for recent pulmonary embolism. Neck and chest CT showed a post-operative seroma without evidence of gas pocket or infection. Chest x-rays revealed a left lower lobe pneumonia and vancomycin/zosyn were started. A brochoscopy was performed and revealed copious secretions in the LUL and LML which were cultured. He was subsequently extubated and transferred out of the T/SICU and to the medical service. Sputum cultures and BAL cultures with pan-sensitive E. coli, Klebsiella and Enterobacter all sensitive to ciprofloxacin so vancomycin and zosyn were discontinued and ciprofloxacin was started to complete 10 day course of antibiotics (last day [2124-7-7]). Polymicrobial nature of growth concerning for aspiration PNA so he was seen by speech and swallow who recommended nectar thickened liquids with plan for re-evaluation once further out from his surgery. He was re-evaluated on the day of discharge with video swallow study and was cleard for regular diet with thin liquids. #. NSTEMI: He had an NSTEMI with positive troponin while hypotensive and in the ICU. He was seen by cardiology who [Hospital 13131] medical management. He was treated with metoprolol, ASA, simvastatin and lisinopril. He had no recurrence of hypotension during this admission and will follow up with Dr. [Last Name (STitle) ] as an outpatient. (Phone number given, please call for next available appointment.) Echocardiogram without evidence of new wall motion abnormality, normal EF. #. CT chest with nodule: As part of the above workup for pneumonia, CT chest was performed and revealed an incidental Left upper lobe 3-mm pulmonary nodule. It is recommended that this be re-imaged with follow up CT scan in approximately 6 months to assess for stability. This should be followed by PCP. [Name10 (NameIs) 4692], an axillary nodule was seen, however on examination this was consistent with a large sebaceous cyst, which the patient says has been stable for "20 years." The patient is stable for discharge to rehab, where he should work with PT/OT due to deconditioning in setting of complex stay. He should continue ciprofloxacin until [2124-7-7]. He should wear his neck brace at alltimes while out of bed until he sees Dr. [Last Name (STitle) 363] in one month. Please also call for an appointment to see Dr. [Last Name (STitle) ] in cardiology in the next 1-2 weeks to follow up for his MI. Medications on Admission: Acetaminophen-Codeine [Tylenol-Codeine #3] - 300 mg-30 mg Tablet - 1 to 2 Tablet(s) by mouth q 6 h prn ASA 325 MG Gabapentin 900 mg TID Hydrochlorothiazide 25 mg daily Hydrocodone-Acetaminophen [Vicodin] - 5 mg-500 mg Tablet - 1 (One) Tablet(s) by mouth q 6-8 h prn Indomethacin 25 mg daily Lisinopril 20 mg Tablet 1 (One) Tablet(s) by mouth once a day Omeprazole 20 mg [Hospital1 ] Simvastatin 10 mg daily B COMPLEX - Tablet - ONE BY MOUTH EVERY DAY Diphenhydramine HCl - 25 mg qHS Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:90 Tablet Sustained Release 24 hr(s) Refills:2 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days: last day of antibiotics [2124-7-7]. Disp:8 Tablet(s) Refills:0 9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for dyspnea. 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day): may stop if pt ambulates TID. Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: cervical spondylosis Non-ST segment elevation MI Pneumonia Hypotension ======= s/p CVA with mild left hemiparesis HTN Hyperlipidemia Gout Discharge Condition: good Discharge Instructions: You were admitted to the hospital because you were having scheduled surgery for an anterior/posterior cervical fusion. You had no complications during your surgery however following your surgery you had very low blood pressure and you lost consciousness. You were intubated and transferred to the ICU. You had a bronchoscopy which showed likely pneumonia in your left lung. You were treated with antibiotics. You did well and were extubated and continued on antibiotics. You had a small heart attack while most likely when your blood pressure dropped. You were evaluated by the cardiology doctors and [Name5 (PTitle) ] should follow up with them in clinic. Wound Care: Keep the incisions dry. You may shower as long as you cover the incisions with Band-aids. Do not take a bath or submerge the incisions under water. You need to wear the brace whenever you are out of bed. You do not need the brace when you are in bed. Do not lift anything heavier than a gallon of milk. do not bend or twist from the neck. Do not smoke. Medications: 1)You were started on Metoprolol which is a blood pressure medicine that you should take to protect your heart. 2) You will need to finish your course of ciprofloxacin, an antibiotic for your pneumonia Please call your doctor or return to the emergency department if you have a fever over 101F or if you have an increase in pain or discharge from the incisions, or if you have chest pain, light headedness, fainting or any other worrisome symptoms. Followup Instructions: You have an appointment scheduled to follow up with Dr. [Last Name (STitle) 363] (orthopedic surgeon) on [7-12] at 10:30. The phone number for the office is [Telephone/Fax (1) 3573]. The clinic is located on the [Location (un) 17879] of the [Hospital Ward Name ] building of the [Hospital Ward Name ]. Please wear your neck brace whenever you are out of bed until your follow up appointment. You should also follow up with Dr. [Last Name (STitle) ] of cardiology as you did have a small heart attack during your admission when your blood pressure was low. Please call [Telephone/Fax (1) 5003] to schedule this appointment. You have an appointment scheduled to follow up your PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 4223] on [Last Name (LF) 2974], [7-7] at 12:15. Please call [Telephone/Fax (1) 7976] if you need to reschedule this appointment. Completed by:[2124-7-4] ICD9 Codes: 0389, 5070, 5849, 9971, 2749, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7490 }	Medical Text: Admission Date: [2139-7-15] Discharge Date: [2139-7-27] Date of Birth: [2069-5-1] Sex: M Service: TRA HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old gentleman status post fall from porch while intoxicated. The patient fell three steps onto a porch. The patient denied any loss of consciousness. The patient was noted to have a right leg deformity and complaining of pain at an outside hospital. The patient was transferred to [Hospital1 346] in stable condition. PAST MEDICAL HISTORY: Hypertension. Hyperlipidemia. Prostate cancer. MEDICATIONS ON ADMISSION: Lipitor and hydrochlorothiazide. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a temperature of 98.2, his heart rate was 25, his blood pressure was 174/74, his respiratory rate was 18, and his pulse oximetry was 100 percent. On general physical examination, in moderate distress secondary to pain. Head, eyes, ears, nose, and throat examination revealed the extraocular movements were intact. A 3-cm forehead superficial abrasion. The trachea was midline. TMJ clear. Neck in cervical collar. Chest revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. Gastrointestinal examination revealed obese, soft, and nontender. Back revealed no back pain or step off. The pelvis was stable. Extremities revealed right distal femur step off, 1.5 cm distal femur, a small 0.5 cm open wound over the fracture, ankle brachial index was greater than 1, palpable distal pedal pulse at 1 plus. On neurologic examination, [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] Coma Score of 14. PERTINENT LABORATORY VALUES ON PRESENTATION: Complete blood count was remarkable for a white blood cell count of 15. Chemistry-7 revealed sodium was 140, potassium was 3.7, chloride was 101, and his blood glucose was 119. Arterial blood gas was 7.51/28/90/23/0. Serum toxicology screen was remarkable for an alcohol of 382. Amylase was 277. IMAGING: A head computed tomography was negative. A computer tomography of the cervical spine showed C1-C2 lateral process fracture. A computed tomography of the abdomen was negative. A computer tomography of the right leg showed a distal femur fracture. A chest x-ray was negative. TLS was negative. A repeat abdominal computer tomography - which was done for the elevated amylase and lipase - was again negative. A magnetic resonance imaging of the cervical spine revealed an increased T2 signal of the C2; consistent with known fracture with prevertebral soft tissue swelling and some spinal canal narrowing. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit with a plan of going to the operating room by the Orthopaedic Service. The patient underwent OR washout and ExFix open reduction internal fixation of the right femur on the day of admission. The patient self-extubated on the following day. The patient underwent odontoid screw fixation of the C1-C2 fracture and open reduction internal fixation of the right intercondylar femur fracture on [2139-7-20]. The Intensive Care Unit course thereafter was largely unremarkable. Mostly notable for patient agitation and confusion. Gradual weaning of sedation much improved the patient's mental status. The patient was transferred to the floor on hospital day nine in stable condition. The [Hospital 228] hospital course on the floor was likely unremarkable. The patient had failed a swallow evaluation on the day of transfer to the floor. Therefore, the patient remained on tube feeds until the day of discharge when the patient underwent another swallow evaluation. This time the patient passed, and therefore was advanced to an oral diet. On [7-22], a chest x-ray revealed a resolving left lower lobe infiltrate. In conjunction with the clinical examination, the patient was treated for a likely pneumonia with levofloxacin for a total of a 10-day course, on which the patient was still on at the time of discharge. DISCHARGE DISPOSITION: The patient was discharged to rehabilitation. CONDITION ON DISCHARGE: Stable. MEDICATIONS ON DISCHARGE: 1. Insulin sliding scale. 2. Latanoprost ophthalmic solution 1 drop both eyes at hour of sleep. 3. Lovenox 40 mg subcutaneously once per day. 4. Levofloxacin 700 mg by mouth once per day (times three more days). 5. Hydrochlorothiazide 25 mg by mouth once per day. 6. Haldol 1 mg by mouth at hour of sleep. 7. Metoprolol 100 mg three times per day. 8. Percocet one to two tablets by mouth q.4-6h. as needed. DISCHARGE FOLLOW UP: The patient was to have followup in the Trauma Clinic, [Hospital 9696] Clinic, and with his primary care physician, [Name10 (NameIs) 3] well as Neurosurgery. [First Name11 (Name Pattern1) 518] [Last Name (NamePattern4) ], [MD Number(1) 17554] Dictated By:[Last Name (NamePattern1) 27758] MEDQUIST36 D: [2139-7-27] 07:35:55 T: [2139-7-27] 08:12:40 Job#: [Job Number 56200] ICD9 Codes: 486, 4019, 2720, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7491 }	Medical Text: Admission Date: [2188-10-17] Discharge Date: [2188-10-23] Date of Birth: [2134-7-25] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 943] Chief Complaint: found unresponsive Major Surgical or Invasive Procedure: intubation, mechanical ventilation History of Present Illness: 54 yo male with Hepatitis C cirrhosis and mult admissions for encephalopathy now with admission s/p increasing confusion, ?fall, AMS and intubation for desaturations in the field. Pt found down by sister in home holding onto a door in basement with bruise on head, likely s/p fall. Sister had noticed he had been increasingly confused over the previous few days after having been doing quite well since discharge from [Hospital1 18] [9-26] (?) s/p hepatic encephalopathy; currently compliant on home meds regimen. Pt transfered to OSH, during transfer pt with acute desaturations and was intubated in the field, requiring ativan and pancuronium. Head CT, neck CT neg for acute pathology. Transfered to [Hospital1 18] for further management. On admission to MICU, pt hemodynamically stable on ventilator and responsive to verbal and physical stimuli with ativan on board from OSH. Past Medical History: 1. HCV cirrhosis (hx portal htn/ ascites/ arices/ encephalopathy/ sbp) 2. Chronic Renal Insufficiency (baseline Cr = 1.6) 3. Diabetes Type II 4. Pancytopenia likely d/t hypersplenism 5. chronic hyperkalemia 6. HTN Social History: lives with sister, current 22 [Name2 (NI) 53278] tobacco, h/o IVDU quit 12yrs ago on methadone, h/o alcohol quit [2166] Family History: Father died at 55 CAD, Mother died at 82 lung cancer Physical Exam: 97.3, 153/90, 71, 14, 100% (on AC 600/14/40%/5) Gen sedated, responsive to verbal stimuli and pain HEENT PERRL, anicteric, abrasion on forehead with L periorbital edema Neck supple without deformity Lungs coarse BS b/l CVS RRR Abd soft nt nd, BS wnl, no hsm, fluid wave not appreciated Ext 1+ pitting edema of ankles, petechiae on b/l LE, 2+DPs Neuro exam limited by sedation, moving all extremities and opens eyes Pertinent Results: ECG([10-17]):Sinus arrhythmia Ant/septal+lateral ST-T changes may be due to myocardial ischemia ST-T wave changes in those leads less pronounced than previous ---- Abd U/S([10-18]):1. No portal vein thrombosis. 2. Persistent small amount of ascites. ---- LLE doppler:There is no evidence of DVT. ---- p-MIBI:1) Normal myocardial perfusion. 2) Normal left ventricular cavity size and systolic function. ---- Chemical cardiac stress: No angina with no ischemic ECG changes. Nuclear report will be sent separately. ---- [2188-10-17] 10:37PM BLOOD WBC-2.8* RBC-2.95* Hgb-9.0* Hct-26.4* MCV-90 MCH-30.6 MCHC-34.2 RDW-18.0* Plt Ct-65* [2188-10-23] 06:50AM BLOOD WBC-2.2* RBC-3.27* Hgb-10.0* Hct-29.9* MCV-92 MCH-30.6 MCHC-33.4 RDW-16.9* Plt Ct-60* ---- [2188-10-17] 10:37PM BLOOD PT-15.1* PTT-27.8 INR(PT)-1.4 [2188-10-19] 02:24AM BLOOD Gran Ct-1160* ---- [2188-10-17] 10:37PM BLOOD Glucose-177* UreaN-40* Creat-1.2 Na-147* K-4.5 Cl-114* HCO3-24 AnGap-14 [2188-10-17] 10:37PM BLOOD ALT-20 AST-42* LD(LDH)-271* CK(CPK)-97 AlkPhos-127* Amylase-39 TotBili-0.6 [2188-10-17] 10:37PM BLOOD Lipase-29 ----- [2188-10-17] 10:37PM BLOOD CK-MB-NotDone cTropnT-0.24* [2188-10-18] 06:32AM BLOOD CK-MB-NotDone cTropnT-0.13* [2188-10-19] 02:24AM BLOOD CK-MB-4 cTropnT-0.05* [2188-10-18] 06:32AM BLOOD ALT-19 AST-42* LD(LDH)-256* CK(CPK)-77 AlkPhos-121* Amylase-37 TotBili-1.4 [2188-10-19] 02:24AM BLOOD ALT-19 AST-42* LD(LDH)-207 CK(CPK)-47 AlkPhos-105 Amylase-37 TotBili-0.7 [2188-10-17] 10:37PM BLOOD ALT-20 AST-42* LD(LDH)-271* CK(CPK)-97 AlkPhos-127* Amylase-39 TotBili-0.6 ---- [2188-10-17] 10:37PM BLOOD Albumin-2.7* Calcium-8.5 Phos-4.0 Mg-1.5* [2188-10-20] 06:40AM BLOOD Albumin-2.4* Calcium-7.6* Phos-2.6* Mg-2.0 ---- [2188-10-18] 06:10PM BLOOD Ammonia-49* [2188-10-17] 09:52PM BLOOD Lactate-1.5 ---- [2188-10-17] 10:42PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.015 [2188-10-17] 10:42PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2188-10-17] 10:42PM URINE RBC-14* WBC-0 Bacteri-FEW Yeast-NONE Epi-0 ---- Blood and urine cultures negative Brief Hospital Course: Mr [Known lastname 23657] is a 54 yo with Hep C cirrhosis and a history of hepatic encephalopathy who presented with another apparent bout of encephalopathy and also s/p a fall and ? resp distress requiring intubation. He was intially in the ICU and then extubated and transferred to the floor. 1. Mental status changes/encephalopathy: This was again likely hepatic encephalopathy from worsening liver fxn. The reason he continues to have these episodes in unclear, although infectious cause must be ruled out. He is afebrile and has no evidence of infection. Abd U/S showed again only a small amt of untappable ascites. Not changed from previous admit. A CT of his head was neg, and despite a low Hct, his levels were stable and stol guaiac was negative. This suggests he is not having a GI bleed. Cultures were drawn from blood and urine and were negative for growth. He was continued on a high dose of lactulose with a goal of 5 BMs/day, but was initially having closer to 10. His dose was dropped to get him to an appropriate range, andhe was sent out on this dose. Again, his methaodne was considered to be a possible factor in his mental status alterations. It was initially held in the ICU, but restarted on the floor, and eventually, the team and the patient agreed on a dose of 15 [Hospital1 ]. The patient was to eventually get off of it all together and can hopefully do this as an outpt. His Cipro and Flagyl were continued as well. 2. Hypoxic respiratory failure: Initially had hypoxia in the field and was intubated. Question of whether this was true hypoxia, or intubation was more for airway protection. It resolved in the ICU and he was extubated. He may have been sedated due to his encephalopathy, causing him respiratory problems. For the remainder of his stay, he had no hypoxia or DOE or other pulmonary issues. 3. Cirrhosis: We continued his propranolol and cipro/flagyl as above. He was sent out on [Hospital1 ] dosing of propranolol after his last admit, but was apparently coming back in on tid dosing. This was continued here, and his PCP can hopefully work to decrease this as an outpt if his BP will not becoem too elevated. This medicine will prevent some portal flow and impair his liver even further if not managed appropriately. His lactulose was given with a goal of 5 BMs/day. He was achieving this, so he was sent out on the hospital dose. Again, no tappable ascites or reason to worry about SBP. Also, no hemoptysis or Hct drop that would suggest varices. 4.Methadone: Initially continued 20 [Hospital1 ], and after much resistance, pt agreed to 15 [Hospital1 ]. Would like to eventually get him off of this all together, but his psychological dependence is strong. Can work on this as an outpt. 5. HTN: Continued his propranolol at outpt tid dose. Adequate control, but could probably go down to [Hospital1 ]. 6. DM2: His outpt regimen is unclear as some records indicate he takes glargine while other say glipizide. He was covered here with SSI alone and maintained blood glucoses in the high 100s(covered with insulin for these). Although glipizide not that good a drug for people in liver failure, pt and his sister both state he does not take insulin shots now, but does take glipizide every day. This could not be confirmed with his PCP. [Name10 (NameIs) ] was sent out on a low dose of glipizide for the short term to help control his blood glucose and asked to see his PCP [Name Initial (PRE) 176] 1 week to get on a better regimen long term. Unfortunately insulin amnagement may be too difficult for him due to his mental capacity. 7. EKG changes: He had questionable changes at an OSH, and an ECG read here was also showing possible ischemia. His cardiac enzymes were cycled and he did have a troponin bump, but flat CKs/CK-MBs. This was likely demand ischemia and not an MI. He had a stress in [Month (only) ] but it wasn't an adequate study, so we performed a p-MIBI here. It was normal, with no evidence of ischemia or perfusion defects. The study was adequate. 8.LLE swelling: Thought to be chronic, but got LLE doppler that was neg for DVT. 9.Foley removal:Pt at one point pulled out his own foley with the bulb inflated. He had bleeding from his penis afterwards that was controlled by pressure. He was monitored closely for clots/bladder outlet obstruction. This did not occur. He had one additional episode of gross hematuria, but then reported no blood in his urine. He also reported no additional dysuria/pain. He was urinating noramlly and without blood on discharge. No Hct drop as a result. 10.Pancytopenia:His blood counts were all low, but monitored daily. He never became neutropenic. Also, his Hct was low, but asymptomatic and stable. He was not transfused. His platelets also stayed low, but stable and no dangerous bleeding was observed. He did not require platelets to stop his penile bleeding episode after the folwy removal. He was discharged with close follow-up by his PCP to put him on a good insulin/diabetes regimen, and with Dr [Last Name (STitle) 497]. Medications on Admission: methadone 30 [Hospital1 ], protonix 40 mg, aspranolol 20 tid, cipro 250 qd, flagyl 250 tid, lactulose 45cc tid, lasix 40 qd, nicotine patch, procrit 40K QW, kayexalate 30cc QW, glargine 20u Qpm Discharge Medications: 1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Lactulose 10 g/15 mL Syrup Sig: Sixty (60) ML PO TID (3 times a day). 6. Methadone HCl 10 mg Tablet Sig: 1.5 Tablets PO twice a day. Tablet(s) 7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO qam. 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Gentiva/[Location (un) 86] Discharge Diagnosis: Hepatic encephalopathy HCV cirrhosis CRI Type II diabetes Pancytopenia HTN Discharge Condition: Good. Pt was mentating normally. Walking around without issue. He was at his baseline per pt. Discharge Instructions: Please call your PCP or return to the hospital if you have more confusion, trouble with your thinking, falls, or you are overly sleepy. Also call if you have any other symptoms that concern you, such as fever or chills. We changed your methadone dose to 15 mg twice a day. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: LM [Hospital Unit Name 5628] Phone:[Telephone/Fax (1) 673] Date/Time:[2188-11-5] 11:00 Provider: [Name10 (NameIs) ] TRANSPLANT,ORIENTATION TRANSPLANT CENTER-MEDICINE Where: TRANSPLANT CENTER-MEDICINE Date/Time:[2188-11-13] 3:00 Provider: [Name10 (NameIs) 970],[Name11 (NameIs) 971] TRANSPLANT CENTER-MEDICINE Where: TRANSPLANT CENTER-MEDICINE Date/Time:[2188-12-9] 2:00 Please call your PCP and make an appointment to follow-up within 1 week to discuss your diabetes management and to follow-up after your hospital stay ICD9 Codes: 2767, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7492 }	Medical Text: Admission Date: [2205-12-6] Discharge Date: [2205-12-7] Date of Birth: [2166-7-13] Sex: M Service: MEDICINE Allergies: Gabapentin / Trazodone / Codeine Attending:[First Name3 (LF) 3326] Chief Complaint: ETOH Withdrawl Major Surgical or Invasive Procedure: none Past Medical History: * Subdural hematoma ([2204-4-12]) from fall * Alcohol and polysubstance abuse * Hepatitis C virus infection * Mood disorder with multiple suicide attempts * ?PTSD, bipolar/anti-social personality/impulse/rage disorders * Migraines * Chronic lower back pain * MVA s/p chest tube placement in [2200] * Seizure disorder since [08] yo, alcohol withdrawal seizures (Please see note from [First Name8 (NamePattern2) 730] [Last Name (NamePattern1) ] [2205-12-7] which calls into question the veracity of this history) * Aspiration pneumonia treated at [Hospital1 2177] from [Date range (1) 27397] Social History: Stays with his girlfriend in [Name (NI) ]. - Tobacco: Smokes 5 cigarettes/day last 2-3 years. - Alcohol: 1/5th daily of hard liquour, has been drinking since 9 yo, has h/o DTs and alcohol withdrawal seizures, - Illicits: Past use of cocaine, heroin, opiates, benzodiazepines documented in [Name (NI) ], but patient currently denying any of this. Family History: Father was an alcoholic. Physical Exam: 39M well known to [Hospital1 18] for multiple alcohol related admissions, BIBA for [Last Name (un) 10737] unresponsive on a park bench. The patient states that today he got back together with his long-term girlfriend/wife who brought him a family sized bottle of Listerine in the mall and then layed on bench and became unresponsive. He states that they began to fight and then she beat him about the head and chest with his own cane. She left and at a time distant to the assault he passed out on a park bench. He states that he drank more of the listerine, "being the bigger man." EMS arrived and finger stick was found to be in the 150's. In the ER he opened his eyes and was able to communicate appropriately despite slurred speech. He adamantly claimed that he only drank listerine, and no other drugs. Initial vitals were 99.1 100 144/78 20 100%. . Plan was for CIWA and observation until sober re-evaluation. However after several hours in observation he began to withdraw and score on CIWA for tremulousness and tachycardia. Given his seizure history and requirement of 6mg Ativan over an hour he was transferred to the [Hospital Unit Name ]. . On arrival here, he is alert, interactive and asking for pain meds . Of note Mr [Known lastname 27389] has had multiple recent admissions as follows: - [Hospital1 18] ICU w/ d/c AMA on [11-14] for presumed isopropyl alcohol intoxication and admission from [Date range (1) 27400] to [Hospital1 2177] for presumed aspiration pneumonia on cefpodoxime/azithromycin - [Hospital1 18] [11-28] for fevers, CP, and productive cough cough. . - [Hospital1 18] ICU from [11-13] to [11-14]. Patient was visiting his wife [Name (NI) ] in the ICU when he was noted to become unresponsive. - Durring his hospitalization [11-28] he called his [Company 191] PCP and complained of not getting enough pain meds, he then told his PCP [Name Initial (PRE) ] "if he didnt give him more pain meds he would put him in as much pain as he ([Known firstname ]) was already in." This resulted in the patient being banned from [Hospital 191] clinic, patient relations involvement and an agreement by which Mr. [Known lastname 27389] is not allowed to get any outpatient prescriptions from [Hospital1 ]. Pertinent Results: [2205-12-6] 09:21PM URINE HOURS-RANDOM [2205-12-6] 06:40PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2205-12-6] 10:31PM BLOOD ASA-NEG Ethanol-82* [2205-12-6] 10:31PM BLOOD Osmolal-314* [2205-12-7] 06:15AM BLOOD Osmolal-290 Brief Hospital Course: 39M with complicated social situation and multiple [Hospital1 18] admission for ingestions of alcohol and its related denatured counterparts. . Listerine Ingestion: Per the ingredient list Listerine is 40% etoh and also includes a salicylate. Mr [Known lastname 27401] ETOH level on admission to the ICU was 85 while his salicylate level was negative. It is likely that ETOH was driving all of his assorted issues. This likely explained his lowish anion gap metabolic acidosis on admission. Using the formula that ETOH is corrected for in the osmolar gap by dividing by 3.8, his osmolar gap is accounted for by his ETOH level, making coingestion with isopropanol or ethylene glycol much less likely. He scored only once on CIWA, over 18 hours ago, and currently has normal vital signs. We will plan for discharge. - Per prior agreement he will not be discharged with prescriptions for any medications . Hypoxia: Suspect medication induced hypoventilion c/b splinting leading to increased CO2 and thus increased CO2 admixture via the alveolar gas equation, stably in the low 90's overnight while asleep. Resolved morning of discharge. . Pain control: This patient is a terrible candidate for opiates, and refuses nsaids, we used low dose tylenol and would not give opiates in any situation if possible. Despite sleeping easily, he continued to request fioricet/fioranol for his migraines when he awakened, but this medication was not in his medication discarge list. He was given tylenol. . Rib Pain: No hct drop to raise c/f splenic rupture, no fractured ribs, no ptx . Multiple Psychiatric diagnoses: Patient was continued on his home regimen, he should continue with his home supply at home. . ?Seizure d/o history: . [First Name8 (NamePattern2) ] [Doctor Last Name ] recent note calls into question his seizure history; however, the patient comes in with a positive barbiturate level. Given his lack of seizure disorders and previous plans, we will discharge him without a prescription for phenobarb. . Dicharge planning: Please refer to the below note from Chief Resident [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] regarding his rules for discharge. . " After discussion with the patient and his consulting services, we will not provide prescriptions for any of his reported home medication including clonazepam, carbamazepine, amitriptyline, olanzapine or mirtazapine. At this time, the risk of significant toxicity including death, in the setting of his [Last Name (NamePattern1) 17577] substance abuse is greater the risk of any potential withdrawal symptoms. . After discussion with neurology we will provide the patient with a short duration of phenobarbital with planned Neurology Access Clinic follow up." Medications on Admission: Meds he should be on that are no longer prescribed by [Hospital1 18]: . thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY cholecalciferol (vitamin D3) 1,000 unit DAILY (Daily). folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). multivitamin Tablet Sig: One (1) Tablet PO once a day. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for Pain. amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). olanzapine 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). Discharge Medications: Meds he should be on that are no longer prescribed by [Hospital1 18]: . thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY cholecalciferol (vitamin D3) 1,000 unit DAILY (Daily). folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). multivitamin Tablet Sig: One (1) Tablet PO once a day. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for Pain. amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). olanzapine 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: ETOH withdrawl Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [Known lastname 27389] you were admitted to the [Hospital1 ] with alcohol withdrawl from drinking listerine. As you know your previous actions at [Hospital1 ] have resulted in our inability to provide you with any outpatient medications. You must establish follow-up with health care for the homeless as soon as possible. You also should follow up with neuro as soon as possible. . Please call [Hospital 86] Healthcare for the Homeless at ([Telephone/Fax (1) 27399] to schedule an appointment for PCP [Name Initial (PRE) ]. If you are feeling concerned about your mental health, you can contact the [Name (NI) 86] Psychiatry Urgent Care Service at 1-[Telephone/Fax (1) 20233]. Please call neurology at [Telephone/Fax (1) 44] to schedule an appointment to be seen as soon as possible in the [Hospital 878] Clinic. Followup Instructions: see above, remember you are no longer able to follow-up at [Company 191] Completed by:[2205-12-7] ICD9 Codes: 2762, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7493 }	Medical Text: Admission Date: [2148-3-11] Discharge Date: [2148-3-21] Date of Birth: [2105-5-31] Sex: M Service: CARDIOTHORACIC Allergies: Bactrim Attending:[First Name3 (LF) 2969] Chief Complaint: Barrett's Esophagus Major Surgical or Invasive Procedure: [2148-3-11] Transhiatal esophagectomy, feeding jejunostomy. History of Present Illness: The patient is a 42-year-old gentleman who had a longstanding history of gastroesophageal reflux disease, almost since birth. Despite being on many medications, the patient has had persistent symptoms. Repeat EGD has shown the patient of the long segment Barrett's disease, approximately 7 cm in length. Biopsy of one of these areas of Barrett's revealed high-grade dysplasia. As such, it was decided to proceed with esophagectomy. Past Medical History: GERD (since birth, protonix since [8-20]), Hiatal Hernia OSA w/ home CPAP, RA, IBS, s/p R tib ORIF '[19], s/p R testicular rupture, s/p Right Inguinal Hernia Repair, s/p L knee synovectomy for RA Social History: 25 pk-yr active smoker, no ETOH Family History: Non-Contributory Physical Exam: General: 42 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple, no lymphadenopathy Card: RRR, normal S1,S2, mucus membranes moist Resp: decreased breath sounds throughout GI: obese, abdomen soft non-tender/non-distended. J-tube in place Extr; warm tr edema Incision: Neck; open clean pink granuated tissue with mild dishcarge, Mid-Abdomn clean/dry/intact w/staples Neuro: non-focal Brief Hospital Course: Mr. [Known lastname 4541] was admitted on [2148-3-11] and underwent successful Transhiatal esophagectomy, and feeding jejunostomy tube placement. He was awakened, extubated, and brought to the SICU in stable condition. The NG-tube and left chest tube were placed to suction. The J-tube was to gravity, neck drain to bulb suction and foley to gravity. He had an epidural and PCA for pain managed by the pain service. He was monitored overnight remained hemodynamically stable and was transferred to the floor. On POD #2 he was started on beta-blockers, gently diuresed, and trophic feeds were started. He was seen by nutrition who recommended Replete with fiber goal of 70cc/hr. POD #3 the chest-tube was removed. POD #4 the neck drainage was noted to have a leak at the anastomosis site, the wound was opened and treated with wet-dry dressing. The drain was removed. The epidural and PCA were removed and he was converted to PO oxycodone elixir via J-tube with good control. His foley was removed and he voided without difficulty. On POD #5 his bowel function returned and his tube feeds was advanced to goal which he tolerated. He was followed by physical therapy. On POD #8 he underwent left thoracentesis for 500cc fluids. A follow-up chest x-ray was stable no pneumothorax. He continued to make steady progress and was discharged to home with VNA on POD 10. He will follow-up with Dr. [Last Name (STitle) ] and undergo a Barium Swallow in weeks. Medications on Admission: Protonix 40 daily, Leucin 40 tid, Imodium prn Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Last Name (STitle) ]: 5-10 MLs PO Q4H (every 4 hours) as needed: give via J-tube. Disp:480 ML(s) Refills:0 2. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: Ten (10) ML PO BID (2 times a day): give via J-tube. 3. Lopressor 100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day: Crush and give via J-tube and flush with 50cc of water after. Disp:60 Tablet(s) Refills:2 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] once a day: give via J-tube. Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Barrett's esophagus w/ HG dysplasia, s/p transhiatal esophagectomy Hiatal Hernia, OSA w/ home CPAP, RA, Irritable bowel syndrome s/p R tib ORIF '[19], s/p R testicular rupture, s/p Right Hiatal Hernia repair, s/p L knee synovectomy for RA Discharge Condition: Good Discharge Instructions: Call Dr.[Last Name (STitle) 28484] office [Telephone/Fax (1) 170] if experience: -Fever > 101 or chills, -Increased shortness of breath, chest pain -Difficulty swallowing or pain with swallowing -Vomiting, diarrhea or abdominal pain -Incision develops discharge or increased redness You may shower, no bathing or swimming for 6 weeks No driving while taking narcotics. Continue stool softners with narcotics. If your feeding tube sutures become loose or break, please tape tube securely and call the office [Telephone/Fax (1) 170]. If your feeding tube falls out, save the tube, call the office immediately [Telephone/Fax (1) 170]. The tube needs to be replaced in a timely manner because the tract will close within a few hours. Do not put any medication down the tube unless they are in liquid form. Flush your feeding tube with 50cc every 8 hours if not in use and before and after every feeding and medications Neck Dressing change wet-moist twice daily Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] on [2148-4-4] at 11:30am on the [Hospital Ward Name 5074] [Hospital Ward Name 23] Clinical Center [Location (un) 24]. Report to the [Location (un) ] Radiology Department for a UPPER GI RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2148-4-4] 10:30am Tube feeds off at Midnight [2148-4-4] for Barium Swallow Completed by:[2148-3-21] ICD9 Codes: 5119
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7494 }	Medical Text: Admission Date: [2187-7-21] Discharge Date: [2187-7-23] Date of Birth: [2140-7-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1115] Chief Complaint: Near drowning. Major Surgical or Invasive Procedure: Intubation EGD History of Present Illness: 47yo M with PMHx of alcochol dependence who presented from OSH after being found face down in pool where at the OSH, the patient was intubated, transferred to [Hospital1 18] for further management and concern for ARDS. Patient was found face down in pool by friends. [Name (NI) ] family report, the patient was done maybe a minute. He was pulled out of the pool by other people. Patient's family is unsure of whether the patient had been drinking that night. EMS was called and per family report chest compressions were started. During chest compressions, the family reports that blood was noted to be coming from the patient's mouth. EMS attempted intubation in the field, but was unsucessful. The patient was brought to OSH, where the patient was intubed. He initially had a pressor requirement with Levophed which was discontinued as the OSH. He was noted to have EtOH intoxication with level of 400 and urine tox screen returned positive for benzodiazepines. The patient was transferred to the ICU for further management. Head CT, Chest CT, abdominal CT were all negative at OSH. He was started onceftriaxone and azithromycin. Patient was transferred to [Hospital1 18] out of concern for ARDS. On arrival to the MICU, patient is sedated, able to follow commands. Review of systems: Unable to obtain [2-22] intubation. Past Medical History: History of excessive EtOH abuse, but reportedly none recently. Multiple prior DUI's in the past. Social History: Smokes 2ppd. Patient's family denies recent EtOH consumption, but reports that in the past, the patient has had difficulty to heavy EtOH consumption. Family denies illicit drug use. Family History: Family history anuerysms (brain and thoracic). Physical Exam: Discharge exam: VS: T 97.6 BP 136/78 P 70 R 18 O2 94%RA General: NAD, AAOx3 HEENT: EOMI, PERRL, Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: mild wheezing in upper lung fields, crackles LLQ Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [2187-7-21] 01:15AM BLOOD WBC-13.6* RBC-4.46* Hgb-12.9* Hct-38.8* MCV-87 MCH-29.0 MCHC-33.4 RDW-13.2 Plt Ct-181 [2187-7-21] 01:15AM BLOOD PT-12.0 PTT-27.3 INR(PT)-1.1 [2187-7-21] 01:15AM BLOOD Glucose-109* UreaN-18 Creat-0.9 Na-147* K-3.6 Cl-112* HCO3-27 AnGap-12 [2187-7-21] 01:15AM BLOOD ALT-53* AST-26 LD(LDH)-221 CK(CPK)-339* AlkPhos-47 TotBili-0.4 [2187-7-21] 01:15AM BLOOD Albumin-3.6 Calcium-8.0* Phos-2.0* Mg-2.0 [2187-7-21] 01:37AM BLOOD Type-ART Temp-38.1 Rates-18/ Tidal V-450 PEEP-10 FiO2-100 pO2-301* pCO2-54* pH-7.36 calTCO2-32* Base XS-3 AADO2-353 REQ O2-64 Intubat-INTUBATED [2187-7-21] 01:37AM BLOOD Lactate-1.3 [2187-7-21] 04:29AM BLOOD freeCa-1.11* Discharge labs: [2187-7-23] 07:16AM BLOOD WBC-7.9 RBC-4.49* Hgb-13.0* Hct-38.1* MCV-85 MCH-28.9 MCHC-34.1 RDW-12.1 Plt Ct-214 [2187-7-23] 07:16AM BLOOD Glucose-97 UreaN-18 Creat-0.8 Na-143 K-3.7 Cl-107 HCO3-27 AnGap-13 [2187-7-22] 02:55AM BLOOD ALT-38 AST-19 CK(CPK)-166 AlkPhos-47 TotBili-1.0 [2187-7-23] 07:16AM BLOOD Calcium-8.7 Phos-3.6# Mg-2.0 Micro: [2187-7-21] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST-Negative [2187-7-21] MRSA SCREEN MRSA SCREEN-Negative [2187-7-21] URINE URINE CULTURE-Negative [2187-7-21] BLOOD CULTURE Blood Culture, Routine-No growth at the time of discharge [2187-7-21] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-Commensal respiratory flora Imaging: [2187-7-21] CXR: 1. Endotracheal tube has its tip 5 cm above the carina. There is a nasogastric tube seen coursing below the diaphragm with the tip not identified. There is a 1.6-cm nodule in the right lung base, which, given its density, would favor a benign process such as a granuloma. Comparison to remote chest imaging to assess for stability would be advised. In the absence of these studies, followup imaging with chest plain film in three months versus dedicated chest CT should be considered. Otherwise, the lungs appear grossly clear. No pleural effusions or pneumothoraces. No evidence of pulmonary edema. Cardiac and mediastinal contours are within normal limits. No evidence of focal airspace consolidation to suggest pneumonia. [2187-7-22] CXR: Interval extubation and removal of nasogastric tube. New poorly defined opacities have developed at the left lung base, and may be due to atelectasis or aspiration considering recent extubation. Lungs are otherwise clear except for a right lower lobe calcified granuloma. [2187-7-23] CT chest w/o contrast: TECHNIQUE: Volumetric, multidetector CT of the chest was performed without intravenous or oral contrast. Images are presented for display in the axial plane at 5-mm and 1.25-mm collimation. A series of multiplanar reformation images were also submitted for review. FINDINGS: A benign diffusely calcified granuloma is present laterally in the right lung base measuring about 1 cm in diameter and corresponding to the recent chest x-ray finding. Within the right infrahilar region, a cluster of calcified peribronchial lymph nodes are present, and results in some extrinsic compression of the lateral segment bronchus. Additional noncalcified nodes are present in this region as well. Multiple peribronchiolar nodules are present involving the left lung to a greater degree than the right, and accompanied by mild bronchial wall thickening. Many of the opacities have a tree-in-[Male First Name (un) 239] configuration, particularly within the left lower lobe. Additional involvement is seen within the left upper lobe, right lower lobe, and right upper lobe. Small, dependent pleural effusions are present bilaterally, right greater than left, with adjacent areas of dependent atelectasis. Heart size is normal. Focal coronary artery calcifications are present. No pericardial effusion. Small hiatal hernia incidentally noted. Exam was not specifically tailored to evaluate the subdiaphragmatic region, but no concerning abnormalities are identified in this region on this very limited assessment. No suspicious lytic or blastic skeletal lesions. 2.3 cm diameter low-attenuation well-circumscribed subcutaneous lesion in the posterior chest wall to the right of midline is likely a sebaceous cyst. IMPRESSION: 1. Benign calcified granuloma in right lower lobe requires no further imaging followup. Calcified and noncalcified right infrahilar lymph nodes with extrinsic compression of lateral segment bronchus, likely placing patient at risk for broncholithiasis. Recommend monitoring for symptoms of this condition such as hemoptysis, cough, lithoptysis and recurrent infections. 2. Multifocal peribronchiolar nodules accompanied by bronchial wall thickening, most marked in the left lower lobe. Findings are consistent with either bronchiolar infection or aspiration. 3. Small dependent pleural effusions, right greater than left. [2187-7-22] EGD: Ulcers in the antrum and stomach body Abnormal mucosa in the antrum Erythema and friability in the duodenal bulb compatible with duodenitis Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 47yo M with PMHx of alcochol dependence who presented from OSH after being found face down in pool where at the OSH, the patient was intubated, transferred to [Hospital1 18] for further management and concern for ARDS, successfully extubated and treated for pneumonia. # Respiratory failure/Pneumonia: Patient intubated upon arrival to the OSH after being found face down in pool for unknown amount of time. Patient was extubated on day 2 of hospitalization. Initially broadly covered with Vanc/CTX/Azithromycin. CXR and CT chest concerning for aspiration PNA. Leukocytosis to 18 at OSH. 7.9 by discharge. Patient with productive cough after extubation, but sputum culture only showed respiratory flora. Patient also does have 60+ year smoking history. O2 sat on discharge was mid 90s on room air. Patient discharged on cefpodoxime (last day [7-27]) and azithromycin (last day [7-25]) for a total of 7 day course. # History of alcohol abuse: Patient's endorses remote EtOH abuse, but reports this was an isolated incidence. Social worker provided support and education. Patient initially covered with CIWA, but did not have evidence of EtOH withdrawal. # Bloody NGT output: Patient on pantoprazole at OSH 40mg IV daily. EGD showed gastric ulcers without evidence of active bleed. No hematemesis and Hct stable since extubation. DC'd home on PO pantoprazole. Need PCP to help arrange repeat EGD in [6-29] weeks. # Lung nodule: Granulomatous lung nodule seen on CXR. CT chest showed benign calcified nodule that require no additional imaging followup. # Transitional issues: - code status: full - follow up: with PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] in [State 108] - new medications: Cefpodoxime, Azithromycin, pantoprazole - pending studies: blood culture no growth at the time of discharge - follow up issues: needs repeat EGD in [6-29] weeks Medications on Admission: Aleeve prn pain Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 3 Days day 1= [7-21] RX azithromycin 250 mg 2 Tablet(s) by mouth daily Disp #2 Tablet Refills:0 2. Pantoprazole 40 mg PO DAILY RX pantoprazole 40 mg 1 Tablet(s) by mouth daily Disp #30 Tablet Refills:1 3. Cefpodoxime Proxetil 200 mg PO Q12H RX cefpodoxime 200 mg 1 Tablet(s) by mouth every twelve (12) hours Disp #8 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Aspiration pneumonia Drowning Alcohol Abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 112528], It was a pleasure participating in your care at [Hospital1 18]. You were admitted after you were found in a pool after drinking alcohol. You were initially intubated (on a breathing machine) to help you breath, and you were treated for pneumonia with antibiotics. Please continue antibiotics as listed below. Please abstain from alcohol to prevent this from occuring in the future. We also found that you have stomach ulcers that are not actively bleeding. You should avoid medications such as Advil, Aleeve, naproxen, ibuprofen, and only take tylenol as needed for pain. Please take pantoprazole for this as directed. You will need a follow up EGD (endoscopy) in [6-29] weeks. Please arrange this with Dr. [Last Name (STitle) ]. We made the following changes to your medications: STARTED Cefpodoxime (last day [2187-7-27]) STARTED Azithromycin (last day [2187-7-25]) STARTED Pantoprazole daily STOPPED Aleeve Followup Instructions: Please call Dr.[Name (NI) 97678] office at [Telephone/Fax (1) 112529] to schedule a follow up appointment within a week of your discharge from the hospital. Completed by:[2187-7-23*] ICD9 Codes: 5070, 5119, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7495 }	Medical Text: Admission Date: [2184-4-21] Discharge Date:[2184-4-27] Date of Birth: [2125-5-16] Sex: M Service: [Location (un) 259] MEDICINE CHIEF COMPLAINT: Fevers and chills, called out from Surgical Intensive Care Unit on [4-23]. HISTORY OF PRESENT ILLNESS: This is a 58 year-old male with a history of end stage renal disease on hemodialysis, history of chronic right foot infections, status post left below knee amputation and a history of thrombosed right upper extremity AV fistula, status post left IJ tunnel PermaCath with a history of GI bleed and ischemic colitis, History of IVDU who was initially admitted from the hemodialysis center as an outpatient where developed fevers, hypotension and altered mental status. He was subsequently admitted to the Intensive Care Unit where he received intravenous fluids and Dopamine drip for less than 12 hours. The patient was pancultured at the time for suspected sepsis and blood cultures on [4-21] grew out 2 out of 4 bottles showing gram positive cocci in pairs and clusters and a foot culture with gram stain showing 3+ positive cocci and 2+ gram negative rods. In addition, his right foot was noted to be malodorous with pus and he is treated empirically with Vancomycin and meropenem and one dose of ceftazidime. Podiatry was consulted and recommended right foot amputation, but patient adamantly refused and so was subsequently transferred to the floor medicine team, with further evaluation from podiatry and possible surgical foot debridement. Patient also had chronic left shoulder pain. Shoulder and neck films in the unit showed that the patient had no acute pathology that explained the shoulder pain. On the morning of transfer the patient was being dialyzed. He wa s awake, alert and had no complaints of shortness of breath, chest pain, light headedness or dizziness. Patient notes chronic left shoulder pain with no radiation. Denies night sweats, fevers or chills. Denies nausea, vomiting or diarrhea. PAST MEDICAL HISTORY: 1) End stage renal disease on hemodialysis. 2) History of thrombosed right upper extremity AV fistula. 3) Status post left IJ PermaCath tunneled. 4) Diabetes mellitus type 2. 5) Hepatitis B. 6) Hypertension. 7) Ischemic colitis with GI bleed. 8) Tuberculosis in the past. 9) Status post left below knee amputation. 10) Multiple right foot infections. 11) History of drug use. 12) Congestive heart failure with an ejection fraction of 55 percent and normal wall motion. 13) History of VR and MRSA. MEDICATIONS ON ADMISSION: Norvasc 10 mg p.o. q day, multivitamin, folate 1 mg p.o. q day, Renagel 800 mg p.o. t.i.d., NPH 40 units q P.M., 60 units q A.M., insulin sliding scale, Epogen 30,000 units subcutaneous three times weekly, Vicodin p.r.n., aspirin 81 mg p.o. q day, Coumadin 1 mg p.o. q day, Protonix 40 mg p.o. q day, Neurontin 100 mg p.o. b.i.d. and methadone 100 mg p.o. q day. PHYSICAL EXAMINATION: Temperature 97.9, blood pressure 128/78, heart rate of 90, respiratory rate of 16, satting 98 percent on room air. In general, this was a gentleman who was awake, alert on hemodialysis, chronically ill appearing in no apparent distress. Oropharynx is clear. No jugular venous distention, no masses in the neck. Chest: Tunneled right catheter with dressing clean, dry and intact. Decreased breath sounds bilaterally. Coronary regular rate and rhythm. Abdomen soft, nontender, nondistended, positive bowel sounds. Extremities: Status post left below knee amputation. Right foot with 3+ edema with dressing clean, dry and intact. Neurologic alert and oriented times three, moved all extremities spontaneously. HOSPITAL COURSE: 1. Sepsis: Patient was transferred to the Intensive Care Unit after three days for hypotension. Patient was resuscitated with intravenous fluids as well as Dopamine for less than 12 hours as above. Culture data showed bacteremia that was persistent. The patient was maintained on Vancomycin dose by levels and meropenem. Patient underwent a foot debridement on [4-23] by podiatry for further evaluation and debridement of his wound. Podiatry had recommended a right foot amputation for optimal control. However, the patient adamantly refused and did not want his other foot amputated as well. Patient up to the date of this discharge summary had no growth to date on his surveillance cultures from [4-23] and [4-25]. 2. Right foot infection: Podiatry was managing this patient in terms of his foot infection. The patient underwent operating room surgical debridement on [4-23] that was uncomplicated. Cultures are still pending. The patient was maintained on Vancomycin and Meropenem. 3. End stage renal disease on hemodialysis: Renal was consulted in management of this patient. Patient was dialyzed Monday, Wednesday and Friday, was continued on phos lowering agents. Patient was also maintained on 1 mg of Coumadin at night for prophylactic use for his tunnel catheter. 4. Diabetes mellitus: The patient was maintained on his NPH. [Last Name (un) ] was consulted in management of the patient. They recommended alternating his NPH for optimal control. The patient was maintained on a regular sliding scale with q.i.d. blood glucose fingers. 5. Cardiology: The patient had an ejection of 55%, question diastolic dysfunction. Given the fact that he is hypotensive his antihypertensive medications were held during this hospital stay until his blood pressure normalized. 6. Chronic pain: The patient had a history of chronic pain as well as history of intravenous drug use and possible heroin use. Patient was maintained on his outpatient doses of methadone and p.r.n. Vicodin postoperatively. Also for chronic right shoulder pain. 7. Anemia: The patient with anemia of chronic disease and end stage renal disease. Patient was transfused for hematocrit of less than 28 percent. Patient got one unit of packed red cells at dialysis on [4-23] and was maintained on his Epogen shots three times weekly at hemodialysis. 8. Constipation: Patient was maintained on Colace, Senna and Dulcolax. 9. Prophylaxis: Patient was maintained on proton pump inhibitor and Pneumoboots. 10. Code: Patient was maintained on full code. The remainder of the hospital course will be dictated by the next intern who will be covering for this patient. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 9755] Dictated By:[Last Name (NamePattern1) 5227] MEDQUIST36 D: [2184-4-25] 22:03 T: [2184-4-25] 22:31 JOB#: [Job Number 101057] ICD9 Codes: 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7496 }	Medical Text: Admission Date: [2146-4-3] Discharge Date: [2146-4-7] Date of Birth: [2120-3-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1042] Chief Complaint: Abdominal Pain, Nausea, Vomitting Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 64236] is a 26 y/o man with IDDM for 8 years who presents with several days of nausea/vomiting and abdominal pain. Two weeks ago, he was diagnosed with sinusitis/sinus infection and given antibiotics. He first noticed epigastric abdominal pain about one week ago, constant, without relation to food. It was a strong, sharp pain that did not radiate. Notably, he had been taking ibuprofen 800 mg q3h for headache associated with sinusitis at that time. In past 2-3 days noticed increased nausea with vomiting. Denies hematemesis. Notes that he last kept something liquid down yesterday morning, but vomitted up everything (both liqiuds and solids) through the day and night. Thus, he came to [Hospital1 18] ED that night. Took insulin during that time intermittently but this is typical for him. . His insulin control and FSG checking has chronically been very poor. He admits to taking insulin about 5 times per week. Further, when he does take it, he taked a standing dose of 10U Reg and 30U of 70/30. He takes his FSG about 1 per month due to discomfort with the prick. He has chronic polyuria and polydypsia. He reports getting regular vision checks with [Last Name (un) ] center and no knowledge of neuropathy, kidney disease, or eye problems. . On ROS, he denies HA, changes in vision, hearing, or swallowing. No fever, sweats, chills, weight loss. He eats very well. No CP, palps, PND, orthopnea. No SOB, pain with breathing, cough, wheeze. No recent bowel of bladder dysfunction. No troubles with limb weakness, sensory changes, poor coordination. He does feel episodes of hypoglycemia if he does not eat following insulin: sweating, palpitations, and anxiety. Past Medical History: IDDM: Poorly controlled DKA X 3 Periperal neuropathy Social History: Patient denies any tobacco use. Uses ETOH socially. No drug use. Patient is a mental health worker in [Last Name (un) 64237] center, he currently lives with fiance. Pt is engaged and expecting daughter in next week. Lives in [Location 18600]. Family History: Family history positive for DM,CVA, cardiac disease [Name (NI) ] mother died at age 45 from heart disease related to diabetes No family history of sickle cell disease Physical Exam: T: 98.8 BP: 139/78 HR: 112 RR: 17 O2 100% RA Gen: Pleasant, well appearing young male in no acute distress, lying comfortably in bed HEENT: No conjunctival pallor. No scleral icterus. MM slightly dry. OP clear. Eye funduscopic exam WNL (no exudates, edema, wiring) NECK: Supple, No LAD, JVD not elevated while sitting upright. No goiter CV: Tachycardic, regular, no appreciable murmur. Physiologically splitting S2. LUNGS: clear to auscultation bilaterally, no wheezing or rhonchi ABD: soft, nontender to palpation, no hepatosplenomegaly EXT: warm, well perfused throughout, no peripheral edema SKIN: No rashes or ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength throughout. [1-19]+ reflexes, equal BL. Normal coordination. Distal foot sensation to light touch decreased. Pertinent Results: MICU Results: [2146-4-3] 08:17PM BLOOD WBC-14.6# RBC-5.97 Hgb-15.6 Hct-48.8 MCV-82 MCH-26.2 MCHC-32.0 RDW-12.6 Plt Ct-327 [2146-4-3] 08:17PM BLOOD Glucose-404* UreaN-16 Creat-1.3* Na-143 K-4.5 Cl-99 HCO3-12* AnGap-37* [2146-4-4] 02:46AM BLOOD Calcium-9.8 Phos-2.9 Mg-1.9 [2146-4-3] 09:52PM BLOOD ALT-13 AST-11 AlkPhos-75 TotBili-0.3 [2146-4-4] 12:22PM BLOOD %HbA1c-14.8* Floor Transfer: [2146-4-5] 04:30AM BLOOD WBC-10.1 RBC-4.97 Hgb-13.2* Hct-39.9* MCV-80* MCH-26.6* MCHC-33.1 RDW-13.0 Plt Ct-267 [2146-4-5] 04:30AM BLOOD Glucose-187* UreaN-10 Creat-0.7 Na-142 K-3.0* Cl-110* HCO3-19* AnGap-16 [2146-4-6] 06:30AM BLOOD Glucose-232* UreaN-8 Creat-0.7 Na-145 K-3.9 Cl-111* HCO3-24 AnGap-14 [2146-4-5] 04:30AM BLOOD Calcium-9.1 Phos-2.2* Mg-1.8 CXR: FINDINGS: The lungs are well expanded and clear. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is evident. The visualized osseous structures are unremarkable. IMPRESSION: No acute pulmonary process. Brief Hospital Course: On arrival to MICU, patient complaining of ongoing nausea and epigastric pain. Vomitting X 2 was witnessed by house staff, the second episode occurring with a small amount of hematemesis. No subsequent hematemesis or significant Hct change. In the MICU, he was placed on insulin drip, IVF, and electrolytes (most notably K) were repleted as needed. His Anion Gap narrowed from 30 to 13 by transfer to floor. His FSGs were initially high 400s and fluctuated between 200-500 in the MICU. Following stabilization, the patient was transferred to the medical floor. His FSG was 420 upon transfer. He was receiving standing NPH [Hospital1 ] and Regular ISS with meals. On floor day 1, his FSGs were in the 200s. His anion gap closed. Potassium and Phos were repleted. The [Last Name (un) ] center was also consulted. . Discharge Medications: 1. 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 2. Insulin Lispro 100 unit/mL Insulin Pen Sig: As per sliding scale Units Subcutaneous four times a day: Use number of units indicated on sliding scale for your measured blood glucose level before breakfast, lunch, dinner, and at bedtime. Disp:2 Pens Refills:5 3. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Forty (40) Units Subcutaneous at bedtime. Disp:2 Pens Refills:2 4. Lancets Misc Sig: One (1) lancet Miscellaneous qachs. Disp:120 lancets Refills:2 5. Test strips One test strip qachs dispense 120 Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic ketoacidosis, IDDM with features of insulin resistance. Discharge Condition: Good Discharge Instructions: You were admitted to the hospital for diabetic keto-acidosis. Diabetic ketoacidosis (DKA) is a severe and life threatening condition that results from uncontrolled blood sugar. This episode of DKA happened becuase you were not regularly taking insulin and becuase your blood sugar was very high. Your recent sinus infection could have also worsened your condition. As a result of this condition, you required admission to the intensive care unit. During your hospitalization, your blood sugar, electrolytes, and metabolism, in general, were restored to a more normal condition. It is extremely important that you keep your blood sugars at more normal levels or this life-threatening condition will happen again. Also, you will develop eye problems, kidney disease, worse leg numbness, and heart disease if your sugars are not controlled better. In order to control your sugars, you need to follow the Insulin regimen that was prescribed by the [Last Name (un) ] center. You will have to take 2 types of insulin. You will take a dose of long acting insulin (Lantus) every night and this dose will be constant. You will take a dose of Humalog insulin before every meal based on the sliding scale chart - thus you have to check your sugar at this time. If you find that you are unable to follow the above insulin plan, you have to call your doctor at the [Hospital ] clinic. Due to your high use of Motrin before admission, you irritated the lining of your stomach. Thus, we treated this problem with a medicine to decrease the acid in your stomach called pantoprazole. You should continue taking this medicine until you see your PCP and [Name9 (PRE) 10748] your stomach problem. If you begin to again experience increasing nausea, vomitting, abdominal pain, or any other concerning symptom, you should contact your PCP or go to the ER. Followup Instructions: You need to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3636] for diabetes care. Your first appointment is [4-29] at 4PM. This appointment is very important!!! You can call ([Telephone/Fax (1) 17484] and ask for Dr.[Name (NI) 64238] office if this time does not work. You need to schedule an appointment with you primary care doctor within the next few weeks to followup your stomach pain after taking Motrin. ICD9 Codes: 3572, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7497 }	Medical Text: Admission Date: [2102-4-13] Discharge Date: [2102-4-17] Date of Birth: [2026-1-20] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [4-13] MVR (29mm [First Name8 (NamePattern2) ] [Male First Name (un) 923] porcine) History of Present Illness: 76 yo F walking to dentists office [3-22] and had SOB/CP/diaphoresis. Transferred to [Hospital1 18] where cath showed 4+MR. Referred for MVR. Past Medical History: # HTN # Bipolar Disorder, had been on lithium, now on risperdal # h/o syncope in [2091] while driving - Some ? of HOCM per [2091] ECHO w/ LV mid cavity gradient increase from 57 to 91 with valsalva - [2092] repeat echo with diminished gradient - Per Dr. [Last Name (STitle) 911], she does not have HOCM. # venous insufficiency w/ history of LLE ulcer # h/o BRBPR with c-scope in [8-15] with grade 1 hemorrhoids # Grave's Disease based on 38% iodine uptake, followed s/p thyroid ablation now on thyroid replacement # Left Medial/Lateral meniscal tear s/p arthroscopy in [2090] due to OA of the knee s/p MVA in [2083] # s/p b/l TKR in [2091] # s/p Left Tibial IM rod # Rectopexy for prolapsed rectum in [2092] # Microhematuria - b/l echogenic kidneys with only mildly diminished renal function # urinary retention # OA # GERD # s/p TAH [2077] # s/p Appy . Social History: She is a nun. Lives in [Location 912] at [Hospital1 913]alone. No tobacco, EtOH, or drugs. Family History: Sister with breast cancer. Father died of MI at 80. Brother died of MI at 40. Physical Exam: HR 57 RR 15 BP 153/79 NAD Lungs CTAB ant/let Heart RRR, + murmur Abdomen Obese, well healed [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 924] warm, no edema; LLE cellulitis & statis changes; well healed bilateral TKR scars Pertinent Results: [2102-4-16] 08:45AM BLOOD WBC-6.0 RBC-2.98* Hgb-8.6* Hct-25.3* MCV-85 MCH-28.8 MCHC-34.0 RDW-15.0 Plt Ct-131* [2102-4-16] 08:45AM BLOOD Plt Ct-131* [2102-4-16] 08:45AM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-135 K-3.9 Cl-103 HCO3-23 AnGap-13 CHEST (PORTABLE AP) [2102-4-15] 10:02 AM CHEST (PORTABLE AP) Reason: s/p removal of chest tubes [Hospital 93] MEDICAL CONDITION: 76 year old woman pod 2 s/p MVR, now s/p chest tube removal REASON FOR THIS EXAMINATION: s/p removal of chest tubes EXAMINATION: AP chest. INDICATION: Mitral valve replacement. Status post chest tube removal. Single AP view of the chest is obtained [2102-4-15] at 10:30 hours and compared with the prior radiograph of [2102-4-13] at 14:20 hours. Patient has been extubated and chest tubes have been removed as has a right-sided Swan-Ganz catheter. Patient is status post cardiac surgery. Increased retrocardiac density in the left side with obscuration of the left hemidiaphragm persists and is consistent with postsurgical atelectasis in the left base. Small left pleural effusion may also be present. In the upper abdomen there is colon interposition on the right side. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 925], [Known firstname ] [Hospital1 18] [Numeric Identifier 926] (Complete) Done [2102-4-13] at 10:21:00 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2026-1-20] Age (years): 76 F Hgt (in): 64 BP (mm Hg): 132/74 Wgt (lb): 162 HR (bpm): 56 BSA (m2): 1.79 m2 Indication: Intra-op TEE for MVR ICD-9 Codes: 440.0, 424.1, 424.0 Test Information Date/Time: [2102-4-13] at 10:21 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 #: 2008AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 5.5 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.8 cm Left Ventricle - Fractional Shortening: 0.22 >= 0.29 Left Ventricle - Ejection Fraction: 55% >= 55% Left Ventricle - Stroke Volume: 102 ml/beat Left Ventricle - Cardiac Output: 5.72 L/min Left Ventricle - Cardiac Index: 3.19 >= 2.0 L/min/M2 Aorta - Annulus: 1.8 cm <= 3.0 cm Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Arch: 2.6 cm <= 3.0 cm Aorta - Descending Thoracic: 2.6 cm <= 2.5 cm Aortic Valve - Peak Velocity: 2.2 m/sec <= 2.0 m/sec Aortic Valve - LVOT pk vel: 1.30 m/sec Aortic Valve - LVOT VTI: 36 Aortic Valve - LVOT diam: 1.9 cm Aortic Valve - Valve Area: 1.5 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe mitral annular calcification. Eccentric MR jet. Effective regurgitant orifice is >=0.40cm2. MR vena contracta is >=0.7cm Severe (4+) 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. No TEE related complications. The patient appears to be in sinus rhythm. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. The left atrium is moderately dilated. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. An eccentric,anterior directed jet and a central jet are seen The effective regurgitant orifice is >=0.40cm2 The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. 7. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. A well-seated bioprosthetic valve is seen in the mitral position with normal leaflet motion. No mitral regurgitation is seen. 2. Left ventricular systolic function is normal. Right ventricular systolic function is normal. 3. Aorta is intact post decannulation. 4. [Location (un) 109] is still mildly decreased with no gradient (Peak of 12 mm of Hg). 4. Other findings are unchanged Brief Hospital Course: She was taken to the operating room on [4-13] where she underwent a MVR. She was transferred to the ICU in stable condition. She was extubated that night. She was transferred to the floor on POD #2. She was confused intermittently and required a sitter. Her confusion improved, she otherwise did well postoperatively and was ready for discharge to rehab on POD #4. Medications on Admission: Aspirin 325', Zocor 20', Desmopressin 0.1', Risperidone 1 am, Risperidone 3 pm, Atenolol 25', Ditropan XL 15', Imipramine HCl 25', Fosamax 70 qSun, Levothyroxine 100', Zantac 150', Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Imipramine HCl 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Risperidone 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. DDAVP 0.1 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 11. Ditropan XL 15 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days: then reassess need for diuresis. 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 10 days: while on lasix. 14. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week: every sunday. Discharge Disposition: Extended Care Facility: [Location (un) 931] House Nursing & Rehabilitation Center - [Location (un) 932] Discharge Diagnosis: MR s/p MVR HTN, Bipolar Disorder, syncope, venous insufficiency, LLE ulcer, hemorrhoids, [Doctor Last Name 933] Disease, urinary retention, GERD, OA 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. [First Name (STitle) ] 2 weeks Dr. [Last Name (STitle) 911] 2 weeks Dr. [Last Name (STitle) 914] 2 weeks Already scheduled appointments: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2102-6-15] 1:30 Provider: [First Name8 (NamePattern2) 161] [Name11 (NameIs) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 921] Date/Time:[2102-9-18] 11:15 Completed by:[2102-4-17*] ICD9 Codes: 4240, 2761, 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7498 }	Medical Text: Admission Date: [2114-10-10] Discharge Date: [2114-10-16] Date of Birth: [2050-3-25] Sex: F Service: MEDICINE Allergies: Sulfonamides / Shellfish / Iodine Containing Agents Classifier / Codeine / Morphine / Heparin Agents Attending:[First Name3 (LF) 3151] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname ] is a 64-year-old woman with a history of ESRD on hemodialysis, CAD s/p MI and PCI, PVD s/p aorto-femoral bypass, diastolic heart failure, asthma, and chronic abdominal pain who presented with acute on chronic abdominal pain and is transferred to the [Hospital Unit Name 153] for hypoxic respiratory failure. . She was last discharged on [2114-9-20] after presenting with acute on chronic abdominal pain. Her evaluation was negative for acute etiologies and she was discharged with outpatient GI follow-up but was unable to keep her appointment. She was in her usual state of health until this morning when she awoke with worsening of her abdominal pain, nausea, two episodes of diarrhea with loose, watery stools, and three episodes of nonbloody emesis. She denied fevers, chills, but had a non-productive cough with thick sputum last night which had resolved by this morning. She was at [Date Range 2286] yesterday and had 4.5L removed per her report, but she has had worsening shortness of breath since last Thursday when she missed her [Date Range 2286] session. She did undergo [Date Range 2286] on Saturday. . In the ED initial vital signs were 98.1 82 187/75 16 96%O2 sat on NRB. She was found to be hypoxic to 78%3L, hypertensive to SBPs 180s, and tachypneic with abdominal pain described as sharp epigastric pain with radiation to her back, and her exam was notable for bibasilar rales and guaiac neg brown stool. She was given dilaudid iv .5 mg x 1 and 1 mg x 1 and placed on a NRB with O2 sat rising to 97%. A chest x-ray was performed and demonstrated bilateral patchy infiltrates and small pleural effusions, and she was given vanc/levofloxacin empirically for pneumonia. Renal was contact[Name (NI) ] for possible [Name (NI) 2286], and ICU admission was requested for hypoxic respiratory failure. . On arrival to the floor, she is requesting pain medication for her abdominal pain and appears uncomfortable. . Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies wheezes. No dysuria. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: - "About 20" hospitalizations over the past 5-6 years for epigastric pain that has eluded definitive diagnosis. According to her primary care physician, [Name10 (NameIs) ] carries a diagnosis of chronic pancreatitis, although this has not been confirmed. Multiple attempts to have her seen in the outpatient GI unit have failed because she has not been able to keep her appointments. - Coronary artery disease; s/p MI in [11/2111] (received stent to RCA and right PDA at [Hospital1 112]) - ESRD diagnosed "10 years ago"; has received hemodialysis since that time. Receives HD on Tues, Thurs, and Sat. Last [Hospital1 2286] was yesterday. Baseline creatinine is in [4-6] range. - Peripheral vascular disease: s/p aorto-femoral bypass with atherectomy in [2099] after near total occlusion; multiple revisions of her aorto-bifemoral and cross femoral grafts since then - Possible chronic mesenteric ischemia with known occlusion of inferior mesenteric artery. - Exploratory laparotomy for pancreas divisum with sphincterectomy of her minor duct in [2096] - Asthma - Schizoaffective disorder - Hypertension - Insulin-independent diabetes mellitus (last measured HbA1c 6.6% in [12/2112]) - History of DVT and clots in aorto-femoral bypass - Lumbar disc disease (with associated back pain) - Hyperlipidemia - Gastroesophageal reflux/gastritis ([4-10] EGD) - Chronic pancreatitis - s/p exploratory laparotomy for pancreas divisum with sphincterotomy of her minor duct in [2096] - Benign pelvic mass, s/p R oophrectomy and hysterectomy - s/p cholecystectomy - s/p arthroscopy of right knee and medial meniscectomy in '[04] - Heparin-induced thrombocytopenia [6-/2113] (positive antibody) Family History: siblings passed away from CAD/heart attacks Physical Exam: ON ADMISSION: GEN: NAD VS: 98 177/73 78 24 98%nrb HEENT: MMM, no OP lesions, JVP undetectable, neck is supple, no cervical, supraclavicular, or axillary LAD CV: RR, NL S1S2 no S3S4 MRG PULM: coarse bibasilar rales ABD: BS+, soft, marked TTP in epigastrum. LIMBS: No LE edema, no tremors or asterixis, no clubbing SKIN: No rashes or skin breakdown NEURO: CNII-XII nonfocal, strength 5/5 of the upper and lower extremities On Discharge: GEN: NAD VS: 97.4, 127/58, 64, 16, 97% RA HEENT: MMM, no OP lesions Neck: JVP undetectable, neck is supple CV: RR, normal S1 and S2, + 2/6 systolic murmur best at RUSB, no rub or gallop Pulm: CTAB, minimal bibasilar crackles, no wheeze or rhonchi. Abd: BS+, soft, minimal epigastric discomfort, non-distended, no rebound and guarding LIMBS: No LE edema, no tremors or asterixis, no clubbing Pertinent Results: Imaging: [10-10] CXR: Multiple areas of patchy opacity in the right mid-to-lower lung and possibly left lung base, raising concern for multifocal pneumonia. Recommend followup to resolution. [10-11] CXR: Worsening pulmonary edema. New retrocardiac opacity likely representing atelectasis. [10-11] Abd X ray: In the single supine view, there is no evidence of large amount of free air within the peritoneal cavity. Lateral decubitus views may be beneficial for further evaluation. Air is seen within the colon and rectum. There are no dilated loops of small bowel or air-fluid levels to suggest obstruction. Surgical clips are seen on the left margin of the pelvic inlet. No significant osseous abnormalities are identified. IMPRESSION: No evidence a large amount of free air on this single portable supine view. If clinically indicated, we would recommend upright or lateral decubitus views for further evaluation. No evidence of small-bowel obstruction. [10-12] Echo: There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal basal inferior akinesis. The remaining segments contract normally (LVEF = 45-50%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Moderate pulmonary hypertension. [10-15] AVF duplex HD access (prelim): no stenosis (pending final read) Blood Counts: [2114-10-10] 12:15PM BLOOD WBC-8.1 RBC-4.71 Hgb-11.0* Hct-34.3* MCV-73* MCH-23.4* MCHC-32.1 RDW-18.9* Plt Ct-179 [2114-10-10] 09:30PM BLOOD WBC-11.6* RBC-4.64 Hgb-10.8* Hct-34.8* MCV-75* MCH-23.2* MCHC-31.0 RDW-18.7* Plt Ct-52# [2114-10-11] 09:43AM BLOOD WBC-11.2 RBC-4.31 Hgb-10.2* Hct-32.2* MCV-75* MCH-23.6* MCHC-31.6 RDW-18.9* Plt Ct-57* [2114-10-11] 05:01PM BLOOD Parst S-NEGATIVE [2114-10-16] 08:00AM BLOOD WBC-7.5 RBC-4.15* Hgb-9.4* Hct-31.1* MCV-75* MCH-22.7* MCHC-30.3* RDW-20.1* Plt Ct-133* Chemistry: [2114-10-10] 12:15PM BLOOD Glucose-180* UreaN-17 Creat-3.6# Na-129 K-GREATER TH Cl-92* HCO3-27 [2114-10-10] 09:30PM BLOOD Glucose-81 UreaN-19 Creat-4.0* Na-135 K-4.9 Cl-95* HCO3-26 AnGap-19 [2114-10-10] 12:15PM BLOOD Lipase-46 [2114-10-10] 09:30PM BLOOD CK-MB-1 cTropnT-0.06* [2114-10-10] 12:15PM BLOOD CK-MB-1 cTropnT-0.04* [2114-10-11] 09:43AM BLOOD Glucose-127* UreaN-25* Creat-4.8* Na-134 K-4.5 Cl-91* HCO3-27 AnGap-21* [2114-10-14] 11:13AM BLOOD Ret Aut-3.0 [2114-10-14] 11:13AM BLOOD VitB12-443 Hapto-233* [2114-10-14] 11:13AM BLOOD D-Dimer-3230* [2114-10-14] 11:13AM BLOOD Fibrino-476* [2114-10-14] 11:13AM BLOOD TSH-1.4 [2114-10-14] 11:13AM BLOOD Vanco-6.8* [2114-10-14] 11:13AM BLOOD ALT-15 AST-23 LD(LDH)-160 AlkPhos-156* TotBili-0.3 [2114-10-16] 08:00AM BLOOD Glucose-195* UreaN-27* Creat-5.5* Na-131* K-4.2 Cl-94* HCO3-27 [2114-10-16] 08:00AM BLOOD Calcium-8.7 Phos-1.5* Mg-2.1 Gases: [2114-10-10] 05:55PM BLOOD Type-ART pO2-65* pCO2-52* pH-7.42 calTCO2-35* Base XS-7 Intubat-NOT INTUBA Comment-NON-REBREA Microbiology [2114-10-10] - Blood cx negative x2 - MRSA screening negative Brief Hospital Course: Ms. [Known lastname ] is a 64-year-old woman with a history of ESRD on hemodialysis, CAD s/p MI and PCI, PVD s/p aorto-femoral bypass, diastolic heart failure, asthma, and chronic abdominal pain who presented with acute on chronic abdominal pain and is transferred to the [Hospital Unit Name 153] for hypoxic respiratory failure. # Hypoxic respiratory failure: On admission it was believed that her respiratory failure was multifactorial with components of volume overload/pulmonary edema, and acute diastolic heart failure in the setting of hypertenion, and also pneumonia were also considered. Given her past history signficant for multiple prior admissions for volume overload in the past, along with a CXR suggestive of fluid overload, fluid overload was the most likely diagnosis. She did not demonstrate clinical signs of infection, and improved with HD, but was started on antibiotics given the concern for possible infection. Her respiratory status improved and she was transferred to the floor. Patient continued to do while on the floor and was weaned off of O2 supplement. She completed a 6 day course of levofloxacin while in house. This can be followed up by her primary care physician # Acute on chronic abdominal pain: Patient has a long history of abdominal pain requiring multiple hospital admissions, with very poor outpatient follow-up. EGD and colonoscopy performed in [2114-2-2] notable primarily for diffuse spasm of colon. She was started on IV dilaudid intially given her NPO status for brief bowel rest. With advancement of her oral intake, she was switched to oral medication and transitioned to home medications as per her narcotics contract. She was discharged on home pain medications and will require refill per narcotics contract on [2114-11-1]. # Thrombocytopenia: On admission, patient's platelets were 179. On day 2, plaetelets were 52. Given the patient's history of HIT, there was concern that the patient had accidentally gotten heparin. After discussion with the HD and floor teams, it was determined that she had not received any heparin in her flushes or dialysate. Given this, her thrombocytopenia was determined to be secondary to either a drug effect or a platelet lysing effect of [Year (4 digits) 2286]. Her platelets remained stable at 57 on hospital day 3 and she was transferred to the floors with instructions to closely follow her platelet counts. Heme was consulted with recommendation to transfuse if platelet < 50. It is possible that this could be from the antibiotics and it is negative for parasites or clumping. However, her platelet counts begin to climb without intervention. This should be followed closely by her primary care physician. # ESRD on hemodialysis. She received HD on [10-10] and [10-11] in the setting of respiratory failure [3-6] volume overload as described above. With the thrombocytopenia, there was some bleeding issue with the fistula. Initially, a fistulogram was going to be performed, but patient has confirmed anaphylactic reaction to contrast dye. Records from [Hospital1 112] was obtained and showed that patient did have cardiac catheterization with angiography in the past and was pre-medicated to prevent the adverse effects. Dopplar of her fistula did not show signs of stenosis. However, as her platelets climbed, her bleeding issue also resolved. She will continue to have her regular hemodialysis. This will be followed by her nephrologist. # History of CAD s/p PCI. Non-active. She continued with home metoprolol, clopidogrel, rosuvastatin, Imdur, and lisinopril. Aspirin was held temporarily given her thrombocytopenia, was was re-initiated upon discharge. This can be followed up by her primary care provider. # Hypertension, fluctuating. She continued on home meds and HD. See above for details. This can be followed up by her primary care provider and her nephrologist. # Acute on chronic systolic/diastolic heart failure. EF estimated to be low on echo around the time of the acute exacerbation. She was treated with HD and supportive care. Her symptoms improved. She may need to have repeat echo after resolution of her exacerbation to reassess baseline function at the outpatient basis. # Schizoaffective disorder. Non-active. She continued on amitriptyline, aripiprazole, and citalopram. No change was done. Social work was consulted and found patient to have good resources, such as the PACT team. She will follow up with her primary care providers and her psychiatrist. # Asthma. Patient continued with home medication. This can be followed up by her primary care provider. # Diabetes mellitus, non-insulin dependent. Her oral medications were held while in house. She was switched to an insulin sliding scale. Patient did well in hospital and resumed her oral medication upon discharge. This can be followed up by her primary care provider. Medications on Admission: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:[2-3] Inhalation every 4-6 hours as needed for cough of wheeze. 2. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY 5. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 7. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO tid 8. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 10. Darbepoetin Alfa In Polysorbat 60 mcg/0.3 mL Syringe Sig: One (1) Injection every other week. 11. Ergocalciferol (Vitamin D2) 50,000 unit : One capsule once a week 12. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 13. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) Inhalation [Hospital1 ] 14. Advair Diskus 250-50 mcg/Dose Disk with Device 1 Inhalation [Hospital1 ] 15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. 17. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 18. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO tid 19. Ipratropium Bromide 0.02 % Solution Sig: One Inhalation qid 20. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 21. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day: 12 hours on 12 hours off. 22. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 23. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day. 24. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 25. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO three times a day. 26. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY 27. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO qid 28. Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day. 29. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 30. Ecotrin Low Strength 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day. 31. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] 32. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every six (6) hours as needed for indigestion. 33. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO tid prn 34. B Complex Tablet Sustained Release Sig: One (1) Tablet daily 35. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO bid 36. Ferrous Sulfate 324 mg (65 mg Iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO bid 37. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 38. Senna 8.6 mg Capsule Sig: One (1) Capsule PO BID:PRN Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [2-3] inhalation Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO three times a day. 8. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Darbepoetin Alfa In Polysorbat 60 mcg/0.3 mL Syringe Sig: One (1) injection Injection every other week. 11. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 12. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for pain: You will get your next prescription on [2114-11-1]. Disp:5 Patch 72 hr(s) Refills:0 13. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) inhalation Inhalation twice a day. 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day): (Advair). 15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 18. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation 4 times a day. 20. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 21. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 22. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 23. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: You will get your next prescription on [2114-11-1]. Disp:60 Tablet(s) Refills:0 24. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO three times a day. 25. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 27. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 28. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 29. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 30. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) application Topical twice a day. 31. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every six (6) hours as needed for gas or indigestion. 32. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain: Do not exceed 4 grams of acetaminophen (Tylenol) especially if you are taking Percocet. 33. B Complex Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 34. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 35. Ferrous Sulfate 324 mg (65 mg Iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 36. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO three times a day: Please take with meals. 37. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 38. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day: 12 hours on 12 hours off. Discharge Disposition: Home With Service Facility: nizhoni Discharge Diagnosis: Primary diagnosis: - Hypoxic respiratory failure, resolved. - Community acquired pneumonia - Acute on chronic abdominal pain, not otherwise specified Secondary diagnosis: - Thrombocytopenia - End stage renal disease on hemodialysis (Tuesday/Thursday/Saturday) - Hypertension - Insulin independent diabetes mellitus - History of coronary artery disease - Acute on Chronic systolic/diastolic heart failure - Asthma - Anemia - Schizoaffective disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Hospital1 69] for abdominal pain that is worse than your regular pain and trouble breathing. You stayed briefly in an intensive care unit. It was thought the difficulty breathing was due to too much fluid in your lungs and also a pneumonia. You were treated with [Hospital1 2286] and antibiotics. Your abdominal pain was not due to blockage in the bowel, and the discomfort was treated with bowel rest and pain medication. Your symptoms improved over time. Please note the following changes in your medications: NONE You are getting refills for your regular narcotics as stated in your narcotics contract. However, you will get the prescription for the following month from your primary care providers on [2114-11-1]. It will be important for you to follow up with your doctors [First Name (Titles) 3] [Name5 (PTitle) 57228] below. You should have your primary care physician check your platelet count and electrolytes. You should continue to have your regular hemodialysis on Tuesday, Thursday, and Saturday. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Continue [Name8 (MD) 2286] per outpatient routine. Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2114-10-17] at 11:15 AM With: [First Name4 (NamePattern1) 1386] [Last Name (NamePattern1) ], 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 Department: [Hospital3 249] When: WEDNESDAY [2114-10-24] at 11:20 AM With: [Name6 (MD) 251] [Last Name (NamePattern4) 1114], M.D. [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2114-10-16] ICD9 Codes: 486, 5856, 4280, 2875, 412, 4439, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7499 }	Medical Text: Admission Date: [2133-5-30] Discharge Date: [2133-6-5] Date of Birth: [2065-10-16] Sex: F Service: MEDICINE Allergies: Vancomycin Attending:[First Name3 (LF) 3913] Chief Complaint: Febrile neutropenia, relative hypotension Major Surgical or Invasive Procedure: paracentesis History of Present Illness: 67F w/hx refractory CLL c/b MDS and recurrent ascites, presenting with fevers, nausea, vomiting, dizziness, and relative hypotension with systolics in the upper 80s-low 90s (SBP normally in 90-100s). The patient last received etoposide and cytoxan five days ago, with subseqeunt neutropenia (ANC 310) on yesterday's labs. The patient had generally been feeling well, and was last seen in clinic yesterday, where she was reported as having a lot of energy and having no complaints. Today, she noticed a decreased appetite, and was nauseous with an episode of vomiting non-bloody emesis. She felt febrile and measured her temperature at 103. . In the ED, the patient was hypotensive below her low baseline, with the lowest SBP measured at 77. She was also tachycardic to 120s, which improved after 2 liters IVF. Blood and urine cultures were sent, and the patient was given cefepime. . On the floor, the patient reports improvement in her symptoms: she is now afebrile. Denies current lightheadedness, dizziness, dyspnea, chest pain, or palpitations. She does endorse worsening fluid accumulation in her abdomen since her last paracentesis on [5-21], but denies abdominal pain or nausea. . Review of sytems: (+) Per HPI. Also endorses decreased urine output since this morning. (-) Denies chills, night sweats, headache, cough, diarrhea, constipation, arthralgias or myalgias. . Past Medical History: 1. CLL. Please refer to OMR note [2131-4-4] for extensive details. Has had multiple treatments, most recent of which was bendamusine on [2132-11-6]. 2. Extrapulmonary TB diagnosed [8-8], now s/p 6 months of therapy with rifampin, INH, and moxifloxacin. 3. Hypothyroidism 4. Osteoarthritis 5. Status post ERCP with sphincterotomy for gallstone pancreatitis and cholangitis, [4-10] 6. Status post cholecystectomy [2132-5-8] 7. History of C. difficile 8. Recurrent ascites . Social History: Pt from [Country 27587]. Smoked [1-5] ppd for 45 years. No ETOH or drugs. Lives at home with her husband, daughter, and grandson. Owned and worked at her own business "helping hands" as a home health aide. Family History: Noncontributory. Physical Exam: Vitals: T:97.5 BP:90/56 P:87 R:22 O2:97% room air General: Very pleasant, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Poor dentition Neck: supple, no appreciable JVD or LAD Lungs: CTAB, good inspiratory effort and air movement. No wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Protruberant and distended, but soft. Dull to mildly resonant to percussion throughout. Non-tender, bowel sounds present, no rebound tenderness or guarding. +Palpable splenomegaly Ext: WWP, symmetric 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: WBC 0.3 (22P, 70L, 8M) Hct 24.6 (B/l high-mid 20s) Plt 40 ANC 66 . Na 133 K 4.6 Cl 104 HCO3 19 BUN 24 Cr 0.7 Glu 123 . Lactate 1.0 . Discharge labs: [2133-6-5] 06:00AM BLOOD WBC-0.7* RBC-2.64* Hgb-9.0* Hct-26.0* MCV-99* MCH-34.2* MCHC-34.7 RDW-18.4* Plt Ct-28* [2133-6-5] 06:00AM BLOOD Neuts-57 Bands-0 Lymphs-35 Monos-5 Eos-2 Baso-0 Atyps-1* Metas-0 Myelos-0 [2133-6-5] 06:00AM BLOOD Gran Ct-399* [2133-6-5] 06:00AM BLOOD Glucose-98 UreaN-14 Creat-0.6 Na-139 K-4.0 Cl-110* HCO3-24 AnGap-9 [2133-6-4] 06:00AM BLOOD ALT-12 AST-15 LD(LDH)-116 AlkPhos-85 TotBili-0.3 [2133-6-5] 06:00AM BLOOD Albumin-2.8* Calcium-8.0* Phos-2.6* Mg-1.9 Micro: [5-30] BCx: neg [5-30] UCx: neg . Peritoneal fluid: [2133-6-4] 03:50PM OTHER BODY FLUID WBC-75* RBC-5100* Polys-2* Lymphs-78* Monos-10* Mesothe-10* [2133-6-4] 03:50PM OTHER BODY FLUID TotProt-2.3 Glucose-9 [2133-6-4] 3:50 pm PERITONEAL FLUID GRAM STAIN (Final [2133-6-4]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): Images: [5-30] CXR: The lungs are clear. There is no focal consolidation, pleural effusion, or pneumothorax. Infrahilar right-sided opacity, in correlation with prior CT, likely corresponds to calcified lymph nodes which could be treated lymphoma. Heart size is normal. There is no pulmonary edema. Brief Hospital Course: Ms. [Known lastname 31303] is a 67 year old woman with refractory CLL on C1D6 of cyclophosphamide, etoposide, and prednisone, presenting with febrile neutropenia, nausea, vomiting, dizziness and hypotension. # Febrile neutropenia: Outpatient notes indicate that the patient had been experiencing intermittent low-grade fevers. She was recently started on empiric cefpodoxime and metronidazole out of concern for possible SBP. All recent culture data (blood, urine, peritoneal fluid) had been negative since [Month (only) 404]. CXR negative for focal consolidation or pulmonary edema. Urine analysis was not concerning for UTI. Patient was started empirically on cefepime/metronidazole for empiric coverage of an intra-abdominal process. Patient had no further fevers and was transferred to the BMT floor where her fevers resolved. She continued her chemo and was ultimately discharged on cefpodoxime/flagyl. Her peritoneal fluid did not have evidence of infection, but final cultures are pending and should be followed up by the pt's oncologist. # Hypotension: Patient was admitted directly to MICU because of relative hypotension with SBPs in 80s. She was given some IVFs and transferred to the BMT floor the next day with stable blood pressure in the 90s systolic. Patient was asymptomatic from hypotension, though she had noted symptoms of dizziness intermittently since her last chemotherapy dose; the dizziness symptoms were described as vertigo-like, does not appear to be related to hypotension. # CLL: Patient presented on Day#6 of Cycle#1 of her chemotherapy regimen. Her current regimen is as follows: Cyclophosphamide 500mg/m2 days 1, 8; Etoposide 50mg/m2 days 1 and 2 (hold day 3); Prednisone 60mg po days 1,2,3,4,5. Per OMR notes, the patient's disease has been generally stable on bendamustine and Rituxan for several months, though her most recent scan showed growth in size of lymph nodes and worsening malignant ascites. Her primary oncologist reports that her disease features chronic low counts due to a dysplastic marrow with poor reserve, and he has been attempting to support her counts with transfusions and GMCSF. Patient was continued on daily Neupogen and allopurinol. Her last monthly dose of pentamidine dose was [2133-5-7], she is to have this dose at her next oncology appointment. She refused nystatin for oral thrush but was started on clotrimazole on the BMT floor. # Ascites: Patient has malignant ascites with a previous diagnostic tap showing cytology similar to her lymphoma. Her last paracentesis was on [5-21], with peritoneal fluid analysis unrevealing for infection and cell counts repeatedly negative for SBP. She was started on cefepime and metronidazole empirically for SBP. Abdomen was very distended during this hospitalization but not painful; patient underwent ultrasound-guided paracentesis by Interventional Radiology which provided the pt with good relief. The fluid studies did not show evidence of infection but final cultures are pending and should be followed up. She is discharged on cefpodoxime/flagyl which can cover prophylactically for SBP as well. # Pancytopenia: Patient's hematocrit dropped from 24 to 20 in the setting of IVFs from the ED and the MICU. She was transfused 1u pRBCs in the ICU before transferred to floor. The patient was transfused with pRBC and platelets prn throughout admission. It is noted that the pt developed hives to plt transfusion which responded to benadryl. Medications on Admission: Medications (as of [2133-5-21]): ACYCLOVIR 400 mg PO Q8 hrs ALLOPURINOL 150 mg PO daily CEFPODOXIME 200 mg PO Q 12 hrs ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Qmonth FILGRASTIM - 300 mcg SC daily FOLIC ACID - 1 mg PO daily LEVOTHYROXINE - 175 mcg PO daily Mylan Generic - No Substitution LORAZEPAM - 0.5 mg PO QHS METRONIDAZOLE - 500 mg PO Q8 hrs NYSTATIN - 5 cc PO 3-4x/day swish and spit OLANZAPINE 2.5 mg PO QHS PRN insomnia PENTAMIDINE 300 mg inh monthly PREDNISONE - 5 mg Tablet PO daily PROCHLORPERAZINE MALEATE - 10 mg PO Q8 hrs PRN nausea & vomiting MAGNESIUM OXIDE - 400 mg PO BID Discharge Medications: 1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO Q1MO (once a month). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pentamidine 300 mg Recon Soln Sig: One (1) Recon Soln Inhalation Q1MO (once a month). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 11. Prochlorperazine Maleate 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for nausea. 12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H (every 24 hours). 14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. Disp:30 Tablet(s) Refills:0 15. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). Disp:30 Troche(s) Refills:1 16. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (un) 2646] Home Care Discharge Diagnosis: Primary Diagnosis: Neutropenic Fever Secondary Diagnoses: Chronic Lymphocytic Leukemia Malignant Ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 31303], You were admitted to the hospital because you were having fevers and your blood counts were low while receiving chemotherapy. You were started on antibiotics and monitored and your fevers resolved without any apparent cause. You received your remained chemo doses. You also had blood and platelet transfusions as needed. Finally, you underwent a therapuetic paracentesis to remove fluid from your abdomen. You are to continue antibiotics at home. You should also continue your GCSF injections. Please take all medications as prescribed. Please follow up with all providers. Please do not hesitate to return to the hospital with any concerning symptoms at all. . Followup Instructions: Please be sure to keep all of your followup appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7779], MD Phone:[Telephone/Fax (1) 3241] Date/Time:[2133-6-8] 1:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9574], [MD Number(3) 1240]:[Telephone/Fax (1) 3241] Date/Time:[2133-6-8] 1:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5340], MD Phone:[Telephone/Fax (1) 1803] Date/Time:[2133-10-5] 8:20 ICD9 Codes: 2761, 2449

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